Training Expert Panel

June 7, 2002

Sponsored by:
The National Institute of Dental and Craniofacial Research
National Institutes of Health

1. Background

   The National Institute of Dental and Craniofacial Research (NIDCR) is the primary sponsor of biomedical and behavioral research and of research training in oral, dental and craniofacial diseases in the United States. The mission of the Institute is to promote and improve health through research. It accomplishes this mission by supporting research and training programs in intramural laboratories and in an extended external community of investigators working in academic institutions and in other research organizations. Support of extramural researchers is provided through the programs and initiatives of the Divisions of Basic and Translational Sciences and of Population and Health Promotion Sciences. Major programs in the first of these Divisions include developmental biology and mammalian genetics, epithelial cell regulation and transformation, oral infectious diseases and immunology, AIDS and oral manifestations of immunosuppression, pain, autoimmune disease and biotechnology and biomaterials. The Division of Population and Health Promotion Sciences supports programs in behavioral and social sciences research, population sciences, clinical trials and patient-oriented research and health disparities. The Division of Intramural Research includes laboratories located on the NIH campus in Bethesda, MD. Intramural scientists perform research in craniofacial and skeletal diseases, craniofacial development, gene therapy, oral and pharyngeal cancer, oral infection and immunity and pain.

   The NIDCR convened a Blue Ribbon Panel on Training and Career Development in 1999. The Panel made a series of recommendations, particularly in regards to the support of programs that enhance multidisciplinary training, provide a diversity of flexible (i.e., long and short term) training opportunities and career paths, encourage diversity in the workforce, create a community of scholars at all levels of professional development interacting with each other and expand the roster of mentors by engaging people from other disciplines and academic units outside of the dental school setting.

   An PA for the Institutional National Research Service Awards (NRSA) or T32 awards supported by NIDCR was issued in 2000 in response to the recommendations of the Blue Ribbon Panel. This announcement incorporated the concepts and changes suggested by the panel and provided enhanced resources to support comprehensive, expanded training programs. Eight awards were made in 2001 and seven are being made in 2002. The rapid advances occurring in biomedical research and the increased demand for translational and for patient oriented research suggest that this is a good time for another in-depth look at our training needs and opportunities. The Director of NIDCR asked that an Expert Panel be convened to help the Institute evaluate existing programs and to suggest new approaches that may be used in the future to maintain a robust training portfolio. This Panel was convened on June 7, 2002. This is a summary of the Panel's deliberations and recommendations.

   To facilitate the discussion, the Panel was asked to address three main topics: 1) issues related to existing programs, particularly the T32s and T35s; 2) new initiatives to support training in clinical research; 4) a Lead Mentor Award; and 5) training needs in emerging areas such as genomics/proteomics, bioinformatics, etc. A series of questions were posed in each of these topics:

1. Existing Programs
   
   
1. Identify deficiencies and over-coverage among research areas included in current T32 portfolio
2. Should we go with a T32 model that is comprehensive or thematic? Are the comprehensive T32s unwieldy and not located in the most appropriate places?
3. Should we un-bundle or separate the T35 (short-term training) from the T32 institutional award? Do we want stand-alone short-term training programs (e.g. for all students, only minority students)? If yes, what should be the goal/objectives of short-term research training for dental students? (At present, most students get involved in short-term training programs primarily to enhance their resume for applying to specialty clinical residency programs, or as merely a summer job).
4. Does research training, as done through the T32 mechanism, make a difference?
2. New Programs
   
   
1. What can be done to enhance training of oral health professionals in clinical research? For example, should we pursue a training program that leads to a Masters in clinical research?
2. Should the NIDCR support a Lead Mentor Award and if yes, how?
3. General Training Needs/Emerging Areas
   
   
   1. What are the best venues for training if we emphasize genomics, proteomics, and bioinformatics?
   2. Who do we want to train and for what research areas?
   3. Where are predocs and postdocs being trained - primarily in dental or medical or other settings?
   4. How can we interest and retain more underrepresented minorities in a research career?
      
      
2. General Discussion
   

   The Director of NIDCR initiated the work of the Panel by indicating that the Institute is at a point of decision regarding training and that the advice of the Panelists will be useful in identifying the directions that we need to move in. The Blue Ribbon Panel proposed a strategy that we need to build upon. The NIDCR needs to enhance its clinical research portfolio and, thus, to have adequately trained clinical researchers. Certain areas of science are accelerating rapidly and the traditional training places (i.e., the dental schools where almost 100% of the NIDCR-supported training is conducted) may not have the resources to adequately train people in these areas. Few of the dental schools can provide training in genomics/proteomics and in other cutting edge areas of science. The Director wants the Panel to come up with new concepts and new directions and even to suggest completely new programs to address these issues. There is a need to get under-represented groups into the pipeline, as the number of minorities entering into the dental or biomedical research arenas is decreasing rapidly. We need to improve intramural/extramural interface and to use our intramural capacity as an added resource for training.

