EM Physician Scientist Training Programs: Opportunities for Residents Committed to Careers in EM Research

By Rachel Dahl, MS and Muhammad Waseem, MD

Summary

Emergency medicine (EM) continues its growth spurt without knowledge of what it will look like as it matures. Perhaps one example that exemplifies EM’s growth is the recent development of physician-scientist training programs (PSTPs) with an EM-focus.

PSTPs are not fellowships, rather they are noncredentialed professional programs that offer a formal organizational structure of support throughout residency for residents committed to careers in research. PSTPs are distinct from residency programs, but their timeline is integrated within and after residency to be able to support young physicianscientists at every step of their transition toward becoming an independent researcher.

This article introduces the role of physician scientists and PSTPs as well as why EM is such an exciting area for physician-scientist training. It includes perspectives comparing PSTPs to other routes to the physician-scientist track, such as research fellowships.

What is a physician-scientist?

Physician-scientists are physicians (MD/DO/MBBS) who are committed to incorporating a significant percentage of research time in their career. Most have had significant research experience during their overall training, evidenced by completing a PhD, MS/MSc with thesis work, or equivalent experience. Physician-scientists more often work in clinical research than in lab or bench research, and the majority work in academic hospitals. Though the percentage of time devoted to research vs. clinics can range, a recent study looking at job outcomes of MD-PhD graduates indicated that about 56% of physician-scientists who work at academic institutions spend a minimum of 50% of their work time in research.

Why choose to apply to a PSTP?

For young physicians truly committed to a career involving research and who want to establish their own lab or research group after completing residency, PSTPs are a desirable option for moving toward that path. PSTP organizational support generally offers all of the following:

• protected research time to work on projects and develop one’s scientific skill set throughout residency; • extra financial support to attend and present research at conferences; • networking opportunities to connect with experts and potential mentors in one’s area of interest; and • assistance with applying for institutional funding and Federal grants, such as a K01.

Dr. Nicholas Mohr, emergency department research director at the University of Iowa, says “what makes an applicant competitive for a PSTP is that they have a strong career of vision. It’s not a particular degree that makes you competitive, it’s that you have an idea of where you are going, that you have an idea of how you’re going to get there, and that you have some concept of how the PSTP pathway fits into that vision.”

Dr. Mohr continues, “we’re looking for someone who has advanced research training already, we look for people who have had some research experience, and where that experience has some connection to what they convey their future career is. A lot of this is about passion to make the world better, passion to make the specialty better, and a passion to learn things that we don’t know already.”

Participating in a PSTP may either extend the duration of residency or it can last a few years post-residency. PSTPs that extend residency may include salary perks that aim to offset the longer duration of training on a resident salary, and likewise may offer the participant an increase in salary equivalent after graduating from residency for the remaining years in the PSTP. PSTPs are variably funded, such as by in-house support, NIH T32 training grants, and more.

An additional benefit to participating in a PSTP is the ability to interact with other new physician-scientists in PSTPs of different disciplines during regular planned social events and academic seminars. This increases opportunities to share ideas and to collaborate between different specialties. Interspecialty collaboration lends itself well to thinking outside the box, which might be particularly beneficial for EM research, which may include a mix of aspects from every medical specialty.

From an organization’s perspective, PSTPs may offer one way to identify potential candidates for future faculty positions. Additionally, PSTPs may offer subtle benefits for members of the department who are not actually participating in the PSTP.

Dr. Nick Mohr says that offering a PSTP is “one way to be really explicit about what the priorities of our department are, what the priorities of our institution are. At University of Iowa, one of our priorities is to train excellent emergency physicians who are going to go out and take care of patients, but one of our priorities really is to continue to change the practice of medicine and to train the next generation of clinician-investigators. And I think that that’s something that is important for residents in our program who are not part of the PSTP, because they are entering a culture where we have this tripartite mission. I think that it is also important for our department to really prioritize creation of new knowledge, dissemination of new knowledge in our own practice of emergency medicine.”

"PHYSICIAN-SCIENTISTS ARE PHYSICIANS (MD/DO/MBBS) WHO ARE COMMITTED TO INCORPORATING A SIGNIFICANT PERCENTAGE OF RESEARCH TIME IN THEIR CAREER."

