The American Federation for Medical Research has presented a series of articles addressing the challenges faced by academic medical centers and other institutions in developing physician-scientists. This is the final part of that series, and it is an interview with James R. Gavin III, MD, PhD. Dr. Gavin has been a leader in academic medicine for several years and has been instrumental in developing and running several programs focused on developing physician leaders for academic medicine. In this interview, we focus on the Robert Wood Johnson (RWJ) Foundation Harold Amos Medical Faculty Development Program (AMFDP). This program has been in existence since 1983 and has focused on the development of the physician-scientist from underrepresented minority groups. Dr. Gavin has served on the AMFDP National Advisory Committee since the program's inception and has been the national program director since 1993. In the 22 years of this program's existence, over 80% of the AMFDP scholars have remained in academic medicine, with many now holding leadership roles at medical schools, research institutes, and the National Institutes of Health (NIH).
Dr. Gavin is a native of Mobile, Alabama, and received degrees from Livingstone College (BSc, Chemistry) and Emory University (PhD, Biochemistry) and Duke University (MD). After spending several years at Washington University in the Division of Endocrinology, he then became the chief of the Division of Endocrinology at the University of Oklahoma Medical Center. Shortly thereafter, he was recruited to the Howard Hughes Medical Institute (HHMI), where he was senior science officer. His recruitment to HHMI was based in part on his previous leadership of an NIH-based medical student research program. Most recently, Dr. Gavin has served as president of Morehouse School of Medicine and is currently a clinical professor of medicine at Emory University School of Medicine. He is a recognized leader of this country's medical community, attested to by his service as a former member of the Board of Directors for the RWJ Foundation, a former president of the American Diabetes Association, and current member of the Institute of Medicine. Dr. Gavin is the author of numerous original investigations, review papers, and book chapters, with his scientific and clinical focus in the area of diabetes. Dr. Gavin's responses to a series of questions follow.
JIM: The RWJ AMFDP (Harold Amos Medical Faculty Development Program) has been extremely successful at training physician-scientists. When the program was being developed, what did the advisors feel were the critical elements necessary for developing a successful physician-scientist and medical school faculty member?
Dr. Gavin: When this program was started, it was with the view that we could produce additional physician-scientists from underrepresented minority groups who could become senior faculty and leaders in academic medicine. It was clear that the route to faculty appointments and subsequent promotion and tenure was through establishment of a program of independent research. In order to assure that this goal was achieved, the program assembled an accomplished National Advisory Committee (NAC) comprising senior academic leaders, members of the national Academy of Sciences, and Nobel laureates to help guide development of selection criteria as well as guidance on design of the elements that would be essential features of a successful program. Without exception, the NAC agreed that one of the most important elements was association of each scholar with a strong, committed mentor in the setting of a productive research environment. There was the expectation that the mentor would provide not only research guidance and direction but would assist the young investigator with navigation of the career pathway in academic medicine. It was also determined that the early years of the research career leading to faculty status had to allow for at least 70% protected time to allow development of a meaningful research program. Accordingly, the program was designed to recruit only those persons whose clinical training had been completed. In addition, the research scholars were strongly advised to sharply curtail the amounts of committee and administrative work undertaken.
JIM: The program has been in existence for over 20 years, and academic medicine and the research environment have changed quite a bit over that time. In your opinion, has there been a change in the necessary resources to develop physician-scientists? If so, please describe these changes.
Dr. Gavin: There have been enormous changes in academic medicine since the launch of this program 23 years ago. Many of these changes have had significant implications for the resources required to develop a successful physician-scientist. The most noticeable change is the requirement for greater commitments to clinical service by those who are clinically trained. Achievement of allocations of time in the 70 to 75% range is increasingly problematic for aspiring physician-scientists. Since this program was designed for such persons, it is not surprising that a fierce competition for the time of these scholars has evolved over the past two decades commensurate with the reductions in reimbursement rates by major insurers, pressures on indirect cost recovery rates, and stronger competition for research dollars, despite the recent doubling of the NIH budget. It should be noted that over this period of time, the average age of the first-time RO1-funded physician-scientist has risen to over 40 years of age! These findings have emerged from the recently concluded study by the National Academy of Science on Pathways to Research Independence, headed by Tom Cech of the Howard Hughes Medical Institute. This implies a longer latency among physician-scientists between the time of completion of training and establishment of independent research programs. In the absence of such independence, it presents a period of vulnerability for increased service demands in order to satisfy basic salary requirements. This sets up a cycle of less time and focus on the research program with less likelihood of achievement of independence. Likewise, there have been similar pressures on many of the best mentors. As competition for limited pools of research funds has stiffened, younger investigators have often found themselves in competition with more senior persons. It should be noted that over this same period of time there has been a substantial surge in the burden of debt for clinically trained persons from underrepresented minority groups. Thus, there have been important changes that have increased the requirements for development of a successful physician-scientist.
