38 minute read
Are We Really Prepared to Be Anti-Racists?
By Maame Yaa A. B. Yiadom, MD, MPH, MSCI, Italo M. Brown, MD, and Christopher L. Bennett, MD, MA on behalf of the SAEM Equity and Inclusion Committee
On June 10, 2020, various emergency medicine groups participated in the Science, Technology, Engineering and Mathematics (STEM) Shut Down “Medicine is a conservative community (#ShutDownAcademia). Academic meetings, conferences, and calls where we tend to be risk averse, yet were canceled as a pause in our consciousness intended to advance our understanding and educate our world and local communities will ourselves on 1.) the persistence of racism, 2.) sources of inequality, and not improve until those of us with 3.) remedies for ineffective government and organizational responses. From influence lead by example.” our reflection we find being a “nonracist” is a response that is good, but not good enough. A challenge in our current society is that there are too few opportunities and outcomes. It calls with evidence that bends the truth, “anti-racist.” This applies to many of us to say something when people are exaggerates significance, or uses the other “isms” (sexism, antisemitism, excluded because it is uncomfortable fabricated information. homophobism, xenophobism, etc.) that we struggle with in our diverse country. The reality is that being an anti-racist is tough, and at times risky. It means speaking up when we see people treated differently, in ways that are unfair and negatively affect their life to include them. It compels us to step back and listen to the details from all sides of any conflict knowing there is bias in how conflict is framed and reported. It encourages us to be uneasy until we address situations where people are disciplined unjustly We see egregious examples of racism in the news which are easy to call out as there are elements of clear ill-will and expressions of dehumanizing fear. At the heart of these issues is conscious and unconscious biases that present themselves in less blatant
ways in everyday life. These biases are gentle pressures that push subgroups of people to the periphery. It is easier and politically safe to not participate yet avoid speaking up. Slinking away when we bear witness to an “incident” should unsettle us. Simply saying “I would have never done something like that” while doing our best to “avoid getting involved” perpetuates problems.
Medicine is a conservative community where we tend to be risk averse, yet our world and local communities will not improve until those of us with influence lead by example. We should not only acknowledge the density of evidence on systemic racism and resultant differences in outcomes, we should translate the assessment into a treatment plan with required action. As physicians, we are fortunate to have a significant, albeit often underutilized, influence on society. Protesting is one of many powerful means of leading change. Diplomacy in conflict, elevating awareness, kindly coaching misguided colleagues, being open to seeing and validating the experience of others, educating the patients and communities we serve, and holding ourselves collectively accountable to standards of equity are more strongly suited ways for us to exercise anti-racism in our privileged positions as health care providers.
Frankly, being an anti-racist is a bigger call to action than many of us are likely prepared to immediately assume for our patients or one another…but it is critical. It involves being unsafe and uncomfortable at times. It requires us to admit we have not fully seen or processed everything happening around us, while committing to the process of correcting our lenses. It urges us to challenge systems and communities in addition to monitoring our personal behavior and biases. Paraphrasing the words of actor Will Smith, “racism and corruption aren’t getting worse, they are just being filmed.” Inaction erases the film, and silence makes us complicit in harm done. We all took an oath to do no harm in our practice and identities as health care providers. Let’s extend it to this chronic, yet now “seen” public health and social justice crisis. To fully embrace anti-racism, our specialty must be willing to admit that 1.) the problem exists, 2.) it affects our practice culture, colleagues, and patients, and 3.) each of us plays a role in the solution. ABOUT THE AUTHORS
Dr. Yiadom is an associate professor of emergency medicine at Stanford University and director of the Emergency Care Health Services Research Data Coordinating Center. She conducts research evaluating and addressing inequities in clinical outcomes among patients with emergency care conditions.
Dr. Brown is an assistant professor of emergency medicine at Stanford University School of Medicine. His academic interests include health equity, social justice, and barbershop-based health interventions focused on improving health outcomes for Black men and boys.
Dr. Bennett is an assistant professor of emergency medicine. His academic pursuits include exploring change in gender, race, and ethnicity representation among residents and faculty.
