According to Boswell,1 Samuel Johnson's famous words about impending doom were, “Depend upon it, sir, when a man knows he is to be hanged in a fortnight, it concentrates his mind wonderfully.” Although Johnson's exact words are in some dispute, their implication is clear. Staring into the eyes of disaster focuses one's thinking. In his article in this issue, Rivkees2 sees a future for pediatrics as imperiled as Johnson's man facing the gallows, and he offers us some achievable solutions to maintain and even expand the important roles of pediatric research, pediatric physician–scientists, and, more broadly, academic pediatrics. However, to grapple effectively with both the problem and the potential solutions, we first need to agree on contemporary definitions of the key terms used in this discussion, a task that may be more contentious than it appears but one that is necessary to advance the conversation begun by Rivkees.
Enlarging the Research World
First, we must agree that biomedical research is more than basic science and that, as a corollary, physician–scientists may be productively engaged in basic, translational, clinical, and even educational research. All of these can and should be areas of rigorous scientific exploration that expand the value of medicine at the levels of discovery and application. If we accept this principle, then the next key goal is to align trainees with the scientific fields to which they bring both enthusiasm and skills.
With this in mind, we can debate Rivkees' contention that the pipeline is, in fact, a problem and, if so, determine at what level the problem occurs. Data from the American Board of Pediatrics show that the number of pediatric residents choosing subspecialty training has been rising for the last eight years or so.3 Many subspecialty fellowship programs have expanded their research opportunities to include rigorous training in clinical and translational research. At the University of Pennsylvania (Penn) School of Medicine, such offerings include masters degrees in clinical epidemiology, translational medicine, and public health, among others. Arguably, we are producing much better trained investigators in these areas than we did in the past. Previously, we assumed that clinical research in particular was learned by performing a project with the IRB rules in one hand and a primer on statistics in the other hand. However, most trainees who choose clinical and translational research paths today have the same “fire in the belly” that is usually associated with successful basic science investigators. Rigorous clinical and translational research contributes important findings to the literature and should be encouraged. Including these areas in national programs, such as the Pediatric Scientist Development Program, is not a relaxation of enrollment criteria for programs traditionally focused on basic science research; instead, it is recognition of the broadening scope of valuable biomedical research. Good mentorship and rigorous requirements are as important for these fields of inquiry as they are for basic science, and the Scholarship Oversight Committees that are required for pediatric subspecialty trainees have the obligation of making sure these essential pieces are in place for any research discipline.
Thus, one could describe the perceived threat to basic science research not as a simple pipeline problem due to lack of interest but, rather, in large part, as due to the development of other areas of sound scientific research coupled with better alignment of trainee skills and career pathways. One could even argue that better-tailored investments in trainees and junior faculty will not only improve the breadth of high-quality science but also will enhance the cost-effectiveness of basic science training by saving resources to support those who are most likely to benefit from them.
Redefining the Academic Health Center
Once we have settled on the meaning of biomedical research, a second term that deserves a more contemporary definition is “academia” and its human product, academicians. At Penn's School of Medicine, where once the tenure track stood alone as the path of career advancement, the research track was established as a nontenure academic home for scientists carrying out independent or collaborative research with no clinical activity and very limited teaching. Most members of this track are PhDs. The school has subsequently implemented faculty tracks for clinician–investigators and clinician–educators (the latter called, informatively, the academic–clinician track), reflecting the expansion of the academic tent. As another example of shifting values that redefine the academic health center, annual Master Clinician Awards at the Children's Hospital of Philadelphia carry significant financial prizes and are meant to demonstrate in both honorific and concrete terms the importance of these individuals in an academic institution.
Although the academic environment may be more welcoming to faculty with a wide variety of skills, both clinicians and investigators find themselves in a more challenging environment that makes it far more difficult to do either job effectively, much less both. Let's be honest—most physician–scientists who spend 80% to 90% of their time in research activities are unlikely to be eminent clinicians and, as determined by their allocation of time, have limited teaching contact with residents in the clinical setting. Conversely, clinicians who spend 80% to 90% of their time in clinical care are unlikely to be funded investigators. However, as Rivkees suggests, physician–scientists and clinicians can work effectively with each other at the intersection of research and patient care. One of those intersections is the conference room. Separate but equal research and clinical conferences occur all too often, but cross-talk in such conferences would not only enrich both clinical and research activities but would also expose trainees to the full range of role models and, just as important, to the value of collaboration. Attending rounds and resident teaching conferences provide perfect opportunities to achieve the same goals. Grand rounds, when they are truly grand, present broad-based expertise to an audience of clinicians, investigators, and trainees.4 A spirited discussion at the end of the talk can present some of the most convincing evidence imaginable of the intellectual relationships among faculty members with different academic interests.
The academic health center is not what it used to be. New areas of investigation, highly complex clinical environments, expansion of faculty tracks, and recognition of teaching as a discipline rather than a hobby have redefined roles and now force us to integrate these parts into a coherent whole.
The New Economics
Economic times are tough for both investigators and clinicians, and pitting one group against the other is unlikely to be productive. Hay5 and Rivkees and Genel6 have provided stark figures about research support in general and pediatric research in particular. However, the villain is not the academic–clinician. Although Rivkees correctly identifies the economic importance of rainmakers among clinicians, most department chairs can attest that much of that rain is used to support poorly reimbursed pediatric subspecialists, productive investigators who need bridge funding, K-awardees who do not have full salary support, and others. In fact, a strong group of academic–clinicians on the faculty should not displace physician–scientists or compromise the institution's research mission. Instead, the academic–clinicians should protect the research time of investigators and establish successful clinical programs that facilitate successful research programs.
Both research funding and clinical reimbursement are diminishing and almost certainly will continue to do so after the November 2010 elections. The question is how to look at the whole picture rather than at its parts. Rivkees suggests that this process begin with a realistic assessment of what a department or institution can do well. The likely conclusion of this assessment is “not everything,” so strategic allocation of dollars must be based on some combination of quality, necessary services, and leverage for extramural funding. Protected time for investigative activities that have little chance for publication or extramural support is almost certainly an early casualty, and this may mean reductions in the ranks of clinicians dabbling in research and established scientists no longer competing effectively for funding. Where possible, this will be followed by (1) reallocation of time with appropriate alignment of skills and responsibilities, and (2) reallocation of funds for clinical, educational, and research programs that are successful (sustaining), promising (building), or absolutely necessary (serving). Conversations within and across institutions, as envisioned, for example, in the Pediatric Research Consortia, would build investigative teams on a more cost-effective and collaborative basis. Instead of limiting success to the big and the wealthy as Rivkees fears, these types of collaborations could foster the success of smaller institutions that have identified and invested wisely in areas of strength.
Whether we are facing Johnson's gallows or Rivkees' tectonic shifts, something bad is about to happen under our feet if we don't discard old definitions and outdated models. We can readily agree on the importance of increased research funding and, for pediatric research, the importance of receiving a fair share of the resources. However, we must also be strong guardians and innovative managers of these resources. By respecting the different contributors to the overall success of the academic health center, by aligning talents with career pathways, and by recognizing both success and failure as early as possible and allocating funds accordingly, we should be able to distribute resources fairly and effectively, attract trainees into a variety of career pathways, and be certain that the fundamental academic missions are preserved. Even in the face of major changes, we have substantial control over our own destinies.
The author thanks Dr. Philip Johnson for his review of this manuscript.