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Careers in academic neurology in the decade of the brain.

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POINT OF VIEW
Careers in Academic Neurology
in the Decade of the Brain
Robert C. Griggs, MD
The past decade has seen major advances in the understanding of neurological disease and revolutionary discoveries that suggest new strategies for disease treatment and prevention. There has also been a sharp
increase in potentially effective treatments requiring
trial in humans or in animal models, including neural
transplantation, growth factors, cytokines and their antagonists or inhibitors, specific immune modulation,
and gene therapy. Justifiable optimism about the future
in investigation of the nervous system and its diseases
led to congressional targeting of the 1990s as the “Decade of the Brain.” A call to action was developed
jointly by academic leaders in neuroscience and the
National Institute of Neurological Disorders and
Stroke 111.
This unprecedented increase in targets for investigation has come at a time of equally unprecedented concern about the upward spiraling of American health
care costs and the fact that almost one-fourth of the
adult population of the United States lacks health insurance in the course of a year [21. These two factors,
among others, have led the leadership of academic
medicine 131 to propose a drastic cut in subspecialty
medicine in the United States. There is a growing sense
that the number of medical graduates going into primary care, currently 20 to 30%, should be rapidly and
permanently increased to at least 50%. It has been
suggested (without much evidence) that the rapidly rising costs of medical care will be brought under control
by placing primary care gatekeepers between patients
and subspecialists 141. Subspecialist numbers would be
decreased to match those currently in place in capitated
payment programs. There have even been serious discussions about retraining current specialists as primary
care physicians because the shift in medical school output to 50% generalists will take more than two decades
to accomplish 15, 61.
The disassociation between optimism arising from
advances in neuroscience and pessimism engendered
by economic realities makes it appropriate to consider
the prospects for careers in academic neurology.
Academic Career Paths
In the recent past, two principal types of academic neurologists filled the ranks of neurology departments.
Approximately 20% of academic neurologists were
laboratory neuroscientists who spent 70 to 90% of
their time on research and had restricted clinical, teaching, or administrative responsibilities 17,8). Extramural
National Institutes of Health (NIH), Veterans Administration (VA), or other support was essential; the more
successful the investigator in achieving grant support,
the more time was available for laboratory research.
The second academic career path, accounting for
80% of academic neurologists, was the teachedclinician, for whom clinical activities comprised 70 to 80%
or more of their effort IS}. Much of the time spent on
clinical work was simultaneously productive in teaching
residents, fellows, and students. Many of these clinical
faculty in research-intensive institutions were geographic full-time as opposed to full-time academicians.
Research was not always part of the career path of
such individuals, but published scholarship could be
substantial and was usually related to clinical studies.
Such individuals often achieved great success in clinical
research, but this was in addition to extensive clinical
and teaching commitments.
This dichotomy was discussed in the 1980s by
Petersdorf 191 as the “two-platoon model” of academic
departments. The two platoons replaced the so-called
triple-threat academician, successful at extramurally
funded research, committed to teaching, and busy with
clinical practice.
From the University of Rochester School of Medicine and Dentistry,
Department of Neurology, Rochester, NY.
Address correspondence to Dr Griggs, University of Rochester, 60f
Elmwood Avenue, Box 673, Rochester, NY 14642.
New Career Paths
Advances in understanding neurologic disorders and
the availability of potential treatments have opened the
door to new opportunities for academic career development (Table 1).Researchers with a 70 to 90% time
commitment to chical investigation are in great demand. This new avenue for academic careers in many
specialties has been recognized by the leadership of
American medicine. A major recommendation of a pa-
Received Jan 27, 1994, and in revised form Feb 15. Accepted for
publication Feb 16, 1994.
Copyright 0 1994 by the American Neurological Association
753
Table 1. Expmding Areas of Inveriigation
in Clinical Neuroscience
Epidemiology and quantitation of neurological disease
Experimental therapeutics
Health services research: quality assessment, appropriateness, outcome research, cost effectiveness, decision
analysis
Disease prevention strategies
Models for improving care of the underserved
Ethics of clinical policies and research
per commissioned by the Institute of Medicine of the
National Academy of Sciences highlights the need for
such research-intensive clinicians [ lo}. The focus of
investigation for such individuals includes experimental
therapeutics, outcome and cost-effectiveness research,
investigation of quality-of-life measures, design of quality assessment, and aspects of the ethics of patient care.
There is a marked increase in funding available for
these areas. Career development must emphasize the
skills necessary to do such research and compete for
extramural funds [lo}.
There is also increased recognition of the importance of the teacher-clinician. Medical schools and
foundations such as the Robert Wood Johnson Foundation and Kellogg Foundation have invested increasingly in programs that fund academicians for teaching
careers. Medical schools have begun to endow fellowships for teachers. The teacher-clinician path can be a
more difficult option for the aspiring academic neurologist. Few medical schools compensate clinical teaching
at a level equivalent to clinical or research activities.
