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Careers in acadedmic neurology 1996.

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POINT OF VIEW
Careers in Academic Neurology, 1996
Susan S. Spencer, MD
Aside from scattered, dated publications addressing
training opportunities or providing individual conceptualizations of the future of academic medicine, there
is little published literature on careers in academic neurology. The American Neurological Association has
been attentive to this situation. Three years ago, members initiated a resident’s symposium at the annual
meeting. Academic neurologists at various stages of
their careers shared their experiences and pathways to
success with neurology residents. In the context of that
symposium, Dr Robert Griggs reviewed the status of
academic neurology careers and published the only
comprehensive survey of opportunities in existence several years ago [I]. Changing views and emphasis in
academic medicine, as well as a funding climate continually undergoing metamorphosis, demand that we investigate once again the future of academic neurology
through an examination of the prospects for, definition
of, and facilitation of careers in academic neurology.
A global approach seems most appropriate, and one
from which we can derive some information, perspective, and hopefully optimism.
What Is a Career in Academic Neurology?
Probably most important to an examination of academic neurology careers is a definition of them. This
is by no means easy or straightforward, and has itself
undergone an evolution, predominantly in the last decade. It is still common to encounter individuals who
believe that basic research is an essential component of
an academic neurology career, and advise students and
fellows of this necessity. In their minds is the “triplethreat” academician, the academic physician who was
epitomized as a world class basic researcher, an inspiring teacher, and an astute and experienced clinician.
Upon recognition that such a “triple-threat’’ individual
cannot possibly excel in all these areas, the “dual-platoon” model of academic medicine became popularized
two decades ago [2]. In this model, the neurologist
as a laboratory neuroscientist and the neurologist as a
teacher/clinician were distinguished from one another.
The laboratory neuroscientists accounted for approximately 20% of academic neurologists, and spent 70 to
From the Department of Neurology, Yale University School of
Medicine, New Haven, CT.
Received Dec 5, 1995, and in revised form Feb 12, 1996. Accepted
for publication Feb 13, 1996.
90% of their time doing basic research in the laboratory, while assuming a minimal amount of clinical,
teaching, or administrative responsibilities. In contrast
stood the teacher/clinicians, the majority of academic
neurologists, who spent 80% of their time on clinical
effort, and assumed considerable teaching responsibilities, while achieving substantial scholarship related predominantly to clinical studies [ 11.
It is only very recently that recognition of the scientific discipline of clinical research has come into its
own. It is not that epidemiology and biostatistics are
new fields, but merely that academic medicine has recognized their importance in furthering the translation
of basic discoveries to the bedside. Clinical investigation cannot be performed by individuals who are untrained to do it, who are unable to appropriately design
studies capable of yielding accurate results [ 1, 31. Clinical research has also become more far-reaching, extending to the areas of health services, bioethics, basic
mechanisms of disease, and mechanisms of diseases as
manifested through their clinical appearance. Clinical
research incorporates evaluation and development of
new diagnostic tests, experimental therapeutics, and epidemiology including prediction, prevention, prevalence, and patterns of disease definition [l, 3, 47. Recognition of the comparable demand for scientific rigor,
extensive training in a clinical subspecialty as well as
in this scientific research discipline, and the necessity
for extramural funding inherent in the pursuit of investigation related to both clinical and basic aspects of
neurology now enables a “three-platoon’’ model of the
academic neurologist. It is possible now to conceptualize the academic neurologist as a laboratory neuroscientist (one with a medical degree with or without a PhD
degree predominantly performing laboratory research
and participating in some related subspecialty clinical
activity) or a clinical neuroscientist (one with a medical
degree, often with additional subspecialty training as
well as training in epidemiology and public health, performing clinical investigation along with considerable
subspecialty clinical activity) whose roles are enhanced
within the academic neurology department by the
teacher/clinician (one with a medical degree with fo-
Address correspondence to Dr Spencer, Department of Neurology,
Yale University School of Medicine, P.O. Box 208018, New Haven,
CT 06520-8018.
Copyright 0 1976 by the American NeuroIogicaI Association
123
cused subspecialty and teaching expertise). Individuals
seeking academic careers are not often counseled as to
the possibility of these three pathways of expertise in
the world of academic neurology.
and commitment to further subspecialty development,
must be available to the teacher/clinician in order to
develop his or her experience and expertise in the clinical subspecialty chosen, providing for opportunity to
enhance that expertise while teaching it to others.
