Developing the Next Generation of Otolaryngologist-Researchers

Otolaryngol Clin N Am

40 (2007) 1295–1309

Developing the Next Generationof Otolaryngologist-Researchers

Shawn D. Newlands, MD, PhDa,*,Daniel A. Sklare, PhDb

aDepartment of Otolaryngology, University of Texas Medical Branch,

301 University Boulevard, Galveston, TX 77555-0521, USAbDivision of Scientific Programs, National Institute on Deafness and Other Communication

Disorders, National Institutes of Health, Executive Plaza South, Room 400C,

6120 Executive Boulevard, MSC-7180, Rockville, MD 20892-7180, USA

Discoveries and the application of new technologies drive new therapiesthat improve patient outcomes. The practice of otolaryngology, as all ofmedical practice, has changed dramatically in the last 15 years based onnew technologies and new concepts of disease, and change will undoubtedlycontinue. We owe our patients access to newer procedures and therapiesthat stem from basic and clinical research, but from where will this innova-tion come? Although many exciting breakthroughs have emanated from theprepared minds of clinicians interacting with their patients, other discoveriesoriginate from clinicians who are trained in the methodologies of science.Increasingly, otolaryngology research draws from such fields as outcomesresearch, information technology, genetics, molecular biology, and biomed-ical engineering.

This article discusses where the clinician-scientists in our specialty havetraditionally come from and how they are likely to be generated in thefuture. Training clinicians to be proficient researchers is as difficult as it isimportant. As a specialty, we have to be aware of emerging areas of inquiryand ensure that opportunities exist to couple the right minds to the rightprojects. Financial incentives, clinical care, and family demands often com-pete for the time and energy required for a career as a clinician-scientist.Recognizing the importance of research to otolaryngology and nurturingthe aspirations of those clinicians truly cut out for this pursuit should ensure

* Corresponding author.

E-mail address: [email protected] (S.D. Newlands).

0030-6665/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.otc.2007.07.008 oto.theclinics.com

mailto:[email protected]

http://www.oto.theclinics.com

1296 NEWLANDS & SKLARE

continued growth in patient-grounded science that will drive our specialtythrough the coming years.

Literature review

Others have written about the training of clinician-scientists in otolaryn-gology and the shortage of clinician-scientists in the specialty, and multipleviews and plans have been put forward. Here we concentrate on the morerecent literature. In 1999, Nadol surveyed junior otolaryngology faculty(less than 5 years out of training) across the nation [1]. He found that71% had completed a clinical fellowship and 9% a research fellowship.Although 93% reported being engaged in research activity, they actuallyonly spent an average of 13% of their time in research. Most of the surveyedfaculty went into otolaryngology to teach, not to conduct research. Whenasked how their academic careers could be improved, however, the topfour suggestions were related to research, particularly research support.Nadol concluded that a need exists for more research training, protectedtime, and ‘‘clarity of job description.’’

Naclerio and colleagues [2] surveyed otolaryngology department chairs.Chairs identified 63% of their faculty as clinician-scientists but reportedthat, on average, they spent only 17% effort pursuing that endeavor. Only8% of faculty members were reported to be funded by the National Insti-tutes of Health (NIH) and 20% by other sources. The authors also foundthat, on average, there are two PhDs per otolaryngology department [2].Wolfe and Weymuller examined the graduates who trained in the NationalInstitute on Deafness and Other Communication Disorders (NIDCD)–sup-ported NIH Institutional National Research Service Award (NRSA) train-ing grant (T32) programs at their institutions (University of Michigan andUniversity of Washington) [3]. Although a high percentage of these traineespursued academic medicine, one fourth to one third eventually were fundedby NIH-mentored clinical scientist development award (K08) grants, anda small percentage became independent investigators. Chole reported a sim-ilar experience with Washington University T32 trainees; 60% enteredacademic medicine, and 17% obtained NIH funding [4]. Wolfe andWeymuller concluded that research training should be phased in late in res-ident training after the resident has identified his or her clinical focus andresearch focus [3]. Such a plan is inhibited, however, by the sometimes rigidand often unaligned residency review committee in otolaryngology, Ameri-can Board of Otolaryngology, and NIH rules. Some of the proposed solu-tions included funding for research mentors, coordination of the careerpath that bridges residency to the K-award, and a joint strategy betweenthe residency review committee, American Board of Otolaryngology, Amer-ican Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS),and the NIDCD/NIH to develop clinician-scientists. Wolfe and Weymulleralso recommended a renewed emphasis on clinical research training, which

