Commentary: Routh Early Career Award: The “Not-So” Painful Journey of a Pediatric Pain Researcher

As a psychologist who studies pediatric pain, I frequently get questions about my area of interest from people outside of my field. The most common is an incredulous, “Children have chronic pain?” This question provides me with an opportunity to offer people a bit of psycho-education about a commonly overlooked pediatric health problem and to talk about my research. To most people, studying pain in children sounds like a painful endeavor. But as crazy as it may sound, studying pain is “not-so” painful. Yes, there are jokes and comments from strangers at parties, and of course the usual research-related struggles (e.g., obtaining grant funding, finding sufficient nonclinical time). That said, pain is a fascinating subject area that bridges basic science and clinical research in new and exciting ways. By definition, pain is a subjective interpretation of an objective experience. It provides a rich opportunity for examining the intersection among individual differences, biological factors, and environmental influences that we as psychologists love to explore.

Throughout my “not-so” painful early career I have benefited immensely from guidance, advice, and practical tips from research mentors, clinical supervisors, senior colleagues, peers, and students. As I continue to grow in my career, the impact of what I have learned from others has become more salient and meaningful. This article presents 12 lessons I found particularly useful in guiding my early career. I am honored to share what I have learned thus far along my “not-so” painful journey.

Lesson 1: Follow Your Dreams

In 1996, I was a junior attending South Eugene High School in Eugene, Oregon. All students participating in the high school’s International Baccalaureate program needed to complete an honors thesis project to fulfill graduation requirements. We were free to select our topics based on area of individual interest; I chose to study the psychological impact of cancer on children and adolescents. My research included developing a survey on attitudes about death and dying, interviewing Child Life Specialists at Oregon Health & Science University (OHSU) in Portland, OR, and speaking with pediatric cancer survivors. At the time I completed this project, I knew very little about research methods and had never heard of the field of pediatric psychology. That said, embarking on this 2-year endeavor as a high school student laid the groundwork for my career. In conducting this research, I learned about pediatric psychology and was introduced to this intriguing field that integrates psychology and medicine. In other words, I was hooked on pediatric psychology when I was only 16 years old.

Following graduation, I pursued a psychology major at the University of Oregon and then completed a child life internship at the Women and Children’s Hospital of Buffalo in Buffalo, NY, to gain hands-on clinical experience with pediatric populations. In 2004, I was accepted into the Pediatric Psychology training program at Case Western Reserve University. Under the mentorship of Dr. Dennis Drotar, I gained the foundational research and clinical skills I needed to become pediatric psychologist. In my path from high school to the present, I followed my dream and accomplished the goal I set for myself nearly twenty years ago. The reality of this accomplishment was solidified just six months ago when I became a faculty member at OHSU. The institution that supported my venture into the field of pediatric psychology research as a high school student is now my employer. To the many students and early career psychologists out there: follow your dreams, they may be more achievable than you think.

Lesson 2: Choose Mentors Who Will Challenge You

I am grateful for the strong mentorship I received over the last 15 years. From my early days as graduate student to my current role as a new faculty member at OHSU, I have many people to thank for their wisdom, leadership, and support throughout my clinical and research endeavors. My advice to people at all stages in their career is to choose mentors who will challenge you. While a nurturing relationship is important, choosing mentors who expect the best and will push you outside your comfort zone will put you on the road to success. Doctors Dennis Drotar, Gerry Koocher, and Tonya Palermo are three individuals who fit this description and truly shaped my career.

Working with Dr. Drotar taught me that mentor–mentee relationships built on respect and admiration also benefit from a little fear. For those of you who know Dr. Drotar, this may sound ridiculous. Why would anyone be afraid of such a soft-spoken kind-hearted man? For me, the fear stemmed from not wanting to disappoint a mentor who invested so much time and energy into my career. As a leader in the field of pediatric psychology, Dr. Drotar was the principal investigator on a National Institute of Health (NIH)-funded training grant (T32) that supported our training. Dr. Drotar’s high expectations are what pushed me to begin publishing as a graduate student. His firm and no-nonsense manner were keys to my early success: working with Dr. Drotar, I got things done, no excuses.