   The Panelists raised the following questions in response to these considerations: 1) what is the incentive for change? 2) how do we know that change will occur? and 3) what is the precise role of the intramural community in this interface? The Director responded that the incentive for change is really the survival of NIDCR. If we cannot train the next generation of researchers, nobody else will. The assurance that change will occur is linked to the need to establish trust. Lastly, the interface with the intramural program needs to be refined and better use needs to be made of this resource. Traditionally, a subset of the Intramural Program has played a role in training, but we expect this involvement to increase. Loan repayment capability is now available in the extramural community in selected areas and it has been available in the intramural program for sometime. Using this type of approach, NIDCR can utilize resources effectively in both communities. NIDCR is the only NIH Institute that can train the next generation of oral health researchers.
   

3. Existing Programs
   
   The Panel began the discussion of existing programs by focusing on the T35s and T32s. In response to a question from the Panel, it was stated that NIDCR currently spends approximately 9-10 million in the T32s and close to 1 million in T35s.
   
   
   1. T35 Mechanism
   
   The Director indicated that T35s were expected to be either a "feeder' program for the future dental research workforce or agents for changing the culture of dental schools with regards to research. The available information indicates that they are not fulfilling these expectations. Recipients of T35 awards are not going into academic careers.

   The Panelists expressed a number of thoughts/concerns/suggestions regarding this mechanism:

   1. The T35s can be more effective if they are linked to mechanisms designed to give dental schools an incentive to change the curriculum and introduce research experiences into the overall training of dental students. A good example is the R25 awards that are being planned by NIDCR. The T35 awards would offset the need for students to generate clinic revenues and allow them to do research.

   2. In the same vein, T35s are much more effective when "bundled" with comprehensive T32s and not as stand-alone awards.

   3. There should be some incentive to increase the mentors who can be part of the undergraduate curriculum. Since clinical faculty have the most impact on students, their involvement as mentors is critical to the success of the training experience.

   4. For the training experience to be meaningful, the trainees should be in a funded lab where exciting research is being performed. Unfortunately, this is not always the case and this needs to be corrected.

   5. Technology should not be the primary driver for training but, rather, the institutional commitment that trainees would go to the places where robust science is being conducted and where important questions about oral and dental health are being investigated.

   
   In conclusion, the Panel felt that the stand-alone T35s should be phased out, and they should be bundled with T32s or R25s. In addition, they should be refocused to ensure that trainees go to funded, active labs performing cutting-edge research. Accountability is essential to insure the success of the training.

   2. T32 Mechanism
      
      

   Based on data presented by the NIDCR staff, the Panel commented on the impressive number of T32s awarded in the last 20 years (accounting for approximately 1,000 trainees) but voiced disappointment regarding the "success rate" (i.e., the number of trainees who have successfully competed for grants). The issues of accountability and of tracking individual trainees (as opposed to entire programs) were brought up. There has to be more strict oversight, including site visits, reports, etc. and program directors have to be held accountable for filling the positions requested and for monitoring the progress of each trainee. The Director indicated that NIDCR has already started a process of "proactive" review and is putting together the tools (i.e., data base) to monitor trainees more carefully and in a timely fashion. The reasons for the lack of success and for the small number of trainees who end up in academic/research positions were discussed. These include an economic disincentive in the face of considerable student debt, the failure to compete successfully for grants, and "burn-out" from being called upon to assume too many responsibilities in patient care, teaching and administration. An important factor is the lack of mechanisms to protect and to nurture young faculty members (this is partially being addressed through the K22 awards).

   Despite this record, the Panel agreed that the so-called "comprehensive" T32s announced after the Blue Ribbon Panel have a number of useful and effective features: 1) they bring together pre and post doctoral trainees. This mingling is good because they all become part of a "community". Not only do dental students benefit from interacting with more advanced trainees, but dental graduates also benefit from contacts with PhDs; 2) they provide the means for faculty training and retraining and for reaching beyond the strict confines of the dental school for mentors and training venues.

