The lifeblood of any specialty is innovation and discovery. It is important for the field of otolaryngology and its patients that we identify, recruit, train, and develop the next generation of researchers in otolaryngology. This article describes programs and resources currently available to otolaryngologists in training and early in their career for their development as clinician-scientists. We describe the background of the current generation of National Institutes of Health–funded otolaryngologists and discern where the next generation might come from. Special attention is given to the National Institute on Deafness and Other Communication Disorders, which focuses on supporting research and research training in hearing, balance, smell, taste, voice, speech, and language, and to programs aimed at the development of clinician-scientists.
Discoveries and the application of new technologies drive new therapies that improve patient outcomes. The practice of otolaryngology, as all of medical practice, has changed dramatically in the last 15 years based on new technologies and new concepts of disease, and change will undoubtedly continue. We owe our patients access to newer procedures and therapies that stem from basic and clinical research, but from where will this innovation come? Although many exciting breakthroughs have emanated from the prepared minds of clinicians interacting with their patients, other discoveries originate from clinicians who are trained in the methodologies of science. Increasingly, otolaryngology research draws from such fields as outcomes research, information technology, genetics, molecular biology, and biomedical engineering.
This article discusses where the clinician-scientists in our specialty have traditionally come from and how they are likely to be generated in the future. Training clinicians to be proficient researchers is as difficult as it is important. As a specialty, we have to be aware of emerging areas of inquiry and ensure that opportunities exist to couple the right minds to the right projects. Financial incentives, clinical care, and family demands often compete for the time and energy required for a career as a clinician-scientist. Recognizing the importance of research to otolaryngology and nurturing the aspirations of those clinicians truly cut out for this pursuit should ensure continued growth in patient-grounded science that will drive our specialty through the coming years.
Literature review
Others have written about the training of clinician-scientists in otolaryngology and the shortage of clinician-scientists in the specialty, and multiple views and plans have been put forward. Here we concentrate on the more recent literature. In 1999, Nadol surveyed junior otolaryngology faculty (less than 5 years out of training) across the nation . He found that 71% had completed a clinical fellowship and 9% a research fellowship. Although 93% reported being engaged in research activity, they actually only spent an average of 13% of their time in research. Most of the surveyed faculty went into otolaryngology to teach, not to conduct research. When asked how their academic careers could be improved, however, the top four suggestions were related to research, particularly research support. Nadol concluded that a need exists for more research training, protected time, and “clarity of job description.”
Naclerio and colleagues surveyed otolaryngology department chairs. Chairs identified 63% of their faculty as clinician-scientists but reported that, on average, they spent only 17% effort pursuing that endeavor. Only 8% of faculty members were reported to be funded by the National Institutes of Health (NIH) and 20% by other sources. The authors also found that, on average, there are two PhDs per otolaryngology department . Wolfe and Weymuller examined the graduates who trained in the National Institute on Deafness and Other Communication Disorders (NIDCD)–supported NIH Institutional National Research Service Award (NRSA) training grant (T32) programs at their institutions (University of Michigan and University of Washington) . Although a high percentage of these trainees pursued academic medicine, one fourth to one third eventually were funded by NIH-mentored clinical scientist development award (K08) grants, and a small percentage became independent investigators. Chole reported a similar experience with Washington University T32 trainees; 60% entered academic medicine, and 17% obtained NIH funding . Wolfe and Weymuller concluded that research training should be phased in late in resident training after the resident has identified his or her clinical focus and research focus . Such a plan is inhibited, however, by the sometimes rigid and often unaligned residency review committee in otolaryngology, American Board of Otolaryngology, and NIH rules. Some of the proposed solutions included funding for research mentors, coordination of the career path that bridges residency to the K-award, and a joint strategy between the residency review committee, American Board of Otolaryngology, American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), and the NIDCD/NIH to develop clinician-scientists. Wolfe and Weymuller also recommended a renewed emphasis on clinical research training, which is better matched to the interests of residents than basic science research . Supporting their suggestion is the finding that students who graduate from medical school are ten times more likely to be interested in pursuing clinical research as part of their career trajectory than basic science research .
