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A Troubling Divorce

March 23, 2013 — Leave a comment

The unhappy marriage between the United States government and science (research, education, outreach) ended this month. We’ve known for years now that the relationship was doomed to fail, with shouting matches in Washington and fingers pointed in all directions. I would more likely describe an end to the relationship between elected officials and human reason, but that would be harsh, and I still have hope for that one. Sadly, this generation of congresspeople signed the paperwork for a divorce with science.

America’s love affair with science dates back to its origins. Later, Samuel Slater’s factory system fueled the Industrial Revolution. Thomas Edison combatted with Nikola Tesla in the War of the Currents. It was a happy marriage, yielding many offspring. The Hygienic Laboratory of 1887 grew into the National Institutes of Health approximately 50 years later. We, the people, invented, explored, and looked to the stars. Combined with a heavy dose of Sputnik-envy, Eisenhower formed the National Aeronautics and Space Administration (NASA) in July 1958. We, the people, then used our inventions to explore the stars.

Since then, generations of both adults and children have benefited from the biomedical studies at the NIH, the basic science and education at the NSF, and the inspiration and outreach from NASA. Since Goddard’s first flight through Curiosity’s landing on Mars, citizens of the United States have not only directly benefited from spin-offsbut also through NASA’s dedication to increasing STEM (science, technology, engineering, mathematics) field participation. Informed readers will know that although the STEM crisis may be exaggerated, these fields create jobs, assuming benefits from manufacturing and related careers. Such job multipliers should be seen as beacons of hope in troubling times.

Focusing on the NIH, it should be obvious to readers that biomedical science begets health benefits. From Crawford Long’s (unpublished and thus uncredited) first use of ether in the 18th century through great projects like the Human Genome Project, Americans have succeeded in this realm. However, as many know, holding a career in academia is challenging. Two issues compound the problem. First, principal investigators must “publish or perish.” Similar to a consulting firm where you must be promoted or be fired (“up or out”), researchers must continue to publish their results on a regular basis, preferably in high-impact journals, or risk lack of tenure. The second problem lies in funding. Scientists must apply for grants and, in the case of biomedical researchers, these typically come from the NIH. With funding cuts occurring throughout the previous years, research grants (R01) have been reduced both in compensation per award and number awarded. Additionally, training grants (F’s) and early career awards (K’s) have been reduced. Money begets money, and reduction in these training and early career grants make it even more difficult to compete with veterans when applying for research grants. Thus, entry into the career pathway becomes ever the more difficult, approaching an era where academia may be an “alternative career” for PhD graduates.

The United States loved science. The government bragged about it. We shared our results with the world. Earthriseone of my favorite images from NASA, showed a world without borders. The astronauts of Apollo 8 returned to a new world after their mission in 1968. This image, the one of the Earth without borders, influenced how we think about this planet. The environmental movement began. As Robert Poole put it, “it is possible to see that Earthrise marked the tipping point, the moment when the sense of the space age flipped from what it meant for space to what it means for Earth.” It is no coincidence that the Environmental Protection Agency was established two years later. A movement that began with human curiosity raged onward.

Recently, however, the marriage between our government and its science and education programs began to sour. Funding was cut across the board through multiple bills. Under our current administration, NASA’s budget was reduced to less than 0.5% of the federal budget, before the cuts I am about to describe. The NIH has been challenged too, providing fewer and fewer grants to researchers, forcing many away from the bench and into new careers. Funding for science education and outreach subsequently fell, too. Luckily, other foundations, such as the Howard Hughes Medical Institute, picked up part of the bill.

I ran into this problem when applying for a grant through the National Institutes of Health and discussing the process with my colleagues. I should note as a disclaimer that I was lucky enough to have received an award, but that luck is independent of the reality we as scientists must face. The process is simple. Each NIH grant application is scored, and a committee determines which grants are funded based upon that score and funds available. With less money coming in, fewer grants are awarded. Thus, with cuts over the past decade, grant success rates plummeted from ~30% to 18% in 2011. When Congress decided to cut its ties with reality in March and allow for the sequester, it was estimated that this number will drop even further. (It should be noted that a drop in success rate could also be due to an increase in the number of applications, and a large part of that decrease in success rate over 10 years was due to the 8% rise in applications received.) This lack of funding creates barriers. Our government preaches that STEM fields are the future of this country, yet everything they have done in recent history has countered this notion. As an applicant for a training grant, I found myself in a position where very few grants may be awarded, and some colleagues went unfunded due to recent funding cuts. This was troubling for all of us, and I am appalled at the contradiction between rhetoric in Washington and their annual budget.

