BRIEF REPORTS
Comparing National Institutes of Health Funding of Emergency Medicine to Four Medical Specialties Sara C. Bessman, MS, Noah O. Agada, MB, MPH, Ru Ding, MS, Wesley Chiang, Steven L. Bernstein, MD, and Melissa L. McCarthy, ScD
Abstract Objectives: The purpose of this study was to compare National Institutes of Health (NIH) funding received in 2008 by emergency medicine (EM) to the specialties of internal medicine, pediatrics, anesthesiology, and family medicine. The hypothesis was that EM would receive fewer NIH awards and less funding dollars per active physician and per medical school faculty member compared to the other four specialties. Methods: Research Portfolio Online Reporting Tools (RePORT) were used to identify NIH-funded grants to 125 of the 133 U.S. allopathic medical schools for fiscal year 2008 (the most recent year with all grant funding information). Eight medical schools were excluded because six were not open in 2008, one did not have a website, and one did not have funding data available by medical specialty. From RePORT, all grants awarded to EM, internal medicine, family medicine, anesthesiology, and pediatric departments of each medical school were identified for fiscal year 2008. The authors extracted the project number, project title, dollars awarded, and name of the principal investigator for each grant. Funds awarded to faculty in divisions of EM were accounted for by identifying the department of the EM division and searching for all grants awarded to EM faculty within those departments using the name of the principal investigator. The total number of active physicians per medical specialty was acquired from the Association of American Medical Colleges’ 2008 Physician Specialty report. The total number of faculty per medical specialty was collected by two research assistants who independently counted the faculty listed on each medical school website. The authors compared the total number of NIH awards and total funding per 1,000 active physicians and per 1,000 faculty members by medical specialty. Results: Of the 125 medical schools included in the study, 84 had departments of EM (67%). In 2008, NIH awarded over 9,000 grants and approximately $4 billion to the five medical specialties of interest. Less than 1% of the grants and funds were awarded to EM. EM had the second-lowest number of awards and funding per active physician, and the lowest number of awards and funding per faculty member. A higher percentage of grants awarded to EM were career development awards (26%, vs. a range of 11% to 19% for the other specialties) and cooperative agreements (26%, vs. 2% to 10%). In 2008, EM was the only specialty of the five not to have a fellowship or T32 training grant. EM had the lowest proportion of research project awards (42%, vs. 58% to 73%). Conclusions: Compared to internal medicine, pediatrics, anesthesiology, and family medicine, EM received the least amount of NIH support per active faculty member and ranked next to last for NIH support by active physician. Given the many benefits of research both for the specialty and for society, EM needs to continue to develop and support an adequate cohort of independent investigators. ACADEMIC EMERGENCY MEDICINE 2011; 18:1001–1004 ª 2011 by the Society for Academic Emergency Medicine
From the Department of Emergency Medicine, Johns Hopkins University School of Medicine (SCB, NOA, RD, MLM), Baltimore, MD; Johns Hopkins University (WC), Baltimore, MD; and the Department of Emergency Medicine, Yale University School of Medicine (SLB), New Haven, CT. Received November 12, 2010; revisions received January 11 and February 23, 2011; accepted February 24, 2011. This project was supported by Grant K01HS017957 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Nicole DeIorio, MD. Address for correspondence and reprints: Sara C. Bessman, MS; e-mail:
[email protected].
