HOW TO BECOME A CARDIOVASCULAR INVESTIGATOR
Where Am I Going? The Future of Academic Cardiovascular Medicine
Valentin Fuster, MD, PhD, FACC*
Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, New York.
* Address correspondence to: Dr. Valentin Fuster, Mount Sinai Medical Center, One Gustave Levy Place, Box 1030, New York, New York 10029-6500. (Email: valentin.fuster{at}mssm.edu).
In the last three decades, the U.S. life expectancy has been prolonged by about one or two years each decade due to advances in cardiovascular medicine. This improvement is the result of the development of better therapies rather than cardiovascular disease (CVD) prevention. Despite this improvement, CVD continues to be the leading cause of death by far (Table 1), and its prevalence is increasing (1).
The picture is particularly grim when looking at the global burden of CVD. In comparing mortality data for 1990 versus estimates for 2020, developing countries will experience about a 100% increase in mortality due to CVD. For developed countries, such as the U.S., cardiovascular mortality is expected to increase by about 20%, from approximately five million deaths annually in 1990 to six million in 2020 (2). In terms of the combined incidence of coronary artery disease (CAD) and CAD mortality, in developed countries, for the same time period we expect to see a 29% increase among women and a 48% increase among men. In developing countries, it is astonishing: we expect to see a 120% increase in CAD and CAD mortality among women and 137% in men (3) (Table 2). So, while we are certainly prolonging life, a huge problem remains.
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Table 2. Estimate of Ischemic Heart Disease Mortality (Thousands) by Region and Gender and Projected Changes Between 1990 and 2020
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An opportunity for clinicians
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Is this an opportunity for clinicians? Absolutely. There will be an increasing number of patients to treat, due at least in part to an increase in the elderly population. According to an American College of Cardiology workforce analysis, the percentage of patients more than 65 years of age treated per cardiologist will increase from 8.6% today to 24.9% in 2020 (Fig. 1) (4). Obviously, we have had modest success in prolonging life, and CVD appears later today, but the great problem facing all of us relates to disease prevention. In the U.S. today, 34.4% of the population have one major risk factor for CVD, and 27.9% have two or more major risk factors (5). The World Health Organization has analyzed deaths in 2000 attributable to leading risk factors, and the first three are blood pressure, tobacco, and cholesterol. Other risk factors that are growing rapidly include lack of fruit and vegetable intake, high body mass index, and physical inactivity. If you think about that, this is largely a description of the metabolic syndrome. If you examine the data, the most important reason why we are dealing with an increased prevalence of CVD and increased mortality appears to be that we are failing at disease prevention.
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Figure 1 Estimated population 65 years old and older with cardiovascular disease per cardiologist (1980 to 2050). Source: American College of Cardiology Workforce Analysis, Internal Task Force on Workforce Report, 2003. With permission from Fye WB. J Am Coll Cardiol 2004;33:221–32.
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There are economic issues as well that are contributing to the problems we face today. Like many world economies, including Europe, health care spending in the U.S. is closely related to the country’s gross domestic product (GDP). The annual percent change in private health expenditures follows the GDP at about a four-year delay. That is, as U.S. GDP increases or decreases, four years later you will see a very similar increase or decrease in private health expenditures.
All of these factors—an increase in the number of individuals over 65 years of age, little CVD prevention, and a country’s economic status—all contribute to a high demand for cardiologists. Now the question becomes: how are we going to increase the supply of cardiologists?
The 35th Bethesda Conference recommended two approaches to confront a growing shortage of cardiovascular specialists (Table 3) (6). First and foremost, we have to increase the number of cardiologists; second, we need to improve practitioner efficiency, productivity, and satisfaction.
One approach recommended by the Conference is to shorten the cardiology training program (7). Instead of three years of medicine for a general clinical cardiologist, there would be two years of general medical training followed by three years of cardiology, one year of which will be very much focused on prevention. In terms of general medicine, there are fewer and fewer people who want to go into internal medicine today because the program is just too long. There is a strong need to recruit people, and one of the ways to encourage more people to enter is to make the training program shorter.
