Neonatology research for the 21st century: executive summary of the National Institute of Child Health and Human DevelopmentAmerican Academy of Pediatrics workshop. Part II: training issues
Ronald L. Ariagno
ABBREVIATIONS. NICHD, National Institute of Child Health and Human Development; AAP, American Academy of Pediatrics; URM, underrepresented minority; ABP, American Board of Pediatrics; NIH, National Institutes of Health.
In 2004, the National Institute of Child Health and Human Development (NICHD) and the Section on Perinatal Pediatrics of the American Academy of Pediatrics (AAP) organized a workshop to address basic and translational research issues in neonatalperinatal medicine. The objectives of the workshop were to identify knowledge gaps and propose research agendas to rectify them. The speakers also addressed physician-scientist workforce issues, especially concerning the shortage of the underrepresented minority (URM) groups in academic careers, and suggested methods to overcome such barriers. The long-term goal of the workshop was for the suggestions to help the scientific community, policy makers, and funding agencies to formulate future research and educational agendas.
CHANGES IN NEONATAL-PERINATAL SUBSPECIALTY CERTIFICATION REQUIREMENTS
In February 2001, the American Board of Pediatrics (ABP) began an extensive review of the duration, design, and content of fellowship training, with wide-ranging inputs from individuals and organizations having an interest in graduate medical education in the subspecialties of pediatrics. The changes developed in the subspecialty training requirements and approved by the ABP were designed to recognize the diverse roles that subspecialists play, to allow greater flexibility in the design of fellowship training, and to place greater emphasis on the evaluation of fellow training at the local levels. These requirements will apply to all candidates enrolling on or after July 1, 2004. (1)
The ABP will continue to require 3 years of training in the standard fellowship and has not approved a clinical-only pathway. It also endorses the goal of using fellowship training as the cornerstone for developing future academic pediatricians. Therefore, the ABP will continue to require scholarly activity during fellowship but has modified the requirements to accommodate a wider variety of academic activities.
The scholarly work must be a mentored research activity and must lead to the generation of a specific “work product.” Furthermore, the ABP asks for the creation of a thesis-like oversight committee at the local institutional level for mentoring and evaluation of the fellows. Such a committee has the responsibility for ongoing assessment of the progress and evaluation of fellows’ scholarly accomplishments. Other details, including the nature of the “work product,” can be found on the ABP Web site. (1)
CURRENT DATA ON NEONATOLOGY FELLOWSHIP TRAINING
In 2002, the Subcommittee on Research of the AAP Section on Perinatal Pediatrics conducted a survey of 100 program directors of US neonatology fellowships. Responses were obtained from 84 program directors (R.L.A., unpublished data). Of 84 programs, 34 (40%) offered 1 to 5 fellowship positions annually, 28 (33%) offered 5 to 9 positions, and 22 (26%) offered [greater than or equal to] 10 positions; 82 (98%) had an approved maternal fetal medicine program.
On average, the fellows spent 20 months in research over the 3-year training period, of which 4 months were “uninterrupted research times” in most programs. Ten (12%) programs offered >6 months of uninterrupted research time. Among the 82 programs responding to questions on mentoring, 610 mentors were identified; 410 (67%) were trained neonatologists and 200 (33%) were nonneonatologists. Overall, the percentage of mentors with federal funding for research was higher for non-neonatology mentors (79% vs 50%).
Over the 3 years covering the survey period, there were 569 fellows who graduated from the programs surveyed. Of these fellows, 192 (34%) chose academic career paths, 119 (24%) opted clinical faculty positions, 35% went into private practice, and 38 (7%) made other, unspecified career choices. Many program directors felt that candidates who initially chose academic careers tended to drop off from academia. The program directors identified lack of funding, insufficient time, inadequate resources, and a shortage of faculty with skills as limiting factors for research training of neonatology fellows and as barriers for multidisciplinary and multiinstitutional collaborations.
