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Neonatology Research for the 21st Century: Executive Summary of the National Institute of Child Health and Human Development–American Academy of Pediatrics Workshop. Part II: Training Issues

Ronald L. Ariagno, MD^*, Linda J. Van Marter, MD, MPH, Rosemary Higgins, MD and Tonse N.K. Raju, MD

^* Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
Children’s Hospital of Boston and Harvard Medical School, Boston, Massachusetts
Pregnancy and Perinatology Branch, Center for Developmental Biology and Perinatal Medicine, National Institute of Child Health and Human Development, Bethesda, Maryland

	ABSTRACT

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
This is the second part of the executive summary based on the presentations and discussions at a workshop on research in neonatology sponsored by the National Institute of Child Health and Human Development and the American Academy of Pediatrics held in January 2004. In this article, neonatology fellowship training requirements and workforce issues are addressed, and the reasons for the shortage of physician-scientists, particularly of the underrepresented minority ethnic groups, are highlighted. Full-length articles from the presented topics are yet to be published.

Key Words: newborn infant • education • brain injury • bronchopulmonary dysplasia • necrotizing enterocolitis • research training • research infrastructure • minority health • health education • board certification

Abbreviations: NICHD, National Institute of Child Health and Human Development • AAP, American Academy of Pediatrics • URM, underrepresented minority • ABP, American Board of Pediatrics • NIH, National Institutes of Health

	BACKGROUND

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
In 2004, the National Institute of Child Health and Human Development (NICHD) and the Section on Perinatal Pediatrics of the American Academy of Pediatrics (AAP) organized a workshop to address basic and translational research issues in neonatal-perinatal medicine. The objectives of the workshop were to identify knowledge gaps and propose research agendas to rectify them. The speakers also addressed physician-scientist workforce issues, especially concerning the shortage of the underrepresented minority (URM) groups in academic careers, and suggested methods to overcome such barriers. The long-term goal of the workshop was for the suggestions to help the scientific community, policy makers, and funding agencies to formulate future research and educational agendas.

	CHANGES IN NEONATAL-PERINATAL SUBSPECIALTY CERTIFICATION REQUIREMENTS

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
In February 2001, the American Board of Pediatrics (ABP) began an extensive review of the duration, design, and content of fellowship training, with wide-ranging inputs from individuals and organizations having an interest in graduate medical education in the subspecialties of pediatrics. The changes developed in the subspecialty training requirements and approved by the ABP were designed to recognize the diverse roles that subspecialists play, to allow greater flexibility in the design of fellowship training, and to place greater emphasis on the evaluation of fellow training at the local levels. These requirements will apply to all candidates enrolling on or after July 1, 2004.¹

The ABP will continue to require 3 years of training in the standard fellowship and has not approved a clinical-only pathway. It also endorses the goal of using fellowship training as the cornerstone for developing future academic pediatricians. Therefore, the ABP will continue to require scholarly activity during fellowship but has modified the requirements to accommodate a wider variety of academic activities.

The scholarly work must be a mentored research activity and must lead to the generation of a specific "work product." Furthermore, the ABP asks for the creation of a thesis-like oversight committee at the local institutional level for mentoring and evaluation of the fellows. Such a committee has the responsibility for ongoing assessment of the progress and evaluation of fellows’ scholarly accomplishments. Other details, including the nature of the "work product," can be found on the ABP Web site.¹

	CURRENT DATA ON NEONATOLOGY FELLOWSHIP TRAINING

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
In 2002, the Subcommittee on Research of the AAP Section on Perinatal Pediatrics conducted a survey of 100 program directors of US neonatology fellowships. Responses were obtained from 84 program directors (R.L.A., unpublished data). Of 84 programs, 34 (40%) offered 1 to 5 fellowship positions annually, 28 (33%) offered 5 to 9 positions, and 22 (26%) offered 10 positions; 82 (98%) had an approved maternal fetal medicine program.

