Appendix II
Summaries of three relevant, recent workshops sponsored by the American Thoracic
Society which discuss issues similar to those in the NHLBI Training Workshop were
presented on behalf of the ATS by Dr. Augustine Choi.
The ATS Executive Committee established a Task Force in Scientific and Clinical
Careers in the summer of 2008. The charge of this task force was to analyze the key
attractions and barriers to entry and maintenance of clinical and scientific careers in
pulmonary, critical care and sleep medicine. The major objectives of the task force was
the following:




The Task Force should present specific recommendations to increase
attractiveness of these careers for trainees at multiple levels and for professionals
in mid-career.
The Task Force should identify specific positive elements of these careers that
could be utilized for greater awareness and increasing entry into the career
pipeline.
The Task Force also should make recommendations about whether and how to
interact with other sister organizations with similar goals in this area.
Within the goals of the Task Force is the identification of specific steps that can
be initiated within the next one to two years to increase attractiveness of these
career pathways.
Additional specific questions include:
How can we increase the “pipeline” of undergraduate, medical and graduate
students interested in clinical and research careers related to pulmonary, critical care and
sleep medicine?
How can we develop a network of “best practice” teaching materials to improve
the quality of student teaching and thereby try to attract more students? Is there a role for
ATS developing a method of recognizing a cadre of master teachers and/or mentors?
The Appendix* includes the summary of the recommendations of the ATS Task
Force in Scientific and Clinical Careers which was sent to the ATS Executive Committee
in December of 2008.
* personal communication approved by the ATS Executive Committee
1
“Attracting and Retaining Individuals in Academic Pulmonary, Critical
Care and Sleep Medicine”
The Academic Career Subcommittee members participated in 2 conference calls and multiple
electronic communications with these interactions designed to analyze key attractions and barriers to
entry and maintenance of clinical and scientific careers in pulmonary, critical care and sleep medicine.
While addressing a broad spectrum of career opportunities in academic Pulmonary/Critical Care
Medicine/Sleep Medicine (Pulm/CCM/Sleep), the Academic Career Subcommittee was deeply
concerned about the shrinking and aging physician-scientist/clinical-investigator workforce, and the
acute need to recruit and retain young physician-scientists in the field of Pulm/CCM/Sleep. A formal
SWOT Analysis (Strengths, Weaknesses, Opportunities and Threats) was undertaken by each committee
member who also reviewed drafts of Task Force survey questions and submitted additional questions for
consideration. This document represents the summary of the formal SWOT analyses as well as the
specific recommendations generated to increase attractiveness of academic Pulm/CCM/Sleep careers
targeting trainees at multiple levels and professionals in mid-career.
General Strengths of a Career in Academic Medicine





Scientific careers in academic medicine are exciting, intellectually stimulating,
enjoyable and satisfying
Many career pathways exist in academic medicine including clinical educator and
physician scientist pathways
An academic career permits an attractive balance between patient care, teaching,
and research as well as intellectual independence and flexibility
Academic medicine is more stimulating than private sector clinical medicine and
offers greater variety and geographic mobility
Academic medicine is a noble calling, particularly in the training of future leaders
of academic medicine
Specific Strengths of an Academic Career in Pulmonary / Critical Care /Sleep Medicine




Pulm/CCM/Sleep provides a procedure-rich specialty with intensive care
opportunities that are attractive to many young physicians.
Academic Pulm/CCM/Sleep medicine offers greater flexibility than private sector
clinical medicine in terms of daily scheduling, meeting family obligations, and
lifestyle
Many excellent role models exist in academic Pulm/CCM/Sleep
The Lung Division of NHLBI is proactive in attracting young trainees and junior
faculty
2


A number of Chairs of Departments of Medicine in prestigious academic medical
centers are Pulm/CCM/Sleep physicians
Divisions of Pulm/CCM/Sleep, as well as their training programs, are highly
regarded in major medical centers
Weaknesses in Choosing an Academic Pulmonary/Critical Care/Sleep Medicine Career











