Perspective commentary from the Society for Pediatric Research: supporting early-stage pediatric physician–scientist success

Introduction

From a scientific perspective, it is a wonderful time to be a pediatric researcher. There are more tools at our disposal than ever before, enabling us to ask and answer big questions. Recent advances in molecular biology (e.g., CRISPR-Cas9 editing), stem cell biology, and tissue engineering allow us to consider interventions and cures for chronic diseases that have never before seemed within our grasp. Analysis of big data, from the genetic code and multi-omics to the electronic medical record, creates opportunities to advance personalized medicine approaches while also addressing population health.

However, the practical realities of being a pediatric researcher today dissuade some from entering or remaining in the field. While absolute dollars in the US National Institutes of Health (NIH) budget have risen, and an array of non-governmental agencies and foundations support discovery, NIH paylines remain relatively low, research “buying power” is constrained, and securing federal grants continues to be challenging. Moreover, competing priorities—such as high clinical demands in the academic environment or the lure of larger earnings from private practice or industry, especially in the face of student loan debt—can lead talented early-stage researchers to opt out of a research-focused career in academic pediatrics.^1,2,3,4

In recent years, a number of publications have suggested systemic changes to sustain and/or improve the physician–scientist development pipeline (from trainee through mid-faculty stages).^2,3,4 This Society for Pediatric Research (SPR) Perspective Commentary provides practical advice to early-stage investigators (ESIs) applying for their first R award and guidance for department/institutional leaders to support their success. The manuscript authors generated names of successful ESIs and mid-career scientists among SPR membership who successfully made the K-to-R transition (N = 14). These physician–scientists were a combination of assistant, associate, and professors conducting a wide range of research from basic to clinical in different areas around the country (refer to Table 1). They were asked a series of open-ended questions (Table 2).

Table 1 Background and demographics of researchers contacted by the authors.

Table 2 Questions.

The practical advice offered by these respondents is integrated throughout this commentary.

We also share examples of departmental support programs that have recently been developed to increase the success rates of K-to-R transition. Our discussion and recommendations focus on two stakeholder groups: (1) early-career child health physician–scientists launching independent research programs; and (2) academic leaders such as division chiefs and department chairs who are in a better position to effect system-level changes that will help to sustain the people and processes needed for child health discovery.

Early-career child health physician–scientists launching independent research programs

“I think the most important piece of advice I have is not to give up! I think junior investigators take a bad score very personally (I know I did); however, senior researchers know that everyone out there has gotten a bad score at some point in their career and it does not define them. Persistence pays.”

A career as a researcher requires a curious mind, clarity of purpose, and perseverance. Even the most successful investigators apply for many more grants than they actually receive. Lines of inquiry that encompass years of work may ultimately prove to be less fruitful than hoped or may hit obstacles in study design or experimentation that cannot be overcome. Despite long days and late nights working at the bench, analyzing clinical research data, and/or writing papers, some researchers will struggle to secure external funding to continue their research programs. So, what, practically, can aspiring researchers do to maximize their chances?

“I have found that >90% of the time there is at least some validity to the critiques that will help shape your A1 [resubmission] proposal and even your overall study design that you will do for REAL. It hurts, but virtually always, the negative critiques make your proposal and science better.”

Becoming a successful researcher requires tenacity. One will submit a number of proposals that will either be unscored (“triaged”) or scored but not selected for funding, along the way to achieving scored and funded grant proposals. This is typical in the world of academia. A common approach is to put a “bad” or negative critique away for a day or two after your receive it, then returning to it when you can review it more dispassionately (after the “sting” has subsided). Even the most critical critique almost always offers ways to improve your science.

Choose the right mentor(s)

Effective mentorship is important at all stages of a research career but is particularly vital when transitioning from a career development award (such as an NIH K) to an independent research award (such as an R01 or equivalent). A mentor (often a mentoring team) can offer invaluable feedback on early drafts of a Specific Aims page or other components of a grant application, providing insights not only on the science but also on “grantsmanship” (e.g., consideration of specific study sections and what reviewers expect to see in grants they are assigned). An effective mentor will also help connect you to collaborators with expertise complementary to your own that you may need to complete the proposed research. The future success of researchers is often correlated with the success of their mentors. Lienard et al. analyzed data from >18,000 researchers and showed that early-career researchers were more likely to be successful with grants if they synthesized what they learned from their mentors into their own area of interest.⁵

The value of the right mentoring team is clear; how do you identify a primary mentor who is the best fit for you? First, crystallize your research interests and keywords, and how you ultimately wish to impact the health of children. Search your institutional websites to identify researchers whose area of research aligns with your interests; be sure to look outside your division and department. Once you have generated a list, talk to your division chief (or fellowship director) to generate more candidates and to refine the list. Reach out to those investigators on your list via email to ask whether they will meet with you. Before meeting in person with a potential mentor, read several of his or her recent papers, assess the investigator’s grants on NIH RePORTER (https://projectreporter.nih.gov) or Grantome (http://grantome.com), and think about how your ideas might fit with the work already going on in that research group. In short, be prepared and be intentional. Before committing to a laboratory or research group to join, attend a laboratory meeting and have lunch or coffee with laboratory members to get a sense for the investigator’s style and availability.

