7
Opportunities to Improve Career Development in Somnology

CHAPTER SUMMARY The science and prevalence of sleep loss and sleep disorders necessitates a larger and more interdisciplinary workforce to advance the field’s knowledge base and provide optimal clinical care. In 2004, there were only 253 principal investigators working on 319 sleep-related research projects (NIH R01). Of the 253 principal investigators, only 151 researchers are involved primarily in clinical sleep research, and 126 focus primarily on basic research projects. Further, only 54 doctorates were awarded with a focus on somnology or sleep medicine. This workforce is insufficient, given the burden of sleep loss and sleep disorders. The National Institutes of Health (NIH) and private foundations have not adequately invested in increasing the research workforce. Since 1997, there have been no new requests for application or program announcements for sleep-related fellowship, training or career development programs. Further, over the period encompassing 2000 to 2004 there was a decrease in the number of career development awards. Given all this, the field is ripe for expansion, but there are too few young and midcareer investigators. To improve the pipeline of individuals in the field, it is critical that the NIH commit to increasing the number of fellowship, training, and especially career development awards. Further, given the limited number of individuals clustered at a small number of institutes, the NIH should fully embrace flexible mentoring programs that are capable of meeting the challenges.



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7 Opportunities to Improve Career Development in Somnology CHAPTER SUMMARY The science and prevalence of sleep loss and sleep disorders necessitates a larger and more interdisciplinary workforce to advance the field’s knowledge base and provide opti- mal clinical care. In 2004, there were only 253 principal investiga- tors working on 319 sleep-related research projects (NIH R01). Of the 253 principal investigators, only 151 researchers are involved primarily in clinical sleep research, and 126 focus primarily on ba- sic research projects. Further, only 54 doctorates were awarded with a focus on somnology or sleep medicine. This workforce is insufficient, given the burden of sleep loss and sleep disorders. The National Institutes of Health (NIH) and private foundations have not adequately invested in increasing the research workforce. Since 1997, there have been no new requests for application or program announcements for sleep-related fellowship, training or career de- velopment programs. Further, over the period encompassing 2000 to 2004 there was a decrease in the number of career development awards. Given all this, the field is ripe for expansion, but there are too few young and midcareer investigators. To improve the pipe- line of individuals in the field, it is critical that the NIH commit to increasing the number of fellowship, training, and especially career development awards. Further, given the limited number of indi- viduals clustered at a small number of institutes, the NIH should fully embrace flexible mentoring programs that are capable of meet- ing the challenges. 233

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234 SLEEP DISORDERS AND SLEEP DEPRIVATION The relative paucity of individuals trained and committed to careers in sleep and sleep disorders research has been recognized by the National Cen- ter on Sleep Disorders Research (NCSDR). It identified the need to train investigators as the highest priority among the 10 major sections of their 2003 research plan (NHLBI, 2003). Attracting, training, and supporting investigators in sleep-related research is critical for fueling the scientific ef- forts needed to make important discoveries into the etiology, pathogenesis, prevention, and treatment of chronic sleep loss and sleep disorders. Further, it is also important to train individuals whose major role will be master clinician, organizer and manager of care, and clinician-educator. In 2004, there were only 151 researchers who had a clinical sleep-related research project grant (R01) and only 126 investigators focused primarily on basic sleep-related research projects.1 The small number of research project grants, 331 in 2004, can be substantially attributed to the limited number of individuals working in the field. It is, therefore, of critical importance that further investment be made to expand the number of well-trained in- vestigators in the field. Many of the strategies described in Chapter 5 to increase the awareness among health care professionals will also likely attract new investigators into the field. These strategies include targeting the career interests of high school and college students, as well as graduate students and students in allied health fields. Further, as will be described in detail in this chapter, increasing the number of investigators in the field will require the National Institutes of Health (NIH), professional societies, patient advocacy groups, and others to significantly increase their investment in career development programs. As a result of the current limited pool of senior investigators and concurrent clustering of senior people at a limited number of academic centers, it will be equally important to adopt flexible mentoring programs that are capable of meeting the challenges. GROWTH OF THE SOMNOLOGY AND SLEEP MEDICINE FIELD Somnology and sleep disorders research is a relatively young discipline that has grown significantly over the last 35 years. However, the current workforce is still not adequate, given the public health burden of the disor- ders (Chapters 3 and 4). Since the establishment of the first sleep center in 1970, clinical recognition of sleep disorders has grown but is still not widely 1Abstracts of all sleep-related R01s in the Computer Retrieval of Information on Scientific Projects (CRISP) database were analyzed under the following thesaurus terms: insomnia, periodic limb movement disorder, restless legs syndrome, circadian rhythm, sudden infant death syndrome, sleep disorder, narcolepsy, sleep apnea, sleep, hibernation, and dream. See Appendix A for further details.