In the next stage of my training as an intern at Boston Children’s Hospital, I had the good fortune of receiving clinical supervision from Dr. Gerry Koocher. Dr. Koocher has amazing clinical acumen and a tremendous breadth of knowledge of pediatric psychology. Having the opportunity to learn from one of the field’s finest was both intimidating and exciting at the same time. Knowing that Dr. Koocher would question me about my case conceptualization and treatment approach, my trek across campus always included a hint of trepidation. Had I prepared enough? Had I done the right thing in session? Dr. Koocher pushed me to work hard with my patients, not by being overly critical but by being a supervisor who expected the best out of his trainees. I will be forever thankful for Dr. Koocher’s wisdom and, of course, for the fact that he filled his office with chocolate.

Finally, Dr. Tonya Palermo has been my role model since I was an eager first-year graduate student at Case. Her name always seemed to come up when people were describing successful Case graduates. Often these conversations included a description of some big research accomplishment that was followed by, “Well, Tonya Palermo did it.” Seeing Dr. Palermo’s success encouraged me to try new things and over the past 10 years, under her mentorship, I have been able to accomplish feats I didn’t think were possible. Dr. Palermo taught me many of her tricks, particularly the value of persistence. She has high expectations of her students and the no-nonsense qualities I aspire to have as a mentor one day.

Doctors Drotar, Koocher, and Palermo all taught me that success involves hard work; there are no short cuts. And of course, there are the “little” lessons, like turning things in well before deadlines, you should always prepare an agenda for meetings, and try to go above and beyond in all that you do. Reflecting back on my relationship with these mentors, I see that my motivation to do well was not only fueled by my desire to succeed but also by my trepidation in disappointing the mentors who spent so much time working with me. Choose mentors who challenge you: You might even surprise yourself by what you can accomplish.

Lesson 3: Identify Your Area of Interest as Early as Feasible

My first publication was a paper completed as part of a graduate school requirement at Case Western Reserve University. Each first-year student was required to do a research project under the tutelage of a faculty member. The project was seen as a way to teach students research and writing skills in preparation for their Master’s thesis. Dr. Drotar suggested that I work with Dr. Tonya Palermo, one of his former students and a new faculty member with an interest in chronic pain. This fortuitous recommendation was a launching point for my career. My first-year paper examined associations among emotional functioning and activity limitations in a chronic headache sample. We found that functional disability mediated the association between pain and depression and that this effect was moderated by age (Lewandowski, Palermo, & Peterson, 2006).

When I started this project my goals were to learn about research methods, write my first paper, and get it published. I did not know that this paper would be a launching point for my research career studying pediatric chronic pain. It was through this work with Dr. Tonya Palermo that I learned about the significant impact of chronic pain on children and adolescents. The level of impairment in a subset of these youth was striking to me, and I started to ask more questions about individual factors that were associated with risk and resilience. Moreover, in working with Dr. Palermo, I learned about the comorbidity of sleep disturbances in this population as well as the elevated conflict levels in many of these families. By the time I completed graduate school, I knew that my career focus would be studying and treating chronic pain in children and adolescents.

Reflecting back on my career, I recognize how valuable it was to have a clear direction early on. I was able to build a knowledge base and develop a cohesiveness to my CV that has been very useful for grant applications, job opportunities, and research collaborations along the way. When asked to speak about my career, having the common thread of pain research gives me a unifying language, a way to draw together my experiences across studies, jobs, and locations.

I recognize that choosing a defined path so early may not be possible for all students or early career psychologists. Many individuals are confined by the limitations of their program, advisor, or available resources. Graduate training is often linked to being part of a laboratory and working with a mentor on his or her own research projects. For some, this research area parallels their own interest, but for others, it is a stepping stone before launching off into their own career. That said, having a common thread or theme is useful and can help you later in your career as you make decisions on your next steps. As you make choices in your training and career, think proactively. Identifying themes in your research and clinical interests early in your training can help you to make calculated decisions to get to where you want to be.

