NHLBI Workshop: Respiratory Medicine-Related Research Training for Adult and Pediatric Fellows

Abstract

The pulmonary physician-scientist has a special niche to generate basic research findings and apply them to a clinical disease and perhaps impact its medical care. The availability of new high throughput-based scientific technologies in the “omics era” has made this an opportune time for physician scientists to prepare and embark on an academic career in respiratory disease research. However, maintaining an adequate flow through the research pipeline of physician-scientist investigators studying respiratory system diseases is currently a challenge. There may not be a sufficient workforce emerging to capitalize on current research opportunities. The National Heart, Lung, and Blood Institute (NHLBI) organized a workshop to assess ways to attract and properly train advanced fellows to pursue research careers in adult and pediatric lung diseases. Participants included representatives from the various pulmonary training programs, respiratory-related professional societies, and NHLBI staff. Deliberation centered on present barriers that might affect interest in pursuing research training, devising better incentives to attract more trainees, and how current research support offered by the NHLBI and the Professional Societies (in partnership with Industry and Patient Support groups) might be better coordinated and optimized to ensure a continued pipeline of pulmonary investigators. Major recommendations offered are: (1) Attract trainees to pulmonary/critical care medicine-based research careers by increasing research exposure and opportunities for high school, college, and medical students. (2) Increase awareness of the outstanding physician-scientist role models in the lung community for trainees. (3) Facilitate mechanisms by which the lung community (NHLBI, professional societies, and partners) can better support and bridge senior fellows as they transition from Institutional Training Grants (T32) to Career Series (K) awards in their early faculty career development.

Appendices

Appendix I

During the Workshop, presentations were made by representatives from the National Heart, Lung, & Blood Institute (NHLBI) and the Respiratory Professional Societies updating research training support available for advanced fellowship trainees and junior faculty. Individual presentations follow:

National Heart, Lung, & Blood Institute and Division of Lung Disease (Dr. Carl A. Roth and Dr. James P. Kiley)

NHLBI offers a broad range of funding mechanisms for individuals in research training, from F30 awards to support fellows in dual degree (M.D./Ph.D.) programs, or F31s for predoctoral fellows, to institutional Ruth L. Kirschstein, National Research Service Awards (NRSA) supporting pre- and postdoctoral trainees and short-term training for health professional students, to the mentored career development awards (the “Ks”). The NHLBI’s Division of Lung Diseases (DLD) supports approximately 60 institutional NRSA training grants and R25 (short-term training for minority students) grants per year. In FY 2007, the DLD T32s were awarded for 14 short-term positions, 113 predoctoral positions, and 306 postdoctoral positions. The postdoctoral positions were filled by approximately 63% M.D.s, and 37% Ph.D.s. The average number of DLD-funded individual NRSA Fellowships (F32s) per year was approximately 25.

The Ruth L. Kirschstein Institutional National Research Service Awards (T32) and Individual Kirschstein Fellowships (F32) support a substantial number of pre- and postdoctoral trainees at institutions across the U.S. In FY 2007, all NIH T32s supported approximately 5,600 postdoctoral training positions and 8,300 predoctoral positions. F32s (Individual Kirschstein Fellowships) supported approximately 1,500 postdoctoral trainees. NHLBI is the second highest institute in terms of number of training positions funded. In FY 2008, NHLBI funded 223 T32 awards, which supported 1,543 training positions at 75 different institutions. Dr. Roth illustrated that the average cost for NHLBI T32 awards has increased from just under $200,000 per grant in FY 1999 to approximately $330,000 each in FY 2008. However, stipend levels in 2008 constant dollars have actually decreased. Stipend levels at the time of this workshop ranged from $36,996 for a new postdoctoral to a high of $51,036 for someone with 7 years or more of postdoctoral experience. These levels may not be financially attractive to individuals considering pursuit of a research career.

If private organizations would want to consider providing financial supplementation to trainees on T32s, there would be problems to consider, such as which training programs or trainees would be supplemented. An alternative possibility would be to supplement individual postdoctoral NRSA fellows (F32). Advantages of this approach would be that the applications would have already been peer reviewed and scored by NIH; applicants gain the experience of writing an NIH application, and then receiving an F32 that potentially could free up a training position on a T32. Also, because the NIH budget has remained fairly level (excluding recent American Recovery and Reconstruction Act stimulus funding), consideration of leveraging other programs, such as the CTSA and also industry/pharmaceutical sources, could be considered. Another incentive for potential researchers is the NIH Loan Repayment Program, which encourages promising researchers and scientists to pursue research careers through repaying up to $35,000 of their qualified student debt per year.

Some organizations have been providing supplemental funding directly to individuals who have received NHLBI mentored K awards. For example, the Pulmonary Hypertension Association provides supplemental salary and research development support to $62,500 per year to 5 years to individuals who receive a NHLBI K08 or K23 grant award for research on pulmonary hypertension.