The Unintended Consequences of COVID-19 Lockdowns
By William Weber MD, MPH on behalf of the SAEM Global Emergency Medicine Academy
In order to curtail the spread of the COVID-19 pandemic by limiting population intermixing, numerous “While lockdowns can lower overall deaths countries have enacted lockdown measures such as curfews, quarantines, from COVID-19, their effect could be or shelter-in-place orders. While these measures have limited human dwarfed by a corresponding rise in vaccineinteractions, their implementation can disrupt other systems meant to preventable deaths.” safeguard population health, leading to increases in childhood mortality, communicable disease, and domestic putting a large number of children at percent of cases. The effects of vaccine violence. Emergency physicians should risk of disease. A June 2020 World disruption on mortality are significant. be aware of the potential collateral Health Organization (WHO) survey of A Lancet article estimated that a sixdamage of COVID-19 lockdowns as health leaders reported disruptions or month pause of current immunization they care for patients. suspensions of around 70 percent of programs in Africa would lead to around Pediatric Vaccination outreach vaccination efforts (e.g., mass vaccination at a refugee camp) and 700,000 vaccine-preventable deaths in children, which is nearly equivalent Pediatric vaccination delivery has 44 percent of fixed-post vaccination to the total worldwide deaths from dropped substantially around the world, efforts (e.g., established clinics). Travel COVID-19 through August 2020. Their restrictions were cited as a cause in 40 models of Africa estimate that for
every COVID-19 death attributable to vaccination clinic visits, 84 deaths in children could be prevented by those vaccinations. While lockdowns can lower overall deaths from COVID-19, their effect could be dwarfed by a corresponding rise in vaccinepreventable deaths.
Other Communicable Diseases
Lockdowns could also lead to a resurgence of infectious diseases, especially in low- and middleincome countries. Malaria, Human Immunodeficiency Virus (HIV), and tuberculosis all require consistent interventions to limit their effects. Lockdowns can prevent patients from accessing clinics, screening, and treatment. Large-scale interventions like mosquito-net distribution become extremely time consuming if people cannot come to a centralized location. According to WHO data, the current sum of deaths related to these diseases is around 2.5 million annually. A Lancet article estimates that care disruptions from COVID-19 could increase deaths related to HIV up to 10 percent, tuberculosis up to 20 percent, and malaria up to 36 percent over the next five years in settings with high disease burden. Lockdowns could contribute to a significant increase in mortality from other communicable diseases in developing countries.
Domestic Violence
Lockdowns restrict people’s ability to leave home, potentially preventing survivors of domestic violence from avoiding dangerous situations. The United Nations reports significant increases in emergency calls related to domestic violence around the world. These episodes of domestic violence have disproportionately affected women, with rates of femicide climbing in multiple countries. Lockdowns can limit the opportunities of people to escape abuse at home, replacing exposure to virus with exposure to violence.
Lockdowns are not a one-size-fits-all approach to COVID-19 and can have unintended consequences, especially in areas with limited health infrastructure. Emergency physicians around the world should consider ways to mitigate unintended effects of lockdowns within their practice such as screening patients for domestic violence or refilling chronic HIV medications if patients cannot access clinics. From a policy standpoint, careful thought should be given to weighing the risks and benefits of lockdowns in the local environment, lest well-intended policies leave people at greater risk.
ABOUT THE AUTHOR
Dr. Weber is an international emergency medicine fellow at the University of Chicago focusing on immigrant/ refugee health. He has worked in Zambia, Ecuador, and South Africa, and serves on the Public Health and Injury Prevention Committee of ACEP. Dr. Weber is a member of the SAEM Global Emergency Medicine Academy.
Zooming in on Virtual Interview Day Strategies
By Jessica Nelson MD, Sarah Greenberger MD, and Alina Tsyrulnik MD on behalf of the SAEM Education Committee
The COVID-19 pandemic has posed multiple challenges for residency programs, not the least of which is the Association of American Medical “Structured interviews with standardized Colleges’ recommendation that all residency interviews be conducted questions or instructions to address remotely. Because the traditional recruitment season is exceedingly predetermined competencies (e.g., empathy, complex, careful planning is essential for a successful transition to a virtual teamwork) ensure that interviewers glean interview experience. The following considerations and strategies may adequate information without duplication.” be useful to residency and fellowship programs as they seek to adapt.
Preseason Planning and Interviews
First, programs need to decide which virtual platform will be universally used by the residency for recruitment. Possible platforms include Zoom, Skype, Microsoft Teams, GoTo Meeting, and Webex. Scheduling programs, like Thalamus, now offer virtual interviews too. Institutional contracts should be considered, as well as cost, ease of use, security, and accessibility across operating systems and devices. Within the platform, the program should choose whether to have a combined virtual space with breakout rooms or independent meetings with separate links for each interview and group session.