Lesson 4: Write a Review Paper

I will start this section with a disclaimer: Writing review papers is challenging. These papers are labor-intensive and require exhaustive literature searches and the integration of vast amounts of data. That said, these manuscripts are well worth the effort. Writing a review is a great way for people early in their careers to boost first author publications. Advice that I often give psychologists embarking on a research career is “Maybe you don’t have data yet, but can you write a review paper?” The most meaningful reviews on which I have participated have focused on topics directly related to a current research interest or those about which I was seeking to learn more in preparation for writing a grant. One example is a review of pediatric sleep measures published in the Journal of Pediatric Psychology (Lewandowski, Toliver-Sokol, & Palermo, 2011). This review examined the psychometric properties of sleep assessment measures commonly used in pediatric psychology research and rated the evidence base for each measure’s use. This paper not only made a unique contribution to the literature but it has also informed my choices regarding sleep assessment tools in my research.

Writing a review can also provide you with the opportunity to collaborate with colleagues at other institutions or in foreign countries. This is because reviews involve defined tasks, work that can easily be accomplished by people in different geographic locations. Writing a review paper also encourages researchers to immerse themselves in a topic and become an expert. This is particularly important for people early in their careers seeking to make a name for themselves among more senior researchers. Finally, write a review because these papers can have a big impact on the field. The reviews I have worked on are some of my top-cited publications, and I often get e-mail inquiries about these manuscripts from colleagues, students, and the general public. So my advice to you: Bite the bullet and write a review paper (or two or three). It is well worth the effort.

Lesson 5: Draw Inspiration From Other People’s Work

This advice is especially important early in your career when you are seeking new ideas or are not quite sure what direction you want to go with your research. Read journals for inspiration and ask yourself a few important questions, “Can I adapt this research question to my work with children?” or “How can I use this type of data analysis in my own research?” I can think of several times in my career when a light bulb went off while I was reading a research paper. One recent example relates to a paper I coauthored that examined reciprocal associations among pain and depressive symptoms in adolescents (Lewandowski Holley et al., 2013). My idea for this paper was sparked while reading an article in which the authors used multilevel modeling to examine associations among pain and mood in adults with back pain (Kroenke et al., 2011). I was struck by the uniqueness of the authors’ approach, and I knew that a study using this methodology had not yet been conducted with children. Moreover, Dr. Tonya Palermo had data from a longitudinal study that could be analyzed using a similar methodological approach. Results from our study showed that changes in pain predicted mood at subsequent time points, and changes in mood predicted subsequent pain. Conducting the analyses and writing this paper was a valuable learning experience and also a good way to get a first author publication. It also fueled my motivation to keep reading the literature. In summary, seek inspiration from the research around you. Whether it is reading journals, attending conferences, or talking with colleagues, you can learn a lot from these sources that will help you generate new directions for your own work.

Lesson 6: Challenge Yourself to Learn Something New

The last thing I imagined when I started my graduate training in psychology was that my research would involve bringing families into a laboratory and conducting experimental pain studies. My vision for my career was helping people, not applying hot and cold sensations and asking participants to (1) tolerate it for as long as possible and (2) rate how much pain they had just experienced. Joking aside, learning experimental pain research and actigraphic assessment of sleep and physical activity has forced me to step outside my comfort zone. My current research is a longitudinal prospective study examining risk factors for the development of chronic musculoskeletal pain in children and adolescents. This project involves bringing children and parents into the laboratory and testing pain modulation using a heat thermode and the cold pressor. Although laboratory techniques are not new to the field of pain research, they were new to me. Conducting experimental pain tasks involved obtaining training in something completely new. I not only needed to learn how to navigate new technology, but I had to learn the “language” of an entirely different research area. The outcome of pursuing this new research direction has been worthwhile, both in terms of publications and having a new skill set to use in future grants and research projects. Moreover, by conducting experimental pain research, I feel like I can make a unique contribution to the literature. Laboratory studies with pediatric pain populations are important both for increasing our understanding of factors that influence alterations in pain processing systems and for identifying mechanisms associated with the development of chronic pain (Wilson, Holley, & Palermo, 2013). My advice to you: try something new. You never know where it may lead you.

