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Abstract
This is a critical time in the history of the dental profession for it to fully embrace the responsibility to safeguard its reputation as a learned profession. In this golden era of scientific and technological advances, opportunities abound to create new diagnostics, preventions, treatments, and cures to improve oral health. Dental schools are the largest national resource entrusted with the responsibility to educate, train, and retain oral health researchers who can leverage such technologies and research opportunities that will benefit the profession at large as well as patients. This article reemphasizes the theme that research training and scholarship must be inextricably woven into the environment and culture in dental schools to ensure the future standing of the profession. An overview of the history of support provided by the National Institutes of Health and National Institute of Dental and Craniofacial Research for the training and career development of dentist-scientists is presented. In addition, new data on the outcomes of such investments are presented along with a comparison with other health professions. This overview underscores the need to expand the capacity of a well-trained cadre of oral health researchers through the reengineering of training programs. Such strategies will best prepare future graduates for team science, clinical trials, and translational research as well as other emerging opportunities. The urgent need for national organizations like the American Dental Association, American Dental Education Association, and American Association for Dental Research to create new alliances and novel initiatives to assist dental schools and universities in fulfilling their research mission is emphasized. To ignore such calls for action is to disavow a valuable legacy inherited by the dental profession. This article was written as part of the project “Advancing Dental Education in the 21st Century.”
- dental education
- dental research
- dentist-scientists
- clinical research
- research training
- career development
The most worrisome consequence of the growing lack of support for research and scholarship in dental schools is the decline in the science base for dental students and the general pall this trend is casting on the current and future pipelines of dentist-scientists. With qualifications that include either a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) alone or a dental degree combined with Master of Science (MS), Master of Public Health (MPH), or Doctor of Philosophy (PhD) degrees, dentist-scientists are uniquely positioned to translate basic science discoveries and knowledge gained from clinical investigations into therapies and evidence-based treatments for patients. We live in an era of unprecedented scientific promise that is driven by fresh discoveries and new technologies.1,2 Hence, developing and sustaining a cadre of well-trained dentist-scientists who have the capacity to effectively translate these new scientific and technological advances into improvements in patient care are critical for the profession of dentistry.3,4
The purpose of this article is to draw attention to the present status of dentist-scientists, the majority of whom develop their academic research careers within dental schools. New data are presented in the context of the history of National Institutes of Health (NIH)-supported programs for the research training and career development of dental researchers. Finally, the article projects ways to positively impact the future size, distribution, and composition of this invaluable group of dental scholars who are millennial learners faced with an explosion in knowledge about human biology and disease. This article was written as part of the project “Advancing Dental Education in the 21st Century.”
NIH’s Investment in Research Training and Career Development
From the earliest days of its existence, the National Institute of Dental and Craniofacial Research (NIDCR), has been involved in the training and career development of dental researchers. A survey sent to 1,822 trainees and fellows in 1973, which received a response rate of 78.7%, found that over 90% of the responding fellows and trainees were employed full-time.5 Interestingly, more than 80% of both groups had held teaching or research positions since the end of their NIDCR-supported training. It was then estimated that NIDCR fellows/trainees in turn sponsored an estimated 960 additional trainees and fellows. The vast majority of these NIDCR-supported researchers reported feeling that their training was significant in helping them achieve their career goals.
The training of dentists for careers as clinical research scientists became formalized with the introduction of the Dentist Scientist Award (DSA) in 1984 that issued awards to individuals or institutions.6 The individual Physician Scientist Award for Dentists and the individual Dentist Scientist Award were combined in 1995 and called the Mentored Clinical Scientist Development Award. This program required supervised research training in a specific basic science with or without advanced clinical training. It was expected then that trainees with individual or institutional awards would proceed to complete formal postdoctoral training. The overall intent was to position the clinical research scientist for tenure-track faculty positions nationwide and to mentor dental students and peers about the transfer and translation of basic science discoveries for the improvement of patient care. As reported by Lipton in 1996, the DSA program was assessed by two measures of success: the placement of trainees in full-time faculty positions and the obtaining of independent grant funding. From 1984 to 1994, a total of 247 trainees received support from one of the DSA programs with the greatest number (33%) specializing in periodontics, followed by orthodontics (15%), oral and maxillofacial surgery (12%), prosthodontics (9%), oral medicine and oral pathology (6% each), endodontics (6%), and pediatric dentistry (4%). Of all the individual DSA awardees, 80% applied for an independent research award; 54% of those were successful. The application and award rates for institutional DSA graduates were 61% and 42%, respectively.
