Training Physician Investigators in Medicine and Public Health Research

Abstract

Objectives. We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health.

Methods. We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows’ mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations.

Results. Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health–related research or practice (9/12).

Conclusions. A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health.

Translation of scientific advances into measurable public health improvements is unacceptably slow. The schism between “public health” and “medicine” is responsible for staggering shortfalls in achieving advances in population health. Despite its heavy per capita spending on health care, the United States’ performance is mediocre when population-level health outcomes are compared with those of other countries.¹

High quality research addressing how best to apply proven strategies to large and diverse populations is in short supply, with the result that resource allocation is only weakly driven by population-based science. Acute care receives disproportionate emphasis relative to preventing and managing the common, chronic diseases responsible for the greatest burden of morbidity and mortality.² Simple interventions known to improve health outcomes are applied only erratically in everyday practice.³ The divergence of medicine and public health has resulted in practitioners and researchers from these fields working too often in parallel rather than in unison.⁴

Although diverse disciplines must contribute to research dedicated to advancing population health, physician investigators are vital to advancing pragmatic solutions at the medicine–public health interface because their grounding in real-world practice settings can focus efforts to improve health systems’ impact on health promotion, prevention, patient safety, and management of chronic disease.⁵ However, only 385 US physicians graduated from formal public health training programs with masters or doctoral degrees in 2008 to 2009, and public health expertise among physicians is generally lacking.⁶ The supply of physician scientists with the requisite skills to advance pragmatic research at the interface of medicine and public health is simply inadequate to the nation’s health challenges.⁷

The current climate of health care reform, as well as evolving national research priorities, lends urgency to developing physicians’ expertise in population health-focused investigation. First, effective study of the impact of alternative models of care delivery, such as the Patient Centered Medical Home and Accountable Care Organizations, requires investigators grounded in health services and population health–oriented research methods. Second, national research funding priorities emphasize research that translates scientific advances into measurable gains in patient and population health. However, scant training is available to physician investigators in the science of implementation, diffusion, and sustainability, which is a critical foundation for careers focusing on the effectiveness and population-oriented end of the translational research spectrum (also referred to as “T3”-oriented research).⁸ Finally, health care and policy advances require that physicians are grounded in health economics and preparedness.

To address these needs, we therefore established an innovative postgraduate fellowship training program to develop a cadre of physician investigators with the research skills to translate and scale up advances in health to the population level. We describe this program and the initial outcomes from the first 2 cohorts of trainees.

METHODS

In 2004, the NYU School of Medicine was awarded funding (T01 mechanism) from the Centers for Disease Control and Prevention (CDC) to launch a 2-year multidisciplinary fellowship training program for post-residency physicians in medicine and public health research. Initial goals of the “Fellowship in Medicine and Public Health Research” (Fellowship) were to develop, implement, and sustain a public health–oriented research training program to increase the nation’s supply of physician investigators focused on health promotion, disease prevention, and preparedness. Primary objectives included:

• Training physician investigators in research by using a core methods curriculum and active engagement in mentored research,

• Developing sustainable linkages between our academic medical center and front line public health organizations, and

• Leveraging these efforts to create a substantive institutional focus on population health research.

Organizational Structure

An Executive Committee met monthly to guide program design and implementation. Composed of key faculty leaders from each of the 3 participating departments, it oversaw program development, implementation, and evaluation, as well as fellow recruitment, selection, mentor matching, and subsequent progress. Committee members also held biannual guidance meetings with individual fellows to review academic and project progress, problem solve, and plan longer-term research and career strategy. An Internal Advisory Committee of deans, chairmen, and other leaders from NYU’s School of Medicine and related Schools, met annually to optimize integration of Fellowship goals and objectives with those of related programs and initiatives across the campus. An External Advisory Board comprised of local, state, and national leaders in medicine and public health research met annually to provide strategic guidance (Figure 1).

FIGURE 1—

Governance and organizational structure, NYU Fellowship in Medicine and Public Health Research.

Eligibility, Recruitment, and Selection

For each of 2 training cohorts, we sought 6 fellows who had completed a board-certified residency training program in internal medicine, emergency medicine, or pediatrics, the 3 disciplines whose faculty leadership collaborated in launching this initiative. The Fellowship was open to graduating residents as well as junior faculty seeking a shift in career focus toward public health–oriented research. Letters and brochures were distributed nationally by mail and e-mail to department chairs, division directors, and residency program directors in the 3 specialties. By focusing on these 3 complementary disciplines, we aimed to enhance the program’s reach while leveraging institutional strengths in research training, health promotion, and preparedness.

