Do general internal medicine fellows find jobs that match their training?

The ambulatory pediatric association fellowship in pediatric environmental health: a 5-year assessment

BACKGROUND

Evidence is mounting that environmental exposures contribute to causation of disease in children. Yet few pediatricians are trained to diagnose, treat, or prevent disease of environmental origin.

OBJECTIVES

To develop a cadre of future leaders in pediatric environmental health (PEH), the Ambulatory Pediatric Association (APA) launched a new 3-year fellowship in 2001-the world's first formal training program in PEH. Sites were established at Boston Children's Hospital, Mount Sinai School of Medicine, George Washington University, University of Cincinnati, and University of Washington. Fellows are trained in epidemiology, biostatistics, toxicology, risk assessment, and preventive medicine. They gain clinical experience in environmental pediatrics and mentored training in clinical research, policy development, and evidence-based advocacy. Thirteen fellows have graduated. Two sites have secured follow-on federal funding to enable them to continue PEH training.

DISCUSSION

To assess objectively the program's success in preparing fellows for leadership careers in PEH, we conducted a mailed survey in 2006 with follow-up in 2007.

CONCLUSIONS

Fifteen (88%) of 17 fellows and graduates participated; program directors provided information on the remaining two. Nine graduates are pursuing full-time academic careers, and two have leadership positions in governmental and environmental organizations. Ten have published one or more first-authored papers. Seven graduates are principal investigators on federal or foundation grants. The strongest predictors of academic success are remaining affiliated with the fellowship training site and devoting < 20% of fellowship time to clinical practice.

CONCLUSION

The APA fellowship program is proving successful in preparing pediatricians for leadership careers in PEH.

A time to be promoted. The Prospective Study of Promotion in Academia (Prospective Study of Promotion in Academia)

OBJECTIVE

The study's objectives were to determine (1) the rate at which department of medicine faculty in the United States are promoted, (2) if clinician-educators (CEs) are promoted to Associate Professor at the same rate as clinician-investigators (CIs), and (3) the variables that predict promotion.

METHODS

The Prospective Study of Promotion in Academia was a part-retrospective, part-prospective (from 2000 to 2003) cohort study. Six-hundred and four Internal Medicine junior faculty across the United States who had been registered as new appointees with the Association of American Medical Colleges in 1995 were invited to participate. Twenty-one percent of these had already left their institution when the study began. One hundred and eighty-three Internal Medicine faculty from 87 institutions in 35 states enrolled. The main outcome measure was the time from appointment as Assistant Professor to promotion to Associate Professor.

RESULTS

Follow-up was complete for all 183 faculty. Among the faculty that achieved promotion, the estimated median time to promotion was 6.0 years (95% Conf. Int.=5.8 to 6.2). The unadjusted sixth-year promotion rate for CEs was 16%, while for CIs it was 26% (P=.002). Independent negative predictors of promotion included low amount of research time (Hazard Ratio [HR] =0.3, 95% Conf. Int.=0.2 to 0.5), having a manuscript review service (HR=0.4, 95% Conf. Int.=0.2 to 0.7), never meeting with Chairman/Chief about promotion (HR=0.4, 95% Conf. Int.=0.2 to 0.7), low job satisfaction (HR=0.5, 95% Conf. Int.=0.3 to 0.9), and working in the Northeast (HR=0.6, 95% Conf. Int.=0.4 to 1.1). Positive predictors included making between 130 dollars and 149,000 dollars per year (HR=1.9, 95% Conf. Int.=1.1 to 3.4), working more than 60 h/wk (HR=1.9, 95% Conf. Int.=1.1 to 3.0), having a career mentor available (HR=1.8, 95% Conf. Int.=1.1 to 2.9), and having access to a grant office (HR=1.6, 95% Conf. Int.=1.0 to 2.6).

CONCLUSION

CEs and CIs appear to be promoted at different rates. The characteristics that are independently associated with earlier promotion may be helpful for institutions and individual faculty that are committed to achieving promotion efficiently.

Motivating factors for academic physicians within departments of medicine

OBJECTIVE

To understand what motivates academic physicians at a time when physician dissatisfaction is prevalent.

SUBJECTS AND METHODS

Of a cohort of 480 physician faculty members (identified from the Association of American Medical Colleges faculty roster) hired at the assistant professor level, 183 were monitored prospectively for a characterization of their success in achieving promotion. In mid-2001, follow-up data were collected about the factors that physicians described as motivating in their work. We conducted this study to understand the differences in motivators between clinician-educators and cliniclan-investigators and between male and female physicians, as well as to validate a previously used instrument developed to assess motivation and occupational values.

RESULTS

Of 183 physicians monitored, 144 (79%) responded to an interim follow-up questionnaire. Factor analysis revealed that physicians' occupational motivators could be grouped statistically into 3 factors: self-expression, helping others, and extrinsic rewards. Compared with clinician-educators, clinician-investigators were more motivated in their current work by having the ability to express themselves (composite factor score, 4.30 vs 3.84; P<.001). Clinician-investigators also rated 4 of the 6 items within the factor of self-expression as being significantly stronger motivators for them than did the clinician-educators. Compared with male physicians, female physicians Indicated they were more motivated by helping others (composite factor score, 4.18 vs 3.89; P=.03).

CONCLUSIONS

Factors that motivate physicians appear to be different for clinician-investigators and clinician-educators as well as for male and female physicians. Understanding the inspiration for physicians may help medical leadership to better motivate and relate to their physician workforce.

Assessing the role of influential mentors in the research development of primary care fellows

PURPOSE

To assess the association between mentorship and both subsequent research productivity and career development among primary care research fellows.

