NINDS's Building Up the Nerve

S4E6: Demystifying Clinician-Scientist Careers

• NINDS • Season 4 • Episode 6

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The fourth Season of the National Institute of Neurological Disorders and Stroke’s Building Up the Nerve podcast, where we discuss the unwritten rules, or “hidden curriculum,” of scientific research at every career stage. We know that navigating your career can be daunting, but we're here to help—it's our job!

In episode 6, we talk about conducting research as a clinician-scientist, including the different paths to research as a clinician and what a clinician-faculty position can look like.

Featuring Erika Augustine, MD, Associate Chief Science Officer, Kennedy Krieger Institute; Edjah Nduom, MD, Associate Professor, Emory University; and Audrey Brumback, MD, PhD, Assistant Professor, The University of Texas at Austin.

Resources

 Transcript available at http://ninds.buzzsprout.com/.

[00:00:00] Lauren Ullrich: [intro music] Welcome to Season 4 of the National Institute of Neurological Disorders and Stroke's Building Up the Nerve, where we discuss the unwritten rules or "hidden curriculum" of scientific research at every career stage. We know that navigating your career can be daunting, but we're here to help. It's our job. [music fades]

Hi, I'm Lauren Ulrich, a Program Director at NINDS. 

[00:00:24] Marguerite Matthews: And I'm Marguerite Matthews, also a Program Director at NINDS, and we're your hosts today. 

[00:00:30] Lauren Ullrich: Last episode, we discussed succeeding as a postdoc, and today we're going to talk about conducting research as a clinician scientist, including the different paths to research as a clinician and what a clinician faculty position can look like. [music]

 Joining us today are Dr. Erika Augustine, Dr. Edjah Nduom, and Dr. Audrey Brumback. 

So let's start with introductions. 

[00:00:59] Erika Augustine: I'm Erika Augustine, Associate Chief Science Officer at the Kennedy Krieger Institute and Associate Professor of Neurology at Johns Hopkins University, both in Baltimore, Maryland. At Kennedy Krieger, I oversee our clinical research operations and specifically I direct our clinical trials unit. My own work focuses on clinical trial readiness in rare neurological diseases, especially pediatric neurodegenerative diseases.

I study a group of neuronal lysosomal storage diseases called the NCLs. And there we are focused on preparing for the therapeutic wave ahead. Our focus is on clinical trial readiness, natural history, and establishing robust outcomes. 

[00:01:45] Edjah Nduom: So I'm Edjah Nduom, um, currently the Daniel Louis Barrow Endowed Chair of Neurosurgery, have to try out that title because it's relatively new, uh, here at Emory, uh, also Associate Professor in Neurosurgery. Um, and I'm an neurosurgeon scientist. I focus on glial blastoma, which is a really deadly brain tumor. Um, and my job is to try and find new ways to treat it, mostly through boosting the immune system.

So trying to turn the part of your body that fights off infections towards actually noticing the brain tumor and attacking it. Um, and I do that through many different ways, sometimes through clinical trials. I particularly focus on clinical trials that have a surgical component, um, actually finding tissue or using tissue in some way to determine how the brain is responding to an immune therapeutic.

I also trying to develop new therapies in my lab, uh, both through translational models with mice, uh, trying different combinations of immune therapies to try and treat brain tumors in mice that might move into clinical trials. Uh, and I also have a growing interest in non coding RNAs. Uh, so RNAs, you know, part of your genetic code um, that doesn't actually create different proteins. Um, so does not produce genes. The types of genetic material that actually have biological functions in the cells without creating proteins. Finding out how those are dysregulated in immune cells and glioblastoma and trying to use that information to treat the tumors a little bit better.

Outside of work, um, have a lot of different hobbies. Um, I like to travel, um, uh, see new places, uh, preferably warm places with something to do. Um, and so when there is time, that's not a meeting and not in the operating room, not in the lab, not on podcasts, [laughter] it is nice to get out and do something different and new.

[00:03:26] Marguerite Matthews: Um, well, I'm a longstanding fan of Erika's, and so now I will be, will be a new onset fan of you, Edjah [laughs]

[00:03:36] Audrey Brumback: Um, so, my name's, uh, Audrey Brumback. I'm a pediatric neurologist and, uh, neuroscientist. I have a clinical practice, uh, here at the Dell Medical School in Austin, Texas, where I take care of mostly kids, but some adults, um, with neurodevelopmental disorders, particularly autism is, um, is my area of focus.

And then I have a lab where I'm trying to understand how we can harness, um, the electrical activity of brain circuits to treat symptoms of different neuropsychiatric conditions like autism. Um, really using really granular approaches like mouse models to map out, um, circuits so that we can turn those on or off or modulate their activity, um, and do that in a way that affects, you know, certain symptoms, but leaves the rest of the brain alone.

In my spare time, uh, I've got two kids and, um, I didn't really like reading growing up, um, and now I love reading because my main hobby is just, like, reading to them, um, and so now I read a ton of, like, young adult literature, which is super fun and easy. 

[00:04:55] Edjah Nduom: Doesn't reading for pleasure feel kind of like, I don't know, decadent in some way, like it's like almost like contraband to [laughter] not read a paper, but reading something just for pleasure. 

