We have had multiple sources of funding to support the fellowship. The primary source for the academic portion of the fellowship was HRSA (Faculty Development in Primary Care: D55-HP-05164), which has provided support for our administrative infrastructure, tuition costs, and stipend fees for the majority of fellows. Some fellows have been funded using National Research Service Awards or T32 grants, and one fellow received partial support from Veterans Affairs. Fellows do some self-funding, occasionally covering some of their own tuition, paying taxes on tuition that was paid for them, and bearing the opportunity cost of receiving a fellow's versus an attending's salary. All fellows have additionally had modest clinical practice income. The department provides space and some gap coverage for faculty effort, particularly that of the department chair.
In this article, we describe outcomes for program completers during the 10 years from 1997 to 2007. We define program completers as “all faculty participants finishing the training program each year regardless of source of stipend support.”
Intensive research training
Master's degree programs.
Completion of advanced degree programs has been shown to support a career in academic medicine.12 Research-intense master's degree programs develop the skills needed to further an academic career, such as developing research protocols, writing grant proposals, and producing manuscripts.13 A major focus of our fellowship was to engage trainees in research-intensive graduate degree programs with an output of at least one published manuscript based on their thesis project. While one program completer received a master's degree in bioethics, a second fellow received a master's degree in business administration, and a third, who already had a clinical research PhD, was exempted from the requirement, the majority (12 out of 15) completed a master's of science in clinical epidemiology (MSCE). The MSCE program, administered by the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania, is a well-known entity with a strong track record of training successful clinical researchers. The MSCE program (1) provides an in-depth, working knowledge of the techniques of clinical epidemiologic research (including clinical trials, cohort and case-control studies, surveys and quasi-experimental studies, meta-analysis, analysis of large epidemiological and claims data sets, outcomes research, decision modeling, population interventions, and clinical economics), (2) provides research experience with mentors in clinical epidemiology and health services research, and (3) brings together, through participation in a seminar series in clinical epidemiology/health services research, faculty and fellows.
Fellows and core faculty meet every other week for 90 minutes to advance the fellows' research training through an interactive meeting focused on academic productivity. The seminars focus on four aspects of the fellows' research: (1) protocol development, including methodological issues regarding different research designs, development of research questions, and plans for analysis, (2) poster and podium research presentations, (3) manuscript development, and (4) grant proposal submission.
Our fellowship was structured on the philosophy that researchers in training succeed best when closely mentored. The development of mentoring relationships between faculty and fellows is a cornerstone of our program. Departmental fellowship mentoring complements any mentoring components of the fellows' master's degree programs. For example, fellows entering the MSCE program have thesis committees established with a primary mentor, a secondary clinical research mentor, and a biostatistician. Committee members come from within or outside of our family medicine department and are selected based on thesis-specific expertise. To increase the breadth of mentoring, on entry to the program, fellows identify areas of clinical and research interest. On the basis of individual interests, fellows are matched with faculty known to be outstanding mentors of junior investigators. Within the first six months of beginning their two-year program, fellows submit an individual development plan outlining short-term and long-term goals, a strategy for meeting those goals, and a plan to evaluate their progress. The plan is reviewed by the core faculty and discussed with the fellow individually by the appropriate mentor. Fellows are expected to meet with their mentors at least twice monthly, with increased frequency as the required research project is designed and carried out.
In addition to their thesis topics, fellows may design projects nested within an existing research endeavor, often one headed by their mentor. The core faculty encourage the fellows to pursue primary and/or secondary data analyses using either quantitative or qualitative methodologies. Primary and secondary data analyses are acceptable for participant protocol development and eventual thesis production.
Access to high-quality datasets is a key to jump-starting research careers by increasing the chances of producing high-quality publications and substantially reducing the time and fiscal barriers associated with primary data collection. However, fellows can select either primary data collection or secondary data analyses.
Career development curriculum
Alternating with the research seminars, fellows attend a series of seminars that address leadership skills in academic family medicine. The leadership and management skills sessions enhance the scientific components of the fellows' training and give them the tools they need to become effective academic leaders. The curriculum includes seminars, workshops, case studies, group partnering exercises, and peer coaching. Fellows are exposed to the foundations of leadership, including organizational management and change, health system administrative structure, critical and nontraditional thinking, negotiation, personnel management, time management, and budget development.