It was NIDCR’s 1997 Strategic Plan that provided the framework for the deliberations of a Blue Ribbon Panel on Research Training and Career Development to Meet the Scientific Opportunities of the 21st Century.7 In identifying the significant research opportunities available to dental researchers, the panel recommended that the institute expand and diversify its research training portfolio and to improve the training environment by emphasizing interdisciplinary training and team-based research. Until 2000, NIDCR-funded training programs were classified as either short-term or long-term and were organized along specific research themes. The introduction of comprehensive institutional training programs in 2000 opened up a new dimension in training as combined dual-degree, DDS-PhD training programs were supported for the first time under the umbrella of the T32 program. These programs offered far more flexibility to dental schools and parent institutions than before, thus facilitating the development of a diverse portfolio of biomedical research focus areas in dental schools. Comprehensive T32 programs also offered a continuum of training options for predoctoral PhD and DDS-PhD programs as well as postdoctoral research training and junior faculty research career development options.
In his report to the National Advisory Dental and Craniofacial Council in June 2008, NIDCR’s training program director, Dr. Kevin Hardwick, presented results of an evaluation of the career outcomes and subsequent research grant success of NIDCR-supported trainees, fellows, and career development awardees supported by NIDCR from 1995 to 2003.7 This analysis showed that individual fellowship recipients of F and K awards were more likely to achieve success as measured by R01 awards than trainees supported by institutional T32 training grants. As a result, NIDCR increased the proportion of its training investment in individual National Research Service Awards fellowships, while encouraging T32 program trainees to gain early grant writing experiences by applying for individual fellowship or career development awards once a research project was defined. The introduction of the T90/R90 in 2010 provided an opportunity for NIDCR-supported T32 programs to utilize 25% of its postdoctoral slots for the training of non-citizen dentists, a group that up to this time was only eligible to compete for the K99/R00 awards.
NIDCR and NIH currently support multiple mechanisms of research training and career development in a wide range of the biomedical and public health sciences (Figure 1). As of 2016, 17 dental schools were supported through T32 awards, of which nine schools received T90/R90 stipends for the support of postdoctoral research training for non-citizen-dentists.8
Physician-scientist workforce (PSW) training pipeline: flow diagram illustrating typical training and career pathways for National Institutes of Health-funded researchers in the health professions
Note: Loss of individuals at key attrition points from the career pipeline are shown, where physician-scientists leave academic research to commit themselves to industry or exclusive clinical practice. The largest hurdle is that occurring after graduate school, with other significant attrition occurring after fellowship/residency and in the transition from junior to senior faculty. Common reasons for the timing of each attrition point are listed.
T32=Institutional Training Grant; T35=Short-Term Institutional Training Grant: F30=Individual Predoctoral Fellowship for physician-scientist; F31=Individual Predoctoral Fellowship; F32=Individual Postdoctoral Fellowship; K=Career Development Award; K08=Mentored Clinical Scientist Award; K23=Patient-Oriented Research Award; K12/KL2=Clinician Scientist Institutional Career Development Award; K99/R00=Pathway to Independence Award; RPG=Research Project Grant
Source: National Institutes of Health. Physician-scientist workforce working group report. 2014. At: acd.od.nih.gov/psw.htm. Accessed 10 Jan. 2017.
Current and Emerging Workforce Issues
Over 80% of federally funded biomedical research in the U.S. is funded by the NIH; and as of 2012, approximately 20,000 biomedical researchers with PhD degrees were awarded NIH Research Project Grants (RPGs).9 Among physician-scientists, 9,000 individuals with Doctor of Medicine (MD) or MD-PhD degrees had active NIH funding, while 341 nurse-scientists and 253 veterinarian-scientists were NIH grantees and 161 dentist-scientists were the lowest number of NIH-funded physician-scientists.9,10 It is difficult to obtain accurate numbers about the total size of the dentist-scientist workforce as data on the numbers of individuals whose research is funded by non-NIH sources are not available and information from pharmaceutical and dental industries is held as proprietary.
In recent years, the quality and sustainability of the nation’s biomedical research workforce has been challenged in multiple ways. The decline in overall federal funding levels has led to a highly competitive environment for grant awards and has compromised the number of research positions and resources available to academic institutions.11–13 In addition, regulatory requirements have significantly expanded, while institutional support has declined along with personnel reductions, making it difficult for investigators at all stages of career development to focus on research while balancing other academic and clinical duties. The most common reasons for trainees to abandon a training program are shown in Figure 1. These pressures are likely to more severely compromise researchers based in dental schools, where numbers of independent and full-time research faculty members, research space, and resources are already small when compared to medical schools and biomedical research facilities.
