Discussion: Trends and Predictors of National Institutes of Health Funding to Plastic Surgery Residency Programs

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Over the past two decades, there has been a dramatic decrease in federal support for medical research, with a concomitant rise in competition for grants from the National Institutes of Health. Silvestre et al. analyzed National Institutes of Health funding in plastic surgery research and identified institutional factors associated with grant acquisition.1 These authors examined National Institutes of Health grants awarded over a 9-year period and compared plastic surgery to other surgical specialties. Their findings suggest that, per capita, plastic surgeons receive the least National Institutes of Health funding of all the specialties evaluated. Programs with stronger academic reputations, as assessed by Doximity and U.S. News ranking, and more than 10 full-time faculty were more likely to obtain National Institutes of Health funding.
Financial challenges to academic centers include declining clinical revenues, capricious third-party payment structures, and a paucity of extramural support. Historically, academic centers used external funding as a source of income to offset revenue losses from researchers who did not have robust clinical practices. Contemporary academic programs, in contrast, are not significantly different than nonacademic practices, where clinical revenue dictates financial solvency. In this context, academic surgeons are often forced to choose between a busy clinical practice and a funded-research enterprise.
All plastic surgeons are impacted by these challenges, regardless of practice type. Research contributions from academic plastic surgeons shape treatment paradigms, improve patient outcomes, and keep our specialty competitive in an environment where non–plastic surgeon providers are expanding scopes of practice. Silvestre et al. have highlighted an important discrepancy in the state of federal funding for plastic surgery research and taken a critical step toward addressing this issue by identifying institutional factors associated with grant acquisition. Their work should serve as a catalyst for discussion among all stakeholders in the specialty.
As with many novel studies, this work raises as many questions as it answers. With no data available on the number of applications submitted, it is difficult to definitively state that certain programs were more successful without knowing how many unsuccessful applications there were.
Academic reputation and faculty size were identified as primary predictors of success. Although it is plausible that these factors influence successful grant acquisition, grants are allocated to individuals, and surgeon-specific factors are likely more important.2 The anecdotal evidence provided in the authors’ discussion includes such individual faculty characteristics: a doctoral degree in molecular biology, Academic Scholar Award, and individual interest in obtaining funding. These factors are undeniably important drivers of success.
The institution-level measures included, although important, are useful in only a limited context. Academic reputation is largely subjective and may not be a meaningful metric for an aspiring investigator, because junior faculty rarely have more than a few choices for their first job. Larger programs may have a higher probability of having senior faculty who can successfully mentor junior faculty with regard to grant funding. However, programs that want to have funded investigators cannot achieve this goal simply by hiring additional faculty. Over 50 percent of National Institutes of Health funding in plastic surgery research went to three programs; although these programs are known for their clinical excellence, they also house well-known plastic surgeon-scientists. An alternative interpretation of these data is that grant funding is related to an individual investigator’s reputation, rather than an institutional reputation; and to the total number of primary investigators (i.e., the ratio of number of grants to number of principal investigators), rather than the total number of faculty.

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