1297DEVELOPING OTOLARYNGOLOGIST-RESEARCHERS

is better matched to the interests of residents than basic science research [4].Supporting their suggestion is the finding that students who graduate frommedical school are ten times more likely to be interested in pursuing clinicalresearch as part of their career trajectory than basic science research [5].

In late 2005, the NIH and AAO-HNS co-sponsored a conference onresearch training and education in otolaryngology. The purpose of thisforum was to identify obstacles to research education and training in otolar-yngology and formulate strategies to overcome these barriers. Among the158 registrants, representing 33 otolaryngology training programs, weremany of the leaders, clinician-scientists, and trainers/research mentors ofthe specialty. A summary of this conference has been published [4].Although a diversity of opinions was expressed at the conference, severaltargeted recommendations to the NIDCD/NIH and the profession emerged,underscored by a concerted call for the development and support of moreflexible models and NIH-sponsored programs for research training inotolaryngology.

Otolaryngology does not uniquely face these problems. Urology andorthopedic surgery, other surgical subspecialties, have even lower rates ofresidents developing into clinician-scientists. Such failure has been attrib-uted to lack of mentorship, clinical pressure, a specialty culture that doesnot value research, financial constraints, poor research background amongresidents in the specialty, busy on-call schedules, and the length of clinicaltraining [6–8].

Career paths

The successful clinician-scientist develops during all stages of training. Itis unusual for someone who has not had significant research training beforehis or her first faculty position to be successful in obtaining funding anddeveloping into a productive clinician-scientist. This section considersresearch opportunities afforded to trainees at various stages of their careers.

Before residencyAlthough one could debate whether clinician-scientists are born or made,

there is no question that many clinicians interested in research self-identifyearly in their education. One way to build our cadre of clinician-scientists isto recruit students interested in science into our specialty rather than try toturn those committed to otolaryngology toward research. Many demo-graphic factors have been correlated with an interest in becoming a clini-cian-scientist [9], including graduation from a private medical school,graduation from a medical school with larger amounts of NIH funding,graduation from a school with an NIH-funded medical scientist trainingprogram (MSTP), and male gender.

Many programs encourage and foster such students. Many medical cam-puses offer summer research experiences for undergraduate students. Most


medical school curricula have mechanisms for medical student research, butperhaps the most likely students to go into academic medicine and continueto participate in biomedical research are MD/PhD students. Most medicalschools have MD/PhD programs, and 41 of these schools receive NIH fund-ing and designation as MSTPs. The MSTP program, administered by theNational Institute of General Medical Sciences, was founded in 1964 toincrease the clinician-scientist pipeline. Up to 8% of medical school gradu-ates hold MD and PhD degrees. Of these graduates, one fourth are fromMSTP programs, one fourth are from other MD/PhD programs, androughly one half obtained the two degrees independently. More than 80%of participants between 1970 and 1990 in MSTP MD/PhD programs wenton to academic careers, and 68% became independent investigators [10].This latter percentage contrasts to less than 1% of graduates from UnitedStates medical schools in general [5].

Clark and Hanel [11] used the appendices of MSTP grant applications tothe National Institute of General Medical Sciences to investigate whichspecialties MD/PhD students gravitate toward. They found that studentswho complete MSTP programs are more than five times as likely to gointo pathology as MD-only students [11]. Similarly, pediatrics, neurology,neurosurgery, and radiology are popular for these students. In contrast,MD/PhD students are unlikely to enter family medicine, emergency medi-cine, rehabilitation medicine, obstetrics and gynecology, and most surgicalsubspecialties. MSTP graduate students are approximately 55% as likelyto go into otolaryngology as MD students, however [11]. Interestingly,41% of MSTP students get their PhDs in biochemistry, cell or molecularbiology, or neuroscience [12], all disciplines well positioned to conductresearch in otolaryngology.

