The clinician/scientist in respirology – a vanishing phenotype!

The Canadian Thoracic Society (CTS) has recently identified an urgent need to create a bold new national agenda to expand both fundamental and clinical research in respiratory diseases. An examination of the research environment makes it abundantly clear that it is time for action and, thanks to its Research Committee, the CTS is doing just that – taking decisive action in collaboration with its partners.

Several issues relating to the state of respiratory research in Canada have prompted this course of action.

A diminishing pool of clinician/scientists

Across Canadian respiratory divisions, only 51 MDs have role descriptions that permit approximately 50% time protection for research. The majority of these (29 of 51) come from the larger centres (eg, The University of Toronto [Toronto, Ontario], The Hospital for Sick Children [Toronto, Ontario] and Laval University [Sainte-Foy, Quebec]). The remaining 22 are thinly distributed among 12 academic divisions. Many well-trained, mid-career clinician/scientists no longer run active research programs.

The increasing burden of respiratory disease in Canada

Six million Canadians were diagnosed with respiratory illness in 2007 (1). Respiratory illness is responsible for 11% of all hospitalizations and 9% of all deaths in Canada (1,2). Respiratory diseases are the third most frequent cause of ‘healthy’ years of life lost to morbidity, and rank third among leading causes of death behind cancer and cardiovascular disease. Moreover, respiratory disease is the only major cause of death that continues to increase (1,2). Conservative estimates of the economic burden of respiratory disease are placed at $9 billion per year and are likely to rise to as much as $15.4 billion per year by 2020 (3).

Reputation as world leader threatened

It is widely believed that Canadian respiratory researchers ‘punch above their weight’ on the global stage. In one assessment of research productivity performed by Michalopoulos and Falagas (4), Canadian researchers ranked fourth behind western Europe, the United States and Japan, publishing a total of 2612 articles between 1995 and 2003. This compares with 19,646 articles published by the top-ranked western European respiratory researchers. While Canada has deservedly enjoyed the reputation of being a world leader in the field of respiratory research, there is deepening concern that this rarefied distinction is in danger of becoming eroded.

Significant deficiencies in manpower, infrastructure, funding opportunities and training identified by respiratory division directors

Canadian respiratory divisional directors point to significant deficiencies in manpower, infrastructure, funding opportunities and training as major barriers to sustaining or increasing research productivity within their institutions. A recent survey conducted by the CTS, which polled divisional directors across the country (n=15), revealed widespread concern about the future of the clinician/scientist, who many say is in grave danger of extinction! Recurrent themes of this survey included the following:

1. Clinically oriented respiratory research is grossly underfunded given the relatively heavy burden of lung diseases. In support of this contention, current conservative estimates suggest that only approximately 4% of all federal funding (from the Canadian Institutes of Health Research [CIHR]) is designated for respiratory research. Of this, less than 30% of the total funding flows to clinical research. Over the past decade, funding agencies have consistently favoured basic over clinical research. The overall success rate for federal (ie, CIHR) funding is approximately 17% – and even less for clinician researchers. The respiratory panel of the CIHR adjudication committee consists mainly of basic scientists, with minority or ‘symbolic’ representation of clinician researchers.

2. Few graduates of respirology training programs currently opt for careers in clinical research. Reduced training opportunities and inadequate funding were listed as common obstacles.

3. An overriding concern was the pervasive deficits in funding for health care, a national manpower shortage, and a major institutional focus on clinical and education deliverables at the expense of research promotion.

The issues outlined above constitute significant challenges; however, they are challenges that we are fully determined to address through the following initiatives:

Establishing a new Research Committee, and developing and implementing an action plan:

In 2009, a new CTS Research Committee was created under the inspirational leadership of Andrew Halayko. This committee consists of 13 elite respiratory scientists from across the country (more accurately – 12 elite scientists and one ‘economy class’ version – me!) with an expanded mandate to strategically advance the research agenda of the CTS in the coming years. After broad consultation, a research action plan has been finalized and is now in the first phase of implementation. This includes the recruitment of a new expert panel consisting of leading basic and clinician scientists who are charged with the prioritization of research questions using a fair and transparent approach (the Delphi process). Research priorities will be set in asthma, chronic obstructive pulmonary disease, sleep-disordered breathing, infectious diseases and pulmonary arterial hypertension in close collaboration with the respective CTS guidelines committees. Who better to identify the current gaps in scientific knowledge than those who have undertaken a rigorous review of the literature to create best-practice recommendations? This approach will provide the necessary horizontal integration to promote effective new translational research initiatives.

