Pediatric academia is evolving in response to a challenging funding environment, trainees choosing clinical and part-time careers over biomedical research tracks, and a shrinking pipeline of physician–scientists and clinician–scholars. The challenge for the pediatrics community is to anticipate and manage these shifts and determine the direction we want academic pediatric departments to move.
The trend toward fewer pediatric-based academicians with classical academic interests is the consequence of numerous factors, including the changing philosophies of a new generation of trainees, education debt burdens, and educational emphases on primary care.1–3 The downward trend in academic pediatrics parallels the decline in MDs entering research careers in other disciplines.2,4,5 The harsh realities of obtaining extramural support for basic or clinical research projects is a legitimate concern for fellows and junior faculty and is a deterrent for those considering research careers. This funding issue is especially pertinent to pediatrics, as funding for child health research has disproportionately slipped over the past decade.6
Physician–scientists are challenged by the new nature of biomedical research, which favors large research groups as a means to maintain funding and research competitiveness. It can be challenging to remain competitive in top-tier research programs when academic duties demand interactions with residents, fellows, graduate students and postdoctoral research fellows. Today's training model presents challenges for aspiring physician–scientists. For those wishing to pursue postdoctoral research training, the current model of fellowship programs is insufficient to launch competitive research careers. Such programs require fellows to extend their training by an additional one to three years—a commitment that is often impractical financially and personally for individuals who have already dedicated many years and many tens of thousands of dollars to their professional training.
Challenges in Training
Cultivating pediatricians who will become physician–scientists is not easy. Often, postdoctoral and junior faculty training programs—such as the National Institutes of Health (NIH) T-level and K-level programs, respectively—struggle to identify individuals with fire in their belly for scientific research. Many of us have seen national basic science training programs relax enrollment criteria to fill slots, accepting applicants with a translational or clinical focus. We notice clinical training programs struggling to find scholars with good long-term academic potential.
The nature of trainee research has shifted, too. With increasing interest in postfellowship clinical positions, fewer trainees focus on the rigorous, prospective clinical or basic science projects that used to dominate fellowship research training and were expected of trainees. Even though we actively point fellows to such projects as the gold standard of rigorous scientific research, trainee research now involves surveys, educational program development, retrospective chart reviews, and Cochrane Reviews. We see quantitative research replaced with qualitative research. These research trends are reflected in pediatric journals, which rarely published studies of these types a decade ago.
The use of existing data sources for fellow research projects can indeed be rigorous, quantitative, and a good fit for the fellowship training period. The important issue is the design and execution of the research project, which frames the trainee's academic career. Fellows need good mentors who know research to guide projects and ensure solid beginnings to competitive research careers. The successes of programs that enforce rigorous research requirements, including the Pediatric Scientist Development Program,7 highlight the benefits that come with high expectations for trainee projects.
Economic Pressures Favor Clinical Faculty Over Research Faculty
Contributing to the shift away from the physician–scientist track are substantive economic pressures that favor recruitment of clinicians over research scholars. Basic and clinical research programs are expensive.8 Revenue generated from extramural funding falls short of project and infrastructure costs. Substantial portions of NIH R01 grant budgets go to salary support, which limits the funds available for project costs. Grant funding seldom recoups the costs of preliminary work and ongoing studies.
The cyclical nature of grant support funding comes with inevitable funding lapses resulting in real risks and costs to departments. Considering that departments of pediatrics have relatively low reimbursement rates and often challenging payer mixes, discretionary funds to offset these costs are limited. Contingency support for lapses in research funding takes from operational dollars or funds for new program support.
Compared with extramural funding, clinical revenue is less cyclical and less prone to immediate cutoffs. Some clinical programs can be revenue generators, especially neonatology, critical care, cardiology, and gastroenterology. Clinical care can benefit institutions through revenues from surgery, laboratory, and diagnostic services. For non-procedure-based disciplines, indirect revenue generated from medical visits and subsequent testing and referrals can greatly exceed subspecialty professional fees. Considering pediatric clinical revenue as a consortium of medical consults, laboratory and diagnostic fees, and surgical revenue, clinical programs can fare well economically.