In late 2005, the NIH and AAO-HNS co-sponsored a conference on research training and education in otolaryngology. The purpose of this forum was to identify obstacles to research education and training in otolaryngology and formulate strategies to overcome these barriers. Among the 158 registrants, representing 33 otolaryngology training programs, were many of the leaders, clinician-scientists, and trainers/research mentors of the specialty. A summary of this conference has been published . Although a diversity of opinions was expressed at the conference, several targeted recommendations to the NIDCD/NIH and the profession emerged, underscored by a concerted call for the development and support of more flexible models and NIH-sponsored programs for research training in otolaryngology.
Otolaryngology does not uniquely face these problems. Urology and orthopedic surgery, other surgical subspecialties, have even lower rates of residents developing into clinician-scientists. Such failure has been attributed to lack of mentorship, clinical pressure, a specialty culture that does not value research, financial constraints, poor research background among residents in the specialty, busy on-call schedules, and the length of clinical training .
Career paths
The successful clinician-scientist develops during all stages of training. It is unusual for someone who has not had significant research training before his or her first faculty position to be successful in obtaining funding and developing into a productive clinician-scientist. This section considers research opportunities afforded to trainees at various stages of their careers.
Before residency
Although one could debate whether clinician-scientists are born or made, there is no question that many clinicians interested in research self-identify early in their education. One way to build our cadre of clinician-scientists is to recruit students interested in science into our specialty rather than try to turn those committed to otolaryngology toward research. Many demographic factors have been correlated with an interest in becoming a clinician-scientist , including graduation from a private medical school, graduation from a medical school with larger amounts of NIH funding, graduation from a school with an NIH-funded medical scientist training program (MSTP), and male gender.
Many programs encourage and foster such students. Many medical campuses offer summer research experiences for undergraduate students. Most medical school curricula have mechanisms for medical student research, but perhaps the most likely students to go into academic medicine and continue to participate in biomedical research are MD/PhD students. Most medical schools have MD/PhD programs, and 41 of these schools receive NIH funding and designation as MSTPs. The MSTP program, administered by the National Institute of General Medical Sciences, was founded in 1964 to increase the clinician-scientist pipeline. Up to 8% of medical school graduates hold MD and PhD degrees. Of these graduates, one fourth are from MSTP programs, one fourth are from other MD/PhD programs, and roughly one half obtained the two degrees independently. More than 80% of participants between 1970 and 1990 in MSTP MD/PhD programs went on to academic careers, and 68% became independent investigators . This latter percentage contrasts to less than 1% of graduates from United States medical schools in general .
Clark and Hanel used the appendices of MSTP grant applications to the National Institute of General Medical Sciences to investigate which specialties MD/PhD students gravitate toward. They found that students who complete MSTP programs are more than five times as likely to go into pathology as MD-only students . Similarly, pediatrics, neurology, neurosurgery, and radiology are popular for these students. In contrast, MD/PhD students are unlikely to enter family medicine, emergency medicine, rehabilitation medicine, obstetrics and gynecology, and most surgical subspecialties. MSTP graduate students are approximately 55% as likely to go into otolaryngology as MD students, however . Interestingly, 41% of MSTP students get their PhDs in biochemistry, cell or molecular biology, or neuroscience , all disciplines well positioned to conduct research in otolaryngology.
There are several ways for our specialty to attract MD/PhD students and other students likely to become clinician-scientists. Primarily, researchers in otolaryngology should be more visible to such students. Specific ways to increase such visibility include individuals who are in otolaryngology departments or conducting otolaryngology research serving on MD/PhD committees, participating in MD/PhD curricula, and serving on dissertation committees. These individuals also could sponsor undergraduate students who are conducting summer research and medical student research. Some of these activities could be sponsored through T32 grant programs, which are discussed later. Several NIH institutes, including the NIDCD, also seek to recruit students on integrated MD/PhD tracks to pursue research in their scientific mission areas through the Ruth L. Kirschstein National Research Service Awards for Individual Predoctoral MD/PhD Fellows (F30) (PA-05-151).
During residency
Most otolaryngology residency training programs allocate time for resident research, and in most cases, the purpose of this rotation is twofold: to make our trainees more sophisticated consumers of research and to foster a greater appreciation of the value of research to clinical practice. At the lead author’s institution, as in many other programs, the mechanism to reach these goals is a research rotation, wherein, the resident experiences the scientific process from conception of a research idea through presentation and publication. The residency-based research experience, typically 3 to 6 months in duration, is generally not adequate preparation for building an independent research career. In some programs, however, additional research training is available, generally through a T32 program.