Training Requirements
Now that the three-platoon model of academic neurology is defined, it is reasonable to ask what training is
necessary to ensure creditable academicians who can
fulfill these various roles. Credibility may itself inspire
success. It is evident that the basic neuroscientist requires 2 to 3 years of fellowship or equivalent doctoral
degree training beyond medical training in which 80
to 90% of the effort is dedicated to basic laboratory
investigation. Such postresidency training would include relevant course work and be followed by a minimum of 3 years of postfellowship support in an academic department with at least 75% of the time
dedicated to basic research. This time would be used
to establish independent research productivity with the
possibility of extramural funding. The environment of
the basic neuroscientist during this fellowship and junior faculty time should have appropriate mentors and
sufficient numbers of federally supported collaborators
to achieve success 11, 5 , 61.
The recommended training required for success of
the clinical neuroscientist has very close parallels [ I , 3,
4, 6-91, A 2- to 3-year clinical research fellowship
must also allot 50 to 75% of the time to research endeavors and training for clinical research. This fellowship should include course work in epidemiology, statistics, study design, and bioethics. The fellowship
might include some clinical subspecialization, but ideally should follow upon a clinical subspecialty fellowship, such that extensive clinical responsibility would
not detract from the scientific rigor of the clinical research training per se. Subsequently, a minimum of 3
years of postfellowship support should be sought in an
academic department, and the individual should devote
no more than 40% of the time to clinical responsibilities. This interval is sufficient to allow establishment
of a clinical research program and direction, while simultaneously establishing clinical expertise in a subspecialty area at a particular center. The environment
needs appropriate mentoring and collaborative opportunities.
The teacher/clinician requires a 2- to 3-year subspecialty fellowship, but in this instance 50 to 75% of
the time should be devoted to clinical responsibility
and subspecialty training. The fellowship should include formal or informal tutored instruction at the
home institution or elsewhere in the clinical subspecialty, and the environment should provide adequate
mentoring. A minimum of 3 years of postfellowship
support in an academic center with sufficient programmatic emphasis in the subspecialty area, or the facilities
124 Annals of Neurology
Vol 40
No 1 July 1996
Profile of the Academic Neurologist
Even in this three-platoon model of academic neurology, all academic neurologists have features in common. They each have postdoctoral, postresidency training which might include a clinical research fellowship,
a clinical subspecialty fellowship, or a postdoctoral laboratory fellowship. They each generate income to support their position or their research, or both, from extramural or clinical sources or a combination. They
each have teaching and clinical responsibilities (in varying amounts). Their highly focused expertise enables
establishment of a productive program. Finally, they
serve as role models for future academic neurologists
and they reap the rewards of an academic career. All of
these items (with the exception of generating income)
distinguish academic and practicing neurologists.
In a practical sense, it is reasonable to ask what is
an appropriate distribution of time in research, clinical
activities, and teaching and administration? Some of
this will depend on the spectrum of the three platoons
of academic neurologist at any individual institution,
since a dearth of teacher/clinicians may demand more
teaching time from others. Similarly, a dearth of clinical neuroscientists and teacher/clinicians may demand
more clinical time from basic neuroscientists. In internal medicine, 482 first-author physicians in peer-reviewed internal medicine journals in a 6-month period
were surveyed and indicated that the mean time spent
on clinical responsibilities was 30% while the mean
In 1985, the Stantime spent on research was 36% [7].
ford Department of Medicine was surveyed; the mean
time spent on research was 21%, with patient care accounting for 30% of the time [lo]. Some authors suggested that the “ideal” academic physician would
spend oneLthird of his or her time in research, onethird in clinical activities, and one-third in teaching
and administration. By newer three-platoon models,
this division will be more variable.
The Rewards of an Academic Career
The mandates to elucidate causes of disease, examine
mechanisms of pathology, learn techniques to diagnose
illnesses, discover ways to prevent them, and define
pathways to intervene in the cascade; to translate these
discoveries into clinical practice; and to train future
neurologists in the wise and timely application of this
knowledge remain unchanged. Accordingly, individuals
pursuing academic careers in neurology will be those
who wish to have an impact on patient care by recog-
nizing issues, asking appropriate questions, and participating in discovering the answers to those questions.