Although a handful of reports evaluated the factors influencing career decisions by medical graduates and pediatric residents, (2-4) no studies have attempted to determine such factors affecting decisions by graduating neonatology fellows. In an informal survey of a small sample of such graduates, factors affecting career-path decisions were assessed (A. Penn, MD, verbal communication, 2004). Some of these factors were differential earning potentials between academia and private practice, lack of adequate training in research methods, and the nature of jobs offered by academic institutions. Graduates felt that nontenured, nonfaculty jobs in academic institutions tended to be focused on clinical work and were a deterrent for academic careers. The candidates felt that such clinical jobs precluded them from applying for federal funding for research due to the emphasis on commitment to clinical service time. Theoretically, these candidates would be eligible for National Institutes of Health (NIH) funding if supported by the academic institution. Employees from biomedical organizations can apply for federal funding, provided they possess qualifications to conduct the specified research and meet requirements described for specific funding types. (5,6) All federal agencies describe their funding programs and the eligibility criteria on their Web sites, as do nongovernmental funding organizations in their respective electronic pages.
SPECIAL TRAINING NEEDS IN RESEARCH METHODOLOGY
A group of subspecialist clinicians should be trained to direct and translate research advances in molecular and genomic research into new neonatal treatments. Such training ought to be structured as multilevel, interdisciplinary, collaborative research strategy. Also, in recent years, most neonatal faculty in academic institutions are finding it increasingly difficult to keep up with the burdens of clinical care, research, and teaching. There is now a great demand for direct, senior-level supervision of patient care because of hospital policies and third-party provider issues. Even the atmosphere for clinical research has become increasing complex and time consuming, in part because of a need to meet the regulatory requirements. Thus, each department develops innovative strategies to balance these opposing forces that take away faculty time that could be used to mentoring fellows in training and guiding them in research.
The availability of an accessible, population-based, high-quality database is as essential for research in epidemiology as is a basic science laboratory for animal experimental research. Such databases can be developed as collaborative efforts among regional perinatal centers for projects by the trainees. Furthermore, to make the best use of such databases, residency and fellowship training programs should enhance the quality of training in epidemiologic and health services research methods. The trainees may be encouraged to study and obtain masters degrees in these subjects.
DEVELOPING RESEARCH SCIENTISTS
To succeed in academic research, one needs “protected” research time. In addition, technical and administrative infrastructures are required, along with start-up funding and high-quality mentors and collaborators. In some Scandinavian countries, this has been made possible by requiring an MD degree before PhD training and by supporting clinical and basic science research in institutions that heavily favor translational research, such as the Karolinska Institute in Sweden.
Many experts indicated that promoting interest in science and scientific research ought to be initiated from very early in one’s educational career, possibly from the high-school level. At least from a practical point of view, such promotions ought to be initiated in the premedical courses and continued through medical colleges, residencies, and fellowships. Excellence in research by medical students, residents, and fellows also needs to be recognized through established awards system.
The average debt burden of medical college graduates rose by 5.4% in 2003. Approximately 58% of students had outstanding educational debt up to $100 000, with 25.4% reporting more than $150 000 in debt. This factor alone can greatly influence one’s career choices, particularly given the great disparity between the salaries of academic physicians and those in private practice. A concerted effort should be made to overcome this influence, including altering the eligibility criteria for the existing “education loan-forgiveness programs” and educational loan-repayment grant-support mechanisms supported by the NIH.
Medical student education should include training in hypothesis-driven clinical research. Summer research fellowships should be offered to enhance interest in academic research careers. Quality and excellence in research by medical students should be recognized through awards that confer prestige. Creation of small grants exclusively for medical student research might enhance grant-writing experience.
Residency training programs should incorporate curriculums on research methodologies and clinical trials designs. Residents should be encouraged to collaborate with established scientists and participate in ongoing clinical trials at their institutions. A system of awards and recognition for excellence in resident research should be incorporated as an effective motivational tool. A greater collaboration between residency programs and professional societies could help strengthen research opportunities for residents. By attempting to match the salaries of fellows with those of the junior faculty, more residents might opt for academic careers.
Expanded funding mechanisms ought to be developed to support new clinical research programs for the junior faculty. Such funding should prioritize translational clinical research and could be strengthened by special systems of review mechanisms. Governmental agencies, research institutions, and professional societies should develop workshops focusing on research methodology, academic careers, and research opportunities, as has been done by the National Institute of Neurologic Diseases and Stroke, the Child Neurologic Society, and the NICHD-Aspen Conference in collaboration with the University of Colorado.