Fellowship
Several fellowship opportunities are available for residents who complete otolaryngology programs. Some programs, particularly in head and neck surgery, neurotology, and pediatric otolaryngology, have 1 year of research experience built into them. Unfortunately, these experiences are short, often part-time, and applied to all participants, not just those interested in an academic career. Some of the full-time research training experiences are currently funded by T32 programs (eg, the head and neck fellowship at MD Anderson Cancer Center). The extent to which these fellowship-based research experiences enable residents to become independent clinician-scientists is unclear. Research is needed to evaluate the use of these experiences in increasing the cadre of clinician-scientists.
After residency/early career
Perhaps the greatest attrition of otolaryngologists from would-be clinician-researchers to full-time clinicians occurs in the transition from training to employment during the first few years of a junior faculty appointment. The pressure on the time of young otolaryngologists is intense. They feel the need to build a practice and refine their surgical skills. They are often sought by residents to “staff cases” and are heavily involved in the on-call schedule. Their teaching responsibilities are new, such that each lecture or presentation takes more time to prepare than it does for seasoned faculty members with lectures already “in the can.” Although these junior faculty members may have negotiated adequate “protected time” to start their research career, they often have not taken into account the actual and perceived peer pressure to “pull their weight” clinically. Often this pressure comes from within. Emerging from fellowship and residency, young faculty members most often identify with their clinically active mentors, with whom they have spent most of the previous 5 to 7 years, rather than their clinician-scientist mentors, with whom they have spent considerably less time.
The elements in a junior faculty’s new department that should be in place to make this transition successful include a culture of inquiry, strong committed leadership, alignment of incentives for research accomplishment, appropriate mentorship, appropriate research resources and facilities, and appropriate time protection. Most clinician-scientists in otolaryngology work in a relatively small number of departments throughout the country. The reason for this distribution is that these departments are the ones that can most likely provide the previously listed elements. Because of these departments’ track records, however, they can attract the appropriate candidates.
Departments in which research is not valued are toxic environments for the career of a clinician-scientist. The key element for a nurturing environment is a true culture of scientific inquiry. This culture is ideally set from the top—the department chair—but should be pervasive throughout the department. Part of this culture includes alignment of incentives. Strong disincentives to research, either financially or in prestige, erode commitment to research among young faculty members. Mentorship is also critical for developing a research career. Because otolaryngology is a small field, many otolaryngology departments lack appropriate research mentors within their ranks for junior faculty members. Some departments circumvent this limitation by forging research collaborations with investigators from other departments, who also serve as primary and secondary mentors to new faculty members.
Another strong element for nurturing successful clinician-scientists is the research environment. Early career faculty members are more successful when they have the opportunity to interact with investigators in their scientific field. Teaming with established laboratories and programs is frequently the road to success for clinician-scientists. Ideally, clinician-scientists will bring a clinical perspective to a research group while basic scientists contribute research experience, technical know-how, grant-writing knowledge, and resources. In the biomedical sciences, full-time researchers usually have had 5 or more years of PhD training and 5 or more years of postdoctoral training before initiating an independent research career. In contrast, otolaryngologists rarely have more than 3 years of scientific training before entering an independent research career trajectory. For this reason, it is often difficult for these new surgeon-investigators to compete favorably with their PhD counterparts for federal research funding. As a group, however, physicians have been shown to compete favorably with nonphysicians in the trans-NIH peer review process .
The NIH awarding components (institutes and centers) have recognized the challenges faced by specific groups in developing a research career trajectory and have launched program initiatives and award mechanisms aimed at facilitating the start-up of the clinician-scientist’s career. The NIH institutes place considerable weight on the career development plan proposed in K-award applications. The availability and quality of mentors and research resources are important factors for budding clinician-scientists to consider before taking a junior faculty position. These factors and future prospective funding sources should be considered before a candidate accepts a new faculty position.
Time protection is an issue that is usually up-front in the negotiation for any new faculty member but is of particular importance with clinician-scientists. Typically, the new faculty member wants to know how much protected time to ask for and for how long. There is no correct formula; however, it is probable that more often than not, the time given is either too little or distributed incorrectly. Common practice is to provide a certain percentage of protection for a period of several years. Often, however, protection is less necessary in the first year—during the arduous period of laboratory set-up—and more necessary during the process of preliminary data collection and grant writing. Because each situation is different, the best approach is customizing distribution of time and resources based on the young faculty member’s experience, the project, and the environment. An important element of this customization is that the chairperson clearly communicates expectations to the faculty member. Inappropriately allotted time and resources are wasteful and discouraging to existing faculty, who are often supporting the new clinician-scientist faculty member.
