What motivates clinicians to do research?

One of the reasons I am writing this blog is to organise my thoughts as I prepare a set of talks for radiology trainees in South Australia, with the goal of demystifying and promoting research. One of the first talks I am planning is a question that doesn’t get considered much among doctors – why would you do research?

The reason this is rarely discussed is that most of the time the answer is simple; research is a requirement of training or practice. But what is it that changes someone from that to a self-motivated researcher?

This is an especially important question in radiology because there is no extrinsic motivation to do research once a fellowship is obtained. Post-fellowship, CME (continuing medical education) credits are generously offered for research activities, but this is a non-factor when the points are easily obtained by less onerous means.

And we aren’t just comparing research to other CME activities. We have to be up front about it, serious research is a big commitment. It sucks up time and energy that you may prefer to spend on other things. So to be fair to prospective researchers we must compare research with their non-medical hobbies and interests.

My experience is that post-fellowship radiologists split their time in several ways:

  • about 60% of radiologist time is spent on non-medical interests and hobbies. Travelling, food and wine appreciation and various sports and fitness activities seem popular.
  • 20% or so spend a significant portion of their time becoming an expert in a subfield of radiology. Maybe another 5% devote much of their life to this, and become truly impressive in their area of knowledge.
  • another 10% develop non-medical expertise. They take courses in management/business, history, cooking, art, and many other things.
  • the remaining few percent goes into research activities.

Maybe it is obvious to most readers why a radiologist who spends all day sitting in a dark room might prefer spending time outdoors when they get home instead of working on a research paper, but it is harder to explain why there is such an imbalance between research and developing expertise. These seem like similar tasks and probably have similar motivations.

Everyone is motivated by different things, and has different values. Some work for money or prestige, some for a fulfilling challenge, some for the human interaction. But when I think back to interviewing for medical school, most of us said it was helping other people that led us to medicine. Even if we didn’t know it at the time there are better ways to make money, other jobs are as challenging, and doctors and patients aren’t always the most social bunch. The unique aspect of medicine is that we affect people’s lives more directly than most other professions can. Or so it seems. More on that in a minute.

If helping people still drives doctors later in their careers, we have a clear reason to do research. Medical research is responsible for all of modern clinical medicine, all the lives saved, disabilities managed or averted, symptoms controlled. So why is there a disconnect, and it remains a minority of doctors who pursue significant research agendas?

The disconnect, I think, is that most people haven’t thought through what helping people actually looks like. I would argue that really improving other people’s lives is almost impossible for non-researchers. Since we have just noted that most doctors enter the field wanting to help people, that last statement might need some explaining.

We can frame this as a maths problem – how much good can you do? This question is surprisingly complex, and we have to turn to economic theory to understand the answer. The back-of-the-napkin calculation goes like this:

A clinical radiologist in a developed country might see a few hundred thousand films in a lifetime, maybe a million if they push. What percentage had important findings? What percentage of those would have been missed by any other radiologist? What percentage of those would have caused harm. Take this number and subtract how many harmful findings you will miss that someone else might have detected.

That is your marginal impact, the amount of human benefit that you personally add beyond the baseline radiologist who would otherwise be doing your job.

In a million studies, I might find a few thousand serious things that could have been missed. I will also miss a similar number of things that other radiologists might have detected. Even if we are generous, my marginal impact to patients over my entire career might be less than a thousand important findings, most of which would have been later detected by other tests when symptoms persisted.

A little bit depressing, right? In actual impact, doctors might not be any better at helping people than anyone else. If we truly care about helping people, there may be much more effective ways. Researchers have explored this topic in depth, if you want to read a good summary of the research “How much good do doctors do?” is a great place to start. There are definitely some questionable assumptions in this research (like any economic modelling), but taken at face value the point is pretty clear.

If you do important research, your marginal impact can be massive.

Let’s give a concrete example. My area of interest is medical informatics. I want to use computers to make radiologists more accurate and more productive. Lets imagine a diagnostic aid system that improves the sensitivity and specificity of mammography reading by a few percent, a small and achievable gain. Let’s do that same napkin maths:

Every year in my state, over a hundred thousand women are screened. The stats show that 15% of cancers are missed at the initial screening, and just under 10% of benign lesions are thought to be cancer. Over 90% of positive screening mammogram reports end up not being cancer, but many of these healthy women end up with harmful biopsies and even surgery.

We bump those numbers in the right direction by a few percent, and we might see thousands of less ultrasounds per year, several hundred less biopsies, a few dozen less surgeries. We might even see a small but noticeable reduction in cancer mortality, maybe one or two women per year surviving longer. And that is in one state, across the world we would multiply those numbers hundreds of times over. The cost saving and the reduction in harm would be more than a single radiologist could ever achieve.

Lets be conservative and say I was responsible for 10% of that research. Lets go even further and say that it was an idea whose time had come, that another research team will achieved better results one year later. Even then my marginal impact, 10% of 12 months of a slightly better system, would completely dominate the impact of my entire clinical career.

This is why research is so impactful. Research is generalisable. What affects one patient can affect all patients, and it is a big world. There are a lot of patients.

Research is also incremental – my above mammography system would have informed the research that improved upon it, another positive not accounted for on my scribble covered napkin. New problems can be solved because of past research, just like electricity lead us to the computer.

Which is all just a long-winded way of explaining my motivation to do research. I would say I want to make the world a better place, but Silicon Valley has forever ruined the phrase. But I do want to make a difference, so here I am.

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