So what is stopping us from offering more slots? Here, again, the survey of training program directors and a parallel recent survey of rheumatology division chiefs, provide some important clues. The biggest obstacle to training more fellows does not appear to be the available applicant pool, the number of approved slots, or the number of available faculty (although each of these issues is important for some programs)—the key missing ingredient is sufficient funds for training fellows. Indeed, there is widespread concern about the ability to maintain funding for fellows even current levels. Complicating the situation is the complex combination of sources of funding for rheumatology fellowships, which includes institutional clinical positions from Medicare GME dollars; other clinical revenues; National Institutes of Health (NIH) funds; the REF; other foundations, such as the Arthritis Foundation (AF); and industry. The ACR is actively working to maximize support for our training programs. The development of an REF endowment for its core programs, especially fellowship training, is on track to reach $25 million by 2010, as a first big step towards a $100-million REF endowment. It’s clear, however, that increasing the number of fellows will require further expansion of the role of the REF as well as better support from other sources, including the NIH.
The National Institute of Arthritis, Musculoskeletal and Skin Diseases (NIAMS) is concerned about career development issues in rheumatology and earlier this year convened a “Roundtable Discussion on Research Career Paths in Rheumatic Diseases” that included leaders of the ACR, REF, AF, NIAMS staff, and members of the Young Investigators Subcommittee of the ACR’s Committee on Research. The group agreed that support for a large number of trainees is required to produce a modest-sized cohort of researchers, and identified two post-fellowship bottlenecks to research career development: the first at the point of competition for an initial mentored faculty-level grant, such as a “K Award,” and the second at the transition from junior faculty to independent status, which typically involves successful application for NIH “R Series” grants. Strategies to address these bottlenecks are possible. By funding K-bridging awards this year, the REF and the AF have proven their ability to jointly devise and rapidly implement such a strategy. These awards will support young faculty whose K grants were ranked very highly by the NIH but not funded, allowing these new investigators to maintain research productivity while reapplying to the NIH. The REF is also working to devise a new grant program to assist rheumatology researchers in achieving the K to R transition using strategies that leverage a modest investment of REF funds to give our younger researchers a competitive edge in applying for an NIH grant.
Help on the Horizon and Beyond
The ACR needs to be just as imaginative in supporting the career development of our practicing clinicians. Our educational activities, clinical practice support staff, advocacy efforts, and an online book on how to start a rheumatology practice that is nearing completion are all part of meeting this challenge. A practice-management course to be offered during the April 2009 State-of-the-Art Symposium in Chicago will feature a full-day session that will expose fellows to practice management concepts and skills.
