Developing The Next Generation

Otolaryngol Clin N Am 40 (2007) 1295–1309

Developing the Next Generation of Otolaryngologist-Researchers Shawn D. Newlands, MD, PhDa,*, Daniel A. Sklare, PhDb a

Department of Otolaryngology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0521, USA b Division of Scientific Programs, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Executive Plaza South, Room 400C, 6120 Executive Boulevard, MSC-7180, Rockville, MD 20892-7180, USA

Discoveries and the application of new technologies drive new therapies that improve patient outcomes. The practice of otolaryngology, as all of medical practice, has changed dramatically in the last 15 years based on new technologies and new concepts of disease, and change will undoubtedly continue. We owe our patients access to newer procedures and therapies that stem from basic and clinical research, but from where will this innovation come? Although many exciting breakthroughs have emanated from the prepared minds of clinicians interacting with their patients, other discoveries originate from clinicians who are trained in the methodologies of science. Increasingly, otolaryngology research draws from such fields as outcomes research, information technology, genetics, molecular biology, and biomedical engineering. This article discusses where the clinician-scientists in our specialty have traditionally come from and how they are likely to be generated in the future. Training clinicians to be proficient researchers is as difficult as it is important. As a specialty, we have to be aware of emerging areas of inquiry and ensure that opportunities exist to couple the right minds to the right projects. Financial incentives, clinical care, and family demands often compete for the time and energy required for a career as a clinician-scientist. Recognizing the importance of research to otolaryngology and nurturing the aspirations of those clinicians truly cut out for this pursuit should ensure

* Corresponding author. E-mail address: [email protected] (S.D. Newlands). 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.07.008

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continued growth in patient-grounded science that will drive our specialty through the coming years. Literature review Others have written about the training of clinician-scientists in otolaryngology and the shortage of clinician-scientists in the specialty, and multiple views and plans have been put forward. Here we concentrate on the more recent literature. In 1999, Nadol surveyed junior otolaryngology faculty (less than 5 years out of training) across the nation [1]. He found that 71% had completed a clinical fellowship and 9% a research fellowship. Although 93% reported being engaged in research activity, they actually only spent an average of 13% of their time in research. Most of the surveyed faculty went into otolaryngology to teach, not to conduct research. When asked how their academic careers could be improved, however, the top four suggestions were related to research, particularly research support. Nadol concluded that a need exists for more research training, protected time, and ‘‘clarity of job description.’’ Naclerio and colleagues [2] surveyed otolaryngology department chairs. Chairs identified 63% of their faculty as clinician-scientists but reported that, on average, they spent only 17% effort pursuing that endeavor. Only 8% of faculty members were reported to be funded by the National Institutes of Health (NIH) and 20% by other sources. The authors also found that, on average, there are two PhDs per otolaryngology department [2]. Wolfe and Weymuller examined the graduates who trained in the National Institute on Deafness and Other Communication Disorders (NIDCD)–supported NIH Institutional National Research Service Award (NRSA) training grant (T32) programs at their institutions (University of Michigan and University of Washington) [3]. Although a high percentage of these trainees pursued academic medicine, one fourth to one third eventually were funded by NIH-mentored clinical scientist development award (K08) grants, and a small percentage became independent investigators. Chole reported a similar experience with Washington University T32 trainees; 60% entered academic medicine, and 17% obtained NIH funding [4]. Wolfe and Weymuller concluded that research training should be phased in late in resident training after the resident has identified his or her clinical focus and research focus [3]. Such a plan is inhibited, however, by the sometimes rigid and often unaligned residency review committee in otolaryngology, American Board of Otolaryngology, and NIH rules. Some of the proposed solutions included funding for research mentors, coordination of the career path that bridges residency to the K-award, and a joint strategy between the residency review committee, American Board of Otolaryngology, American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), and the NIDCD/NIH to develop clinician-scientists. Wolfe and Weymuller also recommended a renewed emphasis on clinical research training, which