All interviewers should have access to a video-ready device and an optimal internet connection. Programs should prepare interviewers by discussing virtual interview etiquette, including platform familiarity, mandated review of application materials in advance, appropriate attire, professional background, minimized backlight, and need to look at the camera (to simulate eye contact) instead of at the screen or their own images. Furthermore, interviews should occur free of distractions: other computer programs should be closed, audio notifications should be muted, and background noise should be avoided. Structured interviews with standardized questions or instructions to address predetermined competencies (e.g., empathy, teamwork) ensure that interviewers glean adequate information without duplication.
Applicants should be encouraged to be “IT-ready” for the interview day by downloading and testing in advance all of the platforms that will be needed/ used. A backup plan should be communicated (e.g., FaceTime, Google Hangouts, phone) in case of technical failures, and a dedicated staff member should be ready to serve as technical support.
Interviews may be exclusively virtual, with both interviewers and applicants at remote sites, or a hybrid model may be utilized with applicants participating remotely but interviewers together in one location. Programs may have applicants view introductions or video tours in a group setting (similar to a traditional interview day), or the residency may house this information at a website that can be reviewed by applicants on their own time. The latter option, combined with multiple interview time slots, may ameliorate time zone difficulties.
Shorter interviews are generally preferable with a virtual format, but programs should consider scheduling time buffers between interviews to troubleshoot technical difficulties, transfer applicants between rooms, and allow interviewers to record thoughts or score candidates. When breakout rooms are utilized, two-minute warnings before interviews conclude will prevent an abrupt end to conversations. Resident interviews, which tend to be less formal, can help replace casual conversations that applicants would normally have on tours or over meals.
After interviews, programs should follow up to identify technical issues and obtain feedback for improvement. A protocol should be established for applicants who request repeat interview days due to technical difficulties. Programs should also consider the potential for unconscious bias and avoid inadvertently penalizing applicants from disadvantaged backgrounds who may have poor internet connections, reduced audiovisual quality, or less professional interview environments.
Virtual Tours
Finding a reasonable substitute for the interview-day tour is one of the greatest difficulties in recruiting on a virtual platform. As many programs are not allowing visiting students to do sub-internship rotations this year, the virtual tour is an especially important opportunity for applicants to familiarize themselves with both the institution and its surroundings. Virtual tours can range widely in content, but typically include highlights of the institution’s location, the emergency department, the residents’ lounge, and educational spaces like the simulation center. Slide presentations, which can be easily shared via many of the online platforms, provide consistency between interview days and require relatively minimal up-front
EDUCATION AND TRAINING
continued from Page 45
resources. A formal video, filmed with the help of the institution’s information technology department or public relations specialists, requires more time and resources but also shows the most polished version of a program. Portions of a formal video may be shared among multiple programs, although ideally the video will also focus on areas specific to the emergency medicine residency. Either a full or condensed version of the video can be posted to the program’s web site and should be sent to applicants via a link in any postinterview correspondence.
For a more personable option, a resident-led tour can be either prerecorded or conducted live. If prerecorded, residents can provide insight into some of the nearby neighborhoods or points of interest in addition to showing areas within the hospital. Live tours of the institution pose multiple challenges. Internet and phone signals are likely to vary throughout the hospital, risking frozen screens, poor audio, and dropped connections. Live tours also pose a high risk of compromising patient privacy. Tours must avoid images of patients and their protected health information. With a live tour there is no chance to edit out information that may be visible on screens or on desks, or patients and families moving through the hospital. The variability of tours and the inability of an applicant to “save” a tour to reexamine at a future time, when making ranking decisions, also make live tours a less desirable option. If there is a strong desire to make the tour more interactive, then consider combining a slide presentation or prerecorded video with a resident question and answer session regarding the program’s location and workspaces.
Interview-Related Social Events
Social gatherings that happen the evening before or after the interview day, as well as during the interview day itself (often over breakfast or lunch), are critical to the interview experience. Many applicants feel that these social interactions help shape their attitudes and opinions toward the program and whether they feel like they will ultimately fit in with a particular group. While an imperfect substitute, applicants should be given an opportunity to talk with residents more casually via a chosen online platform.