Applicants submitted a statement of career goals, previous research and training experiences, and a proposed area of research focus. Criteria for selection included (1) excellence during clinical training, (2) demonstrated interest in research, (3) commitment to public health, and (4) letters of recommendation. Fifteen completed applications were received for the first cohort and 13 for the second cohort. At least 3 of the 6 members of the Fellowship’s Executive Committee interviewed highly qualified candidates, and the full Committee made all acceptance decisions.

Core Program Elements

We established a new Masters of Science in Clinical Investigation degree with a concentration in Public Health Research. The program intertwined 2 core activities: a formal didactic curriculum in public health content and related research methods, and a mentored research project and thesis.

Core courses.

The curriculum addressed core methods for conducting health system–related research with a population health focus. In addition to the traditional emphasis on Principles of Study Design, Biostatistics, and Epidemiology, required courses included Medical Informatics, Health Services Research, Environmental Medicine, Health Economics and Payment Systems, Infectious Health Threats and Preparedness, and Grant Writing. An overview of the curriculum time table is presented in Table 1.

TABLE 1—

Course Outline for Masters of Science Degree, NYU Fellowship in Medicine and Public Health Research

Season	Courses	Credits
Year 1
Summer	Clinical Research Methods; Introduction to Biostatistics	6
Fall	Health Services Research; Introduction to Epidemiology; Environmental Health I, Scientific Integrity and the Responsible Conduct of Research; Integrative Seminar I	10
Spring	Health Economics and Payment Systems; Advanced Quantitative Methods; Environmental Health II; Independent Research; Integrative Seminar II	13
Year 2
Summer	Independent Research	0
Fall	Medical Informatics; Independent Research; Integrative Seminar III	7
Spring	Infectious Health Threats and Preparedness; Grant Writing; Independent Research; Integrative Seminar IV	6

Integrative Seminar.

Trainees and faculty met each week in a required Integrative Seminar throughout the 4-semester Fellowship to learn content not otherwise covered in the course sequence. Semester-long themes included Principles of Health Promotion, Disease Prevention, and Preparedness; Health Systems–Based Research; The Science of Implementation, Dissemination and Sustainability; and Oral and Written Research Presentation.

Research experience with population health focus.

We encouraged fellows to select research topics consistent with their interest and expertise. Faculty mentors guided fellows to define important, answerable research questions with specific attention to core Fellowship themes of generalizability and sustainability, economic implications, potential for dissemination, and population health impact. Despite the 2-year time frame, we encouraged fellows to explore diverse methods for their research questions, and research approaches included primary data collection and analysis, secondary dataset analysis, and modeling. We encouraged fellows to partner with public health agencies, including the New York City Department of Health and Mental Hygiene (NYC DOHMH), the New York City Health and Hospitals Corporation (NYC HHC), and the New Jersey State Health Department. To facilitate such collaborations, fellows were introduced to potential mentors within each agency through seminars and site visits.

Fellows refined their initial protocols and formally presented their research proposals during the fall semester to a Thesis Committee, consisting of the mentorship team described in the section on Mentorship together with members of the Executive Committee. Thesis Committees critiqued fellows’ proposals with regard to methodological rigor, potential for positive impact on population health, and feasibility within a 2-year time frame.

Mentorship.

We placed considerable emphasis on identifying an effective, multidisciplinary team of mentors for each fellow. At the outset, each fellow was paired with an advisor from the Executive Committee who coached the fellow to identify a primary research mentor. To foster potential mentorship relationships early, fellows met informally with 15 to 20 research faculty to discuss their research and careers. Colleagues at public health agencies distributed fellows’ biographies and research interests to agency investigators with aligned interests. After these introductions, fellows narrowed their choices of primary mentor based on common interests and compatibility. Each fellow assembled a multidisciplinary mentorship team with the primary faculty research mentor at the helm, but also including, as appropriate, a colleague from a public health agency, a junior faculty co-mentor, a site mentor (when primary data collection was planned at a site unfamiliar to the lead mentor), and 1 or more faculty with complementary methodological expertise. We established roles and expectations for the mentoring team members and encouraged weekly meetings with the primary mentor and periodic meetings with the remainder of the mentorship team. Fellows also sustained regular contact with their Executive Committee advisor for general advice, troubleshooting, and program evaluation.