Clinician and clinician–educator recruitment and support costs are typically a fraction of clinician–scholar costs, unless clinical programs have substantial build-out costs (e.g., cardiac catheterization suites). “Start-up” packages for clinician–scholars involved in basic or clinical research can cost institutions from $750,000 for junior faculty to $1.5 to 3 million for more senior recruits.8 Clinician–educator positions, on the other hand, involve the stated understanding that the faculty member will earn a substantial proportion of salary and benefits from his or her own clinical billings. Unlike for clinician–scholar hires, funds are typically not required for technical or material support for clinician–educators, or such requirements are modest. The costs to “grow” a faculty of research-based scholars thus subsume the costs for a faculty of clinicians or clinician–educators.
The recently legislated loan forgiveness programs to support pediatric subspecialty training, though well intentioned, will only support subspecialists who practice in underserved areas and will not help the manpower shortages at many academic health centers. These shortages will increase as health care reform increases insurance coverage, leading to the need for additional clinical subspecialty care.9 With increased health care access for children, there will be commensurate increases in the need for subspecialists to meet referrals from primary care practitioners at a time of huge subspecialist shortages. Thus, external forces will drive the need for clinician recruitment.
Recognizing the steady cash flow of clinical billings compared with uncertain long-term gains associated with research program support, there is financial pressure to grow clinical operations. Department leaders may believe they need to fix clinical programs first to help the balance sheet. Such approaches can have unintended consequences for academic departments if the clinical program is the primary focus.
Traditional academic departments are constituted by a basic and clinical research core that comprises a significant proportion of faculty members. Academic promotion for these faculty is dependent on publication, extramural grant support, and peer recognition. These selective pressures, or “academic Darwinism,” mold the intellectual environment.
When promotion for clinicians and clinician–educators is dependent on publications and scholarly work rather than clinical productivity, these faculty members identify stand-alone, part-time projects that will generate a portfolio for academic advancement. Some projects, though, are not competitive for publication in moderate or top-tier journals, nor do they face the selective pressures of external funding review that sculpt project design. When incorporated into traditional research or departmental conferences, such projects change the visible research portfolio of the department. Such activities divert effort from clinical programs and require financial support for physician effort.
Of course, if these projects can lead to new programs with potential for revenue generation or extramural funding, they need to be encouraged. We also need to encourage clinician efforts that can become essential elements of larger clinical and translational research programs. To facilitate these activities, departmental programs can be instituted to develop studies involving clinicians with research interests in broader research teams with a patient-based focus. If emphasis for clinician–educator promotion is shifted to the development of clinical and training programs and contributions to patient-based research programs, the pressure on these faculty to conduct stand-alone, part-time research will ebb.
Academic Exposure for Trainees
The shift toward a clinician- or clinician-educator-based faculty has important implications for the training and inspiration of the next generation of physicians. Trainees are exposed to clinicians and clinician–educators far more often than they encounter grant-funded clinician–scholars. Faculty teaching awards bestowed by residents go to hospitalists or busy clinician–educators rather than to clinician–scholars who have made substantive contributions to their field, of which trainees often know little.
Educational training program director roles now fall to clinician–educators rather than to clinician–scholars as they did in the past. The burdensome requirements of the Residency Review Committee make program director positions as much about regulation and bookkeeping as trainee education and mentoring. Thus, the clinician–scholar and physician–scientist, who can be an ideal role model for research- and non-research-minded trainees alike, will refrain from taking these positions.
The activities of “triple-threat” clinician–scholars engaged in research, clinical care, and education become increasingly restricted to revenue-generating components under popular, mission-based financing models.10 The shift toward mission-based allocation results in the trimming of educational activities and less exposure to trainees for clinician–scholars.
When trainees ask the faculty they see day-to-day to “tell me about your research,” they do not hear about cutting-edge, NIH-funded basic science or clinical investigation. The pattern of transmission of scholarly research from faculty to trainees is changed. A challenge thus rests in developing programs that result in substantively exposing trainees to biomedical research.