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is better matched to the interests of residents than basic science research [4]. Supporting their suggestion is the finding that students who graduate from medical school are ten times more likely to be interested in pursuing clinical research as part of their career trajectory than basic science research [5]. In late 2005, the NIH and AAO-HNS co-sponsored a conference on research training and education in otolaryngology. The purpose of this forum was to identify obstacles to research education and training in otolaryngology and formulate strategies to overcome these barriers. Among the 158 registrants, representing 33 otolaryngology training programs, were many of the leaders, clinician-scientists, and trainers/research mentors of the specialty. A summary of this conference has been published [4]. Although a diversity of opinions was expressed at the conference, several targeted recommendations to the NIDCD/NIH and the profession emerged, underscored by a concerted call for the development and support of more flexible models and NIH-sponsored programs for research training in otolaryngology. Otolaryngology does not uniquely face these problems. Urology and orthopedic surgery, other surgical subspecialties, have even lower rates of residents developing into clinician-scientists. Such failure has been attributed to lack of mentorship, clinical pressure, a specialty culture that does not value research, financial constraints, poor research background among residents in the specialty, busy on-call schedules, and the length of clinical training [6–8]. Career paths The successful clinician-scientist develops during all stages of training. It is unusual for someone who has not had significant research training before his or her first faculty position to be successful in obtaining funding and developing into a productive clinician-scientist. This section considers research opportunities afforded to trainees at various stages of their careers. Before residency Although one could debate whether clinician-scientists are born or made, there is no question that many clinicians interested in research self-identify early in their education. One way to build our cadre of clinician-scientists is to recruit students interested in science into our specialty rather than try to turn those committed to otolaryngology toward research. Many demographic factors have been correlated with an interest in becoming a clinician-scientist [9], including graduation from a private medical school, graduation from a medical school with larger amounts of NIH funding, graduation from a school with an NIH-funded medical scientist training program (MSTP), and male gender. Many programs encourage and foster such students. Many medical campuses offer summer research experiences for undergraduate students. Most

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medical school curricula have mechanisms for medical student research, but perhaps the most likely students to go into academic medicine and continue to participate in biomedical research are MD/PhD students. Most medical schools have MD/PhD programs, and 41 of these schools receive NIH funding and designation as MSTPs. The MSTP program, administered by the National Institute of General Medical Sciences, was founded in 1964 to increase the clinician-scientist pipeline. Up to 8% of medical school graduates hold MD and PhD degrees. Of these graduates, one fourth are from MSTP programs, one fourth are from other MD/PhD programs, and roughly one half obtained the two degrees independently. More than 80% of participants between 1970 and 1990 in MSTP MD/PhD programs went on to academic careers, and 68% became independent investigators [10]. This latter percentage contrasts to less than 1% of graduates from United States medical schools in general [5]. Clark and Hanel [11] used the appendices of MSTP grant applications to the National Institute of General Medical Sciences to investigate which specialties MD/PhD students gravitate toward. They found that students who complete MSTP programs are more than five times as likely to go into pathology as MD-only students [11]. Similarly, pediatrics, neurology, neurosurgery, and radiology are popular for these students. In contrast, MD/PhD students are unlikely to enter family medicine, emergency medicine, rehabilitation medicine, obstetrics and gynecology, and most surgical subspecialties. MSTP graduate students are approximately 55% as likely to go into otolaryngology as MD students, however [11]. Interestingly, 41% of MSTP students get their PhDs in biochemistry, cell or molecular biology, or neuroscience [12], all disciplines well positioned to conduct research in otolaryngology. There are several ways for our specialty to attract MD/PhD students and other students likely to become clinician-scientists. Primarily, researchers in otolaryngology should be more visible to such students. Specific ways to increase such visibility include individuals who are in otolaryngology departments or conducting otolaryngology research serving on MD/PhD committees, participating in MD/PhD curricula, and serving on dissertation committees. These individuals also could sponsor undergraduate students who are conducting summer research and medical student research. Some of these activities could be sponsored through T32 grant programs, which are discussed later. Several NIH institutes, including the NIDCD, also seek to recruit students on integrated MD/PhD tracks to pursue research in their scientific mission areas through the Ruth L. Kirschstein National Research Service Awards for Individual Predoctoral MD/PhD Fellows (F30) (PA-05-151). During residency Most otolaryngology residency training programs allocate time for resident research, and in most cases, the purpose of this rotation is twofold:

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to make our trainees more sophisticated consumers of research and to foster a greater appreciation of the value of research to clinical practice. At the lead author’s institution, as in many other programs, the mechanism to reach these goals is a research rotation, wherein, the resident experiences the scientific process from conception of a research idea through presentation and publication. The residency-based research experience, typically 3 to 6 months in duration, is generally not adequate preparation for building an independent research career. In some programs, however, additional research training is available, generally through a T32 program. Fellowship Several fellowship opportunities are available for residents who complete otolaryngology programs. Some programs, particularly in head and neck surgery, neurotology, and pediatric otolaryngology, have 1 year of research experience built into them. Unfortunately, these experiences are short, often part-time, and applied to all participants, not just those interested in an academic career. Some of the full-time research training experiences are currently funded by T32 programs (eg, the head and neck fellowship at MD Anderson Cancer Center). The extent to which these fellowship-based research experiences enable residents to become independent clinician-scientists is unclear. Research is needed to evaluate the use of these experiences in increasing the cadre of clinician-scientists. After residency/early career Perhaps the greatest attrition of otolaryngologists from would-be clinicianresearchers to full-time clinicians occurs in the transition from training to employment during the first few years of a junior faculty appointment. The pressure on the time of young otolaryngologists is intense. They feel the need to build a practice and refine their surgical skills. They are often sought by residents to ‘‘staff cases’’ and are heavily involved in the on-call schedule. Their teaching responsibilities are new, such that each lecture or presentation takes more time to prepare than it does for seasoned faculty members with lectures already ‘‘in the can.’’ Although these junior faculty members may have negotiated adequate ‘‘protected time’’ to start their research career, they often have not taken into account the actual and perceived peer pressure to ‘‘pull their weight’’ clinically. Often this pressure comes from within. Emerging from fellowship and residency, young faculty members most often identify with their clinically active mentors, with whom they have spent most of the previous 5 to 7 years, rather than their clinician-scientist mentors, with whom they have spent considerably less time. The elements in a junior faculty’s new department that should be in place to make this transition successful include a culture of inquiry, strong committed leadership, alignment of incentives for research accomplishment, appropriate mentorship, appropriate research resources and facilities, and appropriate

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time protection. Most clinician-scientists in otolaryngology work in a relatively small number of departments throughout the country. The reason for this distribution is that these departments are the ones that can most likely provide the previously listed elements. Because of these departments’ track records, however, they can attract the appropriate candidates. Departments in which research is not valued are toxic environments for the career of a clinician-scientist. The key element for a nurturing environment is a true culture of scientific inquiry. This culture is ideally set from the topdthe department chairdbut should be pervasive throughout the department. Part of this culture includes alignment of incentives. Strong disincentives to research, either financially or in prestige, erode commitment to research among young faculty members. Mentorship is also critical for developing a research career. Because otolaryngology is a small field, many otolaryngology departments lack appropriate research mentors within their ranks for junior faculty members. Some departments circumvent this limitation by forging research collaborations with investigators from other departments, who also serve as primary and secondary mentors to new faculty members. Another strong element for nurturing successful clinician-scientists is the research environment. Early career faculty members are more successful when they have the opportunity to interact with investigators in their scientific field. Teaming with established laboratories and programs is frequently the road to success for clinician-scientists. Ideally, clinician-scientists will bring a clinical perspective to a research group while basic scientists contribute research experience, technical know-how, grant-writing knowledge, and resources. In the biomedical sciences, full-time researchers usually have had 5 or more years of PhD training and 5 or more years of postdoctoral training before initiating an independent research career. In contrast, otolaryngologists rarely have more than 3 years of scientific training before entering an independent research career trajectory. For this reason, it is often difficult for these new surgeon-investigators to compete favorably with their PhD counterparts for federal research funding. As a group, however, physicians have been shown to compete favorably with nonphysicians in the trans-NIH peer review process [13]. The NIH awarding components (institutes and centers) have recognized the challenges faced by specific groups in developing a research career trajectory and have launched program initiatives and award mechanisms aimed at facilitating the start-up of the clinician-scientist’s career. The NIH institutes place considerable weight on the career development plan proposed in K-award applications. The availability and quality of mentors and research resources are important factors for budding clinician-scientists to consider before taking a junior faculty position. These factors and future prospective funding sources should be considered before a candidate accepts a new faculty position. Time protection is an issue that is usually up-front in the negotiation for any new faculty member but is of particular importance with clinician-scientists.

