RAMS Research Roadmap

RESEARCH The investigation of the science that has the potential to impact all levels of acute care from hospital operations to the bedside.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

background

Senior RESIDENT

Resources

AUTHORS: Bernard P. Chang, MD, PhD; Katherine Hunold Buck, MD; and Nehal Naik, MD Welcome to the Emergency Medicine Education Roadmap, your definitive step-by-step guide on how to succeed in Research at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, publications can be found in “Resources”.

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

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insider Advice

1 - SENIOR MEDICAL STUDENT Medical School Years 1 and 2. Find research mentors and get involved in research, while building your research skills.

• R each out to research mentors and get involved in research. Consider spending your M1/M2 summer doing research. It can be anything from biomedical, clinical, social science, public health, translational research.

• L ook for student funding opportunities through your institution, EMF-SAEM medical student research grant, NIH (NIH Summer Research Internship), or many other professional/industrial/governmental institutions.

• Try to build your research skills including research design, protocol development, IRB approvals, data collection, and data analysis.

While this can be daunting, work alongside a good mentor to see how each process is done.

Year Off Planning: If you want to take a year off between M3/M4, start looking at opportunities now. They often require preparation on developing a research project with a mentor within the program prior to the application.

Medical School Years 3 and 4: Use your time outside clinical rotations to focus on your research or away rotations in research.

If you want to focus more, consider a year out between M3 and M4 year.

• Electives: Consider using elective time in your M3/M4 years for research. Start planning early, as all research projects take time.

Give yourself time to develop a research question, design it, get it IRB approved (if necessary), collect your data, analyze it, and start writing your paper. Use the SAEM RAMS research for trainees resources to help guide you in each step of your project.

• A way rotations in Research: Also for your M4 year consider away rotations focused on research or research focused clinical education, including NIH Clinical Electives, CDC Epidemiology Elective Program and many more.

• Year Off Options: If your home institution does not have much research, look for numerous opportunities outside. Consider the NIH Medical Research Scholars Program (Applications due on October 1st of each year for the following academic year), or the Doris Duke Clinical Research Mentorship program. There’s lots of opportunities out there if you just seek them out. If you’re interested in Global Health Research, consider the NIH Fogarty Global Health Program for Fellows and Scholars, the Doris Duke International Clinical Research Fellowship, and many more.

• D uring Residency Interview Season: While looking for residencies, consider those who have strong research backgrounds, opportunities for residents to do research (and give time to do it!). If you have a particular research focus, find institutions that match your interests and can help you start your research career early. Some programs offer research integrated into the curriculum, others may offer research fellowships, so find the program that’s right for you.

• M entorship: We cannot emphasize enough the importance of good mentorship. They will help you develop and also avoid pitfalls that may increase frustration and stumbles. Mentors are available at your institution, in your state or across the country in the SAEM / ACEP networks and beyond. Look for mentoring events like SAEM’s Speed Mentoring to give you access to national mentors!

2 - JUNIOR RESIDENT PGY-1: Focus on developing your clinical skills and explore your department’s research opportunities.

• D uring the PGY-1 year, focus on developing a your clinical skills. These are important not only to become a great resident and eventually independent physician, but your strong clinical background will help inform your research questions. Some residency programs have tracks that strengthen your education in specific content areas; if one of those is research, consider completing it.

• You will find that attending physicians and/or upper level residents offer opportunities to get involved in their research projects. As a PGY-1, consider getting involved in small projects that allow for you to focus on your clinical skills. These small projects can help you get to know the research faculty at your institution and help you identify mentors. If you have previous research interests, you can try to focus in these areas, but do not be afraid to branch out as you might find a new passion!

• For those who have the question of “do I start a project from scratch or sign on to a sub-project of a faculty member?” There is technically no right answer to this.

– The ideal situation is where you become open to developing an interest in something that also exists as an existing line of investigation that a faculty member is pursuing. This is not always the case and it is possible to go at your own home grown resident research question. With that said, you still need mentorship (maybe even more so) and be prepared to have to do more ground up administrative research tasks (IRB) writing (protocol) and self driven implementation (data gathering). Ensure what you launch into is feasible with the resources and time that exists.

PGY-2: Consider using elective time for research, find mentors and consider applying for funding.

• Th e PGY-2 year is a great time to use elective time to explore longer-term or more in-depth research projects. Often, you are able to dedicate several continuous weeks to a project by using elective time. However, be prepared to continue working on the project after that time period as very few projects are completed in a few weeks. Also try to plan ahead as you may need IRB approval and this process can be time consuming.

• Spend time developing relationships with the research faculty at your institution. These mentors are invaluable as you develop your research career and are also potential future collaborators. Also consider becoming involved in SAEM academies if you have a specific area of interest; you may be able to join a committee or run for election to their executive board.