Most ESIs will have mentorship teams identified well before they reach their K-to-R transition. However, it is important to note that your mentoring team will likely need to change over time, to support new directions in your research or new techniques to be used.

“I gave up on many ideas. It probably took about 2 years to finally get the first funded R01 from the first successful idea. That said, it was 4 years between the end of my K to my first R01.”

Set realistic expectations when developing research skills and applying for NIH funding

Research is iterative and involves trial and error. You do not know if your experiments will work and will support your hypothesis—that is why they are called experiments! As a result, it takes time to develop good research questions and generate pilot data to define your research direction. Once your initial data support a concise set of aims and a high-quality application, submitting ideas to funding agencies requires realistic expectations. Even with great mentors, a supportive institution, and sound preliminary data, good ideas might require several submissions before receiving funding. Despite the best efforts of NIH and other agencies to employ standardized and consistent review criteria and processes, there will always be heterogeneity among reviewers, study sections, and review cycles. A recent study asked 43 reviewers to evaluate 25 previously funded NIH grant applications; each reviewer received standard NIH instructions for review and then participated in a mock study section. The study found no agreement among the reviewers’ assessment of application quality or in the numeric ratings they assigned.⁶ While the study did not assess the ability of reviewers to differentiate between a “great” application and a significantly flawed one (as the latter presumably would not have been funded), it suggested that reviewers cannot differentiate among the range of “good” to “exceptional” applications—the range of scores in which NIH funding paylines almost always land.

“The NIH score process has a significant element of subjectivity, keep this in mind with revisions and with making the determination that your grant may need to change study sections.”

“A first attempt with a not great score, resulted in invaluable reviews.”

Although the variability inherent in the grant review process can feel arbitrary and beyond the applicant’s control, the successful applicant remains resilient and improves the application after each review. Even if an applicant does not agree with every point made in a critique, there are typically many valid and helpful comments, and the successful physician–scientist learns how to integrate this reviewer feedback into a resubmission. Resubmissions of NIH Research Project Grants (“A1” applications) have success rates over twice that of initial (“A0”) submissions (33.6% vs. 15.6% in 2018), likely due to the combination of the positive effects of peer-review strengthening the application and the variability in scoring among different reviewers in separate cycles.^7,8 In some cases (e.g., K applications), feelings of discouragement after an A0 critique lead to higher rates of attrition; in turn, fewer A1 applications enter the pool for review, and the chances of obtaining funding if you do submit an A1 may increase.

The need for tenacity and persistence in applying for grant funding cannot be overstated. A study of early-stage investigators applying to the National Institute of Allergy and Infectious Diseases demonstrated that 32–43% of applicants stopped applying for NIH funding within 5 years of their first submission; this number increased only a few percent per year after 5 years.⁹ The NIH reports that the average duration of time from the first application to a first funded R01 award was between 3.9 and 6.2 years, indicating that some of those who chose not to submit revised applications upon initial rejection might have been funded if they had persisted.¹⁰

Apply for multiple types of funding

“The R01 is not everything. Get other funding in to sustain yourself until you get your R01.”

While the transition from a career development award to an externally funded large grant (e.g., R01) with the physician–scientist as primary investigator is often a metric of success in one’s physician–scientist career, many other types of grants are also an important part of the process. These can include grants from state and local governments, large nonprofit agencies (e.g., Burroughs Wellcome Fund, March of Dimes), disease- and specialty-specific foundations, and professional societies. These so-called “agency grants” often enable the critical work to demonstrate feasibility and provide the strong preliminary data that will make an R01 grant proposal more likely to be funded.

“Think beyond the NIH to other federal -funded agencies. If you conduct patient-oriented or outcomes research, consider AHRQ or HRSA.”

Use your time wisely

“I guard the first hours of every day for grant writing as these are the most productive. I tend to do the less cognitively intense parts of the grant (resource sharing plan, etc) in the later hours of the day when my brain is tired.”