We are grateful to the Canadian Lung Association (CLA) National Office for its provision of support to this process in the person of Anne Van Dam – an experienced and effective administrator.

Building on our collaboration with the CIHR:

The CIHR have recently acknowledged the need to boost clinical/translational research in Canada (5). The CTS supports this proposal and shares the hope that this can be achieved without eroding funding for excellent fundamental research. The CTS Research Committee is in a unique position to inform and contribute to this innovative federal plan – particularly as it pertains to respiratory research. We certainly welcome the opportunity to contribute to any initiative that ultimately benefits Canadians with respiratory diseases.

Capitalizing on our continued collaboration with the CLA:

As we move forward in addressing the challenges, we will work closely with our partner – the CLA – with whom we enjoy a harmonious relationship and share the common goal of increasing funding for research. The CLA is committed to improving lung health through research and education and, since its inception, has very successfully taken a leading role in raising public awareness of the common pulmonary conditions. The provincial lung associations have launched many effective programs that have provided structured, patient-centred education on prevention and self-management of lung diseases at a grass-roots level. The CLA has contributed in a major way to the creation of the National Lung Health Framework, and has been relentless in lobbying against tobacco smoking and air pollution.

In 2008, the CLA was ranked sixth among the top 10 national fundraising charities, with annual revenues of more than $34 million. Six per cent of the total revenue in that year was spent on research. The CLA provides approximately $0.5 million per year for national fellowship and studentship awards. Of the 11 fellowship applications deemed fundable by the adjudication committee in 2009/2010, only two could be awarded. The CTS grant-in-aid competition is not, strictly speaking, national in scope but, rather, is tri-provincial: only Ontario, Alberta and British Columbia currently participate. Annually, they fund more than $1 million in grants, with the majority funding basic research. In 2007/2008, $336,939 supported clinical research, whereas $840,926 supported basic research.

The CLA executive and its CEO, along with the leadership of the provincial lung associations, will have a pivotal role to play in the national research agenda. Indeed, the success of this initiative will be substantially bolstered if CLA leaders make a firm commitment to assist in the lobbying of stakeholders to enhance funding. The CTS plans to work very closely with the CLA and encourage it to follow the lead of many of the other major national charities that have explored new, federated research funding models.

Leveraging funding:

Finally, after research priorities have been set and partnerships are in place, the next step will be to engage various stakeholders to leverage additional funding. Persuasive business cases will be constructed for each research priority to garner support from various sponsors such as federal and provincial governments, the National Lung Health Framework, the pharmaceutical industry and other funding bodies with an interest in lung health.

Many other initiatives are in the works. There is a renewed emphasis on training of young researchers and a plan to increase funding for fellowships and studentships in the immediate future. The Research Committee is also charting the topography of respiratory research across the nation. In addition, it is creating a website to enhance communication between researchers and to facilitate the creation of future research networks. We are also working on integrating more research content into the successful annual Canadian Respiratory Conference and improving communication (social and scientific) among young investigators. Likewise, the American Thoracic Society has agreed to provide a new Canadian forum (a poster session) for the exclusive purpose of highlighting Canadian research at the 2011 American Thoracic Society meeting in Denver, Colorado (USA).

Clearly, the CTS Research Committee has developed a very ambitious plan to tackle these considerable challenges; however, it will not succeed in isolation. The support of our key partners, including the CLA and CIHR, will be vital. Efforts are also underway to engage academic leaders (divisional and program directors) from across the nation. Obviously, unified support from this key group is a prerequisite for our success.

Support of the broader respiratory community, including you, is also something we count on in this most vital initiative – to establish a strong respiratory research agenda that leads to improvements in the respiratory health of all Canadians, now and for the years to come.

I look forward to your support!

Respectfully submitted,
Denis E O’Donnell MD FRCPI FRCPC
President, Canadian Thoracic Society