In this issue of Academic Medicine, Rivkees1 describes the shifting of the “tectonic plates” of academia and the ensuing challenges facing academic departments of pediatrics. Rivkees thoughtfully discusses potential changes resulting from fewer trainees entering the academic pipeline, increasing emphasis on clinical productivity, and a shifting of the research base to a smaller number of institutions that could place academic departments in peril unless they anticipate and manage the tectonic shifts. Although we concur with the necessity for anticipating change, we draw here on history to consider an alternative view where the changes in academic medicine offer opportunities for vibrant academic departments to embrace new approaches, make unique discoveries, and improve children's health.
The first notion of tectonic plates appears in 1596 in Abraham Ortelius'2Thesaurus Geographicus, where Ortelius hypothesizes that the Americas were “torn away from Europe and Africa ... by earthquakes and floods” and that the “vestiges of the rupture reveal themselves, if someone brings forward a map of the world and considers carefully the coasts of the three continents.” Interestingly, at the time of Ortelius' writing, the enterprise of exploration faced several significant challenges, and many explorers experienced substantial loss. In 1596, Sir Francis Drake, a renowned English sea captain, was exploring the Caribbean and died of dysentery.3 That same year, famed English explorer Sir Walter Raleigh returned from a South American expedition empty-handed.4 One year later, Willem Barents died in the Arctic without finding a Northwest Passage.5 In the face of these challenges, however, exploration and discovery continued, so that by 1620, the Mayflower had landed on Plymouth Rock, having weathered innumerable hardships.6
We would thus propose that leaders in academic departments must consider changes in academic medicine as new courses to be charted rather than as inevitable shifting of the ground beneath them. Under this model, clinical excellence is coupled with discovery, where trainees, faculty, and patients and families are continually exposed to asking questions and identifying ways to move science forward to improve health. In discussing this view, we will draw on our recent experiences at Vanderbilt University School of Medicine, where exploring such opportunities has permitted a vibrant academic faculty to thrive and a departments of pediatrics to flourish.
Rivkees focuses on the shrinking pipeline for trainees entering the academic workforce and raises concern about an emphasis in training on clinical opportunities and diminished expectations for trainee scholarship. As a result of changes in the composition of faculty in academic departments, he worries that trainees are exposed to fewer “true” scientist role models, instead finding role models among clinicians. We wholeheartedly agree that exposure to faculty who perform high-quality scholarship provides important opportunities for helping to engage trainees. However, we would argue that an abundance of such faculty already exists at many superb departments of pediatrics, and thus opportunities abound. Indeed, we believe it is the obligation of leadership to continuously emphasize the importance of research as the foundation of medical practice. At many institutions, including our own, residents interested in pursuing a career in child health research are invited to join and participate in structured activities to encourage their career development. Such societies permit trainees to interact with visiting professors, receive support for their own scholarly work where appropriate, and participate in career development activities with senior faculty. By fostering the career development of such trainees at Washington University and Vanderbilt, we have seen firsthand a consistent growth in the pipeline for clinician–scientists. Although Rivkees raises concern that fellows are increasingly pursuing translational and qualitative questions, implying that such questions are inherently of less value to discovery, we have seen that such approaches can have sufficient academic rigor to make significant contributions to children's health. If the goal for trainees at all levels remains to engage in understanding the importance of discovery, exciting opportunities will continue to present themselves.
Rivkees also discusses economic pressures as a key driving force behind the increasing presence of clinical faculty replacing traditional research faculty in academic medicine. We would suggest an alternative view in which vibrant departments must find ways to value and retain all faculty who contribute to the service, teaching, and discovery missions. The career growth of clinical faculty, who provide excellence in clinical care and offer professional service to their field, must be supported while maintaining expectations for scholarly productivity and discovery by other faculty.