   Some of the T32 programs address specific areas of research (i.e., infectious diseases) and can be considered as training activities focused on a theme. Others are non-thematic, in that they cover a number of science or research areas. Some of the older "thematic" T32s are coming up for competitive renewal and the question is whether they should be transformed into the newer, more comprehensive awards and, if so, whether they should be allowed to maintain the theme approach or not. The Panel felt that NIDCR should support comprehensive programs but that it should not specify themes. Instead the programs should address specific areas of need. The announcement should say that any "theme" outline in the proposal should reflect the overall strengths of the dental schools and of the Academic Health Center. The approach should be flexible enough to let the applicant institutions do what they do well.

   In conclusion, the Panel felt that the current comprehensive T32 approach/program should be maintained but that oversight and accountability should be increased to the level of individual trainees. Both thematic and non-thematic programs can be supported, but they should both rely on the strength of the applicant institution. NIDCR should not dictate "themes" but should spell out broad areas of need. The Institute should restructure the administrative management of the training programs and develop a new infrastructure to manage the comprehensive awards and all training initiatives.

4. New Programs

   1. Master's in Clinical Research

The Director initiated the discussion of this topic by indicating that NIDCR has identified the enhancement of clinical research as one of its priority areas in the immediate future. This will require new programs to train clinician scientists to do sophisticated, cutting-edge clinical research in the next 5-10 years. The NIH-Duke Master's Program on Clinical Research was described as a model in clinical training. It is sponsored by the NIH Warren Mangnuson Clinical Center in collaboration with the Duke University School of Medicine. The key components of this program are:

• Each IC identifies a contact person to review and rank applications from their applicant pool
• Applicants apply to Duke
• NIH admissions committee serves as a nominating committee for the recommended applicants submitted from the ICs
• 20 slots awarded annually
• Duke makes final selection
• IC financial support and time commitment required for staff in the program
• Program designed primarily for clinical fellows and other health professionals who are training for careers in clinical research at the various NIH intramural programs.
• Program may yield a master's in Clinical Research or can be utilized as a non-degree program
• Costs are paid by supporting IC from which the applicant originated
• Costs are $480 per unit (36 units required)
• The applicant pool is concentrated in the NIH Intramural laboratories
• Duke administers the program with 3 Program Directors
• Current graduates are 16
• The program uses distance learning

A master's program like the NIH-Duke program opens up a host of possibilities, including the use of distance learning modalities. There are a number of master's programs in clinical research, but many are perhaps not as rigorous as the NIH-Duke program. The question arises as to whether the master's degree is enough to solve the current deficit in well-trained clinical researchers and as to whether NIDCR should start an initiative to promote this type of training.

The Panel felt that such a program would be a good start but would not solve all problems. To ensure that the awards go only to outstanding programs, the minimum expectations and the criteria have to be clearly specified in the announcement, but NIDCR would have to accept almost on faith that there is content behind course descriptions. A possible approach would be to start it as a pilot. Accreditation would help and a degree of oversight would have to be provided. The program could be linked to a clinical specialty/residency program in the extramural community and the degree would be awarded by the parent university or a partner medical school instead of the dental school (to move away from the traditional dental master's programs). The question was raised as to whether this initiative should be linked to a K-30 type award (for the development of curricula for clinical research). Unfortunately, only one or two dental schools have participated in these awards. A T32 application partnering with schools of medicine or public health is another approach, but the quality of the partners and the relevance of the training to oral health would need to be emphasized. The availability of outstanding mentors can be enhanced through these partnerships. An issue is how to minimize the number of trainees going into private practice after the program is completed. Finally, the Panel mentioned that identifying candidates in the extramural community might be an issue, but that this could be done as a 2-year, part-time junior faculty career enhancement program with the school contributing release time for the candidate. Support of the initiative may require taking funds away from other training programs such as the T32s.

2. Lead Mentor Award

The Director indicated that this idea is based on the observation that trainees do not always avail themselves of the strongest possible mentors. About 50% of current trainees are being mentored by somebody outside a school of dentistry and a number of prominent people were asked what would it take to entice them to mentor dental students. Those who expressed an interest asked what the incentives would be.

The Panel felt that this is a great idea and that NIDCR would act as a broker, identifying both the mentors and the trainee candidates and bring them together. Finding 15-20 mentors would not be too difficult but finding the candidates may be. A good source would be the places where people are getting PhD training and the program could be limited to post-docs. The candidate's interests and background would have to be matched with the mentor's so that they are not too remote from the lead mentor's on-going work.