Professional Societies

American Academy of Allergy, Asthma and Immunology (AAAAI) (Dr. Bruce S. Bochner)

On behalf of the AAAAI, and as Chair of the Research & Training Division of AAAAI, Dr. Bochner presented this organization’s approach to optimizing fellowship and junior faculty training and support. At its last retreat in 2005, one of the areas of focus in the strategic plan for 2006 to 2009 included fostering and disseminating research and new information in allergy and immunology and enhancing by supporting academic allergy/immunology programs. Goals included greater efforts by AAAAI to sustain previously funded investigators whose funding had lapsed and research still had potential, increasing the number of junior allergy/immunology faculty investigators, increasing the number of third-year fellows-in-training who are committed to academic careers (since Al training for board-eligibility is only for 2 years), and to develop faculty transition awards to bridge the critical gaps between fellowship and junior faculty status. By partnering with industry and by enhancing the size of the asthma and allergy research trust corpus, the AAAAI provided ten fellow-in-training awards and one faculty level award, totaling $750,000 in 2007. This expanded to 12 fellow-in-training awards and 4 faculty awards in 2008, totaling $1,105,000, in large part based on new availability of fellowship-to-faculty bridge awards and enhanced availability of third-year fellowship awards. In addition, in 2009, the AAAAI launched the Fellowship of Excellence Training Award, which provides $50,000 per year for 2 years to support the training of an allergy/immunology fellow from an underrepresented minority community at an ACGME-accredited allergy/immunology training program in the United States. This underscores the longstanding commitment that AAAAI has in training physicians of underrepresented minorities. Despite these advancements, because of the economic downturn during 2009, these types of awards have been scaled back by 37%, and current plans are to give only ten awards this year.

Another focus of AAAAI is on programs that bring more young individuals to its national meeting, with the goal of exposing them to career opportunities in allergy/immunology. This includes the Chrysalis Program, which supports the attendance of approximately 20 medical students to the annual AAAAI meeting, the Odyssey Program, which brings approximately 10 underrepresented minority medical residents to the annual program, and the ST*AR Program (Strategic Training in Allergy Research), which is focused on graduate students, Ph.D., or M.D./Ph.D. postdoctoral fellows, numbering approximately 30, so that they can attend a meeting that is more clinically/transitionally oriented than most of the others they will likely attend during their basic immunology training. These are only available to U.S. and Canadian citizens.

Finally, the AAAAI is interested in tracking awardee success. In a recent survey of award recipients from AAAAI (1996–2006), total AAAAI fellow-in-training funding of $1.23 million led to a 12-fold return of investment in that this resulted in subsequent non-AAAAI funding of nearly $15 million dollars. Even more impressive was that $1.6 million dollars of faculty funding from AAAAI resulted in $42 million dollars of non-AAAAI faculty funding, for a 26-fold return on investment. Thus, given the fact that (a) more than 80% of allergy/immunology training programs are not focused on training for academic careers, (b) there are only approximately a dozen T32 programs headed by directors of allergy/immunology programs, and (c) there are few AAAAI academic positions in research open without extramural support, such as the K award mechanism, a minimum of an extra year of research-intensive protected time during fellowship is critical for long-term academic success as is support during the transition from fellowship to faculty, involving mechanisms such as K awards. Finally, the AAAAI would welcome opportunities for cross-training leading to dual board eligibility in both allergy/immunology and pulmonary medicine, as well as opportunities to partner with other organizations and the NIH to foster success for academic allergy trainees.

American Academy of Sleep Medicine (AASM) Research Support for Postdoctoral Fellows (Dr. Clete Kushida)

The AASM represents more than 1,600 sleep centers and the professional interests of more than 7,200 sleep medicine specialists, including multidisciplinary sleep medicine physicians, researchers, academicians, technologists, trainees, and students. The AASM provides funding for all of the American Sleep Medicine Foundation’s (ASMF) administrative costs and has funded most of the ASMF grants. The goal of the ASMF is to support education as well as clinical and basic research, and it awarded its first grants in 2000. Since then, the ASMF has awarded nearly $3 million to 37 projects. The ASMF recently established Physician Scientist Training Awards, which fund salary support, overhead, and supplies. There were five of these awards ($75,000 for 1 year) available for 2008, and four were granted with the following topics: (1) Effectiveness of Night Floats and Naps in Reducing the Risks of Interns’ 24+ Hour Shifts; (2) Sleep, Learning and Parkinson Disease; (3) Modulating Effect of Circadian Rhythm and Sleep/Wake Cycle on Severity of Sleep Apnea Hypopnea Syndrome; and (4) A Pilot Study Evaluating Changes in Pcrit after Therapy for OSA with Oral Appliance Therapy and Upper Airway Surgery. The ASMF has committed $1,875,000 to this award for 5 years. This award and other awards available in which postdoctoral fellows are eligible to apply are described in Table 1.

Table 1 Awards eligible to postdoctoral fellows

The CHEST Foundation (Dr. Alvin V. Thomas, Jr.)

The CHEST Foundation is the philanthropic arm of the American College of Chest Physicians (ACCP). It focuses on four key areas—critical care/end-of-life care; tobacco prevention; humanitarian service; and clinical research—and provides programs and initiatives that support ACCP members in these clinical and research activities. One of the Foundation’s goals is to maintain and strengthen its strategic relationships with private and public organizations to enhance its impact on world health.

The CHEST Foundation Awards Program

One of the important programs of The CHEST Foundation that holds the promise of improving patient care along with supporting clinical investigators is its awards program. The Foundation offers ACCP members a variety of awards in clinical research, leadership in end-of-life care, and humanitarian service. The CHEST Foundation awards have supported ACCP members early in their careers, as well as Distinguished Scholars. In 2009, The CHEST Foundation offered more than $600,000 in awards to ACCP members submitting outstanding applications in a variety of areas relating to cardiopulmonary and critical care medicine.