[00:05:07] Audrey Brumback: And it's so like, I think I used to feel guilty that like I wasn't reading something sort of more serious or whatever. And so like, yeah, now that I'm like just reading like fluff, it's like, Oh, this is why people say reading is fun. 

[00:05:21] Edjah Nduom: Yup. 

[00:05:22] Lauren Ullrich: Fluff is great. I'm very pro fluff. [music] 

[00:05:24] Marguerite Matthews: All right. So I think a lot of people, when they think about research, they think, "Oh, you need to have a PhD to do research as a career." Um, but I think only one of you has a PhD in addition to the MD, so you can, can you talk to the audience a little bit more about your path to becoming a clinician scientist and what drew you to research?

[00:05:50] Audrey Brumback: Should we start with the PhD first or the non PhDs first? 

[00:05:55] Marguerite Matthews: Uh, who's, who's better? No, just kidding.

[00:05:59] Lauren Ullrich: Uh oh [laughter]

[00:06:01] Edjah Nduom: I'm not doing that. 

[00:06:03] Marguerite Matthews: Just start a little war, just a little war on the podcast that's all.

[00:06:07] Audrey Brumback: Nice try. Well, I'll start and just, you know, just because I think that, you know, that is one question that people have is like, "well, what, what good does it do to get you, you know, to have a PhD and, you know, is it necessary?" And so, you know, I, I can speak to that. Um, you know, my PhD advisor didn't have a PhD.

Um, and so I think that, you know, when it comes to, um, basically anything in your life, there's multiple different ways to go about it. Some of which are official and some of which are unofficial. And just because it's unofficial doesn't make it "less than." Um, so I happened to, you know, do like an official program where I got this piece of paper at the end of it.

Um, but really, you know, the part of it that actually matters is like, what I learned doing those projects and during those classes and, you know, you can do all that, as we will hear from our other two guests, 

[00:07:03] Lauren Ullrich: mmhmm

[00:07:04] Audrey Brumback: You know, outside of a formal PhD program with no problem. 

[00:07:08] Erika Augustine: So I came late to interest in research.

I think if you'd asked me at the beginning of medical school, or probably even in the midst of residency, how I anticipated spending my time, I envisioned a full time clinical practice in an academic setting, maybe in an inpatient setting. And it was really the unsolved problems that I found in clinical practice that led me to interest in research.

So I got to the end of residency, realized I had an interest in movement disorders and pursued a movement disorders fellowship, and quickly realized that I had very few tools for patients impacted by a whole variety of conditions. And we usually could sometimes help symptoms, but not necessarily change or ameliorate disease and disease processes.

And I was really interested in learning more about how do you go about creating new therapies? How do I learn more about clinical trials? How do I become involved in clinical trials? And so that kind of set me on, on a path towards research. And I think, you know, I really agree, Audrey, there are so many ways to go about, um, a research career path.

Somewhere along the way, though, I think it's important to have opportunities for a structured education. We took all of this time in medical school, in residency training, sometimes in fellowship, to really hone the clinical skills of our craft. And I think research is no different, whether that's a PhD path, sometimes it's a Master's path, sometimes there may be other paths as well to address the ways to build a new skill set that you then need to apply to better answer research questions. And so for me, that, that sort of structured path looked like a master's in translational research. I was interested in therapeutics. I was not going to go get a PhD, but I needed to understand work at the bench.

I needed to be able to critically evaluate the literature, critically evaluate preclinical work so that I can feel comfortable deciding, is this something that I want to be the face of taking forward and exposing research participants to risk? Is the scientific basis strong enough? And so that was the work of the Master's.

And then, um, I did, uh, some additional training around clinical trial design in the context of the T32 fellowship. So I think that that education piece is important in no matter what form it comes. 

[00:09:41] Edjah Nduom: Yeah, I'd agree with all of that and everything that's been said. Um, you know, I think my path similar to Erika's in the way that I did not set out in my pursuit of a neurosurgical career thinking that I would necessarily be a neurosurgeon scientist.

I knew I wanted to do neurosurgery and address neurosurgical problems. Part of that interest was because there were unanswered questions in the brain, which was different from some of the technically invested surgical specialty. So there was always that, that inquisitiveness, that wanting to change the field in some way through my practice, if not necessarily through formal research when I was looking at neurosurgery.

And then I had a series of experiences, you know, some more formal than others, from being an undergrad and doing a brain and behavior class. And in that class, Dr. Susan McConnell kind of taking us through the seminal experiments in development of the brain. She would do it in a very Socratic fashion. So she would ask us to come up with the experiments that, um, renowned investigators had used to answer questions about how the brain developed, um, and being active in that class and answering questions, I kind of learned, "okay, I can actually in my own mind," which I hadn't thought of myself as a creative person, um, could create experiments in new ways to answer scientific questions. So that was kind of the first kind of "Oh, maybe science would be something that that I wanted to do as a career." I'd always considered science to be far too risky.

It's like you could work on something for a long time and never figure anything out. And I did not like that idea at all. And so, you know, medicine seems a little bit more concrete. I help this patient. I see this patient, help this patient, and move on. Um, then a medical school did a summer of research.

