Editor’s Spotlight/Take 5: Fewer Than One in 20 Current Academic Orthopaedic Surgeons Have Obtained National Institutes of Health Funding

When I learned that only three out of every 1000 orthopaedic surgeons have grant funding through the National Institutes of Health (NIH) [6], I recall feeling that the finding was irrelevant, because the vast majority of orthopaedic surgeons practice outside of research institutions. It didn’t bother me either that the number for our specialty was less than half of that for surgeons overall (7 per 1000), or for cardiothoracic surgeons (13 per 1000), in that same study. Those specialties deal more frequently with life-threatening illnesses, such as cancer and cardiac disease, than we do. And because of that, like it or not, they are funded through larger institutes or agencies within the NIH than are orthopaedic surgeons, who more commonly compete for the thin slice of the pie that is the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (Fig. 1) [18].

Fig. 1.

This pie chart shows the amount of funds enacted for FY2023 for the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) ($685 million) compared to the other institutes, centers, agencies, and offices that are also funded by the National Institutes of Health ($48.497 billion). Data from Table A-1 of the National Institutes of Health (NIH) Funding: FY1996-FY2023 report [18] were used to create this chart.

Fig. 2.

Quanjun Cui MD

But when I discovered—when I first read the article we’re publishing in this month’s Clinical Orthopaedics and Related Research® from Dr. Quanjun Cui’s group at the University of Virginia [10]—that only 4% of academic orthopaedic surgeons have an NIH grant of any sort, I was troubled. Orthopaedic surgeons represent about 2% of physicians in the United States [1], and only 4% of those surgeons are getting the resources they need to discover cures or mitigate the kinds of suffering that come up in at least half of patients’ visits to primary care physicians [17]. I’m not just talking about those big-ticket R01 grants, either. That 4% includes our specialty’s share of all NIH grants. Four percent of the 2% to cure half? That’s a small bite of pie. And as we’ve pointed out in the past on the editorial page here [11], one often has to go deep into one’s career before getting that bite, if one gets it at all. Several metrics in Dr. Cui’s study suggest this remains the case today.

The odds seem stacked against us. Or more precisely, against our patients.

But there was some good news in this study. Men and women investigators in our specialty did about equally well in proportion to their numbers in terms of getting funded (though of course it would be nice if all of us did better, and if there were more women in academic orthopaedic surgery). And this study hinted at pathways to better success—having PhDs in the program may increase our odds.

Normally, I’m not a fan of simple descriptive research, but this one tells a tale too important to miss. For that reason, I hope you’ll read it carefully, but before you do so, join me in the Take 5 interview that follows with the paper’s senior author, Quanjun Cui MD (Fig. 2). He has spent some time on this topic and has some good, thoughtful ideas about how we can tilt the playing field back our way.

Take Five Interview with Quanjun Cui MD, senior author of “Fewer Than One in 20 Current Academic Orthopaedic Surgeons Have Obtained National Institutes of Health Funding”

Seth S. Leopold MD: Congratulations on this important, if somewhat disturbing, study. But how bad is this situation, really? Four percent is only a small number if more people want to go down the extramural research path and were turned away. What is your sense for this—how much good work is out there that isn’t getting funded?

Quanjun Cui MD: Thank you, Dr. Leopold, for the great opportunity to present our work. We know that the overall funding success rate for research project grants has come down from about 30% in the late 1990s to around 20% for the last 15 years. NIAMS grants, which provide most of the funding for orthopaedic surgery, tell a similar story, with the fiscal year 2022 overall funding success rate at 20.5%. R01 grants are even more competitive, with success rates at around 10% [15]. Other major funding sources in the United States, such as National Science Foundation (NSF) grants, as well as organizations abroad like the National Institute for Health and Care Research in the United Kingdom, have similar numbers [13]. The specific numbers for orthopaedic surgeons aren’t available, but if we use these numbers as a proxy, about four in five who seek extramural funding from these sources cannot obtain it. This is despite many grant proposals that demonstrate real promise. Research promotes new discoveries, drives fields forward, and ultimately helps us do what we all hope to accomplish as physicians—provide better care for our patients. While this is certainly a multifactorial issue that doesn’t necessarily have an easy solution, we need to do better in this realm.

Dr. Leopold: And for those who succeed, how hard is the path? About seven years ago, we wrote that NIH research budgets were dropping, and “more than half of the MD/PhD scientists in the United States will celebrate a 43rd birthday before a first NIH grant” [11]. How persistent does one have to be in order to get these much-sought-after NIH grants nowadays?