Awards are offered to members at various levels of membership as follows:

Distinguished Scholar Award (Offered to Senior ACCP Members)

• The Third Eli Lilly and Company Distinguished Scholar in Critical Care Medicine

• Leadership Award (offered to senior members)

• The Roger C. Bone Advances in End-of-Life Care Award

Clinical Research Awards (Except as Noted, Available to all ACCP Members, Including Fellows)

• The ACCP and CHEST Foundation Grants in Venous Thromboembolism (VTE) (available to senior members only)

• The Alpha-1 Foundation and The CHEST Foundation Clinical Research Award in COPD and Alpha-1 Antitrypsin (AAT) Deficiency

• The Association of Specialty Professors and The CHEST Foundation of the American College of Chest Physicians Geriatric Development Research Award (available to ACCP members in their first 5 years of academic faculty appointment)

• The CHEST Foundation California Chapter Clinical Research/Medical Education Award

• The CHEST Foundation Clinical Research Award in Women’s Health

• The CHEST Foundation and the LUNGevity Foundation Clinical Research Award in Lung Cancer

Humanitarian Awards (available to all ACCP Members and Fellows)

Newly named the D. Robert McCaffree, M.D., Master FCCP Humanitarian Awards at CHEST 2008 to honor its founder, Dr. D. Robert McCaffree, the 2009 Humanitarian Awards will be conferred at The CHEST Foundation’s Making a Difference Awards Dinner during CHEST 2009. Awards granted will be at three levels: $5,000, $10,000, and $15,000. These are given to the nonprofit and nongovernmental organizations throughout the world where ACCP members volunteer their time and medical expertise to help those most in need. The ACCP member is given an award certificate. In addition, a $5,000 Ambassadors Group Humanitarian Award is available.

Scientific Abstract Awards (offered to ACCP Members Within 5 years of Training and Fellows)

• Top five poster awards

• Alfred Soffer Research Awards

• Young Investigator Awards

American Lung Association-Nationwide Research Awards and Grants Program (Ms. Elizabeth Lancet)

The American Lung Association’s (ALA) Nationwide Research Awards and Grants Program foster both laboratory and patient-centered research designed to find cures and to prevent and relieve the suffering associated with lung disease. The ALA’s portfolio of awards and grants is unique in its breadth and approach to achieving the ALA’s mission.

The ALA has supported research since 1915 and believes that research is the key that will unlock the door to a better tomorrow for all people with lung disease. We depend on our scientists not only to pursue basic and clinical research but also to illuminate our public health education and outreach efforts.

The ALA funds a wide variety of research in many areas of lung disease. Many scientists are conducting research in the ALA’s main areas of focus: asthma; tobacco-related diseases, such as lung cancer and emphysema; and environmental health. The association also funds research in other areas, such as lung diseases that strike infants and children, the mechanisms of breathing, tuberculosis and AIDS, and deadly lung infections.

The ALA invests in researchers throughout their careers. An overwhelming 90% of American Lung Association Research Award Recipients have gone on to careers in lung health research.

The following grants and awards are part of the ALA’s research program portfolio:

Independent investigator awards

• Biomedical Research Grants: $40,000/yr. Seed monies for investigators researching the mechanisms of lung disease and general lung biology. Duration: up to 2 years.

• Clinical Patient Care Research Grant: $40,000/yr. Seed monies for investigators working on traditional clinical studies examining methods for improving patient care and treatment for lung disease. Duration: up to 2 years.

• Social-Behavioral Research Grant: $40,000/yr. Seed monies for investigators working on epidemiological and behavioral studies examining risk factors affecting lung health. This grant includes studies concerning the ethical, legal, and economic aspects of health services and policies. Duration: up to 2 years.

Training Awards

• Lung Health Dissertation Grant: $21,000/yr. Predoctoral support for students with an academic career focus and/or nurses pursuing a doctoral degree. Research areas of particular interest to the American Lung Association are: psychosocial, behavioral, health services, health policy, epidemiological, biostatistical and educational matters related to lung disease. Duration: up to 2 years.

• Senior Research Training Fellowship: $32,500/yr. M.D.s entering the third and fourth year of their research fellowship, and/or Ph.D.s entering the first and second year of their academic training as scientific investigators. Research areas of particular interest to the American Lung are: adult pulmonary medicine, pediatric pulmonary medicine, and lung biology. Duration: up to 2 years.

Alliance Award Program

The ALA’s research program provides opportunities to focus on targeted lung disease/health issues as well as work with like-minded medical societies in the funding of high-level lung disease research. Major donor sponsors and partners of the American Lung Association support these special research initiatives. The availability of the following award categories and areas of emphasis change annually and may not be offered every year.

Chronic Obstructive Pulmonary Disease

• American Lung Association/Alpha 1 Foundation Research Grant: $40,000/yr. Focused on basic science and clinical research studies of AAT Deficiency and COPD. Duration: up to 2 years.

• American Lung Association/COPD Foundation Research Grant: $100,000/yr. Focused on the treatment or cure of bronchiectasis. Duration: up to 2 years.

Lymphangioleiomyomatosis (LAM)

• American Lung Association/LAM Foundation Research Grant: $40,000/yr. Focused on the abnormal proliferation of smooth muscle that occurs in Lymphangioleiomyomatosis (LAM). Duration: up to 2 years.

Lung Cancer

• American Lung Association/LUNGevity Foundation Lung Cancer Discovery Award: $100,000/yr. Focused on novel medical treatments or a cure for lung cancer. Duration: up to 2 years.

• American Lung Association/Diane Emdin Sachs Lung Cancer Award: $75,000/yr. Focused on advancing small cell lung cancer diagnosis and treatment. Duration: up to 2 years.

Non-Tuberculosis Mycobacterium Diseases

• American Lung Association/NTM Info & Research, Inc. Award: $60,000/yr. Focused on pulmonary nontuberculous mycobacterial (NTM) infection and related infections.

Sleep Disorders

American Lung Association/National Sleep Foundation Pickwick Award: up to $52,000/yr. Focused on research related to sleep and breathing. Duration: up to 2 years.

Other Lung Diseases

American Lung Association/Dalsemer Research Grant: $40,000/yr. Focused on interstitial lung disease. Duration: up to 2 years.