On average, the fellows spent 20 months in research over the 3-year training period, of which 4 months were "uninterrupted research times" in most programs. Ten (12%) programs offered >6 months of uninterrupted research time. Among the 82 programs responding to questions on mentoring, 610 mentors were identified; 410 (67%) were trained neonatologists and 200 (33%) were nonneonatologists. Overall, the percentage of mentors with federal funding for research was higher for nonneonatology mentors (79% vs 50%).

Over the 3 years covering the survey period, there were 569 fellows who graduated from the programs surveyed. Of these fellows, 192 (34%) chose academic career paths, 119 (24%) opted clinical faculty positions, 35% went into private practice, and 38 (7%) made other, unspecified career choices. Many program directors felt that candidates who initially chose academic careers tended to drop off from academia. The program directors identified lack of funding, insufficient time, inadequate resources, and a shortage of faculty with skills as limiting factors for research training of neonatology fellows and as barriers for multidisciplinary and multiinstitutional collaborations.

Although a handful of reports evaluated the factors influencing career decisions by medical graduates and pediatric residents,^2–4 no studies have attempted to determine such factors affecting decisions by graduating neonatology fellows. In an informal survey of a small sample of such graduates, factors affecting career-path decisions were assessed (A. Penn, MD, verbal communication, 2004). Some of these factors were differential earning potentials between academia and private practice, lack of adequate training in research methods, and the nature of jobs offered by academic institutions. Graduates felt that nontenured, nonfaculty jobs in academic institutions tended to be focused on clinical work and were a deterrent for academic careers. The candidates felt that such clinical jobs precluded them from applying for federal funding for research due to the emphasis on commitment to clinical service time. Theoretically, these candidates would be eligible for National Institutes of Health (NIH) funding if supported by the academic institution. Employees from biomedical organizations can apply for federal funding, provided they possess qualifications to conduct the specified research and meet requirements described for specific funding types.^5,6 All federal agencies describe their funding programs and the eligibility criteria on their Web sites, as do nongovernmental funding organizations in their respective electronic pages.

	SPECIAL TRAINING NEEDS IN RESEARCH METHODOLOGY

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
A group of subspecialist clinicians should be trained to direct and translate research advances in molecular and genomic research into new neonatal treatments. Such training ought to be structured as multilevel, interdisciplinary, collaborative research strategy. Also, in recent years, most neonatal faculty in academic institutions are finding it increasingly difficult to keep up with the burdens of clinical care, research, and teaching. There is now a great demand for direct, senior-level supervision of patient care because of hospital policies and third-party provider issues. Even the atmosphere for clinical research has become increasing complex and time consuming, in part because of a need to meet the regulatory requirements. Thus, each department develops innovative strategies to balance these opposing forces that take away faculty time that could be used to mentoring fellows in training and guiding them in research.

The availability of an accessible, population-based, high-quality database is as essential for research in epidemiology as is a basic science laboratory for animal experimental research. Such databases can be developed as collaborative efforts among regional perinatal centers for projects by the trainees. Furthermore, to make the best use of such databases, residency and fellowship training programs should enhance the quality of training in epidemiologic and health services research methods. The trainees may be encouraged to study and obtain masters degrees in these subjects.

	DEVELOPING RESEARCH SCIENTISTS

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
To succeed in academic research, one needs "protected" research time. In addition, technical and administrative infrastructures are required, along with start-up funding and high-quality mentors and collaborators. In some Scandinavian countries, this has been made possible by requiring an MD degree before PhD training and by supporting clinical and basic science research in institutions that heavily favor translational research, such as the Karolinska Institute in Sweden.

Many experts indicated that promoting interest in science and scientific research ought to be initiated from very early in one’s educational career, possibly from the high-school level. At least from a practical point of view, such promotions ought to be initiated in the premedical courses and continued through medical colleges, residencies, and fellowships. Excellence in research by medical students, residents, and fellows also needs to be recognized through established awards system.

