Author + information
- Received December 6, 2013
- Revision received March 1, 2014
- Accepted March 4, 2014
- Published online June 3, 2014.
- Carl W. Tong, MD, PhD∗∗ (, )
- Tariq Ahmad, MD, MPH†,
- Evan L. Brittain, MD‡,
- T. Jared Bunch, MD§,
- Julie B. Damp, MD‡,
- Todd Dardas, MD, MS‖,
- Amalea Hijar, BA, MPP¶,
- Joseph A. Hill, MD, PhD#,
- Anthony A. Hilliard, MD∗∗,
- Steven R. Houser, PhD††,
- Eiman Jahangir, MD, MPH‡‡,
- Andrew M. Kates, MD§§,
- Darlene Kim, MD‖‖,
- Brian R. Lindman, MD§§,
- John J. Ryan, MD¶¶,
- Anne K. Rzeszut, MA¶,
- Chittur A. Sivaram, MD##,
- Anne Marie Valente, MD∗∗∗ and
- Andrew M. Freeman, MD‖‖
- ∗Department of Medical Physiology and Department of Medicine/Cardiology Division, Texas A&M University Health Science Center–Baylor Scott & White Healthcare, Temple, Texas
- †Duke University Medical Center, Durham, North Carolina
- ‡Department of Medicine/Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- §Heart Rhythm Program, Intermountain Medical Center, Murray, Utah
- ‖Department of Internal Medicine, University of Washington Medical Center, Seattle, Washington
- ¶Member Strategy and Career Development Department, American College of Cardiology, Washington, DC
- #Department of Internal Medicine/Cardiology Division and Harry S. Moss Heart Center, University of Texas Southwestern Medical Center, Dallas, Texas
- ∗∗Department of Medicine/Cardiology Division, Loma Linda University Medical Center, Loma Linda, California
- ††Department of Physiology, Temple University School of Medicine, Philadelphia, Pennsylvania
- ‡‡Department of Cardiology, Ochsner Clinical School—the University of Queensland School of Medicine, New Orleans, Louisiana
- §§Department of Medicine/Cardiology Division, Washington University School of Medicine, St. Louis, Missouri
- ‖‖Department of Medicine/Division of Cardiology, National Jewish Health, Denver, Colorado
- ¶¶Department of Medicine/Division of Cardiology, University of Utah Health Care, Salt Lake City, Utah
- ##Department of Medicine/Cardiovascular Section, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
- ∗∗∗Department of Cardiology, Harvard Medical School, Brigham and Women's Hospital, and Boston Children's Hospital, Boston, Massachusetts
- ↵∗Reprint requests and correspondence:
Dr. Carl W. Tong, 110 Medical Research Building, 702 South West H. K. Dodgen Loop, Temple, Texas 76504.
Early career academic cardiologists currently face unprecedented challenges that threaten a highly valued career path. A team consisting of early career professionals and senior leadership members of American College of Cardiology completed this white paper to inform the cardiovascular medicine profession regarding the plight of early career cardiologists and to suggest possible solutions. This paper includes: 1) definition of categories of early career academic cardiologists; 2) general challenges to all categories and specific challenges to each category; 3) obstacles as identified by a survey of current early career members of the American College of Cardiology; 4) major reasons for the failure of physician-scientists to receive funding from National Institute of Health/National Heart Lung and Blood Institute career development grants; 5) potential solutions; and 6) a call to action with specific recommendations.
The majority of advances in cardiovascular care emerge from academic medical centers (AMC) through research, publication, and development of clinical protocols by physicians and scientists (1). Our ability to advance knowledge, to develop novel technologies/therapeutics, to educate trainees, and to provide quality care is currently in jeopardy due to increasingly challenging conditions placed on AMC and early career academic cardiologists. As heart disease remains the number 1 cause of death in the United States (2) and 40% of Americans will develop some form of cardiovascular disease by 2030 (3), academic cardiologists in conjunction with AMC strive to continually improve cardiovascular care through discovery and teaching.