American Lung Association/DeSouza Research Grant: $100,000/yr. Focused on bronchiectasis, infection with atypical Mycobacteria, particularly Mycobacterium avium and infection with Nocardia species. This grant includes epidemiological, laboratory or clinical research. Duration: up to 3 years.

American Thoracic Society (ATS) Research Support (Dr. Jo Rae Wright)

Science and research are among the core values of the ATS. Science forms the foundation for the care that our members provide to their patients and their families. Science also provides essential means for understanding health and disease, discovering cures, and improving the quality of life of the patients whom we serve. As the ATS has strived to produce first-class medical and scientific journals and attract the world’s top scientists to its premier International Conference in pulmonary, critical care and sleep medicine, the Society’s dedication to research is evident as an essential focus of its mission.

In June 2002, when the ATS Board of Directors voted unanimously to create a new research program, the Society further enhanced its strong commitment to the ideals of research. Since that historic moment, the ATS Research Program has grown steadily and continues to thrive. The goals of the ATS Research Program are to foster new research initiatives, to develop careers in research, to enhance the visibility of the ATS in research, and to develop strong collaborations between ATS and patient interest organizations, as well as other organizations that support respiratory-related research.

The ATS Research Program provides “seed funding” for junior investigators early in their research careers. The funding supports junior investigators working in collaboration with more established investigators. Grants are typically $50,000 per year for 2 years. Since its inception in 2002, research support has grown from approximately $100,000 to more than $1.5 million per year.

The Research Program operates under the critical guiding principles of partnership and collaboration. From the genesis of the program, the ATS realized that maximal progress could be made in research if the Society worked in harmony with other organizations focusing on the diagnosis, pathogenesis, and treatment of lung disease. The Research Program operates with the intention that the ATS will set research priorities and share funding responsibilities with other medical, research, clinical, professional, corporate, patient, and nonprofit health organizations with interests in pulmonary and critical care diseases and disorders.

However, each year there are a number of research priorities that are not covered by partnered research grants. To fund these equally urgent research priorities, the ATS Research Program also supports “unrestricted” research grants that are fully supported by the ATS.

In addition, the ATS provides peer review and grants management for ATS/GSK Fellow Career Development Awards that are funded by a generous contribution by Glaxo-Smith Kline, Inc. These awards provide $50,000 for 1 year to enhance career development (generally research training support) of Pulmonary/Critical Care fellowship trainees in ACGME-accredited programs. See Table 2.

Table 2  

A list of research partners and more information about the program is available at http://thoracic.org/sections/research/ats-research-program.html.

Parker B. Francis Fellowship Program (Dr. Thomas R. Martin)

The Parker B. Francis (PBF) Fellowship Program is sponsored by the Francis Families Foundation, a philanthropic foundation based in Kansas City, MO. Since 1976, the Fellowship Program has supported more than 760 new investigators performing clinical, translational, and basic research in pulmonary, critical care, and sleep medicine.

The PBF program supports M.D. and Ph.D. scientists who are within 7 years of their primary degree training and who either have an initial faculty position or who have a strong commitment for a faculty position during their PBF Fellowship. The research areas are broadly defined and relate to clinical, translational, and basic aspects of pulmonary medicine, lung cell and molecular biology, sleep, and control of breathing. Applicants are expected to work with an experienced mentor who has a funded laboratory and provides the scientific framework for the applicant’s project and scientific training. PBF Fellows receive approximately $50,000 per year for 3 years, most of which is devoted to salary support, with supplies covered by the mentor’s laboratory program. PBF Fellows may hold other NIH or foundation awards during their PBF Fellowship period, provided that the other awards are not for the identical work supported by the PBF Fellowship. Each Department of Medicine may have two active PBF Fellows at any given time, but can only receive support for one new PBF Fellow during each application cycle. The PBF Program supports between 15 and 18 fellows per year. Applications are submitted in October of each year and are reviewed by the Scientific Council in January of the following year, for funding beginning the following July. Applications are judged on the quality and career trajectory of the applicant, the experience and success of the mentor in science as well as training, and the scientific quality of the work proposed.

A recent survey of trainees who received PBF Fellowships in 1995, 2000, and 2002 showed that of 47 fellows funded, 40 responded to the survey, and of these, 93% remained active in research. Most spent more than 50% time in research. Since completing the PBF Fellowship, these individuals had received more than $88 million in research grants as principal investigator and had published more than 900 scientific articles as primary, senior, or coauthor. This excellent record of success shows the value of supporting outstanding new investigators in pulmonary research who are working in outstanding scientific training environments.

Appendix II

Summaries of three relevant, recent workshops sponsored by the American Thoracic Society, which discuss issues similar to those in the NHLBI Training Workshop were presented on behalf of the ATS by Dr. Augustine Choi.

The ATS Executive Committee established a Task Force in Scientific and Clinical Careers in the summer of 2008. The charge of this task force was to analyze the key attractions and barriers to entry and maintenance of clinical and scientific careers in pulmonary, critical care, and sleep medicine. The major objectives of the task force were the following:

• The Task Force should present specific recommendations to increase attractiveness of these careers for trainees at multiple levels and for professionals in mid-career.

• The Task Force should identify specific positive elements of these careers that could be utilized for greater awareness and increasing entry into the career pipeline.

• The Task Force also should make recommendations about whether and how to interact with other sister organizations with similar goals in this area.

• Within the goals of the Task Force is the identification of specific steps that can be initiated within the next 1–2 years to increase attractiveness of these career pathways.

Additional specific questions include:

• How can we increase the “pipeline” of undergraduate, medical, and graduate students interested in clinical and research careers related to pulmonary, critical care, and sleep medicine?

• How can we develop a network of “best practice” teaching materials to improve the quality of student teaching and thereby try to attract more students? Is there a role for ATS developing a method of recognizing a cadre of master teachers and/or mentors?