Site visits.

To expose fellows to the wide range of public health programs, institutions, and faculty operating in the New York City area and available for potential training and research collaborations, fellows participated in 14 site visits during their initial months in the program, including NYC DOHMH, NYC HHC, NYC Office of the Chief Medical Examiner, the Center for Urban Epidemiologic Studies of the New York Academy of Medicine, and others. In addition, fellows participated in a DOHMH-sponsored public health seminar series, two 1-day HHC-sponsored Quality Improvement Learning Collaborative Sessions, and numerous outside lectures and special presentations.

Clinical experience.

Fellows maintained modest clinical involvement (10%–20% effort) to remain engaged in patient care and grounded in front-line practice. Settings varied according to the fellows’ specialties and availability of part-time positions. For approximately half of the fellows, clinical practice sites played significant roles in informing or conducting their research.

Paper and grant writing.

Fellows were encouraged to set article- and grant-writing goals with their primary mentors. Peer-led article writing workshops and an in-depth series of Integrative Seminar sessions devoted to manuscript preparation complemented fellows’ mentorship teams in supporting paper writing by fellows. Notification of grant funding opportunities and related logistical support were supplied by fellowship faculty, staff, and mentors. Fellows’ grant-writing skills were developed through participation in an intensive grant-writing seminar at the New York Academy of Medicine as well as by mentorship teams.

Graduation.

Graduation requirements included passing all classes, completing research plan from conception through data analysis, submitting at least 1 abstract to a national professional meeting, submitting at least 1 manuscript for peer review, and preparing a final draft of a grant or career development award. Trainees were required to defend their thesis formally to the Thesis Committee and full Executive Committee. Upon satisfying these requirements, fellows were awarded a Masters of Science in Clinical Investigation.

Program Evaluation

We defined 7 educational objectives that Fellowship graduates were expected to attain upon program completion:

1. Define a specific population-oriented research question with a focus on health promotion, disease prevention, or preparedness.

2. Through appropriate literature review, explain the significance and importance of the research question in the context of current literature and conceptual theory.

3. Specify in detail the study design, population, and sampling method, and selection or development of measurements specific to the research question.

4. Articulate the way in which the research will contribute toward or achieve dissemination of an improvement in health promotion, disease prevention, or preparedness.

5. Write a detailed outline of the plan to collect data and test the hypothesis using an appropriate analytic design.

6. Successfully manage the research investigation to completion.

7. Synthesize, report, and disseminate the research findings as formal presentations (abstracts and posters) and publishable papers, and otherwise publicly communicate the implications of their research broadly and effectively to appropriate stakeholders and policymakers.

These objectives also served as a guide for mentors as they evaluated fellows’ progress during the Fellowship. Two types of outcome metrics, based on performance and academic outcome, were used to evaluate the impact of the Fellowship. Modeled on the Observed Structured Clinical Examination used widely to assess the impact of medical education on trainees’ actual performance of clinical skills,⁹ we developed a novel, multistation, performance-based Observed Structured Public Health Research Evaluation (OSPHRE) to evaluate trainees’ problem-solving competence in population health-oriented research. Tasks included analyzing data and writing an abstract in a condensed time frame, conducting a mock media interview after a possible biohazard event, outlining a quantitative justification for a public health intervention (e.g., depression screening), and mentoring a trainee interested in research. For the first cohort, this performance-based assessment was conducted at the end of the first and second years of the Fellowship; for the second cohort, it was conducted at the end of both the first and second years. Traditional academic outcomes were also tracked, including research output (presentations at national meetings, peer-reviewed publications, and awards of grant funding) during training and after Fellowship completion, subsequent scholarly focus, and academic and leadership positions held. Finally, feedback elicited from fellows and faculty at annual retreats allowed for valuable course corrections and adjustments, ranging from improving access to statistical software to changing the order of core courses in the curriculum.

RESULTS

Two cohorts, each of 6 fellows with diverse backgrounds, enrolled in the Fellowship. The first cohort graduated in June 2007, the second in June 2009. The majority of fellows (9/12) entered the program directly after residency training. Three fellows in each cohort were trained in Internal Medicine, 1 in Emergency Medicine, and 2 in Pediatrics. Nine were women, and 2 were from underrepresented minority groups.

