Impact of Surgeon-Scientist Institutional Transitions on Funding Progression

Introduction

The career development and academic support of surgeon-scientists is a longstanding challenge^1–3. Surgeon-scientists are practicing clinical surgeons who also are engaged in concomitant professional basic science, translational, and clinical research activities.⁴ Research funding is paramount to supporting the career progression and academic success of surgeon-scientists.^4–6 Recent publication of National Institutes of Health (NIH) data demonstrates that clinically-practicing NIH-funded surgeon-scientists have increased in number and total funding cost in 2021 compared to 2012.³ However, various reports have also demonstrated that surgeon-scientists have notably lower NIH-funding relative to clinician-scientists from other clinical specalities,⁴ experience a lower likelihood of funded research proposals,⁷ and are lagging behind in overall research funding when compared to non-clinical investigators.^4,8–11 Although existing literature paints a mixed-picture, with the contemporary economic challenges required to adequately support surgeon-scientist, there is a continued demand to better understand how surgeon-scientists progress through career development and into scientific independence.^1,3,4,12

The early career-development phase is viewed as a critical time period that can inform future academic success.^1,4,6 The NIH has a long tradition of established funding pathways for the career development of surgeon-scientists to develop the necessary skillsets and academic portfolio to progress to scientific and research independence. During professional training, F and T training grants provide pre- and post-doctoral trainees/fellows early mentored research support, while K grants provide junior faculty mentored career development support. The ultimate goal of these funding mechanisms are to provide junior investigators the opportunities to receive foundational research training, develop a track record of scientific productivity, identify areas of research interest, and cultivate a network of mentors, sponsors, and collaborators.

On the other hand, R grants are awarded to established investigators and continue to be an important benchmark for scientific independence and academic success. Although surgeons who are awarded a K grant are more likely to be awarded a subsequent R grant,¹³ still only a minority (between 29% and 42%) are subsequently awarded an R grant.^4,13–16 From 1998–2018, there has been a significant decline in the number of K grants awarded to surgeons.¹⁷ Although many factors may influence a surgeon-scientist’s successful progression from a K to an R grant, major disruptions in environment and/or institutional association may be an important variable to consider.

The research environment and institutional support is one of the key criteria that are used by the NIH to evaluate K and R proposals.¹⁸ Consistent with this, surgeon-scientists relate that protected research time, adequate mentorship, and support from institutional leadership to support academic and research endeavors are important variables that support K to R progression.^1,4,14,18,19 The American Surgical Association Taskforce on Research Sustainability has recently published a blueprint for the optimal support of surgeon-scientists, with various critical recommendations regarding the role of the institution in this support.¹ Despite the critical role that the institution plays in the support of surgeon-scientists, knowledge of the number of institutional transitions and the impact of this changing of institution has on a young career surgeon-scientist to progress to independence research status remains underexplored. We therefore aimed to explore how institutional transitions during a surgeon-scientist’s career development phase (K grant award) impacts the capacity to progress to subsequent scientific independence (R grant award) and analyzed this using publicly available NIH data.

Methods

Study Design and Cohort Identification

We conducted a retrospective cohort design utilizing publicly available data. This study was reviewed by the Washington University in St. Louis Institutional Review Board (IRB) and was deemed to be exempt as non-human subjects research (IRB #202408073). NIH RePORTER (Research Portfolio Online Reporting Tools Expenditures and Results), an online tool for public reporting of funding for NIH grants, was utilized to identify the cohort of surgeon-scientists included in the study.²⁰ NIH RePORTER was queried for new K08 or K23 grants awarded from 2000–2019 to recipients within departments of surgery in the United States (U.S.). K08 and K23 grants were chosen as these are focused on supporting the career development of clinician-scientists (see Table, Supplemental Digital Content 1).²¹ This cohort was then further downselected to only include principle investigators (PIs) with an active clinical surgical practice at the time of the grant submission.

