Abstract
Objective:
The authors examined trends of individual career development awards from the National Institutes of Health (NIH) to psychiatry faculty, especially physicians, in comparison to other departments.
Methods:
Data were obtained on 33,392 career development awards from 2013 to 2022. We examined the number of awards each year averaged for 46 non-psychiatry departments, and for departments of psychiatry, the number of awards to all faculty, physicians, and physicians without a PhD. Linear regressions determined whether number of career development awards increased with time and if estimated slopes differed between faculty in non-psychiatry departments and other groups.
Results:
In departments of psychiatry, 534 faculty received an NIH individual career development award during the ten-year period (534/33,392 or 1.6%), with 118 (22%) to physicians. The number of awards increased significantly over time for other departments and departments of psychiatry (estimated slopes of 3.05 and 2.38, respectively) and did not differ from one another. However the number of awards to physicians and physicians without a PhD in departments of psychiatry (estimated slopes of 0.51 and −0.07, respectively) have not increased. This lack of growth in awards for physicians and physicians without a PhD in departments of psychiatry differed significantly in comparison with the increase shown in awards to other departments over time (both p<0.001).
Conclusions:
The number of NIH career development awards has increased NIH-wide, and for non-physician faculty but not for physicians in departments of psychiatry. These trends raise concerns for the future of psychiatrists in academic research.
Keywords: Physician-scientist, career development award, training grant
Physician scientists, while generally recognized as critical to translational biomedical research, have long been considered an “endangered species” [1]. The process for physician scientists to become independent investigators is long, challenging, and uncertain [2]. Many barriers have been previously identified and include difficulties starting a research career in the context of busy and lengthy clinical training, limited opportunities to build a competitive research portfolio, limited exposure to research mentorship, difficulties in maintaining work-life balance, student debt, and National Institutes of Health (NIH) salary caps, among many others [2,3].
Recognizing these concerns, in 1996, the NIH Panel on Clinical Research recommended approaches to loan repayment programs and career development pathways for patient-oriented research [3, 4]. Again in 2014, the NIH empaneled the Physician-Scientist Workforce Working Group to address issues in the physician scientist workforce, resulting in nine recommendations to the NIH to support development and retention of a more diverse pool of physician scientists [3]. Specialty groups, such as the Consensus Conference of the Alliance for Academic Internal Medicine, have similarly made recommendations to address this ongoing issue [5].
Despite these efforts, within psychiatry specifically, recent work has raised alarms regarding the dwindling pipeline of patient-oriented intervention researchers (clinical trialists; [6]. A modest number of MD-PhDs enter psychiatric residency each year (44 in 2022) [7]. And prior work suggests that while Medical Scientist Training Program/MD-PhD programs are highly successful [3], graduates of these programs most often focus on basic science research, and not patient-oriented nor clinical trials research [8,9], suggesting the importance of also enhancing research training for psychiatry residents without a PhD. Prior efforts to develop research training pipelines and within-residency research training tracks are well described [2,10] and the National Institute of Mental Health (NIMH) has offered specific research funding mechanisms to support research training for psychiatric residents [10]. Yet, it remains unclear whether these initiatives are fulfilling their objective and the number of physician scientists in psychiatry has been increasing.
In this paper, we focus on NIH career development awards which significantly predict transition to independent research careers for physicians [11]. We examined the number of awards to physician scientists in departments of psychiatry and placed them in the context of awards to other departments and departments of psychiatry overall. To do this, we described changes in the number of NIH career development awards to departments of psychiatry (separately examining all faculty, all physicians, and physicians without a PhD) over a ten-year period. We compared trends in the NIH career development awards to other departments in comparison to psychiatry. Finally, given historical geographic inequality in Federal research funding [12], we also examined the geographic distribution of individual career development awards to physicians from departments of psychiatry.