They will train the next generation of neurologists and
have the potential to influence public opinion and policy, while advancing our understanding and treatment
of disease. Individuals who pursue academic careers in
neurology should seek teaching, clinical, or basic investigation as their concentration, while intending to devote time to the practice of clinical neurology.
For Whom?
Who seeks an academic medical career? We have few
data in the field of neurology. Factors that have been
independently correlated with the choice of an academic career include scholastic performance in medical
school, research experience in medical school, younger
age at graduation, and supportive mentorship [ 1I].
Factors unrelated to the choice of an academic career
in previous investigations include the type of high
school or college attended and the year of graduation.
These studies have been done in medicine and pediatrics, but none has addressed neurology specifically. Factors correlated with academic achievement (measured
by rank and citations) include higher class rank at graduation, research experience in medical school, number
of works published within 5 years of graduation, and
the presence of supportive and guiding mentorship
[ 121. Unfortunately, these data on academic achievement are based on the triple-threat or dual-platoon
models of the academicians and have not addressed
achievement in the current triple-platoon scenario.
There has been concern that the current health care
climate and reimbursement decline will force new physicians against an academic career choice. “We now
face a monetary crisis and a crisis in which too few
physicians are willing to make research in health a career” [6]. My reading of the literature suggests this
contention is not entirely true. In 1960, 39% of senior
medical students were interested in research, teaching,
and clinical careers in academics [6, 131. In 1982 this
number had fallen to 22% [14], but by 1990, 29% of
senior medical students were again interested in academic careers [G, 151. An important difference
emerged: Of these individuals, only 1.3% were interested in pursuing a position as a basic neuroscientist,
while most were interested in a clinical neuroscience
career [ 151. Examination of the proportion of all physicians in the United States engaged in research confirms
that over the decade of 1980 to 1990, there was not a
progressive decline in research enrollments [6, 151.
The one area in which the concern is indeed warranted is among women [ 161. Women at all levels are
less interested in academic careers than are their male
colleagues. This is especially concerning, because
women represent an increasing proportion of the work
force in neurology, and in all of medicine. Among
medical students, 31% of women versus 43% of men
were interested in seeking an academic career option.
By the time these individuals reached the housestaff,
only 28% of the women versus 6 1% of men were interested in academic careers. The major perceived obstacle
among the women queried was balancing family responsibilities with teaching, clinical work, and research.
Of greater concern was the minimal mentoring available. Forty-five percent of junior faculty women, versus
8% of men, indicated they had never had a role model.
This situation should become progressively better as
more women achieve positions in academic neurology
from which they can serve as mentors for others. In
the meantime, the mentoring role for women’s advancement in academic neurology must be assumed by
men in leadership roles who alone have the capacity
to spur this evolution to a more equitable distribution.
Changing Spectrum
Academic medicine and all of medicine are undergoing
changes as a result of health care reimbursement and
reorganization. Cadman indicated, “It is a fact that
physicians on medical school faculties are having increasing difficulties in obtaining funding to support
their research and therefore themselves” [6]. This comment applies to all three pathways of academic neurology. The main sources of support include the National
Institutes of Health (NIH) (predominantly for basic
and clinical investigation), private foundations and industry (for some forms of clinical research), and clinical
income (particularly relevant to the teacher/clinician
and to a lesser degree, the clinical neuroscientist).
The figures are startling. NIH funding chances for
new ROl grants declined from 40% in 1975 to 14.2%
in 1990. Funding chances for renewal applications also
declined substantially, from 70% in 1975 to 35% in
1990 [6]. This change in R 0 1 funding is reflected by
medical school revenues, which are increasingly composed of clinical income. In 1980, 15.6% of revenues
of all US medical schools came from clinical practice;
in 1990 this figure was 29.8% [6, 151. In the 1960s,
40% of medical school revenues were derived from research, and of these 30 to 35% were from federal
sources. In 1990, 13% of medical school revenues were
from federal research sources [6, 151.
AIthough this crisis is severe with regard to the funding of the basic neuroscientist, it is of even greater concern in the funding of the clinical neuroscientist. The
proportion of grants submitted by researchers with a
medical degree is said to have been stable at 25% since
1980, with identical priority scores to PhD submissions. It is assumed that this proportion reflects the
submissions of the clinical neuroscientist. However, included in the physician group were MD/PhD candidates, and many physicians submitting grants of a basic
neuroscience tenor. In addition, despite the stability of
Point of View: Spencer: Careers in Academic Neurology, 1996
125
the percentage of grant applications and scores from
medical-degree researchers, the actual numbers have
dropped considerably. Of those funded, by various estimates only 2 to 20% are for clinical research endeavors
[4, 17, 181.