Mentor matching was generally completed within the first 4 months, and refining of research initiatives, establishment of linkages with collaborating agencies, and institutional review board (IRB) submission were accomplished within the first 6 months of the first Fellowship year. Working with their mentors, fellows underwent an interactive process in refining their research proposals, culminating in projects that were approved by the Thesis Committee and NYU’s IRB. Although fellows were typically engaged in more than 1 research initiative, each had a primary project. Table 2 describes participants’ pre- and post-Fellowship positions, primary research projects, and current career foci.

TABLE 2—

Pre- and Post-Fellowship Career Trajectories, NYU Fellowship in Medicine and Public Health Research

	Principal Fellowship Research Initiative		Pre-Fellowship Position	Post-Fellowship Position
Specialty	Title	External Agency Linkage	Title	Title	Focus
General Internal Medicine	A Multilevel Controlled Intervention to Increase Colorectal Cancer Screening Among Latino Immigrants	National Alliance for Hispanic Health	Research Associate	Assistant Professor	Education and training of Masters and doctoral students in public health
General Internal Medicine	Association of Outdoor Ads with Obesity-Related Disparities in NYC	New York Academy of Medicine	Assistant Professor	Instructor	Obesity
General Internal Medicine	Internet Usage Patterns of Patients with Diabetes at Bellevue Hospital	NYC HHC	Resident	Assistant Professor	Health Information Technology
General Internal Medicine	Measuring Patient Outcomes after an Obesity Curriculum for Residents: A Comparison of 3 Different Methods	NYC DOHMH	Clinical Assistant Professor	Assistant Professor	Nutrition and obesity research
General Internal Medicine	Prevalence and Characteristics of Illicit Opioid Users in NYC	NYC DOHMH	Resident	Assistant Professor	Substance use screening and assessment research
General Internal Medicine	Health of African Immigrants in NYC	NYC DOHMH	Resident	Instructor	Medical Director, Correctional Health Services
Emergency Medicine	Factors Associated with Frequent Utilization of Crisis Substance Use Detoxification Services	NYC HHC	Resident	Research investigator	Health policy
Emergency Medicine	Medicaid Patients at High Risk for Frequent Hospital Admission: Real-time Identification and Remediable Risks	NYC HHC, NYC Department of Homeless Services	Resident	Assistant Professor, Emergency Medicine & General Internal Medicine	Research in health care delivery interventions for underserved
Pediatrics	Parents’ Perspectives on Gaining and Maintaining Public Health Insurance	NYC Office of Citywide Health Insurance Access	Resident	Assistant Clinical Professor	Training pediatric house staff
Pediatrics	Randomized Controlled Trial of a Pictogram-Based Intervention to Improve Provider-Patient Communication of Medication Instructions	NYC HHC, NYC DOHMH	Resident	Assistant Professor	Research in health literacy and medication safety interventions in pediatrics
Pediatrics	Readiness to Implement Screening for Maternal Depression Among Pediatricians Serving Low Income Communities	Medical Society of the State of New York	Resident		Private practice
Pediatrics	Maternal Knowledge of Infant Feeding Cues and Maternal Feeding Styles in a Low-Income WIC Population	Public Health Solutions (formerly Medical and Health Research Association); WIC Programs	Resident	Assistant Professor	Research in feeding practices and childhood obesity

Note. DOHMH = Department of Health and Mental Hygiene; HHC = Health and Hospitals Corporation; NYC = New York City; WIC = Women, Infants, and Children.

Table 3 lists the number of peer-reviewed publications, presentations, and grants received that were directly related to Fellowship research. The majority of fellows (10/12) published at least 1 peer-reviewed article related to their Fellowship research (median = 2, range = 0–6). Topics were immediately relevant to population health, and in many cases led to more substantial longitudinal research initiatives that are ongoing. Four fellows in each cohort received a total of 29 extramurally funded grant awards (13 from National Institutes of Health [NIH]/CDC/Agency for Healthcare Research and Quality, 1 from New York State, and 15 from foundations), including career development awards from NIH; Robert Wood Johnson Foundation; Pfizer, Inc.; and New York State.