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235 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT acknowledged to be among the most common chronic health conditions (Chilcott and Shapiro, 1996; Young et al., 2002). Clinical advances have helped to attract and increase the number of clinicians and scientists to somnology and sleep medicine, as evidenced by the growth of membership in professional sleep societies. Since 1995, membership in the American Academy of Sleep Medicine (AASM) has more than doubled, while the Sleep Research Society (SRS) membership has almost tripled (Figure 7-1). How- ever, the recent growth also emphasizes the need for a greater number of senior mentors and leaders in the field. The level of sleep-related research has grown, with over a 100 percent increase in the annual number of new NIH research project grants (R01) awarded in 1995 and 2004 (37 to 82). However, at the same time that the science and magnitude of the problem argues for greater investment, NIH funding of sleep-related activities has reached a plateau. Therefore, there are still substantial deficiencies in the workforce needed to address clinical somnopathy, and needs may be even greater relative to investment in research. Growth in sleep-related research is limited by the paucity of funded investigators in the field. In 2004, only 253 investigators held active sleep- related NIH R01 grants. Although there has been an increase in the number of investigators since 1995, in comparison to other disorders, there are still too few sleep researchers. For instance, the absolute number of funded in- vestigators with sleep-related projects is only around 80 percent of fields such as asthma,2 which is a single disorder that affects 20 to 40 million. Further, funded investigators in sleep-related research tend to be older. The average age of all NIH investigators when awarded their first R01 has steadily risen and now is between 42 and 44 years of age (NIH, 2006b). However, in 2004, the average age of recipients at the time of their first R01 sleep-related grant was 51 (personal communication, M. Snyder, NIH Office of Scientific Affairs, November 8, 2005), which suggests an emer- gent need to replenish the pipeline with new investigators who can sustain the field and make it grow. The limited number of researchers is clustered at a limited number of institutions. Of the 253 funded primary investigators in 2004, 33 percent of all investigators were at the top 10 academic sleep programs (ranking by the total number of somnology and/or sleep disorders grants), and 60 per- cent of all investigators were at the top 25 institutes (Appendix J). Likewise, 34 percent of all sleep-related R01 grants are awarded to the top 10 sleep 2314 individuals with asthma grants were identified by analyzing all 2004 R01 grants. Asthma grants were identified by all R01 grants that contained the word asthma as a thesaurus term. It is important to note that because only one search term was used, this search was not as thorough as the search performed for somnology and somnopathy R01 grants. Therefore, it may represent a significant under representation of the asthma field.

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236 SLEEP DISORDERS AND SLEEP DEPRIVATION AASM Individual Membership, 1995–2006 6000 A) Number of individual 5000 members 4000 3000 2000 1000 0 95 96 97 98 99 00 01 02 03 04 05 06 19 19 19 19 19 20 20 20 20 20 20 20 Year SRS Individual Membership, 1995–2006 1200 B) Number of individual 1000 800 members 600 400 200 0 95 96 97 98 99 00 01 02 03 04 05 06 19 19 19 19 19 20 20 20 20 20 20 20 Year FIGURE 7-1 Individual membership in the AASM (A) and the SRS (B) has contin- ued to grow over their history. SOURCE: Personal communication, J. Barrett, AASM and SRS, (January, 2006). academic programs, and 59 percent of all R01 grants are clustered in 25 institutions. In 2004, Harvard University, the University of Pennsylvania, and the University of Pittsburgh received 46 percent of sleep-related career development awards. Further, although many sleep disorders dispropor- tionately affect minorities (Rosen et al., 2003), the number of minority investigators in the field is poorly representative (Spilsbury et al., 2004). In 2004, only 15 percent of all investigators with an R01 identified themselves as belonging to a minority ethnicity (Asian, African American, Hispanic, Pacific Islander, or other) (personal communication, M. Snyder, NIH Office of Scientific Affairs, November 8, 2005). As minority clinicians and investi- gators are more likely to work in underserved areas (Urbina et al., 1994), a

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237 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT dearth of minority investigators may limit clinical research that requires access to minority populations and ultimately limit the translation of re- search advances to these important populations. Barriers to Sleep Research Career Development Barriers to attracting, training, and sustaining a critical mass of sleep investigators include the poor awareness among the general public and health care professionals and the availability of appropriate mentors to pro- vide scientific and career guidance to new investigators. Exciting basic science research and the dissemination of this excitement to a broad group of potential trainees are necessary and potentially rate- limiting steps in attracting new investigators from a limited pool of indi- viduals committed to academic careers. In 2005, there were 204 student members of the SRS; only 54 individuals received a doctorate in sleep-related research, as compared to 158 in pain and 630 in cancer.3 Given the total number of principal investigators in the field, it appears that the majority of individuals with sleep-related doctorates do not remain in the field. There- fore, although there have been some remarkable successes in scientific in- vestigation aimed at elucidating fundamental sleep physiology and biology (e.g., discovery of a mammalian Clock gene (Antoch et al., 1997; King et al., 1997; Tei et al., 1997) and the cause of narcolepsy (Lin et al., 1999; Chemelli et al., 1999; Mignot et al., 1999; Thannickal et al., 2000; Peyron et al., 2000), the future pace of scientific discovery is limited by the small numbers of active researchers pursuing basic investigation. Fundamental scientific discoveries play critical roles in galvanizing interest in any scien- tific discipline. Recruiting and retaining trainees in somnology and sleep medicine competes with other more established fields, many of which have made highly publicized advances, enjoy widespread respect across medical centers, and are more established as an academic discipline. Investigators, particularly new ones who commit to interdisciplinary sleep-related research, are challenged to prove their value in academic medi- cal centers that are accustomed to recognizing and rewarding individuals with “departmentally” defined research foci. Resource allocation needed to support new investigators may require complex negotiations among academic departments, which may deter new investigators or otherwise limit their access to needed support. In addition, identification of optimal mentoring relationships, critical for career development, will likely require sustained relationships among individuals with competing institutional commitments. 3Data were collected through a keyword search, using either sleep, pain, or cancer, of the Dissertation Abstracts database through DIALOG.

