Can We Prime the Pump for Developing Pediatric Physician-Scientists?

Who will become the next generation of pediatric physician-scientists? This question has provoked increasing calls of alarm because a robust cadre of well-trained, clinically knowledgeable pediatric physician-scientists is critical to fully capture the immense potential of scientific advancements to improve child health. The evidence, however, suggests that fewer, rather than more, young pediatricians are entering scientific careers.^1,–4 

A number of factors are generally accepted as current problems for someone who is considering, and later succeeding, in a career as a physician-scientist. Factors considered to negatively influence those who are considering a career as physician-scientists include the following: lack of exposure to research as undergraduates, medical students, or residents; a paucity of mentors at all levels of education; a lack of a diverse scientific workforce; and exorbitant educational debt. Once a physician embarks on a research career, additional hurdles to becoming successful include excessive clinical demands, time constraints, lack of mentors, limited initial funding for salary and laboratory support, and the lengthy period to obtain independent funding.

In this issue of Pediatrics, Hurst et al⁵ describe the Duke University Pediatric Department’s approach to attracting pediatric physician-scientists and describe the program’s curriculum and infrastructure support to prepare residents and fellows for a successful career launch. Although a small program, the principles of collaborative programs for residents and fellows, engagement with medical students, access to medical school resources, and the providing of peer and faculty role models are sound practices that encompass early opportunities to create enthusiasm for science and research.

One mechanism used in the Duke Pediatric Research Scientist Program (DRSP) was the development of an innovative American Board of Pediatrics (ABP)–approved 4-year resident research pathway that included 18 months for research.⁵ The ABP currently has 2 approved research pathways to support pediatric residents as they begin a research career. The Integrated Research Pathway allows for up to 12 months of research for pediatric residents who have a PhD degree or equivalent and successfully complete their first year of clinical training. Since its inception in 2001, the ABP has approved 118 postgraduate level-1 candidates from 30 programs for the Integrated Research Pathway through 2019. The ABP’s Accelerated Research Pathway allows for academically oriented residents to complete 2 years of general pediatric training followed by 4 years in a subspecialty fellowship; so far, 113 residents have been approved for this pathway since 2003 (S. Woods, personal communication, 2019). Thus, the number of residents and programs subscribing to these valuable pathways has been relatively low.

The pool of MDs and PhDs entering the Residency Match each year is small. The National Institutes of Health (NIH)–funded medical student training programs for combined MD and PhD degrees has been a valuable platform for beginning physician-scientists. Approximately 12% of graduates of medical student training programs pursue pediatrics.⁶ If this proportion held true for all MD and PhD candidates entering the Match, the total number of MDs and PhDs filling pediatric resident postgraduate level-1 positions would have been 74 students in 2014 and 106 students in 2018.⁷ Although not all pediatric physician-scientists hold MD and PhD degrees, MDs and PhDs represent a rich pool of future scientists; however, the pool is shallow.

The DRSP highlights some opportunities and exposes some challenges for other pediatric training programs.⁵ In an academic pediatric program located on the medical school campus, the opportunity for the pediatric faculty to teach or mentor undergraduate and medical students is significantly enhanced. In addition, campus-wide curricula and peer interactions for residents pursuing a physician-scientist career is strengthened and is more efficient through collaborative programs in the medical school and other clinical science departments. Children’s hospitals provide a significant amount of graduate medical education training and may not be located within the medical school campus. In such instances, geographic and time constraints may reduce the opportunities for the important engagement of the pediatric faculty with students and with medical school educational initiatives.

Amassing troops does not necessarily win the battle. Many of the challenges for success as pediatric physician-scientists when they become faculty are mirrored for residents and fellows. Finding salary support for nonclinical time is challenging. Mentored training grants through T32 grants, the Pediatric Scientist Development Program, and R38 awards are valuable when available. Each of these funding mechanisms is limited. Even when available, these grants do not provide for laboratory technical support to allow research to progress when clinical time is required. Loan forgiveness also is a critical benefit to allow those physician-scientists with major debt to pursue their research careers.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development strategic plan and the recently created trans–NIH Pediatric Research Consortium are assessing how the NIH can best support robust growth of the pediatric research workforce. Although the challenges are daunting, so are the rewards of contributing to science and children. The well-organized DRSP is 1 excellent model for priming the pump.⁵ Many pumps are needed to grow our pediatric research workforce.

ABP

American Board of Pediatrics

DRSP

Duke Pediatric Research Scientist Program

NIH

National Institutes of Health