First encounter glial blastoma cells growing. I just saw how resilient and just relentless they were. Thought this was, "Hey, this is a big problem that I could possibly tackle." Did some additional clinical research, um, in undergrad and got to residency, did a year in a lab. Um, so kind of tried it on, still wasn't 100% sure, was still thinking more clinical research and, um, clinical activities as I went forward, um, but then ended up taking an eight month fellowship at the NIH after I didn't get funding to do a different, uh, more clinical research experience that I'd applied for. And during that eight months, um, in the surgical neurology branch under Russ Lonser um, actually had my first kind of success, um, in science and, uh, did some small investigations of the blood brain barrier and brain tumors, um, you know, a retrospective research study, but also a primate study where we do a convection enhanced delivery in primates. And I was doing that surgery myself, um, and really started to think it was like, wow, you know, I think I might have some necessary tools to be successful in research, um, that could be fruitful. Spent, uh, two years at MD Anderson. One year, which was an additional one year research experience, and then I was ready to come back to the NIH as faculty. And so when you add it up, I actually, you know, I put together a postdoc in some ways through a bunch of like individual experiences, um, that kind of got me to where I was, um, and learned a lot of things from my various mentors that sort of added up not fully to a formal Ph.D. and no one's going to give me that sheet of paper, um, but to a lot of the experiences that some people would have in a formal, um, study in, in that way. What I tend to tell, uh, people that are interested in medicine, um, they're considering whether they need to add a Ph.D. on or not, particularly for neurosurgery, uh, people that're interested in neurosurgery, neurosurgery programs are a little bit different and then they tend to have some time for research built in. Um, and so that's one thing that I always tell them to consider that and the length of neurosurgical training. Um, what I always say is if you are at the stage of applying to medical school and you have some really burning research questions that you want to answer and skills you want to pick up in science at that time, it's a great time to do a Ph.D. 'cause you're passionate about it, you want to learn something, and you know, you're gonna really get something out of spending that time doing the Ph.D. If you have this concept that maybe, "oh, I should do an M.D./Ph.D. because that will allow me to do things in the future, but you're not really passionate about studying something right at that time, I would venture that maybe doing an M.D./Ph.D. at that time is not the right answer. Um, that you should do your medical training, find something that sparks your fancy, and you can always make that, that left turn later. 

[00:14:01] Lauren Ullrich: mmhmm 

[00:14:02] Marguerite Matthews: That's a great point. 

[00:14:03] Audrey Brumback: I think that the idea of, you know, what are you actually interested in doing? How are you actually interested in spending your time?

And, you know, for me, I was interested in sort of learning that,- that science piece, you know, sort of beforehand so that, you know, when I did my clinical work, I could use that lens and, um, and yeah, there are just as many people who start with the clinical frustrations and then learn how to figure them out.

[00:14:28] Lauren Ullrich: Yeah, yeah, I, um, was wondering if you all could speak to how you see the relationship between your research and your clinical work, um, and how your clinical training affects the research that you do. Some of you do more clinical trials, some more kind of basic. How do you think about the relationship between those two things?

[00:14:48] Edjah Nduom: I tend to view these, um, uh, as very complimentary. In glioblastoma, uh, you know, as a neurosurgeon, taking care of patients is, is in some ways very concrete. Um, they have a bad problem, they come in, I'm often the first person they talk to about having this disease in, in a lot of ways.

And there's something on a scan. I want to take it away in the safest, um, you know, best way for them to set them off on their disease course the best way possible, minimize risk to loss of function, reduce as much tumor as possible, get an accurate diagnosis, move on. Um, and I love doing that. I love the interaction with patients and I'm sitting down with families, even in these, these really terrible problems and walking them through that in a compassionate way that they appreciate.

Uh, and so I get, I get an immediate reward from that interaction every time I interact with a patient. But glioblastoma, terrible disease, and eventually the surgery is not going to be enough and that frustration of, you know, with every patient, even as well as we start things off, perfect surgery, at some point, they're going to come back with a major problem that I can't fix with surgery.

And so my kind of entrepreneurial, um, kind of creative side, is working in the lab on these long payoff projects. You know, some might turn around in a year, but many turn around in two years or three years or five years. Or even as I'm learning with this clinical trial, I'm working on, eight years. [laughter] Um, and, um, that's a long payoff.

And that is also frustrating because I'm working on this idea for a long time and I'm waiting to see some results from it. Um, but when you see the result from the research that you've done and you can share that with your colleagues and maybe change the way they think about something, um, or change the way that people are studying a particular disease or process, um, then that's a huge payoff, and that could affect many, many more patients than I could ever see, um, in the office, you know, in a year or many years over the course of a career. Um, and so that, that complementarity of, you know, okay, immediate payoff, but still some clinical frustrations versus, you know, long payoffs of frustration of the process of the research, but then that payoff, um, can, can potentially affect those frustrations that I'm having with the individual patients. 

[00:17:00] Erika Augustine: You know, I think as I, as I listen to you and, and think about all the different ways in which you engage with research and how it, um, reflects your desire to help people, your desire to have long relationships, I think it, it really, it underscores that we do what we do and sometimes even our, um, our research paths go back to some of our very early clinical motivations. You know, you go into medicine because you want to help people, and the way that you do that in a clinical context is one person at a time. In research, ideally, you do that in ways that either shape our understanding of disease or shape how we provide care, and you can do that for groups of people at a time. Ideally, lots of people at a time. 