The Appendix (personal communication approved by the ATS Executive Committee) includes the summary of the recommendations of the ATS Task Force in Scientific and Clinical Careers, which was sent to the ATS Executive Committee in December of 2008.

“Attracting and Retaining Individuals in Academic Pulmonary, Critical Care, and Sleep Medicine”

The Academic Career Subcommittee members participated in two conference calls and multiple electronic communications with these interactions designed to analyze key attractions and barriers to entry and maintenance of clinical and scientific careers in pulmonary, critical care, and sleep medicine. While addressing a broad spectrum of career opportunities in academic Pulmonary/Critical Care Medicine/Sleep Medicine (Pulm/CCM/Sleep), the Academic Career Subcommittee was deeply concerned about the shrinking and aging physician-scientist/clinical-investigator workforce, and the acute need to recruit and retain young physician-scientists in the field of Pulm/CCM/Sleep. A formal SWOT Analysis (Strengths, Weaknesses, Opportunities and Threats) was undertaken by each committee member who also reviewed drafts of Task Force survey questions and submitted additional questions for consideration. This document represents the summary of the formal SWOT analyses as well as the specific recommendations generated to increase attractiveness of academic Pulm/CCM/Sleep careers targeting trainees at multiple levels and professionals in mid-career.

General Strengths of a Career in Academic Medicine

• Scientific careers in academic medicine are exciting, intellectually stimulating, enjoyable, and satisfying.

• Many career pathways exist in academic medicine, including clinical educator and physician-scientist pathways.

• An academic career permits an attractive balance between patient care, teaching, and research as well as intellectual independence and flexibility.

• Academic medicine is more stimulating than private sector clinical medicine and offers greater variety and geographic mobility.

• Academic medicine is a noble calling, particularly in the training of future leaders of academic medicine.

Specific Strengths of an Academic Career in Pulmonary/Critical Care/Sleep Medicine

• Pulm/CCM/Sleep provides a procedure-rich specialty with intensive care opportunities that are attractive to many young physicians.

• Academic Pulm/CCM/Sleep medicine offers greater flexibility than private sector clinical medicine in terms of daily scheduling, meeting family obligations, and lifestyle.

• Many excellent role models exist in academic Pulm/CCM/Sleep.

• The Division of Lung Diseases of NHLBI is proactive in attracting young trainees and junior faculty.

• A number of Chairs of Departments of Medicine in prestigious academic medical centers are Pulm/CCM/Sleep physicians.

• Divisions of Pulm/CCM/Sleep, as well as their training programs, are highly regarded in major medical centers.

Weaknesses in Choosing an Academic Pulmonary/Critical Care/Sleep Medicine Career

• Many medical school graduates and residents seek medical careers that do not require a 100-hour work week as Pulm/CCM portends. Current perception is of high stress, long work hours in ICU environment, possibly with required nighttime or in-house call coverage

• Inadequate number of positive role models in academic Pulm/CCM/Sleep medicine

• Residents and fellows have poor understanding of diverse academic career paths

• Difficult to predict which individual trainees are likely to gravitate toward an academic career, making it difficult for training programs to focus limited resources on the most promising candidates

• Disparity in academic Pulm/CCM/Sleep medicine incomes versus private practice

• Limitations in exposing medical students to pulmonary and sleep biology pathobiology

• Lengthy period of research training to become an independent investigator combined with much lower salaries

• Extended duration of ACGME-mandated clinical activities which reduce research experience

• Physician-scientists often are unable to “get away from their work,” meaning that we constantly think about our work and new research ideas. Also, the race for funding never ends so there is no time for a “break”

• Little or no opportunities for part time work because this is not allowed by NIH

• Excessive clinical demands on junior faculty, especially physician-scientists

Opportunities for Increasing Interest in Academic Pulm/Crit Care/Sleep Medicine Careers

• Dispel myths about academic medicine careers: salary structures, lifestyle

• Pulm/CCM/Sleep is a rapidly evolving, evidence-based specialty with many opportunities for basic and clinical research

• Expanded recent efforts at NIH focus on awards for early career trainees, first-time RO1 recipients, and programs to facilitate debt reduction

• Junior faculty could benefit from formal education focusing on career development and research (grant writing, for example), whereas fellows could benefit from more formal education about transitioning careers to faculty status

• Increase opportunities (summer and year round) to expose college students, medical students, and house staff to Pulm/CCM/Sleep research

• Strengthen involvement of Pulm/CCM/Sleep physician-scientists in coursework in medical schools

• Provide a culture of academic medicine where part-time work would be possible for people with young families, combined with a substantial campaign to convince students and residents that academics is flexible and “friendly”

• Research (mostly clinical research) is moving into community hospitals, creating an opportunity for more physician-scientists in locations other than large cities

Threats to Attracting and Retaining Individuals in Academic Pulmonary, Critical Care, and Sleep Medicine

• Declining number of individuals entering pulmonary for the past 5–10 years

• The supply of physician-scientists/clinician-investigators in academic medicine is declining: debt load, prolonged duration of training, research funding woes

• Competing specialties in critical care (surgery and anesthesia) and sleep (neurology)

• Difficulty and uncertainty of securing meaningful extramural grant funding

• Perception of limited job security related to continue grant funding

• Excessive duration of training and time to achieve independent funding

• Increased value in work-life balance and controllable lifestyles in the selection of a career pathway

• 85% of medical students have debt of at least $100,000 at the time of graduation

• Clinical demands in academic centers are already heavy and potentially will increase if 24/7 attending coverage in ICUs is required

• The attraction for Pulm/CCM/Sleep training for many residents continues to be the ICU and procedures

• An aging population will require more Pulm/CCM/Sleep specialists for community clinical work, not for research

