Academic and career development of pulmonary and critical care physician-scientists

RATIONALE: The supply of research-oriented physicians is declining. OBJECTIVES: Define barriers to successful career development in academic pulmonary/critical care medicine and discover strategies that promote the recruitment and retention of research physicians. METHODS: Focus groups and Web-based survey of fellows and junior faculty in pulmonary/critical care and neonatology divisions in 2002. Primary survey areas were educational debt, mentoring, institutional resources, information needs, and academic productivity. MAIN RESULTS: Monthly educational debt payments were a small fraction of junior faculty household income, but the debt/income ratio was larger for fellows and less for female faculty. The debt/income ratio was not associated with the perceived likelihood of an academic career. Respondents felt they lacked understanding of the roadmap to success and formal assistance in career development. Mentors were perceived as personally supportive, but less helpful in career development. Perceived likelihood of an academic career was most associated for faculty with institutional research support and for fellows with mentors' academic advising. Better research skills and more career development activities were associated with respondents having a Ph.D. mentor. Perceptions about academic physicians' job security were pessimistic. CONCLUSIONS: Multiple factors influence decisions to pursue an academic medical career. In addition to alleviating financial pressures, academic careers may be aided by (1) providing more information about career pathways, job expectations, and success rates; (2) increasing career development mentoring; and (3) implementing formal curricula similar to Ph.D. programs. For pulmonary/critical care medicine faculty, current federal educational debt relief programs may have only a modest effect on academic retention.     

Recruitment and retention in academic medicine--what junior faculty and trainees want department chairs to know

Attracting and retaining bright and motivated physicians remains a high priority for academia. Historically, the recruitment of trainees into academia and the retention of junior faculty have been suboptimal. To learn more about the perceived obstacles that discourage the pursuit of academic careers, a Workshop on Academic Career Pathways was conducted during the 2011 Southern Regional Meetings held in New Orleans. The audience included mainly residents and fellows as well as junior and senior faculties. Speakers described career options in academic medicine focusing on the clinician-investigator and the clinician-educator tracks. Afterward, the audience was asked to identify perceived obstacles to recruitment and retention in academic medicine. The group identified 10 major obstacles in 3 categories: financial challenges, personal mentoring and academic skills acquisition. This article summarizes the workshop proceedings and ends with recommendations to chairs and department leaders for improving recruitment and retention in academic medicine based on the discussion.     

Getting Funded

For aspiring clinical investigators, career development awards provide a primary mechanism for "getting funded." The objective of this article is to provide information that will facilitate a successful application for a research career development award. Specifically, we discuss important issues that cut across the diverse array of awards, and we highlight the most common sources of funding, including the unique opportunities that are available for underrepresented minorities. The target audience includes junior faculty and fellows who are pursuing or considering a research career in academic medicine, as well as their mentors and program directors.     

Do general internal medicine fellows find jobs that match their training?

We surveyed employers of general internists at teaching hospitals to determine whether they prefer that new hires are graduates of general internal medicine (GIM) fellowships. We surveyed former GIM fellows who graduated between 1988 and 1994 to determine whether they found jobs with protected research time and whether the positions they found matched their expectations. Employers rated a GIM fellowship, among other criteria, as important for clinician-researchers, but not for clinician-educators. For graduates categorized as clinician-researchers (with more than 33% of their time protected for research), there was a good match between their actual time allocations for research and clinical work and what they recalled their expectations were when looking for a job. Clinician-educators had a marked discordance between actual time allocations for research and clinical work and their recollection of their expectations when looking for a job.     

Succeeding in Aging Research During the Pandemic: Strategies for Fellows and Junior Faculty

Fellows and junior faculty conducting aging research have encountered substantial new challenges during the COVID-19 pandemic. They report that they have been uncertain how and whether to modify existing research studies, have faced difficulties with job searches, and have struggled to balance competing pressures including greater clinical obligations and increased responsibilities at home. Many have also wondered if they should shift gears and make COVID-19 the focus of their research. We asked a group of accomplished scientists and mentors to grapple with these concerns and to share their thoughts with readers of this journal.     

Factors in the choice of academic or practice careers in pulmonary medicine

The characteristics, motives, and sources of job satisfaction were compared between persons choosing a research career in academic pulmonary medicine and those choosing a career in the practice of pulmonary medicine. In a first study, established practitioners and academic researchers were asked what the main influences were on their career decisions, from what they obtained job satisfaction, and why they did or did not choose academic medicine. After these results were obtained a second questionnaire was sent to all pulmonary fellows in U.S. programs asking them their future career plans, reasons for their career choices, factors in their job satisfaction, and attitudes toward an academic career. Both current and future researchers desired intellectual challenge, continued learning, and an opportunity to investigate, whereas established and future practitioners derived more satisfaction from patient care. The opportunity to be creative, the chance to work fixed hours, and to gain national recognition were more important to future academic researchers. The prospective practitioners rated helping people, freedom from bureaucracy, and income level as the major determinants of their career choice. In addition to the personal qualities, many environmental factors, such as participating in a successful research project and encouragement from faculty, were important in leading a pulmonary fellow to select a research career.     