And then for those who have science interests that relate to epidemiology, to policy, you're really just... expanding the scale even more, um, to very large groups of people at a time, all founded on the idea that we're, we're interested in helping people. 

I think for me, the specific type of research that is of interest, it's the same kind of thing. I can go back to what, um, drove my interest in neurology. I loved the way that observation and your exam were so important. And I think that same thing drove me to movement disorders. I think the area of neurology where the most your observation is really um, very much needed. It's your, your greatest tool, your skill of observation.

And then now as I think about trial readiness and that focus that I have, a lot of that is about phenotyping. Again, we're back to observation, thinking about measurement, how do we quantify what we see in a way that is robust. And so those threads of interest just continue to run throughout. 

[00:18:46] Audrey Brumback: I think that, um, it's interesting, I feel like I somehow, uh, or so far, have not quite lived up to my potential as a physician scientist. Um, and I say that because the work that I do in the lab right now is very removed from my patients. Um, it's very much that long view of, uh, return on investment. I think that, for me, the, the, the clinical frustration that started, you know, my interest in autism was, you know, that I'm a neurologist and, there are all these brain disorders, brain conditions where, you know, we don't know how to localize the lesion. Like that's neurology 101 and we just thought, we're not able to do that for disorders like autism.

And so, yeah. I think, you know, blending kind of my, um, understanding of physiology and my ability to patch clamp neurons, um, you know, I, I had initially thought like, maybe I'll be an epileptologist, you know, I'm into electrophysiology; I could look at squiggles on the screen all day. Um. But I thought, you know, in, in the epilepsy field, they're swimming an electrophysiologists.

They don't need me, you know, and so what is a good field that I could actually have an impact? And I think it's for these kinds of conditions where we can scan the brain all we want, we don't see anything. And, you know, the neurological elementary exams are pretty, uh, intact.

And so, you know, how do we localize what's going on with that person? And it's through the function of the brain. It's through the physiological functioning of the brain. And so I think that, you know, my desire to, uh, study circuits is really my neurology lens on, uh, what was previously, you know, considered a psychiatric disorder.

 As I have marched forward, um, I have like a project right now that I'm working on that was absolutely sparked by me sitting in a patient room and being frustrated. [chuckles] And so, like, that, that idea of doing both and having them play off of each other, I think all of us have talked about that, like, that is, that's your day to day life as a physician scientist is, you know, generating hypotheses in clinic and then going and trying to figure 'em out in the lab. 

[00:21:18] Edjah Nduom: So I'm just going to, uh, have our first disagreement, I think on, on the call real quick, because Audrey said that she wasn't living up to her fullest potential as a physician scientist.

And then very eloquently stated how she was using her talents both as a scientist and as a physician to apply the tools that she has to a huge unmet need in our physiological understanding of autism, which to me is the heights of, of what we all hope to do as a physician scientist. And if you look at the the number of people who have autism versus the number of people that have glioblastoma and the potential impact of what you could learn and then potentially have interventions for, I would say that that is what physician scientists are absolutely for. So I will have to reject your [laughter] your prior claim and put you back in your rightful place as doing, doing the right thing.

And I just also want to draw a corollary to that. And as a neurosurgeon scientist, this is one of the things that I often tell trainees that are um, interested in pursuing a career as a neurosurgeon scientist. I think it's really important to take a look at the tools that we specifically have as neurosurgeons and apply those to our research in ways that make use of the specific tools that we have learned.

Um, and so just like you, you know, having those skills and being a neurophysiologist and then applying that to a disease you wanted to fix. Um, it's really important in my research that I specifically use the ability to access the brain during, uh, clinically indicated, uh, neurosurgeries to better understand how our treatments are working for our patients or not. Um, and then use that information to then bring it back, um, to the clinic.

So it's a very bench to bedside and then back sort of approach, um, which I think is really, really important, uh, for physician scientists broadly, specifically for neurosurgeon scientists because of the amount of time we have to spend in the operating room. 

[00:23:04] Audrey Brumback: Yeah, you're talking about synergy. 

[00:23:06] Edjah Nduom: There you go.

[00:23:07] Audrey Brumback: Yeah, because I, I think that that's a question that, you know, we often will be asked is, you know, does your clinical and your scientific life, you know, do they have to be, um, on similar topics? And, for me it's really the, the way that it makes sense is exactly what you just described, where it is that, that, um, bi-directional, um, flow of inspiration and, you know, then knowledge, so... 

[00:23:34] Erika Augustine: That synergy concept I also think of as really being important, not only for driving your interest and your passions, but for feasibility of all of the things that as academic clinician scientists who are asked to do or engage in and the things that we enjoy doing, but there's care, there's our research programs, there may be administrative roles and service to the institution or more broadly, and then there's education. And when those thematically align, I think they actually all have the potential to enhance one another when they're disparate, it becomes quite hard. But having that synergy across all of those domains has become increasingly important for me. And I see that for a lot of others as well. 