Virtual meeting platforms differ from in-person social gatherings in their inability to facilitate “small group small-talk”; therefore, scheduling multiple, smaller social sessions is key. Applicants can start in a large group but then utilize breakout rooms in which 1-2 residents are matched with 2-3 applicants at a time. In these breakout rooms, everyone can unmute and have a discussion. Another option is to use interest-specific breakout rooms. Residents pick a topic that they feel comfortable discussing and have small-group discussions that last for a set, short timeframe. Examples of these types of breakout topics include local recreational activities, relocating with a family, finding housing, and diversity and inclusion programs. All attendees should be encouraged to have their video cameras on and in “gallery view” in order to see all the participants. If more than five participants are gathering, the chat box and “raise your hand” features available on many platforms can be utilized to prevent people from being interrupted or talking over one another. Overall, the number of residents involved in each virtual social event will likely be smaller than for in-person gatherings. Residents may need to be specifically invited to participate in these sessions in order to facilitate an appropriate group size, level of diversity, and relaxed atmosphere.
Second Look
During any interview season, there exists the controversial “second look.” Applicants may fear that if they do not pay an in-person visit to the program after their virtual interview, then the rank committee may underestimate their interest. Programs should address this matter openly and honestly during the general introduction or in the concluding remarks by the program director. Although “second look” visits do not have to be strictly forbidden, the residency leadership should not encourage and should make clear that they do not expect any in-person visits during the current interview season.
ABOUT THE AUTHORS
Dr. Nelson practices emergency medicine and critical care at Washington University School of Medicine where she is an assistant professor and an associate program director for the Anesthesiology Critical Care Fellowship. Dr. Greenberger is an associate professor and the residency program director in the department of emergency medicine at the University of Arkansas for Medical Sciences.
Dr. Tsyrulnik is an assistant professor and an associate program director for the department of emergency medicine residency at Yale University School of Medicine.
Zooming in on Virtual Residency Recruitment: A Program’s Guide
By Kimberly Bambach, MD and Andrew King, MD on behalf of the SAEM Education Committee
The current pandemic has disrupted Reflect on your Program’s to bring their creative ideas to engage medical education in numerous ways, Identity with applicants and spotlight the including residency recruitment. As we Applicants rely on your program’s program. Residents and applicants can continue our fight against COVID-19, online presence to gain insight into the interact through casual virtual hangout social distancing and travel restrictions educational opportunities and culture of sessions, small-group breakout rooms are necessary to keep medical students your program. The first step in cultivating on interview day, or interactive games. safe. SAEM, ACEP, CORD, ACOEP, and your online presence is to reflect on your Inviting applicants to virtual didactics or AAEM released a consensus statement program’s mission and values. What are journal club will also help them sample that all residency interviews will be you most proud of? Why do residents resident life. If an applicant shares an conducted virtually during the 2020- choose to train at your program? interest with a resident at your program, 21 residency application season. This Reflecting on and establishing your consider pairing them so applicants presents unique challenges: how do program’s “brand” enables you to have a can ask questions and form personal programs and applicants find a mutual clear vision of what you wish to convey to connections. “fit” in this virtual landscape? Providing virtual opportunities to explore emergency medicine (EM) programs is critical to supporting applicants who cannot participate in away rotations or interview face-to-face to gain first-hand knowledge of EM programs. The following suggestions will help programs create an applicants. Include Residents on your Recruitment Team Applicants are eager to hear from current residents, and residents are eager to meet their future peers! Consider forming a recruitment committee and Update your Program’s Website Your website is the official source of information on your residency where applicants will glean basic information on the curriculum, didactics, research opportunities, and subspecialty niches. The website should be easy to navigate engaging virtual recruitment experience give residents the opportunity to hold despite the distance. leadership roles. Encourage residents continued on Page 48
and core program information readily accessible. Consider including letters from program leadership, bios on faculty and residents, blog-style entries on the latest program developments, a map of where program alumni currently practice, and information on the surrounding community. Ensure that supplemental program materials, such as brochures, are updated as well.
Get Social Despite the Distance
Tech-savvy applicants are eager to connect with programs via social media. Social media provides an informal platform to give applicants a sense of the culture that they will be missing on the interview trail. Create a residency Twitter account to send brief “tweets” that highlight the people and opportunities that define your residency. Send tweets to celebrate and promote resident accomplishments, share program news and didactic pearls, answer applicant questions, and display photos of residency social events. This is also a way to engage in advocacy and the current national conversations in emergency medicine. Creating an Instagram account is another way to connect through the sharing of photos. Posting at least once a week helps to maintain a connection with your followers.