TABLE 3—

Fellows’ Publications, Presentations, and Research Grant Awards, NYU Fellowship in Medicine and Public Health Research

Outcomes	1st Cohort (2005–2007)	2nd Cohort (2007–2009)	Total
Peer reviewed publicationsa
During Fellowship	2	6	8
After Fellowship completion	12	18	30
Presentations at national meetingsa
During fellowship	10	18	28
After Fellowship completion	24	14	38
Grant awardsb
Federally or publically fundedc	8	6	14
Foundation	12d	3	15

^aIncludes only work on which fellow was the first, second, or senior author.

^bIncludes only grant awards on which fellow was principal investigator or co-principal investigator.

^cIncludes career development awards (1 National Insitutes of Health [NIH] K23, 1 NIH Kl2, 1 New York State Empire Clinical Research Investigator Program award), and 2 R01 awards.

^dIncludes 1 Robert Wood Johnson Foundation and 2 Pfizer Foundation awards.

Performance Evaluation

The first cohort of fellows completed a single performance-based OSPHRE at the end of their second year (6/6 completed). The second cohort completed OSPHREs at the end of their first (5/6 completed) and second (6/6 completed) years. Although this small sample size precluded formal analysis, preliminary data from the second cohort suggested improved performance from first to second attempt in domains of analyzing and reporting data, being interviewed by the media, and basic research mentorship skills. Areas for additional development, such as specific statistical skills, or mentorship approaches, were highlighted in tailored feedback to fellows as indicated according to performance.

Influence on Fellows’ Career Paths

All 12 fellows fulfilled the Fellowship program requirements and were conferred a Master’s of Science in Clinical Investigation upon graduation. Of these, 9 now have careers with specific foci at the medicine–public health interface. One contributes frequently to the literature as director of health care at a large urban correctional facility, another is a full-time investigator at a major health policy research consortium, another joined the faculty of a new school of public health, and 6 have secured positions in academic medical centers at the Assistant Professor rank, where they are actively engaged in public health–oriented research (Table 2). Selected examples of leadership roles in the latter group include spearheading an initiative to provide comprehensive assessment and housing to high-risk patients to prevent frequent hospital admission, advising the Institute of Medicine and CDC regarding health literacy and medication safety, and co-leading a large US Department of Agriculture grant to address childhood obesity. Two fellows became clinician-educators, and 1 entered private clinical practice.

DISCUSSION

We describe a unique and successful Fellowship that trained physician scientists to become leaders in research focused on improving population health. The Fellowship addressed the critical need for physician investigators trained to conduct research that advanced the design and downstream impact of interventions with potential to improve the health of populations.

Several unique aspects of the Fellowship contributed to its success. Its multidisciplinary nature brought together fellows and faculty in the fields of Internal Medicine, Pediatrics, and Emergency Medicine. Didactic and research discussions were enriched by perspectives encompassing the full life span, as well as a broad swath of the health care system with which patients have first contact (e.g., adult and pediatric primary care and emergency department settings). Fellows, nearly all of whose mentorship teams included faculty from other disciplines, commented frequently that they valued their interactions with trainees and mentors with diverse training and backgrounds. The essentially interdisciplinary nature of public health research was further emphasized through the participation of mentors and seminar leaders in health economics, health policy, nutrition, and other fields at allied NYU Schools and NYC agencies.¹⁰

Partnerships with front-line public health agencies, although not without implementation challenges, were central to the Fellowship’s success. Fellows interacted most with the NYC DOHMH and NYC HHC, and these relationships became the central platform for a number of research projects. Challenges reflected differences between public health agency and academic missions and time frames. The urgency felt by public health agencies to advance implementation and evaluation of key initiatives was not always aligned with the academic research process time frame, which included defining, refining, and obtaining IRB approval before an investigation could even begin. In other instances, time pressure felt by fellows to complete publications helpful for advancing the next stage of their careers proved out of step with the pace of an agency initiative. Nonetheless, although not every fellow worked successfully with a public health agency, important collaborations ensued. Fellows’ navigation of these relationships served to lay a foundation for what have become steadily strengthening research collaborations between our academic medical center and agency colleagues.

A fundamental characteristic of our Fellowship was its central focus on themes of implementation, dissemination, and sustainability. From the application process through to final thesis seminars, the program encouraged fellows to define research questions addressing these essential constructs. An entire semester of the weekly Integrative Seminar was devoted to discussing core papers addressing the science of implementation, dissemination, and sustainability, anchored by reading Rogers’ seminal Diffusion of Innovations.¹¹ This emphasis framed a requirement that fellows’ research pass a rigorous “so what” test by the Fellowship’s Executive Committee. Our focus on these themes predated the NIH’s initiation of conferences and funding in implementation science, and has positioned graduates well in the challenges posed by health reform to implement and sustain innovative models of care.^12,13 Several fellows received related research grant support.