There are several ways for our specialty to attract MD/PhD students andother students likely to become clinician-scientists. Primarily, researchers inotolaryngology should be more visible to such students. Specific ways toincrease such visibility include individuals who are in otolaryngologydepartments or conducting otolaryngology research serving on MD/PhDcommittees, participating in MD/PhD curricula, and serving on dissertationcommittees. These individuals also could sponsor undergraduate studentswho are conducting summer research and medical student research. Someof these activities could be sponsored through T32 grant programs, whichare discussed later. Several NIH institutes, including the NIDCD, alsoseek to recruit students on integrated MD/PhD tracks to pursue researchin their scientific mission areas through the Ruth L. Kirschstein NationalResearch Service Awards for Individual Predoctoral MD/PhD Fellows(F30) (PA-05-151).

During residencyMost otolaryngology residency training programs allocate time for resi-

dent research, and in most cases, the purpose of this rotation is twofold:


to make our trainees more sophisticated consumers of research and to fostera greater appreciation of the value of research to clinical practice. At thelead author’s institution, as in many other programs, the mechanism toreach these goals is a research rotation, wherein, the resident experiencesthe scientific process from conception of a research idea through presenta-tion and publication. The residency-based research experience, typically3 to 6 months in duration, is generally not adequate preparation for buildingan independent research career. In some programs, however, additionalresearch training is available, generally through a T32 program.

FellowshipSeveral fellowship opportunities are available for residents who complete

otolaryngology programs. Some programs, particularly in head and necksurgery, neurotology, and pediatric otolaryngology, have 1 year of researchexperience built into them. Unfortunately, these experiences are short, oftenpart-time, and applied to all participants, not just those interested in anacademic career. Some of the full-time research training experiences are cur-rently funded by T32 programs (eg, the head and neck fellowship at MDAnderson Cancer Center). The extent to which these fellowship-basedresearch experiences enable residents to become independent clinician-scien-tists is unclear. Research is needed to evaluate the use of these experiences inincreasing the cadre of clinician-scientists.

After residency/early careerPerhaps the greatest attrition of otolaryngologists fromwould-be clinician-

researchers to full-time clinicians occurs in the transition from training toemployment during the first few years of a junior faculty appointment. Thepressure on the time of young otolaryngologists is intense. They feel theneed to build a practice and refine their surgical skills. They are often soughtby residents to ‘‘staff cases’’ and are heavily involved in the on-call schedule.Their teaching responsibilities are new, such that each lecture or presentationtakesmore time to prepare than it does for seasoned facultymembers with lec-tures already ‘‘in the can.’’ Although these junior faculty members may havenegotiated adequate ‘‘protected time’’ to start their research career, they oftenhave not taken into account the actual and perceived peer pressure to ‘‘pulltheir weight’’ clinically. Often this pressure comes from within. Emergingfrom fellowship and residency, young faculty members most often identifywith their clinically active mentors, with whom they have spent most of theprevious 5 to 7 years, rather than their clinician-scientist mentors, withwhom they have spent considerably less time.

The elements in a junior faculty’s new department that should be in place tomake this transition successful include a culture of inquiry, strong committedleadership, alignment of incentives for research accomplishment, appropriatementorship, appropriate research resources and facilities, and appropriate


time protection. Most clinician-scientists in otolaryngology work in a rela-tively small number of departments throughout the country. The reason forthis distribution is that these departments are the ones that canmost likely pro-vide the previously listed elements. Because of these departments’ trackrecords, however, they can attract the appropriate candidates.

Departments in which research is not valued are toxic environments for thecareer of a clinician-scientist. The key element for a nurturing environment isa true culture of scientific inquiry. This culture is ideally set from the topdthedepartment chairdbut should be pervasive throughout the department. Partof this culture includes alignment of incentives. Strong disincentives to re-search, either financially or in prestige, erode commitment to research amongyoung faculty members. Mentorship is also critical for developing a researchcareer. Because otolaryngology is a small field, many otolaryngology depart-ments lack appropriate research mentors within their ranks for junior facultymembers. Some departments circumvent this limitation by forging researchcollaborations with investigators from other departments, who also serve asprimary and secondary mentors to new faculty members.

