MacDonald, Shannon E. RN; Sharpe, Heather M. RN; Shikako-Thomas, Keiko OT; Larsen, Bodil PhD, RD; MacKay, Lyndsay RN
The transition from trainee to career clinician–scientist can be challenging to navigate. In June 2011, the Canadian Child Health Clinician Scientist Program (CCHCSP) hosted a symposium of clinician–scientist trainees and faculty to explore the barriers and facilitators to a successful transition. CCHCSP is an interdisciplinary program that trains clinician–scientists in the area of child and youth health, in partnership with 17 academic health centers.1 The trainees at the symposium represented a wide array of health disciplines (medicine, nursing, nutrition, and rehabilitation science) at various stages of training. The meeting resulted in ongoing dialogue among the nonphysician trainees about the unique challenges they face, but also about the significant potential they have to provide meaningful contributions to both the scientific and clinical realms. This commentary proposes that nonphysician clinician–scientist trainees and their potential employers need be aware of the specific challenges of this critical career transition stage and the preparation and tools that will contribute to individual and organizational success. Key issues and challenges to address include how to secure a first position, find a mentor, effectively manage time, and establish work–life balance.
What Is a Nonphysician Clinician–Scientist?
What is a clinician–scientist?
Clinician–scientists are clinically trained researchers who continue to pursue a limited amount of clinical work.2 This active role in clinical practice is essential to ensure the credibility and relevance of their research. The benefit of this combined role is that clinician–scientists bridge the “knowledge translation” gap between health research and clinical practice. As the demand for evidence-based health care grows, clinician–scientists enable the flow of evidence to practice and health policy, which ultimately leads to improved patient care and health, and the reciprocal feedback that enables research questions to be rooted in current clinical issues.2–4 The challenge of this role, however, is that clinician–scientists lead a double life, needing to remain current on clinical issues while being competitive with full-time researchers for research funding.5,6
What is unique about the nonphysician clinician–scientist?
Whereas the clinician–scientist model is relatively well established in the discipline of medicine, the nonphysician clinician–scientist is an underdeveloped role.7 Individuals in such positions are clinically trained in allied health disciplines, such as nursing, pharmacy, nutrition, or rehabilitation science and have advanced research training (typically PhD-prepared). They share several commonalities with physician clinician–scientists, including practicing as a health professional while undertaking a program of research in one’s clinical specialty.8 Nonphysician clinician–scientists, however, experience some unique issues that delineate them from their physician colleagues. A major career challenge for most doctoral-prepared nonphysician clinicians is that they generally acquire an academic or clinical position but fail to achieve a combined role.7 Specifically, they have either (1) an academic appointment in a university faculty with an adjunct appointment at a clinical health center without remuneration or (2) a clinical position in which research is not a component of their job description but is conducted in their spare time.2
Positions with formal linkages between academic/research settings and clinical settings are critical to ensure a tenable career for nonphysician clinician–scientists. However, academic institutions, whose primary mandate is teaching and research, have different priorities than clinical settings,9 which focus on patient care. For innovative roles for nonphysician clinician–scientists to flourish, competing cultures of academic and clinical settings must be addressed.8 A key value of the nonphysician clinician–scientist is the ability to facilitate collaboration, rather than competition, between these two cultures by simultaneously addressing their dual priorities. Medicine has many clinician–scientist positions that allow protected research and clinical time, which can provide a template for the creation of such roles in the other health professions. Hopefully, as nonphysician clinician–scientist roles become more established, future trainees will be spared this particular challenge. In the meantime, a plan for fostering the development of these roles is needed,2 and facilitating the transition to career for nonphysician clinician–scientist trainees is an important step.
How to Secure That First Position
Seeking a nonphysician clinician–scientist position adds unique challenges to the job search because these underdeveloped roles often have to be created and negotiated between an academic/research institution and a clinical organization. The trainee may need to act as a catalyst in this process, which can be facilitated by having allies within one or both organizations, who recognize and “sell” the value of the clinician–scientist role and the skills that the trainee contributes.