Getting funded

For aspiring clinical investigators, career development awards provide a primary mechanism for “getting funded.” The objective of this article is to provide information that will facilitate a successful application for a research career development award. Specifically, we discuss important issues that cut across the diverse array of awards, and we highlight the most common sources of funding, including the unique opportunities that are available for underrepresented minorities. The target audience includes junior faculty and fellows who are pursuing or considering a research career in academic medicine, as well as their mentors and program directors.     

Attitudes of internal medicine subspecialty fellows toward primary care

Subspecialists deliver a substantial proportion of primary care but little is known about how their training affects their attitudes toward this role. We surveyed a department of medicine to determine fellows' (N = 34) attitudes toward primary care and how these compared with the attitudes of house staff (N = 45) and faculty (N = 66). Continuous, coordinated, and accessible care as departmental policy was almost unanimously endorsed by all physicians. In contrast, fellows less often supported the provision of such care for their own patients in actual clinical situations. Fellows were also less likely than either house staff or faculty to endorse primary care attributes for their own patients. Departments of medicine should examine how negative attitudes toward primary care develop in subspecialty fellows and whether these attitudes persist after fellowship.     

Geriatrics training in general internal medicine fellowship programs: current practice, barriers, and strategies for improvement

To ensure its growth and prosperity, general internal medicine will need to embrace care of the elderly, research on aging, and geriatrics education as components of its core mission. Experts agree that general internal medicine fellows could benefit from increased opportunities in research on aging and geriatrics education; however, important barriers will hamper efforts to integrate geriatrics training into general internal medicine fellowship programs. This article reviews the barriers to integration and proposes solutions for overcoming those barriers. As a result of interviews and meetings with a broad representation of general internists, geriatricians, funding agencies, and policymakers, we propose 2 interventions: 1) the development of institutional program grants to foster collaboration between general internal medicine and geriatrics faculty in the training of general internal medicine fellows and 2) the creation of a 3-year fellowship program combining general internal medicine and geriatrics. This article discusses the importance of evaluating these and other programs intended to increase the geriatrics experience of general internal medicine fellows, and it describes the potential implications of these changes for a broad array of stakeholder institutions.     

Strength in Numbers: A National Monthly Case Conference Series for Fellows

Small fellowship programs face challenges in providing learners with sufficiently diverse experiences and patient populations. The Fellows Most Difficult Case Conference is designed to broaden geriatric medicine fellows' exposure to cases and to faculty and fellows from around the country through a monthly telephone conference. We describe this innovative approach to a national monthly complex case conference that fellows from almost one‐third of geriatrics fellowship programs attend, including its value to geriatric fellows and faculty and administrative costs. Once per month, a fellow presents a case, a moderator leads the discussion, and 2 faculty members provide teaching points during the 60‐minute session. Participants rated the conference's value using an 11‐item on‐line survey followed by a debriefing held during a regularly scheduled 2017 monthly conference. Thirty‐six percent of eligible participants responded to the survey (67/186), with 75% of respondents reporting that they applied knowledge gained from the conferences to their patient care at least 1 or 2 times per month and 41% that they applied it at least once per week. Participants appreciated the inclusion of multiple programs, the duration of the conference, and the interactive approach. Our administration time was less than 5 hours per month, plus a few additional hours annually to create the academic year schedule. We believe that this national case conference, the first of its kind in the country, involving almost one‐third of geriatrics fellowship programs, is an innovative and valuable way for fellows to explore complex cases and variations in regional perspectives and to connect with additional colleagues.     

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.     

Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study

OBJECTIVES: Computer-based colonoscopy simulation (CBCS) is being utilized in endoscopy training without supporting evidence that it improves patient-based colonoscopy performance. The goal of this pilot study was to determine if CBCS training improves gastroenterology (GI) fellows' patient-based colonoscopy skills. METHODS: Competency at colonoscopy among 4 novice GI fellows who completed a 6-h CBCS curriculum was compared with 4 novice fellows who were not CBCS-trained. Measurements of competency were rendered by supervising faculty by recording "insertion time,"depth of unassisted insertion,"independent procedure completion,"ability to identify endoscopic landmarks,"inserts in a safe manner,"adequately visualizes mucosa on withdrawal," and "responds appropriately to patient discomfort" with each colonoscopy. RESULTS: Simulator-trained fellows outperformed traditionally trained fellows during their initial 15 colonoscopies in all performance aspects except "insertion time" (pp < 0.05). Simulator-trained fellows inserted the endoscope significantly further and reached the cecum independently nearly twice as often during this early training period. Three parameters ("depth of insertion,"independent completion," and "ability to identify landmarks") demonstrated a continued advantage out to 30 colonoscopies. Beyond 30 procedures, there was no difference in the performance of the two groups. CONCLUSION: In this pilot study, a 6-h CBCS curriculum provides an early training advantage by enhancing competency at the early stages of patient-based colonoscopy. These advantages are negligible after approximately 30 patient-based procedures. CBCS-enhanced training may allow faculty to be more efficient with their colonoscopy practice.     