JIM: When did the AMFDP start to include clinical investigators as scholars? Is there a significant difference in the support structure for the clinical investigator when compared to the basic laboratory scientist?
Dr. Gavin: During the early phases of this program, the principal thrust was the development of physician-scientists with strong basic research backgrounds. The reason for this was simply that the most successful models of physician-scientists during that period were characterized by such portfolios. To the degree that membership eligibility in major honorific societies and organizations was considered an important benchmark of career success, it was fairly clear that persons engaging in basic research enjoyed a significant advantage. At that time, NIH funding was heavily biased towards supporting basic investigators, the HHMI was only supporting basic scientists, and the composition of the original National Advisory Committee reflected the very models of success we wanted our scholars to emulate. It was during the second decade of this program's existence that more emphasis began to be placed on clinical investigation. This shift was commensurate with a growing national recognition that the route to effective translation of many important basic science discoveries was through clinical investigation. There was clearly a need for strengthening of a systems approach to the study of important clinical questions, and the molecular biologist needed to have a certain synergy with the physiologist in order to assure breakthroughs in disease states like diabetes, cystic fibrosis, coronary heart disease, multiple sclerosis, and many others. The expansion of the program to include clinical investigation was indeed reflective of the evolution of biomedical research as we entered the decade of the 90s. We also included the category of persons who used epidemiology as a tool for clinical investigation as part of the eligible field of candidates for many of the same reasons. The most important differences in the nature of the support structure for the clinical investigator were the requirements of longer periods of time to generate comparable bodies of work and the need for a more complex research infrastructure, usually requiring access to a clinical research center or comparable facilities. There is also the requirement of the clinical investigator to negotiate many more layers of regulation as the requirements for human studies and the use of investigational pharmaceuticals have become more demanding.
JIM: What elements of the AMFDP could a departmental chair adopt for their use to encourage development of physician-scientists at their institution?
Dr. Gavin: The principal elements from this program that might be used by department chairs to develop more physician-scientists in their departments would be assurance of adequate mentoring, or mentoring with monitoring as we like to think of it, and constant vigilance to seize opportunities for protected periods of time. Admittedly, these are more difficult today, but it now requires that greater use be made of starter sources of funding and of the more nontraditional sources in order to purchase the required release time. Mentoring has to be monitored to assure that the mentors have not lost sight of their responsibility to pursue diligence in shaping the careers of their charges. We would hope that department heads would evaluate the adequacy of the mentoring responsibilities of faculty in a fashion similar to the way in which this program assigns a member of the NAC to each scholar to help assure that the expectations of the program, including appropriate mentoring, occur over the course of the award. This kind of careful attention is required to promote the successful generation of physician-scientists. It may sound like a lot of “hand holding” sometimes, but, over the course of a career, there are certainly times when developing scientists could benefit from it, and department chairs should recognize the occasional need and be prepared to accommodate it. The outcomes certainly are worth such an investment.
JIM: Mentorship is very important. Would you describe what your program looks for in a good mentor?
Dr. Gavin: We place such an emphasis on mentorship because it has emerged as perhaps the most powerful predictor of successful attainment of physician-scientist status by young scholars. The elements of the most effective mentors include a background of success in their own research programs, with achievement of national/international recognition in their respective fields; they will have had a history of success in training other young people, who themselves will have established some record of success in their fields; they will have demonstrated a commitment to support of career development of their protégés beyond the period spent in their labs; they will demonstrate a willingness and have a system in place for spending time with their charges. In addition, we included an opportunity for mentors to accompany fellows to the annual meeting, providing an occasion to directly observe the quality of the interaction and giving the mentor an opportunity to “vote with his/her feet” by actually showing up. After all is said and done, the evidence for commitment, interest, and investment becomes apparent in the behaviors of the most effective mentors. They also know how to blend “tender” and “tough” in their supervision of the scholars to assure the most successful outcomes.