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238 SLEEP DISORDERS AND SLEEP DEPRIVATION As for all scientific fields, new investigators require protected time and support as they transition to independent funding. Increasing fiscal pres- sures and, for physicians, demands to spend more time on clinical services, are threats to protected time critical for career development. New investiga- tors are also often burdened with substantial debt from school loans, pro- viding disincentives to participate in prolonged postdoctorate training. NIH TRAINING AND CAREER DEVELOPMENT PROGRAMS A variety of NIH-funded career development and academic training awards have been sponsored over the past decade (see Appendix H). In par- ticular, there has been growth in the recognition and investment by the NIH in a broad variety of individual and institution-based career training pro- grams, with a recent emphasis on clinical, translational, and interdisciplinary research training. Programs have been developed with the aims of attracting new trainees and developing the research and academic skills, and supporting their transition to independent and externally funded investigators (K01, K02, K08, K23, and K25). Other awards support midcareer development and mentorship skills (K24, K26). National Research Service Award Institutional Training Grants (T32) provide institutions with funds to support the training of individual postdoctoral candidates. The K30 and K12 series of NIH insti- tutional training awards provide institutional support to develop new or ex- panded training programs and curriculum development. NIH Support of Sleep-Related Training Activities To determine the current investment in the field and how the grant portfolio has changed over the last 10 years, this committee performed a detailed review and analysis of the portfolio of NIH sleep-related awards in career training (K), fellowship (F), and training (T). Abstracts of all K, F, and T awards in the Computer Retrieval of Information on Scientific Projects (CRISP) database were analyzed. This database collects informa- tion on the number of federally funded biomedical research projects. Data from the CRISP database were used to assess the number of awards that were classified under the following thesaurus terms: insomnia, periodic limb movement disorder, restless legs syndrome, circadian rhythm, sudden in- fant death syndrome, sleep disorder, narcolepsy, sleep apnea, sleep, hiber- nation, and dream. To limit the number of grants that were not relevant to somnology or sleep disorders, the committee included only grants in which the key words appeared in both the thesaurus terms and the abstract and not the abstract alone. Temporal trends and distributions of awards across NIH institutes and to academic institutions were examined (see Appendixes H and J for compiled findings). The committee did not have access to the

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239 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT applications that were submitted and not funded; therefore, it is not pos- sible to conclusively determine if changes in investment are the result of NIH policy, the number and/or quality of submissions in each area, compo- sition of grant review committees, or combination of these factors. Temporal Analysis of Sleep Training Awards Although there is a statistically significant increase in the total num- ber of K awards from 1996 to 1998 (Appendix H), there was a relative leveling of total awards from 1998 to 2004—despite the establishment by the NIH of three new career development programs and significant in- creases in extramural funding. Further, since 1997, the NIH has not in- vested in a single sleep-related request for application (RFA) or program announcement (PA) career development program (Appendix F). Analysis of the number of sleep-related T and F awards shows an increase between 2000 and 2004 (Figure 7-2). However, the number of K awards decreased over the same time period and a larger proportion went to a smaller group of academic institutions. Three institutions, Harvard University, Univer- sity of Pennsylvania, and University of Pittsburgh, accounted for 27 per- cent of all sleep-related T, K, and F grants received in 2000, 35 percent in 2004. This concentration is even greater if only K award distribution is analyzed. The same three institutions received 29 percent of all K awards in 2000, and 46 percent in 2004. This may reflect the extensive develop- ment of these programs and concentration of senior investigators. 70 60 50 Number of awards 40 2000 2004 30 20 10 0 T Grants K Grants F Grants FIGURE 7-2 Total sleep training, career development, and fellowship grants in 2000 and 2004.

