Challenges and opportunities for growing and retaining a pain research workforce

Introduction

The pain management community recognizes that there is a need to improve the clinical pain research workforce.¹ To better understand this problem, the recent NIH/NINDS workforce survey² asked multidisciplinary clinical pain researchers to identify the factors that have helped them pursue clinical pain research as a career or, conversely, the factors that held them back from pursuing such research. Responses revealed that those who left research to pursue patient care tended to be 1) earlier in their careers and 2) less likely to have received any formal research training or mentoring. Established researchers with training or mentorship experiences were more likely to remain in the research workforce. Across career stages, the survey identified two important factors to help clinicians continue research: 1) support and funding from their home institutions and 2) protected time for writing grant applications and conducting research.

Several key career inflection points exist for aspiring researchers. Beyond training and funding opportunities, environmental support (home and work) is another key factor. Included in this factor are educational debt, challenges associated with parenting, and/or the availability of family support.^3,4 NIH has begun to address some of these structural elements through programs such as the NIH Loan Repayment Program, support for childcare during work-related travel, and extension of early-stage investigator status for familial circumstances.⁵ Building a diverse workforce for clinical pain research is an ongoing goal, and while some evidence shows that racial/ethnic minorities are less likely to choose a research career, a mitigating factor is a positive research environment with mentoring support.^6,7

The pain research workforce pipeline has challenges across the training lifecycle (Figure 1A). These include a limited focus on early training in pain, a limited number of postdoctoral positions, difficulty obtaining first NIH funding, transitioning from a mentored position to an independent researcher, and the high departure rate of mentors and senior investigators. Additionally, compared with other clinical domains, there are very few pain-specific NIH Training grants (eg, 6 pain T32s vs. 20–100 T32s in other fields).

Figure 1.

Existing pipeline for pain clinical research, highlighting challenges and solutions. (A) The NIH/NINDS workforce survey and recent symposium attendees identified a number of “leaks” along the clinical pain research workforce pipeline across the career spectrum. (B) The NIH is engaged in ongoing and new efforts to increase the clinical pain research workforce pipeline. These efforts are being conducted across the NIH institutes. Mechanisms include, but are not limited to the T32, the K23, K24, and K99/R00. The HEAL Initiative has recently increased efforts to support the clinical pain research pipeline by increasing mentorship and training by supporting 1) early-career researchers through the use of HEAL training supplements, 2) early-stage investigators through mechanisms such as the HEAL National K12, 3) midcareer mentors through the use of mechanisms such as the HEAL K24, 4) early-stage and mid-career investigators who are interested in developing new therapeutic skills through the use of the HEAL K18; 5) diverse researchers through the use of HEAL diversity supplements, and 6) establishing the PURPOSE network to connect all pain researchers who are either NIH-funded or are interested in NIH funding to increase collaborative efforts. The broader community—such as universities, institutions, research organizations—can help to improve the clinical pain research workforce pipeline. Their efforts could include improving the training of mentors and increasing pain education training. Universities and other institutions also can increase start-up funds and/or bridge funds.

This report presents a snapshot of the problem, recently presented and discussed in a 2022 symposium at a national pain conference focused on challenges in the clinical pain research workforce. The robust discussion among aspiring (ie, graduate, postdoctoral, fellow) and established pain researchers (ie, faculty) identified additional specific challenges faced by the pain research community. This report presents the data informed by these discussions aimed at generating a wider discussion about the next steps to expand the pain clinical research workforce now and into the future.

Summary of themes discussed by trainees and mentors at the 2022 conference

This clinical pain research workforce symposium highlighted several recurring themes that impact pain researchers’ retention in the workforce, including individual, institutional, and systemic factors. The lack of funding/support was common across these domains, but nuanced discussion brought up specific concerns that should be highlighted for the broader community (Figure 1).

From an individual perspective, many challenges stem from mentors as gatekeepers for access to the science and funding needed to support career development. Finding supportive mentorship can prove challenging in the early stages of research when trainees depend on a primary mentor for funding and scientific direction. While mentorship can be very successful for some; others experience dysfunctional relationships that ultimately prompt them to leave research for other careers.

One of the challenges of the apprenticeship model for clinical research is that it may limit opportunities to learn a range of methodological approaches and skills that would provide flexibility for future funding. Another area for improvement with the standard mentoring dyad approach is that it can create unrealistic expectations for both mentors and mentees. Another issue is that a mentor may not be ready to share study findings publicly due to the scarcity of funding and the desire to sequester preliminary data. This approach limits the ability of postdoctoral fellows to generate data and publications at a rate necessary to successfully find full-time positions and grant funding. Funding scarcity is another factor driving postdoctoral fellows away from clinical research. Moreover, lab and mentorship toxicity should not be a reason for trainees to leave research careers.

Three systemic factors were discussed as potential barriers to pursuing careers in pain research. 1) Difficulty obtaining a professorship/faculty position if a researcher does not already have grant funding, 2) the limited amount of start-up funds and/or protected time an institution provides to early-career researchers receiving professorship/faculty positions, and 3) the limited community for individuals in the clinical pain research space.