Early career academic cardiologists, defined as those who are within 10 years of completion of a cardiology fellowship training program, often find themselves challenged to remain in academics and thus must consider a transition to nonacademic practice. Many early career cardiologists view a career in academics as an opportunity to make discoveries that may lead to new therapies or influence clinical practice in substantive ways. Others view it as an opportunity to educate and train the next generation of providers. Sadly, current uncertainties regarding the viability of an academic career are driving many early career academic cardiologists away.
In light of these developments, the early career professional section of the American College of Cardiology (ACC), along with senior leadership, initiated this manuscript to summarize challenges faced by early career academic cardiologists, to present data on perceived obstacles, and to discuss potential solutions to these challenges and obstacles.
Defining the Academic Cardiologist
Physician-scientists provide direct patient care and conduct research as principal investigators. They formulate research hypotheses based on existing data and their experience in treating patients. They then test their hypotheses by means of basic, translational, or clinical research, culminating sometimes in intellectual property development. Responsibilities of these individuals include overseeing research, publishing results, and writing grants to obtain external funding. Physician-scientists are often expected to provide didactic lectures to medical students and to serve as the teaching attending for medical students and residents on hospital services. By participating in both clinical and research domains, physician-scientists provide a critical bridge to translate clinical observations into the realm of scientific discovery and to return newfound knowledge to direct patient care.
Scientist-researchers dedicate nearly 100% effort to research. Whereas their investigative responsibilities are similar to those of a physician-scientist, scientist-researchers do not have clinical duties.
Clinician-educators dedicate a significant amount of time to educational activities: participating in preceptorships, presenting didactic lectures to house staff and students, and participating as instructors in formal coursework offered through an associated medical school and/or graduate medical education program. The relative distribution of effort among these activities for clinician-educators is predominantly clinical. More recently, preceptor and mentor roles have extended beyond the traditional medical trainee to include allied health professionals, such as physician assistants, nurse practitioners, and pharmacy students.
Clinician-educator-administrators have responsibilities in course administration, rotation administration, and clinical operations in addition to the role of clinician-educator. Administrative roles include program director, director of clinical cardiology, or medical school course director. Some may chair or cochair institutional, regional, national, or international continuing medical education courses.
Pure clinicians have the primary role of providing direct patient care. Unlike the other types of academic cardiologist, pure clinicians are contracted to dedicate essentially 100% of their allotted effort to direct patient care. Pure clinicians who wish to maintain academic interests must do so outside of their allotted and expected clinical time, whereas other categories of academic cardiologist usually have defined protected time for academic pursuits.
Challenges felt by current academic leadership of the ACC
Cuts in research support, pending cuts in graduate medical education (GME), and the decline in reimbursements for clinical activities have come together to create a “perfect storm” that threatens the future health and health care of our nation. These events also threaten early career investigators during this particularly vulnerable career phase. The AMC are challenged by these cuts as well. Left unchecked, this present course will render our nation ill-equipped to meet our rapidly expanding healthcare needs. Furthermore, it is already jeopardizing our nation's longstanding predominance in healthcare research and innovation.
A career in biomedical discovery coupled with the practice of clinical medicine requires many years of preparation, often involving earning both MD and PhD degrees. As such, it is not uncommon for an academic cardiologists to assume their first faculty position in their late 30s. New faculty often face extended “dry spells,” whereas the numerous skills required for success in academia are still in development. Bright, ambitious, well-trained physicians, who seek to discover and advance the field, are sometimes unable to navigate this difficult phase of the academic career path. There is a lack of societal awareness and interest in fostering this career track, failing to recognize its importance to the future healthcare needs of our world. Future benefits to society through enhanced longevity, improved quality of life, economic growth, and tax revenues are at risk.