Many medical school graduates and residents seek medical careers that do not
require a 100-hour work week as Pulm/CCM portends.. Current perception is of
high stress, long work hours in ICU environment, possibly with required
nighttime or in-house call coverage
Inadequate number of positive role models in academic Pulm/CCM/Sleep
medicine
Residents and fellows have poor understanding of diverse academic career paths
Difficult to predict which individual trainees are likely to gravitate towards an
academic career making it difficult for training programs to focus limited
resources on the most promising candidates
Disparity in academic Pulm/CCM/Sleep medicine incomes versus private practice
Limitations in exposing medical students to pulmonary & sleep biology
pathobiology
Lengthy period of research training to become an independent investigator
combined with much lower salaries
Extended duration of ACGME-mandated clinical activities which reduce research
experience
Physician-scientists are often unable to “get away from their work” meaning that
we constantly think about our work and new research ideas. Also, the race for
funding never ends so there is no time for a “break.”
Little or no opportunities for part time work since this is not allowed by NIH
Excessive clinical demands on junior faculty especially physician scientists
Opportunities for Increasing Interest in Academic Pulm/Crit Care/Sleep Medicine Careers





Dispel myths about academic medicine careers: salary structures, lifestyle
Pulm/CCM/Sleep is a rapidly evolving, evidence-based specialty with many
opportunities for basic and clinical research
Expanded recent efforts at NIH which focus on awards for early career trainees,
first-time RO1 recipients, and on programs to facilitate debt reduction
Junior faculty could benefit from formal education focusing on career
development and research (grant writing, for example), whereas fellows could
benefit from more formal education about transitioning careers to faculty status
Increase opportunities (summer and year round) to expose college students, med
students and house staff to Pulm/CCM/Sleep research
3



Strengthen involvement of Pulm/CCM/Sleep physician-scientists in coursework
in med schools
Provide a culture of academic medicine where part-time work would be possible
for people with young families, combined with a substantial campaign to
convince students and residents that academics is flexible and “friendly”
Research (mostly clinical research) is moving into community hospitals creating.
an opportunity for more physician-scientists in locations other than large cities.
Threats to Attracting and Retaining Individuals in Academic Pulmonary, Critical Care
and Sleep Medicine















Declining number of individuals entering pulmonary for the past 5 to 10 years
The supply of physician-scientists/clinician-investigators in academic medicine is
declining: debt load, prolonged duration of training, research funding woes
Competing specialties in critical care (surgery and anesthesia) and sleep
(neurology)
Difficulty and uncertainty of securing meaningful extramural grant funding
Perception of limited job security related to continue grant funding
Excessive duration of training and time to achieve independent funding
Increased value in work-life balance and controllable life-styles in the selection of
a career pathway
85% of medical students carry debt of at least $100,000 at the time of graduation
Clinical demands in academic centers are already heavy and potentially will
increase if 24/7 attending coverage in ICUs is required
The attraction for Pulm/CCM/Sleep training for many residents continues to be
the ICU and procedures
An aging population will require more Pulm/CCM/Sleep specialists for
community clinical work, not for research
Severely impaired NIH funding is greatly exacerbating the shortage of physicianscientists, unlikely to be remedied without substantial increases in funding
Perception that being a physician-scientist means forever being on a treadmill
Women find physician scientist careers less attractive than men
Pulmonary is being dropped as a critical component of critical care training in
some programs
Summary of Recommended Actions:


ATS should join other societies such as Association of Professors of Medicine,
AAP, ASCI etc in nurturing the pipeline for physician scientist careers
ATS should formalize an academic mentoring program for fellows and junior
faculty with academic leaders
4