The safety of bronchoscopy in a pulmonary fellowship program

STUDY OBJECTIVE: To determine the complication rate from supervised training bronchoscopy in a single pulmonary fellowship program, and to examine the effects of fellow and faculty experience on this complication rate. DESIGN: A retrospective review of preexisting quality improvement data from one center for the time period July 1, 1991, until June 30, 2005, was performed. The data were stratified based on the fellow year group and the staff experience level. The types of complications were recorded. SETTING: The study was performed at an accredited pulmonary and critical care fellowship program at a military medical center in the United States. PARTICIPANTS: Fifty-one pulmonary and critical care medicine fellows and 20 staff supervising physicians performed the bronchoscopies that were included in this study. RESULTS: A total of 3,538 training bronchoscopies were performed during the study period with 73 complications for a complication rate of 2.06%. The most common complication was pneumothorax. The overall complication rates for first-year fellows (1stYFs), second-year fellows, and third-year fellows were not significantly different from the total complication rate. Training bronchoscopies supervised by junior staff had a complication rate not significantly different from that of senior staff. The cumulative complication rate for the first trimester for 1stYFs was 3.1%, whereas the cumulative complication rate for the second plus the third trimester for 1stYFs was 1.57% (p < 0.05). CONCLUSIONS: Training bronchoscopy performed during a pulmonary fellowship is a safe procedure in a supervised setting. Patients undergoing bronchoscopy performed by novice bronchoscopists have an increased complication rate during the first trimester of bronchoscopist training.     

Faculty development in general internal medicine. Perceptions concerning academic survival

To understand the educational needs of faculty general internists in academic hospital environments, surveys of general internal medicine division chiefs, department of medicine chairmen, and members of the Society for Research and Education in Primary Care Internal Medicine were undertaken. Results indicated considerable interest in faculty development activities among all physicians sampled. Division chiefs and department chairmen viewed such activities as feasible, potentially effective, and were willing to assume considerable responsibility in providing educational opportunities to their faculty. Although some physicians viewed self-learning as a potentially effective educational method, the vast majority preferred learning in a small group taught by an expert. Specific content areas for faculty development were assessed, as were the skills thought to be essential for personal job satisfaction, academic promotion, and organizational effectiveness.     

Career development in academic medicine

Clinical academic medicine desperately needs the continued infusion of talented young academicians, but many young faculty are not pursuing strategies that optimize their chances for academic survival. Many junior faculty are overburdened with clinical demands and do not have a well-focused research agenda. Such situations will hinder the full development of many talented young persons. In order to optimize chances for success, young faculty should clearly define their goals, carefully negotiate the terms of their employment, practice sound principles of time management, identify a mentor, and develop a focused research agenda.     

CLINICAL RHEUMATOLOGY TRAINING IN AN UNCERTAIN FUTURE. Opinions of Recent and Current Rheumatology Fellows About an Extended Fellowship in Musculoskeletal Medicine

Objective. To estimate among recent and current rheumatology fellows the appeal of a 3-year rheumatology fellowship emphasizing musculoskeletal medicine. Methods. A survey of 348 trainee members of the American College of Rheumatology during 1990–1993, by mailed questionnaire. Results. The response rate was 77.8% (n = 271). Both recent and current fellows indicated that they desired more experience in musculoskeletal medicine. Most notably, 50% of current fellows, and a significantly higher proportion of recent fellows (70%; P < 0.005), indicated that they would have opted for a 3-year fellowship in musculoskeletal medicine had one been available to them at the completion of their residency. Conclusion. Expertise in musculoskeletal medicine is desired by a sufficient proportion of recent and current rheumatology fellows to warrant the investment in another year of training.     

Contributions of general internal medicine teaching units

OBJECTIVE: To identify and describe general internal medicine teaching units and their educational activities. DESIGN: A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997. MEASUREMENTS AND MAIN RESULTS: Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine. CONCLUSIONS: General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers. Presented at the national meeting of the Society of General Internal Medicine, April 1998, and the Bureau of Health Professions, June 1998. This work was supported by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Md, grant 103HR960470P000-000; and the Society of General Internal Medicine.