Methods
We conducted several queries via the advanced search option in NIH Reporter to ascertain all career development award information by utilizing these search terms: Fiscal Year included all years between 2013 and 2022, department type of “PSYCHIATRY” and application ID included an “01” grant year and separately included these grant mechanisms: “K01”, “K08”, “K23”, “K25” and “K99”. Supplement awards (datafiles with a suffix of “S1” or “A1S1”) were removed. Two authors separately conducted online searches of the 534 Principal Investigators to ascertain highest degree (PhD, DO, MD, MD-PhD, etc.). Discrepancies between the 2 reviewers were re-reviewed and a final determination agreed upon (although not part of our a priori hypotheses, one author (DA) completed online searches of all physicians to ascertain if residency in psychiatry and child and adolescent psychiatry fellowship were completed). We utilized “Organization State” from the resulting data files to create regions using the Electronic Residency Application Service (ERAS) supplemental application definitions (See Table 1 footnotes). The total number of career development awards NIH-wide (K01, K08, K23, K25 and K99) were retrieved from NIH Reporter [13] for years 2013–2022. We ascertained the total number of “Department Type”(s) in NIH Reporter. To examine the number of career development awards per non-psychiatry department, we took the total number of career development awards each year, subtracted the number of career development awards to departments of psychiatry in that same year, and divided by the number of non-psychiatry departments searchable in NIH Reporter.
Table 1.
Geographic distribution of K awards (i.e., K01, K08, K23, K25, K99) to physicians in departments of psychiatry over a ten-year period (2013–2022) by ERAS regions and relative to US population per region in 2013 and 2022
| ERAS Regiona | # of K awards to physicians in psychiatryb | % of K awards to physicians in psychiatry c | % of US Population 2013 per regiond | % of US Population 2022 per regione | # of K awards to physicians in psychiatry per 100,000 people 2013 | # of K awards to physicians in psychiatry per 100,000 people 2022 |
|---|---|---|---|---|---|---|
| Pacific | 32 | 27.1% | 16.0% | 15.8% | 0.062 | 0.060 |
| Mountain | 2 | 1.7% | 7.2% | 7.6% | 0.009 | 0.008 |
| West north central | 10 | 8.5% | 6.5% | 6.4% | 0.048 | 0.046 |
| East north central | 13 | 11.0% | 14.6% | 14.0% | 0.028 | 0.028 |
| West south central | 4 | 3.4% | 11.9% | 12.4% | 0.011 | 0.010 |
| East south Central | 2 | 1.7% | 5.9% | 5.8% | 0.011 | 0.010 |
| South Atlantic | 18 | 15.3% | 20.4% | 21.0% | 0.028 | 0.025 |
| Middle Atlantic | 22 | 18.6% | 12.9% | 12.5% | 0.053 | 0.052 |
| New England | 15 | 12.7% | 4.6% | 4.5% | 0.102 | 0.099 |
Pacific=AK, CA, HI, OR, WA;
Mountain=AZ, CO, ID, MT, NM, NV, UT, WY;
West north central=IA, KS, MN, MO, NE, ND, SD;
East north central=IL, IN, MI, OH, WI;
West south central=AR, LA, OK, TX;
East south central=AL, KY, MS, TN;
South Atlantic=DC, DE, FL, GA, MD, NC, PR, SC, VA, WV;
Middle Atlantic=NJ, NY, PA; and
New England=CT, ME, MA, NH, RI, VT.
= Number of individual career development awards to physicians in departments of psychiatry 2013–2022
= Percent of individual career development awards to physicians in departments of psychiatry 2013–2022
We graphed the mean number of career development awards to non-psychiatry departments by year and the number of awards to departments of psychiatry by year for: all awards, awards to physicians, and awards to physicians without a PhD. For these four groups, we used linear regression in SAS statistical software version 9.4 to estimate slopes (defined as the rate of change of number of K awards funded across these 10 years) and tested whether the slopes differed significantly from zero (indicating no change). We then tested whether the estimated slope for the average number of career development awards to non-psychiatry departments differed from the estimated slopes for: all career development awards to departments of psychiatry, awards to physicians in departments of psychiatry and awards to physicians without a PhD in departments of psychiatry.
Finally, we examined the geographic distribution of individual NIH career development awards to physicians in departments of psychiatry using the ERAS defined Regions. However, because of the modest number of awards to physicians in departments of psychiatry over these 10 years (n=118), we did not examine trends by region but instead present the total number of awards (across 2013–22) for each ERAS region. For comparison, we utilized Census data to show population distributions by ERAS region in 2013 and 2022 [14, 15].