View From the Ground
The ACC conducted an online survey of its early career membership between September 17, 2013 and October 11, 2013. E-mail survey invitations and 3 follow-up reminders were sent to 2,957 randomly selected individuals within this member group. Inclusion criteria included being within 10 years of fellowship completion and self-identification as an academic cardiologist. The ACC received 324 responses, 218 of those met the inclusion criteria. The majority (87%) resided in the United States, were male (71%), and completed training within the last 5 years (58%). Self-identified distribution of categories were as follows: scientist-researcher (1%); physician-scientist (8% at >75% research, 13% at 40% to 75% research, and 38% at <40% research); clinician-educator (25%); and clinician-educator-administrator (15%). Whereas this survey resulted in a modest response rate, the ACC market survey team estimates that 7% to 10% of the 8,651 early career cardiologists within the ACC are academic cardiologists.
The majority (85%) of early career academic professionals actively sought an academic position (Fig. 2). Top reasons included academic environment (81%), desire to teach (70%), and interaction/exposure to diverse disciplines and new ideas (70%). Approximately two-thirds (64%) indicated a desire to conduct research as a motivation to seek out an academic position. Furthermore, 57% of respondents stated the ability to do greater good as a reason for their choice. A smaller fraction of respondents (13%) indicated reduced clinical responsibility as a reason.
The vast majority of respondents (88%) strongly believed that physicians need to lead or be part of healthcare research. However, respondents identified multiple obstacles (Fig. 3). A majority pointed to lack of time (78%), unstable funding (73%), burdensome regulatory compliance (72%), being disadvantaged when competing against pure PhDs (69%), discouragement of academic pursuits by overemphasis on relative value unit (RVU)-based metrics of performance (62%), and insufficient support from the home institution (52%).
The vast majority (91%) reported insufficient external funding (defined as equivalent to National Institutes of Health/National Heart, Lung, and Blood Institute [NIH/NHLBI] K08/K23 direct funding of $500,000), which is a major challenge for progression into a stable academic career. The distribution of external grant funding resembled a negative exponential curve: 80% (no funding), 11% ($5K to $499K), 5% ($500K to $999K), and 4% (>$1M). NIH grants accounted for approximately 43% of external funding for academic pursuits of early career academic cardiologists (median: $117,500). Non-NIH grants accounted for a larger percentage of the external funding (median: $126,000).
Correlation analyses revealed the following factors as associated with a greater ability to obtain >$500K of external funding (Fig. 4): onsite mentoring; sufficient institutional resources; collaborative connections; and the perception that one's institution values academic pursuits.
Economic difficulties experienced by the academic cardiologist included financial disincentives and RVU tracking (Fig. 5). Most practitioners (71%) reported the reduction in pay required to pursue academic endeavors as a significant disincentive. Nearly one-half of respondents (49%) reported a reduction of ≥$75,000 per year. The majority of academic practitioners (79%) reported that RVU are tracked and nearly one-half (46%) did not receive RVU-like credit for academic endeavors. Clearly, this focus on clinical productivity leaves less time for 2 important motivators of the academic professional: research and teaching.
Tangible factors such as onsite mentoring, institutional commitment, and the availability of collaborators directly contribute to the success of early career cardiologists. Thus, development of these resources where they do not exist, and preservation of them where they do, are essential. Interestingly, institutional value placed on academic pursuits also contributes to successful grant applications, demonstrating the need for recognition of non-RVU-generating activities of early career academic cardiologists.
Our survey lends objective credence to the concern that the career path of academic cardiology is in peril and that early stage faculty are particularly challenged. The NIH/NHLBI K-grants funding level of $500K is critical to providing dedicated research time, but it does not cover research-related costs (e.g., equipment, personnel, reagents, animals, and clinical database access). Thus, we believe that the 91% of survey respondents who have not achieved this level of funding are challenged to emerge with success in the research arena. Moreover, the lack of institutional recognition of academic endeavors (e.g., RVU credit) and pay reductions further discourage early career members from continuing to pursuit academic cardiology.