Departments of neurology will, however, need such
individuals to develop the curriculum changes that the
next decade will bring. A major priority will be the
teaching of neurology to students and residents destined for careers in primary care. Academic neurology
departments have not, in general, concerned themselves with the neurological education of such nonneurologists 111, 121.
Current leaders of academic neurology will argue
that increased emphasis on funding of clinically driven
studies and an increase in the number of clinical researchers in neurology departments may dilute rigorous, laboratory-based neuroscience and dwarf the impact of such research on our specialty. There is every
reason to believe that such is not the case. The allocation for federal support of fundamental science increased substantially in 1994 [ 131. The pharmaceutical
industry is investing heavily in basic neuroscience as
well as clinical programs. Rather, a major cause for
concern is the impact of the Association for American
Medical Colleges and federal government policies on
career directions of those entering medicine f14J. If
the strategies for increasing primary care physician
754 Annals of Neurology Vol 35 No 6 June 1994
numbers culminate in an antiacademic hias, the excitement of basic and clinical neuroscience may be overshadowed in the minds of the young by concerns about
economic survival.
Availability of Funding
for Academic Positions
That virtually all departments of neurology are recruiting new faculty (see below) gives an optimistic view of
the immediate future for aspiring academic neurologists. Will this expansion continue? Will funding continue at its present level, decrease, or increase? The
major sources of funding of academic departments in
1986 [8} still obtain today. At that time, aggregate
support of all departments included practice 36%, university hard money 23%, extramural research 22%,
citylstate 896, and VA 11%. Current trends suggest,
however, that there will be changes. N I H funding increased for 1994 1131 but is likely to remain constant
{ 151. Funding of research by the VA has decreased
and is likely to decrease further [lb]. This decrease
could have a disproportionately large effect on academic neurology because neurology departments have
a high proportion of support from VA funding. In contrast, other sources of research support are likely to
increase. Pharmaceutical industry support for basic and
clinical neurological research has increased dramatically
{ 171. There is the risk that control of drug costs by the
federal government will stifle industry investment in
research, but the current rapid expansion of clinical
trials in neurological disease predicts that for neurology, at least, the funding will increase. Major new federal funding for clinical investigation will support
health services research ElS]. The Agency for Health
Services Research is increasingly funding outcome and
appropriateness investigations of neurological disease.
There is a recent proposal by members of congress to
establish a trust fund for medical research funded by
several possible mechanisms (e.g., a monthly set-aside
on health insurance premiums) [171. Such discussion
focuses attention on the importance of increasing research funding. Moreover, the health insurance industry has demonstrated a willingness to fund studies of
cost-effectiveness and outcome research and quality-oflife assessment. In Rochester, New York, for example,
the major insurance carrier, Blue Cross, has established
a $3 million annual fund for studies that have the prospect of reducing health care costs while preserving or
improving the quality of care.
An increasing number of neurologists are being recruited into the drug industry. The academic establishment often mourns the “loss” of such individuals, but,
in fact, many increase in research productivity and continue to maintain vigorous ties to academic teaching
programs. An increase in the options available for tal-
ented clinical neuroscientists increases the attractiveness of a career in academic clinical neurology [20).
One major source of funding for academic departments is likely to decrease, i.e., procedurally derived
practice income. Neuroimaging and various electrophysiologic studies are reimbursed at a higher hourly
rate than cognitive neurology [2 If. Both academic departments and practicing neurologists have been able
to fund the high costs of cognitive neurology and
teaching by procedure-derived practice income. Proposed changes in reimbursement [22} and referral patterns [4] are likely to lower such income. Unless these
procedures are shown to have a favorable effect on
outcome, health care costs, and the quality of life, this
use will fall and income will decline. The ResourceBased Relative Value Scale (RBRVS) was designed to
increase support for cognitive as opposed to procedure-based medical care. It has not as yet accomplished
this goal.
The practice income of academic medical centers
may, however, benefit from health care reform. Because much of the care of the medically un- and underinsured is provided by teaching hospitals, adequate
insurance coverage could substantially improve the
clinical income of academic departmenis [3, 231. Support for faculty teaching neurology to medical students
and to nonneurologist residents ought to be provided
but is unlikely co be sufficient to support many academicians. Nonneurologists are currently taught predominantly by practicing and not by academic neurologists
[ll]. No new support for academic departments can
be expected from this quarter. Rather, the contribution
of private university and state monies to support teachers of neurology will almost certainly decrease. Tuition
is not rising to keep pace with inflation [24] and many
medical schools are considering strategies to reduce
tuition.
