Off the Roadmap? Family Medicine’s Grant Funding and Committee Representation at NIH

Congratulations to Dr. Lucan and colleagues at Penn. Their article begins an important discussion for our discipline that needs to begin with the data that they have presented and then develop an organizational and disciplinary strategic plan to train and promote family medicine investigators of all our related disciplines at NIH. As Lloyd Michener noted, we have missed too many open calls for membership on NIH committees and study sections for a myriad of reasons that we need to better understand and correct.

First a minor complaint. Until recently, NIH ranked medical schools, hospitals, and departments by dollars awarded in each fiscal year. Since 2003, our department was ranked in the top ten on the NIH website, but not in your article, which used a different methodology. I was grateful to find us listed in the on-line appendix and noted that we were not alone in being ranked in the appendix but not Table 2 of your article. (We did not totally lose our bragging rights.) The authors did note the discrepancy between the top ten departments for number of awards and for total funding. I am sure my colleagues at Maryland, Utah, and UCSF would have been happy to receive honorable mentions. NIH has dropped this annual ritual in order to adopt the Co-Principal Investigator model that promotes collaboration but challenges such departmental calculations.

The NIH website did publish success rates by departments for FY2007. The NIH-wide average of reviewed Research Project Grant applications (i.e., the R series) that received funding was 22.5% (5,162 of 22,981) and for Family Medicine 16.1% (27 of 168). Family Medicine's success rate exceeded that of Social Science Departments (0%), Other Clinical Sciences (4.5%), Dentistry (9.1%), Administration (10%), Nutrition (12.5%), Veterinary Science (13.6%), Biomedical Engineering (14.1%), and Psychology (14.7%). The most successful applicants were Genetics (30.5%) and Otolaryngology (30%). In FY2007 Family Medicine represents 0.52% of the NIH's funded R series research grants, which compares favorably with the 0.20 to 0.33 percent observed by the authors from 2002-2006 for total awards and may represent the beginning of the payoff for the growing percentage of training K awards discussed by the authors.

Specifically regarding the NIH Roadmap, Dr. Michener mentioned the emerging role of the Clinical and Translational Science Awards (CTSAs). Each of the 38 institutions that have received these awards, which are designed to "re-engineer the clinical research enterprise," are required to have Community Engagement Cores. Dr. Michener co-chairs the national Community Engagement Key Function Committee, charged with coordinating CTSA Community Engagement efforts and meeting the CTSAs' 4th objective-- improving the public's health. We held our first Face-to-Face Meeting at a National Eye Institute building in Rockville, MD, on October 24, 2008. By my count of the official attendance list 35 of the 38 CTSAs were represented. If we exclude the five "orphan" medical schools (without academic departments or divisions of family medicine, i.e., Cornell, Harvard, Hopkins, Washington U, and Yale) and the two CTSAs at research institutions (i.e., Rockefeller University and Scripps Research Institute), then the remaining 28 CTSAs were represented by 6 family medicine departments (21%) and (with Lloyd Michener) by 3 sitting chairs and one former chair. In addition, 3 of the 18 invited guests were also family physicians, representing AHRQ, NACHC (National Association of Community Health Centers), and NAPCRG. Although the CTSAs are awarded through the National Center for Research Resources (NCRR), one of the most technology-oriented units of NIH, and NCRR hosted the meeting, the Community Engagement Face-to-Face was also attended by representatives of the Office of Behavioral and Social Sciences Research, NCCAM, NCI, NHLBI, NICHD, NIDCR, and NIMH. The NIH staff present were listening to what we said. Considerable discussion on PBRNs (and supplemental awards for CTSAs to develop new collaborations with PBRNs) indicated that they are looking for those Blue Highways. Clearly, family medicine is a significant presence on this part of the NIH Roadmap. With strategic efforts we can help NIH become more effective and more relevant to the patients and communities we serve.

Competing interests:   None declared

Dr. Michener raises some interesting points which we should address:

First, while we cannot comment on other disciplines at this time, we do know that the involvement of family physicians in research has NOT been static. As we show in Table 2, although the PROPORTION of physician awardees from departments of family medicine has remained relatively stable, the absolute NUMBER of physician awardees has increased steadily from 2002-2006. If the same is not true in other disciplines, then we can sympathize (or given that our increases have been tiny, empathize).

Second, we agree that clinical research is “a team sport”. As we affirm, “research is increasingly interdisciplinary and networked” and ”research as a culture is shifting to encompass more collaborative and team-based models.” What we miss in our study is collaborative arrangements and co-investigation with other clinical disciplines (as we note in our limitations). However, we do NOT miss PhDs (if they were PIs on grants). We examine both scientist awardees (PhDs or equivalent) and physician-scientist awardees (MD/PhDs or equivalent) in both Table 2 and the text. Likewise, for committee membership, we “discern between family physicians and other family medicine doctors (eg, clinicians, such as pediatricians and internists, or nonclinician researchers, such as statisticians and social scientists, with appointments in departments of family medicine).”

Finally, with regard to “balkanization” and “slow diffusion of information across our boundaries”, this may be changing. Members within the family of Family Medicine organizations (including AAFP, STFM, and NAPCRG) are mobilizing to converge upon NIH in a coordinated way for discussion with leaders about how family medicine and NIH can increase engagement for mutual benefit. Study authors will be part of this effort. We hope that not only better transmission of RFP’s between organizations will result, but also new directions for RFPs with new kinds of research to support downstream translation.