Create a Virtual Tour
For those applicants who are unable to tour the clinical space in person, creating a virtual tour allows them to visualize what it is like to be a resident in your emergency department. Simply film a walk-through of the department highlighting important clinical spaces (trauma bays, critical care bays, etc.). Additional training sites or rotations may also be included. Add personality to the virtual tour by including narration or commentary from current residents.
Optimize Interview Day Logistics
As emergency physicians, we are well-equipped to anticipate potential setbacks. There are several steps you can take to ensure that interview day runs smoothly: • When an applicant is selected for an interview, provide clear expectations
for interview day, including an itinerary that includes video conference IDs and links. • Provide applicants with information about the video conferencing platform so that they can make any necessary installations ahead of time. • Anticipate that technological malfunctions will inevitably occur.
Ensuring that faculty are familiar with the platform and conducting a test call prior to interviews may identify issues.
Providing applicants with a back-up, such as a phone number to call if the video call is disconnected, will help set applicants at ease.
Beware of Potential Biases
Unconscious bias training for interviewers is more important now than ever, as virtual interviews may potentially introduce novel biases to resident selection. During video interviews, the interviewer may notice details of the interviewee’s environment that convey personal information, such as the applicant’s religion or socioeconomic status. Distractions or disruptions due to technological malfunctions or unexpected events may occur. Consider the potential for conscious and unconscious biases in these scenarios.
It is our hope that these tips will spark creativity and help programs and applicants forge real connections during this "virtual" application season. This is a stressful and unprecedented time for programs and applicants, and acknowledging this fact is important. COVID-19 will not stand in the way of our mission to train exceptional emergency physicians and recruit our future colleagues.
Additional Resources
• Virtual Residency Recruitment in the
Time of COVID • Zooming In Versus Flying Out: Virtual
Residency Interviews in the Era of
COVID-19 • Twelve Tips for Tweeting as a
Residency Program
ABOUT THE AUTHORS Dr. Kimberly Bambach is chief resident in the Department of Emergency Medicine at The Ohio State University Wexner Medical Center.
Andrew King, MD is an associate professor, associate residency program director, and medical education fellowship director, Department of Emergency Medicine, The Ohio State University Wexner Medical Center.
Member Profile: Maureen (Mo) Canellas, MD, Administrative Fellow
Maureen (Mo) Canellas, MD, University of Massachusetts Medical School, Administrative Fellowship
Search for SAEM-approved fellowships in the Fellowship Directory to find programs that meet the highest standards of training in your subspecialty. View the criteria for SAEM-approval of fellowship programs at www.saem.org/fellowship.
What was your fellowship experience like?
My time at UMass has been invaluable. Last year, I was immediately welcomed as a member of the leadership team and taught about the goals and trajectory of the department. Suddenly, I was privy to the how, when, and why of department changes. The most unique experience has been the debrief meetings with my fellowship director after team meetings. We discuss what I would have changed or done differently, what politics may be at play, and what values were aligned or misaligned between parties. Being able to have that time for reflection on my leadership style and management has been a unique experience that I did not know I would have during fellowship.
What advice would you give to someone who is on the fence about doing a fellowship?
I would advise anyone who is considering this fellowship to reach out to their medical director or operations team to discuss their interest. They have invaluable insight and can help advise you through your decision process. Overall, administration fellowships can be quite flexible and personalized toward your interests in administration and leadership. The one or two years of extra training will allow you to hone your administrative skills beyond what you would be able to going straight into an attending job. In addition, many administrative fellowships offer protected time and subsidized tuition for a graduate degree (e.g., MBA, MHA, MPH). These opportunities are invaluable and can help set you apart from other candidates for leadership positions.
What was the most career-enhancing, or eyeopening thing, you gained from the fellowship?
I capped off my first year of fellowship with the coronavirus pandemic. It has been inspiring to watch the administration team work tirelessly to manage all the needed changes in the department. Even through the pandemic, the administration team ensured my learning and fellowship experience continued at full speed. From learning about staff redeployment and the creation of unique care spaces to implementing my own intubation protocol, these first-hand experiences of leading in ambiguity have been vital to my development as a leader and manager.
What are your career plans after fellowship?
I plan to stay in academic emergency medicine, hopefully as part of a clinical operations and administration team. Outside of clinical work, I plan to continue researching national visit and metric trends through my involvement with the Emergency Department Benchmarking Alliance. I hope to utilize national research insights to improve patient care and experience in my own emergency department as well as improve and inform the national practice of emergency medicine.
