New Challenges and Paradigms for Mid-Career Faculty in Academic Medical Centers

Success, like beauty, is difficult to define, but one knows it when one sees it. A reasonable definition is the achievement of satisfaction and happiness in one's profession, which then defers the definition to that of happiness and satisfaction. These will be dependent on the extent and directions of one's passion, the pursuit of which promotes satisfying productivity. Physicians who choose to conduct their careers in an academic setting have a multitude of career models to pursue, representing varied mixes of effort devoted to clinical care, research, teaching, and administration. Not uncommonly, the particular blend of activities may evolve over time and there may be transition from one institution to another. Despite these variations, the mid-career faculty member of North American medical schools share many common experiences and challenges. Despite their track record of success within academic medical centers, mid-career faculty may also experience frustration or loss of direction. There are many reasons that this may occur. For example, the academic “honeymoon” is over, whereby forgiveness for the errors of inexperience or naivete[Combining Acute Accent] are long gone. Filling a niche within the institution brings stability, but may also engender the perception by the mid-career faculty member of being taken for granted. This may, in fact, be a misperception. In contrast to junior colleagues, the successful mid-career faculty member may no longer receive direct mentoring or institutional resources and may misinterpret this as abandonment. Contrary to this sentiment, supervisors of mid-career faculty members may see this evolution of institutional support as a discrete indication of success and the opportunity to redirect resources to those at an earlier stage in their careers. It is with these observations that we offer insights into maintaining and advancing a successful academic medical career. These challenges are part of a developmental process that unfolds in response both to individual and setting-specific characteristics. This paper explores this process, organizes the themes that are encountered along most career development pathways, and offers suggestions to promote both success and satisfaction. 1. Maintaining and Diversifying Support Career advancement most often will require extramural funding acquired only through substantial effort. The specific composition of support will differ across academic tracks. In most circumstances some success in acquiring competitive public funding is mandatory. Although this may not always be a necessity for success, it has ripple effects and is often a criterion judged by trainees as they chose their mentors. Although this clearly applies to the physician scientist, clinical educators at many institutions also benefit greatly from the successful acquisition of competitive public grant funding. The importance of this is recognized by our professional academic societies (for example the American Society of Nephrology, the National Kidney Foundation, the Polycystic Kidney Disease Foundation, among others) some of which offer courses to address strategies, and thus, will not be further discussed here. Rather, this discussion will focus on other funding sources also suited to mid-level faculty. Pharmaceutical Industry Industry-generated and sponsored research is greatly facilitated if a basic infrastructure (e.g. contracts office, business administration, clinical research space, research personnel, etc) is in place or readily available. Such fee-for-service research, in which company derived/monitored protocols are implemented at clinical centers, can generate income, but rarely leads to academic prominence. This research may be performed to generate revenue to support the infrastructure, which can be used to perform investigator-initiated research (discussed below). Often in this type of research, studies are performed to address marketing strategies rather than scientific questions. The sponsor owns the data with little benefit to the faculty member other than the acquisition of funds that can be used for subsequent independent activities. Occasionally, if the faculty member has a strong interest in the subject of investigation and plays a leadership role, then such research may contribute to credentials for career advancement required in many academic medical centers. Participation in Steering Committees is one such leadership activity that may also substantively affect the direction of this type of research. Apart from leadership opportunities, industry-funded studies may represent an opportunity to gain experience in trial design and networking with other investigators. Industry-derived protocols are designed by the company, which also owns the data. Thus, the conduct and interpretation of these studies are likely to be influenced by the effect of the company's financial bottom line rather than by the pursuit of knowledge. As a consequence, a potential important downside of participating in this type of research activity is the perception that the faculty member is supporting marketing through their research, which can raise questions about possible conflicts of interest. Beyond the limited recognition typically derived from this type of research, we strongly advise that care be taken to avoid the appearance of conflict of interest when seeking to publish research emanating from activities for which consulting fees have been paid by company sponsors. We offer the following recommendations: (1) when in doubt, seek counsel from academic supervisors who fully consider the commitments and restrictions inherent to an academic faculty position; and (2) do not rely on company sponsors to provide this counsel. Investigator-initiated pharmaceutical company-funded research can be very rewarding academically. This type of pharmaceutical research brings much more benefit to the faculty member as long as total ownership of the intellectual property resides with the investigator. In addition, companies benefit from publications generated without their influencing the academic process, as the studies are much more credible, and therefore, influential. Such studies typically succeed when a track record exists with the relevant product or class of agents. They most typically succeed with research arms of companies rather than with marketing divisions. Investigator-initiated protocols will still be governed by detailed contracts that should be written in a fashion that protects the intellectual property of the academic scientist. Furthermore, it should be expected that funding covers the full investigative costs. This is a very important consideration because investigator-initiated studies may not be prioritized within companies commensurate with company-initiated projects, thereby creating pressure to accept inadequate budgets. Other Industry The foregoing discussion related to pharmaceutical companies relates, as well, to companies owning chains of dialysis facilities and/or manufacturing dialysis and dialysis-related equipment. Research supported by or in collaboration with these large dialysis organizations (LDOs) can be highly fruitful and mutually beneficial because of the opportunities for large-scale observational research and, at times, the development and implementation of clinical trials. Possible three-way relationships among academic medical centers, LDOs, and other industries, particularly Pharma, provide yet another model to fund and implement research not otherwise feasible. Such research relationships can often be brokered by a faculty member at an academic medical center to finance and conduct research that can leverage large and national administrative datasets or dialysis populations. To get industry support for investigator-initiated research there must be a clear intersection between the industry's interest and that of the investigator. Intellectual property rights need appropriate bidirectional protection of which control should not be lost. Intellectual property is one of our most important products and highly influences the reputation of investigators. Companies