Despite decreases in total funding amount and award success percentage (Fig. 6), NIH/NHLBI career development K08 (basic research) and K23 (clinical research) grants remain relatively obtainable. In 2012, the funding success rates were 32.1% and 20.9% for K08 and K23, respectively (4). Between 2007 and 2010, 49% of K08 grants were awarded to adult cardiology (5). Thus, NIH/NHLBI career development grants remain viable sources of grant support for early career academic cardiologists. However, all K-grants are grouped together and awarded by their priority score without regard to subcategories (i.e., K01, K02, K08, K12, K23, K24, K25, K99/R00); consequently, early career academic cardiologists compete with more established applicants (e.g., mid-career K02). In this light, we have worked with NHLBI program officers and a past chairman of K-grants review study section to compile a list of major reasons for the failure of physician-scientists to receive funding (Table 3).
Successful K-grants provide robustly positive impact on the development of early career cardiologists. These grants require institutions to allocate 75% to dedicated research efforts. This dedicated research time provides the early career professional with time to develop critical skills and to acquire preliminary observations and reagents. In other words, these career development awards are a pivotal juncture in the emergence of a cardiologist-scientist.
Improving fellowship training
We must better prepare fellows to succeed early in their careers. However, changes in fellowship training needed to meet this goal must occur without extending the current fellowship duration of 3 to 5 years.
Allocating dedicated research time during fellowship training correlates with the decision of fellows to pursue an academic career (6–10) and allows for the completion of research resulting in publication during fellowship (6–10). The NIH/NHLBI's top reasons for failure to obtain grants (Table 3) emphasize the need for fellows to be better prepared. This preparation includes proposal writing, proficiency in specialized research skills (e.g., basic, clinical, and translational research techniques), and completion of transferable products (e.g., novel reagents). Inherent in the ability to train competitive fellows is dedicated research time.
Mentorship is a critical part of all training programs (7,8,10,11), and outstanding mentors should be acknowledged and rewarded by institutional leadership. The NIH/NHLBI critique illustrates that the quality of mentorship needs to improve. Protected time for the mentor and credit for successful mentoring will help create a strong group of future mentors.
Opportunities for education on the broader range of skills pertinent to the academic practice should be expanded. Fellows must be adept at delivering cost-effective care with attention to error prevention (12). Furthermore, department chairs, program directors, and other clinical leaders should educate fellows on the details of their specific supervisory functions (e.g., department, laboratory). As time constraints of fellowship training will not allow education of all fellows in all of these areas, programs must provide flexibility in aspects of their training program to allow for acquisition of specific skills needed for given career paths.
Fellows choosing a clinician-educator track need formal training in education to navigate the complexities of curriculum development, educational assessment, and accreditation regulations. Training in educational methodology and mentorship are critical for those striving for excellence as an educator. Training in educational research will help clinician educators produce scholarly work related to their teaching effort and contribute to their understanding of best practices in medical education.
Developing novel partnerships and alternative funding sources
Partnership between university systems and clinical entities can provide stability during early career years. Under this type of partnership, a university system supports a portion of salary dedicated to academic pursuits whereas the clinical entity provides support for effort dedicated to patient care. Any salary support for the academic cardiologist derived from external grants is counted as salary savings to the university system and then reapplied toward the academic cardiologist's research. This partnership provides stability and amplifies the effect of external grants. This type of partnership, successfully implemented at Texas A&M University partnering with Baylor Scott & White Healthcare, provides upfront stability for roughly 5 years.
Creating partnerships with institutions hosting a Clinical and Translational Science Award from the NIH can be helpful. A portion of Clinical and Translational Science Award funds is used to support the training of early stage investigators, including KL2 Career Development Awards. Similar to NIH-K awards, these awards mandate 75% protected time for research and related career development activities and typically provide approximately $25,000/year in research support. These awards often include a didactic component and provide for coursework toward a master's degree in clinical investigation.
Another alternative source for funding are investigator-initiated trials, through which uses for newer drugs or new uses for established agents (13) are investigated. Establishing training and research partnerships with pharmaceutical companies outside of investigator-initiated trials is also possible. For example, the Rutgers Pharmaceutical Industry Fellowship Program involves participation of 17 pharmaceutical companies to fund 1 to 2 years of training in research and advocacy for those who hold doctorates in pharmacology (14). However, pharmaceutical partnerships require special focus to ensure that conflicts of interest, or the appearance thereof, do not emerge.