Successful early-career child health scientists identify the importance of time management. Those who have been funded in the past 5–10 years recommend blocking off time to work on grant ideas—at the time of day when you have greatest mental clarity, in an alternative location, and/or away from distractions to promote deep concentration. Books such as The Clockwork Muse by Eviatar Zerubavel or Deep Work by Cal Newport provide more comprehensive strategies for time management. Turning off email or enabling an out-of-office reply during these time blocks also helps to reduce interruption. Since these larger blocks of time are harder to come by, they can be optimized by focusing on critical thinking tasks related to your aims and research strategy, while shorter time gaps can be used to complete lower cognitive-load tasks and accompanying grant documents, such as biosketches or letters of support. Finally, having up to a 6-month timeframe for grant preparation allows for your mentors and others to review the work and provide thoughtful feedback with ample time for revision. In addition to time management, there are other books that provide useful guidance including writing, grant writing, leadership, and asking for what you need (Table 3).

Table 3 Additional book recommendations.

Academic leaders who can effect system-level changes

“The process takes a long time, and it is essential to have departmental leadership who understand that you need time to develop your research.” and will support you to get there.

Individual departments and institutions play a significant role in supporting early-career researchers. Departmental support can be financial (such as start-up or bridging funds for research) or functional (e.g., limiting clinical responsibilities while external funding is sought). Institutional support can also be “advisory,” such as providing formalized grant writing programs or offering mentorship. Developing internal resources for fledging researchers is also very helpful. A comprehensive program that includes written resources, examples of funded applications, and formal pre-review of grant applications can improve success rates. Additional resources that departments can develop are outlined below.

Mentorship

Departments should employ consistent processes to ensure the timely and correct constitution of mentoring committees and the frequency of committee meetings. Empowering the mentee to set the agenda for these meetings is a core skill that aids in the transition from a K to an R grant award. Committee reports should summarize mentee progress; articulate clear goals, metrics, and timeframes; and be completed and filed promptly after each meeting.

Mentoring panels (also known as mentoring teams or scholarly oversight committees) are established during fellowship or at the time of hire as a research-intensive junior faculty member. Because a single individual can rarely provide for all aspects of mentoring and scientific breadth, scholars should typically have a panel of three to four members. The content area of your research and the experimental and data analysis skills needed for your project should be represented on your mentoring team; again, these needs may evolve as the research progresses. Mentors should be selected for their excellence as scientists, defined by an enduring record of strong extramural funding and scholarly productivity. In addition, they should have a strong skill set in collaboration, leading teams effectively, and evidence of effective mentoring through a clear track record of mentee first-author publications, awards, and successful promotion. Some institutions favor mentoring contracts, which jumpstart a shared vision of career progression, produce viable goals and timelines, and delineate expectations for the various interactions between an early-career faculty member and the mentoring team. It is important that these goals align with institutional expectations for promotion and tenure.

Peer writing groups

“Choose an area of investigation that you love.”

Often, early-career researchers assume that just focusing on good science in their applications will lead to success without realizing the importance of the actual writing to make their ideas clear (and fundable).

The Department of Pediatrics at the University of Pittsburgh Medical Center (UPMC) has instituted a K grant writing course for its junior faculty. This year-long course is facilitated by a senior physician–scientist (C.M.B.) and modeled after a program started in the Department of Medicine at Pittsburgh for writing F32 grants. Participants attend 6 monthly classes in which component sections of an F32 or individual K application are evaluated, and they present their own drafted sections for peer review. While the course is for writing K grants, the majority of time is spent on teaching applicants how to write about their science and is broadly applicable to future grants, including R01s. Since the inception of this program, 76% (30/39) of applications from course participants were ultimately funded, comprising F32, K, and prominent foundation awards (e.g., American Heart Association and Parker B Francis awards). It is hoped that the UPMC Pediatrics program, and others like it at various institutions, can achieve similar success rates as these pediatric programs mature. ESIs are also encouraged to engage with professional societies to enhance these skills as well. For example, the SPR has a junior members’ section and offers programs in which ESIs can access experienced SPR members to assimilate skills in grant writing.

“Take a course offered for K or R grants on project mapping and timelines, stick to your timelines no matter what, if you can’t use excel or lucidchart, post-its on a large white board work just fine.”

The UPMC's Department of Medicine also has a “K to R” program in which an ad hoc group of 3–4 faculties (some within the specific division and others with specific content expertise) meets with the R award applicant. The candidate, who is a “graduate” of the K writing course and is holding a K award, submits a Specific Aims page to the committee prior to the meeting. During the meeting, the candidate presents his or her Specific Aims and Preliminary Data sections (given that they have completed the previous course, it is assumed they know how to effectively assemble the rest of the proposal). The committee intensively critiques and questions the applicant, ultimately deciding to support or to defer the grant submission; typically, candidates present “deferred” proposals again 6 months later, after having done extensive work to revise the proposal. If the resulting R grant application is not funded, the committee re-convenes to assess the summary statement and assists the candidate in generating responses to the critiques. Since the program’s inception, six of the seven people who completed it obtained R01 funding, and the other received an R56 (an NIH bridge award to support work while an R01 resubmission is generated).