We agree completely that we need ”to be more inclusive of other disciplines.” Again, negotiations with NIH for data comparing the primary -care specialties and looking at co-investigation are ongoing by our group.

Competing interests:   None declared

My hat is off to Sean Lucan and colleagues for completing the difficult task of reviewing the role of FM in the NIH grant awards. Their conclusions, that FM is infrequently included in NIH awards and review committees, matches the observations of the CTSA Community Engagement Committee. Clearly, there is much work to be done, and opportunities for those who have breached these walls to share the lessons learned with those who are seeking to scale them.

But I am concerned that the study misses two or three key issues. The first is the static number of physicians from all disciplines who report involvement in research, which has not grown over the last two decades, even as the numbers of physicians and the NIH budget have increased. The slow aging and dwindling of the ranks of physician scientists have led to repeated calls for actions. Against this backdrop, the increase in FM investigators is a rare success story, even if there is considerable room for improvement. Focusing on the larger issue of the declining number of physician scientists would connect us with colleagues in other disciplines who face the same problem, and who may be able to help with ours.

The second issue is related. Clinical research in increasingly a team sport, with physicians and PhD researchers playing complementary roles. Yet, this study only counts the work of family physician researchers. Among IM chairs in research intense schools, the PhD researchers are rapidly growing, quite successful, and gleefully included in the research totals. We might learn from their model; we certainly have here at Duke! Adding other researchers to the count would not eliminate the problem of under representation, but might help put it into a more solvable context. The resolution to the inadequate number of FM researchers is to train more, but also to train them to be a member of larger teams, with PhD colleagues.

Finally, the CTSAs have unearthed a third problem of balkanization. We have multiple overlapping professional organizations, with slow diffusion of information across our boundaries. Notices of NIH RFPs to one group are rarely transmitted to another, while calls for study section nominees go unanswered. The Council of Academic Family Medicine may help remedy this problem, but will require significant effort in communication, and in linking departments and research networks.

In all, Sean Lucan and colleagues have helped all of us greatly. Now, we need to take their work and expand our focus to be more inclusive of other disciplines. As the NIH is called to account for translating research into improved health, it will take family physicians, along with all of our colleagues to make a difference.

References: Schafer AI. Recommendations for revitalizing the nation’s physician- scientist workforce. Available at: (http://www.im.org/PolicyAndAdvocacy/PolicyIssues/Research/PSI/Documents/APM%20PSI%20Report.pdf.pdf) accessed online November 11, 2008. Dickler HB. Clinical Research Task Force II Recommendations. Available at: (http://www.aamc.org/research/apr/hdickler.pdf) accessed online November 11, 2008.

Competing interests:   None declared

Dr. Mold is an expert in this area. The “Blue Highways” article, on which he is co-author, was seminal. I am honored that the first comments come from him.

Dr. Mold is, of course, correct that the emphasis at NIH is on Basic science (budget allocation: ~56% basic science, ~41% applied research, ~3% infrastructure). However, initiatives like Roadmap/CTSAs may (or could) promote greater focus on community practices and more interdisciplinary cross cutting.

It is also true that the NIH organizational structures is largely disease-based (our forthcoming qualitative paper on perspectives from within the NIH gives additional weight to this observation). But there are centers promoting work without specialty or even necessarily specific disease focus. For instance, NCMHD (Minority Health and Disparities), funds a variety of projects not so disparate to the focus and philosophy of family medicine. The center even has RFAs for CBPR!

With regard to rich getting richer and the exclusion of new investigators, this too may be changing. In fact just this month, the NIH adopted “new investigator policies designed to encourage early transition to independence”: http://grants.nih.gov/grants/guide/notice-files/NOT-OD-08-121.html This initiative gives favorable treatment to those trying to “break in”.

Perhaps an Institute of Primary Care would be a good thing. But I tend to agree more with an NIH informant from our forthcoming qualitative paper: “bring the family practice perspective to the question, not the question to family practice”. In other words, family physicians need to have input at existing institutes and centers and be at the same table with specialty experts, not separated from them and disenfranchised.

Billionizing AHRQ is a splendid idea! (I’m not holding my breath in the current global economy)

Affirmative action is a complicated issue. Unintended consequences could include even lower appraisal of the value of FM within the research community, especially if would-be FM investigators unable to compete are given hand-outs and fail. Less politically-charged perhaps is the specialty-insensitive affirmative action plan that is in place for new investigators (mentioned above). And less-explicitly would be working with NIH leadership to change funding priorities (holding leadership accountable for their translational promises, which would create new opportunity for primary-care researchers)

I believe what we need is a multifaceted strategy: greater research inoculation (starting with an introduction to research in medical school and emphasizing research throughout residency training), better preparation (e.g. through novel fellowships or possible other NIH-funded training programs), greater voice in the process (by participating on advisory committees, in “public” seats if need be), and greater participation (partnering with existing infrastructure including CTSAs, and influencing how new RFAs are worded and focused)

The bottom-line is that FM leaders need to sit down with NIH leaders. There is much to discuss.

Competing interests:   None declared