Career paths
The successful clinician-scientist develops during all stages of training. It is unusual for someone who has not had significant research training before his or her first faculty position to be successful in obtaining funding and developing into a productive clinician-scientist. This section considers research opportunities afforded to trainees at various stages of their careers.
Before residency
Although one could debate whether clinician-scientists are born or made, there is no question that many clinicians interested in research self-identify early in their education. One way to build our cadre of clinician-scientists is to recruit students interested in science into our specialty rather than try to turn those committed to otolaryngology toward research. Many demographic factors have been correlated with an interest in becoming a clinician-scientist , including graduation from a private medical school, graduation from a medical school with larger amounts of NIH funding, graduation from a school with an NIH-funded medical scientist training program (MSTP), and male gender.
Many programs encourage and foster such students. Many medical campuses offer summer research experiences for undergraduate students. Most medical school curricula have mechanisms for medical student research, but perhaps the most likely students to go into academic medicine and continue to participate in biomedical research are MD/PhD students. Most medical schools have MD/PhD programs, and 41 of these schools receive NIH funding and designation as MSTPs. The MSTP program, administered by the National Institute of General Medical Sciences, was founded in 1964 to increase the clinician-scientist pipeline. Up to 8% of medical school graduates hold MD and PhD degrees. Of these graduates, one fourth are from MSTP programs, one fourth are from other MD/PhD programs, and roughly one half obtained the two degrees independently. More than 80% of participants between 1970 and 1990 in MSTP MD/PhD programs went on to academic careers, and 68% became independent investigators . This latter percentage contrasts to less than 1% of graduates from United States medical schools in general .
Clark and Hanel used the appendices of MSTP grant applications to the National Institute of General Medical Sciences to investigate which specialties MD/PhD students gravitate toward. They found that students who complete MSTP programs are more than five times as likely to go into pathology as MD-only students . Similarly, pediatrics, neurology, neurosurgery, and radiology are popular for these students. In contrast, MD/PhD students are unlikely to enter family medicine, emergency medicine, rehabilitation medicine, obstetrics and gynecology, and most surgical subspecialties. MSTP graduate students are approximately 55% as likely to go into otolaryngology as MD students, however . Interestingly, 41% of MSTP students get their PhDs in biochemistry, cell or molecular biology, or neuroscience , all disciplines well positioned to conduct research in otolaryngology.
There are several ways for our specialty to attract MD/PhD students and other students likely to become clinician-scientists. Primarily, researchers in otolaryngology should be more visible to such students. Specific ways to increase such visibility include individuals who are in otolaryngology departments or conducting otolaryngology research serving on MD/PhD committees, participating in MD/PhD curricula, and serving on dissertation committees. These individuals also could sponsor undergraduate students who are conducting summer research and medical student research. Some of these activities could be sponsored through T32 grant programs, which are discussed later. Several NIH institutes, including the NIDCD, also seek to recruit students on integrated MD/PhD tracks to pursue research in their scientific mission areas through the Ruth L. Kirschstein National Research Service Awards for Individual Predoctoral MD/PhD Fellows (F30) (PA-05-151).
During residency
Most otolaryngology residency training programs allocate time for resident research, and in most cases, the purpose of this rotation is twofold: to make our trainees more sophisticated consumers of research and to foster a greater appreciation of the value of research to clinical practice. At the lead author’s institution, as in many other programs, the mechanism to reach these goals is a research rotation, wherein, the resident experiences the scientific process from conception of a research idea through presentation and publication. The residency-based research experience, typically 3 to 6 months in duration, is generally not adequate preparation for building an independent research career. In some programs, however, additional research training is available, generally through a T32 program.
Fellowship
Several fellowship opportunities are available for residents who complete otolaryngology programs. Some programs, particularly in head and neck surgery, neurotology, and pediatric otolaryngology, have 1 year of research experience built into them. Unfortunately, these experiences are short, often part-time, and applied to all participants, not just those interested in an academic career. Some of the full-time research training experiences are currently funded by T32 programs (eg, the head and neck fellowship at MD Anderson Cancer Center). The extent to which these fellowship-based research experiences enable residents to become independent clinician-scientists is unclear. Research is needed to evaluate the use of these experiences in increasing the cadre of clinician-scientists.