ATS should continue to advocate for additional mechanisms of salary support for
promising academic oriented transitioning fellows with mandated protected time
and for debt reduction grants for junior faculty
ATS should convene PIs of pulmonary training grants to strategize on best
practices in recruitment and retention of academic fellows
ATS should continue to identify major concerns of residents, fellows, and junior
faculty for pursuing careers in academic medicine
ATS should develop recommendations for the comprehensive mentoring of
fellows and junior faculty pursuing careers in academic medicine focusing
particularly on challenges presented by specialization in Pulm/ CCM/ Sleep.
Include website information with links for both mentors and mentees
ATS should disseminate detailed financial data (salary) for faculty during their
first few years of academic practice to help dispel myths of dramatic salary
differential between academic and private practice in the first several years postfellowship
ATS should collect and disseminate accurate data related to career success and
retention rates for academic Pulm/CCM/Sleep faculty that may offset pessimistic
attitudes about academic career viability
Increase exposure of medical students to strong Pulm/CCM/Sleep role models
ATS should fund a prospective assessment of trainee characteristics that predict
future success in academic Pulm/CCM/Sleep and assist academic training
programs and divisions in recruitment, selection, and training of the most
promising candidates for successful careers in academic Pulm/CCM/Sleep.
References
1. Revitalizing the Nations Physicians Scientist Workforce. Association of
Professors of Medicine, Report of the Physician Scientist Taskforce. Monograph
pgs 1-45.
2. Academic and Career Development of Pulmonary and Critical Care PhysicianScientists. Am J Respir Crit Care Med 173: 23–31, 2006.
3. Attitudes & Perceptions of Internal Medicine Residents Regarding Pulmonary and
Critical Care Subspecialty Training,” CHEST 2005, 127; 630-636.
4. Pulmonary and Critical Care: The Unattractive Specialty,” CHEST 2005, 127;
1085-1087
ATS Scientific and Clinical Careers in Pulmonary, Critical Care and
Sleep Task Force
Sister Societies and Other Organizations Subcommittee
5
Charge: How can the ATS work with sister societies to improve the attractiveness and
eliminate some of the barriers to careers in pulmonary, critical care and sleep?
SWOT Analysis:
Strengths:
1. Each of the major sister organizations including the American Thoracic Society
(ATS), the American College of Chest Physicians (ACCP), the Association of
Pulmonary and Critical Care Program Directors (APCCCMPD) and the Society
for Critical Care Medicine (SCCM) are strongly committed to increasing the
pool and numbers of individuals entering clinical, academic, and public health
careers in pulmonary, critical care and sleep, and related disciplines.
2. The larger organizations have complementary strengths, with the ATS most
vocally supporting academic and research careers, while the focus of ACCP and
SCCM remains largely centered on clinical career. The APCCMPD is principally
focused on training.
3. Most of our members (including leadership) are members in at least two of these
organizations. Therefore, cross talk should be easily facilitated. The
APCCMPD group is independent and convenes both in association with the
international meetings of the ATS and the ACCP.
4. Workforce analysis continues to support expansion of the numbers of
individuals needed for Pulmonary, Critical Care, and Sleep Career, meaning that
the career outlooks for those who select to train in our specialties looks to remain
extremely favorable for the foreseeable future.
Weaknesses:
1. Traditionally some competition has been perceived in attracting fellow members
to one or another of these sister societies. This perception has perhaps limited
concerted efforts to increased recruitment of members in training to the general
area of pulmonary, critical care, sleep and related disciplines.
2.
While these sister societies have focused on increasing the participation of
subspecialty fellows at their international meeting, relatively little effort has been
centered on attracting internal medicine residents, and undergraduate science
students to attend these meetings. These individuals have not yet made career
selections.
3. Healthcare reimbursement for Pulmonary and Critical Care is currently not as
attractive as other subspecialties, such as cardiovascular medicine,
gastroenterology, and oncology. This is not the situation for sleep medicine,
which for the near future may serve as a mitigating factor.
6
4. Work-life balance is increasingly perceived as unfavorable for career selection in
pulmonary and critical care medicine. This limits recruitment in general, but may
also significantly negatively impact the recruitment of female candidates into
clinical careers within these disciplines, particularly critical care.
5. The pool of US students entering science and technical related careers continues
to decline. However, internationally trained individuals in these disciplines
remain plentiful.
Opportunities:
1. Considerable opportunities exist to reach out to both undergraduate students and