Changing Pediatric Research Environment
The focus on the clinical program, without parallel or greater support for the clinical research or basic science research component, can culminate in a maturing research faculty receiving no renewal from incoming junior clinician–scholars to advance departmental research. If departments do not face changes in academia with careful planning and purposeful adjustments to hiring practices, the academic climate will change. Departmental makeup can shift from a traditional research-based faculty to a largely clinical faculty over a period of several years.
Difficult challenge lies in guiding and managing workforce composition and recognizing the unique, essential, and complementary roles of clinician–scholars, clinicians, and clinician–educators. If scholarly activity is required for academic promotion, we must address how we can pay for such in the current economic climate when we have to build and run our departments with less financial support than in the era of NIH funding growth and steady clinical reimbursement rates.
With limited funding and changing faculty makeup, it is inevitable that we will see a less pluralistic pediatric research base. Substantive pediatric research will become consolidated in academic health centers with the financial resources to support pediatric research. The commitment to research is irrespective of program size, but favors large, stand-alone children's hospitals with endowment income and control over clinical revenues and indirect cost revenue from grants, which are additional funds awarded to the institution to support research infrastructure.
Considering the shifting tectonic plates of pediatric academia, I propose several ideas for moving forward in this changing environment. Some of these ideas may work and others may not; some will be welcome and others frowned on. The intention is to encourage discussion about this issue and promote creative thinking to address the changing climate of pediatric research.
Not all research can be supported.
Not all research is rigorous enough to be financially supported. It is important that the research face of a department be projects that are extramurally funded and/or can be published in respectable journals, irrespective of whether projects focus on clinical or basic science, or whether they come from clinicians, educators, or scientists. Rather than encouraging research-minded clinicians to pursue stand-alone, part-time projects with little chance for funding, we should include these physicians in larger clinical and translational programs where they play an essential role. If clinicians are developing rigorous projects with good chances of success, these projects need to be supported along with the time for research effort. A premium should be placed on projects with clear future directions, the potential to be published in good journals, and fundability.
Promotion process for clinician–educators.
Promotion and tenure committees can reconsider the type of scholarly work that is considered in the promotion process for clinician–educators. Promotion requirements that encourage stand-alone, part-time research projects are costly and distract physicians from clinical program development and clinical activities. If clinicians' primary responsibilities are clinical care, efforts directed at contributing to medical care improvement and developing special clinical programs and education activities should be emphasized. Credit should also be given to physicians who play important roles in clinical or translational research teams but do not direct the research program.
The vision to grow a clinician–scholar faculty.
If research is a mission of a department, the need to maintain and grow a clinician–scholar faculty cannot be lost in pursuit of clinical growth. Clinical departments will always need to recruit clinicians; research programs are not essential for clinical care and are expensive and may be given less priority in recruitment. A small candidate pool of physician–scientists makes recruiting these faculty members difficult. Bottom-up growth models for developing a cadre of clinician–scholars are much less expensive than top-down programs and can have a positive impact for a modest price.11,12 For example, departments can create special programs to attract residents and fellows with intrinsic interests in research, with the intention of developing these individuals into a well-trained cadre of clinician–scholars over time. Effective pipeline programs will grow and preserve the clinician–scholar.
Develop academic track-specific programs.
Departments need to recognize the shift to a clinically based faculty and develop special programs for this physician group, building on their special strengths and focus. Departments are traditionally organized by organ system. Similarly, we can organize faculty by track and develop track-specific programs to foster creativity and departmental contribution.
Considering clinician–scholars, emphasis can be placed on the development of skills needed for research program development, securing funding, publishing, laboratory management, research support needs, and interaction with other research programs. Considering clinicians and clinician–educators, emphasis can be placed on practice management, clinical operations, and multidisciplinary program development. Clinical program directors can be charged with the development of outcome-based quality assurance and cost-effectiveness care programs, setting program targets.
Trainee exposure to rigorous biomedical research.