JIM: The relationship between a mentor and a mentee is usually quite close, and it is often difficult for either to determine when it is time for the mentee to become independent. How should junior investigators approach this dilemma, and when does a mentee know when it is time to become independent?
Dr. Gavin: The appropriate timing for independence of the mentee is always a delicate question. We have found that such transitions are most difficult when the mentee remains at the same institution as the mentor and seeks to develop an independent, thus competitive, program of investigation. When the mentee relocates to a different institution, it is often with the blessing of the mentor and with the understanding that the young investigator is “taking with him/her” an area of inquiry that will be the focus of the research program for the physician-scientist and one that can emerge as unique for the mentee. This is the outcome we see in the most successful and supportive mentor/mentee relationships. My own view is that it is the mentor who will be the main driver of the timing for independence under the best of circumstances. The mentee who finds him/herself in the position of having to “push” for independence may be in a difficult situation. There really should not be a great deal of resistance to this transition when the physician-scientist has achieved the appropriate level of readiness, is viewed as an attractive recruit by a credible program, and has shown evidence of productivity and the ability to successfully engage the funding mechanisms. When the mentoring is adequately monitored, it is more likely that these discussions will be occurring and the benchmarks are being evaluated in ways that will clearly reveal when the “time has come” for the move to independence. It is a time of celebration and not contention or consternation when the relationship has worked best.
JIM: As a dean of a medical school, what are the greatest challenges you face in developing academic physicians? What are some of the mechanisms or programs by which you deal with these challenges?
Dr. Gavin: In my capacity as a senior academic leader, the principal challenges to developing young physician-scientists have been largely the ones I have alluded to in my earlier comments. There is first the issue of assuring them that it is doable. As senior scientists, we need to be careful not to complain so loud or so often that our younger colleagues want no part of such uncertainty and misery. There is the constant challenge for the clinically trained person of finding the means of generating protected time. It is not unusual to find that in order to cover the 15% of their salary line that is derived from clinical revenues, some may actually have to spend 25 to 30% of their time, depending on issues like patient mix, reimbursement rates, coding efficiency, and collection rates. Development of young physician-scientists must be a priority for senior administrators and the subject of constant and serious diligence. Someone must be charged with the direct responsibility of making sure this priority is not marginalized or lost. Just like we find it essential to develop means of monitoring the mentoring process, it is just as necessary to monitor administrative oversight of career development for physician-scientists. The associate dean for research or director of graduate training programs will often be the types of persons who will have this as one of their chief responsibilities.
JIM: Tell us your opinion regarding the importance of diversity in academic medicine and research.
Dr. Gavin: The issue of the importance of diversity is one that increasingly declares itself. The need to avail ourselves to the entire pool of talent becomes more and more urgent as this country becomes more and more diverse in its population mix. Moreover, the solutions to the enormous health problems that are increasing global concerns will benefit from the passion and input of persons for whom such problems have both personal and professional resonance. The need to effectively involve communities in research protocols increasingly requires that communities can see some “elements of themselves” in the research activity, usually in the form of the personnel who are driving the activity. The degree to which there is knowledge of cultural nuances, lifestyle issues, values, and, of course, languages are increasingly important features of the research activities that will be required to translate major basic discoveries to health benefits for humankind. Even at the level of policy making and priority setting, it is important that diverse perspectives and voices are at the table. Thus, the composition of our professional societies, our major advisory bodies, and our legislative committees needs the benefit of an appropriate level of diversity.
JIM: Do you have any final points that you would like to make?
Dr. Gavin: My final comment really speaks to the need for a long-term commitment to effect change in the profile of representation within the ranks of physician-scientists. First, there is the need to sustain an emphasis on the training of physician-scientists. Then there is the additional need to assure that the appropriate level of diversity is achieved in this mix of investigators. The type and intensity of commitment demonstrated by the Robert Wood Johnson Foundation in the Harold Amos Faculty Development Program must be emulated by university programs and other agencies to ensure that the opportunities for development of not just successful physician-scientists can occur but people who will be leaders in their areas. We have been at this for over 20 years and feel we are finally able to approach getting it right. The evidence is in the quality of the products of the program and the growing impact of their scientific careers and leadership in their chosen areas of work.