Challenges to a PSTP

New MD/DOs may shy away from the longer duration of training associated with a PSTP track, particularly when they lack role models or mentors who can answer questions about the difficulties of pursuing a dual career. Mentorships are crucial, in part to be able to discuss issues such as work-life balance and self-care with an experienced person who has dealt with similar challenges. Mentors also play a critical role in helping new physician-scientists learn the ropes of obtaining funding, figuring out ways to balance academic versus clinic time, finding the right fellowship, and so forth. The lack of and need for role models and mentors for physician-scientists in all medical specialties is a problem that the NIH has openly recognized, with concern that this contributes toward the continuing depletion of the number of U.S. physician scientists, boding poorly for our ability as a nation to continue to remain at the forefront of scientific medical breakthroughs. Finding a mentor as a physician-scientist is even more of a challenge within newer academic areas such as EM, simply because of its novelty. Participating in a PSTP can facilitate the ability to find connections to experienced mentors through organizational networks of the faculty who support the PSTP.

For some residents, a drawback to pursuing the physicianscientist track is that less time is dedicated to patient care. Additionally, there is the burden of time and energy dedicated to generating funding for research and the well-known longterm compensation disparity compared to non-academic positions. Generally, physicians who opt for a physicianscientist career path in academic medicine are cognizant of the long-term compensation disparity compared to their private practice peers. They have to decide whether the differences in compensation and patient care are balanced out by the benefits associated with working in an academic hospital, such as the security of tenure, the opportunity to grow as a leader in the field, the ease in finding collaborators, and fundamentally the potential to expand and shape the future of EM through research and teaching.

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Why is EM such a unique specialty for a physician-scientist?

Evidence-based medicine is at its strongest in EM, where critical, algorithmic decision-making is best informed by the most ground-breaking epidemiologic research. Further, the broad nature of EM lends itself to a unique variety of myriad research opportunities, such as improving our understanding of cardiopulmonary physiology, aiming to optimize prehospital to hospital care, and developing the intersection of EM with community health. This makes EM one of the most exciting fields to study, with great capacity for growth for physician-scientists.

Dr. Nick Mohr agrees that the breadth of potential topics in EM research is part of its value: “EM research is not a narrow clinical specialty. There is no reason that we need to view it as only to study things that we can use clinically in an emergency department. It is medicine more broadly, it is answering questions significant for public health, it is answering questions that are significant for making the lives of our patients better, and that crosses a lot of boundaries.”

Dr. Sara Krzyzaniak, associate professor at Stanford University and program director of emergency medicine residency, also agrees: “I think that emergency medicine is beautifully broad. We touch so many different parts of healthcare, patient’s lives, everything from those social determinants of health through the pathophysiology of disease, we cover all of that, and we cover all of these different fields. Yes, we’re resuscitation specialists, but we also take care of transplant patients, we take care of cancer patients, we take care of all these different groups of people, so I think that the possibilities for a physician-scientist in emergency medicine is really broad. And I think that the understanding that you get going through EM residency I think really prepares you to be able to look at that whole picture.”

In addition to the advantage of the wide breadth of potential topics, Dr. Mohr also believes that the clinical schedule of the emergency physician is appropriately complementary to a research career: “With a lot of things, being able to have uninterrupted laboratory time, writing time, is critical. And it’s something that I think really works well with the EM clinical schedule.”

PSTP vs. Academic Fellowship vs. Research Electives/Track in Residency

Part of what makes PSTPs unique from academic fellowships is its integration throughout the residency timeline. This generally allows for longer continuity on the same project during residency, while at the same time, the residentphysician-scientist is building professional relationships. However, other options are available for pursuing a physicianscientist track outside of participating in a PSTP, such as participating in research electives during residency or participating in academic fellowships after residency.