The availability of time for maintaining clinical competence and research remains a great obstacle for the midcareer faculty member to remain in academia. Many institutions discourage midcareer faculty from investing time in research, particularly when their research time is not fully reimbursed. To retain academic faculty and facilitate mentorship of junior faculty, the parent institution and the funding agencies must make greater investments in support of midcareer faculty.
Clinical research grants ought to allow greater allocations for administrative support to handle research-related and patient-related paperwork. Innovative review mechanisms need to be considered for research applications from midcareer clinical faculty, giving priority to multidisciplinary research. Salary support for research time should be superior, or at least equal, to those earned by practicing physicians.
Awards can be instituted to recognize excellence in clinical research. Research funding targeted to attract PhD students to work on clinical projects might attract more qualified scientists into these fields.
Role of Senior Faculty
The senior faculty should serve as mentors for the junior faculty and support clinical research by providing access to established patient populations and large databases or serving as coinvestigators on clinical research projects. For the late-career clinical faculty, new funding mechanisms may be needed to support clinical research sabbaticals for senior faculty. Career-enrichment awards are needed for highly experienced clinicians wishing to gain new research skills.
URM PHYSICIAN-SCIENTIST ISSUES
A URM is defined as the racial and ethnic group represented in smaller proportions in academic fields relative to its proportion in the general population. With nearly one third of its population belonging to smaller ethnic groups, the United States is one of the most ethnically diverse countries in the world. (7) It is estimated that by the mid-21st century, minority groups will exceed 50% of the US population.
Unfortunately, the burden of disease remains very high in the US minority populations. The frequency of diabetes, hypertension, cancer, asthma, and disorders in mothers and their infants in the perinatal periods are considerable higher among the Native American Indian, black, and Hispanic/Latino populations, (8,9) yet only 3.4% of medical school enrollees are Hispanic, and among all medical school faculty, only 4.9% is represented by the URM ethnicities. (9-14) Studies also show that the frequency of URMs graduating from college certificate programs has remained low at 13%, and the frequency of obtaining PhD degrees is at 7%. URM faculty in medical schools are also less likely to be promoted into higher academic ranks.
Besides fairness and equity, there are other reasons to rectify the shortage of URM ethnic groups in academic medical careers. URM faculty are more likely to address minority health issues, conduct research to rectify health disparity, and serve the underserved patients in large urban areas. (10,11) They will be important role models for future students and provide a diverse perspective, enriching the growth of the institution.
Approximately 12.5% of the US population is of Hispanic origin (12.5%), and >20% of them live in the southwestern states. (7) One must also note that not all “Hispanic” people are the same: “Hispanic” or “Latino” could mean that the person is Mexican, Puerto Rican, Cuban, or South or Central American or is from other Spanish cultures, regardless of race, each of which has a diverse set of cultural beliefs, traditions, shared values, and religious and linguistic backgrounds. The Hispanic/Latino communities possess distinct cultural empathy among themselves. Studies have shown that Hispanic scientists are more likely to succeed in recruiting research subjects from the Latino communities than other scientists.
Factors Leading to Lack of URM Role Models
The paucity of URM groups entering medical schools in general, and the rarity of those entering academic medicine in particular, remain the main reasons for a URM shortage in academic ranks. These related deficiencies further hamper successful networking opportunities among themselves and in helping URM students and residents. Mentors from different backgrounds might not have common cultural experiences, which hinders the establishment of proper rapport and lines of communication. These differences may also lead to incorrect assumptions and subtle or overt discrimination and prejudice. (12) The URM candidates is often faced with the dilemma of wanting to serve their community while maintaining their workload and demand to serve on a multitude of institutional committees. (13,14)
Often hailing from less affluent families, URM graduates tend to face additional pressures to begin practice and earn soon after graduation. (12) Although an increasing number of URM physicians have chosen pediatric residencies, (12) a larger proportion are burdened by educational loans. The debt burden was reported by 48% of non-URM medical school graduates, compared with 75% of URMs graduates. (12)
Most institutional doctrines extol the virtue of cultural diversity but do not foresee the difficulties of attaining and maintaining such diversity. Ethnic and racial stereotyping may lead to misunderstanding, alienation, and workplace insecurity. Subtle or overt differences in one’s social conduct, including demeanor, might be misinterpreted because of a lack of cultural awareness. Often URM health care workers feel that their performances are scrutinized with greater vigilance and their errors are exaggerated.