The analyses and deliberations of the physician-scientist workforce working group—charged by the NIH director, Dr. Francis Collins, to assess the status of all groups of physician-scientists—found significant current and future trends that relate to research training, career development, and retention.9,10,14 For the first time, an individual grant applicant and awardee was tracked as a single unit of analysis, thus creating a more accurate representation of training and research outcomes over a 13-year period.
The working group found that, from 1999 to 2012, the numbers of NIH grant applications from dentist-scientists only increased by 61 submissions as compared to 171 more applications from the veterinarian group.10 However, the success rates for both groups in 2012 was 17.3%, suggesting that the higher number of awards to veterinarians was likely a reflection of their higher number of applications (Figure 2). For individuals with MD or MD-PhD degrees, trends resembled that seen for veterinarian-scientists, as application numbers almost doubled from 1999 to 2012 while the numbers of awards remained relatively static. This trend likely reflects an increasingly competitive funding environment for biomedical research in general. In 2012, over 1,000 MD clinicians without PhD degrees were active in NIH-funded research compared to almost 5,000 MD-PhD researchers with NIH funding (Figure 3). Non-clinician PhD researchers have also been affected by the highly competitive funding environment as application numbers from this group have been on the rise since 2003 without corresponding trends in grants awarded (Figure 4).
Number of individual National Institutes of Health research project applications (dotted lines) and awards (solid lines) to dentist-scientists and veterinarians, 1999 to 2012
Number of individual National Institutes of Health research project applications (dotted lines) and awards (solid lines) to MDs and MD-PhDs, 1999 to 2012
Number of individual National Institutes of Health research project applications (dotted line) and awards (solid line) to PhDs, 1999 to 2012
In 2012, the average age of dentist-scientists in the independent workforce was 54.6 years for males and 52.7 years for females.15 Most striking is the fact that, over a 13-year period, applications from dentist-scientists between 31 and 40 years of age sharply declined, while the highest award success rates were for dentist-scientists in the age group of 51 to 60 years. Female dentist-scientists were awarded almost one-third the total number of RPGs as compared to other physician-scientist groups, where female awardees approximated 22%.
Data on the application and success rates of early career dentist-scientists show a sharp decline in the number of Loan Repayment Program (LRP) applications as well for the K series of career development awards.14 While 11 LRP awards were granted to 19 dentist-scientist applicants in 2004, submissions have declined sharply since. In 2012, only two of five LRP applications were awarded to dentist-scientists (data not shown). The same trend is seen for the K-series applications. Career development grant applications from both dentist-scientists and veterinarians have been on a downward trend, while award numbers (never particularly high in these groups) have remained discouraging (Figure 5). Although there has been a downward trend in the number of K grant applications from MDs and MD-PhDs, the numbers of applications and awards for MDs have been significantly higher when compared to MD-PhDs (Figure 6). For non-clinician PhD applicants for K awards, success rates of around 30% have remained fairly stable, while the number of applications from this group increased by fivefold (Figure 7).
Number of K grant applications (dotted lines) and awards (solid lines) to dentist-scientists and veterinarians, 1999 to 2012
Number of K grant applications (dotted lines) and awards (solid lines) to MDs and MD-PhDs, 1999 to 2012
Number of K grant applications (dotted line) and awards (solid line) to PhDs, 1999 to 2012
Taken together, these data indicate alarming trends for the dentist-scientist workforce as the number of dentist-scientists with independent grant funding is the lowest among health professions and far lower than for non-clinician PhD researchers. Most alarming is the shrinking of the pipeline of junior investigators who seek research grants to launch their research careers at a time when more senior dental researchers are considering retirement options. These data suggest that the future of dentist-scientists is threatened and may represent a vanishing species in dental academia.
Re-Engineering Research Training Programs
Debates about the adequacy of the overall biomedical research workforce ecosystem in the U.S. are ongoing, based primarily on concerns about the relationship between supply and demand.11,16 A dominant culture for training non-clinician PhDs for academic tracks prevails but has resulted in prolonged postdoctoral training, difficulties in securing faculty positions, and delays in setting up independent research programs. Graduate training programs in the biomedical sciences are now proposing reforms to broaden PhD training so that graduates are prepared for careers outside academic institutions. Furthermore, the pool of non-clinician PhD graduates is far more robust than that for the clinical sciences and offers a valuable resource as mentors and sponsors for dentist-scientist trainees. Orienting PhD trainees to academic settings that extend beyond medicine to schools of dentistry, public health, and pharmacy should create a more sustainable equilibrium for the overall biomedical research enterprise.