[00:24:19] Audrey Brumback: Yeah. We all are at risk of spreading ourselves too thin, you know, and I think that that's, you know, an easy way to do it is to have things not be aligned in that way. 

[00:24:28] Lauren Ullrich: mmhmm 

[00:24:30] Marguerite Matthews: For the MD PhD, it's sort of built in that you're, you're going to have a dedicated amount of time, a few years to be able to work on a research project in order to complete, um, the requirements for receiving the PhD, but for other types of clinical training, what can you expect in terms of getting research done?

Is there opportunities for research within just basic medical school training? Should you wait until you're a resident? Are there residency programs that allow protected time for research? Like, what does that look like? Especially if you're not committed to, you know, however many years it will take to receive a PhD in addition to the MD.

Um, if people are just curious and maybe want to also tinker around and see what some research questions they can ask and try to, um, address while, um, pursuing a clinical degree. 

[00:25:26] Edjah Nduom: I think, um, it really just depends on your interest at any given time and how interested you are. I wouldn't necessarily advocate trying out a lab at a point where you're really not interested in laboratory work, or you're not interested in the lab that's available, or that sort of thing. You're going to end up disliking the experience, and it's going to turn you off from the whole enterprise.

 In 

medical school, depending on the medical school, it can get a little bit tricky because there are going to be institutions that will have a lot of different investigators doing a lot of different types of research where they have a really established culture of people coming in and working in the lab.

And then there are also institutions that maybe don't have as many experiences. And so it may be just that little bit harder. But even in those cases, you will often find that within the city, um, or in your metropolitan area, there may be other institutions that you can reach out to, learn about a lab, spend some time in the lab.

Medical schools are very different. Some have it built in. Uh, Emory, for example, has this discovery program built in that's five months. There are other, um, uh, schools that have up to a year built into the medical school curriculum where you can investigate anything as basic as you would like to or as clinical as you want to, built into the curriculum. And that's something to researcher as you're looking at graduate programs. 

And then same thing for residency. So neurosurgery, as a 7 year program traditionally has had some amount of elective time or research time built in, but that varies widely. Um, there are some programs where there are 2 contiguous years of research or elective time.

There are some where it's kind of 6 months at a time over the seven years. A lot of the residents will use that time to do research. Many where a lot of the residents will use that time to do elective fellowships. Um, and so kind of learning the culture of the various programs as you go through will tell you how much of an opportunity there will be to do research.

The thing that I tend to try and emphasize to trainees, though, is at any of those levels there are multiple different entry points, um, into the research enterprise. I didn't do research in high school, nor did I do an honors program in undergraduate, I did not take a year off between undergraduate and medical school, nor between medical school and residency. But if you get bitten by the bug, there are also multiple different times when you can take a pause in your clinical training and add on additional research training that will then qualify you for the next step.

[00:27:53] Erika Augustine: I would add, at all of those entry points, um, it takes a little bit of initiative or letting people know what you're interested in or might be interested in and that also at almost every entry point, there are structured programs that can help you explore that interest as well. Either establish your career in research or explore that career in research.

And I agree going all the way back to middle school, there are structured programs for that and it doesn't always seem like it at the time, but that high school, college, medical school, fellowship, early faculty time period, those are the times where you may have the most flexibility and the greatest number of options to explore because there are these structured programs to help you do so. And again, does not always seem like it at the time, but for many, um, for many, you are the most unencumbered by other responsibilities or obligations. And so you have this flexibility to explore, to learn, to consider how this might resonate with you and in a career. So I think considering those entry points is a great concept and great framework for thinking about exploration and then structured support.

[00:29:18] Marguerite Matthews: And Audrey, for you, even with the M.D./Ph.D. Program, um, did you do any research while you were in your clinical training before you formally sort of entered, um, the Ph.D. process? Was there any time to continue working on things after you returned to medical school? Like, did you do a formal postdoc where you were just looking at research after you finish all your many years of medical school? 

[00:29:42] Audrey Brumback: Yeah, the thing about doing a Ph.D. Is, um, in the middle of medical school is then you go back to med school and then you do your residency. And by the time you, you know, emerge from the fog of clinical training, the entire scientific enterprise has moved on without you. [laughter]

Um, and you know, it is like riding a bicycle, but you're also learning a lot from scratch because there's been a lot of advances. I think that, sort of getting back to what was said earlier, you know, that idea of like, well, what are you actually interested in doing?

Well, for me, when I, um, went from medical school to residency, I knew that I wanted to do research and I knew that child neurology was a long training program and that, you know, I wasn't getting any younger. And so I specifically sought out, uh, training programs where, um, there was a strong research component.

Um, in fact, I was able to do one of the very few programs in the country where this was possible, um, where I was able to do a single year of pediatrics and then, um, jump right into the neurology and then have that extra year that would have gone towards general pediatric training and have that be a postdoc year. 

[00:30:49] Marguerite Matthews: mm

[00:30:50] Audrey Brumback: And so I was able to really get that, like, dedicated postdoctoral training where I was living the life of the 80/20, uh, physician scientist where I was in lab, you know, um, for 80% of my time, and then I had a clinic. Um, I was able to jumpstart that a little bit sooner because I had sought out that, uh, research opportunity embedded within neurology training.