The imposition of gatekeepers between patients and
specialists such as neurologists may decrease referrals
to practicing neurologists. The number of practicing
neurologists is already in excess of the ratio in capitated
payment programs [2 51. Effective arguments have
been advanced that the ratio in current capitated programs vastly underestimates the need for neurologists
in a true cross section of society, particularly with the
rapid increase in the number of the elderly and in their
age-associated neurologic problems. Neurologists and
other specialists whose services are disproportionately
needed by the elderly will have to establish that their
expertise benefits these patients and are cost effective.
Career Development
The prerequisites for an academic career have not
changed. The success of the laboratory researchintensive academic neurologist depends upon the following: (1) a 2- to 3-year fellowship (or equivalent PhD
training) in which 80 to 90% of effort is directed toward the laboratory and in which appropriate courses
are taken, (2) following fellowship, a minimum of 3
years of subsequent support in an academic department committed to providing adequate time (usually
more than 75%) for research, (3) an environment that
includes mentors who have been successful in securing
federal support for research, and (4) sufficient numbers
of collaborators with successful research programs to
provide opportunity for extramurally funded joint
projects. It requires on average 4 or more years of
75 g>or greater time commitment to research before
extramural funding can be obtained.
The necessary elements of a career in clinical research are similar (Table 2). Those recommended by
Lee and Goldman [ 101 emphasize the need for courses
in statistics, study design, and data analysis and rigorous
research supervision in a fellowship. The length of support and need for mentoring in a junior faculty position
are identical to the needs of the laboratory-based individual.
Availability of Positions
in Academic Neurology
The American Neurological Association (ANA) under
the leadership of its president, Peter J. Dyck. set out
to increase the involvement of neurologists-in-training
at thc annual scientific meeting. Neurology training
programs were invited to send one resident per program to the ANA meeting; a combination of ANA
and industry-solicited funds subsidized residents' costs
for the meeting. More than 100 residents attended and
were invited to a symposium on Careers in Academic
Neurology. The program included a panel presentation
and discussion by leaders of academic neurology and a
presentation that considered current and future paths
for academic career development as well as current
TuAle 2. Essential Elements of Career Development:
Cliriical Raeavrh
Fellowship
Formal course work
Epidemiology
Statistics
Study design
Bioethics
Two years (minimum) mentored research training
<20% FTE clinical responsibilities
Junior faculty position
Department support for 3 (or more) years
Mentoring collaborators
7 0 7 ~ETE for research (can include appropriate clinical
and teaching activities)
Extramural support
"Expanded and tnodificd from [lo].
FTE
= full-time equivalent.
Point of View: Griggs: Careers in Academic Neurology 755
opportunities in academic departments. In preparation
for the presentation of career opportunities, the ANA
surveyed neurology programs about potential full-time
faculty positions in neurology departments in the
United States and Canada. This survey updates a similar survey conducted a decade earlier IS}.
A questionnaire was sent to neurology program directors in the United States and Canada requesting
information as to areas in which the program was currently recruiting or planning to recruit in the near future. A list of 26 possible subspecialties was provided
for specific numbers of recruitments-in-progress.
Follow-up letters and telephone calls achieved a 98%
completion rate.
Number of Neurologists Entering
Academic Work
There are 544 resident positions available each year
E26J. Between 65% and 70% of the positions are filled
in the annual match, although ultimately more than
80%) of the positions are filled. If one assumes that
the number of neurologists entering academic work
is equivalent to the current career demographics of
neurologists t7, 27), 20% of current residents may
pursue an academic career (Table 3). Thus, an estimated 90 individuals per year may enter an academic
career.
Results of Neurology Department Survey
The programs surveyed report recruitments-in-progress for more than 300 faculty with planned recruitments for more than 300 more within the next year
(Table 3). The major areas of recruitment (Table 4 )
include positions in epilepsy and electroencephalography (EEG), neuromuscular and electromyography
(EMG), pediatric neurology, stroke, dementidbehavioral neurology, molecular biology, and neuroimmu-
Table 3. CompariJon 4 Resident Numbers
and Positions Available
Estimated Number of Neurologists Available
for Academic Positions
Resident positionslyear
Approximate number of residentsiyear
Proportion of residents entering full-time
academic positions
Estimated number (maximum) of neurologists
entering academic neurology
Estimated Number of Total Positions
in Academic Neurology (Neurology
Program Survey)
Recruitment currently in progress
Recruitment planned
Total recruitment
544
450
Major Areas of Faculty Recruitment
(Current and Planned)
No. of
Opportunities
Epilepsyielectroencephalography
Neuromuscular electromyography
Pediatric neurology
Stroke
Dementia
Clinical neurology
Molecular biology
Neuroimmunology
97
80
67
68
65
59
50
47
Other areas include movement disorders, 2 1, neuropathology, 20,
neurovirology, 10, neuroirnaging, 11, neurooncology, 22, neurorehabilitation, 12, neuro-ICU, 10, neuroophthalmology, pan, neurotoxicology, sleep disorders, neuroepidemiology
ICU = intensive care unit
nology. A large number of general clinical neurologists
are also being recruited. Openings exist in many other
subspecialty areas (see Table 4).