For example, one route is to use residency electives to participate in research projects or research tracks. Dr. Sara Krzyzaniak explained that Stanford’s EM ACCEL program allows a lot of flexibility for research within the EM residency: “Our ACCEL program does allow someone interested in research to commit dedicated time to this endeavor, but it’s not a formal PSTP program. As a program we have some of the most elective time in the country of four-year programs, and so the ACCEL pathway is a way to structure that elective time such that we are encouraging our residents and supporting them so that they have a pathway trajectory through all of this elective time, and hopefully at the end of four years have provided them with a cohesive thing that they have done with that time. Within the ACCEL program

PROGRAM UNIVERSITY OF IOWA PSTP NORTHWESTERN PSTP

Dedicated time for research during residency Four months of dedicated research time in PGY1-PGY3 years.

Salary bonus/ Funding for travel and conferences Annual academic allowance of $4,000 in addition to travel funds provided to EM residents. This may be used for academic expenses such as books, professional memberships, research supplies, or travel.

Residency duration 3 years

Other Guaranteed acceptance to the Department of Emergency Medicine Associate Scholar Program or Clinical Fellowship in the department of EM upon successful graduation from residency. PGY-1, PGY-2 focus is on clinical development, exploring interests and opportunities, connecting with potential mentors. PGY-3, PGY-4 include time for dedicated research projects.

Supplemental funds for travel to conferences, educational and career development courses, and grant-writing courses.

4 years

Program website https://medicine.uiowa.edu/emergencymedicine/ education/physician-scientist-training-pathway-pstp https://www.feinberg.northwestern.edu/sites/physicianscientist/pstp-programming/emergency-medicine/index.html

Note: The information in this table was taken from informational websites of each institution during the time of this writing and may no longer be accurate. Please contact institutions directly for current information about each program.

there is opportunity for research, and we have research lines, and as a program in general we have a pretty high research expectation of our residents, but it’s not a true PSTP; it’s not a dedicated year of time to really focus on research. It’s 22 weeks of elective time over the four years of residency, but it all falls into the second, third, and fourth years. We are aiming to create a PSTP program. We only became a department in 2015, so this is something we’ve been in the early phases of creating for several years… and I think we will see a PSTP program in the near future.”

Some EM residency programs like at Johns Hopkins University have incorporated a fourth year of residency to include a final year of fellowship-like training in one of EM’s subspecialties (e.g., research, ultrasound, toxicology, etc.) Other programs, like University of Rochester, also offer dedicated residency research tracks. These types of programs include opportunities to participate in research projects as well as may include classes in ethics, grant-writing, survey design, and epidemiology and biostatistics methods.

Academic fellowships which offer sustained, dedicated time and support for research and career development, typically over a two-year course after residency, are another option for young physician-scientists. Many of the EM research fellowships incorporate an additional Master’s degree (such as in public health, epidemiology, or clinical investigation) along with financial support, career development courses, mentorship opportunities, academic seminars, and other opportunities. SAEM offers an online RAMS Research Roadmap that includes helpful tips about the EM research track, including research fellowships and funding.

Some new EM-focused clinician-scientist training programs (CSTPs) have recently been developed which, similarl to PSTPs, offer organizational support to assist physician-scientists. These programs are designed for physicians who are already boardcertified, but otherwise offer similar financial and mentorship support as a PSTP. At the time of this writing, the author was unable to obtain perspectives from representatives of these programs.

Summary

The new development of EM PSTPs reflects the growth and potential of EM as an expanding area of research for young physician-scientists. PSTPs offer exciting opportunities for future EM residents who want to contribute to a significant portion of their career as a research scientist. PSTPs are noncredentialed professional programs that are unique in that they offer comprehensive support throughout residency, and potentially beyond residency, to enable transition to independence as a physician-scientist.

ABOUT THE AUTHORS: Rachel Dahl MS is a third-year medical student at University of Iowa Carver College of Medicine, concurrently completing an online Master’s of Public Health at University of California Berkeley. Rachel plans to become either an Emergency Physician or Trauma Surgeon with additional interests in community and global health. rachel-dahl@uiowa.edu Dr. Waseem is a professor of emergency medicine and pediatrics at Weill Cornell Medical College, New York and research director for the department of emergency medicine and vice chair for the Institutional Review Board at Lincoln Medical Center.