Clinical practice and practical experience as a medical educator
A root cause of health disparities in our nation is the provision of care in a culturally restrictive manner.14 To improve the health care quality and outcomes of ethnically diverse patients, we designed the clinician-educator component of our curriculum to give our fellows the skills and knowledge necessary to deliver culturally competent care to multicultural clients. Fellows conduct their clinical practice in a medically underserved area. They also interact with learners (medical students and family medicine residents) through lectures, small-group work, and one-on-one clinical precepting sessions informed by the educational techniques covered in the seminars.
Outcomes of the Fellowship Program
The outcomes we describe here cover two domains critical for the academic success of junior faculty: academic productivity and funding. For the purpose of analysis, we define academic productivity as a composite measure of manuscript publication that includes original research, scientific reviews, book chapters, and editorials published in peer-reviewed and non-peer-reviewed medical journals. We assessed funding using a composite measure of research and career development funding.
Other outcomes we considered include the clinical settings in which our fellows work (medically underserved communities/areas [MUC/MUA] versus non-MUC/MUA) and the recruitment and retention of underrepresented groups. For the latter, we used the HRSA-defined categories of educationally disadvantaged (an individual comes from an environment that has hindered him or her in obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school), ethnically underrepresented (an individual categorizes him- or herself as American Indian, Alaska Native, Asian [other than Chinese], black/African American, Hispanic/Latino, Native Hawaiian, or other Pacific Islander), and economically disadvantaged (an individual comes from a family whose parents' annual income is below levels established by HRSA).
Seventeen fellows have matriculated since 1997. Two fellows dropped out, leaving 15 program completers. Six program completers were women, and nine were men. Fellows matriculated directly from residency training with the exception of one who had been in clinical practice. Tables 2 illustrates the productivity and funding outcomes for each of the fellows.
Completion of master's programs
All program completers graduated from their master's degree programs, except for the one who had previously earned a scientific PhD and was exempted from the requirement.
All but one program completer have published peer-reviewed articles. Only one fellow had published before entering the fellowship (data not included in Table 2). To date, the cumulative manuscript-associated productivity for the 15 program completers is an average of 7.6 (range: 0–30; median: 6) peer-reviewed research manuscripts and 8.1 (range: 0–27, median: 7) non-peer-reviewed publications (book chapters, letters to the editor, editorials, and invited commentaries). Dividing by the median time since completion of the fellowship (five years) results in an average of 1.6 peer-reviewed publications and 3.4 total publications per fellow per year. Table 2 illustrates the publication productivity of the program completers.
Twelve of the 15 program completers have received research grants. Program completers have been the principal investigators on 39 funded studies and coinvestigators on 24 funded studies. Five program completers have secured funding through an NIH career development award (CDA), and nine have received other awards (e.g., National Research Service Awards or foundation funding). Of the six program completers who applied to the NIH loan repayment program, four successfully obtained support. Table 2 illustrates the grant productivity of program completers.
All program completers demonstrated commitment to improving the health of underserved or vulnerable populations through translational research. Our fellows' research has focused on reducing disparities in maternal-child health, decreasing intimate partner violence, improving treatment adherence among older persons with depression, reducing the symptom burden in older persons with cancer, reducing disparities in cancer prevention, and reducing the progression of HIV infection. All program completers provided care in MUC/MUA settings during their training, and 12 continue to practice in MUC/MUA settings. Fourteen program completers hold academic faculty positions.
Recruitment and retention of underrepresented groups
Four of our program completers came from underrepresented or disadvantaged backgrounds. One came from an economically disadvantaged background, one from a background both economically and educationally disadvantaged, and two from ethnically underrepresented groups.
We believe that our fellowship program has met its goal of developing family medicine clinical researchers who can and will conduct independent research that addresses the needs of underserved populations. It succeeded through a rigorous curriculum that includes training in research-oriented master's degree programs. Since its inception in 1997, our program has trained 15 program completers whose commitment to fixing health disparities is demonstrated in their choice of research questions (e.g., mental health, women's health, intimate partner violence, health literacy, aging, end-of-life care, and HIV care), modalities (community-based participatory action and mixed-method models), and site of practice (underserved areas). Twelve program completers still practice in medically underserved communities, with one serving as medical director at a federally qualified health center. The outcomes presented in this article show that we have a strong track record of training leaders in primary care research whose clinical efforts greatly contribute to the mitigation of health disparities nationally and globally.