Another strong element for nurturing successful clinician-scientists is theresearch environment. Early career faculty members are more successfulwhen they have the opportunity to interact with investigators in their scien-tific field. Teaming with established laboratories and programs is frequentlythe road to success for clinician-scientists. Ideally, clinician-scientists willbring a clinical perspective to a research group while basic scientists contrib-ute research experience, technical know-how, grant-writing knowledge, andresources. In the biomedical sciences, full-time researchers usually have had5 or more years of PhD training and 5 or more years of postdoctoral train-ing before initiating an independent research career. In contrast, otolaryn-gologists rarely have more than 3 years of scientific training beforeentering an independent research career trajectory. For this reason, it isoften difficult for these new surgeon-investigators to compete favorablywith their PhD counterparts for federal research funding. As a group, how-ever, physicians have been shown to compete favorably with nonphysiciansin the trans-NIH peer review process [13].

The NIH awarding components (institutes and centers) have recognizedthe challenges faced by specific groups in developing a research careertrajectory and have launched program initiatives and award mechanismsaimed at facilitating the start-up of the clinician-scientist’s career. TheNIH institutes place considerable weight on the career development planproposed in K-award applications. The availability and quality of mentorsand research resources are important factors for budding clinician-scientiststo consider before taking a junior faculty position. These factors and futureprospective funding sources should be considered before a candidate acceptsa new faculty position.

Timeprotection is an issue that is usually up-front in the negotiation for anynew faculty member but is of particular importance with clinician-scientists.


Typically, the new facultymemberwants to knowhowmuch protected time toask for and for how long. There is no correct formula; however, it is probablethat more often than not, the time given is either too little or distributed incor-rectly. Common practice is to provide a certain percentage of protection fora period of several years. Often, however, protection is less necessary in thefirst yeardduring the arduous period of laboratory set-updand more neces-sary during the process of preliminary data collection and grant writing.Because each situation is different, the best approach is customizing distribu-tion of time and resources based on the young faculty member’s experience,the project, and the environment. An important element of this customizationis that the chairperson clearly communicates expectations to the faculty mem-ber. Inappropriately allotted time and resources arewasteful anddiscouragingto existing faculty, who are often supporting the new clinician-scientist facultymember.

Funding for clinician-scientists in otolaryngology

Many academic otolaryngologists get their initial funding through smallgrant programs. Many of these programs are sponsored by the AAO-HNSand other professional societies. The review of these grant applications hasbeen consolidated into an academy program called the centralized otolaryn-gology research efforts (CORE). Grant applications for academy grants andeight other professional societies (ie, American Academy of Facial Plasticand Reconstructive Surgery, American Academy of Otolaryngologic Al-lergy, American Head and Neck Society, American Hearing ResearchFoundation, American Laryngological Association, American RhinologicSociety, American Society for Pediatric Otolaryngology, and the TriologicalSociety) are reviewed in one comprehensive review committee each spring.This mechanism was adopted to ensure high-quality reviews for each pro-posal and facilitate funding of meritorious proposals by stimulating consid-eration of proposals across different grant mechanisms. An additionalbenefit has been to afford otolaryngologists the opportunity to participatein a study section format and, as a result, become better grant writers them-selves. The centralized otolaryngology research efforts mechanism considersproposals that, cumulatively, award up to $650,000 per year. Details onapplying for these grants are available at http://www.entlink.net/research/grant/Foundation-Funding-Opportunities.cfm.

The NIH T32 mechanism supports research training that is not readilyamenable to support through individual training grant mechanisms. Suchtraining includes research training for otolaryngology residents and postre-sidency fellows within clinical departments. Currently, 12 NIH T32 grantsare awarded to otolaryngology programs for resident training in research.Most of these programs are designed to support research training for otolar-yngology residents for 1 to 2 years, with the goal of nurturing clinician-sci-entists, but there are variations. These programs are generally found in

http://www.entlink.net/research/grant/Foundation-Funding-Opportunities.cfm

http://www.entlink.net/research/grant/Foundation-Funding-Opportunities.cfm


institutions with large research infrastructures and vary across institutionswith respect to the duration and phasing of the research training experi-ences. There is, however, no consensus on the optimal design. The NIDCDrequires that its mentored K-award applicants have had at least 2 years ofprior research experience since their undergraduate education.