Data Collection

Data collected from NIH RePORTER on the selected cohort included year of new K grant award, number of publications associated with the K grant, funds awarded with the K grant, institution associated with the K grant both at the initial award and during annual renewals, and status of prior F training grants. Another query was performed on NIH RePORTER to identify if any of the study cohort obtained new R01, R21, or R35 grants²¹ from 2000–2023. This query for R grant awards included data four years more contemporary than cohort identification to eliminate lead-time bias. The year of new R grant award, number of publications associated with the R grant, funds awarded with the R grant, and institution associated with the R grant both at the initial award and during annual renewals was similarly collected from NIH RePORTER.

Next, online searches were conducted to collect data regarding surgeon-scientist clinical specialty, year of clinical fellowship completion, professional degrees obtained, number of institutional moves, and years for each institutional move to supplement data on institutional transitions that was derived from data collected from NIH RePORTER. We referred to online curriculum vitaes and institutional faculty web pages for these publicly disclosed variables. PhD (Doctor of Philosophy), MPH (Master of Public Health, and MS (Master of Science) degrees were recorded separately. If a surgeon-scientist obtained a different type of secondary degree, these degrees were combined and collectively termed other secondary degrees.

Additionally, United States Department of Defense (DoD) and National Science Foundation (NSF) online databases were queried for any grants awarded to the K grant cohort from 2000–2023 after the K grant award. For supplementary analysis, we grouped NIH R grants, DoD grants, and NSF grants, and collectively termed them independent career grants in order to investigate the role of alterative funding agencies in addition to the NIH.

Hospital Funding Tier Determination

Institutions associated with K and R grant awards were then denoted as either lower-, mid-, or upper-tertile with regards to their level of NIH funding respective to all institutions for the year of the grant award. Next, the upper-tertile was further separated into top-20 institutions, and then a middle- and lower-group that evenly divided the remaining institutions in this top-tertile per year (see Figure, Supplemental Digital Content 2). Data on the amount of institutional NIH funding was similarly derived from NIH RePORTER.

Data Analysis

First, all data associated with the K grants were analyzed. Descriptive analysis for categorical and continuous variables were displayed as frequencies with percentage and medians with interquartile range [IQR], respectively. Similar analyses were conducted on R grants. Next, two groups were created: K grant awardees who subsequently were awarded an R grant, and K grant awardees who did not subsequently receive an R grant. After similar reporting of categorical and continuous variables, differences between categorical and continuous variables were analyzed using Fisher’s exact tests and Wilcoxon rank-sum tests, respectively.

For primary outcome assessment, the association between institutional transition and success in progression from K to R grants was evaluated through univariable and multivariable analysis. Both univariable and multivariable analysis evaluated whether the total number or timing of institutional transitions relative to the timing of the K grant award were associated with receipt of at least one R grant. This analysis was then repeated to analyze factors associated with receipt of multiple R grants. As secondary outcome assessment, the same multivariable analysis was repeated to evaluate factors associated with the receipt of both a first and multiple independent career grants. Variables were removed as needed for optimal model performance of all multivariable models. All tests were performed 2-tailed, and statistical significance was set at p<0.05. Data analysis was performed with SAS version 9.4 (Durham, North Carolina, United States).

Results

Demographics of K Grant Awardees

A total of 265 surgeon-scientists who were awarded new K08 or K23 grants from 2000–2019 in the U.S. (Table 1). K08 grants comprised the majority of K grants awarded (222/265; 83.8%). Of the 265 total surgeon-scientists with new K grants, 109 (41.1%) were subsequently awarded a future R01, R21, or R35 grant.

Table 1.

Surgeon-Scientists with K Grant Awards with and without Progression to R Grant Funding Baseline Characteristics.