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240 SLEEP DISORDERS AND SLEEP DEPRIVATION Support of training grants may also diminish. The NIH reported that in response to rising tuitions and steady budgets that if the current formula used to determine the number of awards is not altered there would be an overall loss of 4,000 training grant slots by 2015 (Bhattacharjee, 2005a). Institute-Specific Funding of Career Development Awards Career development awards in sleep are sponsored by numerous NIH institutes (see Appendix H). In general, for any given award category, with few exceptions no more than one new career development award was granted in any given year between 2000 and 2004. Since 2000, investment in career development awards for clinical scientists, K08 and K23, has var- ied. The National Institute of Mental Health (NIMH) and the National Heart, Lung, and Blood Institute (NHLBI) awarded the greatest number of grants. In 2003 and 2004 there was only one new K08 award. Although there has been greater investment in the K23 series, it is still minimal with five new awards in 2003 by four different institutes. K24 awards for mid- career development have also been minimal in 2003 and 2004, with no new awards in 2003 and only three in 2004—two of which were by the NHLBI. There has also been very limited investment in the K07 academic career awards, designed to improve curricula and emphasize development of scien- tist leadership skills. Apart from the Sleep Academic Award program, there has been very little investment through the K07 mechanism, no new awards were granted in 2003, and only three in 2004. Further, no institute apart from the NHLBI has supported this mechanism for sleep-related awards. Over the 5-year period between 2000 and 2004, there has been even less investment in career development awards for mentored research (K01), independent scientists (K02), and senior scientists (K05). All three of these mechanisms historically have been used to support basic research. NIMH was the first institute that supported these three mechanisms for sleep- related activities, but in recent years there has been a marked decrease. For example, in 2002, the NIMH supported six sleep-related K01 awards, seven K02 awards, and two K05 awards. In 2004, these numbers have decreased to two K01 awards, two K02 awards, and one K05 award. These latter statistics underscore the relatively small amount of investment of any given institute in sleep research training, with no evidence that any institute or the Trans-NIH Sleep Research Coordinating Committee has assumed leader- ship in this area. Although the decrease in career development awards is dramatic, it is important to note that over the same period, there has been an increase in fellowship awards (Appendix I). Of the 314 career development awards that were funded during the five years between 2000 and 2004, NHLBI sponsored 94 (29 percent), and the NIMH sponsored 162 (52 percent). One third (32 of the 94) of sleep-related

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241 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT NHLBI-sponsored training grants were K07 awards devoted to the Sleep Academic Award program, which were designed to support the development of curricula and educational leadership, not research training. The vast ma- jority of the Trans-NIH Sleep Research Coordinating Committee member institutes—many of whom have a large portion of the sleep-related research project grant portfolio (Appendix G)—have minimally supported career de- velopment. The underlying reasons may be multiple, including poor or low numbers of applications, insufficient sleep-related research expertise on study sections (which is also partially affected by a limited number of senior mem- bers of the field), and lack of awareness of the extent of the problem. Further, K awards are expensive; consequently, institutes are often reluctant to invest heavily in the K awards, especially in periods of budget constraints. One potential strategy to offset the lack of investment would be to leverage the combined resources from multiple member institutes of the Trans-NIH Sleep Research Coordinating Committee to develop a larger pool of money for training programs. In 2003, the NIH supported 845 K23 career development awards at a total cost of over $114 million, or an aver- age annual cost of $135,000 per award. If four institutes were to cosponsor a K23 program in somnology or sleep medicine, this would cost each insti- tute approximately $34,000 annually per award, a 75 percent decrease in expense. The committee strongly recommends joint investment in training programs; it does so recognizing that there are potentially increased over- head costs associated with tracking and implementing an annual transfer of funds between institutes. Further, mechanisms need to be developed to en- able all institutes contributing to a joint effort to be acknowledged in con- gressional goals for new grants. NIH Roadmap Initiatives As part of the NIH director’s research agenda, a series of roadmap initiatives was identified to foster the development of interdisciplinary train- ing for investigators at all levels of their careers. These initiatives emphasize translational research, behavioral/social sciences, and quantitative sciences. Between 2004 and 2005, $8 million was invested in the establishment of seven K12 Multidisciplinary Clinical Research Training Programs (NIH, 2006a). Because sleep-related research is particularly well suited to interdis- ciplinary and translational strategies, it could serve as one of several key programs for these new initiatives New NIH Career Award Support Recognizing the difficulty of becoming an independent researcher and in response to the Institute of Medicine’s and National Academies’ report,

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242 SLEEP DISORDERS AND SLEEP DEPRIVATION Facilitating Interdisciplinary Research, on fostering independence among young biomedical researchers, the NIH recently announced the creation of three new initiatives (Bhattacharjee, 2005b). Each initiative is designed to facilitate postdoctoral fellows into independent faculty positions. The first—the NIH Pathway to Independence Award program—is a 5-year award composed of two phases (NIH, 2006b). The initial phase (K99) is a 1- to 2-year mentored period designed to allow investigators to complete their supervised research work, publish results, and search for an indepen- dent faculty position. The second, independent phase (R00) would com- prise the remaining 3 years of the award and is structured to provide financial support to awardees who secure an assistant professorship while they establish their own research program and successfully apply for an NIH investigator-initiated (R01) grant. The second mechanism is an inde- pendent research grant program, which does not require preliminary data. The final initiative is to speed up the R01 grant application turnaround time for new researchers who fail to receive an award on their first attempt. Summary of NIH Support of Career Development Programs In summary, analysis shows that no single NIH institute has made sub- stantive investments into sleep-related research career development or train- ing awards. There are alarming downward temporal trends in level of sup- port for research training and career development, suggested by the recent drop in funded K awards, with further clustering of funding to fewer insti- tutions. Institutes that support large levels of sleep research funding should also be encouraged to make a significant investment in career development initiatives. Funding trends also suggest that there are very few individuals with training support to develop careers in basic sleep science. There are many existing training grants or large research programs in disciplines re- lated to somnology or sleep medicine (e.g., internal medicine, neurology, psychiatry, psychology, otolaryngology, nursing, epidemiology, neuro- science, and health services research). Given the interdisciplinary nature of the field, these programs provide an additional mechanism for increasing the number of somnology and sleep medicine trainees. Although there is an exciting national movement toward supporting interdisciplinary and trans- lational research highlighted in roadmap initiatives, existing programs largely have not recognized the potential of the somnology and sleep medi- cine field as a prototype for these initiatives. This represents a great oppor- tunity to both foster development of sleep research and to forge new inter- disciplinary approaches.