The training paths and career goals for physician-scientists are naturally different from those of non-clinician PhDs.12,15–18 In addition, economic and educational drivers that involve the changing landscape of health care are placing new demands on academic health centers, and these tensions are being transferred to researchers with clinical training. Perhaps the biggest shortfall in the current physician-scientist and overall biomedical research enterprise is the lack of data at institutional and national levels to provide a history and real-time view of training and career outcomes.10
There is a sore lack of definitive data at institutional and national levels on the training and career outcomes of graduate students, postdoctoral researchers, and dental faculty members who perform research on the dental, oral, and craniofacial complex. Increased efforts in collecting and sharing data will increase transparency and act as a catalyst for change in the following areas: a) the current size and composition of the dental research workforce, including those performing extramural research funded by agencies other than NIH, researchers in community health and population science, and individuals employed by industry; b) the scope and magnitude of deficiencies in training dentist-scientists and researchers in the craniofacial sciences; c) how well the programs that relate to DDS-PhD training such as K awards are working and whether they should be expanded; d) the level of diversity in the pool of dentist-scientist trainees; e) the competing demands placed on dentist-scientists with dual research and clinical duties; f) economic factors such as debts, loans, salaries, and funding; g) length of training and the time taken to reach independence; h) the availability of a diverse pool of mentors; and i) how other countries train and support dentist-scientists.15,16
Several distinctive hurdles confront dentist-scientists at all stages of research training and career development.19 While several graduates of DDS-PhD programs have succeeded in academic research and now occupy leadership positions in dental schools, the attrition of trainees and graduates is an issue of great concern. DDS-PhD trainees may opt to exit dual-degree programs prior to fulfilling graduation requirements or choose to not pursue an academic career after graduation. The length of training, relatively high debt burdens, and economic disincentives including income differentials between the private and academic sectors have been found to be among the most common reasons that individuals decline this career path.20 Furthermore, integration of scientific and clinical training is often poorly defined for dual-degree programs that remain compartmentalized in dental school settings. Achieving an optimal work-life balance during and after training is also difficult for dentist-scientists who struggle to meet tenure-track standards for independence in research, teaching, patient care, and service activities. Since non-clinician PhD faculty members in dental schools experience difficulties in succeeding with R01-level research, there is a shift of priorities away from research. When combined with the shrinking pool of DDS-PhD faculty members, the pool of mentors and role models for dentist-scientist trainees and new graduates is a resource that is rapidly shrinking.21 This trend has also compromised the base of scientific instruction and training offered to dental students.
Moving forward, it is imperative that dental schools make concerted efforts to leverage resources that are available in schools of medicine and in academic health science centers. Such resources could include but are not limited to providing a larger pool of mentors and tapping into curriculum and career development activities sponsored by training programs and other NIH-supported initiatives such as the Clinical and Translational Sciences Centers. Concerted efforts to create more holistic institutional mentoring programs that support junior faculty and trainees engaged in clinical and translational sciences are needed in dental institutions. As described by Byington et al., mentoring using a multilevel matrix that includes self-, senior researcher, peer, and staff guidance along with leadership training and management essentials has proven to be highly effective in generating a strong pipeline of pediatrician researchers.22
Since NIH-funded dentist-scientists only represent one arm of the research workforce based in dental schools, understanding the true composition of the broader community of dentist-scientists is also important. Such knowledge will lead to a more thorough needs assessment for each interest group and an evaluation of current programs so that proven best practices can emerge. Furthermore, leaders in academic and organized dentistry must collaborate to strategize ways to diversify the dentist-scientist workforce by investing in DDS faculty educators who trained in the U.S. or in foreign dental schools and who have an interest in engaging in team-driven clinical research projects.
According to its strategic plan, it is expected that NIDCR will expand its existing research training and development programs and launch new initiatives to ensure a strong research workforce that is dedicated to improving dental, oral, and craniofacial health.23 By organizing a blue ribbon panel of experts to stimulate debate on issues of concern, NIDCR could lead efforts to reengineer the dentist-scientist enterprise. Participants could include training program directors and dental school deans, associate deans of research, faculty, and trainees, as well as stakeholder organizations like the American Association for Dental Research (AADR), the American Dental Education Association (ADEA), and the American Dental Association (ADA). This group could strategize ways to streamline dual-degree programs with a recommended curriculum, while expanding research training in new areas that represent emerging needs of oral health care in the U.S.
The community of dental researchers, academicians, practicing dentists, stakeholder organizations, and leaders must come together to create a new generation of scholars who are well positioned to compete for extramural funding and with the capacity to engage in a wide range of opportunities and emergent technologies.22–28 There is no better time than now to protect dentistry’s reputation as a knowledge-based profession and to advance and translate knowledge for the benefit of the patients we treat.
Footnotes
Editor’s Disclosure
This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted independently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project’s directors and the coordinators of the project’s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA.
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