The URM trainees should be encouraged to utilize a number of available opportunities for developing contacts with peers and future mentors at national and regional meetings, such as those of the National Medical Association, the AAP, and the Pediatric Academic Societies. The process of mentoring is complex and is “a dance for 2.” Mentors provide leadership and guidance, but they should also provide prospective counseling, education, and monitoring of career progress and facilitate participation at meetings. A seasoned mentor also facilitates the growth of the trainees by introducing them to prospective collaborators and employers.
Academicians should also attempt to educate the URM trainees in the value and rewards of being in academic careers, including intellectual challenge, the pleasure of sharing research findings and ideas, training students and junior faculty, and personal and intellectual gratification from contributions to science. Financial incentives should be given to mentors who train URM candidates and fellows. The incentive could be in the form of supplements to existing grants or credits for the time spent on mentoring activities. Such efforts should be organized in collaboration with the granting agency and the grantee institution.
Popularizing the existing NIH grant programs should be an initial step (Table 1). Students in the earliest periods of their training (high school and college) should be educated about such programs. (6,7)
SUMMARY AND CONCLUSIONS
Future advances in neonatal-perinatal medicine hinge on proper planning for developing trained researchers and workforce for the 21st century. Medical school, residency, and fellowship training programs should incorporate exciting advances in research methodologies as part of the curricula. Attempts also should be made to develop innovative strategies to enhance the high-quality physician-scientist pool in academic medicine. Along the same lines, promoting ethnic, racial, and gender diversity in clinical research and academic careers will help address many of the existing gaps in social justice and health disparities. Such efforts also help to attain higher representation of our multicultural, multiethnic, heterogeneous society in areas such as health, education, safety, quality of life, and employment.
TABLE 1. Examples of Some Federal Research Support Programs
Grant/Award Mechanisms Descriptions
Minority research The Minority Access to Research Careers
opportunities program administered by the
National Institute for
General Medical Science awards research
grants to help increase the number and
capabilities of minority biomedical
research scientists; the programs
include (1) honors undergraduate
research training grants, (2)
predoctoral fellowships, (3) faculty
fellowships, and (4) visiting-scientist
Minority supplements to Supplements to existing grant awards are
existing programs available to support minority
scientists collaborate in the same
area of research as the parent grant
Career-reentry grant Available to facilitate reentry into
supplements academic career for scientists who had
to interrupt their career paths for
family reasons; these grants are
awarded as supplements to existing
Centers of Excellence grant Many instates of the NIH offer a variety
types of the NIH of institutional awards for research
in a wide variety of diverse fields
ranging from stem-cell research to
health services research and from
Parkinson’s disease to research in
alternative and complementary medicine
Loan-repayment programs Two-year commitment to a research career
is needed to receive the loan-repayment
program administered by several NIH
institutes and centers; the award will
repay up to $35 000/y of qualified
repayable educational debt, a portion
of federal taxes, and components of
Clinical research For patient-oriented research or
research on the causes and consequences
of disease in human populations
Pediatric research For research directly related to
diseases, disorders, and other
conditions in children
Health disparities research To support research related to topics in
health disparities; at least 50% of the
time commitment is needed for 2 years
For individuals of An individual of “disadvantaged
disadvantaged backgrounds background” is defined according to the
low family-income levels set by the US
Bureau of the Census
Contraception and The long-range objective of this research
infertility research support is to promote investigations
that evaluate, treat, or ameliorate
conditions resulting from failure of
couples to either conceive or bear
young and for research that leads to
new or improved methods of preventing
* For more information, see ref 6.
