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

INTRODUCTION

The family of family medicine organizations has recently stated that research is integral to the specialty of family medicine; all family physicians have a role in generating new knowledge and increasing research capacity.¹ This recommendation is not new.² Even before becoming an official US medical specialty in 1969,³ the World Health Organization recommended establishing research as a foundation in the emerging discipline of family medicine.⁴ Yet since its inception, family medicine has struggled to develop a research base.⁵ After 4 decades, the specialty has still not achieved a high level of research infrastructure,^6,7 involvement,^8,9 funding,¹⁰ productivity,^11,12 or credibility.^2,13

In contrast, family medicine has a well-developed clinical infrastructure with high productivity, boasting the second greatest number of clinicians¹⁴ and providing the highest number of health care encounters in the United States.¹⁵ Because of substantial clinical presence, family physicians may be instrumental in helping to bridge the chasm between medical knowledge and actual clinical care toward improved population health.¹⁶ Such bridging is a stated focus of the National Institutes of Health (NIH), highlighted for instance in NIH’s Roadmap for Medical Research.¹⁷ In fact, Roadmap has been cited as “an immediate opportunity for family medicine to contribute to the mission of the NIH.”⁶ Family medicine’s clinicians, for example, might participate in Roadmap’s Clinical and Translational Science Awards,¹⁸ partnering with veteran investigators, to perform practice-based research in community practices.¹⁶ By contrast, family medicine’s researchers could potentially lead some of these efforts.^{7, 13}

Unfortunately, though, neither family medicine’s clinicians nor its researchers have strong foundations in these areas: family medicine has had a historically poor track record with the NIH,¹⁰ perhaps in part because of the NIH structure. NIH, the nation’s leading source of support for biomedical research,¹⁹ comprises 20 institutes and 7 centers that focus primarily on specific organ systems, disease categories, and scientific specialties.²⁰ Although new initiatives, such as Roadmap and Clinical and Translational Science Awards, could foster greater engagement with primary care, the research interests of family medicine may still not be well-aligned with the agendas of NIH institutes and centers—potentially to the disadvantage of family medicine research, the NIH mission, and overall population health in this country.

Because the agendas of the institutes and centers are largely set by NIH advisory committees, increasing family medicine representation on such committees provides an opportunity for greater engagement and is a goal of family medicine’s leaders.^1,6 Through membership, family medicine can participate in research review and help set priorities for national research spending. As a baseline, we were unable to identify any reports quantifying family medicine’s membership on NIH advisory committees in the published literature.

Increasing funding from NIH is also a goal of family medicine leaders.^1,6,13 Levels of funding for family medicine were reported most recently by Rabinowitz et al,²¹ but only for a single year (2003) and with no estimates of change through time. Trends in funding were assessed by Campos-Outcalt et al for the years 1984 to 1997.¹⁰ The conclusions of that study may no longer apply, because from 1998 to 2003 Congress doubled the NIH budget.²² Since 2003 no studies have evaluated trends in NIH grants to family medicine.

Our study had 2 specific aims: (1) to quantify current family medicine membership on NIH advisory committees, and (2) to assess the level and distribution of NIH grants to departments of family medicine during the past 5 years (2002 through 2006).

METHODS

This study used a cross-sectional design and was conducted by staff and a visiting scholar at the Robert Graham Center for Policy Studies. The study protocol was approved by the American Academy of Family Physicians’ Institutional Review Board.

RESULTS

Family Medicine Represented on NIH Committees

The NIH listed 154 chartered advisory committees on its Web site.²⁵ Thirteen committees were inactive and 3 had no appointed members (Figure 1⇓). Of the active committees, special emphasis panels (SEPs) have neither standing nor reported memberships, and individual integrated or initial review groups (IRGs) were often divided into multiple subcommittees (2 to 14). In total, there were 229 IRGs and subcommittees. Considering all active committees and subcommittees with standing members together, there were 295 groups.

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Figure 1.

Chartered NIH advisory committees with active standing memberships.

— = included groups; - - - = excluded groups; BSC = board of scientific counselors, IRG = integrated or initial review group, NAC = national advisory council or board, NIH = National Institutes of Health, PAC = program advisory committee, SEP = special emphasis panel.

^aSpecial emphasis panels have no standing (or reported) memberships.