There is a second issue that is tied to policies of this country: the number of foreign-born individuals permitted to enter the U.S. and remain here to work is decreasing sharply. At the present time, about one-third of all cardiology trainees in this country are international medical graduates (IMG) (8). As we decrease the number of IMGs, how can we increase the number of cardiologists coming out at the end of the clinical training track?
Predicting out to 2050, there will come a time when we cannot go any further with improving CVD except through disease prevention, although this is very expensive. We also predict that well into the future there will be too many cardiologists. But at this moment, we need many more cardiologists because the mortality and prevalence of CVD are continuing to increase sharply and will continue to do so for the next 10 to 15 years.
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Research funding: Challenges and opportunities
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What is happening with research funding in this country? Where once we only saw opportunities, today we face major challenges: the number of applications submitted to the National Institutes of Health (NIH) between 1993 and 2003, in terms of new grants and grant renewals, has been flat even though the budget at NIH has doubled during this same 10-year period (9). At least two-thirds of the increase in the NIH budget has been necessary for the grants that are approved because much more expensive research is being conducted today. Unfortunately, the number of grants being awarded from NIH to investigators 35 years old and younger is decreasing, falling from 23% of all NIH awards in 1980 to just 4% in 2000 (10,11).
For senior investigators, the new and renewal application process is just part of your life. However, younger cardiologists often ask whether it is really necessary to do all of this. If you have such thoughts, it means you probably do not have the heart for investigation. If you make your choices based on issues relating to whether or not the situation offers more or less security, you are not an investigator.
In reviewing biomedical research in the U.S., it has been unbelievably important economically as well as in every other respect, and it has had a large impact on this country. This is good news. Unfortunately, at the present time, the news regarding NIH funding is not so good. We have gone from a doubling of the NIH budget in 1999 to 2004 to a projected increase for 2005 of just 2.6%. Compounding the financial problems is the significant shift of monies from science into biodefense; while that is still funding science, it is certainly not funding the biomedical science we are used to working with as investigators. This shift in priorities is a reality and will continue for the foreseeable future. It has been projected that, to just keep up with what we were doing in terms of biomedical research, we need an 8% to 9% annual budget increase from now on, so this 2.6% increase in 2005 is a problem.
Another important issue goes back to our IMGs. A very interesting paper was recently published arguing that as U.S. dominance in science decreases, reaching equivalency with Europe, there will be a greater need for IMGs (12). This has a lot to do with progress in science depending heavily on the worldwide exchange of ideas, information, data, materials, and people. There has been a great concern, expressed in editorials published in various journals, that in many respects the U.S. has become isolated, and the common belief is that there is no need to pay attention to what is happening outside our borders. However, this is occurring at the same time that our dominance in science is being challenged by the growth of scientific research done elsewhere. One solution is to bring more IMGs into the U.S., not as clinicians but as investigators. Unfortunately, the hurdles for foreign students have gotten much greater in the last few years.
Another issue worth mentioning has to do with politics. The current political scenario has been heavily criticized in terms of science, in particular the 1,000 committees who actually advise the federal government. A recent commentary in The New England Journal of Medicine noted that politicians are free to do whatever they want, but there are concerns relating to the injection of politics into science and to what extent science is a priority in the current administration (13).
The last of the major issues confronting biomedical research is the financial status of academic medical centers. Investigators in academic centers are being asked to do too many tasks, leaving too little time for creativity. This has had an incredibly negative impact on young investigators trying to find mentors.
