The Rehabilitation Medicine Scientist Training Program: Updates and Perspectives on Addressing an Ongoing Need in Physiatric Research

Abstract

The shortage of physician-scientists in Physical Medicine and Rehabilitation remains a critical problem. The Rehabilitation Medicine Scientist Training Program (RMSTP) was developed in 1995 to provide structured career development training for aspiring rehabilitation medicine researchers. Initially funded by a 5-year K12 grant from the NIH National Center of Medical Rehabilitation Research (NCMRR), the structure was revised in 2001, continued in a stable format through 3 additional funding cycles (2001–2006, 2006–2012, and 2012–2016), and was again revised to a research education program (NIH R25) model in 2019. With this change in format of the RMSTP we now report the productivity of funded trainees and discuss future directions informed by the RMSTP’s current R25 structure.

INTRODUCTION

There is a shortage of well-trained physician-scientists in PM&R. In general, they are difficult to recruit and retain and have been called “endangered species”¹. The absolute number of physician-scientists has declined in the last decade and the age of this cohort of researchers is on the rise¹. There is also a gender gap with fewer female researchers. Female academic physiatrists feel less supported in conducting research and apply for fewer grants than their male counterparts².

Medical school faculty are key trainers of future physician-scientists, yet more than 86% of osteopathic and 46% of allopathic medical schools in the US lack academic departments of PM&R with training programs³. Many lack substantial research programs and lack role models for future physiatric researchers. Compared to related specialties that frequently collaborate clinically with PM&R such as orthopedics and neurology, there are fewer PM&R departments with any NIH research funding (Figure 1)⁴. 29% (n=26) of all academic PM&R departments have NIH funding compared to 26% (n=46) of all academic orthopedic departments and 53% (n=80) of all academic neurology departments. Moreover, when considering departments with NIH funding in 2019, the average number of funded PIs was lower in PM&R departments (mean 3.5) compared to Orthopedic (mean 4.0) and Neurology (mean 11) departments. This translated to less total NIH research dollars in PM&R than other related specialties in 2019 (Figure 2)⁴. Few departments can substantially support their research mission without strong extramural support, and inadequate research funding can quickly decimate progress made through career development support⁵. In order for PM&R departments to prosper in academic institutions and to be self-sustaining sources of future academicians, it is essential that more departments are populated by rigorously trained researchers with track records comparable to those in other specialties.

Figure 1.

Number of PM&R Programs at US Medical Schools with NIH Research Funding in 2019 Compared to Related Specialties (from the Blue Ridge Institute of Medical Research)

Figure 2.

Total NIH Research Funding in 2019 of PM&R Programs at US Medical Schools Compared to Related Specialties ($ millions, from the Blue Ridge Institute of Medical Research).

The Rehabilitation Medicine Scientist Training Program (RMSTP), launched in 1995, was designed to address the shortage of physician-scientists in PM&R through an NIH K12 grant mechanism. In 2001 the structure of the RMSTP was revised and a detailed history has previously been reported⁶. The RMSTP was refunded twice since 2001 with the most recent funding cycle running from 2012–2016. At the end of this cycle the National Institute of Child Health and Human Development (NICHD) announced their intention to phase out discipline-specific K12 grants in favor of institutional and individual awards, and also to eliminate the specific physician focused K12. With this shift, we transitioned the RMSTP to a research education program model and obtained R25 funding from NICHD in 2019. We now refer to the program format from 2001–2016 as K12RMSTP and from 2019 to present as RMSTP. In light of these changes, we now review the impact and past structure of the K12RMSTP, and how it might inform future models for training physician scientists in PM&R, including the current RMSTP.

PROGRAM DESIGN

Overview

The K12RMSTP included the following phases: Pre-application, Phase 1 (funded) and Phase II (mentored, unfunded). The program phases have been described in detail previously⁶, but are briefly presented below followed by a detailed description of the Research Career Development (RCD) Workshop curriculum and networking activities. The K12RMSTP was jointly managed by two program directors (Drs. Boninger and Whyte) from 2006–2016. An Advisory Board consisting primarily of highly successful physiatric researchers worked with the program directors to select individuals for the pre-applicant and applicant phases of the K12RMSTP. Additional Advisory Board responsibilities included attending the AAP annual meeting and participating in the RCD Workshop’s didactic and small-group mentoring sessions. Advisory Board members serve as constant resources for K12RMSTP participants by providing individual advice as needed and by facilitating networking, providing guidance on successfully translating skills acquired in training to rehabilitation themes, interfacing with the national scientific community to help recruit participants, monitoring the overall progress of the K12RMSTP, and providing feedback to the program directors.