Membership for the 295 groups totaled 5,464 (Figure 2⇓). There were 21 committee members from departments of family medicine. Of these, 9 were family physicians. For the other 12, 1 was a pediatrician, 1 was an internist, and 10 had nonmedical doctoral degrees. Departments of family medicine had members on just 6.4% of all committees (and subcommittees), accounting for only 0.38% of advisory committee members. For family physicians specifically, these proportions were 2.7% and 0.16%, respectively.

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Figure 2.

Active National Institutes of Health advisory committees and members.

FMs=family medicine doctors, FPs=family physicians.

Almost 75% of the NIH institutes and centers had no family medicine input on committees, and only a minority of the NIH agencies from which family medicine received funding had family medicine committee members (Table 3⇑). Almost 85% of family medicine committee involvement was on IRGs. There was only 1 committee with a family medicine–affiliated chair in all of NIH (an IRG at the National Cancer Institute).

DISCUSSION

Our study had 2 main findings. First, although absolute and proportionate funding to family medicine increased after the doubling of the NIH budget, increases have been rapidly diminishing, and absolute funding levels have remained as miniscule as they have been for more than 20 years.¹⁰ Moreover, for reasons discovered by Rabinowitz et al, the family medicine funding levels we report may overestimate, by as much as two-thirds, the money actually going to principal investigators in core family medicine organizational components.²¹ And although our analysis shows that physicians were consistently the group of family medicine researchers most successful in obtaining NIH grants, almost one-half of physician principal investigators may not actually be family physicians.²¹

Second, family medicine has minimal representation on NIH advisory committees. Stakeholders from departments of family medicine are, thus, largely disenfranchised, having few seats at the table and little say in setting the national research agenda. This lack of representation is particularly true and perhaps most ironic for family physicians, whose extensive clinical practices^32,33 and community ties make them ideally suited for advising on dissemination, implementation, and adoption of research.³⁴

As the NIH struggles to translate the fruits of biomedical research into practice, family medicine struggles to fortify and invigorate its research capacity. A less-understood outcome of this mutual frustration is the failure to make the more than 200 million annual patient visits to family physician practices¹⁵ a source of medical discovery, new knowledge, and greater engagement between family medicine and NIH. Results from our study and previous work suggest potential strategies to facilitate greater connection and mutual benefit.

One strategy focuses on committee membership, both for practicing family medicine clinicians and career family medicine investigators. Practicing family physicians could serve in public seats on NIH advisory committees, offering community experience, clinical insights, and practice perspective. The Federal Advisory Committee Act requires that membership on NIH advisory committees be fairly balanced in terms of points of view represented, and national advisory councils and boards and program advisory committees specifically must have one-third public members by law.³⁵ The other two-thirds are for scientific members—such as career family medicine investigators—with established records of research success.³⁵ Although it is unclear that greater participation on NIH advisory committees will result in greater funding for family medicine research, it will certainly give family physicians greater voice in setting national research priorities and in shaping NIH efforts to translate basic science discovery to front-line clinical practice. Self-nomination to advisory committees is one mechanism that makes increased membership possible.³⁵

A second strategy is greater research training. In our data, most family physician grantees and family medicine committee members had additional advanced degrees. NIH and family medicine could strengthen partnerships for advanced degrees and research training through National Research Service Award expansion, greater involvement in the Howard Hughes Medical Institute, NIH fellowships, or novel research training programs.

A third strategy is to draw on past successes by family medicine. As shown in our study and as noted by others,³⁶ only a select group of departments of family medicine have any substantial engagement with the NIH. Through hub-and-spoke networking,¹³ these sites might supply role models and teachers to bring lessons about building successful research enterprise to the larger family medicine community (perhaps even through novel programs and financial backing from the NIH). Lessons from leaders could be helpful, not only for community family medicine clinicians,³⁷ by fostering participation in practice-based investigations and quality-improvement initiatives, but also for aspiring career family medicine investigators,¹³ by providing guidance on grantsmanship and counsel on doing national-level research.