Summary of multi-level proposed solutions

Individual level

While some potential challenges to expanding the pain research workforce are institutional and systemic, commitments to mentoring at the highly local level (ie, an individual lab PI) is a critical strategy⁸ for addressing individual factors. Mentors should thoughtfully develop a training plan for their postdoctoral fellows that involves technical training and clear milestones for career transitions. Although a good mentor can serve as a coach, a mentor cannot solve all the problems an early-career researcher may experience. Since a primary mentor requires assistance in meeting the diverse needs of a mentee, establishing a larger mentoring network shows early-career investigators that they are not alone and can benefit from their various mentors' expertise and experience throughout their careers.

Community level

Moving beyond the classic mentor-mentee dyad, mentorship networks can provide an important opportunity to develop diverse skills and perspectives to support a resilient pain research workforce. One solution to expand the mentorship support for pain medicine is engaging multidisciplinary mentorship networks. By bringing in mentors from other fields such as implementation science, health economics, data science, and health services research, the pool of scientific questions and availability of mentors can expand significantly. One important skill for mentors is being open about research challenges and having the resilience to manage a long-term research career.

Organizational level

While the NIH plays an important role in shaping the pain medicine research agenda and workforce (Figure 1B), universities and other institutions also can be part of the solution by establishing training programs and supporting diverse faculty and trainees to build a foundation for funded research. In addition, foundations (eg, Rita Allen Foundation and Mayday), and other seed grant funding institutions can be important in developing the workforce pipeline. Increasing interest in pain medicine and pain research early in a trainee’s career could be important. One example is the NIH/NINDS-funded Pain Undergraduate Research Experience (PURE) summer program.⁷ An explicit focus on diversity and inclusion in research can advance the field by bringing diversity of thought and perspectives to pain-related research questions and solutions. Finally, another important area for supporting the development of pain research is building entrepreneurship programs that will support scientific partnerships with industry that can accelerate technological advances in the field.

System level

Ultimately, many challenges constricting the size of the pain clinical research pipeline (Figure 1A) directly relate to systemic issues and barriers pertaining to support for pain research. Unlike many other specialties, pain mentorship has lacked funding mechanisms to support this critical career development activity in both clinical fellowships and research labs.⁹ Without funding to formally support mentorship efforts, mentors are forced to focus on their individual projects that may or may not support trainee development. Unlike a mentoring-focused grant (eg, T32s and K24s), other funding mechanisms do not allow a mentor to focus on developing future talent. While it is beyond the scope of this work, the challenges faced by physicians in pursuing a research career¹⁰ are especially challenging in pain medicine.

A strong and diverse workforce of multidisciplinary experts is essential for discovering effective pain solutions. Within the past 3 years, the NIH has funded several efforts to help increase and sustain the pain research workforce (Figure 1B). These efforts have focused on increasing mentorship and training by supporting 1) early-career researchers, 2) postdoctoral fellows and their mentors through a training mechanism, 3) early-stage investigators through mechanisms such as the HEAL K12 National Pain Scholars Program, which supports new faculty at the instructor and Assistant Professor levels through their first 3 years prior to becoming PI on a K award or a R award, 4) midcareer mentors through the use of mechanisms that protector time to mentor the next generation of researchers such as the K24 grant, 5) funding for researchers from diverse backgrounds, and 6) establishing a network to connect all pain researchers who are either NIH-funded or interested in obtaining NIH funding. The new Positively Uniting Researchers of Pain to Opine, Synthesize, & Engage (PURPOSE) network brings together stakeholders across pain research to broaden the talent pipeline.

Overall, the discussion at the 2022 symposium focused on 5 areas that highlight challenges in the future of clinical pain research. These include 1) funding challenges for pain-focused training programs, 2) the lack of diverse training opportunities and the need for broader postdoctoral research support, 3) the lack of support throughout the training lifecycle, 4) difficulty finding and working with assigned mentors, and 5) engaging stakeholders such as universities, foundations, and seed organizations in advancing the pain workforce. These areas provide obvious points to start addressing the leaky pipeline for clinical pain research. They provide clear areas of focus for institutions, program leaders, and NIH for the foreseeable future.

Funding

Research reported in this publication was supported by the NIH HEAL Initiative through the National Institute of Drug Abuse under grant number R24DA055306 (MCBA), National Institute of Biomedical Imaging and Bioengineering under grant number K08EB022631 (MCBA), the National Institute of Diabetes and Digestive and Kidney Diseases under grant number R01DK115478 (BJK), the National Institute of Neurological Disorders and Stroke under grant number R25 NS100118 (BJK), and the National Institute of General Medical Services T34GM145436 (BJK).

Conflicts of interest: This report does not represent the official view of the National Institute of Neurological Disorders and Stroke (NINDS), the National Institutes of Health (NIH), or any part of the U.S. Federal Government. No official support or endorsement of this article by the NINDS or NIH is intended or should be inferred.

 

High Level Concept: Discussing the issue of the pain research pipeline from multiple perspectives, including workshop participant feedback.