METHOD

In 1998, using a self-administered questionnaire, the authors surveyed 215 fellows who graduated from 25 National Research Service Award (NRSA) primary care research programs between 1988-1997 to assess quantitative aspects and qualitative domains of their mentorship experience during fellowship training.

RESULTS

A total of 139 fellows (65%) responded to mentorship questions a median of four years after their fellowship. Thirty-seven fellows (26.6%) did not have an influential mentor, 42 (30.2%) reported influential but not sustained mentorship, and 60 (43.2%) had influential and sustained mentorship. Individuals with influential mentorship spent more time conducting research (p =.007), published more papers (p =.003), were more likely to be the principal investigator on a grant (p =.008), and more often provided research mentorship to others (72.5% versus 66.7% of those with unsustained mentorship, and 36.4% of those with no influential mentor, p =.008). After controlling for other predictors, influential and sustained mentorship remained an important determinant of career development in research. On qualitative analysis, fellows identified three important domains of mentorship: the relationship between mentor and fellow (such as guidance and support), professional attributes of the mentor (such as reputation), and personal attributes of the mentor (such as availability and caring).

CONCLUSIONS

Influential and sustained mentorship enhances the research activity of primary care fellows. Research training programs should develop and support their mentors to ensure that they assume this critical role.

Looking forward to promotion: characteristics of participants in the Prospective Study of Promotion in Academia

OBJECTIVES

To determine what clinician-educators consider important for promotion, and what support they find helpful and useful for success.

DESIGN

Cross-sectional study.

SETTING

Eighty academic medical centers in the United States.

PARTICIPANTS

One hundred eighty-three participants of the Prospective Study of Promotion in Academia comprising assistant professors in departments of medicine from 80 different medical schools in 35 states.

MEASUREMENTS

Differences between clinician-educators' and clinician-investigators' work activities, promotion preparedness, and faculty support needs.

RESULTS

One hundred seven (58%) of the faculty were clinician-educators (CEs), and 63 (34%) were clinician-investigators (CIs); the remaining 13 fit neither category. Participants had been in their faculty position for 4.7 years. Ninety-eight percent of CIs reported a publication expectation for promotion, and 75% of CEs also reported such an expectation. More CIs had career mentors available than CEs (68% vs 32%, P <.001). Seventy-nine percent of CIs indicated >10% protected scholarly work time, compared to only 35% of CEs (P <.001). Fifty-three percent of CIs as compared to 32% of CEs (P <.01) meet more often than yearly with their chief/chair for performance review, and more CIs have seen written promotion guidelines (72% vs 51%, P <.01). Clinician educators believed out of 11 job performance areas, research, written scholarship, and reputation were the 3 most important factors that would determine the success of their application for promotion. Both CEs and CIs sense that CIs are more likely get promoted (82% vs 79%).

CONCLUSIONS

Clinician educators are less familiar with promotion guidelines, meet less often with superiors for performance review, and have less protected time than CI colleagues. There is dissonance between CEs' beliefs and previously published data from promotion committee chairs in the importance given to specific aspects of job performance.

Indicators of early research productivity among primary care fellows

OBJECTIVE

Little is known about the impact of fellowship training in primary care on subsequent research productivity. Our goal was to identify characteristics of research fellows and their training associated with subsequent publications and research funding.

DESIGN

Mail survey in 1998.

SETTING AND PARTICIPANTS

1988-1997 graduates of 25 National Research Service Award primary care research fellowships in the United States.

OUTCOME MEASURES

1) Publishing 1 or more papers per year since the beginning of fellowship, or 2) serving as principal investigator (PI) on a federal or non-federal grant.

RESULTS

One hundred forty-six of two hundred fifteen program graduates (68%) completed the survey. The median age was 38 years, and 51% were male. Thirty-two percent had published 1 or more papers per year, and 44% were PIs. Male gender (odds ratio [OR], 3.6; 95% confidence interval [95% CI], 1.4 to 9.2), self-reported allocation of 40% or more of fellowship time to research (OR, 4.4; 95% CI, 1.8 to 11.2), and having an influential mentor during fellowship (OR, 5.0; 95% CI, 1.5 to 17.2) were independently associated with publishing 1 or more papers per year. Fellows with funding as a PI were also more likely to have an influential mentor (OR, 3.0; 95% CI, 1.3 to 7.2).

CONCLUSION

Primary care fellows who had influential mentors were more productive in research early after fellowship. Awareness of the indicators of early research success can inform the policies of agencies that fund research training and the curricula of training programs themselves.

Program directors' perspectives on federally funded fellowship training in primary care research

PURPOSE

To describe the organization, models of training, and institutional impact of National Research Service Award fellowship programs in primary care research.

METHOD

Survey of 25 directors of currently-funded and former training sites.

RESULTS

Twenty-four program directors (96%) completed the survey. Programs allocated 39% of fellows' time to course work leading to an advanced degree or other didactic instruction, and 40% of time to the conduct of research. Collaborations with other training programs within the institution occurred at 83% of sites. Programs commonly (54%) or exclusively (42%) relied on a research model of "early research independence" in which the fellow defined an area of research interest, rather than an "apprenticeship" model in which the fellow worked in a senior investigator's research area. These programs enriched the local academic environment, but required extensive financial subsidies. The high costs of training often had adverse impacts on recruitment and other components of the training process.

CONCLUSION

Research training programs in primary care often substitute acquisition of advanced degrees for early immersion in research. The "early independence" model of research differs from fellowships in the medical specialties, and requires further study to assess its effectiveness. The need to subsidize training costs poses substantial problems for the institutions that host these fellowship programs.