Some limitations should be considered. The most prominent is generalizability. This article describes a single program developed within a resource- and research-rich institution. According to figures released by the NIH, the University of Pennsylvania's School of Medicine ranks second in the nation in terms of total research awards to academic medical schools. For fiscal year 2005, the university received 1,153 total awards, including research and training grants, worth a total of more than $470 million. The University of Pennsylvania also has an established interdisciplinary tradition and commitment to disease-related programs, as evidenced by its 43 centers and institutes and the more than $97 million in NIH-sponsored program projects. Institutes, centers, and multidisciplinary projects run extensive seminar and educational programs, as well as pilot grant support programs. And so we acknowledge the argument that our outcomes result in part from unique resources. At the very least, our outcomes strongly support the development and expansion of family medicine training opportunities in other resource- and research-rich institutions. We also believe that the fundamental model of faculty development presented in this article can be implemented in a wider variety of settings. Mainous and colleagues7 found that whereas publication productivity did not vary significantly between research-intense and non-research-intense institutions, grant productivity was higher in research-intense institutions. With additional resources directed at supporting grant productivity, faculty training programs such as ours can succeed even without our unique resources.
The training of primary care faculty has often focused on education rather than research. The training of primary care researchers is challenging on a national level.5,15,16 Internal medicine, pediatrics, and obstetrics-gynecology have larger and longer track records in NIH research than does family medicine because of the ages of their specialties and the concordance of NIH funding preferences with the subspecialty training divisions within their professions. To develop an awareness of the family medicine perspective at NIH and academic institutions, we need to draw on our discipline's strengths in training clinical researchers skilled in community-based, multidisciplinary research. Only the federal programs funded under Title VII of the Public Health Service Act are specifically designed to support family medicine training. However, in 2008, Title VII funding was dramatically reduced to about $150 million—half of what it was in fiscal year 2006, and only a small percentage of which is devoted to research training.
Other mechanisms of training primary care researchers include programs supported by foundations, such as the Robert Wood Johnson Foundation's Clinical Scholars Program. For the past 30 years, the Clinical Scholars Program has trained its fellows using mechanisms similar to ours.11 It proportions time in the same way, making 20% of the fellows' time available for clinical work and setting aside 80% for training in program development, research methods, and leadership development. It also develops trainees' skills in health care research via formal coursework, individual mentorship, and guidance in project development with a similarly defined product of a graduate-level research project. Unlike our program, however, it has the advantage of The Robert Wood Johnson Foundation's national network of scholars and mentors and assets of some $10.7 billion.17
A lot has been written about what factors make a successful faculty researcher. Clearly, individual, departmental, and institutional characteristics are all important.18 Individual characteristics that favor success include adequate exposure to and a passion for research. Access to fellowship training provides a clear advantage,19,20 as does having a definable research agenda, research networks, and several simultaneous projects available for collaboration.6 Perhaps the most important factor is simply having the time to conduct research. But unless such time is protected, it is often lost to clinical and teaching responsibilities or stymied by family medicine departments' inadequate funding. Family medicine departments with a clear research priority and strong research leadership can produce successful researchers, as measured by peer-reviewed papers and grants.19 And institutions can help by providing networks and mentors outside of the department as well as by encouraging research via promotion standards.6,18
One of the many interdependent components making up the structure of our model of faculty development—and a major one—is the quality of the relationships established between our fellows and their mentors. To build a strong core of research mentors, we aggressively recruit experienced family medicine researchers and other faculty from outside of our department (or jointly appointed with our department) for their expertise in biostatistics, epidemiology, health services, community-based participatory methodology, and medical anthropology. Our fellows' collaborative relationships with their mentors lead to academic success in their graduate programs and professional success in publications and grant applications. The fellows also learn the value of successfully competing for one's own funding and are encouraged to apply for both private and federal career development awards to support their continued development as independent researchers. Of course, this foundation for the future depends on ongoing availability of quality mentors. Our program completers have now begun filling mentorship roles for the next generation of fellows.
This model of rigorous research training and multifaceted career mentoring successfully trains family medicine clinical researchers, even in the face of limited research funds and the demanding requirements of the rank and tenure systems common at research-oriented universities. We believe it can, and should, be successfully replicated at other institutions.
This publication was supported in part by a Health Resources and Services Administration grant (D55-HP-05164) for Faculty Development in Primary Care.
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© 2009 Association of American Medical Colleges
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