Results
During this ten-year period, 33,392 NIH career development awards were granted, with 534 (1.6%) to departments of psychiatry and 118 to physicians in departments of psychiatry (56 to physicians without a PhD). Online searches confirmed that 115/118 physicians completed psychiatry residency and 27 completed child and adolescent psychiatry fellowship training.
The mean number of career development awards to the 46 non-psychiatry departments increased from 2013–2022 (black square marker, Figure 1) with slope of 3.05, which was significantly different than zero (95% CI 2.09–4.02; p<0.001). The number of career development awards to departments of psychiatry (round marker) also increased during this time with slope = 2.38 and significantly differed from zero (95% CI 0.97–3.79; p=0.005). Neither the trend for number of career development awards to physicians in departments of psychiatry (triangular markers; slope = 0.51; 95% CI −0.39–1.41; p=0.23), nor the trend for the number of career development awards to physicians without a PhD in departments of psychiatry (open square marker; slope = −0.07; 95% CI −0.58–0.43; p=0.75) differed significantly from zero.
FIG 1.
Number of K Awards1 to (1) Departments of Psychiatry (round marker), (2) non-Psychiatry Departments (square black marker)2, (3) All Physicians from Psychiatry Departments (triangular marker) and (4) Physicians from Psychiatry Departments without a PhD (square white marker, bottom line) examining funding of 01 awards from 2013–2022. Linear trend lines added
Figure 1 footnotes.
1 = Includes these mechanisms: K01, K08, K23, K25, K99
2 = All K awards to departments other than Psychiatry, divided by the number of non-Psychiatry Department categories in the NIH REPORTER Advanced search (total number of departments = 47).
We tested for differences in slopes between mean number of career development awards to non-psychiatry departments over time and career development awards to departments of psychiatry (t16=0.9; p=0.37), career development awards to physicians in psychiatry departments (t16=4.5; p=0.0004) and career development awards to physicians without a PhD in psychiatry departments (t16=6.6 p<0.0001) over time. We did not complete online searches to identify degree (MD/MD-PhD vs. PhD) for non-psychiatry department faculty (32,858 awards) and therefore were unable to examine differential trends for physicians specifically in non-psychiatry departments.
Table 1 shows the number and percent of career development awards to physicians in departments of psychiatry by ERAS region during this 10-year period. Census data for each ERAS region is presented for both 2013 and 2022.
Discussion
We examined trends in NIH individual career development awards to departments of psychiatry from 2013–2022. We found that the number of career development awards from NIH has increased over that decade and awards to psychiatry departments have increased at a similar rate as awards to other departments during this period. However, the number of physicians in departments of psychiatry receiving individual career development awards has not grown. Physician scientists play a critical role in patient-oriented research, but their numbers are limited. While the NIH budget has increased from $29b in 2013 to $46b in 2022 [16] (a 58% increase) and the number of career development awards rose from 2,957 to 4,197 during this period (a 42% increase), only an average of 12 physicians from departments of psychiatry (including 2.7 child psychiatrists) received an individual NIH career development award annually during this same period.
Why has the number of annual training grants awarded to physicians within departments of psychiatry during our study period remained essentially constant? One possible explanation is that that the number of physicians entering psychiatry is relatively fixed and limits the available pool of future physician investigators. However, the number of psychiatry residency program positions have increased during this period. According to the NRMP data archive there were 1063 psychiatry residency positions in the 2009 MATCH (those individuals would be anticipated to complete residency in 2013) and this increased to 1556 in the 2018 MATCH (a 46% increase); thus, there were approximately 493 additional residency positions scheduled for completion of training in 2022. It may not be the number of psychiatry residency graduates but instead the pool of individuals focused on a potential research career (i.e., the pipeline of qualified early career physician scientists in psychiatry) that is relevant. Recent work has supported that many residencies report some form of research opportunities in residency, but only about one quarter (58) have a formalized research track and few (22) report specific research track funding [10]. Few MD/PhDs enter psychiatry each year (44–49 per year, in 2020–2022 [7]). Substantial reductions in funding for treatment research at NIMH from 2003 to 2019, along with requirements for identified mechanistic targets prior to pursuit of efficacy trials [6] may also contribute to the declining numbers of physician researchers in psychiatry focusing on patient-oriented research and clinical trials [6].