• Severely impaired NIH funding is greatly exacerbating the shortage of physician-scientists, unlikely to be remedied without substantial increases in funding

• Perception that being a physician-scientist means forever being on a treadmill

• Women find physician scientist careers less attractive than men

• Pulmonary is being dropped as a critical component of critical care training in some programs

Summary of Recommended Actions

• ATS should join other societies, such as Association of Professors of Medicine, AAP, ASCI, etc. in nurturing the pipeline for physician scientist careers

• ATS should formalize an academic mentoring program for fellows and junior faculty with academic leaders

• ATS should continue to advocate for additional mechanisms of salary support for promising academic oriented transitioning fellows with mandated protected time and for debt reduction grants for junior faculty

• ATS should convene PIs of pulmonary training grants to strategize on best practices in recruitment and retention of academic fellows

• ATS should continue to identify major concerns of residents, fellows, and junior faculty for pursuing careers in academic medicine

• ATS should develop recommendations for the comprehensive mentoring of fellows and junior faculty pursuing careers in academic medicine focusing particularly on challenges presented by specialization in Pulm/CCM/Sleep. Include website information with links for both mentors and mentees

• ATS should disseminate detailed financial data (salary) for faculty during their first few years of academic practice to help dispel myths of dramatic salary differential between academic and private practice during the first several years post-fellowship

• ATS should collect and disseminate accurate data related to career success and retention rates for academic Pulm/CCM/Sleep faculty that may offset pessimistic attitudes about academic career viability

• Increase exposure of medical students to strong Pulm/CCM/Sleep role models

• ATS should fund a prospective assessment of trainee characteristics that predict future success in academic Pulm/CCM/Sleep and assist academic training programs and divisions in recruitment, selection, and training of the most promising candidates for successful careers in academic Pulm/CCM/Sleep.

References

• 1. Revitalizing the Nations Physicians Scientist Workforce. Association of Professors of Medicine, Report of the Physician Scientist Taskforce. Monograph, pp 1-45.

• 2. (2006) Academic and Career Development of Pulmonary and Critical Care Physician-Scientists. Am J Respir Crit Care Med 173:23–31.

• 3. (2005) Attitudes & Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training. Chest 127:630–636.

• 4. (2005) Pulmonary and Critical Care: The Unattractive Specialty. Chest 127:1085–1087.

ATS Scientific and Clinical Careers in Pulmonary, Critical Care and Sleep Task Force

Sister Societies and Other Organizations Subcommittee

• Charge: How can the ATS work with sister societies to improve the attractiveness and eliminate some of the barriers to careers in pulmonary, critical care and sleep?

SWOT Analysis

Strengths

• 1. Each of the major sister organizations, including the American Thoracic Society (ATS), the American College of Chest Physicians (ACCP), the Association of Pulmonary and Critical Care Program Directors (APCCCMPD), and the Society for Critical Care Medicine (SCCM) are strongly committed to increasing the pool and numbers of individuals entering clinical, academic, and public health careers in pulmonary, critical care, sleep, and related disciplines.

• 2. The larger organizations have complementary strengths, with the ATS most vocally supporting academic and research careers, whereas the focus of ACCP and SCCM remains largely centered on clinical career. The APCCMPD is principally focused on training.

• 3. Most of our members (including leadership) are members in at least two of these organizations. Therefore, cross-talk should be easily facilitated. The APCCMPD group is independent and convenes both in association with the international meetings of the ATS and the ACCP.

• 4. Workforce analysis continues to support expansion of the numbers of individuals needed for Pulmonary, Critical Care, and Sleep Career, meaning that the career outlooks for those who select to train in our specialties looks to remain extremely favorable for the foreseeable future.

Weaknesses

• 1. Traditionally some competition has been perceived in attracting fellow members to one or another of these sister societies. This perception has perhaps limited concerted efforts to increase recruitment of members in training to the general area of pulmonary, critical care, sleep, and related disciplines.

• 2. Whereas these sister societies have focused on increasing the participation of subspecialty fellows at their international meeting, relatively little effort has been centered on attracting internal medicine residents, and undergraduate science students to attend these meetings. These individuals have not yet made career selections.

• 3. Healthcare reimbursement for Pulmonary and Critical Care is currently not as attractive as other subspecialties, such as cardiovascular medicine, gastroenterology, and oncology. This is not the situation for sleep medicine, which for the near future may serve as a mitigating factor.

• 4. Work-life balance is increasingly perceived as unfavorable for career selection in pulmonary and critical care medicine. This limits recruitment in general, but also may significantly, negatively impact the recruitment of women candidates into clinical careers within these disciplines, particularly critical care.

• 5. The pool of U.S. students entering science and technically related careers continues to decline. However, internationally trained individuals in these disciplines remain plentiful.

Opportunities

• 1. Considerable opportunities exist to reach out to both undergraduate students and Ph.D. students and internal medicine residents early in their training, before final career selection has been made. Particular interest might be focused on M.D./Ph.D. students interested in academic careers.

• 2. Sleep medicine currently enjoys attractive reimbursement and, in a mixed specialty career, can mitigate several of the factors listed above (reimbursement and work-life balance).

• 3. Numerous internationally trained individuals have interest in pulmonary, critical care, sleep, and related disciplines but are hampered in completion of training due to regulatory and legislative issues (e.g., Visa and NIH training grant issues).

• 4. Both the ATS have excellent support services for approaching and communicating with governmental bodies and agencies about these concerns. Furthermore, these sister societies have a significant history of working together on key regulatory issues.

Threats

• 1. Projected worsening of medical economics and health care reimbursements threatens to reduce interest in clinical careers. Considerable concerns exist about reduced reimbursements for ICU-related diagnoses as well as changing reimbursement for pulmonary and sleep diagnostic procedural reimbursements.