Grant review services

“Find someone not in your direct field who is knowledgeable to proof the grant and make sure that it is written in a style that a study section member would be able to ‘get it.’”

Grant writing is certainly a skill that the successful pediatric physician–scientist must master, and learning how to frame compelling and clear grant proposals is a long-term process. An application may contain great ideas but be plagued by a simple flaw that could result in its being unscored at study section. Asking at least one seasoned grant writer to read it before submission allows for flaws to be discovered prior to submission. Many academic institutions offer various forums and infrastructure to ensure measured, rigorous evaluation of grant documents for their faculty. Grant guidelines (both federal and agency) are dynamic and change frequently, so the physician–scientist should see grant writing as a skill that requires continuous learning.

Developed by leaders at Vanderbilt University Medical Center, the Edge for Scholars (www.edgeforscholars.org) program—an integrated blog, newsletter, and social media platform with >14,000 users—can be leveraged by researchers anywhere. The site directly addresses the practical concerns of early-career researchers and their mentors. Because conversations can be conducted with anonymity and authors aim for a high level of immediacy and candor, the discussions can be more revealing and helpful than in other career development forums. The Edge provides a means to locally and nationally disseminate key insights for career development directly to target groups of scholars. For Vanderbilt students and faculty, the program also creates a systematic approach to provide insight and process support for grant preparation that includes these components:

“Read a library of successfully funded R01s and use these as templates/outlines.”

Library of Funded Grants comprises >150 funded grants (including K, VA CDA, R03, R21, R01, and NIH Loan Repayment Program applications). Materials, often including summary statements and revised versions, and these examples are often used as teaching materials in workshops and seminars. Many institutions have similar collections of previously funded grant applications; ESIs should inquire about this potential resource with the local University grants officials.

“Take a fantastic workshop on how to break down a grant [application] into its components and manage them in a project timeline.”

Grant Pacing Workshops teach process management steps required to submit a competitive K or R award. Two days of workshops review the components of grants, offer checklists, and teach methods to enumerate and map tasks on a timeline to completion. Workshops are offered 16 weeks in advance of each standard NIH application cycle deadline.

“The university’s mock R study section wiped the floor with my first attempt but really pushed me to have more rigor and clarity.”

Internal Study Section is held 1 month in advance of each NIH application cycle deadline for K and R applications and resubmissions. Selected reviewers are carefully matched to applicants’ content and methodology. The review process, discussion, scoring, and comments are handled exactly as in an NIH study section. Sessions are videotaped, and applicants are encouraged to review the video and mock summary statements with their mentoring team.

Reflecting a slightly different model, the UPMC Department of Medicine maintains a paid internal grant reviewing core, consisting of senior, well-funded faculty members. Two reviewers are assigned to each grant proposal (F32, K, R), are mandated to spend at least 5 h of review time (paid by the hour) and must provide written assessment of strengths and weaknesses in each of the five categories that comprise an NIH review (Significance, Investigator, Innovation, Approach, and Environment). While this program is very young, there are signs of success, with some participants having obtained R01 awards.

Summary and conclusions

The road to becoming a successful, independently funded pediatric physician–scientist is demanding, but it is important to remember that the reward at the end is invaluable: contributing to improved health and safety of children. While our PhD colleagues lead important discovery programs to help children, pediatric physician–scientists are uniquely positioned to drive clinically relevant scientific advances informed by clinical experience. Because of this, pediatric physician–scientists are vital to the future of our field. It can be difficult to know how best to support an early-career pediatrician interested in devoting his or her career to research, as each investigator’s path toward obtaining independent funding is unique. Every path, however, shares common features that must be supported, nurtured, and refined throughout the early stages and beyond. These include the maintenance of a confident resilience on the part of the investigator, the development of diverse and effective mentoring teams, and the reinforcement of grantsmanship skills, including time management.

Investigators can be further developed through well-structured institutional or departmental programs such as those described above. However, in the same way that each investigator’s path is novel, no single approach can be applied to all institutional settings, as each academic institution has its own historical, logistical, and administrative intricacies. Not all institutions might have the funding to support a full slate of programs like these, but it is certain that every investigator would benefit from one or more of the support mechanisms described. The examples provided here offer  an initial framework to customize a program that fits with the number, type, and experience of the local investigators at a particular institution. Ultimately, the formula for success as a pediatric researcher is a combination of institutional support, personalized mentoring, individual diligence, and perseverance mixed with passion and purpose to advance children’s health through discovery.