5. General Training Needs: Emerging Areas

   NIDCR is working on an initiative to enhance the infrastructure and research capacity of the nation's dental schools. The outcome of this initiative will be evident in a few years but, in the meantime, there are areas of science that are moving very rapidly and there is concern that dental schools will not have the capability to fully participate in the modern research enterprise because of limited human and laboratory resources. Of particular interest is the area of genomics/proteomics, one of 3 major areas identified as an area of emphasis in NIDCR's long-range research agenda. An expert panel in this field of biomedical research was convened by the Institute at the end of May, 2002 and made some recommendations about how to address the broad opportunities that exist in genomics and proteomics research. Strategies to train the appropriate work force in the genomics and proteomics of oral, dental and craniofacial diseases are needed to keep pace with the emerging opportunities and to make dental researchers competitive in this science area.

   An important question is whether the objective is to provide training in certain cutting-edge technologies or comprehensive research training overall. The only choice is to identify the people who have the technologies and to get them on board so that oral health researchers can be trained in the use and application of the newer technologies. This implies identifying these people wherever they are and offering them incentives to train dental/oral researchers. Dental schools have to bring the rest of the Academic Health Center into collaboration in order to create proper training models. The question of short-term (i.e. 1 week) versus longer, more formalized training was discussed. Many universities have core facilities for the new technologies and the missing link is an educational one. They could be used for short-term (i.e. 1 week) exposure (through courses) of dental students and researchers. This type of opportunity is relatively easy to take advantage of, but the mentors need to understand that this is a valuable experience. Others argued that this type of short-term training is not enough, but that advantage could be taken of the comprehensive T32 awards for more structured training in genomics and proteomics. If we want people to use these new technologies in oral/dental research, more intense training is needed. The approach would be to identify the places where these technologies are being used successfully and to offer them incentives (especially ample funds) to train researchers from a dental/oral health background. Shorter-term models can be tailored to dental students, as a mechanism to introduce them to the field and increase their awareness of the opportunities, learn the vocabulary of the field and perhaps choose careers in it. A suggestion was made that training in these areas could be particularly enhanced by offering supplements to ROI recipients to offer training opportunities. A possible "broker" role for NIDCR was proposed but others felt that NIDCR should solicit applications for research projects using these technologies and require them to provide training to students. The T32 award can be used as a vehicle to enhance the partnership with other units to enhance the training environment. The challenge is to be able to provide "transitional education" and the two approaches (short and long-term training) are probably needed at this point to improve the outlook for dental researchers. Perhaps some of the training needs in this area can be addressed by tying the training to the Lead Mentor Awards and by opening up intramural programs and courses to extramural candidates.

   The Panel also discussed other general training issues, including the need to introduce research into dental education and to involve more clinical faculty in the support of research, since they are the ones who influence dental students the most. A more flexible curriculum supporting student research is needed and initiatives such as the upcoming R25 being issued by NIDCR are a way to approach the issue. Although there is now some momentum for curricular changes in dental schools, other activities can be sponsored to enhance the appreciation and the support of the clinical faculty for research. These include a "summer camp", 3-week course in which they would visit a lab and learn about the importance of research and a "clinical research day"; where clinical and basic researchers can interact with others.

   A final question addressed by the Panel was the approach to recruit and incorporate more minority individuals into the research workforce. Admission of minorities into dental schools has dropped in recent years and few minorities are exposed to research. NIDCR has participated in training activities such as the MARC program, but this is still limited for a number of reasons. There are other successful models such as the STAR program in San Antonio, and much more needs to be done to attract minorities to dentistry and to oral, dental and craniofacial research. Although the applicant pool for graduate education in sciences is generally small, more needs to be done to market dental/oral research better. Early exposure through summer programs (T35s) can be a way to target minority students.

National Institute of Dental and Craniofacial Research
Training Panel
June 7, 2002

Panelists:

John Alderete
University of Texas Health Science Center at San Antonio

Mark C. Herzberg
University of Minnesota Twin Cities

Michael Ignelzi
University of Michigan - School of Dentistry

Joanna B. Olmsted
University of Rochester

Jennifer Webster-Cyriaque
University of North Carolina Dental School

Guest Speaker:

Denedra McPherson
Clinical Center, NIH
NIH-Duke Masters Program

NIDCR Attendees:

Sarah Glavin
Sharon Gordon
George Hausch
Lorranye Jackson
Lynn King
Dushanka V. Kleinman
Eleni Kousvelari
Jim Lipton
Ricardo Martinez
Ann Sandberg
Rochelle Small
Cheryl Stevens
Larry Tabak