	Full Cohort With K Grant Funding (n=265)	Cohort of K Grant Awardees who Subsequently Obtained R Grant Funding (n=109)	Cohort of K Grant Awardees who Subsequently Did Not Obtain R Grant Funding (n=156)	P-value Comparing Cohorts That Did and Did Not Receive R Grant Funding
Clinical degree				0.17
MBBS	2 (0.8)	2 (1.8)	0 (0)
MD	263 (99.2)	107 (98.2)	156 (100)
Secondary degree				0.043
MBA	14 (5.3)	8 (7.4)	6 (3.8)
MS	14 (5.3)	2 (1.8)	12 (7.7)
MPH	18 (6.8)	9 (8.3)	9 (5.8)
PhD	47 (17.7)	28 (25.9)	19 (12.2)
Other	5 (1.9)	2 (1.8)	3 (1.9)
Previous F grant	28 (10.6)	19 (17.4)	9 (5.8)	0.004
Type of K grant				0.62
K08	222 (83.8)	93 (85.3)	129 (82.7)
K23	43 (16.2)	16 (14.7)	27 (17.3)
Years of independent practice at the time of K grant award	4.2 [2.5]	3 [2–5]	4 [3–7]	<0.001
Number of publications associated with K grant*	14.7 [16.5]	13 [6–22]	7.5 [4–16]	0.003
Total funding dollar amount per K grant*	$141,677 [$31,048]	$133,110 [$123,550–153,554]	$122,503 [$125,336–158,517]	0.64
Tertiles of NIH funded institution where K grant was awarded
Upper-tertile	262 (98.9)	108 (99.1)	154 (98.7)	0.78
Top-10 of upper-tertile	102 (38.5)	48 (44)	54 (34.6)	0.13
Top-20 of upper tertile	146 (55.1)	64 (58.7)	82 (52.6)	0.38
Middle group of upper tertile	115 (43.4)	44 (40.4)	71 (45.5)	0.66
Lower group of upper tertile	1 (0.4)	0 (0)	1 (0.6)	0.78
Mid-tertile	3 (1.1)	1 (0.9)	2 (1.3)	0.58
NIH ranking of institution	17 [6–38]	17 [5–32]	17 [7–44]	0.128

Values representing frequency (%) or median [interquartile range]

Those who were subsequently awarded new R grants had more secondary degrees, particularly PhD’s (25.9% vs 12.2%, p=0.043), a shorter time from the start of independent practice to K grant award (median 3 years [IQR 2–5] vs 4 years [IQR 3–7], p<0.001), more publications associated with their K grant (median 13 [IQR 6–22] vs 7.5 [IQR 4–16], p=0.003), and had a higher rate of prior F grant awards compared to those who were not awarded new R grants (19% vs 9%, p=0.004; Table 1). Of the 265 total new K grant awardees, 262 (98.9%) were associated with top-tertile NIH-funded institutions, with 146 (55.1%) associated with top-20 NIH-funded institutions (Figure 1). The subspecialties with the highest success rate of K to R grant funding progression included colorectal surgery (7/11; 63.6%), minimally invasive surgery (7/9; 78%), and thoracic surgery (16/28; 57.1%; Figure 2).

Figure 1.

Distribution of New K and R Grants Awarded Relative to Institutional NIH Funding Rank.

Figure Legend: A) The NIH funding ranking of the institutions associated with each new K grant awarded. B) The NIH funding ranking of the institutions associated with each new first-time R grant awarded.

Figure 2.

Clinical Specialties of All Surgeon-Scientists with New K Grants Who Do and Do Not Progress to R Grant Funding.

Figure Legend: Clinical specialty of each surgeon-scientist who received a new K grant and those that received a new R grant, with only consideration of new first time R grants.

Demographics of R Grant Awardees

Of the 109 surgeon-scientists who were subsequently awarded an R grant, 86 (78.9%) were awarded an R01 (Table 2). Of the 109 R grant recipients, all were awarded their R grant while serving as faculty at a top-tertile NIH-funded institution, with 69 (63.3%) awarded to faculty at top-20 NIH-funded institutions (Figure 1). An additional 12 surgeon-scientists obtained independent career grant funding from the DoD and NSF (see Figure, Supplemental Digital Content 3).

Table 2.

Surgeon-Scientists With R Grants Baseline Characteristics.

