External Advisory Committee Report: Training and Career Development in Patient-Oriented Research

Table of Contents


Executive Summary

The SPOR National Steering Committee mandated an External Advisory Committee to address the deficiency of patient-oriented researchers (both clinician and non-clinician) within academic health science centres in Canada, a shortage which limits integration of research into clinical practice and health care decision-making.

Simply put, Canada needs more, as well as more kinds, of patient-oriented researchers.

Barriers to POR training and career development

Through extensive review of Canadian and international literature and analysis of evaluation data, the Committee identified best practices in POR training and career development and the main barriers that are keeping us from achieving those best practices. Three key overarching issues predominate:

  1. Institutional environment and sustainability
  2. Governance and investment
  3. Training models

Patient-oriented research depends on contributions from a breadth of professionals, both clinicians and non-clinicians, trained in research. Their role is inherently multidisciplinary and translational, and investigators often straddle or cross between the pre-POR/ POR arenas. POR trainees and investigators must be able to work simultaneously in both clinical and academic environments, from hospital to community and primary care settings. In practice, however, academics – especially non-clinicians – are not encouraged to work in health environments, nor are clinicians easily able to maintain strong academic activities, even those within academic health science centres, let alone based elsewhere.

Canada needs a major increase in the number of health clinician scientists – nurses, occupational therapists, pharmacists, social workers, physiotherapists, psychologist, and other health professionals – who combine research and clinical practice in their daily work. However, very few jobs exist which enable these clinician scientists to integrate research and clinical work; for this group of POR investigators, lack of employment opportunities tends to be the most critical of all the barriers. Clinicians are particularly likely to have multiple bosses across multiple sites, and find themselves caught in competing priorities and accountabilities, faced with high patient needs and low clinical resources. Canada also needs to stabilize its shrinking cadre of physician-scientists; these are most affected by the very long training period and postponement of employment and rewards this career choice entails.

Furthermore, Canada has an urgent need to expand the number and scope of non-clinical POR investigators, including but not limited to methodologists, health economists, behavioral scientists, biostatisticians, implementation scientists and health policy researchers. Canada is missing key expertise needed to address urgent health care questions. These investigators must have opportunities to integrate POR activities and skills into their training, with supports that enable them to focus on POR research. Finally, pre-POR research, the essential foundation to POR success, must remain strong and well-connected to POR: trainees who straddle the line should be welcomed within the POR strategy.

Guiding principles

Building on its analysis of the barriers to POR recruitment and retention, the Committee derived a set of Guiding Principles which integrates the evidence regarding best practices in POR training and career development (described in detail in Annex C). The Principles were intended to provide a framework and guidelines for the Committee's recommendations: any proposals made by the Committee must effectively address and incorporate the following Principles:

  1. Training and career development in POR should be a shared responsibility between all relevant stakeholders.
  2. POR should be built on inter-professional collaborations and engage diverse contributors to POR.
  3. An overarching longitudinal vision should support individuals throughout the POR training and career pathway.
  4. Pipelines are critical and should draw a diversity of trainees to POR.
  5. Training programs should foster integration and respect between clinical and research domains and model interdisciplinary collaboration with shared leadership.
  6. POR training should include professional life-skills.
  7. Trainees should be exposed and prepared for a range of alternative career pathways.
  8. The early-career transition from training into early career development requires targeted support.
  9. Mid-career clinician scientists should also be supported by a distinct sustainability program.
  10. Debt incurred over the course of POR training and career development should be minimized.
  11. Compensation should be appropriate, competitive and equitable for contributions across clinical, education and research domains.
  12. Mentorship across POR training and career development should be recognized, valued and appropriately rewarded.

"There must be a shared vision as well as shared responsibility: such a vision needs to be jointly held before responsibilities can be assigned." (Stakeholder)

The committee tested these preliminary Guiding Principles in a national workshop with key stakeholders. Overall, participants broadly endorsed their proposed scope and coverage, but suggested that they could be more coherently and effectively stated by collecting them together as a smaller number of broader Principles.

National stakeholders concluded that the absolute and over-riding need is to address POR training and career development as a shared responsibility, which itself must be based in shared strategy. Second, they expressed need for a longitudinal vision, which addresses the POR career lifecycle as a coherent and connected whole, rather than as fragmented, short-term pieces. Within that larger strategy, early-career transition must be recognized as an issue of particular urgency. Finally, Canada needs new training approaches, interdisciplinary and patient-oriented, which model the collaborative environments in which they will work.