ª 2011 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2011.01138.x
ISSN 1069-6563 PII ISSN 1069-6563583
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H
ealth research is highly valued because it benefits society, the economy, and the general health.1 The National Institutes of Health (NIH) is the single largest source of health research funding in the United States.2 In 2009, over 43,000 research project applications and 4,600 fellowship or training grant applications were submitted, of which 21% and 35% were funded, respectively.3 Relatively little is known about NIH funding by medical specialty except that each NIH institute and center has a specific research agenda often focused on a particular body system(s) and ⁄ or set of related disease conditions.2,4 Unlike most medical specialties, emergency medicine (EM) is not defined by a single organ system or group of related disease conditions. Instead, it specializes in the evaluation and treatment of all potentially life-threatening conditions. Because emergency departments (EDs) play an important role in the safety net system, EM also provides a variety of unplanned, nonemergent health care services. The wide spectrum of EM research makes it relevant to multiple NIH institutes and centers. The purpose of this study was to compare NIH funding received by EM to the specialties of internal medicine, pediatrics, anesthesiology, and family medicine. The disease conditions and patient populations of the latter specialties overlap substantially with those of EM, hence their preference for comparison. We hypothesized that EM would receive fewer NIH awards and less total funding dollars per active physician and medical school faculty member compared to the other four specialties. METHODS Study Design We conducted a cross-sectional study using 2008 NIH funding data, which is the most recent year with final funding information at the organizational level. We merged it with physician workforce data and U.S. medical school faculty information to estimate the total number of NIH grants and total dollars awarded per active physician and per faculty member for EM, internal medicine, family medicine, anesthesiology, and pediatrics. Study Population Using Research Portfolio Online Reporting Tools (RePORT), we identified all NIH-funded grants in 2008 (http://report.nih.gov/award/trends/AggregateData. cfm). Study Protocol We filtered the aggregate data to include all 133 U.S. allopathic medical schools listed on the Association of American Medical Colleges’ (AAMC) website (http:// www.aamc.org/). For each medical school, we identified all grants awarded to EM, internal medicine, family medicine, anesthesiology, and pediatrics in fiscal year 2008. For each grant, we extracted the project number, project title, dollars awarded, and name of the principal investigator. We accounted for funds awarded to faculty in divisions of EM by identifying the department of the EM division and searching for all grants awarded to EM faculty within those departments using the name
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of the principal investigator. We counted grants awarded to EM divisions as EM grants and subtracted them from the grants awarded to the affiliated departments of the EM divisions. We determined the number of active physicians in the United States for each of the five medical specialties of interest. The American Medical Association (AMA) has a physician masterfile database that tracks professional and demographic information of all doctors of medicine and osteopathic medicine in the United States. We identified the total number of active physicians in the United States by medical specialty with the 2008 Physician Specialty report published by the AAMC, which is based on the AMA’s physician masterfile.4 To determine the total number of faculty by medical specialty, two trained research assistants (RAs) independently assessed the website of each medical school listed by the AAMC over a 12-week period (April 2010 to June 2010) and counted the number of primary faculty in the relevant departments. We defined primary faculty as faculty, affiliated faculty, fellows, and emeritus professors listed on the department website with a doctoral degree (i.e., MD, DO, PhD, MD ⁄ PhD). Residents and volunteer faculty were excluded. We examined the reliability of the RA’s faculty estimates. The correlation between the two RAs across specialties ranged from 0.57 (EM) to 0.78 (internal medicine). Discrepancies most frequently occurred when the RAs used different methods of identifying faculty on a medical school website or counted staff or voluntary faculty by mistake. When the difference between the two faculty counts divided by the larger count was over 10% for a given department, the website was revisited and a consensus count between RAs and principal investigator was reached. When faculty counts were within 10% (median difference 3%, range 0% to 10%), we calculated the average. Data Analysis We performed a descriptive analysis to compare the total number of awards and total dollars of funding per active physician and per faculty member by specialty. RESULTS We excluded eight of the 133 AAMC allopathic medical schools because six were not open in 2008, one did not have a website, and one did not have funding data available by medical specialty. Of the remaining 125 medical schools, 84 had departments of EM in 2008. NIH awarded over 9,000 grants and approximately $4 billion in 2008 to the five medical specialties of interest (see Table 1). Approximately three-quarters of the total grants (71%) and funding (76%) were awarded to internal medicine. In contrast, less than 1% of the grants and funding were awarded to EM. Also, EM had the second-lowest number of awards and funding per 1,000 active physicians and the lowest number of awards and funding per 1,000 faculty members. Of the 66 EM grants, we identified eight awards to EM investigators in divisions affiliated with other departments. Table 2 displays the types of grants awarded by medical specialty. A higher percentage of grants awarded
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Table 1 Total NIH Grants Awarded and Total Funding per Active Physician and Faculty Member by Medical Specialty for 2008
All five specialties EM Anesthesiology Family medicine Internal medicine Pediatrics
Total Awards
Total Funding
No. of Active Physicians
Awards ⁄ Physician*
Funding ⁄ Physician
No. of Faculty
Awards ⁄ Faculty*
Funding ⁄ Faculty
9,237 66 278 154 6,575 2,164
$4,004,993,788 $21,027,187 $87,840,107 $44,089,393 $3,033,590,842 $818,446,259
423,876 30,742 38,724 103,315 193,851 57,244
22 2 7 1 34 38
$9,449 $684 $2,269 $427 $15,649 $14,298
69,126 4,313 7,164 6,651 37,331 13,667
134 15 39 23 176 158
$57,938 $4,875 $12,261 $6,629 $81,262 $59,887
*Per 1,000 active physicians and per 1,000 faculty members.