PhD students and internal medicine residents early in their training, before final
career selection has been made. Particular interest might be focused on MD/PHD
students interested in academic careers.
2. Sleep medicine currently enjoys attractive reimbursement, and in a mixed
specialty career, can mitigate several of the factors listed above (reimbursement
and work-life balance).
3. Numerous internationally trained individuals have interest in pulmonary, critical
care and sleep, and related disciplines, but are hampered in completion of training
due to regulatory and legislative issues (e.g. Visa and NIH training grant issues).
4. Both the ATS have excellent support services for approaching and
communicating with governmental bodies and agencies about these concerns.
Further, these sister societies have a significant history of working together on
key regulatory issues.
Threats:
1. Projected worsening of medical economics and health care reimbursements
threatens to reduce interest in clinical careers. Considerable concerns exist about
reduced reimbursements for ICU related diagnoses as well as changing
reimbursement for pulmonary and sleep diagnostic procedural reimbursements.
2. Uncertainty that reduced funding for basic and clinical research at the Federal
level and for public health initiatives might occur threatens to reduce interest in
research and academic careers in pulmonary, critical care and sleep, and related
disciplines.
3. Increased focus of the next generation of trainers on appropriate work-life balance
may further threaten our already overtaxed specialty areas.
Suggested Solutions:
7
1. Greater communication and concerted efforts between these sister societies and
other organization will be needed to increase the numbers of individuals seeking
careers in pulmonary, critical care, sleep, and related disciplines.
2. Consideration may be given for either a summit meeting or a joint conference call
series involving representatives of the sister societies and organizations to
improve the attractiveness and eliminate some of the barriers to careers in
pulmonary, critical care and sleep and related areas, as listed below.
3. Concerted efforts must be undertaken to increase participation of undergraduate
science students, MA and PhD students, and undifferentiated internal medicine
residents, as well as international trainees within each of the key societies and
organizations. Suggested mechanisms can include expanded travel awards and
committee memberships specifically for these types of trainees to participate at
these meetings. In addition, we may want to focus some specific effort on
MD/PhD students or MD/MPH students seeking academic careers.
4. Consideration should be given for outreach activities of domestic and
international trainees at the undergraduate or internal medicine level beyond
participating at the international meetings of these societies. For instance, the
societies might consider expanding grants or even joint funding opportunities
specifically to facilitate the lab research or training of such individuals, who have
to yet select a career area.
5. The societies need to continue to jointly lobby governmental and regulatory
organization to support increased training slots for pulmonary, critical care, sleep,
and related disciplines.
6. Investigate and support studies of new clinical staffing models that improve worklife balance.
7. Increase communication and joint efforts of the sister societies to voice concerns
about Medicare reform and reimbursement changes so that reduced clinical
revenue does not further compromise recruitment of trainees into pulmonary,
critical care, sleep, and related disciplines.
8. Enhanced joint efforts of the sister societies to communicate and work for stable
governmental funding both for training and research in areas related to
pulmonary, critical care, sleep, and related disciplines.
9. Increased joint effort of the sister societies to communicate and petition for
governmental and legislative reform bringing relief for international trainees (e.g.
enhanced opportunities for NIH training grant participation, more flexible visa
rules). This would significantly foster greater influx of learners into pulmonary,
critical care, and sleep medicine and related research areas.
8
Pulmonary and Critical Care
ATS Task Force on Career Attractiveness
S.W.O.T. analysis
Process:
Committee members and local Pulmonary/Critical Care Medicine (PCCM) faculty and
fellows were contacted in person and by email and asked to describe what they found
attractive or unattractive about a career in PCCM. In addition, small unstructured focus
group meetings were held with internal medicine residents who had recently decided on
9
subspecialty fellowship. Comments were organized into S.W.O.T. format and circulated
to committee members for comment and revision. We focused on issues related to house
staff choice of a career in PCCM, rather than Fellows’ choice of academic careers or
career retention of practicing PCCM specialists and scientists.
Review of data over the past 5 years from the NRMP does not indicate dwindling interest
in PCCM. On the contrary, the number of fellowship programs, slots, and applicants have
all increased and the ratio of applicants to positions has remained stable. We considered
