February 26, 2018 | Rohan Khera, MD
Career Development

As much as a third of fellowship training in cardiology is represented by time that can be dedicated to research, often identified as a research year. However, unlike most medical training up to this point that has an inherent structure and tangible goals, the research year in fellowship represents a new period in training. There is no structure, no set goals to achieve and a daunting set of skills that are required to be successful but not routinely acquired during clinical training.

In full disclosure, I am pursuing an academic track in fellowship training, and transitioned from residency directly to two years of research as a part of my fellowship training. In spite of my interest in a research career and some experience in my area of work, I found the lack of structure challenging. I wondered how the nature of this phase of training was perceived by four fellows, and how they feel that this period of training could be leveraged to help them achieve their career goals. I followed this thought with a candid conversation with James A. de Lemos, MD, FACC, professor and former program director of the cardiology fellowship program at the University of Texas Southwestern.

Alana Lewis, MD, a second-year cardiology fellow at the University of Texas Southwestern, is scheduled to start her one year of dedicated research next year. She is looking forward to it, mainly to understand if a career with a focus on research is right for her. She appreciates how the fellowship curriculum allows a year of mentored research for all fellows, allowing them to understand the nuts and bolts of research. Nimesh Patel, MD, a third-year fellow in his research year headed for a cardiac electrophysiology fellowship next year, echoed Alana's thoughts on his expectations from the year. However, he endorsed practical challenges, particularly the steep learning curve for methodology, dependence on collaborators to keep projects on track and general uncertainty when a research project does not work out the way it was expected. Curtis Steyers, MD, a third-year fellow at Washington University in St. Louis, MO, who is also in his research year and headed for a procedural subspecialty training in cardiology, says that his involvement in research has helped him gain a better understanding of how to appraise published literature. He notes that the success of this own research projects relied on his mentors – both their involvement and familiarity with research methodology. Patel and Steyers both agree that only few faculty in a given subspecialty at an institution are actively involved in research, which limits the number of good opportunities for developing strong research mentor-mentee relationships in research in these fields.

I posed an open-ended question to all three of them; would they feel comfortable leading research studies as a full-time professional in an academic center or at least a part of their time in a busy clinical practice? Alana said she did not know yet. The other two said no.

Finally, I talked to a fourth-year fellow, Daniel Cheeran, MD, for whom research became an important part of his career goals, although he was not sure if it would be that way when he started. Like others, Cheeran approached research in fellowship without any pre-conceived notions, and agreed that the pace and structure of his third year of fellowship made it challenging to determine if research was the right fit for him. He pushed through, found a nurturing mentoring relationship and had some early successes that led to bigger things. He signed on to an additional year of research, not knowing what to expect, and is now busy juggling two to three projects, masters-level training in research methodology and considering a path where he would be a grant-funded clinical investigator without ever envisioning one during clinical fellowship. When I posed a question about independence, he said he would be comfortable leading a project on his own, adding that he now knows how seeking out counsel and help is commonplace at all levels of training and even beyond.

Based on my discussion with the fellows, I asked de Lemos what he thought of some of the questions that came up. What would be an ideal year spent doing research for fellows? What do leaders in the field expect graduating fellows to have gained from their research experience in fellowship? What would be his take on making the research year more structured, like the rest of the fellowship? To him, the goal of a dedicated year of research in fellowship is the ability to engage in an open-ended pursuit of a set of questions of interest. He and other fellowship leaders hope that fellows are able to see one project through to completion, regardless of the study’s outcome, and learn something in the process. He also appreciated that with the amount of time spent on research, gaining a skill set that made graduating fellows comfortable with considering a career that involves research is a reasonable goal.

For fellows who complete a year of research, their experience and ultimate comfort with research depends on their success, the publication of their findings and an understanding of how their work may impact patient care. All four fellows and de Lemos agreed that a lot of these experiences are by chance.

I contend that time spent on research in fellowship does not live up to the same rigor as the clinical training, where a chance positive training outcome would be unacceptable. Maybe the answer is to allow open-ended pursuit for those few fellows that have specific ideas they wish to pursue. For those who do not have ideas, which is arguably the majority, should be provided a structure they feel comfortable with, along with a pathway they recognize as leading to an end. The solution to limited research mentorship in a fellow's field of interest may be pairing up with mentors who spend most of their time on research, and on a topic of interest that may not be aligned directly with a fellow’s clinical affinity. If the goal of spending a research year is to be proficient at research, the mentorship should maximize a fellow's chances of achieving just that. Patel agreed with this suggestion, but Cheerin felt that he would not find it as interesting. De Lemos agreed that it would help the fellows, but require reshaping how fellows and faculty view this year.

My exercise in understanding how we can improve upon this year brought up more questions than answers. However, that probably means that this topic is ripe for conversation. A year spent on research has an opportunity cost – for the fellows, fellowship and health system – and there needs to be a way for everyone to benefit from this investment. In addition to improving the current structure, tailoring the skill set one acquires to their ultimate career goals could be useful. This skill set could be in the form of distinct tracks for the research year, similar to tracks we chose in clinical fellowship. It could be a regimented exposure to trial design for those working towards large clinical practices and with possibilities of engaging in clinical trials; a scientifically rigorous quality improvement research training for others who could play such a role in their future practices; a similarly thorough approach for those wishing to teach and expand the evidence base in medical education; or a pre-specified combination of the above.

I recognize that the discussion above is my personal view of research in fellowship and does not account for individual preferences, loans and finances, family commitments, and regional variation in opportunities that play a central role in ultimately determining the career pathway one chooses. However, as long as research is an integral part of fellowship training, the ability to innovate and iterate is essential to ensure that research is a real competency gained in fellowship training, and not merely a lost opportunity and a year spent waiting on the next one.

Acknowledgement: I would like to thank James A. de Lemos, MD, FACC; Alana Lewis, MD; Nimesh Patel, MD; Curtis Steyers, MD; and Daniel Cheeran, MD, for their contribution to this article.