Pre-application Phase

The goal of the pre-application phase was to foster the most and highest quality applications for the funded portion of the K12RMSTP. Since the grooming provided within the pre-application pathway is relevant to any mechanism of career development support, the RMSTP philosophy has been to provide this guidance to as many pre-applicants as is reasonable to accommodate (knowing that a few will be funded by the K12RMSTP, a few will recognize that this is not the career model for them, and others will seek other forms of career development support). Increased demand, as well as supplemental funding from the Craig H. Neilsen Foundation, led the pre-applicant pool to grow from 6–9 per year in earlier funding cycles to 11–17 per year in the most recent cycle. Pre-applicants typically spend anywhere from a year to several years in the pre-applicant phase depending on how early they applied, whether they undertook a clinical subspecialty fellowship prior to applying for K12RMSTP funding, and their previous background (e.g., PhD). Participation in the program as a pre-applicant entailed attendance at the annual RCD Workshop, quarterly mentoring phone calls with one of the program directors, and development of the Phase 1 application. The curriculum design for the pre-application pathway was intended to result in selection of a highly qualified mentor and development of a competitive application. Accordingly, participants spent time refining their research interests, determining the skills and mentorship they would need, identifying and negotiating with specific mentors, and designing a career development plan and a research plan in collaboration with their mentor(s). Participants were challenged to identify research domains that defined their scientific interests rather than defining their interests based on specific patient populations or problems. Key mentor qualifications included content expertise to support the project, a strong mentoring, publication and funding track record, and adequate funding, resources and infrastructure to support a K12 fellow during the award period. Applicants were encouraged to seek out the most qualified mentors and to embed themselves in the mentor’s group for the duration of their fellowship. Scientists from diverse specialties and backgrounds were identified as qualified mentors, including basic researchers, bioengineers, and clinician scientists in PMR, neurology, orthopedics, and other related fields.

Phase 1

Phase 1 fellows were awarded up to 3 years of salary and research support, contingent upon satisfactory progress. This phase was focused on optimizing productivity as well as overcoming challenges faced during this period. Trainees were strongly encouraged to identify projects in their mentors’ laboratories that would support early publications while their more autonomous projects were maturing, and they were encouraged to identify early grant funding timelines both as grant writing practice and to augment their research resources.

Phase 2

While K12 funding was limited to three years, the K12RMSTP faculty continued to provide mentorship for an additional two years to help with the transition to independence. During this period, Phase 2 fellows received training and guidance in how to effectively negotiate departmental support (including space, start-up packages, and salary support), identify research roles on their mentor’s projects, secure pilot funding, and to develop viable next funding steps. Many trainees remained in the environment where they completed their post-doctoral training but assumed independent investigator status or pursued additional years of training. Others sought a new position during this phase.

After the fifth year, participants were considered graduates of the program. Graduates remained integral members of the RMSTP community and were often called upon to teach didactic portions of the RCD Workshop at the AAP meeting, provide mentorship in small groups, and serve as an informal mentorship network for the pre-applicants and Phase 1 and 2 fellows throughout the year. This format provided helpful continuity and additional perspectives for trainees within the RMSTP program and helped create a mutually supportive community of individuals at all stages of development seeking research careers.

Research Career Development Workshop and Networking Activities

Training of the K12RMSTP pre-applicants, fellows and graduates represents a continuum of activities that occurred over several years. The activities can be broken down into the following three basic areas:

1. Research Career Development Workshop

2. Quarterly mentoring calls

3. Networking

For pre-applicants, funded fellows and phase 2 fellows, the quarterly calls and RCD workshop were mandatory. For K12RMSTP graduates, attendance at the RCD Workshop was voluntary and often limited to the mentoring/ networking sessions that occurred at the meeting. As the trainees moved through the program, the nature of these activities shifted to accommodate their varied training needs. Each activity is described below along with examples of how they changed over time.

Research Career Development Workshop

The RCD Workshop provided approximately 12 hours of didactics, small and large group interactive sessions, and mentorship distributed over 3 days at the AAP annual meeting. K12RMSTP workshop attendees were also provided time to attend key elements of the regular meeting where they presented additional posters or papers and interacted with scientific peers. In response to attendee feedback and the increasing critical mass of engaged trainees who could discuss their experiences first-hand, the proportion of content provided during small group activities increased over the years. Content was divided into 2 concurrent tracks, one for those preparing their Phase 1 application (pre-applicant) and one for funded and Phase 2 fellows seeking to optimize their progress. Some sessions of interest to both levels of trainees were combined. Each year the workshop content changed somewhat, based on feedback from the prior year, as well as perceptions about the changing needs of the increasingly more senior mix of attendees. The Specific Aims session was one of the most highly rated aspects of the workshop. This activity was introduced because of the importance of the aims page to grant applications and included iterative rounds of feedback and revision within small groups mentored by an Advisory Board member.