Everyone’s Entitled to an Opinion, But…
By Gerald Maloney, DO The Case
It’s been the talk of the department. One of the chief residents — soonto-be new faculty member — has made several posts on his blog endorsing controversial theories about the coronavirus pandemic, including comments that minimize the severity of the illness and the need for social distancing and use of masks. While he has not identified his employer, he does identify himself as a physician. His posts have received several thousand views. When confronted, he states that he has a right to his opinions on this topic and a First Amendment right to make the posts. His statements contradict the hospital’s public health messaging regarding coronavirus. Should he be permitted to continue making and posting his controversial statements?
It is not unusual for a conflict between personal beliefs and professional obligations to arise in clinical practice. Physicians have a wide array of personal beliefs on a variety of topics within and
outside of medicine and are no more likely to universally agree with each other on all topics than any other segment of the population. Even within the realm of medical care, there is wide divergence of opinion on the evidence supporting various interventions — the ongoing debates over thrombolysis for acute stroke being one obvious example. Respect for the rights of individuals to have their own opinions has been a tenet of civil rights in our society. This falls in with a broad definition of autonomy as an ethical principle; however, it is also a tenet of professional ethics that outside considerations (such as a personal belief on an issue) should not affect the delivery of medical care. We frequently deliver care to patients with whom we may disagree. We deliver care to physically or verbally abusive patients, criminals, and enemy combatants. We deliver care to patients who wear hats or have tattoos endorsing political beliefs that are the opposite of ours and are expected to do so in an entirely nonjudgmental fashion. While there are cases in which these conflicts come out into the open (a previously discussed case in this column being the physician who has a strong moral opposition to birth control refusing to prescribe emergency contraception), even then, the physician is expected to find a way to ensure the patient stills receives the care he or she requires. Our
duty is to focus on what is best for the patient, even if it does not comport to our personal beliefs.
Given this, the aforementioned scenario raises two pressing questions: 1.) Given that what the physician is endorsing is not what is supported or recommended by the best available evidence and the opinions of the rest of the medical community, is he behaving unethically by espousing beliefs in his role as a physician that may endanger the health of patients? 2.) Because he is making these posts on his own blog, during non-work time, and identifying himself only as a physician and not speaking for his employer, can the hospital ask him to desist from exercising what he believes is his right to free speech?
While there are disputes about what may be the best approach or best treatment for a given condition, the physician has an obligation, when making recommendations to his patient, to do no harm and make recommendations that he reasonably foresees as being in the best interest of the patient’s health and well-being (beneficence and nonmaleficence). Thus, even if the physician holds a differing opinion (for example, that wearing masks in public or social distancing is unnecessary), if the best available evidence and the preponderance of medical opinion contradicts this opinion, he needs to err on the side of doing the least harm for his patient. Even though a blog post or tweet may not be targeted to an individual patient the way a face-to-face encounter would be, it would still be reasonably expected that a person viewing that post might feel he or she is receiving expert medical advice on the topic. The recent sanctioning of two physicians who posted a video that directly contradicted recommendations from multiple professional and public health agencies underscores the obligation of physicians to be responsible in making recommendations — even if posted on their own blog and on their own time.
The right to free speech certainly exists with few limitations (namely those done to incite a disturbance or that create a safety risk); however, employers have a right to impose their own restrictions as to what their employees can and cannot say publicly. Even if an employee does not identify himself as speaking in an official capacity on behalf of the hospital, any public statement he makes — because it can be easily found and potentially linked to the employer — is subject to the employer’s code of conduct and the consequences of breaking that code. Thus, although an individual is entitled to exercise his right to free speech, if an employer deems that speech harmful to the organization, the employer may opt to exercise the right to terminate employment.
The Conclusion
Absent any medically compelling information that supports his position, the physician, ethically, should not be making public recommendations that may result in harm to his patient (or the public in general). The hospital does have the right to ask him to desist in his blog posts or risk losing his job — even if he does not identify himself as their agent — since the information he is posting can be readily discovered and potentially linked to his employer.
ABOUT THE AUTHORS Gerald Maloney, DO, associate professor of emergency medicine, Case Western Reserve University and associate medical director, Louis Stokes Cleveland VA Medical Center.
From K to Baby R to Big R: Should I Apply for an R03/R21?