are often very satisfied to have some access to research results before publication. Furthermore, the value of research is often enhanced when results are established independent of a company. General Clinical Research Center The general clinical research center (GCRC) is a resource for collaboration, mentoring, and funding and should be considered when seeking diversification of research support. Although there are policies that apply across institutions, unique local arrangements occur. For example, intramural support via the GCRC may be a recruitment incentive. Furthermore, in some circumstances an established disease-oriented basic scientist may be thrilled to work with junior colleagues in a clinical investigation. In addition, investigator-initiated research can be presented to the GCRC for partial support. Nationwide incorporation of GCRC into the new Clinical Translational Science Awards will undoubtedly provide additional opportunities for collaboration across the broad spectrum of translational research. Philanthropy Here we refer especially to local philanthropists and, particularly, those outside of the context of standard giving or foundations. A foundation may have announced grant cycles and topics. We are referring here to investigator initiation of a granting process that differs from the announcement. The philanthropists are approachable in this setting on the basis of the personal and institutional reputation of the investigator. A particularly effective approach is the collaborative initiative wherein several investigators from one institution jointly propose a project. Thus, it is important to get connected and stay connected with potential benefactors through activities such as community-based committees or projects, such as a fund-raising committee organized for the expansion of a hospital wing. As other examples, local National Kidney Foundation, American Heart Association, and Diabetes Foundation committees are populated by influential business leaders. We believe that implementing this strategy is something senior and mid-level faculty members should teach/mentor their junior colleagues. Although receipt of donations to support research activities should not be the motivation for these activities that bring many nonmonetary rewards from community engagement, philanthropists often are pleased to find opportunities to provide financial support for research programs addressing relevant health issues. Fundraising in this manner can be particularly helpful for bridging and for small start-up projects and seeding larger, publicly funded research programs. Again, using the above example, the National Kidney Foundation's local affiliate provides special opportunities and can effectively be addressed in a similar manner, as this can lead to national awareness bidirectionally benefiting both parties. 2. Coping with Funding Loss All academic faculty members should develop strategies to reduce the possibility of losing grant funding. One key component of this strategy is diversification of support. Diversification can be accomplished through collaborations that should begin at an early stage of career development even while developing one's own independent scholarly activities. We advise that investigators should develop mixed portfolios not only with respect to content area, but also with respect to primary leadership versus collaborative research roles. In addition to diversifying sources of support, old collaborative relationships represent potential avenues for new initiatives that can replace those that have ended. The goodwill among collaborators becomes an important asset, one to nurture at all times. 3. Mentoring Acquiring, managing, and maintaining good mentoring throughout the academic life cycle is a critical component of both success and satisfaction. As we mature in our careers and take on mentoring roles, the expectations from our own circle of mentors may change, but does not need to be diminished in value. Transitioning from being principally on the receiving end of mentoring to providing mentorship can be challenging. Sometimes, the first recognition of this can be the ordering of authors. Our advice is to initiate these discussions early and often. Mentoring of junior faculty frequently overemphasizes independence in research to the detriment of the junior faculty member's career. This is particularly true at a time when much research necessitates a multifaceted approach using numerous areas of technical and scientific expertise. In our opinion the wise mid-level mentor should recognize this risk and encourage their junior colleagues to be independent in one area of research while collaborating in other areas with more experienced investigators. Recognizing and supporting the needs of junior colleague's demands a new set of activities in which leadership of research and teaching activities, at times, are relinquished and opportunities to play roles on the local, regional, and national scene are passed along to others. While promoting the career development of others, mid-level faculty members face the challenge of continuing to develop in their own careers, addressing their evolving set of challenges. Among them is how to provide good mentorship. As faculty members move into mid-career, seeking mentoring about providing mentorship can be very useful. Beyond this, mentoring continues to represent an important conduit to staying connected, which is equally relevant to the mid-level faculty member as they are being mentored or providing mentoring to junior colleagues. Learning the skills of getting and staying connected with an ever broadening circle of professionals and organizations is a central role of mentors. Open discussions about this goal are critical, so that the passing down of opportunities to become involved in national roles/committees is not inadvertently overlooked. Despite inexperience, we advise you to not underestimate your potential to function on the regional and national scene, to not wait to be “selected,” and to proactively go after these roles and relationships, guided and assisted by your more senior colleagues to increase your visibility. Furthermore, this is often a central demand of successful career development. Tenure track physicians frequently need to demonstrate national reputations. Regional recognition may be sufficient for some other career models, but we advocate not limiting one's focus on the minimum needed for the career path. Connections with the broader renal community can be one of the very most rewarding aspects of our careers. Two extraordinary essays were recently published on this topic (1,2). 4. Working with Authority and Managing Conflict In academic medicine settings, faculty members tacitly consent to be led by individuals in more senior positions of authority. These individuals may be one's mentor, division chief, department chair, dean, or chancellor on the academic side and/or the clinical management team on the clinical side. Our comments are applicable to either. Most conflict derives from more than one source or individual and can often be avoided. Conflict is often a byproduct of failing to engage in effective communication necessary to create common missions. Dialogue equals bilateral and open authority in the end, but one has to get to that end by anticipating and navigating around conflicting agendas, thereby pre-empting the problem. This is achieved by practicing direct communication, without end-runs. Thus, providing constructive criticism does not have to threaten authority. We recommend concentrating on moving forward, not dwelling on past events, and defining what it takes to move forward in detail and from both perspectives. Mention of the criticism or disagreement will often be better received if joined by a simultaneous positive suggestion/direction. Constructive criticism and joint problem solving engages with authority to solve problems rather than threatening that authority. The ability to find content/tone of discourse that helps transform potentially adversarial interactions into opportunities for overcoming disagreement is a central challenge. 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