Negotiating a position
The nonphysician clinician–scientist entering a joint appointment between two organizations must negotiate a realistic plan to “marry” the two positions and the organizational expectations. The trainee needs to be able to articulate the proposed balance of being a competitive researcher and an effective clinician. This requires an understanding and clarity about both the systems in which the positions operate and the role as a clinical scientist.
Negotiation for protected research time is a critical part of this process, involving a reasonable split of research time to clinical work and/or teaching10—ideally, 75:25. Competitive salary support that adequately compensates for both clinical and research activities needs to be negotiated, possibly including seed funding for the first year(s) to enable a program of research to be established while operating grant applications are in development and adjudication. It is critical that relevant evaluation criteria be established for annual reviews to ensure that the new clinician–scientist is judged according to appropriate criteria and not as a full-time clinician or researcher. The trainee should review a copy of the department’s requirements for tenure and promotion and discuss these with the potential employer in negotiating for protected research time. In a developing role such as the nonphysician clinician–scientist, it is especially important to document job responsibilities, proportion of time allocated to research and clinical/teaching responsibilities, salary, criteria for evaluation, and opportunities for mentorship from senior faculty.11
Finding the right fit
When considering career opportunities, it is important for the trainee to ensure that the position fits with his or her career and life goals. There is a big difference between being sought after for a position and actually wanting to do the work involved.12 The position has to be congruent with the trainee’s vision of his or her career path and research goals. Accepting a position that fails to demonstrate this congruency is likely to result in dissatisfaction for both the trainee and the organization. Some strategic tips for negotiating a position and finding the right fit can be found in List 1.
Who Can Guide the Way?
Mentorship is critical
Given that the nonphysician clinician–scientist is a developing role with no clear guidelines for career development, mentorship is a critical component of a successful transition from trainee to career and can lead to higher professional achievement and career satisfaction.13,14 The fluidity and flexibility of the clinician–scientist role means that these individuals may have more choices about how to spend their time than in the “typical” career. Making such decisions requires experience and judgment about consequences that the trainee may not possess, making guidance from an experienced mentor all the more important.15 The positive impact and particular characteristics that distinguish a good mentor have been well summarized in a systematic review by Sambunjak and colleagues.16
Mentors are scarce
A unique challenge for trainees embarking on careers as nonphysician clinician–scientists is that the scarcity of these positions leads to a corresponding scarcity of mentors.2 At the same time, the lack of colleagues in comparable roles increases the professional isolation,7 making mentorship even more critical. This dilemma necessitates some creativity on the part of the trainee seeking a mentor. One option is to build a team of mentors to meet the trainee’s needs, such as having a content (or scientific) mentor and a process (or academic) mentor.15 The content mentor should be a senior scientist in the trainee’s research field, but not necessarily in the trainee’s academic or clinical discipline, who can provide guidance on research-specific issues. This mentor may or may not be located at the same institution as the trainee. The process mentor should be a senior scientist in the trainee’s home department, who does not necessarily need to be focused in the same content area.16,17 This individual should have similar disposition, strengths, weaknesses, and family responsibilities as the trainee, providing career wisdom and advice, such as guidance on tenure, promotion, and local politics, more than any specific scientific content or techniques.18 Ideally, the process mentor would be a clinician–scientist, thus possessing expertise on bridging the clinical and research fields, having navigated the path him- or herself. Useful tips for choosing a mentor are in List 2.
How to Effectively Manage Time
For clinician–scientists to succeed, they must remain active and competent in the clinical arena while meeting the requirements of academic advancement—namely, research, education, and service.8 Typically, the nonphysician clinician–scientist has a higher requirement for undergraduate and graduate teaching than his or her physician counterpart. Balancing these various job responsibilities necessitates highly effective strategies in time management, including balancing teaching and clinical assignments, setting priorities, saying “no” to avoidable time drains, and protecting writing time.