After residency/early career
Perhaps the greatest attrition of otolaryngologists from would-be clinician-researchers to full-time clinicians occurs in the transition from training to employment during the first few years of a junior faculty appointment. The pressure on the time of young otolaryngologists is intense. They feel the need to build a practice and refine their surgical skills. They are often sought by residents to “staff cases” and are heavily involved in the on-call schedule. Their teaching responsibilities are new, such that each lecture or presentation takes more time to prepare than it does for seasoned faculty members with lectures already “in the can.” Although these junior faculty members may have negotiated adequate “protected time” to start their research career, they often have not taken into account the actual and perceived peer pressure to “pull their weight” clinically. Often this pressure comes from within. Emerging from fellowship and residency, young faculty members most often identify with their clinically active mentors, with whom they have spent most of the previous 5 to 7 years, rather than their clinician-scientist mentors, with whom they have spent considerably less time.
The elements in a junior faculty’s new department that should be in place to make this transition successful include a culture of inquiry, strong committed leadership, alignment of incentives for research accomplishment, appropriate mentorship, appropriate research resources and facilities, and appropriate time protection. Most clinician-scientists in otolaryngology work in a relatively small number of departments throughout the country. The reason for this distribution is that these departments are the ones that can most likely provide the previously listed elements. Because of these departments’ track records, however, they can attract the appropriate candidates.
Departments in which research is not valued are toxic environments for the career of a clinician-scientist. The key element for a nurturing environment is a true culture of scientific inquiry. This culture is ideally set from the top—the department chair—but should be pervasive throughout the department. Part of this culture includes alignment of incentives. Strong disincentives to research, either financially or in prestige, erode commitment to research among young faculty members. Mentorship is also critical for developing a research career. Because otolaryngology is a small field, many otolaryngology departments lack appropriate research mentors within their ranks for junior faculty members. Some departments circumvent this limitation by forging research collaborations with investigators from other departments, who also serve as primary and secondary mentors to new faculty members.
Another strong element for nurturing successful clinician-scientists is the research environment. Early career faculty members are more successful when they have the opportunity to interact with investigators in their scientific field. Teaming with established laboratories and programs is frequently the road to success for clinician-scientists. Ideally, clinician-scientists will bring a clinical perspective to a research group while basic scientists contribute research experience, technical know-how, grant-writing knowledge, and resources. In the biomedical sciences, full-time researchers usually have had 5 or more years of PhD training and 5 or more years of postdoctoral training before initiating an independent research career. In contrast, otolaryngologists rarely have more than 3 years of scientific training before entering an independent research career trajectory. For this reason, it is often difficult for these new surgeon-investigators to compete favorably with their PhD counterparts for federal research funding. As a group, however, physicians have been shown to compete favorably with nonphysicians in the trans-NIH peer review process .
The NIH awarding components (institutes and centers) have recognized the challenges faced by specific groups in developing a research career trajectory and have launched program initiatives and award mechanisms aimed at facilitating the start-up of the clinician-scientist’s career. The NIH institutes place considerable weight on the career development plan proposed in K-award applications. The availability and quality of mentors and research resources are important factors for budding clinician-scientists to consider before taking a junior faculty position. These factors and future prospective funding sources should be considered before a candidate accepts a new faculty position.
Time protection is an issue that is usually up-front in the negotiation for any new faculty member but is of particular importance with clinician-scientists. Typically, the new faculty member wants to know how much protected time to ask for and for how long. There is no correct formula; however, it is probable that more often than not, the time given is either too little or distributed incorrectly. Common practice is to provide a certain percentage of protection for a period of several years. Often, however, protection is less necessary in the first year—during the arduous period of laboratory set-up—and more necessary during the process of preliminary data collection and grant writing. Because each situation is different, the best approach is customizing distribution of time and resources based on the young faculty member’s experience, the project, and the environment. An important element of this customization is that the chairperson clearly communicates expectations to the faculty member. Inappropriately allotted time and resources are wasteful and discouraging to existing faculty, who are often supporting the new clinician-scientist faculty member.
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