Lesson 7: Learn When to Say Yes and When to Say No

As an early career clinician and researcher, I have already started to feel the pressure of deciding which opportunities to accept and which to decline. Watching my mentors navigate their own careers, I have seen that the more successful you are, the more you are asked to do things. Unfortunately, as you become more accomplished, the 24-h day doesn’t get longer and it is impossible to do everything.

Dr. Tonya Palermo has a special handwritten sign in her office reading, “Just say no!” that comes out a few times each year. As her mentee, I learned that this sign appears at key times: when Dr. Palermo has a grant deadline, a study section, or conferences to attend. The sign is a reminder to Dr. Palermo to focus on her own work and her own research priorities. Working with Dr. Palermo, I have learned that to be successful, one must learn when to say no. Occasionally, researchers need to prioritize their own work and deadlines: Saying no is important to staying on the road to success.

That said, knowing when to say yes is just as important as when to say no. In 2010, I was invited to serve as the Program Chair for Division 54’s conference programming for the 2012 American Psychological Association Convention. I knew that the opportunity to be on the board of Division 54 was something I could not pass up. I had spent years as a trainee in the Society of Pediatric Psychology, and I knew being a board member would be crucial to my transition from being student member to becoming a colleague. My position as a Program Chair helped me to network with others in the field, and I am pleased to say, moved me from citing the experts to knowing them in person, sharing a dinner, and collaborating on their research projects. My advice to you, taken from Dr. Palermo, is to learn when to say yes and when to say no.

Lesson 8: Apply for Small Grant Funding

Apply for small grant funding because small awards can have a big impact. In 2011, I was a new faculty member in the Department of Anesthesiology and Pain Medicine at the University of Washington. Each year, the department awards one or two $10,000 grants to junior faculty members seeking to fund small research projects or kick start larger research studies. I applied for a grant to study associations between smoking and chronic pain in young adult twins. My interest in twin research was piqued after learning that the state of Washington collects information on twin status through the Department of Motor Vehicles’ records. Initially, these data were collected to avoid issuing duplicate licenses, but later they served a second purpose and became a recruiting database for health researchers at the University of Washington (Strachan et al., 2013). I had an interest in twin research and knew that pain items were included in the questionnaire so, I thought, why not apply for a grant? I was successful in getting the grant and later published the findings. Results of my study revealed that associations among smoking and chronic pain in young adult twins are better accounted for by non-shared factors than by shared familial factors/genetic effects (Holley et al., 2013). This interesting finding further sparked my interest in studying how social and emotional factors (e.g., roles, attitudes, reinforcement by others) influence health behaviors and pain.

Obtaining this small grant was also important because I needed grant writing experience. My goal was to obtain an NIH Career Development Award, but I had never applied for independent funding. Moreover, this project gave me the much-needed confidence and experience to apply for even larger grants. Apply and keep applying: You never know what you will get, and these small funds can be invaluable to your career.

Lesson 9: Aim High Even Against Big Odds

I feel like we do this every day as clinicians and researchers. We take on challenging clinical cases and submit manuscripts to top-tier journals. For me, the biggest challenge of my career, thus far, was applying for a Career Development Award (K23) from the NIH. If you have looked into this—or any NIH award—the statistics are daunting. As junior researchers, we can easily get discouraged when hearing the doom and gloom of funding statistics. Faced with low success rates, many people early in their careers may shy away from pursuing grant funding. We see our mentors and senior colleagues struggling to support their own work, and it can make us call into question our own ability to succeed. In addition, writing a grant takes huge amounts of time and energy and, for new researchers, this often means fitting grant writing into a packed clinical schedule.