Best practices

The Committee distilled the wide range of available evidence and expertise, to identify the best practices for POR training and career development, described in Section 2, which must be embedded in its recommendations.

The POR training environment should be equally accessible to all POR trainees, and should integrate across mentors, disciplines, professions, and academic and clinical sites from hospital to community. It should incorporate both POR-specific and broader professional skills, including key areas such as informatics and knowledge translation. Connection to patients, the critical and unique aspect of POR, should be central to training for all POR investigators, whether clinician or not.

POR training supports should place primary emphasis on supporting training programs (rather than individual awards), as programs can be designed to require, support and reward the creation of training environments that meet best practices standards. Furthermore, programs can be held accountable for the environments they create and the training outcomes they achieve. A small pool of individual POR awards should address gaps and needs left unfulfilled by training programs.

To enable high-quality, high-impact patient-oriented research, the POR work environment should be built upon an explicit agreement among the multiple funding partners.  A shared job description should integrate and equally value the research and clinical roles, and define explicitly how they will be sustainably resourced, mentored, and supported within a broader program/ team. Jobs for non-clinicians should incorporate patient interactions, and enable them to participate in POR in leadership roles (not just supportive ones). Jobs must be expanded in primary care and community settings.

Recommendations

Having established its Guiding Principles, and identified the standards for POR training and career development required by evidence and best practice, the Committee then sought a context in which these could be achieved. The Committee was acutely aware that the major barriers to effective training and career development in patient-oriented research are systemic: poor research-clinical interactions, silos and isolation, lack of jobs, lengthy and costly training. These result from the various pieces of the system working at best in isolation, at worst in conflict with each other.

If CIHR took the funds it currently invests in POR training and career development - about $7M per year – it could invest them in a new set of carefully-designed, evidence-based funding mechanisms, focused on highly-accountable training programs, and encouraging interactions between them. The likely result is that a small but more diverse group of trainees will get better training. But the cadre overall won't and can't grow. Institutional environments and interactions won't improve. Jobs won't be created. Canada's ability to do and apply research that improves patient outcomes won't noticeably change.

What we describe in our recommendations in Section 3, therefore, is not a new set of isolated CIHR programs. That approach has been tried many times, and it has failed many times. Instead, we offer the best systemic solution we can find, recognizing that it is systemic barriers we face.

In our first two recommendations, we set out the essential nature of a solution to the POR human resources challenge: it must be based on a shared vision and longitudinal strategy, developed together by key stakeholders, to create integrated training and career development supports based on best practices. Furthermore, integrating the key elements of the Strategy for Patient-Oriented Research (SPOR) - especially the training strategy and the SUPPORT Units - is essential and urgent.

The structure we believe most able to operationalize these principles is most easily described as a “network”. In Recommendation 3, we therefore propose creating a national network which connects a roundtable of major funders of POR human resources (provinces, institutions and research funders), and patients and professional organizations, with the wide range of essential stakeholders; together they will develop evidence-based POR training and career development supports.

The Committee expects that it would take about two years to build an operational POR training and career development network. Recommendations 4-6 are for CIHR only, and address the use of CIHR's POR funding during that transition, as well as their eventual incorporation into the network's resources.

To launch the network development process, CIHR has unique capacity – and responsibility – to be the network's early champion and convenor, but success will other key funders – especially provinces – to take up early leadership roles. A meeting with key stakeholders should take place by Fall 2013, to determine willingness to take a networked approach to POR training and career development.

The Committee is persuaded that a network partnership model offers the systemic solution we need to the systemic problems we face. At the same time, we recognize the challenge of transformational change. Even as this report was being written, however, the POR environment has changed: SPOR and provincial efforts are developing both the foundational relationships as well as the infrastructure upon which a network could be built. There are many indications that over the last year, stakeholders have become uniquely willing and able to come together, and this network is an idea whose time has come.

Recommendation 1: Adopt Guiding Principles

Support for POR training and career development should adhere to the following guiding principles:

  1. Shared vision: Stakeholders should work together to define a shared vision of integrated research and clinical capacity, and a framework to change the context and culture of POR training and career development.
  2. Longitudinal strategy: Specific initiatives, actions and investments should derive from a comprehensive longitudinal strategy which is collectively developed, and whose implementation is a shared responsibility.
  3. Integrative training: Training approaches should be grounded on evidence and best practices, and built collectively such that they integrate clinical and research training in a collaborative and multidisciplinary training environment.

