A lot of clinicians are skeptical of outcomes re-
search because some of what has been published
is of lesser quality.
Certainly a lot of lower-quality outcomes research
has been published, but the bar is being raised. When
you think about studies that have affected national
policy and clinical practice, they are published in high-impact journals that are read by physicians in other
fields, payors, and policymakers. That research has to
be very high quality.
You have been doing research as an indepen-
dent investigator for nearly a decade. Have you
experienced any major obstacles or setbacks
along the way?
Every day there is a setback or challenging
moment. Trying to balance the life of a surgeon,
family member, researcher, teacher, and director
of a large group is a daily challenge. The current
funding environment is incredibly tough, to the
point where you need to be writing 10 to 20 grants
a year just to keep a research group above water.
So, I spend a great deal of my time writing grants.
This process can be interesting but at times incredibly frustrating. One of the most innovative things I
helped develop to increase live donor kidney transplantation in this country—kidney exchange—has
been developed essentially without NIH funding.
In fact, let’s take it further than that. My col-
leagues and I laugh at the irony that almost every
JAMA, NEJM, and Lancet paper we have ever writ-
ten has been unfunded, which means the most
exciting, innovating, and highest-impact work that
I have done has not been fundable, and yet, these
are the studies that are changing our field. The
projects that are fundable are focused on incre-
mental advances and somewhat “safe,” but the
ideas that will shake up our field are not incre-
mental advances. They are aimed at huge paradigm
shifts that are nearly impossible to fund, not just
because of the priorities of federal funding agen-
cies, but because of the funding timeline of at least
two years between writing a grant and getting the
money to do the work. Also, it is very dishearten-
ing that the current hospital environment judges
surgeons based on RVUs [relative value units] and
the revenue we generate for the hospital, rather
than the quality of the research or our generaliz-
able impact. It is frustrating to see my mentees
struggle to find protected time to be successful
in their own research endeavors. I would say that
every day is a challenge.
With the funding environment the way it is today,
are funding agencies being pressured to avoid
risks because they have so little money to give?
This puts pressure on the investigator to strategically ask for funds. It is such a chess game at
some level. Would you agree?
I think that even historically fundable research
has always been that which proposes incremental advances. We often say that by the time the
grant is funded, you have already completed half
the work. If I think of a really exciting idea, and
I start designing and doing the study and writing
the paper, the paper will likely be published in a
Dr. Segev multitasking
on his treadmill desk in
his home office