The following is an alphabetical list of speakers at the workshop: Duane Alexander, MD (NICHD, Bethesda, MD); Ronald L. Ariagno, MD (Stanford University School of Medicine, Stanford, CA); Phyllis Dennery, MD (University of Pennsylvania, Philadelphia, PA); JoAnne Goodnight, PhD (NIH, Bethesda, MD); Jeffrey B. Gould, MD (Stanford University School of Medicine, Stanford, CA); William W. Hay, Jr., MD (University of Colorado, Denver, CO); Rosemary Higgins, MD (NICHD, Bethesda, MD); Alan H. lobe, MD, PhD (University of Cincinnati, Cincinnati, OH); Steven Klein, PhD (NICHD, Bethesda, MD); Gall A. McGuinness, MD (American Board of Pediatrics, Chapel Hill, NC); Josef Neu, MD (University of Florida, Gainesville, FL); William Pearce, PhD (Lorna Linda University School of Medicine, Lorna Linda, CA); Anna Penn, MD, PhD (Stanford University School of Medicine, Palo Alto, CA); Tonse N. K. Raju, MD (NICHD, Bethesda, MD); Catherine Y. Spong, MD (NICHD, Bethesda, MD); Marta Valcarcel, MD (University of Puerto Rico School of Medicine, San Juan, Puerto Rico); Linda Van Matter, MD, MPH (Children’s Hospital Boston, Boston, MA); and Robert M. Ward, MD (University of Utah, Salt Lake City, UT). The meeting agenda and the names of all registered participants will be published on the NICHD Web page (www.nichd.nih.gov).
(1.) American Board of Pediatrics. Changes in training requirements for subspecialty certification. Available at: www.abp.org/ahpfr1024.htm. Accessed December 9, 2004
(2.) Zweifler J, Gonzalez AM. Teaching residents to care for culturally diverse populations. Acad Med. 1998;73:1056-1061
(3.) Cull WL, Yudkowsky BK, Shipman SA, Pan RJ. Pediatric training and job market trends: results from the American Academy of Pediatrics third-year resident survey, 1997 2002. Pediatrics. 2003;112:787-792
(4.) American Academy of Pediatrics, Division of Health Policy Research. Executive summary: periodic survey of fellows 43. Available at: www.aap.org/research/periodicsurvey/ps43aexs.htm. Accessed December 9, 2004
(5.) National Institutes of Health. Grants and funding opportunities. Available at: http://grants1.nih.gov/grants. Accessed December 9, 2004
(6.) National institute of Child Health and Human Development. Funding by NICHD. Available at: www.nichd.nih.gov/funding/funding.htm. Accessed December 9, 2004
(7.) US Census Bureau. Index of Census 2000. Available at: www.census.gov/census2000. Accessed December 9, 2(104
(8.) Cohen JJ. Disparities in health care: an overview. Acad Emerg Med. 2003;10:1155-1160
(9.) Leslie JC, Galvin SL, Diebl SJ, Bennett TA, Buescller PA. Infant mortality, low birth weight, and prematurity among Hispanic, white, and African American women in North Carolina. Am J Obstet Gynecol. 2003;188:1238-1240
(10.) Stoddard JJ, Back MR, Brotherton SE. The respective racial and ethnic diversity of US pediatricians and American children. Pediatrics. 2000; 105:27-31
(11.) Olson K. Data brief: despite increases, women and minorities still underrepresented in undergraduate and graduate S&E education. Available at: www.nsf.gnv/sbe/srs/databrf/sdb99320.htm. Accessed December 9, 2004
(12.) Colbum L, Zhang K, Tidlen E, Terell E. Minority students in medical education: facts and figures Xll. Available at: https://services.aamc. org/Publications. Accessed December 10, 2004
(13.) Wilson DE, Balofin J. Has the well run dry? Priming the diversity pump in PbD programs. J Assoc Acad Minor Phys. 1999;10:27-33
(14.) Reede JY. A recurring theme: the need for minority physicians. Health Aff (Millwood). 2003;22:91-93
Ronald L. Ariagno, MD *; Linda J. Van Marter, MD, MPH ([double dagger]); Rosemary Higgins, MD ([section]); and Tonse N.K. Raju, MD[section]
From the * Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California; ([double dagger]) Children’s Hospital of Boston and Harvard Medical School, Boston, Massachusetts; and Pregnancy and Perinatology Branch, Center for Developmental Biology and Perinatal Medicine, National Institute of Child Health and Human Development, Bethesda, Maryland.
Accepted for publication Nov 23, 2004.
No conflict of interest declared.
Reprint requests to (T.N.K.R.) National Institute of Child Health and Human Development, 6100 Executive Blvd, Room 4B03, Bethesda, MD 20892.
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