[00:31:18] Lauren Ullrich: This is the perfect segue, um, to our questions about, like, what can clinical faculty research positions look like? Um, so you mentioned this 80/20, um, and we talk a lot about protected time for research, how to balance the research and the clinical duties, and all the other things that you talked about earlier, Erika, um, education, administrative duties. And how do these things look different, depending on the type of institution that you're at, like a medical center, a hospital, government, um, if you all could speak to that.

[00:32:01] Edjah Nduom: I mean, I can talk about the neurosurgeon scientist thing. Um, and it's really interesting because, um, uh, so I've been in two different environments, so I've been in government, um, neurosurgeon scientist and now kind of in an academic, major academic center. Um, and so there's not many neurosurgeons at the NIH, um, Surgical Neurology Branch.

It's had four for most of its existence that I'm aware of.

[00:32:24] Marguerite Matthews: And then you left us. [laughter] 

[00:32:28] Edjah Nduom: I was recruited away, uh, back to where I trained. Uh, so, you know, I trained at Emory University and they recruited me back here as faculty. 

But so, so the Surgical Neurology Branch, so, uh, being at the NIH, uh, in the Intramural Research Program meant that my position came with whatever research funding, um, that I had. And I had some, uh, expectations of clinical service, uh, to the clinical center, uh, which was very minor. Um, they expected me to do somewhere around 50 cases a year, uh, five zero. So like a little less than one week. Um, and, uh, to take call a week at a time. 

Typically once a year, maybe I got called in, um, and then doing my research, which is really why I was there. Um, and that research, just like it does now, included doing surgeries that had a research bent, providing tissues to collaborators, tissue to my own lab, um, and actually a clinical trial that I designed there to measure immune responses in patients that were getting immune therapy for glioblastoma.

Um, and so at the NIH, salary: set, no change whether I do more cases or less. Um, budget basically, uh, defined by the position, not really applying for grants separately.

 Time spent, uh, it didn't matter what I did, essentially, I was going to get paid the same, um, at the particular level of role and have the research funding, um, to do it. 

Um, and the currency of the NIH --and this is critical; so knowing what you're being evaluated for, um, to continue to have your salary to move into different ranks and whatever-- was essentially strictly on research productivity: papers published, presentations, you know, finishing clinical trials, those sorts of things. And the other things that at an academic institution on the outside that might also be valued, so service and the clinical activity, really didn't factor significantly into the equation at all, um, in the NIH intramural research program. 

With the fear of talking too long, I'll talk about my setup here at . So for most neurosurgeon scientists, the most research time you're going to get is about 50% of your effort, quote unquote effort. Um, there are some very rare neurosurgeon scientists, maybe doing deep brain stimulation for Parkinson's, um, that sort of thing who may end up having something that's more of a 25%/75% where they are 25% clinical, 75% research or 20/80. That is very rare. Um, and I don't know of a neurosurgeon that has the setup that some neurologists, other physician-scientists might have where it's three months of clinical service time, concentrated, um, or one month here and then two months off sort of thing.

Typically for a neurosurgeon, you're kind of splitting up your week in some ways, at least in all the models that I've seen. So myself personally, I'm 50% research, that means I have two half days of clinic. Um, and then I take call. My call is really like one in 12, essentially. Um, so that's not too much of my percent effort. Um, then I operate. I have one operative day a week, um, that's kind of set. And then I may end up having to operate for a half day or so, um, on different days, depending on urgency and related, uh, things that are needed for my patients on a given day. So that kind of rounds up to my 50%. Um, but some weeks might be different where I'm operating four days that week because of need. And some weeks, like this week, I don't have anything scheduled. 

So I'm not going to operate this week. Now, here's the critical part. So how do I get paid? [laughter] I get paid as a neurosurgeon. You know, that is different from how say a straight basic science PhD would get paid. Um, but I do work kind of like a PhD does sometimes and the NIH doesn't pay neurosurgeon salary, how do we make all that work? Um, so 50% of my salary is based on my clinical productivity. I'm expected to be productive at the level of half of an academic brain tumor neurosurgeon. So if I do the cases that half of an academic brain tumor neurosurgeon in my region would do, then I'm good.

And if I exceed that, then I can get additional production pay. That is actually a very generous setup, um, having spoken to neurosurgeon scientists across the country. The reason this setup works at Emory is because my department chair happens to value neurosurgeon scientists. And likes the fact that, you know, I have the potential to bring in NIH dollars and prestige and papers and everything, uh, to the institution and it has prioritized neurosurgeons to do the science themselves.

So they came up with a model that would be attractive to neurosurgeons who do that. There are many other institutions where the neurosurgeons who do research primarily work with PhDs. They do mostly clinical activity. They may influence what the PhD is doing, but they would rarely be the actual PI of the grants that are submitted.

Long answer, but um, that is how being a 50 50 neurosurgeon scientist works, uh, where I am. 

[00:37:16] Marguerite Matthews: And just to follow up on that, do you notice that there are a lot of opportunities to have that sort of split? Or is that rare? 