Medical Students
The average debt burden of medical college graduates rose by 5.4% in 2003. Approximately 58% of students had outstanding educational debt up to $100000, with 25.4% reporting more than $150000 in debt. This factor alone can greatly influence one’s career choices, particularly given the great disparity between the salaries of academic physicians and those in private practice. A concerted effort should be made to overcome this influence, including altering the eligibility criteria for the existing "education loan-forgiveness programs" and educational loan-repayment grant-support mechanisms supported by the NIH.

Medical student education should include training in hypothesis-driven clinical research. Summer research fellowships should be offered to enhance interest in academic research careers. Quality and excellence in research by medical students should be recognized through awards that confer prestige. Creation of small grants exclusively for medical student research might enhance grant-writing experience.

Resident Physicians
Residency training programs should incorporate curriculums on research methodologies and clinical trials designs. Residents should be encouraged to collaborate with established scientists and participate in ongoing clinical trials at their institutions. A system of awards and recognition for excellence in resident research should be incorporated as an effective motivational tool. A greater collaboration between residency programs and professional societies could help strengthen research opportunities for residents. By attempting to match the salaries of fellows with those of the junior faculty, more residents might opt for academic careers.

Junior Faculty
Expanded funding mechanisms ought to be developed to support new clinical research programs for the junior faculty. Such funding should prioritize translational clinical research and could be strengthened by special systems of review mechanisms. Governmental agencies, research institutions, and professional societies should develop workshops focusing on research methodology, academic careers, and research opportunities, as has been done by the National Institute of Neurologic Diseases and Stroke, the Child Neurologic Society, and the NICHD-Aspen Conference in collaboration with the University of Colorado.

Midcareer Faculty
The availability of time for maintaining clinical competence and research remains a great obstacle for the midcareer faculty member to remain in academia. Many institutions discourage midcareer faculty from investing time in research, particularly when their research time is not fully reimbursed. To retain academic faculty and facilitate mentorship of junior faculty, the parent institution and the funding agencies must make greater investments in support of midcareer faculty.

Clinical research grants ought to allow greater allocations for administrative support to handle research-related and patient-related paperwork. Innovative review mechanisms need to be considered for research applications from midcareer clinical faculty, giving priority to multidisciplinary research. Salary support for research time should be superior, or at least equal, to those earned by practicing physicians.

Awards can be instituted to recognize excellence in clinical research. Research funding targeted to attract PhD students to work on clinical projects might attract more qualified scientists into these fields.

Role of Senior Faculty
The senior faculty should serve as mentors for the junior faculty and support clinical research by providing access to established patient populations and large databases or serving as coinvestigators on clinical research projects. For the late-career clinical faculty, new funding mechanisms may be needed to support clinical research sabbaticals for senior faculty. Career-enrichment awards are needed for highly experienced clinicians wishing to gain new research skills.

	URM PHYSICIAN-SCIENTIST ISSUES

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 
A URM is defined as the racial and ethnic group represented in smaller proportions in academic fields relative to its proportion in the general population. With nearly one third of its population belonging to smaller ethnic groups, the United States is one of the most ethnically diverse countries in the world.⁷ It is estimated that by the mid-21st century, minority groups will exceed 50% of the US population.

Unfortunately, the burden of disease remains very high in the US minority populations. The frequency of diabetes, hypertension, cancer, asthma, and disorders in mothers and their infants in the perinatal periods are considerable higher among the Native American Indian, black, and Hispanic/Latino populations,^8,9 yet only 3.4% of medical school enrollees are Hispanic, and among all medical school faculty, only 4.9% is represented by the URM ethnicities.^9–14 Studies also show that the frequency of URMs graduating from college certificate programs has remained low at 13%, and the frequency of obtaining PhD degrees is at 7%. URM faculty in medical schools are also less likely to be promoted into higher academic ranks.

Besides fairness and equity, there are other reasons to rectify the shortage of URM ethnic groups in academic medical careers. URM faculty are more likely to address minority health issues, conduct research to rectify health disparity, and serve the underserved patients in large urban areas.^10,11 They will be important role models for future students and provide a diverse perspective, enriching the growth of the institution.