• If you have a large project in mind that would require funding, consider applying for a resident research grant through organizations like SAEM, EMRA, or EMF (the Emergency Medicine Foundation). These applications are often due in the fall and winter for funding that begins in July; please see the individual applications for a timeline as they all vary slightly and by year.

Preparing these is time consuming, so please plan ahead and communicate with mentors early if you are interested in applying.

Please see the SAEM grants page for resources and links to grant application information.

3 - SENIOR RESIDENT PGY-3/4: Continue your involvement in research projects and begin to plan for your post-residency research career.

• The PGY-3/4 year(s) are times to continue your involvement in research through local projects or projects funded by resident grants (see R2 year for more information). Each of these projects furthers your research knowledge and helps you build your CV for application for future endeavors including funding, fellowships and jobs. Consider starting a National Institutes of Health (NIH) biosketch as this is required for many grant applications and can help identify areas of strength and weaknesses that may influence your next steps.

• This also an important time to think about areas interest to you and research questions in these areas. These answers will help you decide what the next step will be after residency when there are countless opportunities and no two research careers will be the same. Based on your current level of research knowledge / education, consider what the best next step for you will be. Please see the “post-residency and beyond” link for some of these next steps including research training bootcamps, fellowship, funding mechanisms and what a research career could look like.

4 - FELLOWSHIP Post-Residency and Beyond (1-5 years): Consider research fellowship training where one is given support to take formal

coursework in research methods, study design, and statistics. Also consider obtaining a masters in clinical outcomes research or MPH. These are all stepping stones on the path to research funding.

• R esearch Fellowships: There are many Emergency Medicine Research Fellowships across the county. Research fellowships offer protected research time, additional education (described above), and mentorship. Each program varies and some are NIH funded through T32 grants. Regardless of the specific program, research fellowships can create a strong foundation to help start your career.

Please see the SAEM Fellowship Directory for the most up-to-date list of research fellowships.

• R esearch Training Bootcamps: Consider attending a research training bootcamps or statistical courses either as an upper level resident or soon after graduation. These are available through national emergency medicine organizations such as SAEM ARMED or ACEP EMBRS, the NIH, and many private companies (for example, Statistical Horizons). You will learn important skills and network with others interested in research; as you move forward, they are potential collaborators!

• F unding Mechanisms: Ultimately, the goal of most researchers is “independence”, that is to say, receiving some external grants or funds that allow you to do the research that you love and also help support the mission of your home department and university.

How to get there?

– Some institutions offer internal research funding, but the majority is granted through external funding mechanisms such as the NIH, the Agency for Healthcare Research and Quality (AHRQ), the SAEM Foundation, PCORI and the Emergency Medicine Foundation (EMF). There are also private companies who have started funding projects in specific areas of interest such as West Health. The NIH funds projects through each of its institutes. NIH Reporter can be used to see what each institute has funded previously. NIH Program Officers are a great resource as you consider applying for NIH funding. The AHRQ funds projects in specific priority areas that can be found on their website. Foundations like SAEM and EMF fund projects at a variety of levels including trainees. These can be general calls for applications or content-specific so check their offerings often or sign up for their email notifications.

• As we said, the big goal of these efforts as a resident and early investigator is most often research independence. In order to become an independent researcher, you must obtain grants to support your dedicated research time. There are many ways to obtain this funding. For many, this will be one of the large independent grants by the NIH, an R series grant (with the R01 being the most commonly recognized and considered one of the “gold standards” of research independence). However, private research funding is increasing through private companies and foundations.

• Prior to achieving research independence, most researchers will obtain training grants such as the K grants available through NIH. Not only do these provide significant amounts of dedicated time for research and training, these help build strong CVs with research track records and publications that are necessary for large funding opportunities. Each organization and institute is different so please look carefully at their websites and rely on good mentors to help you find the right path for you.

5 - BACKGROUND Description and Background:

A career with a focus on research in emergency medicine is a rigorous but thrilling path as a career. Here we seek to give you a broad overview of what exactly being a “researcher” in the ED means, and some nuts and bolts of how you can get to becoming your own full fledged independent investigator! Importantly, while it isn’t necessary to know very early on in your career if a research path is for you, there are many ways during your education process to get yourself oriented to research opportunities and paths to development.

Career opportunities for academic-researchers include clinician-investigator positions in EDs in addition to administrative and operational roles, helping to create and provide the department infrastructure crucial to successful research in an academic ED.

Why an Academic Research Path in Emergency Medicine?