[00:37:25] Edjah Nduom: Really great question. My institution is one of the, I'd say, relatively few neurosurgery departments that's set up exactly this way.

I know people at some institutions that are actually really world renowned for research whose set up is very much, um, eat what you kill. Um, so they are a neurosurgeon and they will get paid as a neurosurgeon insofar as they operate like a neurosurgeon. And if they're not operating as much as their other colleague, their other colleague will make much, much more than them because of their clinical activity being much, much more. 

 There are other institutions that have no research neurosurgeons really at all. And you can go there and they may talk about, "oh, we'll support your research." Um, but they have no history and no mechanism to put dollars behind it. Um, and so it, you could do it, but it'll be really, really hard to figure out how that works. Um, and so it's very competitive to get the positions, um, like my own, um, that really, uh, set you up that way.

[00:38:22] Erika Augustine: Even though you were speaking from the perspective of a surgical specialty, I think there are so many things that you touched upon that resonate for other fields as well. One, there are many, many models. And those models may differ in general institution to institution. They also may bucket themselves into differences across, uh, federal settings, private academic institutions, public or state academic institutions, private practice.

All are going to be very different. Um, and it helps to know and understand your field. So, you know, what I hear and what I often advise as being very important is having frank conversations with other people about how their positions are structured, how the reimbursement models work within their departments, how research is supported, what happens in funding gaps, because we all have funding gaps.

There are very few people that never have a funding gap. Talking with other people about what that can look like and understanding the whole spectrum from very challenging to very ideal. It's really useful to know as you explore what works for you, how to evaluate the options available to you and how you know what you're looking for as you go forward.

Uh, so there really are so many models and all of the factors that you talk about, I think very much apply within neurology as well. 

[00:40:02] Audrey Brumback: I think one thing that, um, you know, uh, upcoming generations, uh, have going for them is, is that people are talking now about, you know, how much money you make. And, you know, that was a taboo subject for our parents generation.

And so, now you have people, you know, posting on social media, all their trials and tribulations and it's just become a much more open conversation where we're not just seeing the tips of each other's success icebergs. We're actually able to see, you know, how a person actually functions in the role that they're in.

And I think that that idea of having conversations with people and just having that frank conversation about what is it really like for you, um, to know, like, is this actually going to work for me is so important. 

[00:40:55] Lauren Ullrich: So our last question is, um, looking towards the future, right? So what are the options for career advancement for clinician scientists, um, might think about being a chair of a clinical department or running a stroke center or, you know, something along those lines.

What can those different futures look like? 

[00:41:16] Erika Augustine: Anything you want it to be. And I don't think that's evident when you're in medical school or in residency. It seems like the path forward is I choose a lane towards private practice or I choose a lane towards academic medicine. Maybe I'm a researcher, then I'm a chair, I'm a dean, and I'm done, [laughs] if I'm going to really sort of take the full academic path.

And I think what is not so clear is that there are many opportunities to continually evolve the career that you would like for yourself as you better understand your passions, the people with whom you like to work, the skills that you have and the skills that you're looking to build, you get to continue to learn and build skills throughout a career.

And again, I don't think we frame education in that way. It's one of the most exciting things about medicine is that you get to continually learn. And about a research career, you get to continually learn. And there are all of these other options and other opportunities, whether that has to do with, um, discovery and licensing and patenting and creating patents and creating new products or really a deeper dive into education or opportunities to develop new models of care. Whatever those interests are, there are ways to craft a career around it, and I think we should talk about that more because you have these options and opportunity and flexibility that I think is not always evident. 

[00:43:03] Edjah Nduom: I don't know that I could answer that better. Um, that was a great all encompassing answer. The only thing I'll add is just to emphasize that, um, a career can have different phases, um, in that, you know, you could be a very heavy research scientist PI for a season, um, and then you may move to a more administrative mentorship season, um, and that may might be okay, or you might move to an innovation and very business and, you know, whatever heavy season later, or it might be academic leadership, president of the university or dean or what have you, um, or something else.

Um, you know, I have a friend who's a psychiatrist who is a novel writer, um, and his book just got published. 

[00:43:43] Marguerite Matthews: Drop the name, drop the name. 

[00:43:46] Edjah Nduom: Uh, so Justin Key, uh, and, uh, he's a psychiatrist, Justin Key. 

 He does, uh, kind of futuristic horror, um, you know, psychiatric thriller stuff. 

Um, so "The World Wasn't Ready for You," is the, the thriller that he has uh, coming out this fall. 

[00:44:03] Lauren Ullrich: We'll put it in the show notes. 

[00:44:05] Edjah Nduom: Absolutely. 

[00:44:06] Audrey Brumback: I think, um, you know, I completely agree with everything that, um, you guys said. And I think just one other component to it is, you're sort of forced to do things in lanes early on, you know, like we all have to take algebra, you know, like there are certain majors that you, you know, have to pick.