In 1993, the NIH issued a consensus report, the Lenfant Report, stronglyrecommending twodpreferably contiguousdyears of research training forpostdoctoral health professionals (generally physicians). This recommenda-tion was made on the basis of many prior years of data regarding the subse-quent research granting success and longevity of research funding of healthprofessional postdoctoral fellows trained on NIH T32 grants. In compliancewith the Lenfant Report, most applicants to the NIDCD for new and renewal(competing continuation) otolaryngology resident-directed T32 programsover the last decade have augmented or modified their training programs tooffer a 2-year research training period to otolaryngology residents. This train-ing period often immediately follows completion of a 1-year internship in gen-eral surgery. The NIDCD experience with otolaryngology resident-directedT32 programs has raised questions, however, concerning whether the findingsof the Lenfant Report may be generalized to the cohort of surgically trainedotolaryngology physicians trained by NIDCD-supported T32 programs.

To probe this question, a study was conducted by the NIDCD in late2003 seeking to determine the relationship between career outcome (aca-demic practice versus private practice/other) and the duration of T32-sup-ported research training (2 years versus alternative models less than anaggregate of 24 months, and generally 12 months) for otolaryngology resi-dent trainees supported on longstanding NIDCD-funded T32 training grantprograms. The assumption was made that individuals practicing academicmedicine were more likely to engage in research, either as a principal inves-tigator or substantive collaborator, than those in private practice. Only T32appointees who completed their research training and clinical training wereincluded in the survey. Prior or subsequent individual NRSA fellowshipsupport was added to T32-supported research training support. Six activeNIDCD-funded T32 programs that have provided research training tootolaryngology residents for 10 years or longer (range: 10–26 years) wereassayed, representing data from 1986 through May 2003.

Overall, 99 trainees were included in the NIDCD study. Of these individ-uals, 75 completed less than 2 years of NRSA-supported research training(typically, 12 months of training), whereas 24 completed a full 2 years ofresearch training; those 2 years were almost always contiguous. Of thetrainees who received 2 years of research training, 62% entered academicpractice. Of the trainees who received less than 2 years of research training,68% entered academic practice. Seventeen percent of both groups ofacademicsdthose who received 2 years of research training and thosewho received less NRSA-supported research trainingdwon subsequentNIH research funding as principal investigators.


Within the limitations of this survey (non-NRSA research training wasnot considered), no evidence exists to support the 2-year model of researchtraining as more efficacious in producing academic otolaryngologists thanalternative models that involve shorter or more distributed periods ofresearch training during the period of surgical internship and subspecialtyresidency. Alternative models to the contiguous 2-year model may bemore efficacious in nurturing surgeon-investigators. Distributing theresearch training experience more broadly across the long period of resi-dency training may guard against the resident in training from becoming de-focused from the academic scholarship and research interests nurturedearlier in the residency period. Concentrating the major part of researchtraining in the later years of residency may be optimal, because by then, clin-ical interests have crystallized, and research pursuits can be brought intoalignment with clinical interests and expertise. The net effect is health pro-fessionals who have built and sustained research interests over years of clin-ical training and who are fresher and more current in scholarship andresearch. Such individuals are more likely to pursue a career in academicpractice than private practice.

Factors other than the duration of research training are important influ-ences in the career path that health professionals seek. Primary among thesefactors are research mentorship resources, clinician-scientist faculty rolemodels, and the research culture of a given program. Sixty-five percent ofgraduates from NIDCD-supported T32 programs in otolaryngology gointo academic medicine, and 17% receive NIH grant support as principalinvestigators. Fifty percent of K-mechanism awards (primarily K08 awards)to otolaryngologists come from clinicians who have participated in T32programs as residents [4]. The large, research-intensive academic residencyprograms that have T32 programs attract residents interested in academicclinician-scientist careers, but sorting outda prioridthe factors that leadsome residents who participate in them to enter academic medicine/researchand others to enter private practice is difficult. Perhaps some light concern-ing the yield or return on investment of the NIH-sponsored T32 programscould be shed by comparing graduates of these programs to residents whocompleted the same residency programs but were not supported by theT32, or to individuals who did not receive extended research experience.