	R Grant Recipients (n=109)
Type of R grant
R01	86 (78.9)
R21	20 (18.3)
R35	3 (2.8)
Total funding dollar amount per R grant	$373,750 [$300,684–479,980]
Years of independent practice at time of initial R grant	8 [6–11]
Years between K grant and R grant award	4 [3–6]
Number of total new R grants
One	62 (56.9)
Two or more	47 (43.1)
Tertiles of NIH funded institution where R grant was awarded
Upper-Tertile	109 (100)
Top-10 of Upper Tertile	43 (39.4)
Top-20 of Upper Tertile	69 (63.3)
Middle Group of Upper Tertile	38 (34.9)
Lower Group of Upper Tertile	2 (1.8)
NIH Ranking of Institution	15 [6–32]

Impact of Institutional Transition on K to R Progression

The impact of institutional transition on progression from a new K to a new R grant was evaluated. On univariable analysis, neither the number of total institutional moves nor the timing of institutional moves was associated with progression to new R grants (all p>0.05) (see Table, Supplemental Digital Content 4). However, prior F grant awards (OR 3.45 [95% CI 1.50–7.95], and PhD secondary degrees (OR 2.63 [95% CI 1.36–5.10]) was associated with PI progression to a new R grant. On multivariable analysis, prior F grant award (OR 3.94 [95% CI 1.65–9.42]), PhD secondary degree (OR 2.88 [95% CI 1.45–5.73]), and other secondary degrees (OR 2.17 [95% CI 1.04–4.56]) were associated with progression to a new R grant (Figure 3). On univariable analysis, when considering only those who were awarded an R grant, institutional transition was found to not be associated with progression to multiple R grants (p>0.05) (see Table, Supplemental Digital Content 5). Similarly, no factors were identified on multivariable analysis to be associated with the receipt of multiple new R grants (Figure 3).

Figure 3.

Multivariable Analysis of Factors Associated with R Grant Award.

Figure Legend: A) Impact of institutional transition, surgeon-scientist, and institutional factors on receipt of a new R grant after new K grant. B) Impact of institutional transition, surgeon-scientist, and institutional factors on receipt of additional new R grants after first R grant.

Impact of Institutional Transitions on K to Progression to Any Independent Career Grant

The impact of institutional transition on progression from a new K to a new independent career grant of any type was evaluated. On multivariable analysis, similar with results in evaluation of only R grants, prior F grant award (OR 3.39 [95% CI 1.42–8.06]), PhD secondary degree (OR 2.74 [95% CI 1.39–5.40]), and other secondary degrees (OR 2.30 [95% CI 1.10–4.83]) were associated with progression to a new independent career grant of any type, yet none of these factors were associated with receipt of multiple new independent career grants of any type (Figure 4).

Figure 4.

Multivariable Analysis of Factors Associated with Any New Independent Career Grant Award.

Figure Legend: A) Impact of institutional transition, surgeon-scientist, and institutional factors on receipt of any new independent career grant after new K grant. B) Impact of institutional transition, surgeon-scientist, and institutional factors on receipt of additional new any independent career grants after first of any independent career grant.

Impact of NIH Funding Rank on Grant Awards

The NIH funding rank of the institutions associated with both the new K and new first-time R grant awarded to surgeon-scientists were depicted graphically to evaluate the change in institutional ranking at the time of each grant award (Figure 5). The median and interquartile range of institutional NIH funding rankings for the new K and R grants for surgeon-scientists that did not change institutions for these two grants was 13 (IQR 5–32) and 13 (IQR 6–31), respectively. The median and interquartile range of institutional NIH funding rank for the new K and R grants for surgeon scientists that did change institutions for these two grants was 29 (IQR 6.3–52) and 17 (IQR 7–41), respectively.

Figure 5.

NIH Funding Ranking of Institutions Associated with Each New K and New First-Time R Grant for Surgeon-Scientists with Grant Progression.

Figure Legend: A) For surgeon-scientists who progressed from K to R grant awards, the NIH funding ranking of the institution associated with each grant is depicted for two groups: those that stay at the same institution for the two grants and those that move to a different institution for the two grants, B) The median and interquartile range of institutional NIH funding rankings for the new K (median 13, IQR 5–32) and R (median 13, IQR 6–31) grants for surgeon scientists that do not change institutions for these two grants, C) The median and interquartile range of institutional NIH funding rankings for the new K (median 29 [IQR 6.3–52]) and R (median 17 [IQR 7–41]) grants for surgeon-scientists that do change institutions for these two grants.