Understanding the drivers of continued increases in the number of awards for PhDs could potentially be leveraged to develop programs to enhance funding rates for psychiatrists. However, the results from this study, which simply describe these trends, cannot inform such approaches and some barriers/opportunities considered by physician researchers may differ from PhDs (e.g., some PhDs may not be able to transition to high paying clinical jobs). Issues with recruitment and retention of physician scientists, not just in psychiatry, have been a long-term concern [1]. Prior work has discussed potential approaches for development of physician scientists generally [17]. Koelkebeck and colleagues [18] conducted a review of the literature on barriers for early career psychiatrists to pursue research and highlighted: (1) the lack of protected time and work-related stress, (2) lack of funding (e.g., from debt, to lower salaries to lack of funding for research projects), (3) lack of mentorship, and (4) lack of training in research. Early career psychiatrists must wrestle with opportunity costs of pursuing a research career – for example, the median salary for psychiatrists is substantially higher than the NIH salary cap, which increased from 179,700 in 2013 to 203,700 in 2022 (a 13% increase [19]). In addition, K awards offer incomplete salary coverage for the required 75% research effort, meaning institutional support becomes increasingly burdensome for departments of psychiatry when supporting physician scientists. As has previously been described, departments of psychiatry are often already facing financial challenges [20].
In 2014, Feldman and colleagues [3], in the NIH Physician-Scientist Workforce Working Group report, made the following recommendation, “…establish a new physician-scientist-specific granting mechanism…provide a longer period of support, potentially lengthening the R00 phase to 5 years…This new grant series, as well as K and all other training awards, should rigorously enforce protected time of at least 75 percent effort and provide sufficient salary support to make that possible.” Changes like this are still likely needed to support enhancement of the physician scientist workforce in psychiatry. Our results suggest that the current approaches to research training for psychiatrists have not substantially altered the number of physicians in departments of psychiatry receiving an individual NIH career development award from 2013–2022.
Finally, our results further suggest that the distribution of awards does not follow the population distribution generally. Highly competitive research-oriented institutions may be concentrated in ways which do not follow US population patterns. Moreover, highly qualified candidates may have preferred geographic locations (e.g., the US coasts). Still, attention should be paid to the distribution of training awards to physicians in psychiatry to ensure fostering of future academic environments across the US.
Our results must be viewed within the context of multiple limitations. First, the NIH Reporter database does not include awards made to individuals via institutional awards (e.g., via Clinical Translational Science Awards programs or other K12 programs) and we do not include career development awards through the Veterans Affairs system in these analyses. Physicians may preferentially benefit from such awards. Second, our search retrieved only career development awards in the “01” year awarded to departments of psychiatry. Those receiving the grant in another department and subsequently moving to a department of psychiatry would not be identified through our approach. Thus, our results identify individuals who were in a department of psychiatry at the time of initial award. Unfortunately, our results do not allow comparison of trends for physicians in departments of psychiatry to physicians in other departments. The NIH Reporter database does not include information about Principal Investigator’s degree(s) and thus we retrieved information through online searches (location of data online is recorded in our dataset which is made available to others through Open Science Framework). Interestingly, the 2014 workgroup recommended creation of a “Biomedical Workforce Dashboard application that provides real-time tracking of the career development and progression of the workforce.” Such a dashboard (or inclusion of PI degree(s) in the NIH Report searchable database) would allow easy monitoring of trends for physician scientists and comparisons between types of departments.
Funding source:
This work was supported in part by NIMH grant R25MH125758 (ZP, DA, SS) and NIDA grant K24DA058882 (JTS).
Footnotes
Declarations:
The authors declare no conflicts of interest.