Back to NASA. As we know, President Obama was never a fan of the organization when writing his budget, yet he spoke highly of the agency when NASA succeeded. Cuts proposed by both the White House and Congress to NASA in 2011 for a reduction of $1.2 trillion over 10 years have already been in place. This was enough to shut down many programs, reduced the number employed, and led to the ruin of many of its buildings. However, the sequester, an across-the-board cut, also hit NASA very hard. As of yesterday, all science education and outreach programs were suspended. This was the moment that Congress divorced Science.

All agencies are hit hard by these issues, and it isn’t just fields in science, education, and outreach. Yet, speaking firsthand, I can say that these cuts are directly affecting those of us on the front line, trying to enter the field and attempting to pursue STEM-related careers. Barriers are rising as the result of a dilapidated system. Having had numerous encounters with failed F, K, and R awards amongst friends and colleagues simply due to budget constraints (meaning that their score would have been awarded in a previous year, but the payline was lowered to fund fewer applications) and seeing children around New York who are captivated by science education but are within a system without the funds to fuel them, I can comfortably claim that we are all the forgotten children of a failed marriage.

Whether it be due to issues raised in this post or your own related to the sequester, remember that this is a bipartisan issue. There are no winners in this game, except for those congresspeople whose paychecks went unaffected after the sequester. I urge you to contact your elected official. Perhaps, we can rekindle this relationship.

Flexner and Curricular Reform

November 19, 2012 — 1 Comment

While working with our medical school on curricular reform, an often-mentioned piece of literature is the Flexner Report.  Most, if not all, of those on the committees know what this is and what it entails. However, those with whom I have discussions about the reform outside of the committees are often left dumbfounded. Many understand the need to reform medical curricula, but far less know the history of its structure in the United States.

Prior to the 20th century, American medical education was dominated by three systems. These included an apprenticeship system, a proprietary school system, and a university system. Lack of standardization inevitably resulted in a wide range of expertise. Additionally, the best students left the United States to study in Paris or Vienna. In response, the American Medical Association established the Council on Medical Education (CME) in 1904. The council’s goal was to standardize medicine and to develop an ‘ideal’ curriculum. They requested the Carnegie Foundation for the Advancement of Teaching to survey medical schools across the United States.

Abraham Flexner, a secondary school teacher and principal not associated with medicine, led the project. In one and a half years, Flexner visited over 150 U.S. medical schools, examining their entrance requirements, the quality of faculty, the size of endowments and tuition, the quality of laboratories, and the teaching hospital (if present). He released his report in 1910. It was found that most medical schools did not adhere to a strict scientific curriculum. Flexner concluded that medical schools were acting more as businesses to make money rather than to educate students:

“Such exploitation of medical education […] is strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.”

In response, the Federation of State Medical Boards was established in 1912. The group, with the CME, enforced a number of accreditation standards that are still in use today. They implemented a curriculum with two years of basic science curriculum followed by two years of clinical rotations as their ‘ideal’ curriculum. The quality of faculty and teaching hospitals were to meet certain standards, and admissions requirements were standardized. As a result, many of these schools shut down. Prior to the formation of the CME, there were 166 medical schools in the United States. By 1930, there were 76. The negative consequence was an immediate reduction in new physicians to treat disadvantaged communities. Those with less privilege in America also found it more difficult to obtain medical education, creating yet another barrier for the socioeconomically disadvantaged in America. Nonetheless, the report and its followup actions were key in reshaping medical curricula in the United States to embrace scientific advancement.

Today, medical schools across the country embrace the doctrines established 100 years ago. Most schools continue to follow the curriculum previously imposed. Scientific rigor is a key component. However, medical educators are currently realigning curricula to embrace modern components of medicine and to focus on the service component of medicine that is central to the doctor-patient relationship.