To achieve this vision, standards for promotion for clinical faculty should emphasize contributions in service, including development of high-quality clinical programs, extraordinary contributions in leadership and administration, and service to organizations that enhance health, furthering the mission of departments and schools. At the same time, support for faculty engaged in scholarship should be enhanced and strengthened. At Vanderbilt, we recently created a faculty scholars program recognizing excellent clinician–educators early in their careers who are interested in scholarship. The program provides additional protected time for scholarship, resources for research, and monthly group mentoring sessions where scholars interact with each other and senior faculty and participate in a self-designed curriculum. Expectations for these scholars are drawn expressly from promotion criteria and include service on national committees, participation in scholarly activities, and invited presentations at other institutions. Providing mentoring for these scholars and all faculty is a crucial component of facilitating success. The Office of Faculty Development at Children's Hospital Boston promotes the concept of a community of mentors surrounding faculty throughout their careers.7 The office provides extensive resources for mentoring for all faculty, including training in mentoring for mentors and training in how to be mentored for junior faculty.7 We have recently adopted a similar model at Vanderbilt that has been received with great enthusiasm from the faculty, resulting in leadership training opportunities, more successful promotions, and higher satisfaction.
We agree with many of the solutions suggested by Rivkees to ensure the success of academic departments. For example, clarifying the promotion process for clinician–educators, growing a clinical scholar faculty, developing track-specific career development programs, and exposing trainees to rigorous biomedical research are all laudatory goals. It is also true that creating a clear vision for academic departments and securing resources are vital components for success. In addition, we agree that departments of pediatrics must not exist in a vacuum and should draw from relevant institutional partners. We would further suggest that creating partnerships beyond schools of medicine to draw on institutional strengths would further broaden the base for advancement of discovery. We also support advocacy for expansion of National Institutes of Health programs that encourage careers in discovery for physician–scientists.
Rivkees is a dedicated and accomplished pediatric scholar, and his article is an important contribution that provides valuable insights. He speaks in his article of “academic Darwinism,” and perhaps it may be wise at this point to remember Darwin's own words on reading Malthus and grasping insight from the class struggle of the industrial revolution. “The final cause of all this wedging,” Darwin realizes, “must be to sort out proper structure and adapt it to change.”8 In the end, our ability to adapt is the key. We would suggest that solutions be viewed as growing opportunities for forward movement as opposed to reactive responses to inevitable changes. Just as the challenges occurring in the late 16th century must have been discouraging to those pursuing exploration, forward vision and charting a course for success are likely to position academic departments to embrace excellence in clinical care and discovery and to ultimately improve health. Academic pediatrics remains today a vibrant and exciting discipline with extraordinary leaders and committed trainees. We must continue to inspire all who embark on the voyage to excellence, keeping our eyes on the horizon and not the gathering storms. Our patients and their families demand this, and we cannot afford to fail.
1 Rivkees SA. Perspective: Tectonic shifts in academic pediatrics: Changes and adaptation. Acad Med. 2011;86:644–648.
2 Kious WJ, Tilling RI. This Dynamic Earth: The Story of Plate Tectonics. Version 1.14. United States Geological Survey, United States Department of the Interior. Washington, DC: United States Government Printing Office; 1996:8.
3 Kelsey H. Sir Francis Drake: The Queen's Pirate. New Haven, Conn: Yale University Press; 2000.
4 Hume MAS. Sir Walter Raleigh: The British Dominion of the West. 4th ed. London, UK: T. Fisher Unwin; 1906.
5 Williams G. Arctic Labyrinth: The Quest for the Northwest Passage. Berkeley, Calif: University of California Press; 2010.
6 Philbrick N. Mayflower: A Story of Courage, Community, and War. New York, NY: Penguin Group; 2006.
7 Emans SJ, Goldberg CT, Milstein ME, Dobriner J. Creating a faculty development office in an academic pediatric hospital: Challenges and successes. Pediatrics. 2008;121:390–401.
8 Gitlin J. Review of Darwin: An exhibition at the American Museum of Natural History. J Clin Invest. 2006;116:845.