By David H. Jang, MD, MSc, on behalf of the SAEM Research Committee
For any young investigator with an years of 75 percent protected time with interest in research, one of the primary a modest research budget ($25,000–goals is to land a career development $50,000 per year depending on the award (CDA) which provides the time, institute). Based on my own experience training, preliminary data, and time being about halfway done with my K (did I say time twice?) to transition to award (K08HL136858), the reality of an independent investigator. There are applying for an R01 is starting to sink various CDAs available that include but in. My K currently provides $25,000 are not limited to the National Institutes per year for research supplies. At first of Health (NIH) K awards (K08 and K23 glance that seems like a lot for a young being the most common), foundation investigator, but I quickly realized early CDAs such as the SAEM Foundation on that I needed more money! Science Research Training Grant (which provides is not cheap. I am quite fortunate in that $150,000 per year for two years), I have an amazing mentor (Dr. Todd the Harold Amos Medical Faculty Kilbaugh at the Children’s Hospital of Development Program, and others. Philadelphia) and a lab with robust While they differ in small ways, many of staffing. I didn’t have to worry about these CDAs provide substantial salary hiring my own technician or preparing support with a modest research budget or buying common reagents, but there to allow awardees to competitively were project-specific equipment and compete for independent funding. supplies I needed to be successful — I will discuss other funding opportunities within the context of an and that was going to require more money than what my CDA provided. NIH K award (or CDA equivalent). K I don’t think I’m the only young awards provide anywhere from 3–5 investigator in this situation, so I wanted to share my own experiences with some common funding mechanism available within the NIH system that those on CDAs may want to consider leveraging to bolster both their war chest and street credit to land that first R01. This is by no means exhaustive and there are certainly many equivalent funding mechanisms designed to do the same thing (i.e., SAEM Foundation grants). The question about R03 and R21 grants comes up a lot among many investigators at our stage, so this article is meant to provide some context about whether a junior investigator might want to apply for one. For context, I am a little more than halfway through my K08, which is focused on the intersection of mitochondrial function, therapeutics, and critical care illnesses (mostly toxicology, since I am a toxicologist). Before moving further, it is worth noting a CDA is not a requisite for these grant opportunities nor are they needed to apply and obtain an R01. With that out of the way:
The R21
An R21 is often referred to as a “highrisk, high reward” grant. It supports two years and a total of $275,000 in direct costs. Clearly a good chunk of change, it is often used to generate data for an R01. While a two-year grant seems “easier” to get, NIH data clearly shows these are as difficult, if not more difficult, to obtain than an R01. At least half of those obtaining an R21 are established investigators. Because of this, many mentors advise younger investigators to “just go for the R01” because: a.) R21s are not renewable, b.) they can be as competitive as R01s, and c.) the time to write up an R01 may not be substantially different from an R21. In my own experience, my early K work was focused on treatment of mitochondrial dysfunction with a succinate prodrug (NV118) using in vitro poisoning models. We saw some very exciting results, so I pitched an R21 to explore the use of this drug in a murine model of poisoning that was well-received (R21ES031243). I proposed a straightforward two aim project and did not suck up too much time to prepare. While one does not get any special consideration for being an early-stage investigator (ESI) with this mechanism, there were a few comments from reviewers that noted this R21 would help me apply for an R01,
which is nice for study section members to recognize. I also applied for this R21 with my mentor (Todd Kilbaugh) as a coinvestigator (Co-I) and did not ever refer to him as a “mentor” in the application. I discussed his role as a Co-I and what skills he would bring to the project, which I think is important for those who want to involve their mentor as a Co-I. As a general rule for those on a CDA, this is an important time to establish your area of expertise. It must be clear that it is different from your mentor’s area of expertise, especially if you intend to apply for future funding with said person. At the time of the application, we did not even have a paper together, so do not let that be a barrier if you are early in your CDA with your mentor.