• 2. Uncertainty that reduced funding for basic and clinical research at the Federal level and for public health initiatives might occur threatens to reduce interest in research and academic careers in pulmonary, critical care, sleep, and related disciplines.

• 3. Increased focus of the next generation of trainers on appropriate work-life balance may further threaten our already overtaxed specialty areas.

Suggested Solutions

• 1. Greater communication and concerted efforts between these sister societies and other organization will be needed to increase the numbers of individuals seeking careers in pulmonary, critical care, sleep, and related disciplines.

• 2. Consideration may be given for a summit meeting or joint conference call series involving representatives of the sister societies and organizations to improve the attractiveness and eliminate some of the barriers to careers in pulmonary, critical care, sleep and related areas, as listed below.

• 3. Concerted efforts must be undertaken to increase participation of undergraduate science students, M.A., and Ph.D. students, and undifferentiated internal medicine residents, as well as international trainees within each of the key societies and organizations. Suggested mechanisms can include expanded travel awards and committee memberships specifically for these types of trainees to participate at these meetings. In addition, we may want to focus some specific effort on M.D./Ph.D. students or M.D./M.P.H. students seeking academic careers.

• 4. Consideration should be given for outreach activities of domestic and international trainees at the undergraduate or internal medicine level beyond participating at the international meetings of these societies. For instance, societies might consider expanding grants or even joint funding opportunities specifically to facilitate the lab research or training of such individuals, who have to yet select a career area.

• 5. Societies need to continue to jointly lobby governmental and regulatory organizations to support increased training slots for pulmonary, critical care, sleep, and related disciplines.

• 6. Investigate and support studies of new clinical staffing models that improve work-life balance.

• 7. Increase communication and joint efforts of the sister societies to voice concerns about Medicare reform and reimbursement changes so that reduced clinical revenue does not further compromise recruitment of trainees into pulmonary, critical care, sleep, and related disciplines.

• 8. Enhanced joint efforts of the sister societies to communicate and work for stable governmental funding both for training and research in areas related to pulmonary, critical care, sleep, and related disciplines.

• 9. Increased joint effort of the sister societies to communicate and petition for governmental and legislative reform bringing relief for international trainees (e.g., enhanced opportunities for NIH training grant participation, more flexible visa rules). This would significantly foster greater influx of learners into pulmonary, critical care, and sleep medicine and related research areas.

Pulmonary and Critical Care

ATS Task Force on Career Attractiveness

S.W.O.T. Analysis

Process: Committee members and local Pulmonary/Critical Care Medicine (PCCM) faculty and fellows were contacted in person and by email and asked to describe what they found attractive or unattractive about a career in PCCM. In addition, small unstructured focus group meetings were held with internal medicine residents who had recently decided on subspecialty fellowship. Comments were organized into S.W.O.T. format and circulated to committee members for comment and revision. We focused on issues related to house staff choice of a career in PCCM, rather than Fellows’ choice of academic careers or career retention of practicing PCCM specialists and scientists.

Review of data during the past 5 years from the NRMP does not indicate dwindling interest in PCCM. On the contrary, the number of fellowship programs, slots, and applicants has all increased and the ratio of applicants to positions has remained stable. We considered the goal of this exercise to maintain the health of a vigorous field of Medicine, rather than respond to a demographic crisis.

Strengths

• 1. High acuity, high stakes, high adrenaline medicine

• 2. Applied physiology prominent feature of diagnosis and management

  • a. Appeals to the mechanically inclined

  • b. Bridges basic and clinical science

  • c. Ideal teaching material for clinician-educators

• 3. Wide range of practice settings

  • a. Ambulatory care

  • b. Critical care

  • c. Sleep medicine

• 4. Wide range of patient care opportunities

  • a. Occupational medicine

  • b. Short-term consultation

  • c. Long-term chronic care

  • d. Palliative care

  • e. Acute crisis intervention

• 5. Wide range of potential lifestyles which can evolve over time

  • a. Fully in-patient

  • b. Critical care

  • c. Ambulatory care

  • d. Sleep

• 6. Procedure-oriented practice, if desired, with expanding procedural options

• 7. Opportunities for public health and political advocacy

  • a. Tobacco

  • b. Air pollution

  • c. Industrial medicine

  • d. Global health

  • e. Disaster management

• 8. Some diseases, for example PAH, CF, and ARDS, have had major breakthroughs and improvements in outcomes in recent years

• 9. Multi-system disease management

  • a. Critical care crosses silos: the general internist for the really sick

  • b. Many pulmonary diseases are multi-system (PAH, neuromuscular diseases, rheumatologic illnesses, cancer)

• 10. End-of-life care

  • a. Opportunities for rewarding relationships with patients and families

  • b. Opportunities to improve neglected area of medical care

Weaknesses

• 1. Many common PCCM diseases have little public awareness (COPD, ARDS) or bearing the stigma of self-induced illness (emphysema).

• 2. Common chronic illnesses have intractable symptoms and little new therapy (COPD).

• 3. House staff typically encounter outpatient treatment “failures” whose treatment appears formulaic:

  • a. Refractory COPD and asthma

  • b. Continued smokers

  • c. Medical non-adherence

  • d. Progressive CF patients

  • e. Lung transplant failures

• 4. Almost all patients suffer dyspnea, a miserable symptom with no treatment.

• 5. Compensation and work hours (or at least their ratio) may not be on a par with “competing” subspecialties, such as Cardiology and GI.

• 6. Critical care practice can lead to mid-career burnout.

• 7. General sense that much of ICU care is wasted on patients unlikely to benefit.

• 8. Perceived by house staff as not having a particularly family-friendly lifestyle, and few female role models.