Dr. Cui: We know that the path is hard, and several published studies support this idea. Funding rates for surgeon-scientists are declining, and while the likelihood of successfully obtaining funding increases as more proposals are submitted, the expectation needs to be that grant applications will, at least initially, be rejected [5, 14]. Worse still, surveys of surgeons have indicated that more than two-thirds do not believe that having a basic science career is even possible as a surgeon [9]. There are many reasons for this. They include the aforementioned difficulty in obtaining extramural funding, as well as issues like the need for clinical productivity, increased administrative work, and a desire for a better work-life balance. Persistence certainly is key here, as grit and drive are often the first prerequisites to successful funding.

Dr. Leopold: Based on at least some limited comparisons I tried to make with your data [21], it looks like the proportions aren’t changing much over time. So let’s talk a little about solutions. I know that the Orthopaedic Research and Education Foundation (OREF) has some good career development grants and other funding opportunities for individuals interested in doing serious research [16], as does MTF Biologics [12]. What pathways do you recommend individuals follow who want to increase their odds of getting NIH-level extramural funding and sustaining it?

Dr. Cui: You’re right—the proportions certainly don’t seem to be changing much. Without increasing funding budgets across the board, this is a hard problem to solve. Before that can happen though, I think there needs to be a paradigm shift regarding how scientific pursuits are valued. So many high-quality grants are rejected simply because there isn’t enough funding, and we ultimately don’t know what happens to these ideas.

In terms of solutions, there are several additional pathways that we can look toward, both inside and outside the NIH. Early career involvement is competitive, but funding sources like K-awards or T32 grants are both options [20]. Furthermore, while we weren’t able to look specifically at collaborative funding in our CORR® paper, the NIH does allow co-PIs on grants. Teaming up with other surgeon-scientists and non-surgeon-scientists is an option that should be considered.

Looking outside the NIH, other national agencies like the NSF are options, though they will have much of the same competitive nature as NIH funding. As you mentioned, OREF grants are also an option [7]. In fact, one recent study found that residents who are awarded resident-specific OREF grants go on to academic careers at higher proportions than their non-awarded counterparts [19]. I am grateful that I was a fortunate recipient of both OREF and MTF research grants before I was able to obtain NIH and Department of Defense (DOD) grants. We should certainly work with residents and encourage them to pursue these types of endeavors.

The Clinician Scholar Career Development Program (CSCDP) is a separate option for preparing those interested in a career as a surgeon-scientist [3], as are American Academy of Orthopaedic Surgeons (AAOS) and Orthopaedic Research Society (ORS) grant-writing workshops. Subspecialty funding sources such as the Orthpaedic Trauma Association and American Association of Hip and Knee Surgeons are options as well. All of these and others are great options for gaining experience before going for larger, R01-level funding. The key to be successful in getting NIH-level extramural funding and being able to sustain it, in my opinion, is team building and close collaboration with PhD scientists.

Dr. Leopold: More broadly, what should our academic departments and professional societies do differently to make the pathway to an R01 (or other similarly robust funding) easier to navigate? Can you take this beyond your suggestion to hire PhDs (since I think most university campuses will have plenty of PhD collaborators to engage with clinicians who have compelling problems to study)?

Dr. Cui: Departments need to continue to value and support scholarly pursuit for both residents and faculty. Incorporating research-year tracks into programs and expanding dedicated research time, along with the funding available for basic and clinical research, are imperative [2]. This is particularly true for those who indicate a desire to develop the skills necessary for success as a surgeon-scientist. When building a strong research team, include the recruitment of PhD scientists with interests in orthopaedic research and pursue collaborations between principal investigators, departments, and institutions. Our professional societies do a great job of advocating for us as well. Groups like the AAOS, AOA, ORS, and American Society for Bone and Mineral Research are powerful assets, and they should continue to push for increased funding to support musculoskeletal research. Expanding access to programs like the CSCDP would be great as well.

Dr. Leopold: To what degree should we be looking elsewhere altogether—outside the NIH and other large federal agencies—to answer the research questions that matter most to our patients, and what do you see as the most promising avenues for doing that?

Dr. Cui: The NIH and other large federal agencies such as the NSF and DOD are great (though competitive) options, as are other smaller grant mechanisms that we’ve previously discussed here. One other source that people should consider pursuing is industry funding. In fact, orthopaedic surgeons receive more funding from industry sources than most other specialties, and in amounts that exceed the funding received from the NIH [4, 8]. This somewhat helps make up for the fact that orthopaedic surgeons receive a disproportionately small percentage of NIH funding compared to the number of patients and conditions that we treat. Of course, there are a few caveats to this. Steps need to be taken to minimize conflicts of interest, and we need to make sure that we reduce any biases that can be associated with industry funding. Overall, we need a multifaced approach to research funding. Doing so will help as many people as possible pursue high-quality research that will drive our field forward.