Recommendation 2: Integrate with other SPOR initiatives

The External Advisory Committee (or the working body which takes up the next phase of this work) should work with the SPOR SUPPORT Units and Networks to take these recommendations to the next stage of development.

Recommendation 3: Create a SPOR Network in Training and Career Development

A Network in POR Training and Career Development should be created as one of the group of networks supported through SPOR.

Recommendation 4: Roll existing POR funding into the network once operational

In the shorter term, CIHR's existing POR training and career development programs should continue to function. Once the network has developed to the stage of being ready to fund programs and awards, all of CIHR's current funding for POR training and career development should be rolled into the network. New grants and awards provided during transition should be conditional on integration in some form into the network, while current fundees should be encouraged, but not required, to integrate. The existing CIHR program budgets to be rolled into the network are:

  • Health Professional Student Research Awards (HPSRA)
  • MD/PhD Grant Program
  • Clinician Scientist (Training and Salary)
  • RCT Mentoring
  • Ongoing commitments to special activity funding, such as New Investigator workshops, travel awards, conference and meeting support related to POR

Recommendation 5: Changes to current POR programs during transition

Improve equity and access to current CIHR POR programs by:

  1. Allowing new institutions to apply for support through the MD/PhD Grant Program, and distributing the available vouchers among a larger number of institutions
  2. Introducing a parallel stream in the Clinician Scientist Awards which explicitly invites applications from outside medical and dental schools.

Recommendation 6: Changes to open training and career development programs

Improve access to open award competitions by examining eligibility and review criteria to eliminate systemic barriers for POR applicants in both institutional and primary care environments. Ensure that appropriate expertise is included in review processes. Communicate these changes widely to eligible POR applicants. A working group should be established with the other two federal granting agencies to address those awards which are jointly managed. Awards to be assessed include:

  • Canada Graduate Scholarship Master's Awards
  • Canada Graduate Scholarship Doctoral Research Awards
  • CIHR Fellowships
  • CIHR New Investigator Awards
  • Vanier Canada Graduate Scholarships
  • Frederick Banting and Charles Best Canada Postdoctoral Fellowships
  • Canada Research Chairs

Annex A: EAC Members

Chair – Dr. Norman D. Rosenblum
Pediatric Nephrologist and Senior Scientist, The Hospital for Sick Children
Professor of Paediatrics, Physiology, and Laboratory Medicine and Pathobiology
Associate Dean, Physician Scientist Training, and Canada Research Chair in Developmental Nephrology
University of Toronto

Dr. Jean-Patrice Baillargeon
Associate Professor, Departments of Medicine and Physiology/Biophysics
Director, Clinician Investigator Program
Université de Sherbrooke

Dr. Chaim Bell
General Internist, Mount Sinai Hospital, Toronto
Associate Professor and Clinician Scientist, University of Toronto
CIHR-CPSI Chair in Patient Safety & Continuity of Care

Dr. Catherine Hayward
Professor, Pathology and Molecular Medicine, and Medicine
Associate Dean of Graduate Studies (Health Sciences)
McMaster University

Dr. Carol Herbert
Professor, Professor, Departments of Family Medicine and Pathology
Centre for Studies in Family Medicine
Western University

Dr. Liisa Holsti
Assistant Professor, University of British Columbia
Canada Research Chair in Neonatal Health and Development

Dr. Peter Nickerson
Professor, University of Manitoba
Associate Dean of Research, Faculty of Medicine

Dr. Jennifer Stinson
Scientist, Child Health and Evaluative Sciences
Advanced Practice Nurse, the Hospital for Sick Children, Toronto
Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto

Dr. Thérèse Stukel
Senior Scientist, Institute for Clinical Evaluative Sciences (ICES), Toronto
Professor, the Dartmouth Institute for Health Policy and Clinical Practice,
Dartmouth Medical School, Hanover, NH, USA
Professor, Institute for Health Policy, Management and Evaluation, University of Toronto

Jared Wilcox
President, Canadian Society for Clinical Investigation (CSCI)
MD/PhD candidate, University of Toronto
President, Clinical Investigator Trainee Association of Canada (CITAC)

Dr. Brent Winston
Associate Professor, University of Calgary
Graduate Education Committee Coordinator, Critical Care Medicine
President, Canadian Society for Clinical Investigation (CSCI)

Full Report

The full report (English only) is available upon request by contacting spor-srap@cihr-irsc.gc.ca.

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