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Typically, the new faculty member wants to know how much protected time to ask for and for how long. There is no correct formula; however, it is probable that more often than not, the time given is either too little or distributed incorrectly. Common practice is to provide a certain percentage of protection for a period of several years. Often, however, protection is less necessary in the first yeardduring the arduous period of laboratory set-updand more necessary during the process of preliminary data collection and grant writing. Because each situation is different, the best approach is customizing distribution of time and resources based on the young faculty member’s experience, the project, and the environment. An important element of this customization is that the chairperson clearly communicates expectations to the faculty member. Inappropriately allotted time and resources are wasteful and discouraging to existing faculty, who are often supporting the new clinician-scientist faculty member. Funding for clinician-scientists in otolaryngology Many academic otolaryngologists get their initial funding through small grant programs. Many of these programs are sponsored by the AAO-HNS and other professional societies. The review of these grant applications has been consolidated into an academy program called the centralized otolaryngology research efforts (CORE). Grant applications for academy grants and eight other professional societies (ie, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngologic Allergy, American Head and Neck Society, American Hearing Research Foundation, American Laryngological Association, American Rhinologic Society, American Society for Pediatric Otolaryngology, and the Triological Society) are reviewed in one comprehensive review committee each spring. This mechanism was adopted to ensure high-quality reviews for each proposal and facilitate funding of meritorious proposals by stimulating consideration of proposals across different grant mechanisms. An additional benefit has been to afford otolaryngologists the opportunity to participate in a study section format and, as a result, become better grant writers themselves. The centralized otolaryngology research efforts mechanism considers proposals that, cumulatively, award up to $650,000 per year. Details on applying for these grants are available at http://www.entlink.net/research/ grant/Foundation-Funding-Opportunities.cfm. The NIH T32 mechanism supports research training that is not readily amenable to support through individual training grant mechanisms. Such training includes research training for otolaryngology residents and postresidency fellows within clinical departments. Currently, 12 NIH T32 grants are awarded to otolaryngology programs for resident training in research. Most of these programs are designed to support research training for otolaryngology residents for 1 to 2 years, with the goal of nurturing clinician-scientists, but there are variations. These programs are generally found in

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institutions with large research infrastructures and vary across institutions with respect to the duration and phasing of the research training experiences. There is, however, no consensus on the optimal design. The NIDCD requires that its mentored K-award applicants have had at least 2 years of prior research experience since their undergraduate education. In 1993, the NIH issued a consensus report, the Lenfant Report, strongly recommending twodpreferably contiguousdyears of research training for postdoctoral health professionals (generally physicians). This recommendation was made on the basis of many prior years of data regarding the subsequent research granting success and longevity of research funding of health professional postdoctoral fellows trained on NIH T32 grants. In compliance with the Lenfant Report, most applicants to the NIDCD for new and renewal (competing continuation) otolaryngology resident-directed T32 programs over the last decade have augmented or modified their training programs to offer a 2-year research training period to otolaryngology residents. This training period often immediately follows completion of a 1-year internship in general surgery. The NIDCD experience with otolaryngology resident-directed T32 programs has raised questions, however, concerning whether the findings of the Lenfant Report may be generalized to the cohort of surgically trained otolaryngology physicians trained by NIDCD-supported T32 programs. To probe this question, a study was conducted by the NIDCD in late 2003 seeking to determine the relationship between career outcome (academic practice versus private practice/other) and the duration of T32-supported research training (2 years versus alternative models less than an aggregate of 24 months, and generally 12 months) for otolaryngology resident trainees supported on longstanding NIDCD-funded T32 training grant programs. The assumption was made that individuals practicing academic medicine were more likely to engage in research, either as a principal investigator or substantive collaborator, than those in private practice. Only T32 appointees who completed their research training and clinical training were included in the survey. Prior or subsequent individual NRSA fellowship support was added to T32-supported research training support. Six active NIDCD-funded T32 programs that have provided research training to otolaryngology residents for 10 years or longer (range: 10–26 years) were assayed, representing data from 1986 through May 2003. Overall, 99 trainees were included in the NIDCD study. Of these individuals, 75 completed less than 2 years of NRSA-supported research training (typically, 12 months of training), whereas 24 completed a full 2 years of research training; those 2 years were almost always contiguous. Of the trainees who received 2 years of research training, 62% entered academic practice. Of the trainees who received less than 2 years of research training, 68% entered academic practice. Seventeen percent of both groups of academicsdthose who received 2 years of research training and those who received less NRSA-supported research trainingdwon subsequent NIH research funding as principal investigators.

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Within the limitations of this survey (non-NRSA research training was not considered), no evidence exists to support the 2-year model of research training as more efficacious in producing academic otolaryngologists than alternative models that involve shorter or more distributed periods of research training during the period of surgical internship and subspecialty residency. Alternative models to the contiguous 2-year model may be more efficacious in nurturing surgeon-investigators. Distributing the research training experience more broadly across the long period of residency training may guard against the resident in training from becoming defocused from the academic scholarship and research interests nurtured earlier in the residency period. Concentrating the major part of research training in the later years of residency may be optimal, because by then, clinical interests have crystallized, and research pursuits can be brought into alignment with clinical interests and expertise. The net effect is health professionals who have built and sustained research interests over years of clinical training and who are fresher and more current in scholarship and research. Such individuals are more likely to pursue a career in academic practice than private practice. Factors other than the duration of research training are important influences in the career path that health professionals seek. Primary among these factors are research mentorship resources, clinician-scientist faculty role models, and the research culture of a given program. Sixty-five percent of graduates from NIDCD-supported T32 programs in otolaryngology go into academic medicine, and 17% receive NIH grant support as principal investigators. Fifty percent of K-mechanism awards (primarily K08 awards) to otolaryngologists come from clinicians who have participated in T32 programs as residents [4]. The large, research-intensive academic residency programs that have T32 programs attract residents interested in academic clinician-scientist careers, but sorting outda prioridthe factors that lead some residents who participate in them to enter academic medicine/research and others to enter private practice is difficult. Perhaps some light concerning the yield or return on investment of the NIH-sponsored T32 programs could be shed by comparing graduates of these programs to residents who completed the same residency programs but were not supported by the T32, or to individuals who did not receive extended research experience. An important NIH-sponsored research training mechanism available to individual junior faculty is the mentored clinician-scientist career development (K-) award. The most commonly used K-award for junior faculty at NIDCD is the K08 mechanism, aimed at developing basic science research programs. A goal of the K08 mechanism, from its inception in 1972, was to foster MD independent researchers to foster clinical and translational research. Over time, however, it became apparent that most MDs conducting research funded by this mechanism were performing basic research. An increasing proportion of successful applicants were MD/PhDs. Because the K08 program was not the conduit to bridge the clinical and basic science

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worlds that federal biomedical policy makers hoped it would be, the Mentored Patient-Oriented Research Career Development Award (K23) program was started in 1998 as a sister program to the K08 program to nurture patient-based research. Over a 6-year period, this mechanism has grown in popularity NIH-wide and boasts a 35% success rate for funding [5]. Over the years, the number of K08 applications NIH-wide has climbed steadily, although the number of awards has stabilized. As a result, this mechanism has become more competitive, with success rates falling from approximately 60% in the 1990s to 40% in 2003 [5]. The benchmark for success of the mentored K-award program, which aims to nurture junior clinical faculty in launching their own research programs competitive for NIH funding, is the rate of conversion of K-awards to subsequent R01 awards. Traditionally the gold standard of research funding success, the R01 grant, primarily funds independent investigator-initiated research projects. The NIDCD places even greater emphasis on the R01 than other NIH institutes, which make greater use of larger, multi-project grant mechanisms (eg, program project grants). In the NIDCD junior mentored clinician K-award (K08 and K23) portfolio, approximately 50% of the awardees are otolaryngologists. Of the 24 otolaryngologists awarded new K08 and K23 awards in federal fiscal years 1995 through 2001, 67% applied for a follow-up R01 award, and 37% were awarded an R01. Although these application and award rates are not significantly different than NIH-wide estimates for the K08 application and award rates (70% and 45%, respectively) over the same time period, NIDCD feels that its K08/K23 program is not yielding a desirable return on investment for either its otolaryngologist or other clinical communities. At NIDCD, the K23 mechanism remains underutilized because of a paucity of patient-oriented research in the overall grant portfolio of this institute. The NIDCD is very supportive of the K-award mechanism. The award currently provides up to $105,000/y of salary support and $50,000/y of research support for a 75% professional effort, based on a 40-hour work week. Other NIH institutes also support otolaryngologists through the Kaward mechanism. The National Institute of Dental and Craniofacial Research targets primarily dentist-scientists but also funds favorably reviewed otolaryngologist applicants who propose research within its mission area. The National Cancer Institute funds head and neck cancer research. Institute-wide, however, single investigator grants are funded at a low rate, and the success rate of K08 applicants has only been 20% over the last 3 years. Another resource of funding for clinician-scientists is the new (2002) extramural NIH loan repayment program (LRP) (http://www.lrp.nih.gov). This program does not fund research but rather provides student loan debt relief for investigators who are conducting qualifying research, including patient-oriented research or pediatric research. This award can provide

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up to $35,000/y for 2 years, plus associated federal taxes, and is renewable. The purpose of the program is to offset educational debt to encourage research careers, particularly among clinically trained individuals who are increasingly discouraged from devoting a major portion of their careers to research because of the need to earn sufficient income to defray medical school debt. It is hoped that the junior members of the otolaryngology community interested in clinical research and pediatric research will take advantage of the NIH LRP. In fiscal year 2006, only 15% of the loan repayment program awards made by the NIDCD were to otolaryngologists.

Clinician-scientists in otolaryngology: current state Data collected by the AAO-HNS counted 128 active NIH grants awarded to otolaryngologists as of March 2007. Some of those counted were not research grants, such as T32 grants and conference (R13) grants. Eighty-three of these grants were made by the NIDCD. In this section we focus on R01 grants and K-awards. As of March 2007, 44 individual otolaryngologists held 50 R01 grants at 24 institutions. These grants were concentrated in larger research institutions (11 institutions accounted for 70% of the grants), and all were awarded to otolaryngologists in academic practice. Of the awardees, 12 held MD/PhD degrees, 11 were department chairs or chiefs of otolaryngology divisions in surgery departments, and 8 were women. Only 17 of the grants had been competitively renewed. Of the 50 R01 grants, 36 (72%) were from the NIDCD, 8 were from the National Cancer Institute, and 6 were from the National Institute of Dental and Craniofacial Research. Among otolaryngologists there were 29 K-awards: 18 from NIDCD, 4 from the National Cancer Institute, 4 from the National Institute of Dental and Craniofacial Research, and 3 from other institutes or agencies. Nineteen institutions are represented, but 50% of the K-awards reside in just five institutions. Seven awardees were MD/PhDs, six were women, and three were conducting patient-based research (K-22 or K-23). As with the R01s, the awards were concentrated in just a few institutions.

Keys to success in funding The keys to funding success and the keys to career success for the clinician-scientist are substantially the same. Particular elements of ‘‘grantsmanship’’ are sometimes lost on the newest clinician-investigators that might augment the probability of success. First, before submitting any proposal to the NIH, grant writers should contact the responsible program officer at the institute that is the anticipated target for the area of research interest. As a port of entry, they may refer to that institute’s web site and identify the director for research training or research career development. The program

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officer is able to offer valuable advice to the new and budding otolaryngologist-investigator on the research purview and priorities, peer review process, and funding trends of that NIH institute. Understanding that career development award applications, unlike R01 applications, require a systematic career development (research training) plan in addition to a research plan is another important element for funding success. Neophyte applicants often do not include a sufficiently detailed career development plan within the application but put all their efforts into detailing a research plan that is often overambitious. Establishing a strong mentorship team and delineating the respective roles of the primary mentor/ sponsor and secondary sponsors, if any, are important steps. It is also vital to garnerdand document within the applicationdstrong institutional support/commitment for the candidate and the career development plan. Part of an appropriate environment that should be explicit in a career development award application is detailing the time protection provided. Reviewers want to be confident that the candidate will be protected by the institution to the level promised, and a clear explanation of the arrangement between the applicant and his or her department and institution improves reviewer confidence. Another element that should be described explicitly is how the candidate and the mentors interact during the grant period. Especially if mentors are not in the same department as the candidate or are otherwise physically separated, explicit detail of how the mentoring and supervisory components occur strengthens an application. A track record of applying for and garnering small grants by the K-award applicant is another often-overlooked element that can strengthen the application. In otolaryngology, this track record is facilitated by applying for grants from the AAO-HNS or the subspecialty societies through the centralized otolaryngology research efforts review panel. Other good sources of early career development funds include professional and voluntary organizations, such as the Deafness Research Foundation. Future directions One of the recommendations of the conference on research training and education in otolaryngology was to compensate the research mentors/sponsors of the NIH K-awards for their services, as has been provided on the NIH Roadmap institutional career development (K12) awards [4]. Because the time of clinician-scientists in academic medical center settings is typically under challenge from competing sources and must be accounted for with respect to cost, such reimbursement for service would provide an incentive for the most sought-after established and senior investigators to commit time to the mentorship of budding and new otolaryngologist-scientists. Another recommendation in the conference on research training and education in otolaryngology report was to establish institutional awards to provide 2 years of transition (gap) mentored support for departments

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planning to establish junior tenure-track faculty earmarked for budding otolaryngologist-investigators planning to submit mentored K-award applications. To facilitate the emergence of independent otolaryngologist-investigators from junior faculty not yet ready to craft a mentored K-award competitive for funding, NIDCD is planning to pilot a competitive research supplement program. It is widely acknowledged that successful faculty role models who are available and willing to provide sustained research mentorship are key to the development of new clinician-investigators. It is hoped that such a research supplement award would help hardwire a mentorship commitment for new tenure-track clinical faculty through directly tethering the new faculty member to a funded NIH research grant or multi-project grant held by an established investigator in his or her department or a collaborating department. A generous support package would be provided, and a 50% time commitment over 2 to 3 years would be required. With the stepped-up mentorship experience afforded by this program, it is hoped that the awardees could more competitively follow-up and launch their independent research career trajectory through a follow-up mentored K-award or new investigator R01 grant application. A network of seasoned otolaryngologist-investigators available to mentor new and budding clinician-scientists was recently discussed within the academic sector of otolaryngology and warrants thoughtful planning and implementation. Summary It is widely acknowledged that it is in the interest of the public and the specialty that we upgrade our training and nurturance of otolaryngologist-scientists. Many obstacles have been identified, but perhaps the most daunting is the relatively low percentage of otolaryngology residents who are genuinely committed to this career path. As pointed out by Minor [4], the fundamental issue is attracting and selecting the right people, individuals who have the ‘‘visceral and intellectual drive’’ to pursue a scientific career. Only after selecting the right people can potentially fruitful strategies be brought to bear on this problem. In this article, we described opportunities for research training and support at discrete milestones along the road to becoming a clinician-scientist. What is missing is an integrated roadmap for the clinician-scientist, validated through the collective experiences of those who have succeeded at forging this career pathway. Training experiences starting in medical school, or earlier, and ending in fellowship are typically fragmented, rather than additive or integrated, and trainees find themselves with multiple projects but no coherent line of inquiry. What the field needs is the flexibility and vision to allow the building of integrated training programs that include meaningful research and clinical training that produce fully, subspecialtytrained clinician-scientists with a direction of inquiry that is established early in the timeline of clinical training and serves as the foundation for successfully obtaining the necessary funding vehicles. Such an integrated approach

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has been adopted in neurology [14] . Development of such a track requires flexibility, particularly by the residency review committee, to allow some unevenness in training experiences and duration to account for the unpredictable nature of inquiry. We also must change the culture in our specialty to view research as a valuable, vital endeavor on par with patient care. This change starts with promoting a culture of inquiry in all of our training programs, training residents, and students in the scientific method and making them appreciate the value of a well-done study and, thus, better consumers of scientific literature. It also involves raising the level of our specialty journals. The PhD scientists in otolaryngology departments (or associated with otolaryngology departments and appointed elsewhere) need to share in nurturing this culture. These individuals are valuable mentors and critical to a scientific approach to health care delivery. Although beyond the scope of this article, assuring continued interest of biomedical and behavioral scientists in otolaryngology and human communication is critical to the continued health of research in our field. Resources are scarce and should be concentrated among individuals likely to succeed-young, committed, prepared, enthusiastic, and realistic clinician-scientists. Such young stars, with proper support of time, space, money, and mentorship, have the only true hope for success in this increasingly competitive funding environment. Recipients of such gifts of opportunity must understand their responsibilities. Resources must come with well-communicated expectations, not just of research development but of overall career development. Incentives must be aligned with feasible opportunities, and academic departments must continue to support excellence and success in the research, clinical, or educational arena. Successful clinician-scientists exist in our specialty within select academic departments. Chairpersons must balance all components of the missions of their departments and distribute these across their faculties to be truly successful. Most clinician-scientists need to be part of a clinical team to protect their time and avoid being at risk of consumption by clinical duties. Most researchers are not high-volume clinical stars, and the success of the entire faculty should be shared.

Acknowledgments The authors would like to thank the American Academy of Otolaryngology– Head and Neck Surgery for sharing their information regarding research funding among otolaryngologists and Cheryl Langford for her editorial assistance.

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