Table 2 Percent Distribution and Total Funding* for Different NIH Award Types by Medical Specialty for 2008
EM Award Type Total Fellowship (Fs) Career development (Ks) Training (Ts and D43) T32 (domestic) D43 (international) Other Ts Research projects (Rs) R03 (small) R21 (exploratory) R01 equivalent (large) Other Rs Program projects (Ps) Cooperative agreements (Us) U01 U10 Other Us Support for research programs (Ss) Resource grants (Gs) Clinical research program (Ms)
Anesthesiology
Family Medicine
Internal Medicine
Pediatrics
Awards
Funding
Awards
Funding
Awards
Funding
Awards
Funding
Awards
Funding
n = 66 0 26
$21,027 $0 $2,582
n = 278 5 11
$87,840 $567 $3,839
n = 154 2 23
$44,089 $144 $5,176
n = 6,575 3 15
$3,033,591 $8,722 $172,358
n = 2,164 2 19
$818,446 $2,221 $67,698
3
$295
5
$2,889
3
$1,097
7
$127,823
6
$28,790
0 3
$0 $295
4 0
$1,767 $0
3 0
$1,030 $0
5 0
$109,714 $7,637
5 0
$25,325 $2,040
0 42
$0 $9,328
1 73
$1,122 $65,037
0 58
$67 $29,227
2 61
$10,472 $1,375,682
1 60
$1,425 $442,418
0 9
$0 $1,117
2 6
$290 $3,169
6 10
$739 $3,082
2 5
$6,942 $71,103
3 7
$4,390 $29,066
33
$8,211
65
$60,809
31
$20,546
51
$1,241,006
47
$385,108
0 2
$0 $2,265
0 3
$769 $11,831
11 2
$4,860 $1,584
3 6
$56,631 $587,879
3 4
$23,854 $111,444
26
$6,422
2
$3,677
10
$6,055
8
$712,019
9
$159,025
8 18 0 0
$4,093 $2,329 $0 $0
2 0 0 0
$2,549 $0 $1,128 $0
8 0 2 1
$3,692 $0 $2,363 $732
5 1 2 0
$291,152 $63,841 $357,026 $2,711
5 2 2 0
$81,745 $18,677 $58,603 $1,000
2
$135
0
$0
1
$73
0
$3,458
0
$227
0
$0
0
$0
0
$0
0
$42,938
0
$5,624
Awards are percentages of the column N. *Total funding in thousands. R01 equivalent grants include R01, R37, DP1, and DP2.