As trainee exposure to physician–scientist and clinician–scholars slips, we need to ensure that medical students, residents, and fellows are exposed to an expanding array of clinical, translational, and basic science research. Day-to-day exposure to these is challenging, but integrating research into core curricula is possible. Providing free time for trainees to attend research conferences can help. Within the constraints of the workweek with fixed and limited hours for education, these approaches will require a shift in trainee time allocation.
Defining departmental identity and paying for it.
Departments need to define their identity. If a department has a clinical focus, special areas of clinical excellence that garner regional and national recognition can be developed. If it has a research focus, specific areas of investigation will need support. Hybrid models emphasizing excellence in clinical care and research are also feasible, but specific areas of focus need to be defined within the broad scope of clinical and research activities.
As discussed, developing a clinician–scholar faculty base requires significantly more up-front hiring costs than recruiting clinicians or clinician–educators. If a department makes a commitment to research excellence, the costs will be substantial. A department with a clear, multidisciplinary identity can more effectively handle these costs through stewardship of collective resources.
If we recognize pediatrics solely by its clinical mission, it will be difficult to collect enough revenue to support clinician–scholar program development. However, we can define pediatrics and pediatric revenue by the entire scope of pediatric care that takes place in a children's service or hospital, by including revenues from diagnostic imaging, laboratory medicine, and surgery pediatric economic viability is much stronger. Nonprocedure service providers have difficulty standing alone as generators of self-sustaining revenue. As such, the development of multidisciplinary programs that encompass the expertise of medical, diagnostic, and surgical programs is needed to develop a viable pediatric revenue collective.
Moving beyond an MD pediatric research base.
Extramurally funded pediatric clinician–scholars are a tiny group, resulting in a small pool of legitimate candidates for departments aiming to be major centers of research and discovery. Talented junior physician–scientists are heavily recruited by numerous institutions. Remaining competitive in recruiting is a major challenge for departments with modest endowment income or discretionary funds.
In comparison, there is a vastly greater pool of PhD scientists than physician–scholars. PhD scientists typically have more extensive research training than do MDs and have declared research their career choice. Meshing PhD scientists with MDs in a research program is a realistic solution to the clinician–scholar shortage that is only getting worse. PhD scientists can fit into the departmental research base and the educational curricula and, with their special skill set, contribute to research competitiveness.
No longer standing alone.
Considering the evolution of biomedical research, stand-alone pediatric research programs are difficult to support financially and intellectually. Integration of pediatric research programs with other institutional basic science and clinical research programs can provide infrastructure and support for pediatric research. As such, high-value pediatric research can grow by partnering with basic science, other clinical, and subspecialty departments. Such interactions, in turn, will cross-fertilize programs with different research focuses, opening new areas for investigation.
New NIH programs needed.
We need to advocate for expansion of NIH programs that cultivate the development of physician–scientists, programs such as the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pediatric Scientist Development Program and the Child Health Research Career Development Award Program.13 We should consider new initiatives that specifically support the expansion of pediatric research, like the Pediatric Research Consortia Establishment Act (H.R. 758).14 Children make up 25% of the U.S. population,15 yet support of research in childhood disorders makes up less than 10% of the NIH extramural budget. Departments of pediatrics need more extramural support for their mission to advance the care of children and adolescents if we truly value the next generation.
The generational changes of pediatric trainees and changing medical economics mean that we are seeing the tectonic plates of academia shifting to new types of research, new faculty composition, and a new breed of trainees. Contributing to the shift from the physician–scientist to the clinician and clinician–educator career path are substantive economic pressures that favor the recruitment and development of clinician faculty over research scholars. Considering where pediatrics is moving and the economic realities of medicine and biomedical research funding, academic pediatrics can be restructured in a way that preserves the discipline and ensures that high-quality research continues.
Once shifts in tectonic plates occur, they do not remit, and more will follow. Our challenge is to anticipate and manage these shifts and carve a clear path for the plates of academia by changing our academic model.
The opinions expressed in this article are those of the author alone.