Journal Advertisements
The validity of information from the program survey
was tested by review of advertisements in the following
five publications that list positions in U.S. academic
neurology: Anrials of Neurology, Archities of Neurology,
Neurology, Dendrite, and Academic Physician. In this review, positions were tabulated by program and specialty area to avoid counting a single position more
than once. The period of review included the 12
months prior to the department survey.
A substantially smaller number of available positions
(255) were advertised. It is likely, however, that institutions seeking more than one individual in a subspecialty area would not specify a larger number. In fact,
5 1 advertisements did not specify a particular focus or
area of interest.
The number of fellowships (362 positions) currently
listed in the Association of University Professors of
Neurology (AUPN) directory documents the availability of advanced training. As with advertisements,
the AUPN directory lists only one slot per position.
Two or more fellowship positions are available for
many fellowships.
-20%
90/yr
USA
Canada
316
324
38
36
628
Table 4. Neurology Program Suwty: Opportunities Available
(in US.Departments of Neurologyj
74
756 Annals of Neurology Vol 35 No 6 June 1994
Health Care Reform
The Clinton health plan [23, 28, 29} and major policy
statements from academic medical leaders {29, lo}
propose major cutbacks in the number of residents
entering specialties such as neurology. Reductions as
high as 50% have been predicted r31). Such cutbacks
may have the undesirable effect of decreasing the interest of medical school graduates in entering neurology,
including academic neurology. Given the number of
positions available in academic neurology, however, a
reduction in resident numbers will increase, not decrease, the likelihood of career opportunities in academic neurology.
Health care reform is expected to result in managed
care and capitated programs, and fewer positions for
practicing neurologists. The support of academic departments financed largely from clinical income will be
threatened by such changes. It is essential for academic
neurology departments to emphasize research and for
academicians collectively to argue strongly for an
expansion of research support. In this climate of rapid
change, it is of overwhelming importance that neurology emphasize education of the public. As Roger
Rosenberg has recently stressed, “through education,
the scientific and public health importance of neurology and neuroscience will become manifestly evident
to all. Public support of neuroscientific funding will
foilow. . . .” ~32-j.
Conclusion
The current availability of careers in academic neurology should encourage optimism for the future despite
the potential for academic centers to be “ravaged by
the financial contraints imposed by medicine . . . and
administrative burdens which create an unstable environment within the research community” [33]. The
large number of available positions could suggest a
thriving academic enterprise. It may equally well suggest a paucity of top-quality faculty candidates. The
recent call that “neurology programs [should} increasingly rely on clinical teacher-investigators . . . to fuel
the multi-faceted mission of the medical school” [34}
is consistent with current recruitment targets of neurology departments.
There are a large number of positions available in
academic neurology. The 1993-1994 survey of neurology programs indicates that there are as many as
eight positions available for every neurologist planning
to enter academic work. A survey of journal advertisements supports the same conclusion. There are, however, major threats to the specialty of neurology arising
from the perceived national need to expand the number of generalist physicians and to limit access to specialty physicians. These apparent threats can become
the opportunity to strengthen neurology by recruiting
the brightest students into academic departments.
Neurology must expand clinical research that establishes the cost effectiveness of our specialty and emphasize to the young the excitement of basic and clinical investigation in neuroscience. Even if the number
of positions for neurological practice does not continue
its rapid increase, academic neurology can be expected
to grow. We must increase our efforts to excite young
people in careers in neuroscience E323. The prospects
for success are bright for appropriately trained and
well-mentored academic neurologists, whether laboratory based, clinical investigator, or teacher-clinician.
The American Neurologic Association symposium for neurology
residents was organized by Drs Richard Rudick and Michael Rasminsky under the leadership of the Scientific Program Committee
(chaired by Ira Shoulson, MD). The panel moderated by Dr Jerome
Posner also included Drs Robert Barchi, Dennis Choi, Howard
Fields, Lindy H a r d , and Anne Young.
I thank Drs Steven Rmgel, Richard Rudick, and Martin Samuels for
helpful advice on this manuscript, Ms Laura Vaudreuil of the American Neurological Association and Ms Nancy Malloy and William
Martens for assistance with the survey, and Mrs k s a Oppelt for
secretarial assistance.
Presented in part at the American Neurologic Association Symposium for neurology residents, Boston, MA, October 17, 1993.
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