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I recently received the 42nd grant rejection of my academic career, bringing my overall success rate down to 10%. I was disappointed, of course, but rejection is a well-entrenched part of the academic game. It prompted me, though, to look at this game from the perspective of a surgeon who works in global health and writes grants to fund surgery research.

I asked myself three questions:

  1. How bad is a 10% success rate?
  2. Why is 10% so bad?
  3. What can be done about it?

Although the U.S. has a plethora of research funders, I focus on the National Institutes of Health (NIH) for four reasons.

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First, the NIH is the biggest funder of health-related research in the United States. Second, where it goes programmatically, a lot of other funders follow. Third, the NIH maintains a public record of all applications it gets and the ones it funds (which I use to answer Question 1). Fourth — and maybe most importantly — NIH funding is the sine qua non of success in the academic medical world.

The NIH offers a dizzying constellation of granting instruments, but of specific importance to the academic clinician is the R01. The R01 funds research projects supported by strong preliminary data for up to five years. Because its focus is, in the words of the NIH, on funding “mature” research, being awarded one signals that the recipient’s research career is established. Career advancement in academic medical centers is contingent on securing one or more R01s. Other grants are nice, but they simply cannot answer the fundamental question any department chair wants to know: Is this person fundable? Can she or he be trusted to bring grant funding into the medical center?

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When I was on the job market a few years ago and interviewers would ask, single eyebrow properly arched, about my NIH track record, what they really wanted to know was “Why don’t you have an R01?”

Question 1: How bad is a 10% success rate for surgery research funding?

In 2020, the NIH awarded 6,297 R01s out of the 32,339 submissions it received, or 19.5%. This makes my 10% success rate look pretty bad. But my rate doesn’t tell the whole story, since it is across all the grants I’ve ever written, most of which weren’t to the NIH.

My funding average is horrendous if I look at only those that went to the NIH. Of those 14 applications, not one of them was funded. For the record, not all of these were for R01s.

What’s going on?

Question 2: Why is 10% so bad?

It is distinctly possible that I’m a terrible scientist who is incapable of scientific reasoning, persuasive writing, or asking interesting questions. Maybe I’ve failed at nabbing an R01 because I don’t deserve one.

But there’s another possibility, one that may have to do with the way the NIH is structured.

Composed of 21 separate institutes and six centers, the NIH isn’t a monolith. It contains massive institutes like the National Cancer Institute and the National Heart, Lung, and Blood Institute. These two alone operate on a combined an annual budget of more than $10 billion —one-quarter of the entire enterprise. It also contains well-known institutes like the National Institute of Allergy and Infectious Disease, led by Dr. Anthony Fauci, with an annual budget of $6 billion.

Yet of these 27 institutes and centers, not one focuses on surgery.

Surgical issues come up sporadically, to be sure. The National Institute of General Medical Science, for example, funds injury and critical care. The National Cancer Institute has expressed interest in cancer surgery, and, alongside the National Institute of Minority Health and Health Disparity (the fourth-least funded institute at $390 million) publishes the only opportunity in the NIH to study surgical disparities.

And that’s it. Barring the odd sentence here and there, surgery essentially doesn’t figure in the NIH’s plan.

The same holds for global health. Bringing up the funding rear is the NIH’s smallest center: the Fogarty International Center (annual budget: $84 million). Fogarty — the single NIH entity actually devoted to global health — has a budget one one-hundredth the size of the National Cancer Institute and National Heart, Lung, and Blood Institute. To put it a different way, out of its total funding, the NIH devotes two cents of every $10 to global health.

Structure is destiny. So far in 2021, the NIH has funded about 1,500 R01s at a cost of almost $750 million. Of these, only 40 — totaling about $22 million — have an explicit focus on surgical delivery, surgical outcomes, or surgical disparities. And only one of them even mentions patients outside of the U.S.

Three percent of R01 funding is dedicated to surgery; 0.2% of the overall NIH budget is earmarked for global health; and 0.09% of what the NIH funds even remotely affects people outside our borders. Three percent might sound like a lot. It isn’t.

When I was in training, my senior resident used to joke: When a psychiatrist wants to hold the elevator doors open, he uses his hands. After all, he’ll never need those. When a surgeon wants to hold the elevator doors open, she uses her head.

Surgeons, the implication is, are basically motor neurons wrapped in hubris and a white coat. Surgical research, by extension, isn’t true research and it definitely isn’t good science.

But which is the chicken and which the egg? If 3% of R01 funding goes to surgery, what choice does a newly minted surgeon have but to remain focused on doing surgery instead of research. How else are careers established, medical school debts paid, and kids sent to college? This setup poses a massive problem for any surgeon who wants to make a career out of research. Unless she develops a novel fluorescent marker or can add a hydroxyl group to an opioid, she’s basically sunk.

And heaven help her if she cares about global surgery, and wants to do something about the farmer in rural Madagascar who’s had a tumor on the left side of his face for 30 years, or the young girl in Malawi born with a club foot, or the Tanzanian boy whose guts are spilling out of his belly because his abdominal wall didn’t form while he was in utero.

She’s got nowhere to turn to advance her academic career. Other funders may help pay for small research projects, but those won’t do much for her career. Structure is destiny.

Question 3: What can be done about it?

After this most recent grant rejection, I took to Twitter to ask my colleagues if anyone knew of a person working in global surgery who had been successful in getting an R01. They didn’t. While it’s possible that I’m a bad scientist, I know the rest of my colleagues in the global surgery space aren’t.

So what can be done about this state of affairs?

One possible answer, of course, is, “Nothing.” After all, devoting 3% of funding toward surgery would be appropriate if that accurately reflected the burden of disease amenable to surgical care.

But it doesn’t.

Several colleagues and I have estimated that about 30% of the world’s disease burden requires management by surgery at some point. Clearly, 30% is not 3%. Globally, someone dies of a surgical disease every two seconds. More than 95% of people living in sub-Saharan Africa cannot access surgery when they need it.

In short, funding for surgical disease doesn’t match its burden.

This is unconscionable. Nearly 17 million people die of surgical diseases a year, and we have no academically viable way to understand or fix this. In fact, the NIH funnels more money every year into a center actively awarding grants for music therapy, phytochemicals, green light therapy, breathing techniques, yoga, and tai chi than it does into surgery.

It’s time for the NIH to put its money where the disease burden is. It’s time for a National Institute of Surgery.

Mark G. Shrime is the chair of global surgery at the Royal College of Surgeons in Ireland, a lecturer in global health and social medicine at Harvard Medical School, and author of the forthcoming book, “Solving for Why: A Surgeon’s Journey to Discover the Transformative Power of Purpose” (Twelve/Hachette, January 2022).

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