Career development in endoscopic research: current status and recommendations

Transcription

1 Career development in endoscopic research: current status and recommendations Dennis M. Jensen, MD Los Angeles, California At a recent meeting of the Research Policy Committee of the American Digestive Health Foundation (ADHF), a new division chief who is a laboratory scientist complained about the lack of research and career development funding available for his new and mid-career clinical investigators and endoscopists. His insight may have been new to him but this has been the status quo for several decades. In his logical analysis, he pointed out that the National Institutes of Health (NIH) and Veterans Administration (VA) have supported hypothesis-driven studies by laboratory scientists for many years but very few endoscopists are funded or appear competitive. When I asked him why he thought the NIH and VA do not support endoscopy research and career development, his opinion was that the grants and applications of endoscopists were not good enough scientifically to compete against those of laboratory researchers. He also thought that no special training was needed to perform endoscopy research, in contrast to laboratory research. I think that his analysis was superficial but rather telling about the crisis for GI clinical research and career development of endoscopists interested in research. The lack of commitment to training and funding in endoscopic research has resulted in a self-fulfilling prophecy of sparse expertise in clinical and endoscopic research and career development in the United States. In the absence of organized training programs in clinical and endoscopic research, such as the programs that have been available to laboratory scientists for years, tenacious young investigators must seek advice and mentoring from clinical investigators in other institutions, ask for help from faculty From the Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California. Reprint requests: Dennis M. Jensen, MD, CURE: Digestive Disease Research Center, West LA VA Med. Ctr., Bldg. 115, Rm 318, Wilshire Blvd., Los Angeles, CA 90073; djensen@medl.medsch.ucla.edu. Gastrointest Endosc 1999;49:S Copyright 1999 by the American Society for Gastrointestinal Endoscopy /99/$ /0/95810 in diverse disciplines (such as biostatistics, epidemiology, and biomedical engineering), and seek constructive criticism of their hypotheses and studies from those capable and willing to give it. PURPOSES The goals of this article are to comment on the significance and importance of GI endoscopic research and career development in the United States, to discuss the current status of career development, including deficiencies, problems, and funding, and to make recommendations for improving the current situation. SIGNIFICANCE OF CLINICAL AND ENDOSCOPIC RESEARCH AND CAREER DEVELOPMENT Table 1 presents some reasons for career development in endoscopic research in the United States. GI and liver diseases are among the most frequently diagnosed conditions of ambulatory and hospitalized patients. Common medical problems such as GERD, abdominal pain, and GI bleeding account for significant illness or disability and consume significant health care resources. Furthermore in practices of gastroenterologists, more than 50% of GI cases are diagnosed or treated with the use of endoscopic procedures. Many important clinical and outcomes questions about clinical gastroenterology, hepatology, and endoscopy could be answered by systematic studies. 1,2 These would expand knowledge about the clinical conditions and ultimately improve the health care of patients with these conditions. On the basis of my recent experience with research training and mentoring for endoscopic and GI outcomes research, I believe that talented young investigators are being attracted to this field of clinical investigation. They will contribute important new knowledge relevant to the health care of patients with GI and liver disorders. This is one ray of optimism about clinical outcomes and endoscopy career development. As an example, at a recent Academic Skills Workshop, which was a national meeting organized by the ADHF and American Gastroenterological Association (AGA) for young investigators, twice as many applicants were inter- S100 GASTROINTESTINAL ENDOSCOPY VOLUME 49, NO. 3, PART 2, 1999