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243 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT Professional Organization and Foundation Support of Career Development Professional societies have played important roles in sponsoring career development across a wide variety of disciplines. Well-established car- eer training awards are available from professional organizations with interest in somnology and sleep disorders, such as the American Heart As- sociation, American Diabetes Association, American College of Chest Phy- sicians, American Lung Association, and the American Thoracic Society, among others. Table 7-1 shows the number of career development awards several organizations made in 2004. Since sleep-related research is relevant to several of these organizations, the number of sleep-related training grants is also provided. It is worth noting that investment in sleep-related research is low for all professional organizations profiled below; for example, de- spite the significant association of sleep disorders and cardiovascular dis- ease, only 2 of the 845 awards given by the American Heart Association’s career training program portfolio supported sleep-related research. One im- pediment leading to the limited support from these organizations is that they might not recognize the important role they have in fostering interdis- ciplinary research, as they are focused on more traditional organ-based research. There are two primarily sleep-focused organizations that have training awards: the National Sleep Foundation (NSF)’s Pickwick Club Award, and the American Sleep Medicine Foundation (ASMF)’s Faculty Career Ad- vancement Award. The ASMF, affiliated with the American Academy of Sleep Medicine, annually sponsors between four and six fellowship awards, each as much as 2 years in duration and for a maximum annual funding level of $60,000. From 2003 to 2005 the program received on average 18 applications (per- sonal communication, R. Money, AASM, November 9, 2005). In 2005, the TABLE 7-1 Career Training Awards by Professional Organizations with Secondary Interests in Sleep (2004) Total Awards Sleep Awards American Heart Association 845 2 American Diabetes Association 9 0 American College of Chest Physicians 11 1 American Lung Association 115 2 American Thoracic Society 6 0 NOTE: The information contained in this table was obtained from personal communication with appropriate staff members at each organization.

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244 SLEEP DISORDERS AND SLEEP DEPRIVATION ASMF also developed the AASM/Pfizer Scholars Grant Program in Sleep Medicine to provide support for career development of junior faculty in somnology and sleep medicine. The Pickwick Club Fellowship of the NSF, an independent public health advocacy organization, awards two to four fellowships of 1 to 2 years in duration for postdoctorate trainees in sleep-related research. Support is primarily for annual salary support ($35,568 to $45,048). In 2004, in- vestment in research training by the NSF is estimated at approximately $180,000. Foundations, such as the Francis Family Foundation, have made no- table contributions to training pulmonary scientists through the Parker B. Francis Fellowship Program. Over the last 30 years, this foundation has contributed nearly $40 million in support of more than 600 fellows, some of whom have worked in the somnology and sleep medicine field. Each award is for 3 years, and provides stipends, fringe benefits, and travel ex- penses to postdoctoral fellows or newly appointed assistant professors to enable their research development related to pulmonary disease and lung biology. A survey of former fellows demonstrated that greater than 90 per- cent of respondents are currently employed in academic settings and spend a significant portion of their time on research. Summary of Foundation Support of Career Development Programs Given the overall paucity of support, further investment is required by private foundations for career development. Foundations, such as the Parker B. Francis Foundation and the Cystic Fibrosis Foundation (Box 7-1) are excellent models of sustained foundation support for research career development. Although professional organizations cannot directly support research fellowships, through associated foundations they have made moderate to large investments in research career development, in- cluding funding for some trainees with a primary somnology and somno- pathy focus. Funds for these programs have been derived from endow- ments and well-organized, targeted fund-raising efforts. This analysis identifies the potential availability of funding for sleep training from multi- and interdisciplinary initiatives available through professional organiza- tions with secondary interests related to sleep loss and/or sleep disorders, in addition to the need for organizations with primary sleep-related agen- das to invest more heavily in developing the next generations of investiga- tors. Similar to the committee’s call for multiple institutes of the Trans- NIH Sleep Research Coordinating Committee to combine resources to support career development programs, private foundations should also explore mechanisms to coordinate their efforts. This will ensure that the maximal effect from these efforts is realized.