Furthermore, we evaluated analysis was performed to evaluate the NIH funding institute for surgeon-scientists (see Figure, Supplemental Digital Content 6). Of the NIH Institutes that awarded ≥5 K grants (AHRQ, NCI, NHLBI, NIA, NIAID, NIAMS, NICHD, NIDDK, and NIGMS), only K grant awardees from the NIAID (6/3; 50%) and the NIDDK (21/42; 50%) funded subsequent R grants to surgeon-scientists at rate ≥ 50%.

Discussion

This study focused on evaluating the impact of institutional transition on the ability of surgeon-scientists to progress from K to R grant funding and demonstrates many important findings. First, surgeon-scientists progressed from new K grant funding to new R grant funding at a rate of 41.1% from 2000–2023. Secondly, nearly all new K grants and all new R grants were awarded to surgeon-scientists who were at institutions ranking in the top-tertile of all NIH funded institutions. Third, amongst the 141 of 256 (53.2%) of surgeon-scientists that moved institutions at least once, only 4 (1.6%) moved institutions before they were awarded their new K grant. Lastly, institutional mobility during the funding period of the new K grant did not have a statistically significant impact on the future first R grant award, however, prior F award and advanced secondary degrees were associated with increased odds of subsequent first new R grant receipt. These findings serve to inform the public, granting agencies, and the surgical community regarding the historical and emerging trends in achieving vital career development and independent investigator NIH funding.

The overall rate of conversion from a new K grant to a new R grant that we observed at 41.1% is within the range of established literature, ranging from 29%–42%^8–10,14,16 There is notable heterogeneity in comparing our findings to prior studies. Namely, our study evaluated only new K08 and K23 grants awarded to surgeon-scientists, which were defined as PIs with a MD degree and an active clinical surgical practice at the time of the grant award. The current study included any surgical specialty categorized as within a department of surgery at their institution through NIH RePORTER, including traditional general surgery subspecialties and other surgical specialties, such as urology, plastic surgery, orthopedic surgery, neurosurgery, and otolaryngology. Some prior studies have included general surgery and similar other surgical subspecialties,¹⁴ while others only consider general surgery and separate out non-general surgery subspecialties^8,16 or only consider general surgery sub-specialties.^9,10 Additionally, not all prior studies specified their analysis to surgeon-scientists and instead broader cohorts.^8,9 While a prior study included only PIs with new K08 or K23 grants,⁹ most prior literature included a larger range of grants to define their cohorts to evaluate K to R grant progression.^10,11,14

We observed that there was a higher number of new K and R grants aggregated among highly funded institutions. This trend of increased concentration of NIH funding dollars to the top-ranking institutions has previously been shown at a departmental level.²² Consolidation in NIH departmental-wide funding is far more evident for surgical departments than medical departments.²² This consolidation, in part, may be explained by the availability of resource-rich infrastructure as well as core-services, which provide investigators access to unique tools, reagents, and services that enhance their abilities to generate compelling data and support new grant applications. Additionally, highly funded institutions typically have grant writing workshops, mock study sections, and diverse access to seasoned mentors with a track-record of successful grant funding.¹² Access to mentors is considered to be fundamental metric for success on K grants to learn from their experience of successes and shortcomings in establishment of a balanced clinical and investigative career.^1,12,22,23 Similarly, institutional research environment is a key component in NIH peer-review grant assessment.^1,18 While institutional NIH funding rankings are often referenced by the Blue Ridge Institute For Medical Research (BRIMR) annual rankings,²⁴ BRIMR was founded in 2006 and therefore utilization of that data was not feasible for this study.