Teaching and clinical commitments
The determination of teaching assignment should be part of the negotiation before accepting any position. If this negotiation is left until after the job is accepted, the issue of time management is further complicated. However, even within the confines of the job requirements, there are strategies for optimizing use of time for research activities. One such strategy is grouping teaching assignments into a single term, leaving an eight-month block open each year for focused research activities.19 Another strategy is to ensure that early in one’s career, teaching assignments are in the trainee’s area of expertise in order to reduce preparatory time and enrich and highlight one’s expertise.20
The challenges of clinical practice for the nonphysician clinician–scientist role are quite unlike those faced by physician clinician–scientists. Whereas physicians face the challenge of keeping their clinical practice commitments from infringing on their research time,21 the typical nonphysician clinician–scientist has to negotiate clinical practice into his or her job description, as most academic positions in the allied health profession do not facilitate or promote ongoing clinical practice. Given that such clinical involvement is a necessary complement and source of inspiration for one’s research as a clinician–scientist, negotiating clinical time into one’s job description is essential to ensure that clinical practice does not become an add-on to one’s normal working hours.
Determining which activities contribute toward career goals is a crucial process. Sackett12 has suggested that generating a priority list and updating it every six months is a worthy exercise. The priority list should include the following12:
* List 1: Things I’m doing that I want to quit.
* List 1a: Things I’ve just been asked to do that I don’t want to do.
* List 2: Things I’m not doing that I want to start.
* List 3: Things I want to keep doing.
* List 4: How I plan to shorten List 1 and lengthen List 2 over the next six months.
Although generating this priority list is of value in itself, discussing it with a mentor can ensure that time is focused on the most constructive activities.
To achieve the goals of a clinician–scientist, it is often necessary to say “no” to as many opportunities as one takes on.15 This is doubly true for the nonphysician clinician–scientist, who often has two employers with competing demands. Having a clear picture of one’s program of research will enable the trainee to know what commitments are in line with his or her career goals. One way to envision this “picture” is through use of a career planning grid in which the trainee can outline his or her goals and commitments for the coming year under such headings as research, administration, teaching, service, clinical activities, networking, self-development, conference attendance, and writing time.15 Providing one’s department head(s) with a copy of the career planning grid and referring to it when asked to take on new tasks and responsibilities can facilitate some agreement on what constitutes reasonable additions or changes to the plan.
Protecting writing time
A key skill that the new clinician–scientist must learn is how to find the time to produce publications in peer-reviewed journals. There are various proposed approaches to carving out writing time, and the key is finding the best fit with one’s style. Some researchers write for an hour every morning before getting wrapped up in the day’s business, others dedicate one day a week to writing and do so in a place where e-mail and colleagues cannot find them,22 and yet others embark on writing retreats, where they are removed entirely from normal environmental demands for three to four days for focused times of writing and reflection.15 The key as a new academic is determining the best fit for one’s maximum productivity and jealously protecting that time. List 3 provides some tips for protecting writing time and other aspects of time management.
Is Work–Life Balance Really Possible?
Maintaining work–life balance can be challenging for all clinician–scientists, who tend to be in positions with poorly defined roles with fluid boundaries and time expectations. In an effort to meet the mandates of two masters, the academic employer and the clinical setting, many clinician–scientists (who tend to be high achievers) fall into the trap of trying to fulfill the demands of two full-time positions. In the more common physician clinician–scientist position, this often involves conducting research during the hours following a full day’s clinical service,2 whereas the nonphysician clinician–scientist often has the equally daunting task of fitting in clinical commitments on evenings or weekends. The challenge of balancing multiple roles and the demands of this after-hours time commitment often leads clinician–scientists to sacrifice family life or eventually discontinue research endeavors all together.2
So how does one achieve a healthy work–life balance as an aspiring clinician–scientist, and does such a balance even exist? The answer to the latter question is probably “no”—at least, not on a day-to-day basis. With the demands of two professional roles, in addition to one’s personal responsibilities, it is unreasonable to expect that the clinician–scientist can be all things to all people on a daily basis. It is more realistic to expect some fluctuation back and forth, with hopes of achieving balance overall in one’s life. Some days, work will take precedence, whereas on other days, “life” will. If these balance out over the course of a month or year, then one can claim some level of success.