Most postgraduate research training programs for physicians have a subspecialty focus and target basic and clinical, as opposed to population– and health system–oriented, research. Traditional fellowships in General Internal Medicine, Pediatrics, and Emergency Medicine provide basic research skills and mentorship to pursue clinical research, but do not typically foster acquisition of in-depth population research skills or collaboration with colleagues from other specialties and public health agencies. Although our program shared important areas of focus with the Robert Wood Johnson Foundation’s Clinical Scholars Program and its Health & Society Scholars Program, as well as with some Agency for Healthcare Research and Quality funded T32 initiatives, it was distinguished by its core emphasis on issues of implementation, dissemination, and sustainability, and on forging collaborations with front-line public health agencies. Whereas some programs impart research training to mid-career faculty, we chose to focus primarily on fellows in the post-residency period, valuing the early acquisition of research skills over the greater understanding of real-world context that accompanies additional years of experience.^14,15

Fellowship participants acquired substantive research skills and experience, allowing them to graduate with tangible successes and strong prospects for making meaningful career contributions to population health. Early indications point to significant downstream impact of a number of Fellowship research initiatives that served as pilots for scaled up, extramurally funded initiatives currently being pursued by graduates as junior faculty. Three fourths of graduates have now embarked on research-oriented career paths with a focus on medical care delivery and public health. Our outcomes compared favorably with those reported by other highly selective research fellowship training programs. In separate surveys conducted of graduates of the Harvard General Internal Medicine Fellowship Program as well as of the National Cancer Institute’s Cancer Prevention Fellowship, the median number of fellowship publications was 2, the same number we reported.^16,17 After completion of the Harvard fellowship, 47% of graduates were engaged as clinician-investigators, 22% as clinician administrators, and 30% either as clinicians or clinician-educators, indicating that heterogeneity of career paths among graduates of research fellowships was seen in other research training programs as well.

The Fellowship provided additional, secondary benefits. Fellowship funding facilitated recruitment of research faculty, including a health economist and a physician investigator in the field of health-related behavior change. Research investigations initiated by fellows resulted in important new collaborations and alliances. The Fellowship program leveraged the creation, at the School of Medicine level, of a new Population Health Research Initiative, a transdisciplinary undertaking focused on advancing T3-oriented research in close collaboration with NYU’s CDC-supported Prevention Research Center and its NIH-supported Clinical and Translational Science Institute. The Masters of Science degree pioneered by the Fellowship facilitated establishment of an allied training program in Translational Medicine within the Clinical and Translational Science Institute, and provided the framework for a new K12 award to train junior faculty in comparative effectiveness research. Most recently, a new Department of Population Health has been launched at our medical school. Taken together, these related developments are testimony to the impact that extramural support for a training program can have in providing critical “activation energy” at an academic medical center ready to expand in the targeted area.

Despite the Fellowship’s emphasis on sustainability, it faced its own challenges in this domain. The Institutional Research Training Grant Program, through which the Fellowship was funded, was not slated for long-term support at the CDC. As a result, the Fellowship program was not able to recruit subsequent cohorts. This challenge was emblematic of the critical shortfall in national support for postgraduate physician training in T3-oriented research, which was particularly acute for the generalist specialties whose fellowships were not supported by Medicare graduate medical education funding. The Robert Wood Johnson Foundation programs mentioned previously, while outstanding, are offered at only a limited number of sites, and new Agency for Healthcare Research and Quality T32 opportunities are infrequent. Inadequate support for physician investigator training in population health-oriented research, with no federal agency as enduring champion, is a significant barrier to building much needed research capacity in this era of reform and attention to the impact of health care delivery on the health of populations.^18,19

Our experience indicated that a research fellowship for physicians can bridge the divide between medicine and public health and advance the conduct of applied population-based research. Core didactic training together with mentored research experiences in real-world settings built core skills and experience. Fellows conducted substantive research, often with enduring impact, and most are currently engaged in public health practice or research. Ultimately, the Fellowship’s legacy will be in the impact of its graduates on health. Preliminary indications bode well. Our experience and the success of our fellows suggests that policies to promote funding for such multidisciplinary, population-health focused research training programs for health professionals should be actively pursued.