OUT OF COMMITTEE: Outcomes Research and Evidence-Based Medicine | Revamping NIH Clinician-Scientist Training Pathways with T32 to R25 Transition: Expansion of Programing and Preparation for Change
Allison K. Ikeda, MD, John S. Oghalai, MD, Jay F. Piccirillo, MD, Debara L. Tucci, MD, MS, MBA, and Michael J. Brenner, MD
Otolaryngology has a long tradition of scientific innovation, and the National Institutes of Health (NIH) T32 research awards have been a mainstay of research training, providing yearlong blocks of protected time for research during residency. Exposure to research in medical school or residency can be a defining experience that influences individuals’ career trajectory, affording a foundation for maturation into an independent clinician-scientist.1 These programs have played a vital role in cultivating scientific leadership in the specialty; the T32 awards provide structured scheduling of research experiences, integrating research with clinical activities, coursework tuition, and budgeting of stipends or training-related expenses. However, a challenge with T32 programs involves the requirement for adherence to restrictive National Research Service Award (NRSA) fellowship criteria, which can limit flexibility and customization to specific department residency research training needs.
There is also a need to enhance diversity among clinician-investigators in surgery. In otolaryngology, women and individuals from underrepresented racial and ethnic groups constitute only a small portion of funded investigators.2 A pool of investigators that is more reflective of society offers the promise of greater breadth in research endeavors, more representative enrollment in clinical trials, and progress in mitigating longstanding health inequities.3 Such considerations have provided the impetus for developing a more flexible and inclusive approach to expanding the scientific workforce in otolaryngology. The new programs involve phasing out T32-based resident research funding and rollout of five new R25 research education program funding mechanisms (Figure 1).
The five NIH R25 programs are designed to:
- Complement and/or enhance the training of a workforce to meet the nation’s biomedical, behavioral, and clinical research needs;
- Encourage individuals from diverse backgrounds, including those from groups underrepresented in the biomedical and behavioral sciences, to pursue further studies or careers in research;
- Help recruit individuals with specific specialty or disciplinary backgrounds to research careers in biomedical, behavioral, and clinical sciences; and
- Foster a better understanding of biomedical, behavioral, and clinical research and its implications.4
Current T32 programs that fund resident research are expected to transition to the new National Institute of Deafness and Other Communication Disorders (NIDCD) Mentored Research Pathway for Otolaryngology Residents and Medical Students (R25) at time of renewal. The change will allow institutions to customize research training to their programs, considering residency program structure, the variable research experience levels of residents, and need for flexibility in research experience and budget. Research during medical school and residency can serve as an on-ramp to an academic career, instilling investigative curiosity and equipping individuals with technical skills. Research experience garnered during these formative years prepares individuals for future clinician-investigator careers. Individuals supported by the R25 programs not only engage in experimental studies, but also develop mentoring relationships and enhance their competitiveness for future career development awards. These programs connect medical students and resident-investigators with experienced investigators who can support and engage their research ambitions.
There are important differences between the new R25 pathway and the T32 programs that have long been the workhorse mechanisms for supporting medical student and resident research. For example, medical students can undertake either short-term research experiences or research experiences that span an academic year (nine months). Resident-investigators engage in funded research for 12 to 24 months, completed within the residency at 80% effort. In a major shift from the T32 mechanism, resident research activities are no longer constrained to one-year increments and instead have the added flexibility to occur in shorter increments, at a minimum of three consecutive months (Figure 2). Funds are available to support resident research during clinical rotations, to provide for continuity and sustained research effort during the residency training years. Additionally, the R25 will cover tuition for coursework (up to specific dollar limit), whether in a degree-earning program or not. Several questions remain, including how the changes will affect medical students, residents, program directors, and the specialty. To better understand these perspectives, we connected with various stakeholders to discuss the reasons for the changes and potential advantages of the new programs.
In 2020 Debara L. Tucci, MD, MS, MBA, Director of the NIDCD, and Alberto Rivera-Rentas, PhD, NIDCD research training officer, organized focus groups with T32 directors, department chairs, and clinician-scientists with T32 training to assess the current state of resident research training. Several obstacles were identified (including grants appointments in one-year increments, a one-year pay back agreement for residents, and preset stipends and training-related expenses, in accordance with NRSA policy), providing a rationale for the transition of T32 to a new mechanism of residency research training. Dr. Tucci shared, "We developed the new grant mechanisms to provide otolaryngology residency training programs with the flexibility to tailor programs to their needs and create the best possible residency research training experience.”
The changes address many of these hurdles but also present new challenges, such as implementation and integration with new or existing programs. A summary is provided in the online supplement, and full details are at https://grants.nih.gov/grants/guide/rfa-files/RFA-DC-20-002.html#.
The University of Southern California (USC) is one of the first institutions to be awarded the NIH R25 funding. Its two-year research component will occur before clinical residency training begins and includes four days in the research laboratory and one day for clinical experience per week. According to John S. Oghalai, MD, department chair of otolaryngology-head and neck surgery at USC, “Doing some clinical work during the research time is important in teaching and training residents how to do both simultaneously. Our residents who choose the clinician-scientist career path are going to have to do that their whole careers. It is only 20% clinical, but at least it gives them the chance to start learning duality of lives, and I think it's a terrific mechanism.”
Other programs with longstanding T32 programs are awaiting review of their R25 applications. Jay F. Piccirillo, MD, T32 program director at Washington University in St. Louis, shared his perspective on the pending application. “To have two years where you focus on your research is a wonderful time to think deeply about important problems that research can solve.” He explained, “The second year is very valuable to consolidate all the learning, and the uninterrupted mentored research is foundational with the relevant coursework and career development. At WashU, we feel the combination of two uninterrupted years of mentored research, formal coursework in research design and biostatistics, and career development with T32 trainees from other specialties is critical to training the next generation of physician-scientists.”
Discussions with other T32 directors expressed some concerns about the transition, including added scheduling complexity if applying scheduling flexibility, given rigid residency training structure and requirements for clinical coverage, and low-yield training during intermittent 20% clinical experiences. Other T32 programs face decisions about expansion versus reduction to fit four-resident limit and opportunities to make changes, regarding timing and scheduling of research within existing frameworks.
The transition of the NIH T32 to R25 otolaryngology resident research training award stimulated awareness and interest and led to awards at institutions that did not previously have NIH T32 otolaryngology resident research training. This change may also mean lower levels of funding for programs that have historically supported multiple positions. Future studies are necessary to understand benefits and pitfalls of the R25 program. Lastly, developing a pipeline of clinician-investigators from diverse backgrounds is critical for cultivating a scientific workforce prepared to meet the needs of a growing diverse society.
- Physician-Scientist Workforce Group. Physician-Scientist Workforce Working Group Report. National Institutes of Health; 2014. Accessed May 10, 2022. https://acd.od.nih.gov/documents/reports/PSW_Report_ACD_06042014.pdf
- Munjal T, Nathan CA, Brenner MJ, Stankovic KM, Francis HW, Valdez TA. Re-engineering the surgeon-scientist pipeline: advancing diversity and equity to fuel scientific innovation. Laryngoscope. 2021;131(10):2161-2163.
- Megwalu UC, Raol NP, Bergmark R, Osazuwa-Peters N, Brenner MJ. Evidence-based medicine in otolaryngology, part XIII: health disparities research and advancing health equity. Otolaryngol Head Neck Surg. 2022 Jun;166(6):1249-1261. doi:10.1177/01945998221087138
- National Institutes of Health. NIDCD's Mentored Research Pathway for Otolaryngology Residents and Medical Students (R25 - Clinical Trial Not Allowed) Overview. Accessed May 20, 2022. https://grants.nih.gov/grants/guide/rfa-files/RFA-DC-20-002.html