The benefits of a career in academic research medicine are numerous. Aside from the intangible pleasure of being able to create new knowledge and focus on stuff you personally find interesting, a career as a researcher affords multiple opportunities in the realm of academic development, from helping to mentor and work with junior investigators or medical trainees, to interacting with individuals from all levels of the healthcare space who may be impacted by your work. The incredible thing is that research can be done on so many levels of acute care medicine; from looking at the pathophysiology of pulmonary diseases at the cellular level, to examining broad psychosocial factors leading to homelessness, research in emergency medicine can be done across multiple levels of analysis.

What are the challenges?

While a career in research can be an exciting and immensely rewarding path as an emergency physician, challenges do exist. One major step is training. While we are trained in medical school on some basic research methods, often one must undertake additional training both formally and informally to flesh out the intellectual toolbox necessary for becoming a scientist. These include additional training in research methods, study design, and yes….gulp…..statistics. Additionally, much of research is supported by a number of grants and funding mechanisms outside of your immediate home ED. The pursuit and obtaining of external funds is crucial for many researchers and at times requires patience, diligence and a bit of a thick skin. Learning the lingo and alphabet soup of funding institutions and mechanisms may seem intimidating and daunting at times, but do not fear! References, from your mentor, colleagues, and yes even this program on RAMS, are here to help you orient yourself to this awesome career path.

Mentorship:

We cannot emphasize enough the importance of good mentorship. They will help you develop and also avoid pitfalls that may increase frustration and stumbles. Mentors are available at your institution, in your state or across the country in the SAEM / ACEP networks and beyond. A good first step is to find your area of interest and look to see if there any faculty who are doing work in that area.

You can also help network beyond your local institution. Societies such as SAEM are great places to branch out and meet other curious budding scientists and mentors. Look for mentoring events like SAEM’s Speed Mentoring to give you access to national mentors!

6 - RESOURCES Articles: • Nishijima, D.K., Yadav, K., May, L., Kraynov, L. and Mark Courtney, D., 2013. Description and productivity of emergency medicine researchers receiving K23 or K08 mentored research career development awards. Academic Emergency Medicine, 20(6), pp.611-617.

• Scott Van Epps, J. and Younger, J.G., 2011. Early career academic productivity among emergency physicians with R01 grant funding. Academic Emergency Medicine, 18(7), pp.759-762.

Journals and Publications • A cademic Emergency Medicine • A nnals of Emergency Medicine • J ournal of Emergency Medicine • Emergency Medicine Journal • W estern Journal EM • Trauma

7 - INSIDER ADVICE Dr. Lauren Klein, Research Fellow, Hennepin County Medical Center

“I knew I wanted to do research before even starting residency, and the opportunities I found early on as an intern at HCMC made me realize this would be a very good place to do a research fellowship. I saw how much was produced and the environment was conducive to what I wanted to do and what I wanted to study. I didn’t really look into other programs, so I can’t comment there.”

Dr. Corita Grudzen, Vice Chair Research, New York University

“Being a clinician-investigator is a way to continue to care for patients at the bedside while tackling our specialty’s toughest problems.”

Dr. Sam Mclean, Vice Chair Research and PI of AURORA, CRASH, University North Carolina-Chapel Hill

“I’m incredibly grateful for the opportunity to pursue a research career during the 17 years since graduation from EM residency. The opportunity to constantly learn new things, the intellectual and personal freedom, and most of all the chance to help those who are suffering, in a different way than clinical practice, have been a joy. My advice to medical students interested in research is to get involved in a project or project that will allow you to attend a national research meeting of some kind, and present your findings. My advice to residents is to focus on developing outstanding clinical skills during residency, but do a research project during residency to demonstrate interest. My advice to junior faculty is to (1) find outstanding mentors with demonstrated success in getting where you want to go (e.g., if you want a NIH K award, find mentors who have had a K award), both within and outside EM, (2) negotiate to get yourself a few years with some protected time for develop a research area and initial career development grant, and (3) focus, focus, focus on your research and try to avoid doing anything else in your work life other than developing your research and showing up for shifts (say no to as much other stuff as you can).”

Dr. Alex Manini, Professor of Emergency Medicine, Mount Sinai Health System

“Whether you are interested in basic science, epidemiology, health services, risk stratification, or clinical trials, getting involved in research is great way to complement one’s academic career in medicine. If your career aspiration is to become an independent investigator someday, then there are a variety of tried-and-true methods to relatively easily get your foot in the door for eventual NIH funding. These include, but are not limited to, research fellowships, T32 programs, institutional KL2s or K12s, or even individual K08 and K23 grants.”

Final Thoughts from the Authors:

“As you can see from the overview, it’s a quite a long path towards research independence. On average it takes about 6 years AFTER residency until one is successful at obtaining a K grant, and a median total of nearly 12 years post-residency (IQR 11-15 years) until one gets their first R01. The path may be long, but along the way you will be developing a lifelong intellectual toolkit that will allow you to approach many of the most challenging questions in acute care medicine in a methodological and creative way.”