An important NIH-sponsored research training mechanism available toindividual junior faculty is the mentored clinician-scientist career develop-ment (K-) award. The most commonly used K-award for junior faculty atNIDCD is the K08 mechanism, aimed at developing basic science researchprograms. A goal of the K08 mechanism, from its inception in 1972, was tofoster MD independent researchers to foster clinical and translationalresearch. Over time, however, it became apparent that most MDs conduct-ing research funded by this mechanism were performing basic research. Anincreasing proportion of successful applicants were MD/PhDs. Because theK08 program was not the conduit to bridge the clinical and basic science


worlds that federal biomedical policy makers hoped it would be, the Men-tored Patient-Oriented Research Career Development Award (K23)program was started in 1998 as a sister program to the K08 program to nur-ture patient-based research. Over a 6-year period, this mechanism has grownin popularity NIH-wide and boasts a 35% success rate for funding [5]. Overthe years, the number of K08 applications NIH-wide has climbed steadily,although the number of awards has stabilized. As a result, this mechanismhas become more competitive, with success rates falling from approximately60% in the 1990s to 40% in 2003 [5].

The benchmark for success of the mentored K-award program, whichaims to nurture junior clinical faculty in launching their own research pro-grams competitive for NIH funding, is the rate of conversion of K-awards tosubsequent R01 awards. Traditionally the gold standard of research fundingsuccess, the R01 grant, primarily funds independent investigator-initiatedresearch projects. The NIDCD places even greater emphasis on the R01than other NIH institutes, which make greater use of larger, multi-projectgrant mechanisms (eg, program project grants).

In the NIDCD junior mentored clinician K-award (K08 and K23) port-folio, approximately 50% of the awardees are otolaryngologists. Of the24 otolaryngologists awarded new K08 and K23 awards in federal fiscalyears 1995 through 2001, 67% applied for a follow-up R01 award, and37% were awarded an R01. Although these application and award ratesare not significantly different than NIH-wide estimates for the K08 applica-tion and award rates (70% and 45%, respectively) over the same timeperiod, NIDCD feels that its K08/K23 program is not yielding a desirablereturn on investment for either its otolaryngologist or other clinical commu-nities. At NIDCD, the K23 mechanism remains underutilized because ofa paucity of patient-oriented research in the overall grant portfolio of thisinstitute.

The NIDCD is very supportive of the K-award mechanism. The awardcurrently provides up to $105,000/y of salary support and $50,000/y of re-search support for a 75% professional effort, based on a 40-hour workweek. Other NIH institutes also support otolaryngologists through the K-award mechanism. The National Institute of Dental and Craniofacial Re-search targets primarily dentist-scientists but also funds favorablyreviewed otolaryngologist applicants who propose research within itsmission area. The National Cancer Institute funds head and neck cancerresearch. Institute-wide, however, single investigator grants are funded ata low rate, and the success rate of K08 applicants has only been 20%over the last 3 years.

Another resource of funding for clinician-scientists is the new (2002)extramural NIH loan repayment program (LRP) (http://www.lrp.nih.gov).This program does not fund research but rather provides student loandebt relief for investigators who are conducting qualifying research, includ-ing patient-oriented research or pediatric research. This award can provide

http://www.lrp.nih.gov


up to $35,000/y for 2 years, plus associated federal taxes, and is renewable.The purpose of the program is to offset educational debt to encourage researchcareers, particularly among clinically trained individuals who are increasinglydiscouraged fromdevoting amajor portionof their careers to researchbecauseof the need to earn sufficient income to defray medical school debt. It is hopedthat the junior members of the otolaryngology community interested in clin-ical research and pediatric research will take advantage of the NIH LRP. Infiscal year 2006, only 15% of the loan repayment program awards made bythe NIDCD were to otolaryngologists.

Clinician-scientists in otolaryngology: current state

Data collected by the AAO-HNS counted 128 active NIH grantsawarded to otolaryngologists as of March 2007. Some of those countedwere not research grants, such as T32 grants and conference (R13) grants.Eighty-three of these grants were made by the NIDCD. In this section wefocus on R01 grants and K-awards.

As of March 2007, 44 individual otolaryngologists held 50 R01 grants at24 institutions. These grants were concentrated in larger research institu-tions (11 institutions accounted for 70% of the grants), and all wereawarded to otolaryngologists in academic practice. Of the awardees,12 held MD/PhD degrees, 11 were department chairs or chiefs of otolaryn-gology divisions in surgery departments, and 8 were women. Only 17 of thegrants had been competitively renewed. Of the 50 R01 grants, 36 (72%) werefrom the NIDCD, 8 were from the National Cancer Institute, and 6 werefrom the National Institute of Dental and Craniofacial Research.

Among otolaryngologists there were 29 K-awards: 18 from NIDCD,4 from the National Cancer Institute, 4 from the National Institute of Den-tal and Craniofacial Research, and 3 from other institutes or agencies. Nine-teen institutions are represented, but 50% of the K-awards reside in just fiveinstitutions. Seven awardees were MD/PhDs, six were women, and threewere conducting patient-based research (K-22 or K-23). As with the R01s,the awards were concentrated in just a few institutions.

Keys to success in funding

The keys to funding success and the keys to career success for the clini-cian-scientist are substantially the same. Particular elements of ‘‘grantsman-ship’’ are sometimes lost on the newest clinician-investigators that mightaugment the probability of success. First, before submitting any proposalto the NIH, grant writers should contact the responsible program officerat the institute that is the anticipated target for the area of research interest.As a port of entry, they may refer to that institute’s web site and identify thedirector for research training or research career development. The program


officer is able to offer valuable advice to the new and budding otolaryngol-ogist-investigator on the research purview and priorities, peer review pro-cess, and funding trends of that NIH institute.

Understanding that career development award applications, unlike R01applications, require a systematic career development (research training)plan in addition to a research plan is another important element for fundingsuccess. Neophyte applicants often do not include a sufficiently detailedcareer development planwithin the application but put all their efforts into de-tailing a research plan that is often overambitious. Establishing a strong men-torship team and delineating the respective roles of the primary mentor/sponsor and secondary sponsors, if any, are important steps. It is also vitalto garnerdand document within the applicationdstrong institutional sup-port/commitment for the candidate and the career development plan.

Part of an appropriate environment that should be explicit in a careerdevelopment award application is detailing the time protection provided.Reviewers want to be confident that the candidate will be protected bythe institution to the level promised, and a clear explanation of the arrange-ment between the applicant and his or her department and institutionimproves reviewer confidence. Another element that should be describedexplicitly is how the candidate and the mentors interact during the grantperiod. Especially if mentors are not in the same department as the candi-date or are otherwise physically separated, explicit detail of how the mentor-ing and supervisory components occur strengthens an application.

A track record of applying for and garnering small grants by theK-award applicant is another often-overlooked element that can strengthenthe application. In otolaryngology, this track record is facilitated by apply-ing for grants from the AAO-HNS or the subspecialty societies through thecentralized otolaryngology research efforts review panel. Other good sourcesof early career development funds include professional and voluntary orga-nizations, such as the Deafness Research Foundation.

Future directions

One of the recommendations of the conference on research training andeducation in otolaryngology was to compensate the research mentors/spon-sors of the NIH K-awards for their services, as has been provided on theNIH Roadmap institutional career development (K12) awards [4]. Becausethe time of clinician-scientists in academic medical center settings is typicallyunder challenge from competing sources and must be accounted for withrespect to cost, such reimbursement for service would provide an incentivefor the most sought-after established and senior investigators to committime to the mentorship of budding and new otolaryngologist-scientists.

Another recommendation in the conference on research training and ed-ucation in otolaryngology report was to establish institutional awards toprovide 2 years of transition (gap) mentored support for departments


planning to establish junior tenure-track faculty earmarked for buddingotolaryngologist-investigators planning to submit mentored K-award appli-cations. To facilitate the emergence of independent otolaryngologist-investi-gators from junior faculty not yet ready to craft a mentored K-awardcompetitive for funding, NIDCD is planning to pilot a competitive researchsupplement program. It is widely acknowledged that successful faculty rolemodels who are available and willing to provide sustained research mentor-ship are key to the development of new clinician-investigators. It is hopedthat such a research supplement award would help hardwire a mentorshipcommitment for new tenure-track clinical faculty through directly tetheringthe new faculty member to a funded NIH research grant or multi-projectgrant held by an established investigator in his or her department or a collab-orating department. A generous support package would be provided, anda 50% time commitment over 2 to 3 years would be required. With the step-ped-up mentorship experience afforded by this program, it is hoped that theawardees could more competitively follow-up and launch their independentresearch career trajectory through a follow-up mentored K-award or newinvestigator R01 grant application. A network of seasoned otolaryngolo-gist-investigators available to mentor new and budding clinician-scientistswas recently discussed within the academic sector of otolaryngology andwarrants thoughtful planning and implementation.

Summary

It iswidely acknowledged that it is in the interest of the public and the specialtythatweupgradeour trainingandnurturanceofotolaryngologist-scientists.Manyobstacles have been identified, but perhaps themost daunting is the relatively lowpercentage of otolaryngology residents who are genuinely committed to this ca-reer path. As pointed out by Minor [4], the fundamental issue is attracting andselecting the right people, individuals who have the ‘‘visceral and intellectualdrive’’ topursue a scientific career.Only after selecting the right people canpoten-tially fruitful strategies be brought to bear on this problem.

In this article, we described opportunities for research training andsupport at discrete milestones along the road to becoming a clinician-scien-tist. What is missing is an integrated roadmap for the clinician-scientist,validated through the collective experiences of those who have succeededat forging this career pathway. Training experiences starting in medicalschool, or earlier, and ending in fellowship are typically fragmented, ratherthan additive or integrated, and trainees find themselves with multiple pro-jects but no coherent line of inquiry. What the field needs is the flexibilityand vision to allow the building of integrated training programs that includemeaningful research and clinical training that produce fully, subspecialty-trained clinician-scientists with a direction of inquiry that is established earlyin the timeline of clinical training and serves as the foundation for success-fully obtaining the necessary funding vehicles. Such an integrated approach


has been adopted in neurology [14] .Development of such a track requires flex-ibility, particularly by the residency review committee, to allow some uneven-ness in training experiences and duration to account for the unpredictablenature of inquiry.

We also must change the culture in our specialty to view research as a valu-able, vital endeavor on par with patient care. This change starts with promot-ing a culture of inquiry in all of our training programs, training residents, andstudents in the scientific method and making them appreciate the value ofa well-done study and, thus, better consumers of scientific literature. It also in-volves raising the level of our specialty journals. The PhD scientists in otolar-yngology departments (or associated with otolaryngology departments andappointed elsewhere) need to share in nurturing this culture. These individualsare valuable mentors and critical to a scientific approach to health care deliv-ery. Although beyond the scope of this article, assuring continued interest ofbiomedical and behavioral scientists in otolaryngology and human communi-cation is critical to the continued health of research in our field.

Resources are scarce and should be concentrated among individualslikely to succeed-young, committed, prepared, enthusiastic, and realistic cli-nician-scientists. Such young stars, with proper support of time, space,money, and mentorship, have the only true hope for success in this increas-ingly competitive funding environment. Recipients of such gifts of opportu-nity must understand their responsibilities. Resources must come withwell-communicated expectations, not just of research development but ofoverall career development. Incentives must be aligned with feasible oppor-tunities, and academic departments must continue to support excellence andsuccess in the research, clinical, or educational arena.

Successful clinician-scientists exist in our specialty within select academicdepartments. Chairpersons must balance all components of the missions oftheir departments and distribute these across their faculties to be trulysuccessful. Most clinician-scientists need to be part of a clinical team to pro-tect their time and avoid being at risk of consumption by clinical duties.Most researchers are not high-volume clinical stars, and the success of theentire faculty should be shared.

Acknowledgments

The authorswould like to thank theAmericanAcademyofOtolaryngology–Head andNeck Surgery for sharing their information regarding research fund-ing among otolaryngologists and Cheryl Langford for her editorial assistance.

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Documents

Developing the Next Generation of Otolaryngologist-Researchers