2 Table 1. Why should there be career development in endoscopic research in the United States? Gastrointestinal and liver diseases are very common. 50% of clinical GI involves endoscopy for diagnosis and/or treatment. Talented young investigators will be attracted and will contribute important new knowledge. Clinical and Health Services research in this field will improve the health of U.S. patients. Research may reduce the cost of health care for digestive diseases. Table 2. Career development for GI clinical versus basic scientist Basic Clinical Salary on a training grant? Most Very few or none Adequate protected time? Yes No Assigned clinic time? Little Lots Research space? Lots Little Research training? Mentored Ad hoc Career development awards? Many Very few or none ested in careers in clinical and outcomes research than in laboratory or basic science research. The other reasons that research and career development in endoscopic research should be fostered is that such research has the potential to improve the health of patients in the United States and elsewhere. The research is relevant to real medical problems and has the interest of the public, including members of the US Congress. Consider colorectal cancer as an example. There is an increased awareness of the clinical problem and screening has been approved for elderly Medicare patients. There is also more interest in both laboratory and clinical research of colon cancer. This may provide more opportunities for career development and also funding of patient-oriented and endoscopy research. As an added benefit of endoscopic and outcomes research, the cost of health care also may decrease, particularly as a result of health services research about cost effectiveness of different management strategies and treatments. CURRENT STATUS OF CAREER DEVELOPMENT IN ENDOSCOPIC RESEARCH The second purpose of this article is to discuss the current status of career development in GI endoscopic research, including deficiencies, problems, and funding sources. I will start the process by contrasting career development for GI clinical or endoscopic investigators with career development for basic or laboratory scientists (Table 2). Table 3. Elements of training for an endoscopic research career Clinical gastroenterology and hepatology GI endoscopic procedures Clinical and Outcomes research methodology via courses, seminars and research experience Mentoring by skilled researchers to provide training about designing, conducting, and reporting hypothesis-driven studies Table 4. Problems for career development in endoscopic research in the United States No federal priority to train such researchers No federal funding for endoscopic research career development No US centers specific for this training No organized curriculum or programs Ad hoc training and mentoring with sparse career development The dichotomy of opportunity between career development training programs for laboratory scientists and those for clinical research by GI fellows or young faculty typically exists in most academic medical centers in the United States. Whereas the reasons and history behind the dichotomy differ in various institutions, the end result has been to discourage clinical researchers and encourage the best and brightest to pursue careers in laboratory research. This has led to a shortage of experienced GI clinical investigators and academic endoscopists in this country. 1,3 They are becoming an endangered species relative to basic researchers. Career development in clinical GI research and endoscopy has been neglected for so long that a crisis has developed, because very few clinical researchers have been trained or funded over the last 25 to 30 years. 2,3 Obviously without training or funding there is little hope of successfully competing for research monies with the well trained, carefully nurtured, and very adequately supported basic or laboratory scientists. Fortunately there has been an increased awareness of endoscopic and health service research in the United States recently. In part this is because of the revolution in health care with the emphasis on managed care. Effectiveness, cost savings, and management strategies have evolved through the managed care industry in the guise of better medical treatment. Recent decisions about managed care and effectiveness, however, have been more often made on the basis of economics rather than data from medical or health services research. In addition there has been increased awareness of certain medical problems with the emphasis on targeted VOLUME 49, NO. 3, PART 2, 1999 GASTROINTESTINAL ENDOSCOPY S101

3 Table 5. Potential funding sources for training and career development in endoscopic research ADHF ASGE Awards for training: Wilson-Cook Olympus ADHF Outcomes Research Training Awards Robert Wood Johnson Fellowships General CRC CAP Awards NIH GI Training Grants ADHF, American Digestive Health Foundation; ASGE, American Society for Gastrointestinal Endoscopy; CAP, Clinical Associate Physician; CRC, Clinical Research Center; NIH, National Institutes of Health. research by the US Congress and more recently by the NIH. For example, clinical and outcomes researchers in gastroenterology and hepatology have benefited from the initiatives in research of H pylori, colorectal cancer, and hepatitis C. Interest has grown in outcomes research by various GI societies such as the American Society for GI Endoscopy (ASGE), AGA, and American College of Gastroenterology (ACG), which fund some modest sized clinical and endoscopic research studies. 4 The elements of training for a career in endoscopic research are more expansive than most laboratory training programs. Those interested in GI endoscopic research have to master several types of skills (Table 3). Candidates typically must have excellent training in clinical hepatology and gastroenterology. This includes training in the care of patients as well as learning from skilled clinicians and teachers how to perform GI endoscopic procedures. Currently laboratory scientists who are parttime clinicians or endoscopists cannot adequately train the next generation of clinical or endoscopic investigators. A cadre of dedicated and skilled clinicians and clinical investigators is required. Training, nurturing, and integrating the next generation of investigators into divisions of digestive diseases in academic medical centers are major challenges to current and future leaders of medical departments and chiefs of these divisions. Another element of the research training is learning clinical and outcomes research methodology through courses, seminars, and actual research experience. Programs through Schools of Public Health can provide detailed courses in biostatistics, epidemiology, study design, decision analysis, data management, pharmacoeconomics, and many other aspects of health services training and research. Simultaneously mentoring by skilled clinical and endoscopic researchers in designing, conducting, analyzing, and reporting hypotheses-driven studies is critical for training individuals interested in clinical Table 6. Solutions for career development in endoscopic research More funding for: Career development of new investigators Successful investigators as mentors and researchers Training grants for GI outcomes research Centers for training and research Investigator-initiated studies Multicenter trials outcomes and endoscopic research. The mentoring is the most important element in training new clinical investigators or academic endoscopists. 2 Mentoring, however, is not standardized and few experienced mentors are available to conduct such training in US centers. Few funded positions exist for such research mentoring in the United States, in comparison with the laboratory research opportunities. Funding for career development of endoscopy and clinical GI researchers should be available for 4 to 5 years and should support 75% to 80% protected time, similar to funding for laboratory researchers. This commitment of protected time is necessary to master the elements of training enumerated in Table 3, to perform research, and to compete for research funding. Some of the problems relevant to the career development for endoscopic research in the United States are listed in Table 4. No federal mandate or priority has existed to train clinical researchers. For example, NIH GI training grants typically do not include career development in endoscopic research and most do not have slots to train GI patient-care or health services investigators. No US centers have been specifically funded to train GI clinical or endoscopic researchers. Except for a few programs having a GI health-services emphasis, no organized curriculum or didactic training programs have been developed in the United States to specially train those interested in a career in GI clinical or endoscopic research. Most of the training for endoscopists interested in clinical research continues to be ad hoc in nature with little mentoring. This is in significant contrast to the many federally funded career development programs for the laboratory scientist in gastroenterology or hepatology, and the lack of funded programs for the GI endoscopy researcher are extreme. RECOMMENDATIONS TO IMPROVE CAREER DEVELOPMENT IN ENDOSCOPIC RESEARCH In my opinion, the highest priority for funding in GI clinical and endoscopic research should be for S102 GASTROINTESTINAL ENDOSCOPY VOLUME 49, NO. 3, PART 2, 1999