Access to key personnel, information regarding funding opportunities, and knowledge of resources are crucial to obtaining external grants. Thus, the creation of regional networks of collaborators, mentors, and networks of sharable resources can enhance access to early career professionals. Electronic media allows for remote mentoring. Regional sharing of resources allows for experiments to occur when the home institution lacks the capability of conducting experiments locally. The ACC is well positioned to facilitate these efforts.
The early career professional section of the ACC has initiated a college-wide mentorship program. Additionally, a new partnership between the ACC and infoEd (15) has established a searchable database of funding resources, providing members access to information that would otherwise be difficult to locate.
Seeking policy changes
We must better educate the public, elected representatives, and regulatory officials regarding the critical importance of medical education and research (16). The reduction in deaths due to coronary artery disease from ∼470 of 100,000 per year in the 1960s to ∼150 of 100,000 per year in 2010 (1) is an excellent example of the benefit achieved by cardiovascular innovation. Despite this, cardiovascular disease remains the leading cause of death in the United States (2), and heart failure is a progressive disease with 5-year mortality greater than that of most cancers (17–19). Clearly, more research is needed. Increased awareness is critical in enhancing societal investment in research to tackle the grave issues.
A major reason for declining societal investment in GME has been our failure to demonstrate the value that AMC provide to society. We must reinforce to the public that AMC perform critical functions: training the next generation of physicians; hosting the majority of medical advances; treating the most vulnerable and challenging populations (e.g., those who require multidisciplinary care, those with advanced diseases not treatable elsewhere, and those who are indigent). Furthermore, increased GME funding is critical to ensure that AMC are prepared for the increases in patients accessing our healthcare system as a result of the Affordable Care Act.
Advocacy requires direct involvement. Our role as academic cardiologists must be explained and justified to the public. We must do a better job of determining the return on societal investment and communicating that information. This public education needs to begin at the regional and state level. Ultimately though, to best effect policy change, these efforts must be coordinated at the national level.
The cost for caring of cardiovascular disease patients has risen significantly (20,21). We must contain this growth in costs and demonstrate to the public that we are consciously working to trim expenditures. Finding efficient ways to treat patients and reduce expenditures can bend the cost growth curve. Actual savings may translate into broader overall support for development of physician-investigators dedicated to enhancing our future.
Call to Action
We are witnessing a convergence of events that threaten the existence of the academic cardiologist career path. Traditional mechanisms of research support and investment in education are declining. Competition for funding continues to increase. In response, some institutions are devaluing the academic enterprise. Our survey and NIH/NLHBI critique suggest strongly that early career academic cardiologists are facing career-threatening challenges, arguably more so than ever. Failure to renew the pipeline of academic cardiologists threatens our ability to meet the healthcare needs of the future. Thus, we call on the ACC and our colleague-members to act on the following specifics (Table 4) for the good of society and the preservation of our profession.
This effort was supported in part by the American College of Cardiology, grants from the National Institutes of Health (#NIH/K23HL11660 to Dr. Lindman, and #NIH/K08HL114877 to Dr. Tong), and an American Heart Association grant #13FTF16070002 to Dr. Brittain. Dr. Bunch serves on the advisory board of Boston Scientific; and receives consulting fees from St. Jude Medical and Biosense Webster. Dr. Dardas received the ACC/Daiichi Sankyo Career Development Award; and is a research site co-investigator for ENDURANCE CAP (Heartware Destination Therapy Trial). Dr. Lindman received consulting fees from Gerson Lehrman Group Research; and assay support for research from BG-Medicine and Roche. Dr. Sivaram is a member of the Data Safety Monitoring Board for Medtronic. Dr. Freeman receives consulting fees from Gilead; and speaking fees from Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- American College of Cardiology
- academic medical center
- general medical education
- National Heart Lung and Blood Institute
- National Institutes of Health
- relative value unit
- Received December 6, 2013.
- Revision received March 1, 2014.
- Accepted March 4, 2014.
- American College of Cardiology Foundation
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