to EM were career development awards (26%, vs. a range of 11% to 19% for the other specialties) and cooperative agreements (26%, vs. 2% to 10%). In 2008, EM was the only specialty not to have a fellowship or T32 training grant. EM had the lowest proportion of research project awards (42%, vs. 58% to 73%). The R01-equivalent grants awarded to EM investigators in 2008 addressed diverse topics such as emergency informed consent, substance abuse interventions, tissue
plasminogen activator use in stroke treatment, heart failure risk stratification, factors associated with human immunodeficiency virus risk, and evaluation of the Oregon parity law (data not shown). DISCUSSION This report is one of the first to estimate the total number of NIH grants and funding dollars by total active
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physicians and faculty for five medical specialties. In 2003, the American College of Emergency Physicians (ACEP) presented NIH training grant funding data that ranked internal medicine highest compared to the other four specialties in terms of total number of awards, dollar amounts, and dollars per resident ($5,021.30 ⁄ resident).5 Pediatrics ranked second, with $2,257.48 per resident, followed by anesthesiology ($559.48 ⁄ resident), EM ($50.66 ⁄ resident), and family medicine (which received no NIH training grants in 2003). Consistent with ACEP’s finding, we determined that in 2008, internal medicine, pediatrics, and anesthesiology ranked higher than EM for all award types. However, EM also received fewer total NIH awards and funding dollars overall and per active faculty, compared to family medicine. Among the five medical specialties, EM had a relatively low proportion of research project grants and was the only specialty to receive no training grants or fellowships. Collectively, these awards not only support independent investigation of important scientific questions, but also serve as mechanisms for trainees to gain research experience and skills. Of note, the National Heart, Lung, and Blood Institute recently funded six new research training fellowships in EM using the K12 mechanism (http://grants.nih.gov/grants/guide/rfa-files/ RFA-HL-11-011.html). There are many possible explanations why EM received fewer awards and funding dollars than the other four specialties. First, EM remained a division at a substantial proportion of schools in 2008 (33%). According to federal funding data from 2000 to 2003, faculty at schools where EM is a department are eight times more likely to receive federal funding than faculty at schools where it is not.6 Second, since the NIH traditionally funds more basic science research, EM may receive less funding if there is a smaller proportion of investigators interested in basic science. Finally, EM is one of the highest paying specialties of the five examined, so the opportunity costs of choosing research over clinical practice are substantial unless EM faculty are subsidized through their departments and institutions until they can succeed at obtaining extramural support. LIMITATIONS The results of this study must be interpreted in the context of the following limitations. First, the generalizability is limited because we only examined NIH-funded grants to five specialties at accredited medical schools for 2008. If RePORT included grant funding data for other federal grant funding agencies and foundations, EM may have ranked higher among the five specialties because EM conducts a substantial amount of clinical, public health, and policy research that is funded elsewhere (e.g., Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Robert Wood Johnson Foundation).6 Second, the
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numerator (funding for 2008) and denominator (2007 active physicians and 2010 departmental faculty) data were not from the same year, but this difference is expected to affect all five specialties equally. Third, we could not determine the accuracy of faculty information provided on the medical schools’ websites, but the results by faculty were largely consistent with the results by active physician. Fourth, our data are based only on awards to principal investigators, since it was not possible to identify coinvestigators. Similarly, our approach identified grants awarded to EM principal investigators and not all grants related to EM research. Capturing all EM-related research is not possible given its heterogeneity. However, ideally, EM investigators are leading the research on EM care. Finally, we could not compare the funding success rate among specialties because RePORT does not include data on unfunded grant submissions. Future areas of research include expanding this investigation to include all medical specialties, other funding agencies, and funding rates over time. CONCLUSIONS We examined National Institutes of Health support awarded to five medical specialties in 2008 and determined that EM is one of the least funded, perhaps because of its youth, emphasis on clinical research, and opportunity costs of clinical practice. Given the benefits of health research, it is important that EM support research careers among its trainees so that the specialty creates an adequate cohort of independent investigators. References 1. Croxson B, Hanney S, Buxton M. Routine monitoring of performance: what makes health research and development different? J Health Servs Res Policy. 2001; 6:226–32. 2. Dorsey ER, de Roulet J, Thompson JP, et al. Funding of US biomedical research: 2003–2008. JAMA. 2010; 303:137–43. 3. National Institutes of Health. Research Portfolio Online Reporting Tools. Frequently Requested Reports. Available at: http://report.nih.gov/frrs/ index.aspx. Accessed Jun 14, 2011. 4. Association of American Medical Colleges. Center for Workforce Studies. 2008 Physician Specialty Data. Available at: http://www.omionline.org/newsite/docs/specialtyphysiciandatabook.pdf. Accessed Jun 14, 2011. 5. American College of Emergency Physicians. Research Committee. Report on Emergency Medicine Research. Dallas, TX: ACEP, 2005. 6. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press, 2007.
