American Pediatric Academia: The Looming Question
Article Outline
Academic conferences and editorial columns have been marked in the past decade by addresses lamenting the decline of the physician-scientist, asking, “Where have all the young ones gone?”1, 2, 3 Further into the decline of the physician-scientist, coupled with progressive shortfalls of research funding and clinical revenues that have been very problematic for pediatrics, we wonder whether the next tough question will be, “Where have American academic pediatric departments gone?”
From 1998 to 2003, the National Institutes of Health (NIH) budget doubled under visionary political and research leadership. In 1997, 32 departments of pediatrics had >10 NIH grant awards.4 By 2005, >45 departments of pediatrics had >10 NIH research grants.5 Yet, as the NIH budget doubled, pediatric research growth did not keep up. The pediatric portfolio of the NIH represented 14.1% of funding in 1994.6 By 2000, this mark slipped to 12.6%.6 In 2005, the pediatric portfolio was 11.3% of NIH funding—25% less than 10 years earlier.6
Perhaps reflecting funding and faculty development issues, or perhaps not, pediatric research is shrinking on the center scientific stage. If one looks at the published reports in top-tier journals, including Science, Nature, The Proceeding of the National Academy of Sciences, The Journal of Clinical Investigation, and The New England Journal of Medicine, there has been a decline in publications from American departments of pediatrics; American pediatric departments contributed 35% fewer reports to these top journals in 2006 than in 2000.7 It is important to note that this decline is not unique to pediatrics; there has been a general decline in America’s contribution to the most meritorious literature.8
Concomitant with the decline of the physician-scientist has been large growth in the ranks of academic clinicians in pediatric departments. Financial pressures have the potential to limit the ability of this growing faculty component to contribute to scholarly activities if faculty compensation is tied to relative value unit-based clinical productivity alone.9 Proper compensation and time for education, research, publication, and non-clinical departmental activities is also needed, because these activities give a medical center enthusiasm and purpose.
The importance of the pediatric clinician-scientist is recognized at all levels of academia. Developing clinician-scientists for departments of pediatrics requires time and capital outlay that tops $1 million per junior faculty member. It costs $150,000 to $250,000, including salary, fringe benefits, and laboratory support, to train a fellow for 3 years. After completion of a fellowship, another $650,000 to $800,000 is needed to support a junior faculty member in the early years of academic growth.10 After academic independence is realized, junior and senior pediatric physician-scientists are hard-pressed to achieve sustained funding to provide substantial salary support in the current funding climate. Both junior and established senior clinician-scientists will need episodic financial support to cover funding shortfalls. Recognized for intellectual and scientific contributions, these individuals can quickly become a financial liability to departments.
In several pediatric subspecialties, including pediatric surgery, neonatology, gastroenterology, cardiology, and critical care medicine, the maximum NIH-funded salary is significantly less than the typical salaries of active practitioners.11 Although academically desirable, fully funded clinician-scientists in these subspecialties may be unaffordable, because salary supplementation needed for academic retention hurts the bottom line.
We are concerned that pediatric physician-scientists are not being trained in basic or clinical science with the same rigor and depth as PhD graduate students, with whom physician-scientists will be competing for funding. Many of us serving on grant review panels observe a “research-quality gap” between junior pediatric MD and PhD scientists. The research component of pediatric fellowship training will not succeed if viewed as a hobby or if mentors are chosen by fellows on the basis of collegiality. Reflected by the success of graduates of programs like the national Pediatric Scientist Development Program,12 pediatric academicians do know how to train physician-scientists—place talented individuals with great mentors and provide protected time to be creative and thrive. As is being done at a few pediatric centers, similar programs can be developed.
Pediatric departments will need to rethink their missions over the coming decade.
Serious manpower and leaderships issues that limit academic growth are present in many departments of pediatrics. In pediatric endocrinology, for example, >70 positions are posted on the job-listing site of the Lawson Wilkins Pediatric Endocrinology Society,13 and many prestigious section-chief positions remain unfilled after lengthy searches. Perhaps we should establish distinct clinical and research training tracks in substitute of the “3-years of training for all” approach in place for 2 decades now. Shortening the duration of fellowship training for a clinical track to 2 years (or less) will speed the entry of needed clinicians to the workforce—helping one problem—and free precious departmental dollars for physician-scientist support—helping another.
Pediatric departments will need to rethink their missions in the coming decade. Biomedical research and faculty development is expensive. It may not be financially feasible to support clinical operations, medical education, the research enterprise, and faculty development and growth. Cultivating clinical faculty to develop clinical programs of excellence with sound revenue streams may be a legitimate alternative to a 4-part mission and an important form of faculty development. Such a model will be far richer if pediatric-based clinical programs are linked with institutional research programs, which can be directed toward elucidating disease mechanisms and optimizing treatment. Placing fellows and junior faculty members in non-pediatric departments during periods of training will cultivate the needed broad-based multidisciplinary ties among pediatric, basic, and other clinical departments.
Considering the current funding and medical economic climate, pediatric research may contract at many individual institutions. This change in the pediatric research base will heighten the need for federally funded center programs that can provide the needed infrastructure to maintain and enhance research in childhood diseases and disorders. In structuring such program, it will be crucial that additional funds be earmarked for pediatric research, rather than reallocating an already tight NIH pediatric research portfolio.
Failing the aforementioned, uncovering dollars to maintain academic strength and expansion may turn out to be the major challenge to academic pediatrics in the next decade. The future of academic pediatric growth in the United States may fall on the shoulders of those departments able to secure substantial philanthropic dollars, corporate investment, or medical school leaders willing to invest precious funds for the next decade. Ten years from now, we should not be surprised if pediatric academic medical prowess and leadership in the United States is concentrated in a handful of institutions that have been the beneficiaries of past and current philanthropy and commit themselves to developing the resources needed for academic achievement.
Institutions unable to make strong commitments to the years ahead with real and substantive dollars may find themselves moving from asking “Where have all our young ones gone?” to asking “Where has our once vital and thriving department gone?” And this question may arrive much sooner than we imagine.
References
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- http://grants.nih.gov/grants/award/awardtr.htm.
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- www.ncbi.nlm.nih.gov/entrez/. Accessed April 12, 2007.
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- North MA. Missions, monies and metrics. A funds flow to preserve the academic mission. 2005. In: Academic Practice Compensation and Production Survey for Faculty and Management: 2005 report based on 2004 data.
- Recruitment and development of academic pediatricians: departmental commitments to promote success. Pediatr Res. 2002;51:662–664
- . Recent trends in the funding and utilization of NIH career development awards by surgical faculty. Surgery. 2004;136:232–239
- www.med.yale.edu/pediat/pedsci/. Accessed April 12, 2007.
- www.lwpes.org/. Accessed April 12, 2007.
EDITOR’s NOTE: Periodically in the AMSPDC section, we publish a perspective on an important topic in academic pediatrics. The opinions expressed in such commentaries reflect those of the individual author(s) and not necessarily those of AMSPDC as an organization. —Bonita Stanton, MD, Section Editor, The Journal of Pediatrics
PII: S0022-3476(07)00367-8
doi:10.1016/j.jpeds.2007.04.018
© 2007 Mosby, Inc. All rights reserved.