An emphasis on research offers major economic dividends to society. According to six research papers authored by nine distinguished economists working independently of each other, advances in medical research generate dramatic returns in health and in economics. Specifically, a summary report by the Albert and Mary Lasker Foundation documents that the "extended healthy lives" of Americans is in great part due to advances in medical research. While these advances consume $45 billion annually, the return on this investment is staggering. The work of the nine economists, published first in the report Exceptional Returns (14,15), estimated that increases in life expectancy in the U.S. between 1970 and 1990 were worth roughly $2.8 trillion a year. This represents a rate of return on research investment >100 to 1. Reduced mortality from CVD alone was estimated to be worth $1.5 trillion a year.
The problem politicians have with this kind of investing is that it takes a long time to come to fruition—they will not see any thing from today’s investments until 10 years from now. The short-sighted nature of this approach led the late Mary Lasker, for whom the foundation is named, to once observe: "If you think research is expensive, try disease" (14). I am mentioning this because I hope academic institutions and scientists will have a significant impact in dealing with our political leaders and encouraging long-term science funding in this country.
Although there are problems with present funding at the NIH and many general hurdles for investigators, other organizations are doing very well in stepping up to offer solutions, such as the American College of Cardiology and the American Heart Association. Of course, there is an incredible amount of money invested by industry too, and this has to be taken into account in any discussion of medical research. The tremendous investment by philanthropists in the U.S. also is unique; it does not happen in many other parts of the world, but here it supports science with about $20 billion a year of funding. Consequently, despite the hurdles, the good news for young investigators is this: if you like research, you will make it. The door of entry may be different than it was for previous generations, but that door is there.
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Personal search and approach
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To find the door and establish a career in research, you must be practical. First, consider who you are and what you are good at. Know yourself, do not fool yourself; never get into something you do not have the talent for. Second, once you discover what you are good at, there are three critical issues: mentorship, pursuing your work in depth, and then staying focused. This applies to anything you do in life, at least anything that you do well. You must invest in your talent, but do not invest in what you do not have talent for because that is very costly. So how well do you know yourself? That is an issue that has no simple answer, but is something where you may be helped by people who know you and are close to you, including mentors.
Think about the characteristics of creativity or innovation. The current thesis of creativity and innovation says that first you have to be free, but freedom involves risk. If you do not like to take risks, forget it; you are not an investigator. The second set of characteristics of creativity is altruism, communication, and team effort. This is new, because the theory used to hold that you were the only one making it and nobody else. Right now, if you want to make it alone, forget it. Today, creativity and innovation requires a team effort and altruism; you give and you get. That is what a team means. A team is not just your friends. This is why the word altruism applies and why it is very important for success.
The third characteristic of creativity is confidence and passion, while the final characteristics are that of being consistent and hard-working. Some of these things are genetic, and some are acquired; to me, being consistent and hard-working is genetic. There are people born tired and others who are not. When you are trying to find out who you are, remember it is who you are in your environment and in your genetics. You have to consider all of this before you will be able to decide if you have the framework of an investigator.
Once you know who you are, the next important question is: what career do you want to follow? Do you want to be a clinician doing research, a pure researcher, an educator, or do you want to be everything? A professional clinical investigator is someone who spends 80% of his or her time involved in clinical trials doing outcomes research or epidemiology. This requires advanced training (i.e., MD, MPH, and so on). Conversely, the clinical investigator is in patient care as a team player with a professional clinical investigator. The clinical investigator does not need special training. The physician scientist spends 80% of his or her time doing laboratory research while interfacing with the clinic. Advanced research training is required (i.e., MD or MD/PhD), and this position is possibly the most threatened in major medical centers. Finally, in defining the clinician/academician, there is the translational scientist. This individual conducts clinically oriented research (from molecules to outcomes), pulling it all together as a team player. Advanced research training, often a PhD degree, is required. The translational scientist is extremely important for quite literally the translation of research; they are the bridge between the professional clinical investigator and the physician scientist. As you are planning your career, particularly in the more basic research fields, you need a mentor and institutional support that trains you to be a team member, because there is nothing in modern research that does not require a number of people.