Approximately 12.5% of the US population is of Hispanic origin (12.5%), and >20% of them live in the southwestern states.⁷ One must also note that not all "Hispanic" people are the same: "Hispanic" or "Latino" could mean that the person is Mexican, Puerto Rican, Cuban, or South or Central American or is from other Spanish cultures, regardless of race, each of which has a diverse set of cultural beliefs, traditions, shared values, and religious and linguistic backgrounds. The Hispanic/Latino communities possess distinct cultural empathy among themselves. Studies have shown that Hispanic scientists are more likely to succeed in recruiting research subjects from the Latino communities than other scientists.

Factors Leading to Lack of URM Role Models
The paucity of URM groups entering medical schools in general, and the rarity of those entering academic medicine in particular, remain the main reasons for a URM shortage in academic ranks. These related deficiencies further hamper successful networking opportunities among themselves and in helping URM students and residents. Mentors from different backgrounds might not have common cultural experiences, which hinders the establishment of proper rapport and lines of communication. These differences may also lead to incorrect assumptions and subtle or overt discrimination and prejudice.¹² The URM candidates is often faced with the dilemma of wanting to serve their community while maintaining their workload and demand to serve on a multitude of institutional committees.^13,14

Often hailing from less affluent families, URM graduates tend to face additional pressures to begin practice and earn soon after graduation.¹² Although an increasing number of URM physicians have chosen pediatric residencies,¹² a larger proportion are burdened by educational loans. The debt burden was reported by 48% of non-URM medical school graduates, compared with 75% of URMs graduates.¹²

Most institutional doctrines extol the virtue of cultural diversity but do not foresee the difficulties of attaining and maintaining such diversity. Ethnic and racial stereotyping may lead to misunderstanding, alienation, and workplace insecurity. Subtle or overt differences in one’s social conduct, including demeanor, might be misinterpreted because of a lack of cultural awareness. Often URM health care workers feel that their performances are scrutinized with greater vigilance and their errors are exaggerated.

Potential Solutions
The URM trainees should be encouraged to utilize a number of available opportunities for developing contacts with peers and future mentors at national and regional meetings, such as those of the National Medical Association, the AAP, and the Pediatric Academic Societies. The process of mentoring is complex and is "a dance for 2." Mentors provide leadership and guidance, but they should also provide prospective counseling, education, and monitoring of career progress and facilitate participation at meetings. A seasoned mentor also facilitates the growth of the trainees by introducing them to prospective collaborators and employers.

Academicians should also attempt to educate the URM trainees in the value and rewards of being in academic careers, including intellectual challenge, the pleasure of sharing research findings and ideas, training students and junior faculty, and personal and intellectual gratification from contributions to science. Financial incentives should be given to mentors who train URM candidates and fellows. The incentive could be in the form of supplements to existing grants or credits for the time spent on mentoring activities. Such efforts should be organized in collaboration with the granting agency and the grantee institution.

Popularizing the existing NIH grant programs should be an initial step (Table 1). Students in the earliest periods of their training (high school and college) should be educated about such programs.^6,7

	SUMMARY AND CONCLUSIONS

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

	ACKNOWLEDGMENTS

 
The following is an alphabetical list of speakers at the workshop: Duane Alexander, MD (NICHD, Bethesda, MD); Ronald L. Ariagno, MD (Stanford University School of Medicine, Stanford, CA); Phyllis Dennery, MD (University of Pennsylvania, Philadelphia, PA); JoAnne Goodnight, PhD (NIH, Bethesda, MD); Jeffrey B. Gould, MD (Stanford University School of Medicine, Stanford, CA); William W. Hay, Jr., MD (University of Colorado, Denver, CO); Rosemary Higgins, MD (NICHD, Bethesda, MD); Alan H. Jobe, MD, PhD (University of Cincinnati, Cincinnati, OH); Steven Klein, PhD (NICHD, Bethesda, MD); Gail A. McGuinness, MD (American Board of Pediatrics, Chapel Hill, NC); Josef Neu, MD (University of Florida, Gainesville, FL); William Pearce, PhD (Loma Linda University School of Medicine, Loma Linda, CA); Anna Penn, MD, PhD (Stanford University School of Medicine, Palo Alto, CA); Tonse N. K. Raju, MD (NICHD, Bethesda, MD); Catherine Y. Spong, MD (NICHD, Bethesda, MD); Marta Valcarcel, MD (University of Puerto Rico School of Medicine, San Juan, Puerto Rico); Linda Van Marter, MD, MPH (Children’s Hospital Boston, Boston, MA); and Robert M. Ward, MD (University of Utah, Salt Lake City, UT). The meeting agenda and the names of all registered participants will be published on the NICHD Web page (www.nichd.nih.gov).