Quarterly Mentoring Calls

The RMSTP Program Directors held quarterly teleconferences with pre-applicants and Phase 1 and 2 fellows. This was done, in part, because the majority of research mentors were not physiatrists or even rehabilitation scientists. The Program Directors sought to help resolve any training difficulties, to help guide translation to rehabilitation problems, and to provide guidance on the realities of employment within academic rehabilitation. The groups were divided such that there were no more than 4 participants (organized by phase of training) with the Program Director on each 1-hour call together. Quarterly calls were reduced to yearly calls for graduates of the program.

Networking

Networking occurred frequently during the Workshop at the AAP annual meeting. Aims groups and mentorship groups enabled the development of formal and informal relationships between trainees of different levels, RMSTP graduates, and Advisory Board members. The RMSTP Advisory Board and Program Directors facilitated additional networking opportunities for RMSTP fellows by making introductions to key individuals inside and outside the AAP. The RMSTP also held an annual social event at the AAP meeting to further facilitate networking opportunities in more informal settings. Additionally, the AAP scheduled a high visibility plenary platform for RMSTP presentations at the annual meeting. Each year, three RMSTP fellows presented their research to all attendees at the AAP meeting. AAP meeting attendees informally commented on the increasing rigor of the research that was presented at the Annual Meeting, largely due to the RMSTP trainees and fellows, suggesting that the program had a broader impact on the scientific culture of our academic society.

K12RMSTP Outcomes and Accomplishments

There were 28 graduates of the K12RMSTP between 2002 and 2018 who completed 5 years of training (three years of funded Phase 1 and two years of Phase 2). Graduates were considered in 4 cohorts based on the year they completed Phase 2 (Table 1). Overall, 32% of graduates hold the rank of Professor, 39% are Associate Professor, and 25% are Assistant Professor. The percentage of graduates holding rank of Associate Professor and Professor increased with time since graduation across the cohorts. The location and role of K12RMSTP graduates in leadership positions (chair or vice chair) and current trainees are indicated in Figure 3. There are currently 5 K12RMSTP graduates who are PM&R department chairs. In addition, numerous K12RMSTP graduates are in vice chair positions (Table 1). The percentage of graduates holding leadership positions also increased with time since graduation across the cohorts.

Table 1.

Current K12 RMSTP Graduate Characteristics

	Cohort 1 2006–2008 (n=9)	Cohort 2 2009–2011 (n=8)	Cohort 3 2012–2014 (n=7)	Cohort 4 2015–2018 (n=4)	Total (n=28)
Female, n (%)	3 (33)	3 (38)	4 (57)	1 (25)	11 (39)
Rank Assistant Professor, n (%) Associate Professor, n (%) Professor, n (%) No Faculty Appointment, n (%)	1 (11) 1 (11) 6 (66) 1 (11)	1 (12) 5 (63) 2 (25) -	2 (29) 4 (57) 1 (14) -	2 (50) 1 (25) - 1 (25)	6 (21) 11 (39) 9 (32) 2 (7)
Leadership Position, n (%)	5 (56)	5 (63)	2 (29)	-	12 (43)
Total Publications, (n)	630	373	334	110	1470
Publications Per Graduate, Median (IQR) [range]	66 (56) [0–123]	42 (47) [12–85]	41 (47) [11–93]	29 (27) [13–63]	51 (47) [0–123]
Major Funding as PI, n (%)	6 (66)	7 (88)	3 (29)	1 (25)	17 (57)

Figure 3.

The location and role of K12RMSTP graduates in leadership positions and active R25 trainees.

Publications

K12RMSTP graduates were productive in publishing, averaging 12 publications in total and more than 6 as first author during the five years of training. Of note, the publications of the 16 fellows in the K12RMSTP for at least two years, but less than the full five, averaged over 9 publications with more than 3 as first author. Total publications and median publications per graduate increased across the cohorts with increasing time since graduation (Table 1). While the majority of papers were published in rehabilitation-focused journals, the list also includes publications in Nature, New England Journal of Medicine, Proceedings of the National Academy of Sciences, PLoS One, Brain, Journal of American Medical Association (JAMA), JAMA Pediatrics, and many other high impact journals.

Grant Funding

Major funding as PI, and therefore scientific independence, was defined as receiving an NIH R01, VA Merit Review, Department of Defense, National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), Patient Centered Outcomes Research Institute (PCORI), or Canadian Institutes of Health Research grant. Overall, 57% of graduates achieved major funding as PI. The percentage of funded graduates is greater in the 2 earlier cohorts compared to the 2 cohorts graduating most recently (Table 1). Importantly, four of the top ten NIH funded rehabilitation programs are chaired by K12RMSTP graduates (Pitt, Case Western, University of Minnesota, and Johns Hopkins).