Whether you have a CDA or not, I do think there are a few caveats for those interested in this funding mechanism. For a young investigator who is looking for funding to support time, the R21 is not the way to go. Without killing all your budget on salary, one will probably ask for a 10–15 percent effort which is small in terms of “shift buy down.” It is way more fruitful to go for that CDA. Another myth about an R21: while the grant instructions state that preliminary data is not required, the data show that most funded R21s include some form of preliminary data. Having served on a study section that reviewed R21s, I personally “buy into it more” if there is some form of preliminary data. Obviously, the definition of what constitutes preliminary data is in the eye of the beholder. As with all grants, perhaps the most important thing to do is to talk to the program officer (PO). I discussed my research idea early in the process and was in close contact after my first submission and resubmission (without being the clingy type) which I think helped tremendously. The last point
RESEARCH
continued from Page 53
is that not all NIH Institute and Centers (ICs) offer the R21 mechanism. Again, reach out to the PO so you don’t waste time crafting an application that can’t even go to the appropriate IC. My K’s home IC (NHLBI) did not offer the R21 so I reached out to another IC (NIEHS) where my toxicology work also fits in. For those within the NIH system, going though different ICs is a good way to expand your work and portfolio to remain agile in terms of future funding.
The R03
An R03 is a much smaller grant than an R21, offering $50,000 per year for two years for a total of $100,000 in direct costs so it is for a very focused project that can be completed in two years. Again, this is also a popular funding mechanism that I have known many to apply for. The same advice applies: a CDA should be the primary mechanism to garner salary support, as an R03 is not an effective way to obtain salary support. If one is early
in their career with some support (institutional KL2 or K12 for example), then an R03 may be a consideration. Some ICs will use the R03 mechanism for other purposes, such as a mini career development award (NIA GEMSSTAR to promote aging-related research) or in my case to bolster funding for K awardees. Many ICs use the R03 mechanism specifically made available to only K awardees in their last two years or within two years of finishing their K awards.
It is probably not shocking to know that with the fierce competition for research dollars, the conversion from K award to R01 (while improved with having a K award) is far from a slam dunk. With this recognition, this specific R03 is used to better support K awardees with more funding, make one more competitive for an R01 submission, provide more experience with grant writing, etc. This K-specific R03 is similar to a normal R03 except that one is required to also submit a K progress report and explain how the R03 will be used. Reviewers will look for productivity on the K award (publications, data, and career advancement) and specifically how the R03 will help the K awardee obtain an R01. In my case, I pitched developing a large animal model of poisoning to study alteration in mitochondrial function to set-up work for my future R01 submission. I specifically described how the K has led to the R03 application, what I envision the R03 to do to help
with my upcoming R01 submission and what data/papers I anticipate with the proposal (R03HL154232). Part of the grantsmanship for this mechanism is to show how this work will expand your expertise and exactly how this will benefit your R01 application. At least based on my experience with reviewer comments, they clearly know where we are in our stage of career and I felt they were looking for reasons to score the application well. The obvious metric for K awardees and this R03 is to convert to an R01, so the more you can make your case how this will happen and that funding the R03 is critical for this, the more likely you will be get this. I also think another valuable feature in general is the summary statement. The comments from this R03 is useful to anticipate issues that may crop up for the R01 submission since in most instances one will probably submit their R01 to the same IC that is funding their K (study section may differ though).
The Timeline
It is worth mentioning that from the time of submission to funding can be
close to a year and well over a year with resubmission. This is important to consider in your overall timeline. For the R21, my first submission was in February 2019 and while close to the pay line, it was not funded. I found this out over that summer and resubmitted in the fall cycle of the same year with the resubmission being recently funded… so overall the timeline was about 1.5 years! The R03 was submitted around November 2019 (slightly different submission cycle) and while funded on the first cycle (July 2020) we are still talking 9–10 months.
In conclusion, the primary purpose of any CDA is to obtain the skills, papers, and data to submit a competitive R01. Even though many ICs offer “bonus points” for being an ESI, competition is still tough, so anything you can do to increase productivity and data is an asset. Depending on where you are in your development, consider applying for a smaller R (R03 or R21) if you find it fits within the greater plan for an R01 as opposed to “applying for the sake of applying.” Finally, I want to put in a plug for the SAEM grant writing workshop, which is taught by outstanding and successful EM researchers and is an awesome resource for young researchers to learn the skills needed to craft a competitive grant. SAEM is fully dedicated to the growth of the research pipeline for our specialty and offers a variety of grants for investigators in different stages of their careers to further this critical mission.
If there are any ideas or requests for future articles related to research (e.g. mentorship, ways for medical students or residents to get involved, etc. please let us know. The SAEM Research Committee has a vested interest in promoting the research aspect of SAEM to everyone in any stage of their training.
ABOUT THE AUTHOR Dr. David H. Jang is an assistant professor in the Department of Emergency Medicine and Division of Medical Toxicology at the University of Pennsylvania Perelman School of Medicine. He is a member of the SAEM Research Committee.