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245 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT BOX 7-1 Model Investment by a Foundation into Career Development: The Cystic Fibrosis Foundation An example of a scientific community that has rallied to support the career development of research trainees is in cystic fibrosis. Despite the relative rarity of this condition in the population (30,000 children and adults), and the relatively small pool of researchers available to recruit from, foundation support has succeeded in developing a cadre of pro- ductive researchers, who largely have a strong history of sustained aca- demic contributions. Three key programs have been developed through the Cystic Fibrosis Foundation: the Clinical Fellowship Program, the LeRoy Mathews Program, and the Harry Shwachman Fellowship. To- gether, these programs provide support for the full spectrum of trainees: combined clinical/research fellowship training, early research career de- velopment (enrolling fellows within the first 4 years of training), and junior faculty development. Support for these programs is derived from well- organized fund-raising and philanthropy. The combined support for these training programs represents approximately 2 percent of the annual Cystic Fibrosis Foundation budget. The Clinical Fellowship Programs expose fellows early in their train- ing to working in a multidisciplinary team environment. Annually, approxi- mately 23 fellows are supported, at a total cost of $1.2 million. It supports first and second years for the clinic, and during the third and fourth year supports time for basic, translational, or clinical research. Fellows re- ceive an annual base salary of $52,000 with an additional $10,000 for research supplies. Most junior and many senior faculty members who staff the 115 accredited Cystic Fibrosis Foundation centers have derived some support through this program. The LeRoy Mathews program is a smaller program, with an annual cost of approximately $345,000. It targets the development of fellows and their transition to a junior faculty role. Each awardee is supported for 6 years. Two fellows are supported at any given time. Fellows may be accepted into the program up to their fourth year of specialty training. The Harry Shwachman fellowships are 3-year programs that target junior faculty with the goal of supporting their development as indepen- dent investigators. These awards are considered to be equivalent to NIH K08 awards in the scope of support for protected time and in the require- ment for mentored research. The Cystic Fibrosis Foundation also utilizes these programs to create a “community” of scholars through sponsorship of fellows to attend spe- cial sessions at national meetings.

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246 SLEEP DISORDERS AND SLEEP DEPRIVATION The Role of Mentoring and Availability of Sleep Mentors Numerous studies have documented the pivotal role of mentoring in career development (Chilcott and Shapiro, 1996; Palepu et al., 1998; Young et al., 2002; Lieff et al., 2003). The Council of Graduate Schools promoted the concept that: “Mentors are advisors, people with career experience will- ing to share their knowledge; supporters, people who give emotional and moral encouragement; tutors, people who give specific feedback on one’s performance; masters, in the sense of employers to whom one is appren- ticed; sponsors, sources of information about and aid in obtaining opportu- nities; models of the kind of person one should be to be an academic” (Zelditch, 1995). The cornerstone of most training programs, including NIH and foundation-funded programs, is evidence of a strong mentor-mentee relationship. Multiple mentors are required for multidisciplinary research training. Many advocate for formal oversight committees for trainees and junior faculty. Successful peer-reviewed training awards include clearly articulated roles for mentors as the responsible agents for overseeing the entire scope of the trainee’s career development program. The availability of appropriate mentors to provide scientific and career guidance to new investigators (as well as to serve as a catalyst to attract such individuals to the field) is limited, with some variation across institu- tions. There is currently a concentration of investigators and grants at a limited number of academic institutions. Even highly established sleep aca- demic centers have a paucity of senior mentors. This often requires senior mentors to be responsible for several mentees, potentially reducing the ef- fectiveness of the mentorship relationship. The availability of mentors is also limited by the fiscal constraints of academic medical systems and struc- tures, which normally do not always recognize the contribution of men- toring to the institute’s mission. Increasing fiscal pressures at academic cen- ters require faculty to be increasingly accountable for justifying their effort in relationship to compensation. Mentoring is, in general, not a compen- sated activity. Thus, there are growing disincentives for potential mentors to assume new mentorship relationships. The limited availability of appropriate mentors has far-reaching conse- quences to the growth of the field. Trainees may make decisions to enter certain fields because of the reputation of accessible mentors. Securing pro- tected time and research support from external sources requires commit- ment by at least one strong mentor. Young investigators benefit enormously by relationships with a mentor who can help negotiate complex academic settings, prioritize goals and work, critically examine research methods and data interpretation, refine presentation and scientific and grant-writing skills, and develop high levels of professionalism.