Gender and K12 RMSTP Accomplishments

When considering K12RMSTP accomplishments by sex, women comprised 42% of leadership positions, 35% of all independent researchers with major federal funding and authored 40% of total publications. The top NIH-funded physiatrist in a medical school PM&R department in 2019 is a female K12RMSTP graduate⁴. While in general, female rehabilitation researchers apply for fewer federal grants and are less likely to be promoted to higher academic ranks², female K12RMSTP graduates are nearly as likely as their male counterparts to achieve funding, publish manuscripts, and achieve leadership positions. More work is needed in this regard, but our experience suggests that the networking, mentoring, and directed curriculum may provide critical resources to support gender equity in rehabilitation research.

Additional Indicators of Productivity

The K12RMSTP fellows and graduates have won multiple national awards including five AAP Early Career Academician Awards, an American Paraplegia Society Excellence award, and numerous best paper awards from journals such as the Archives of Physical Medicine and Rehabilitation, the American Journal of Physical Medicine and Rehabilitation, and Spine and one which was chosen as the most influential paper of its year by the Journal of the American Academy of Child and Adolescent Psychiatry. The group also includes a Presidential Early Career Award winner presented by President Obama, and the Athena Outstanding Research Award.

The Current RMSTP

With NIH R25 funding in 2019, the RMSTP transitioned to a research education program model focused on supporting career development in the absence of K12 funding. The goals of the current RMSTP remain to (1) identify and recruit promising physician candidates for rehabilitation research careers; (2) optimally prepare these candidates to develop a competitive mentored career development funding application (e.g., NIH K award); and (3) support productivity during training and facilitate the transition to scientific independence. The educational program of the RMSTP is designed in the following phases:

1. Pre-application – as before, during this phase we recruit promising residents and junior faculty interested in rehabilitation research and educate and guide them to identify a scientific domain, a training environment, and scientific mentorship team that will allow for the best possible training grant application. Since candidates must now compete for independent career development funding, we place a greater emphasis in this phase on building a competitive biosketch.

2. Applicant – once the candidate’s track record is sufficiently competitive, an appropriate mentor and institution is found, and a strong set of aims is developed, candidates move to the Applicant phase. In this phase, they are invited to submit up to 3 grant applications to the RMSTP annually for “pre-review”. Those applications are sent to a Program Director, Advisory Board Member, and a recent graduate for structured peer review, in sufficient time to allow for revisions prior to submission to the funding agency.

3. Funded fellow – once funded, in this phase fellows receive additional training and support through workshop attendance and quarterly calls to ensure high productivity during their mentored training and facilitate a successful transition to independence. The funded fellows can continue to receive pre-review of grants as described above.

4. Graduate – those who have completed 3 years of mentored training remain part of the RMSTP community, mentoring pre-applicants and fellows, and continuing to cultivate their skills through ongoing interaction with RMSTP faculty, as needed.

Many successful elements of the K12RMSTP have been continued in the RMSTP. This includes the recruitment of physician interested in research early in residency, the RCD Workshop at the annual AAP meeting, the quarterly teleconferences that continue through funding, and the graduated approach to training with participants moving from pre-applicants to applicants to funded fellows. One important change is that the K12RMSTP was uniquely focused on physiatrists. However, the conceptual approach to training and the training infrastructure that we developed are equally relevant to members of other medical specialties working in rehabilitation and seeking to enhance their research skills. Thus, the RMSTP now offers training to physicians in other rehabilitation-relevant specialties. The R25 funding has also allowed us to expand our Advisory Board from primarily successful physiatric researchers to now include a majority of non-physiatric rehabilitation researchers. This expanded faculty help recruit physicians from other disciplines, strengthen the RCD Workshop, and expose participants to a broad range of scientific themes pursued by successful rehabilitation scientists. They also provide links to other important structures and organizations that support rehabilitation research. It should be noted that the format of the current RMSTP remains flexible and can be easily adapted to virtual delivery if necessary. The 2021 RCD workshop will be entirely virtual due to the COVID pandemic with a hybrid of pre-recorded didactic sessions, real-time small group discussions, and 1:1 discussions.

The K12RMSTP has been very successful, as judged by the volume and quality of applicants, support from the AAP and nominating departments, evaluative feedback from those in training, and productivity and academic successes of RMSTP graduates. Based on this experience, we aim to preserve these elements while supporting career development in rehabilitation research.