Sustaining the clinical in clinical translational research.

Clinical research requires clinicians. Yet, clinicians attempting to conduct translational research are faced with intense pressures and distractions. The complexities of 21st century clinical care and those of research make success impossible for someone who dabbles in either. Historically, clinicians on medical school faculties were expected to care for patients, teach, and conduct research that led to scholarly publications and peer-reviewed grants. These last two metrics drove decisions of promotions committees and engendered respect from academic colleagues. During the latter half of the 20th century, clinicians devoted less time to patient care and turned over many of their daily duties to house officers and fellows. Inevitably, this led to a situation where medical errors were blamed, correctly or incorrectly, on full-time members of the faculty. The Libby Zion case and Medicare audits of major academic centers jolted medical schools into recognizing their responsibilities for patient care. The importance of teaching and patient care became more commonly recognized in the promotions process, but less frequently the primary determinant of a tenure decision. To accommodate this collision of cultures, medical schools developed nontenured clinical tracks for appointment and promotion. None of these adaptations, however, addressed the crux of the matter; we have not developed a cadre of well-trained, highly productive clinical/translational researchers who protect their time to succeed in what they love. The purpose of this editorial is to present concepts that may (or may not) help address this problem.