A important finding from our multivariable analysis is that we observed that prior F awards and advanced secondary degrees, particularly a PhD, are associated with successful conversion from a K grant to both an R grant and overall independent career grants. There are multiple possible explanations for this finding. First, these surgeon-scientists have likely had more formal experiences dedicated to study methodology and experimental design through their training programs, advancing their knowledge of the scientific process. Secondly, they are more likely to have taken grant writing classes or participated in related workshops, improving their grant writing skills. Lastly, these surgeon-scientists had dedicated time for research during these training or degree programs, which may not be available to full-time clinicians. While a prior study has shown that previous F award rate is higher in cardiovascular surgeon-scientists who progress from K to R grant funding relative to those who never obtain R grant funding, this was only demonstrated on univariate analysis,⁹ whilst our data shows this on multivariable analysis. This same study also showed a numerically higher rate of advanced secondary degrees in the K grant to R grant group, although this only trended toward significance.

Analysis of data relative to NIH funding agency demonstrated similar results to previous studies. Mann et al. showed that 72.9% of surgeon-scientists were funded by the NCI, NHLBI, NIAMS, NIDDK, or the NINDS.⁵ The current results show that 64.5% of K and 63.3% R grants were also funded by these same institutes. Notably, however, is the stark difference in how many K and R grants that are awarded to surgeon-scientists between the different NIH institutes. The NCI and NHLBI, the two funding agencies with the largest number of K grants over our study period, only transitioned 35.3% (18/51) and 41.4% (29/70) of awardees from K to R grants, respectively. These findings highlight the persistent challenges that exist in supporting surgeon-scientists’ academic careers, and their capacity to transition to scientific independence. It also highlights the need for continued financial investments in the surgical sciences, which aim to address more than 30% of the global disease burden.^4,5,25,26

Our study observed that institutional transition during the career development phase did not positively or negatively impact progression to R grant funding. We acknowledge that success in progressing in grant funding from K to R is multifactorial and many of these variables cannot be accounted for with review of NIH RePORTER data. It must be noted that we did not have data on NIH grant submissions declined, rather only the approved grants, meaning this value of 41.1% is not a true success rate. NIH grant submissions have been shown to be accepted at a rate of 22.5% to 27% from surgical department, lower compared to medical specialties at 26.1% to 34.1%.⁷ It must be stated that this rate of 22.5% to 27% for surgical department approval rate does not specify to the clinical status of the principle investigator (PI) or the type of NIH grant.

We acknowledge there are important limitations to our study. First, faculty gender, race, and academic rank could not be reliably collected or reported. PI gender is not a variable included in NIH RePORTER, and assumption of gender based on name or appearance of PIs on institutional faculty rosters could not be performed without introducing bias. Faculty academic rank at the time of grant receipt was not widely available in NIH RePORTER or on institutional faculty rosters. With >50% of the data variables on this missing, inclusion of this data was deemed inappropriate for our analysis. Additionally, this study only collected data on new K08, K23, R01, R21, R35, DoD, and NSF grants in order to focus on clinically focused surgeon-scientists. It is possible that a subset of the surgeon-scientists reviewed received other types of NIH grant funding or funding through other federal or non-federal organizations that are K or R grant equivalent. Of note, Veterans Administration (VA) grant award data incorporation was attempted, but was not publicly available for our full study period, and therefore could not be included in our analysis. Most notably, our study lacked the capacity to determine the motivation of surgeon-scientists who transitioned to another institution. Since the motivations for this are typically highly individualized, our study lacked the context of these institutional transitions that may have been influenced by either professional or personal motivations, or both.

Conclusions

Surgeon-scientists progression from K to R grant funding is 41.1%. A vast majority of surgeon-scientists received their K grant awards (98.9%) and R grant awards (100%) at top-tertile NIH-funded institutions. Neither the number of institutional moves nor the timing of moves impacted surgeon-scientist ability to progress from K to R grant funding, including moving institutions during the award-period of the K grant. Prior F awards and advanced secondary degrees, particularly PhD degrees, are positively associated with successful K to R grant receipt on multivariable analysis. Institutional association and formal, dedicated investigative training are critically important to success with grant award and progression to scientific independence.