In 2010, the Commission on Education of Health Professionals for the 21st Century was launched, one century after the release of the Flexner Report. By the turn of the 21st century, gaps within and between countries were glaring. Health systems struggle to keep up with new infectious agents, epidemiological transitions, and the complexities and costs of modern health care. Medical education has once again become fragmented. There is a mismatch between aptitude and needs of populations. We focus on hospitals over primary care. Leadership in medicine is lacking. The interdisciplinary structure of medicine requires that we no longer act in isolated professions. As a result, a redesign of the curriculum is required.

The Commission surveyed the 2420 medical schools and 467 public health schools worldwide. The United States, India, Brazil, and China, each having over 150 medical schools, were the most heavily sampled. In contrast, 36 countries had no medical schools. Across the globe, it cost approximately US$116000 to train each medical graduate and $46000 for each nurse, though the number is greatest in North America. There is little to no standardization between countries, similar to the disjointed nature within the United States in the early 20th century. The globalization of medicine thus requires reform.

Reform of medical education did not stop with Flexner. After the science-based curriculum introduced by the report, the mid-20th century saw a focus on problem-based learning. However, a new reform is now required that seeks a global perspective. A number of core professional skills were recommended by the Commission, and these must be implemented in medical curricula across the globe.

Within the United States, medical educators seek to reform curricula to be more in-line with the global perspective of the modern era, focusing more on global health initiatives and service learning. Additionally, health care reform in America will bring with it new challenges, and medical school curricula must keep up. How this will be accomplished is still under heavy discussion.

When considering any reform, it is helpful to remind oneself of its historical context. In this case, the disjointed structure within the United States at the time of Flexner parallels the disjointed global structure of the world seen today. Though changes will be of a very different nature, motivations remain the same.

As promised before, I plan to write on topics related to my experience in medical school, graduate school, and the combination of the two. For those who do not know, I am a student in an MD-PhD program (thus the “MudPhud” in the title of the blog). The classic paradigm is one that follows a 2-4-2 model of training. Our particular program follows the following pattern:

  • 2 years of medical school – These are the preclinical years, where we study biochemistry, histology, pathology, physiology, pharmacology, and related topics. It is mostly lecture-based, though our school utilizes a problem based learning (PBL) model. A few graduate school courses are taken in parallel with medical school. 
  • 3.5-4.5 years of graduate school – We then transition to graduate school, where a few courses are taken in the first year of graduate school (third year in the program). After rotating in multiple labs during the previous years, we settle into a lab and perform research for the following years. This ends with the defense of a doctoral dissertation.
  • 1.5 years of medical school – These are the clinical years, where students practice on the wards in each of the required fields. This portion of training culminates in graduation from the medical school and thus the MD-PhD program.
  • After the program – Students take multiple paths, ranging from medical residency to a postdoctoral fellowship to work in industry. Most will go on to residency.

The challenge in the transition from medical school to graduate school is not an easy one. In medical school, one must acquire large quantities of data and share this knowledge at regular intervals (usually on written exams). One could consider it like a very fast treadmill where you do not have access to the controls. The treadmill will continue to push you, but you may feel challenged to keep up. Or you might not feel this challenge. To be honest, I did not find this to be too fast, but the challenge for me was the lack of control over my schedule, from an emotional standpoint. During this time, you build a rapport with a large group of classmates who will later become colleagues. The shared experience of medical school creates solidarity among this group.

In graduate school, things change. You are now on your own, in a place where you are now at the bottom rung once again. It is exciting on one hand, because you can now choose what to study and how to direct your education. On the other hand, you may feel lost. As opposed to a treadmill, this is more like jogging through a forest, where vision is limited. You can take breaks to reorient yourself, and you can move at your own pace. However, it is difficult to know whether you are making progress, how fast you should be moving, or whether you are completely lost. Your friends in medical school are now moving on, and you no longer share the rapport you previously had with them. This creates a distance, and it is often emotionally trying.

For as challenging as the graduate school transition might be, the benefits outweigh the drawbacks. You are now able to study what truly fascinates you. You have control over your schedule, and you determine your own pace. You have access to a vast array of resources, and you can take on additional projects outside of your program. For example, I found myself volunteering with mentorship programs, science fairs, and even with a community clinic. The challenges you face in graduate school make each success far more rewarding than if they were easy. A simple rotation or a year-long research project cannot create the same level of suspense, mostly due to their limited timelines and more structured projects. Failure begets learning. Success begets inspiration.