4 D Jensen Figure. Problems and solutions for endoscopic research in the United States. career development. Training and mentoring of young and mid-career physicians seriously interested in careers in GI patient-oriented research should be the target groups, because so little funding is available to them now. The leadership of the ASGE has made research one of the high priorities, as emphasized in recent editorials in Gastrointestinal Endoscopy. 2,3,5 Some currently available potential sources of funding for training and career development in endoscopic research are listed in Table 5. At this time the funds for career development from industry through the ADHF-ASGE (Wilson- Cook and Olympus awards) provide scant protected time (1 year only), are few in number (7 awards for the entire United States), and have limited monies ($35,000 to $40,000 each). However they do support junior faculty for 1 year and the emphasis is on career development of endoscopic researchers. Only 2 ADHF-Outcomes Research Training awards are awarded per year in the United States: $50,000 a year for 2 years of advanced didactic training for a masters degree or PhD (for example, in public health, epidemiology, or health services research). The other sources of funding listed in Table 5 for career development are for general clinical investigators: Robert Wood Johnson fellowships and General Clinical Research Center-Clincal Associate Physician Awards. However endoscopists may qualify for these awards and for funding on NIH GI Training Grants under certain circumstances. What else is needed to alleviate the shortage of GI clinical and endoscopic researchers? More funding, particularly from federal sources, for career development of new investigators interested in endoscopic research should be a high priority (Table 6). Simultaneously funding of successful patient-oriented investigators as mentors (of trainees or younger faculty) and researchers will be necessary to alleviate the current crisis that has resulted from neglecting to train GI clinical and endoscopic researchers in the United States. In addition the funding of institutional NIH-type training grants for career development of clinical and endoscopic researchers ought to be considered. The current NIH training grants for laboratory scientists could serve as a model to develop a parallel program in clinical or endoscopic career development. However more discussion, standardization, and guidance about several important aspects are required, including a standard curriculum for the didactic program (such as a Masters of Public Health or Masters of Science in Health Services), the qualifications of the faculty in terms of training and research funding, the details and strategies for mentoring of trainees, and the scope of GI endoscopic, clinical, and health services research that would be encouraged. Simultaneously more funding from all sources for hypotheses-driven, investigatorinitiated studies in patient-oriented gastroenterology, hepatology, and endoscopy ought to be developed, including multicenter trials. It is encouraging that the NIH recently announced 2 new types of career development awards in clinical research. Generalists, specialists, and sub-specialists in all fields may apply. The NIH K23 Award is for career development of new patient-oriented investigators. In contrast the NIH K24 Award is for mid-career investigators to serve as research mentors of trainees or younger faculty members and to perform research in patient-oriented studies for up to 5 years. I hope that many GI sub-specialists, including gastroenterologists, hepatologists, and endoscopists eventually will apply for these awards and several will be funded. This type of federal funding could start to alleviate the shortage of experienced GI clinical investigators and academic endoscopists in this country. Funding for the K23 and K24 awards will start in VOLUME 49, NO. 3, PART 2, 1999 GASTROINTESTINAL ENDOSCOPY S103

5 July 1999 for the first applications, which were submitted June What are other problems and solutions for endoscopic research in the United States? In my opinion, the final, long-term solution to the crisis in GI clinical and endoscopic research is more complex and inter-related than the funding of career development. This is illustrated in the Figure. More funding of all types will be required over several years to develop a critical mass of trainees, investigators, and centers that can successfully perform high-quality endoscopic research and compete for research dollars. Patient-oriented researchers in gastroenterology, hepatology, and endoscopy also should continue to consider collaboration with laboratory scientists, those who develop new technologies, and other health services researchers. 2 Through these efforts, new knowledge about digestive diseases will be attained, the health care of patients with these disorders will improve, and the cost of care involving endoscopy may decrease. REFERENCES 1. Sandler RS, Everhart J, Fenster F, Jensen DM, Johanson J, Lieberman D, et al. A primer on outcomes research for the gastroenterologist: Report of the American Gastroenterologic Association Task Force on Outcomes Research. Gastroenterology 1995;109: Pasricha PJ. Shining the light on endoscopic research: perspectives of a young investigator. Gastrointest Endosc 1998;47: Sivak MV. Endoscopic research in America? Gastrointest Endosc 1997;46: Discovery. American Digestive Health Foundation Research Awards Nord HJ. The American Society for Gastrointestinal Endoscopy at the turn of the century and beyond. Gastrointest Endosc 1998;47: S104 GASTROINTESTINAL ENDOSCOPY VOLUME 49, NO. 3, PART 2, 1999