Data Availability:
Data generated for this work is available via this link: DOI 10.17605/OSF.IO/TY69Z
REFERENCES
- 1.Wyngaarden JB. The clinical investigator as an endangered species. New England Journal of Medicine. 1979;301(23):1254–9. [DOI] [PubMed] [Google Scholar]
- 2.Arbuckle MR, Gordon JA, Pincus HA, Oquendo MA. Bridging the gap: supporting translational research careers through an integrated research track within residency training. Academic Medicine. 2013;88(6):759–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Feldman AM. The National Institutes of Health Physician-Scientist Workforce Working Group report: a roadmap for preserving the physician-scientist. Clinical and translational science. 2014;7(4):289. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Nathan DG. Clinical research: perceptions, reality, and proposed solutions. Jama. 1998;280(16):1427–31. [DOI] [PubMed] [Google Scholar]
- 5.Salata RA, Geraci MW, Rockey DC, Blanchard M, Brown NJ, Cardinal LJ, et al. US physician–scientist workforce in the 21st century: recommendations to attract and sustain the pipeline. Academic Medicine. 2018;93(4):565–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kayser RR, Arbuckle M, Simpson HB. Pipeline in Jeopardy—Challenges in Developing Patient-Oriented Interventions Researchers in Psychiatry and Opportunities for Action. JAMA psychiatry. 2022;79(2):95–6. [DOI] [PubMed] [Google Scholar]
- 7.AAMC. Report on Residents, Oct 2022. Available from: https://www.aamc.org/data-reports/students-residents/data/report-residents/2023/table-b4-md-phd-residents-gme-specialty, Accessed 27 Jun 2024. [Google Scholar]
- 8.Harding CV, Akabas MH, Andersen OS. History and outcomes of 50 years of physician–scientist training in medical scientist training programs. Academic Medicine. 2017;92(10):1390–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Goldstein JL, Brown MS. The clinical investigator: bewitched, bothered, and bewildered--but still beloved. The Journal of clinical investigation. 1997;99(12):2803–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Blacker CJ, Morgan RJ. Research tracks during psychiatry residency training. Academic Psychiatry. 2018;42:698–704. [DOI] [PubMed] [Google Scholar]
- 11.Nikaj S, Lund PK. The impact of individual mentored career development (K) awards on the research trajectories of early-career scientists. Academic Medicine. 2019;94(5):708–14. [DOI] [PubMed] [Google Scholar]
- 12.Mohammadi E, Olejniczak AJ, Walker GE, Nagarkatti P. The impact of geographic inequality in federal research funding: A comparative longitudinal study of research and scholarly outputs in EPSCoR versus non-EPSCoR states. Plos one. 2023;18(6):e0286991. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.NIH RePORT. Career Development, Jan 2024, Available from: https://report.nih.gov/nihdatabook/category/17, Accessed 19 Apr 2024. [Google Scholar]
- 14.United States Census Bureau. State Population Totals: 2010–2019, 15 Dec 2021, Available from: https://www.census.gov/data/datasets/time-series/demo/popest/2010s-state-total.html, Accessed 19 Apr 2024. [Google Scholar]
- 15.United States Census Bureau. State Population Totals and Components of Change: 2020–2023, 18 Dec 2023, Available from: https://www.census.gov/data/tables/time-series/demo/popest/2020s-state-total.html, Accessed 19 Apr 2024. [Google Scholar]
- 16.Sekar K National Institutes of Health (NIH) Funding: FY1996-FY2023, 8 Mar 2023, Available from: https://crsreports.congress.gov/product/pdf/R/R43341/45, Accessed 19 Apr 2024. [Google Scholar]
- 17.Kupfer DJ, Hyman SE, Schatzberg AF, Pincus HA, Reynolds CF. Recruiting and retaining future generations of physician scientists in mental health. Archives of General Psychiatry. 2002;59(7):657–60. [DOI] [PubMed] [Google Scholar]
- 18.Koelkebeck K, Stefanovic MP, Frydecka D, Palumbo C, Andlauer O, Riese F, et al. Barriers and facilitators to conducting research by early career psychiatrists: a literature review. Global psychiatry. 2019;2(2):135–54. [Google Scholar]
- 19.NIH Central Resource for Grants and Funding Information. Salary Cap Summary (FY 1990-Present) 2024. [Available from: https://grants.nih.gov/grants/policy/salcap_summary.htm, Accessed 19 Apr 2024. [Google Scholar]
- 20.Magen J, Rapaport MH. Psychiatry departments under constrained funding mechanisms or what is a chairperson to do? Academic Psychiatry. 2016;40:869–73. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data generated for this work is available via this link: DOI 10.17605/OSF.IO/TY69Z