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247 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT OPPORTUNITIES TO ACCELERATE SOMNOLOGY AND SLEEP MEDICINE CAREER DEVELOPMENT Each challenge also presents opportunities to develop novel strategies for career development, to enhance the recognition of somnology and sleep disorders research as an interdisciplinary field and more effectively inter- face with other related disciplines, and to build upon existing NIH and private foundation initiatives. In addition to strategies described in Chapter 5, additional strategies include the following: • Training in somnology and sleep medicine can be structured to complement those of other programs and vice versa, by interactively engag- ing trainees in other programs. The interdisciplinary organization of the field creates a foundation for trainees from multiple fields to participate and apply their methods or expand their initial foci to questions relevant to somnology and somnopathy. The NIH can foster this by adopting trans- institutional training programs. • The NIH Roadmap explicitly emphasizes the importance of interdis- ciplinary research, especially aimed at achieving translational research ob- jectives. As academic institutions vie for support from NIH Roadmap pro- grams, incorporation of somnology and sleep disorders research as a translational research focus may provide a competitive edge. • The innovation of the new NIH K12 training programs—which provide support to an educational institution for career development experiences for clinicians leading to research independence—and their sensitivity to respond to the scientific needs of the community make these programs desirable avenues for providing support for both men- tors and mentees interested in somnology and sleep disorders. Modern communication technologies make long-distance mentoring feasible and effective. • Recent loan repayment policies have been initiated at the NIH, which may substantially reduce the burden of loan repayment in return for evidence of scientific activity and further investment in academic training. Targeting sleep-related research trainees and junior faculty for NIH loan repayment is suggested as a potentially important recruitment tool. Availability of NIH and foundation training programs are a crucial source of support to ensure protected time and resource investment in new investigators. • The growing strength of several private organizations (e.g., founda- tions, professional societies, industry) committed to promoting sleep health and somnology and sleep disorders professionals is a largely untapped re- source for support for trainees.

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248 SLEEP DISORDERS AND SLEEP DEPRIVATION Potential Mechanisms to Improve Training A particular challenge for development of investigators in sleep research is that currently few institutions have the critical mass of established inves- tigators in this area to provide mentorship and training. This suggests that mechanisms need to be sought to leverage the intellectual resources at these few institutions. Remote Mentoring Programs Successful career development awards require the identification of a strong mentor. However, if such mentors may only be located at the candidate’s home institution, there would be little growth of somnology and/or sleep disorders research expertise in institutions other than the few large academic programs. Further, educating grant reviewers of career de- velopment applications allows more flexibility in the range of mentorship relationships—a flexibility needed to allow the field to grow. There are several NIH mechanisms to support midcareer development and mentorship skills (K24, K25). In 2004, however, only three individuals were awarded a new K24 grant in somnology and/or sleep medicine (no new grants were awarded in 2003), and there were no new K25 awards in somnology and/or sleep medicine for the same year. The new K12 Transla- tional Research Institutional Training program also provides salary support for mentees. However, no K12 scholars identified a sleep-related focus in their research application. These data indicate the need for greater NIH investment in developing and supporting the effort of mid- to senior-level investigators as mentors and to provide support for mentoring time. Specialized NIH programs have also been developed to facilitate the creation of national networks of mentors and mentees. However, due to budgetary constraints, some NIH institutes are no longer funding under- graduate programs. Two programs were very successful in developing mentoring skills of mentors, creating new mentor-mentee relationships, and exposing trainees to intensive research experiences—Brown University’s Summer Sleep and Chronobiology Research Apprenticeship (see Chapter 5) and the Summer Research Institute in Geriatric Psychiatry (Box 7-2) (Halpain et al., 2001). Another approach to efficiently “matching” mentors and mentees across institutions is through networks supported by professional societies. The American Thoracic Society established a mentoring program in 1999 and serves as a clearinghouse for mentors and mentees with complementary issues (and sometimes concordant gender). The American Thoracic Society provided venues for matched mentors and mentees to meet with the goal of facilitating the mentoring relationship.

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249 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT BOX 7-2 Summer Research Institute: A Model Program for Mentor-Mentee Networks The Summer Research Institute is a 10-year-old program that has created a national network of mentors in a relatively small field (geriatric psychiatry). The Summer Research Institute provides a useful model for attracting new investigators to a defined field and for bridging and short- ening the transition period from fellowship to first research funding. The program offers a 1-week “boot camp” in research career survival skills for postdoctorates and junior faculty. At the end of each program, a work- shop facilitates interactions and sharing of research among all trainees. The program’s success is evidenced by the career trajectories of train- ees. Of the approximately 300 program alumni (postdocs, junior faculty), 80 percent now hold full-time academic positions, and 50 percent or so have competed successfully for extramural research from the NIH and foundations. In 2005, the SRS and the AASM also initiated a long-distance mentor- mentee program. This program is still under development; too few data are available to evaluate its effectiveness or level of participation. In summary, the pivotal role of mentorship in attracting trainees to sleep medicine and facilitating their academic success is clear. Given the relatively small numbers of available mentors, additional efforts are needed to encourage NIH, professional societies, and foundations to provide sup- port for developing mentors. In addition, creative use of national networks of mentors and mentees needs to be encouraged. Funding agencies need to recognize the role of long-distance mentorship plans, if those plans ad- equately address important issues in successful mentor-mentee relationships. Given all this, the field is ripe for expansion, but there are too few young and midcareer investigators. Integration of Somnology and Sleep Medicine with Other Training Programs Another strategy to be considered is providing additional training posi- tions to already established training grants in relevant disciplines, such as neuroscience and clinical epidemiology. This, when combined with the re- mote mentorship model, would have considerable benefit. It would not only provide a new mechanism to provide training to trainees, but also the men-