the goal of this exercise to maintain the health of a vigorous field of Medicine, rather than
respond to a demographic crisis.
Strengths
1. High acuity, high stakes, high adrenaline medicine.
2. Applied physiology prominent feature of diagnosis and management
a. Appeals to the mechanically inclined.
b. Bridges basic and clinical science
c. Ideal teaching material for clinician-educators
3. Wide range of practice settings
a. Ambulatory care
b. Critical Care
c. Sleep medicine
4. Wide range of patient care opportunities
a. Occupational medicine
b. Short-term consultation
c. Long-term chronic care
d. Palliative care
e. Acute crisis intervention
5. Wide range of potential lifestyles which can evolve over time
a. Fully in-patient
b. Critical Care
c. Ambulatory Care
d. Sleep
6. Procedure-oriented practice, if desired, with expanding procedural options.
7. Opportunities for public health and political advocacy
a. Tobacco
b. Air pollution.
c. Industrial medicine
d. Global health
e. Disaster management
8. Some diseases, for example PAH, CF and ARDS, have had major breakthroughs
and improvements in outcomes in recent years.
9. Multi-system disease management
a. Critical Care crosses silos: The General Internist for the really sick
10
b. Many pulmonary diseases are multi-system (PAH, neuromuscular
diseases, rheumatologic illnesses, cancer)
10. End-of-life care
a. Opportunities for rewarding relationships with patients and families
b. Opportunities to improve neglected area of medical care
Weaknesses
1. Many common PCCM diseases have little public awareness (COPD, ARDS) or
bearing the stigma of self-induced illness (emphysema).
2. Common chronic illnesses have intractable symptoms and little new therapy
(COPD).
3. House staff typically encounter outpatient treatment “failures” whose treatment
appears formulaic:
a. Refractory COPD and asthma
b. Continued smokers
c. Medical non-adherence
d. Progressive CF patients
e. Lung transplant failures
4. Almost all patients suffer dyspnea, a miserable symptom with no treatment.
5. Compensation and work hours (or at least their ratio) may not be on a par with
“competing” subspecialties such as Cardiology and GI.
6. Critical care practice can lead to mid-career burnout.
7. General sense that much of ICU care is wasted on patients unlikely to benefit.
8. Perceived by house staff as not having a particularly family-friendly lifestyle, and
few female role models.
Opportunities
1. Increasing public awareness and attention is being paid to asthma and COPD.
2. Staffing shortages in Critical Care will persist for the foreseeable future.
3. Increasing emphasis is being placed on multidisciplinary care, protocols, and
patient safety, for which ICUs have been the advance guard.
4. Epidemic of sleep-disordered breathing is occurring as a complication of obesity.
5. House staff exposure to successful outpatient management of pulmonary disease
can be improved.
6. House staff teaching on pulmonary services can be improved
a. Some programs excel in MICU, others on in-patient services
b. Few excel at teaching outpatient management and continuity
c. Commitment to teaching cited by many house staff as strong positive
when present
d. Role modeling and teaching of long-term doctor-patient relationships and
management can be strengthened in many programs
Threats
11
1. Reimbursement always under stress; several of CMS proposed “never events” are
common and probably cannot be completely eliminated in ICU patients.
2. Society of Critical Care Medicine (SCCM) is positioning itself as the critical care
society and multiple non-PCCM pathways into critical care exist.
3. One-year sleep fellowship may divert many applicants away from Pulmonary or
PCCM.
4. Demands for 24-hour attending staffing of ICUs may make lifestyle less
attractive.
5. Hospitalist movement has created opportunities to practice critical care in many
hospitals without the need for additional fellowship training.
6. Duty hour restrictions on house staff have increased service demands on PCCM
fellows in some programs, especially for ICU coverage. Disgruntled Fellows are
one of the most effective deterrents for interested house staff.
Recommendations
1. An enthusiastic commitment to house staff education was routinely cited as a
feature that attracts house staff to a subspecialty. Application of this will
necessarily vary by local institutional resources. However, the following should
be considered:
a. Careful weighing of educational versus service requirements for house
staff on pulmonary or ICU rotations.
b. Formal curriculum development as a vehicle to focus faculty on
educational issues and methods.
c. Self-conscious role modeling by clinicians.
d. Efforts to recognize and reward teaching excellence at the Divisional and
Departmental levels.
e. Incorporating regular didactic sessions into medical ICU or pulmonary
rotations.
2. Broaden house staff exposure to the wide range of practice, scientific, and
lifestyle opportunities within the field.
a. Incorporate exposure to successful outpatient management and
longitudinal care into house staff training.
b. Provide opportunities for house staff participation in research or advocacy
activities.
c. If funding is available, sponsor house staff attendance at national or
regional specialty society meetings.
12