As of this post, I have spent approximately 6-12 hours per day over the past few weeks attempting to solve minor issues in our PID controller. This required repetition of the same calibration trials daily, while I would  focus on creating a script for data analysis. It’s not challenging, and I’m used to it. However, it reveals a common issue in graduate school: we spend quite a bit of time on minutiae. For some reason, we also enjoy it.

It is this concept of delving into the abyss that I find fascinating about graduate school.

I am currently in the later stages of preparing my thesis research proposal, which I will be defending in our version of a Ph.D. qualifying exam before the end of the year. The proposal follows the format of an NRSA F30 application, a fellowship for dual degree students. It’s quite interesting, but I thought this would be a great opportunity to discuss the possible components of research proposals. Not all of these sections would be included in a standard proposal, and this list can be adapted for projects in both clinical and basic science research. The sections I included were:

  1. Motivation – Here, we provide a brief background in order to both describe our motivation for the project. More importantly, however, this serves to capture the attention of the reader while laying a broad foundation. This should be limited in length.
  2. Theoretical Framework – This does not apply to all studies but is helpful for laying out the problem statement. Briefly, the line of inquiry should be addressed. Variables within the project and their interrelated concepts should be laid out. In social science and basic science research, these can be useful in laying out the assumptions of the project. The results of the project can be generalized, but we must place a hold on how far this can be taken. Such a framework provides a foundation for later discussions of the project and its results.
  3. Problem Statement – This is a brief description, within the context of the theoretical framework, of what is to be addressed. It is best if we describe not only what is sought, but why we wish to seek it. This is often incorporated into the above sections and rarely stands alone.
  4. Specific Aims – In either a list or series of paragraphs, the aims of the project should be outlined. These can be hypothesis-driven or purely exploratory. It is best to group the aims into broad “sub-projects,” where each aim informs the next. The NIH states that these should “describe concisely and realistically what the proposed research is intended to accomplish.” It is an expansion of the problem statement into tangible goals. For each aim, be sure to specifically state each hypothesis. Additionally, any experiments to be performed should be described here. However, the aims are once again brief.
  5. Literature Review – A full literature review could span countless pages. However, a research proposal’s review must be focused. Each of the studies referenced here should be linked back to the problem statement. For example, if one wishes to determine the effects of aspirin on vascular outcomes, it would be beneficial to focus on studies of the mechanisms of aspirin and various determinants of vascular outcomes. However, it would be less useful to provide background on the various alternatives to aspirin. Keeping this focused and relating papers back to the problem statement will add to the overall understanding of the proposal.
  6. Methodology – Papers typically include a methods section. However, the methodology section in research proposals should be much more expansive. The purpose is to describe how each of the aims will be addressed with a plan of the experiments and expected results. In doing so, this demonstrates a level of competency in the project at hand. It also provides readers with evidence that the project is sound. Go into detail with the methods, but be sure to relate these back to the specific aims.
  7. Preliminary Data – Preliminary data may be sparse, but such data is useful in showing that the project is realistic. These data should follow the previous section on methodology. Unlike a thesis, these data do not yet tell a complete story, which makes sense for a research proposal. Nonetheless, be sure to discuss the results briefly in order to demonstrate competency and to show that the project can be done. Clinical studies may have less preliminary data in early proposals. However, these data could be as simple as a survey. For basic science work, the preliminary data are often slightly more involved.
  8. Budget – Operating costs for a project vary, and the budgets depend on the type of application. A training fellowship (e.g., F series) should include costs of tuition, whereas a project grant (e.g., R series, K series) would focus on the expenditures for the lab.
  9. References

This differs from a thesis in that the thesis will go into detail when displaying results, discussing the data, and formulating conclusions.

Clinical trials often include schematics where various hypotheses are tracked, following alternative routes in methodology. Some proposals will need to discuss ethical issues which may arise in the course of the study. Nonetheless, the general pattern of specific aims -> literature review -> research plan -> preliminary data holds for most proposals, and it is this pattern that I followed in mine.

Of course, at my stage, who am I to say what is the right way to write these things? If you want an accurate depiction of what is expected for grants (which are basically proposals), check out some of the formats below: