RESIDENT & FELLOW SECTION
Opi nion and Sp ecial Articles: Challenge s and
opportunities in defining car eer identity in
academic neurology
David J. Lin, MD, Merit E. Cudkowicz, MD, MSc, and Tracey A. Cho, MD
Neurology
®
2018;91:670-672. doi:10.1212/WNL.0000000000006284
Correspondence
Dr. Lin
There has never been a more exciting time to become a neurologist. As we emerge from training
in clinical neurology after 4 or more years of residency and fellowship, many of us are faced with
the core challenge of how to define and develop our career identity. That is, how do we continue
to take great care of our patients, and now also advance our careers and make contributions to
a dynamic field? Here, we focus on developing career identity within academic neurology,
noting that careers in private practice neurology and other settings have unique sets of chal-
lenges, rewards, and opportunities.
In academic neurology, as in academic medicine, the 3 traditional cornerstones are patient care,
education, and research. The canonical academic identities are the physician-scientist,
clinician-educator, and “triple threat” (clinician, researcher, and educator). The process of
developing career identity in academic neurology has always been challenging, often occurring
at a critical period of other life milestones, such as purchasing homes or expanding families.
Successfully establishing oneself and finding meaning in one’s work is critical for career satis-
faction and preventing burnout.
1
Today, given the changing landscape of neurology, the
process of developing career identity has unique opportunities and challenges. We highlight
these issues and discuss potential solutions that can be instituted at the departmental, orga-
nizational, and national levels.
Perhaps the most well-paved career track for academic neurologists is that of the physician-
scientist. Milestones for career advancement for physician-scientists are relatively clear—grant
funding enables protected time, allowing for productivity in the form of publications, which in
turn facilitates local, national, and international recognition. While the milestones are relatively
clear, emerging as an independent physician-scientist seems more daunting than ever. Several
articles in the last decade have highlighted the obstacles facing physician-scientists, including
mounting medical school debt, the long years of training required, the growing complexities of
both clinical and research documentation, and historically flat to downtrending NIH
paylines.
2,3
More can be done by academic departments and organizations to help facilitate dual
clinician-research careers. First, during clinical training, despite often being in close geographic
proximity to basic and clinical scientists, it is not immediately obvious how to become
meaningfully involved in a scientific program. On the other side of the coin, many neuro-
scientists are hungry for clinical perspectives to inform their ongoing research. Thus, more local
initiatives such as speaker series, joint conferences, and social events to encourage dialogue
about synergistic goals and complementary skill sets between scientists and clinicians, starting
during early career phases, would be helpful.
Second, mentored career transition awards for clinician-scientists such as the NIH K award
(K08 or K23) are more difficult to obtain,
4
certainly as compared to the early 2000s, which saw
a doubling in the NIH budget between 1998 and 2003.
5,6
Given the stiff competition for limited
funding, successful K awards now seemingly require at the minimum preliminary data
equivalent to or resulting in a paper, a dedicated mentor and supportive scientific envi-
ronment, and cle ar mi lestones to scientific independence. To this end, pre-K-award
From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
670 Copyright © 2018 American Academy of Neurology
Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
programs such as the NIH R25 grant and AAN Career
Development Awards have been successful in helping to
provide protected time to acquire some skills and gather
preliminary data. Additional or expanded funding along
these lin es provided by departments and organiz ations will
be helpful to encourage trainees forming an identity in
research. Early seed funding for novel ideas and method
development that represent a departure from those of
established mentors will help support innovation and new
perspectives from emerging clinician-scientists.
The comprehensive clinical translation process, from identi-
fication of a question in clinical neurology to hypothesis-
driven scientific experiments at the bench to drug and device
development and clinical trials in humans, requires expertise
spanning innumerable aspects of basic, clinical, and trans-
lational science. Institutions and organizations should recog-
nize the current gaps in the clinical translation process and
strategically focus funding, starting at the level of trainees, to
encourage all types of investigation.
7,8
More support for
young investigators to gain specific expertise in drug and
device development as well as clinical trials should be pro-
vided as these have not been traditional focus areas for career
development grants. This also should include the recognition
that industry (e.g., biotechnology, pharmaceutical, and med-
ical device companies) can uniquely contribute to the scien-
tific training of young investigators (i.e., via joint
academic–industry fellowship programs). As academic and
industry interests align, it will also be beneficial for young
clinical investigators to learn to manage potential conflicts of
interest.
In contrast to the relatively well-worn path towards becoming
a physician-scientist, there is no clear track for aspiring
clinician-educators. This is unfortunate because as the di-
agnostic and therapeutic complexity of clinical neurology
continues to increase, the value of effective educators in
clinical neurology has never been more apparent. Those in-
terested in medical education in neurology usually dedicate
additional time during training to teaching medical students
and resident peers. Mentors who have been successful in the
area of medical education (i.e., residency program directors or
medical student clerkship directors) can provide valuable
advice. But after training ends, there are no clear or common
mechanisms to help residents and fellows develop medical
education careers. At many institutions, there is no dedicated
academic advancement track for clinician-educators. On this
note, and as a first step, academic departments need to
Table Suggested local and national solutions to promote career development for neurology-trained clinician-scientists,
clinician-educators, and academic neurologists
Academic neurologists Neurologist–scientists Neurologist–educators
Local/departmental Create initiatives during residency
such as certificate programs or
scholarly pursuits that provide
neurology trainees with additional
structure and mentorship around
specific focus and interest areas (i.e.,
global health, diversity and inclusion,
quality and safety)
Form initiatives encouraging dialogue
and synergy between scientists and
clinicians
Provide courses or workshops with
specific curricula for developing
neurologic teaching skills
Critically evaluate and learn from
programs and structures that help
support clinician–scientists and
clinical educators
Provide seed funding to develop
novel ideas and methods
Create Master Clinician programs
that bring together education-
oriented faculty and provide focused
bedside teaching to trainees
Support academic–industry
partnerships geared toward
development of young
clinician–scientists (i.e., joint
fellowship programs)
Develop clear milestones for
academic advancement of education-
oriented faculty
Organizational/national Develop support structures for
nontraditional academic
neurologists; i.e., neurologists
focused on hospital medicine
(neurohospitalists), patient safety, or
global health, among others
Provide additional early career
funding opportunities to allow
protected time for scientific
development and preliminary data
collection for trainees and early
faculty
Provide grant funding geared
specifically for the development of
teaching skills in clinical neurology
Create formal programs for young
investigators to gain expertise in
clinical trials and drug and device
development
Develop ACGME fellowship programs
in neurology clinical education
Identify and reserve sources of
funding for dedicated teaching time
from clinical educators
ACGME = Accreditation Council for Graduate Medical Education.
Neurology.org/N Neurology | Volume 91, Number 14 | October 2, 2018 671
Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
recognize the unique value that e ffective clinician-teachers
bring to neurology and establish clear milestones for career
advancement for education-focused faculty. Different from
grants and papers in the research track, such milestones may
include patient outcome metrics, teaching awards, or feedback
by trainees and peers on teaching and mentorship.
One of the main challenges is funding for careers in neurology
education. There are currently no funding mechanisms to
support time dedicated to teaching. Here we draw a distinc-
tion between developing teaching skills in neurology vs
medical education research. To preserve the art of clinical
neurology, funding should be dedicated to developing the
unique set of skills necessary for highly effective and engaging
teaching of clinical neurology. This could come in the form of
departmental or national courses and conferences with spe-
cific and objective curricula for developing neurologic teach-
ing skills. Accreditation Council for Graduate Medical
Education-accredited fellowship programs for neurology
educators should be developed. Master Clinician programs
within academic departments that bring together education-
oriented faculty at all levels could provide (1) real-time
patient-focused teaching and feedback on the neurologic
history, examination, diagnosis, and management to trainees;
(2) a community of faculty with distinct clinical experience
and expertise; and (3) synergy and structure around clinical
education.
It would be naive and perhaps wishful to think that funding in
our current model of reimbursement would provide sub-
stantial protected time for young faculty to teach. To this end,
creative sources of funding for education should be consid-
ered. Could Medicare recognize the unique talent of clinical
educators by earmarking teaching funds for individuals or
departments? Or could clinician-educators who have a track
record of clinical excellence and expertise receive more in
reimbursement for dedicating extra time to teaching trainees
during a patient encounter?
We have thus far discussed the process of defining career
identity for clinician-scientists and clinician-teachers, but
what about new and emerging identity templates in academic
neurology? For example, the growing volume, demand, and
complexity of inpatient neurology services coupled with na-
tional pressure to reduce in-hospital length of stay has fueled
the birth and growth of the neurohospitalists, who specialize
in the high quality and efficient delivery of in-hospital care to
neurology patients.
9,10
How do neurohospitalists create aca-
demic identity as they negotiate their funding and time among
clinical care, education, and research? Furthermore, patient
safety and quality, neurology in the developing world (global
health), and diversity and inclusion both in departments and
in the field are all critical conversations in neurology today.
We need to cultivate residents, fellows, and young faculty with
mentorship, protected time, and clear milestones for career
advancement in all of these areas. Initiatives during residency
programs such as certificate programs, tracks, or scholarly
pursuits that provide additional training, mentoring, and
structure can help trainees explore different interests early on.
We should evaluate the programs and structures that are
working for clinician-scientists and what is starting to work in
the area of clinical education for inspiration to help develop
experts in neurology quality and safety, global health, and
diversity and inclusion.
More can be done at the departmental and national levels to
support the academic development of young neurologists.
Aspiring clinician-scientists would benefit from additional
early-career funding to develop novel ideas and methods as
well as more formalized training in clinical trial methodology
as well as drug and device development. Clinician-educators
would benefit from specifi c programs focused on the de-
velopment of clinical teaching skills, finding concrete ways to
dedicate funds for time spent on teaching, and the de-
velopment of clear milestones for academic institutional ad-
vancement. Ongoing evaluation of structures and programs
for clinician-scientists and clinician-educators will inform the
development of other identities in academic neurology
(table). Such upfront investments by departments and na-
tional organizations will help prevent burnout, maximize ca-
reer satisfaction, and usher in the next generation of leaders in
neurology.
Author contributions
David Lin: manuscript concept, manuscript draft. Tracey
Cho: manuscript concept, manuscript draft. Merit Cudko-
wicz: manuscript concept, manuscript revision.
Acknowledgment
The authors thank Martin A. Samuels for comments on this
manuscript.
Study funding
No targeted funding reported.
Disclosure
The authors report no disclosures relevant to the manuscript.
Go to Neurology.org/N for full disclosures.
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672 Neurology | Volume 91, Number 14 | October 2, 2018 Neurology.org/N
Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
DOI 10.1212/WNL.0000000000006284
2018;91;670-672 Neurology
David J. Lin, Merit E. Cudkowicz and Tracey A. Cho
in academic neurology
Opinion and Special Articles: Challenges and opportunities in defining career identity
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