	FOOTNOTES

 
Accepted Nov 23, 2004.

Reprint requests to (T.N.K.R.) National Institute of Child Health and Human Development, 6100 Executive Blvd, Room 4B03, Bethesda, MD 20892. E-mail: rajut{at}mail.nih.gov

No conflict of interest declared.

	REFERENCES

TOP ABSTRACT BACKGROUND CHANGES IN NEONATAL-PERINATAL... CURRENT DATA ON NEONATOLOGY... SPECIAL TRAINING NEEDS IN... DEVELOPING RESEARCH SCIENTISTS URM PHYSICIAN-SCIENTIST ISSUES SUMMARY AND CONCLUSIONS REFERENCES

 

1. American Board of Pediatrics. Changes in training requirements for subspecialty certification. Available at: www.abp.org/abpfr1024.htm. Accessed December 9, 2004
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3. Cull WL, Yudkowsky BK, Shipman SA, Pan RJ. Pediatric training and job market trends: results from the American Academy of Pediatrics third-year resident survey, 1997–2002. Pediatrics. 2003;112 :787 –792[Abstract/Free Full Text]
4. American Academy of Pediatrics, Division of Health Policy Research. Executive summary: periodic survey of fellows 43. Available at: www.aap.org/research/periodicsurvey/ps43aexs.htm. Accessed December 9, 2004
5. National Institutes of Health. Grants and funding opportunities. Available at: http://grants1.nih.gov/grants. Accessed December 9, 2004
6. National Institute of Child Health and Human Development. Funding by NICHD. Available at: www.nichd.nih.gov/funding/funding.htm. Accessed December 9, 2004
7. US Census Bureau. Index of Census 2000. Available at: www.census.gov/census2000. Accessed December 9, 2004
8. Cohen JJ. Disparities in health care: an overview. Acad Emerg Med. 2003;10 :1155 –1160[CrossRef][ISI][Medline]
9. Leslie JC, Galvin SL, Diehl SJ, Bennett TA, Buescher PA. Infant mortality, low birth weight, and prematurity among Hispanic, white, and African American women in North Carolina. Am J Obstet Gynecol. 2003;188 :1238 –1240[CrossRef][ISI][Medline]
10. Stoddard JJ, Back MR, Brotherton SE. The respective racial and ethnic diversity of US pediatricians and American children. Pediatrics. 2000;105 :27 –31[Abstract/Free Full Text]
11. Olson K. Data brief: despite increases, women and minorities still underrepresented in undergraduate and graduate S&E education. Available at: www.nsf.gov/sbe/srs/databrf/sdb99320.htm. Accessed December 9, 2004
12. Colburn L, Zhang K, Tidlen E, Terell E. Minority students in medical education: facts and figures XII. Available at: https://services.aamc.org/Publications. Accessed December 10, 2004
13. Wilson DE, Balotin J. Has the well run dry? Priming the diversity pump in PhD programs. J Assoc Acad Minor Phys. 1999;10 :27 –33[Medline]
14. Reede JY. A recurring theme: the need for minority physicians. Health Aff (Millwood). 2003;22 :91 –93[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) P3Rs: Submit a response P3Rs: View responses Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Ariagno, R. L. Articles by Raju, T. N.K. Search for Related Content PubMed PubMed Citation Articles by Ariagno, R. L. Articles by Raju, T. N.K. Related Collections Premature & Newborn

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