Opportunities

• 1. Increasing public awareness and attention is being paid to asthma and COPD

• 2. Staffing shortages in Critical Care will persist for the foreseeable future

• 3. Increasing emphasis is being placed on multidisciplinary care, protocols, and patient safety, for which ICUs have been the advance guard

• 4. Epidemic of sleep-disordered breathing is occurring as a complication of obesity

• 5. House staff exposure to successful outpatient management of pulmonary disease can be improved

• 6. House staff teaching on pulmonary services can be improved

  • a. Some programs excel in MICU, others on in-patient services

  • b. Few excel at teaching outpatient management and continuity

  • c. Commitment to teaching cited by many house staff as strong positive when present

  • d. Role modeling and teaching of long-term doctor-patient relationships and management can be strengthened in many programs

Threats

• 1. Reimbursement always under stress; several of CMS proposed “never events” are common and probably cannot be completely eliminated in ICU patients.

• 2. Society of Critical Care Medicine (SCCM) is positioning itself as the critical care society and multiple non-PCCM pathways into critical care exist.

• 3. One-year sleep fellowship may divert many applicants away from Pulmonary or PCCM.

• 4. Demands for 24-h attending staffing of ICUs may make lifestyle less attractive.

• 5. Hospitalist movement has created opportunities to practice critical care in many hospitals without the need for additional fellowship training.

• 6. Duty hour restrictions on house staff have increased service demands on PCCM fellows in some programs, especially for ICU coverage. Disgruntled Fellows are one of the most effective deterrents for interested house staff.

Recommendations

• 1. An enthusiastic commitment to house staff education was routinely cited as a feature that attracts house staff to a subspecialty. Application of this will necessarily vary by local institutional resources. However, the following should be considered:

  • a. Careful weighing of educational versus service requirements for house staff on pulmonary or ICU rotations.

  • b. Formal curriculum development as a vehicle to focus faculty on educational issues and methods.

  • c. Self-conscious role modeling by clinicians.

  • d. Efforts to recognize and reward teaching excellence at the Divisional and Departmental levels.

  • e. Incorporating regular didactic sessions into medical ICU or pulmonary rotations.

• 2. Broaden house staff exposure to the wide range of practice, scientific, and lifestyle opportunities within the field.

  • a. Incorporate exposure to successful outpatient management and longitudinal care into house staff training.

  • b. Provide opportunities for house staff participation in research or advocacy activities.

  • c. If funding is available, sponsor house staff attendance at national or regional specialty society meetings.

Appendix III

Steven H. Abman

University of Colorado School of Medicine

The Children’s Hospital

Aurora, CO 80045

Bruce S. Bochner

Division of Allergy and Clinical Immunology

Johns Hopkins University School of Medicine

Baltimore, MD 21224

Brian Carlin

Association of Pulmonary and Critical Care Medicine Program Directors

Drexel University School of Medicine

Allegheny General Hospital

Pittsburgh, PA 15212

David M. Center

Associate Provost for Translational Research

Pulmonary, Allergy and Critical Care Medicine

Boston University

Boston, MA 02118

M. Brad Drummond

Pulmonary and Critical Care Medicine

Johns Hopkins University School of Medicine

Baltimore, MD 21224

Thomas Ferkol

Pediatric Pulmonary Training Directors Association

Department of Pediatrics

Washington University School of Medicine

St. Louis, MO 63110

Deanna Green

Pediatric Pulmonary Division

Johns Hopkins University

Baltimore, MD 21287

David Ingbar

Pulmonary, Allergy, Critical Care and Sleep Division

University of Minnesota School of Medicine

Minneapolis, MN 55455

Clete Kushida

American Academy of Sleep Medicine

Stanford Sleep Disorders Clinic and Research Center

Stanford, CA 94305-5730

Elizabeth Lancet

American Lung Association

New York, NY 10006

Thomas R. Martin

Parker B. Francis Foundation

University of Washington

VA Puget Sound Health Care System

Seattle, WA 98195

Hugh O’Brodovich

Department of Pediatrics

Lucile Packard Children’s Hospital

Stanford School of Medicine

Stanford, CA 94305-5208

Allan I. Pack

Center for Sleep and Respiratory Neurobiology

University of Pennsylvania School of Medicine

Philadelphia, PA 19104

Nirav G. Shah

Pulmonary and Critical Care Medicine, NIH

National Institutes of Health

University of Maryland Medical Center

Baltimore, MD 21201

Alvin V. Thomas, Jr.

American College of Chest Physicians

Howard University

Division of Pulmonary and Critical Care Medicine

Howard University Hospital Washington, DC 20011

Scott T. Weiss

Channing Laboratory

Brigham and Women’s Hospital

Boston, MA 02115

Jo Rae Wright

American Thoracic Society

Cell Biology, Pediatrics and Medicine

Duke University School of Medicine

Durham, NC 27710

Pamela Zeitlin

Pediatric Assembly, American Thoracic Society

Department of Pediatrics

Johns Hopkins University

Baltimore, MD 21224

National Heart, Lung, & Blood Institute

Thomas Croxton

Airway Biology and Disease Branch

Division of Lung Diseases

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, Maryland 20892-7952

James P. Kiley

Division of Lung Diseases

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, Maryland 20892-7952

Helena Mishoe

Office of Minority Health Affairs

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD 20892-7952

Carl A. Roth

Associate Director for Scientific Program Operation

Director, Office of Science and Technology

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD 20892-7952

Michael Twery

National Center on Sleep Disorders Research

Division of Lung Diseases

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, Maryland 20892-7952

Gail Weinmann

Division of Lung Diseases

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, Maryland 20892-7952

Roy L. White

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, Maryland 20892-7952