A final, related, strategy involves partnerships with existing research infrastructure, both within and outside family medicine.^2,13 Family physicians in community practices might develop collaborative relationships with practice-based research networks³⁸ and academic health centers that are part of the Clinical and Translational Science Awards consortium.⁶ They could thereby contribute to generating new knowledge by informing research questions,¹³ carrying out trials, and developing ideas for new kinds of research.¹⁶ For established family medicine investigators, expanding roles as collaborators, consultants, coinvestigators, and mentors will be important. Mentoring in particular will be key as family medicine strives to increase numbers in its research vanguard, developing new talent capable of independent investigation.^1,7,13 Burgeoning junior investigators could look to veteran grantees—preferably in family medicine but also in other disciplines—for mentoring through career development programs (ie, K awards).^1,6,13,21 Encouragingly, with disproportionate percentages of new awards and K awards going to family medicine during the last 5 years, partnering with mentors and existing research infrastructure may already be occurring.

Our study has notable strengths. Analyses of awards over the last 5 years allowed us to appreciate that there has been little substantive change in funding to family medicine since previous analyses, specifically in relation to the doubling of the NIH budget. We also considered application type, which had not been reported previously. Data on advisory committee memberships provided additional perspective and corroboration not found in published literature.

In spite of these strengths, we must consider limitations in interpreting our results. First, we can make no comment about family medicine investigators who were collaborators or co–principal investigators, as such data were not available from NIH. This omission is important because research is increasingly interdisciplinary and networked.³⁹ Although the ability to perform autonomous investigation has traditionally been a measure of the status and vitality of a discipline,²⁹ research as a culture is shifting to encompass more collaborative and team-based models.^39,40 NIH just started collecting reliable data on co–principal investigators in 2006, and future studies should evaluate family medicine’s role in collaboration. Indeed, interdisciplinary cooperation may be essential for family medicine to develop a critical mass of competent investigators.^1,13

Second, there was some risk of misclassifying researchers in our data owing to family physicians working outside departments of family medicine or principal investigators having multiple departmental affiliations, for example. Rabinowitz et al reported 22 out of 149 cases (15%) in 2003 in which family medicine researchers were actually listed under departments of public health and preventive medicine.²¹ Although we received assurance from Office of Extramural Research that the data provided for our study was complete and accurate, if the same level of misclassification were at play, family medicine would have actually received 0.32% of NIH awards from 2002 through 2006 rather than the 0.28% we report. The potential for misclassification or missed identification for advisory committee members is also a concern. Only a single affiliation for each committee member was listed; thus, any family medicine researchers using a primary, non–family medicine affiliation would have been uncounted. Conversely, any principally non–family medicine researcher using family medicine as a primary affiliation would have been captured inappropriately. Given the tiny membership percentages we report, however, even large errors would not have changed our overall findings meaningfully.

Third, we had to limit our analysis of advisory committees to those with standing memberships—that is, we had to exclude special emphasis panels. To be generous, even if we were to make the unlikely assumption that every special emphasis panel had at least 1 family medicine member, then the percentage of advisory committees with family medicine members would increase from the 6.4% we report to 13.5%, and family medicine membership would rise from 0.38% of all members to 0.82%. In our view, this change would not represent a meaningful difference.

Finally, we do not provide a comparison group—another medical specialty, for instance—for our analyses. Listed affiliations on committee rosters were not sufficient to distinguish generalists from subspecialists in other specialties. Based on prior work, however, family medicine spends substantially less time on research than other primary care fields.^1,7,41 In fact, according to a 2001 report, departments of family medicine receive roughly 6% as much NIH funding as do departments of pediatrics, and about 1% as much as departments of internal medicine.⁴² Negotiations with NIH for data comparing grant applications and success rates among specialties are ongoing by our group.

Despite limitations, we can confidently conclude from our study that family medicine is not well-engaged with the NIH and is essentially off the Roadmap. The NIH director has written, “NIH needs to have an explicit and dynamic process for supporting critical scientific programs that cut across scientific areas and that none of the individual institutes could support on its own.”²⁶ This kind of sentiment drives the Roadmap and Clinical and Translational Science Award programs and speaks directly to the integrative role of family medicine.³⁶ At the same time, the Future of Family Medicine project and family medicine leadership have called for increasing emphasis on research^1,13,43,44 and engagement with the NIH.^1,13 Family medicine and the NIH have what each other wants, but the potential for greater partnership has not been realized. Lack of family medicine involvement in the planning and performance of federally funded research has implications for the direction of biomedical research in this country, its relevance to actual patient care, and its ultimate impact on public health. Lack of NIH support for family medicine investigational initiatives has implications for family medicine’s research capacity and the status and vitality of the specialty. Through greater research training, collaborations, and self-advocacy, family medicine might foster a better relationship with the NIH, to the benefit of both.