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250 SLEEP DISORDERS AND SLEEP DEPRIVATION tor with expertise in the primary discipline, such as neuroscience or clinical epidemiology, at the host institution might also become interested in sleep research. The development of midcareer mentoring awards for 1 to 2 years would allow midcareer investigators in institutions with little sleep expertise but relevant skills (e.g., neuroscience or clinical epidemiology) to get retrained in sleep research. They would do so in collaboration with one of the com- prehensive sleep centers described elsewhere in this report. Such mentoring could be a combination of time spent at the comprehensive sleep center and remote mentorship while at their own institution. The home institution would need to indicate its commitment to developing a sleep research pro- gram for this to be a viable, productive strategy. Somnology—the branch of science devoted to the study of sleep and wakefulness—requires a larger interdisciplinary research workforce. This can be accomplished by both attracting individuals from other related fields and by establishing a new cohort of researchers who work specifically on sleep-related topics. As presented in this chapter, the current status of the sleep research field requires new mechanisms to be considered to seed insti- tutions that currently lack the intellectual resources. Recommendation 7.1: The National Institutes of Health and pri- vate foundations should increase investment in interdisciplinary somnology and sleep medicine research training and mentoring activities. The National Institutes of Health, foundations, and professional societies should utilize and develop further funding mechanisms to attract young investigators into the field of somnology and sleep medicine. As a reflection of the interdisciplinary nature of somnol- ogy and sleep medicine, members of the Trans-NIH Sleep Research Coordinating Committee should be encouraged to combine re- sources to sponsor grants for disciplinary and cross-disciplinary training and mentoring activities (T, F, and K funding mechanisms) of medical students, graduate students, postdoctoral fellows, clini- cal fellows, and junior faculty. To implement this recommendation the following should be considered: • The Trans-NIH Sleep Research Coordinating Committee should establish a somnology and sleep medicine career development program. This program should support trainees for a significant number of years, spanning research training in fellowship and research career development as a faculty member. It should also

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251 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT facilitate mid-career training opportunities (e.g., K21, K24), the Academic Career Award for Education and Curriculum Devel- opment program (K07), and research education grants (R25). • Existing training grants or large research programs in disciplines related to somnology or sleep medicine (e.g., internal medicine, neurology, psychiatry, psychology, otolaryngology, nursing, epi- demiology, neuroscience, health services research) should allow for the addition of a sleep medicine trainee. Where pertinent expertise is not available on-site, remote mentoring at other in- stitutions should be encouraged. REFERENCES Antoch MP, Song EJ, Chang AM, Vitaterna MH, Zhao Y, Wilsbacher LD, Sangoram AM, King DP, Pinto LH, Takahashi JS. 1997. Functional identification of the mouse circadian Clock gene by transgenic BAC rescue. Cell 89(4):655–667. Bhattacharjee Y. 2005a. NIH career awards. Universities may have to pay more in support of graduate training. Science 310(5754):1601. Bhattacharjee Y. 2005b. NIH career awards. Young scientists get a helping hand. Science 310(5754):1601. Chemelli RM, Willie JT, Sinton CM, Elmquist JK, Scammell T, Lee C, Richardson JA, Williams SC, Xiong Y, Kisanuki Y, Fitch TE, Nakazato M, Hammer RE, Saper CB, Yanagisawa M. 1999. Narcolepsy in orexin knockout mice: Molecular genetics of sleep regulation. Cell 98(4):437–451. Chilcott LA, Shapiro CM. 1996. The socioeconomic impact of insomnia. An overview. Pharmacoeconomics 10(suppl 1):1–14. Halpain MC, Jeste DV, Katz IR, Reynolds CF. 2001. Summer Research Institute: Enhanc- ing research career development in geriatric psychiatry. Academy of Psychiatry 25: 48–56. King DP, Zhao Y, Sangoram AM, Wilsbacher LD, Tanaka M, Antoch MP, Steeves TD, Vitaterna MH, Kornhauser JM, Lowrey PL, Turek FW, Takahashi JS. 1997. Positional cloning of the mouse circadian Clock gene. Cell 89(4):641–653. Lieff SJ, Tolomiczenko GS, Dunn LB. 2003. Effect of training and other influences on the development of career interest in geriatric psychiatry. American Journal of Geriatric Psy- chiatry 11(3):300–308. Lin L, Faraco J, Li R, Kadotani H, Rogers W, Lin X, Qiu X, de Jong PJ, Nishino S, Mignot E. 1999. The sleep disorder canine narcolepsy is caused by a mutation in the hypocretin (orexin) receptor 2 gene. Cell 98(3):365–376. Mignot E, Young T, Lin L, Finn L. 1999. Nocturnal sleep and daytime sleepiness in normal subjects with HLA-DQB1*0602. Sleep 22(3):347–352. NHLBI (National Heart, Lung, and Blood Institute). 2003. National Sleep Disorders Research Plan, 2003. Bethesda, MD: National Institutes of Health. NIH (National Institutes of Health). 2006a. Roadmap Initiative to Provide Training for Fu- ture Leaders of Clinical Research. [Online]. Available: http://nihroadmap.nih.gov/ clinicalresearch/clinicaltraining/futureleaders.asp [accessed January 25, 2006]. NIH. 2006b. Resources for New Investigators. [Online]. Available: http://grants2.nih.gov/ grants/new_investigators/ [accessed January 25, 2006].

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