When deciding whether to write a K23, I muddled over these “what-ifs” and my own self-doubt. Moreover, even after I wrote the grant, a colleague suggested one week before the submission deadline that I probably should not submit the application because it was unlikely it would be funded. I ignored that recommendation, sent in the application, and was awarded the grant. I am currently in the middle of the 5-year research project that uses a combination of psychophysical and psychological assessment to understand the mechanisms that contribute to the transition from acute to chronic musculoskeletal pain. Specifically, the project aims to (1) identify psychological, psychophysical, and parent factors that predict the development of chronic pain in youth with new-onset musculoskeletal pain complaints and (2) determine the feasibility and efficacy of a Web-based behavioral pain intervention for children and adolescents with this type of pain. Facing long odds and applying for this grant taught me it is important to aim high; you never know what you may achieve. Yes, it is a tough climate but people do succeed, it might as well be you garnering money to support your own research.

Lesson 10: Rejection Makes the Heart Grow Fonder and the Paper Stronger

A few months ago, I read an interesting article published in Science regarding rejected manuscripts. The authors analyzed data on the submission history of over 80,000 manuscripts submitted to 923 bioscience journals over a two-year period from 2006 to 2008. Results showed that when manuscripts were rejected by one journal and subsequently accepted by a different journal, they received more citations than those accepted to the original journal (Calcagno et al., 2012).

As an early career researcher, I can list a number of manuscripts that I coauthored that were rejected by one journal and subsequently accepted by another. I vividly remember the first rejection e-mail I received when I submitted one of my earliest papers for publication. It was disheartening to learn that, while I had put so much time and energy into the manuscript, it would not be considered for publication. With the support of my coauthors and mentors, we revised the paper, submitted it to a different journal, and eventually received that acceptance letter for which I had been waiting. In the years that followed, I have had to use similar perseverance (and a refusal to bow to defeat) for other publications. Yes, rejection still hurts, but revising and resubmitting papers is a part of our job. Now we have data to back up the old adage (revised a little): Rejection makes the heart grow fonder and the manuscript stronger.

Lesson 11: Don’t Be Afraid to Make Changes Midstream

We all will face key decision points in our career, and sometimes these are major choices that will impact the direction of both our personal and professional lives. I figured this was on the horizon sometime in my life, as I have witnessed many mentors and colleagues make significant career moves. For me, it just happened sooner than expected. In the Fall of 2013, my family circumstances changed, and I needed to move. The prospect of changing cities and jobs was difficult on multiple levels, the majority of which related to my career. I was in the middle of my K23, the grant I had worked so hard to get. My mentor and entire research team were in Seattle, WA, and there were the daunting logistics of starting a new job and transferring an NIH grant.

I am now several months postmove and am happy to report that it all worked out well. I exchanged one beautiful city for another, one great workplace for another, and a city known for its coffee for a city known for its microbrews. The move also forced me to step outside my comfort zone. In Portland, I needed to network with new colleagues and develop new research collaborations. While scary, tackling these opportunities has helped me gain independence as a researcher.

This journey has taught me the importance of seizing new opportunities if they present themselves. Changes midstream can be scary, but you just may end up where you are supposed to be. Remember my high school honors thesis? By ending up in Portland, Oregon, at OHSU, I have literally come full circle.

Lesson 12: Remember What is Most Important

You will have good days at work, and you will have bad days at work. An academic career is not without ups and downs and, in fact, is probably defined by them. Remembering what is important will help you to keep things in perspective, stay grounded, and continue trudging ahead when things aren’t going well. The things that make us happy vary, as do the people, values, and mementos we hold most important. While pursuing your training and your career, always reflect back on what is important to you; I truly believe that is an important part of your path to success.

Funding

This article was supported by a K23 Career Development Award from the Eunice Kennedy Shriver National Institute on Child Health and Human Development (HD071946).

Conflicts of interest: None declared.