A few investigators will say they want to be an educator, which is fantastic, but you do not get a dime of research money for that; in that sense, being an educator is more of a vocation. However, can you be a triple threat: a researcher, a clinician, and an educator? It is possible if you are a clinician who has research talents as a clinical investigator that you will be able to do part-time or translational research while you are an educator on the side. You have to work very hard for a career like this, but it is possible. Realize though you will not be seeing many patients, you still need to have a history of clinical excellence.
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Conclusions
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As teachers, we must teach medical students and residents the incredible power of research, and we must feel it. Fellows and junior faculty members need a great training environment, again a team effort, and it has to be from a group of good people. Importantly, we must also teach the public and the politicians; we have to show we are creative, that we care, and that the work we do improves the state of human health as well as the economy.
Finally, some of today’s fellows will become our leaders. There is no question about that. In the past, a leader was a good manager, but the future will require strong communication skills, empathy, altruism, and the ability to create change. They will need people skills that allow them to align and motivate. Tomorrow’s leaders must be thick-skinned, because they will be creating change against resistance. Also, they will possess the personal qualities of knowledge, actions, and values. You can say anything you want in a free society, but if your neighbor does not believe what you say, forget it. When you talk, you must have credibility and people will believe you; know what you are talking about, and people will listen. This is what is required of our next generation of leaders if they are going to make things happen.
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References
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1. American Heart Association Heart Disease and Stroke Statistics, 2005 Update. Dallas, TX: American Heart Association; 2005.2. Reddy KS. Cardiovascular disease in non-Western countries N Engl J Med 2004;350:2438-2440.[CrossRef][Web of Science][Medline] 3. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization Circulation 2001;104:2746-2753.[Abstract/Free Full Text] 4. Fye WB. Introductionthe origins and implications of a growing shortage of cardiologists. J Am Coll Cardiol 2004;44:221-232.[Abstract/Free Full Text] 5. Greenlund KJ, Zheng ZJ, Keenan NL, et al. Trends in self-reported multiple cardiovascular disease risk factors among adults in the United States, 1991–1999 Arch Intern Med 2004;164:181-188.[Abstract/Free Full Text] 6. Hirshfeld Jr. J, Fye WB. Summary of task force recommendations to address the growing shortage of cardiologists J Am Coll Cardiol 2004;44:272-275.[Free Full Text] 7. Zoghbi WA, Alegria JR, Beller GA, et al. Working group 4international medical graduates and the cardiology workforce. J Am Coll Cardiol 2004;44:245-251.[Free Full Text] 8. Fuster V, Hirshfeld Jr. JW, Brown AS, et al. Working group 8defining the different types of cardiovascular specialists and developing a new model for training general clinical cardiologists. J Am Coll Cardiol 2004;44:267-271.[Free Full Text] 9. Goldman E, Marshall E. Research funding. NIH grantees: where have all the young ones gone? Science 2002;298:40-41.[Free Full Text] 10. Bonow RO. The challenge of balancing scientific discovery and translation Circulation 2003;107:358-362.[Free Full Text] 11. Mandel HG, Vesell ES. From progress to regressionbiomedical research funding. J Clin Invest 2004;114:872-876.[CrossRef][Web of Science][Medline] 12. Leshner AIUS. science dominance is the wrong issue Science 2004;306:197.[Abstract] 13. Steinbrook R. Science, politics, and federal advisory committees N Engl J Med 2004;350:1454-1460.[CrossRef][Web of Science][Medline] 14. Passell P, Funding First Exceptional Returns. The Economic Value of America’s Investment in Medical Research. New York, NY: Mary Lasker Foundation; 2000Available at: www.laskerfoundation.org. Accessed October 15, 2001.. 15. Rosenberg LE. Exceptional economic returns on investments in medical research Med J Aust 2002;177:368-371.[Medline]
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An opportunity for clinicians
Research funding: Challenges and...