There are, however, certain steps that the trainee should take to ensure that a balance of sorts is achievable over the long term. First and foremost, as the trainee explores employment options as a new clinician–scientist, he or she must be realistic and truthful with him- or herself and with potential employers about what demands he or she can meet. Given that nonphysician clinician–scientist roles are less clearly defined and developed, it is likely that job definitions are not one-size-fits-all, making it particularly important that there is a clear understanding and a written contract between the trainee and his or her future employer as to the expectations of the position. It is also important for the trainee to be true to his or her personal and professional goals in determining whether the proposed position will allow him or her to achieve these. In the same vein, the trainee needs to be realistic about what is achievable in his or her personal life and about what his or her priorities will be. As important as it is to learn to say “no” to unnecessary work demands, finding ways to say “no” to outside commitments is equally important. Tips for finding a work–life balance are seen in List 4.
When Is the Transition Over?
The length of the transition period will vary for each individual, depending on his or her maturity, experience, and familiarity with the culture and politics of the work environment.23 Seeking and securing the first position is, in many ways, only the beginning. Embarking on a new career as a nonphysician clinician–scientist involves a time of uncertainty, given the limited role models or templates to follow. Unlike physicians, there may be few, if any, other nonphysician clinician–scientists in the department, necessitating time to build understanding among colleagues about the role and responsibilities of the position.
Not surprisingly, the first few years are critical to establishing one’s research and role in an organization. Establishing a productive research program requires the nonphysician clinician–scientist to hit the ground running, with a well-thought-out plan and strategies in place to secure funding and catalyze the research program. Ideally, the trainee will secure internal start-up funding from his or her institution in the first year of hire to support small projects or pilot work, which act as the building blocks for larger grants. These are the foundation for seeking prestigious and competitive early-career investigator awards from regional or national funding competitions, typically within the first five years of a position. At this point in his or her career, the trainee should be displaying independence from former supervisors by producing publications independent of their coauthorship.24 After five or six successful years at an institution, the former trainee will likely seek tenure and promotion. In some respects, this marks the “end of transition,” although the challenges of time management and work–life balance will be ongoing, and continued mentorship remains invaluable.12,25
Cultivating a New Career Path
Nonphysician clinician–scientist trainees embarking on their careers face many of the same challenges as their physician counterparts, and some issues unique to this developing role. The newness of the nonphysician clinician–scientist position is an opportunity to cultivate a new career trajectory and to carve out a niche traditionally limited to colleagues in medicine. Following a nontraditional career path may seem daunting, but it can provide rich experience and opportunities for the trainee and make significant academic and clinical contributions. The transition from trainee to career is an important one, requiring careful consideration and a long-term vision of career and life goals. It is important to remember that the career of a clinician–scientist “is a marathon, not a sprint.”26
Acknowledgments: The authors would like to thank the following individuals for their review of the manuscript: Dr. Karen Benzies, Dr. Annette Majnemer, Kelly Mrklas, and Dr. Norm Rosenblum. Additionally, the authors wish to acknowledge the Canadian Child Health Clinician Scientist Program (CCHCSP) for hosting the mini-symposium in June 2011 addressing the topic of career planning for clinician–scientist trainees.
Other disclosures: Shannon MacDonald received funding from the CCHCSP, a Canadian Institutes of Health Research Strategic Training Initiative; Women’s and Children’s Health Research Institute; University of Alberta Faculty of Nursing; Alberta Innovates–Health Solutions; and the Izaak Walton Killam Memorial Trust. Heather Sharpe received funding from CCHCSP and the Remax/Alberta Children’s Hospital Foundation Fellowship. Keiko Shikako-Thomas received funding from CCHCSP, NeuroDevNet, and the Montreal Children’s Hospital Research Institute/Foundation of Stars.
Ethical approval: Not applicable.
Previous presentations: A preliminary draft of this paper was presented as a poster at the CCHCSP national symposium, Ottawa, Canada, October 2011.
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