In a mail survey of all clinical and basic researchers
in departments of neurology in the United States 2
years ago, the clinical researchers indicated that they
were less well supported, had considerably less time for
research, and had less postdoctoral training than did
the basic researchers [4]. Forty-four percent of clinical
researchers in neurology had federal funding for their
research, compared with 82Y0 of basic investigators. Patient revenue, on the other hand, provided salary support for almost all the clinical researchers and almost
none of the basic investigators. Furthermore, reorganization of the US health care system with increasing
emphasis on primary care, reduction of subspecialists,
and reduced reimbursement bodes for progressive deterioration in the clinical income of both academic and
practicing neurologists. Thus, every source of income
for the basic and the clinical neuroscientist and
teacher/clinician is declining.
These reimbursement and funding issues are likely
to impact all neurologists, perhaps practicing neurologists to an even greater extent. Increased attention is
being devoted to the funding of academic medical centers. The grant review process, programs of training,
and recognition of the importance of both basic and
clinical research are undergoing change. Congressional
and NIH attention to the need for medical school and
academic medicine and research support is increasing.
It is likely that progress will be made toward correcting
some of the deficiencies of research support for all neuroscientists in academic communities through the proposals presently before Congress, and these will improve the more dire situation in clinical research as
well. However, they require our continued and vocal
support.
Job Availability
“The dissociation between optimism derived from advances in neuroscience and pessimism engendered by
economic realities makes it appropriate to consider the
prospects for careers in academic neurology” [ 11. This
statement underlines the situation and prompts further
investigation of job availability in this climate of uncertainty. Maybe because the mandate to explore ways to
improve our identification, understanding, diagnosis,
and treatment of disease remains, and despite the adversarial economic and political climate, job availability
in academic neurology has not declined. A 1993 survey
of academic neurology departments, supplemented by
a review of journal advertisements, documented 300
ongoing recruitments in academic neurology, with over
126 Annals of Neurology
Vol 40
No 1 July 1996
300 imminently planned [I]. Griggs [l] indicated that
this represented eight academic positions for every neurologist with academic aspirations. The main areas of
faculty recruitment at that time were epilepsy/electroencephalography (EEG), neuromuscular/electromyography (EMG), pediatric neurology, stroke, and dementia (in that order).
Recognizing the major changes that have occurred
in only several years, and the appearance of the tripleplatoon model of academic neurology, it is reasonable
to reexplore job availability. A review of neurology advertisements for the 12 months, July 1994 to 1995,
supports the statement that academic neurology recruitment is healthy: 248 positions were advertised
(compared to 255 in the prior survey). (There was an
honest attempt made to eliminate any redundancies in
these advertisements.) The major areas of recruitment
still include epilepsylEEG, neuromuscularlEMG, pediatric neurology, degenerative disease, and stroke, in
that order. However, the frequency of advertising for
several areas progressively increased over the year.
These emerging subspecialties include rehabilitation,
neurooncology, critical care, and health services. An individual interested in pursuing an academic neurology
career has many choices. Furthermore, we might well
anticipate even more demand for neurologists to care
for a population of advancing age whose vascular, immune, and degenerative central nervous system maladies may increasingly fall into the domain of treatable
illnesses.
Future
There are many avenues that might improve the future
of academic medicine and neurology. Some programs
and initiatives are already in progress. The NIH grant
review process and award procedure to legitimize and
equalize funding for clinical and basic research is being
studied. We need to improve medical research training
and exposure in medical school and residency programs, where we should emphasize mentoring as early
as possible. Male leaders must serve as mentors for
women aspiring to higher levels in academic neurology.
Protected research time must be secured for both clinical and basic research by neurology faculty. We also
need to examine and expand nontraditional industrial,
corporate, and foundation liaisons for research support,
and create deans and departmental advisors for clinical
research.
Despite clear obstacles, we have multilevel recognition of the problems, understanding of the continued
need, defined directions to go, and many indications
of the health of academic neurology. Indeed, balancing
these various forces suggests that this should be an attractive career alternative for neurologists now in
training.
References
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Point of View: Spencer: Careers in Academic Neurology, 1996 127
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