There's medical school as a whole lane, um, that you pick as opposed to other careers. And as you get further and further along, um, the lines between the lanes get blurrier, um, and, and the best place to be is at the interfaces between different, you know, uh, fields or ways of thinking, um, you know, if, if it doesn't exist yet, um, then create it. Uh, the sort of most prominent example in my experience is with neuroimmunology. Neuroimmunology used to be just multiple sclerosis. And, um, and then, uh, you know, it was discovered that, gee, all these people who are having uh, psychosis and seizures and, uh, they actually have an autoimmune disorder. These people have, uh, encephalitis, an NMDA receptor encephalitis and, and now that's an entire field. And so, throughout medicine, like, basically the way specialties get started is that people just start doing them. You know, if you wanted to be a neuromuscular neurologist, you bought an EMG machine and you hung a shingle and you declared that you were, you know, a neuromuscular neurologist.

And, you know, I've kind of done that with autism neurology, you know, like that wasn't a thing. Um, but I, you know, decided it was going to be my thing. You know, things that don't exist right now, um, create them. [music] 

[00:45:55] Marguerite Matthews: Well, thank you all for sharing your wisdom with our audience today.

Can I ask each of you for one last piece of parting advice? 

[00:46:06] Edjah Nduom: I would say generally, uh, my, my advice tends to boil down to pursuing the passions that you have and at times that you have them and finding role models who have modeled something about what it is that you're trying to pursue. Finding people that have done it before and talking to them about it and asking for advice, uh, will almost always be, uh, the right move. You know, even if it's an informal thing at a conference, uh, that sort of thing, uh, pulling somebody aside and, and just learning a little bit more about what they do could be, uh, career changing. It was for me.

Dr. Lonser, who I worked with, uh, at the surgical neurology branch. It all started because I saw him at a conference and he was talking about this convection enhanced delivery to deliver molecules to the brain. I thought that was really cool. Um, and I remembered that and I asked him a question about it. Um, and so he came to mind immediately when I was trying to find something new to explore that could further my career. Um, you know, again, did wonders. 

[00:47:03] Erika Augustine: I would add once you've found your passions and you have your community and strong mentorship to really remember the value of persistence. There are many, many people with great ideas, yet not all have staying power, and I think understanding that there will be sometimes rejection, but then taking the learning opportunity from that and feeding it forward into what comes next, that actually is the thing that sustains a research career. If you're founded on your passions, you're going to have important questions.

You're going to have great ideas. You will find your community. That next part though, is the resilience, finding paths to resilience and really being persistent, um, and dogged in your determination to move forward. 

[00:47:55] Audrey Brumback: I always, uh, tell my daughters, like, the biggest compliment I give them is, "Hey, that was good noticing."

I really appreciate, uh, how, how important it has been for me to just notice things and to, to be curious about those things that I'm noticing. Um, and that is, I think, what kind of keeps me going when I'm really tired and feeling burned out is, you know, when I'm sitting there in a patient visit and they say something and I'm like, "wait, what?" [laughs]

And, and you know, I could at that fork in the road, you know, just brush it off and move on with whatever I was going to ask, or I could take that fork towards the "Oh, that was weird. [laughs] Wait, tell me more about that." Um, and I think that that like, that's what keeps me going is the, is indulging my curiosity, um, when I noticed things.

[00:48:54] Marguerite Matthews: Lauren, what's your advice? 

[00:48:56] Lauren Ullrich: I think what we heard throughout this episode is that there isn't just one way to be a clinician scientist. Like there's a lot of different on ramps. There's a lot of different types of research you can do, a lot of different types of medicine you can do.

Um, and probably the most important thing for you to find your path seems to be a theme this season is that self reflection and self knowing. And really asking yourself those hard questions about what sustains me? What do I need to be fulfilled? And then trying to find the path that best fits with that as opposed to trying to fit yourself into something.

Uh, what about you, Marguerite? 

[00:49:36] Marguerite Matthews: I think that's great advice and I really just appreciate all the different perspectives. I'm not a clinician, but I really like this idea of not just doing something because it sounds like it could be interesting. Like, I'm just going to do this research project just in case maybe that door opens and rather just taking your time to decide, "Wow, I have some questions now," or "that was really interesting," or "I had this interaction and now I want to know a little bit more." It seems like there's a lot of flexibility to create a career that suits you. Um, and it may start with the clinical piece, it may start with the curiosity piece.

You happen to merge them together at the same time early on in your training, or you allow one thing to move to the next. I mean, I know a few people who have done the Ph.D. first and then went back to medical school because they were really interested about a little bit further of understanding what the clinical problems were to influence how they were approaching some of these research questions.

So it's so lovely to hear each of your stories that many similarities, but also really beautiful differences, um, and how you got to the research and how you created what seems like really fulfilling, um, careers that you're settling into. So thank you all. [outro music] 

[00:50:54] Lauren Ullrich: That's all we have time for today on Building Up the Nerve. Thank you to our guests this week for sharing their expertise, thank you to Tam Vo and Ana Ebrahimi for production help, and thank you to Bob Riddle for our theme song and music. We'll see you next time when we tackle applying for a faculty position. You can find past episodes of this podcast and many more resources on the web at ninds.nih.gov. 

[00:51:21] Marguerite Matthews: Be sure to follow us on Twitter @NINDSDiversity and @NINDSFunding. Email us with questions at NINDSNervePod@nih.gov. Make sure you subscribe to the podcast on Apple Podcasts or your favorite podcast app so you don't miss an episode. We'll see you next time.