This transcript has been edited for clarity.

Robert A. Harrington, MD: Hi. This is Bob Harrington, from Weill Cornell Medicine, on Medscape Cardiology and theheart.org. As you know, we like to try to stay current with timely topics in cardiovascular medicine, whether it's some new piece of science coming out in the literature, a clinical trial that's just been presented, or sometimes policy issues that affect the practice of cardiovascular medicine or the research associated with cardiovascular medicine.

Watching everything that's going on over the past couple of months with funding cuts at the National Institutes of Health (NIH) and other federal agencies that support research, like the National Science Foundation and the Department of Defense, I thought it would be a good opportunity to take two perspectives and have a conversation.

One would be to hear from somebody who trains many investigators — in this case, clinician investigators. The second is to hear from a couple of early-career investigators to see how they're thinking about these changes and how it might affect their career choice or ways that they might be approaching their careers.

I'm really fortunate to have with me my good friend and colleague, Dr Adrian Hernandez. Adrian is a professor of medicine at Duke University, where he also serves as the executive director of the Duke Clinical Research Institute (DCRI). Adrian has been on the podcast with me a number of times, so welcome back, Adrian.

Adrian F. Hernandez, MD: Thanks, Bob, for having me.

Harrington: I'm also going to put Adrian to work on this podcast and ask him not just to answer questions but to ask some questions as well.

Next up is Dr Beth Feldman. Beth is a cardiovascular medicine fellow at Weill Cornell Medicine. Her specialty and her area of interest in which she's training is heart failure. Dr Feldman, thanks for joining us.

Elizabeth W. Feldman, MD: Thank you for having me.

Harrington: Last but not least is Dr Henry Foote. Henry is a pediatric cardiology fellow who's just beginning his fellowship in intensive care medicine and is also doing research training at the DCRI. Henry, thank you for joining us as well.

Henry Foote, MD: Thanks for having me. Good to be here.

Funding Cuts and the New World

Harrington: Let's start with you, Adrian. You and I have talked about this over the past couple of months since the change in administration. We've seen all sorts of challenges coming out of the federal funding scene.

We've seen a proposal to cut indirect costs from the individually negotiated rates that we all have to a standard 15% across the so-called facility administration charges. We also see grants being terminated, grants being stopped, and slowing down of new notices for application. As somebody who runs a large research institute that depends heavily, but not exclusively, on federal funding, give us a sense of the world from your vantage point.

Hernandez: The world certainly is changing and it's been very dramatic, especially in certain corners of the US where people weren't expecting the degree of change that is upon us right now. We see it across all areas of science and research.

My hope is that, as we're going through those changes, it actually makes us think about what is really core to our mission. What do we need to double down on? One of the things that's really important is that, whenever you have these types of challenges, seeing how the community comes together to meet those challenges and do something really innovative in terms of our research. Also, a topic related to today is ensuring that the next generation thrives. That's really key right now.

Harrington: As we think about this ecosystem, I'll call it, of funding for biomedical research, there's been this longstanding relationship contract, if you will, between the federal government and the research universities. Surrounding that has been private industry, the pharmaceutical industry, the device industry, and the biotech industry. There have been the foundations — the American Heart Association and the National Kidney and Cystic Fibrosis Foundations — and then there have been the philanthropists.

You're at a place that, for a long time, has had many different funding streams and has really purposefully tried to balance all of those. How are you thinking about this? You said new opportunities. Do you mean areas of science that maybe your group is particularly good at, or do you mean funding sources that maybe you need to shift to?

Hernandez: Well, both. Certainly, you want to continue advancing science that has become a really high priority. Cardiovascular disease is a high priority. It's a chronic health condition for which it's really clear that there's a greater emphasis in terms of addressing right now. We've seen the curve, so called, bending the wrong way, and so developing what's next and also implementing what's next.

The other thing is that, whenever you have this dramatic change and much of it focused on administrative efficiency or effectiveness, it actually is a good opportunity for asking the fundamental questions of, what is really important and what can we streamline?

There are many reasons why certain steps have been added to the research process that were well justified in the past, but times have changed. Think about some of the things that we have access to now that can make things more efficient and more effective, such as AI, to help us be more compliant. We should be able to take advantage of technology to do so.

Harrington: One of the discussion points I've utilized on my trips to Washington over the course of the past couple of months is that if you look at the regulations surrounding the F&A (facilities and administrative costs), they've increased 160% in the past 10 years.

As you pointed out, I don't think any of it was mal-intended. It was a case of one thing gets added after another. One of the ways to cut down the indirect cost of doing research is to remove some of that regulatory burden. I agree with you, Adrian. It's a great time to have those conversations.

Hernandez: Exactly.

Different Training Pathways

Harrington: Let's start in with our early-career folks here. Beth, talk to us a little bit about what it is you are trying to do, what it is you're training to do, and where you are in your training. I just generically said a third-year fellow, but give us the real sense of what you're trying to accomplish.

Feldman: I'm not at the end yet, but I'm getting closer to the end of my training. I went to Duke undergrad but I was not pre-med in college. I was a healthcare consultant for 3 years, so I got a sense of the business world, then decided to go to med school, did a post-bach, and then, after med school, did internal medicine residency at Hopkins.

At Hopkins, I got interested in cardiology. I'm now in my third year of my general cardiology fellowship at Cornell, and then, a month from now, I'll be a heart failure transplant fellow. My ultimate career goal is to work in heart failure transplant. I also may end up doing a critical care year after this so that I can be fully heart failure and critical care trained.

My goal is primarily, honestly, to be a great clinician, and then to have research be a part of my general practice. I'm not doing a T32 grant, so I won't be a true physician-scientist, but my goal in terms of research has always been to be able to independently ask questions based on my clinical work and then be able to answer them with clinical research. That's always been my goal.

Harrington: Talk a little bit about the consulting experience. It's interesting. Over the years I've met many former McKinsey-ites, Deloitte-ites, and Boston Consulting-ites who have come into medicine, and they bring a unique background. Are you interested, for example, in economics or policy? What was it about your consulting life that led you to medicine?

Feldman: It was really the health policy side. I'm not really an economics person. When I started out in the consulting world, it was right when the ACA, the Affordable Care Act, was passed. Many of my initial projects were large health systems that were trying to grapple with what the ACA meant, how to reduce their readmissions, and things like that.

Medicine had always been in the back of my mind. I grew up with a father who was a physician, who's actually a physician-scientist, and I'd always thought about it but wasn't ready to take that step in college.

Once I started working with physicians and health systems, I realized that I don't really want to be doing PowerPoints and thinking about global health system issues as much as I want the authority as a physician to actually take care of patients. If I want to work on policy, I can do that on the side.

Harrington: Good for you. We'll come back to this because it has some funding implications. Henry, let me turn to you. Give us a sense of your journey to get where you are and what you are interested in. You're doing things a little bit differently in that you're doing a formal research fellowship.

Foote: Beth, it's nice to know that other people are interested in doing multiple fellowships, as someone who's pursuing two of my own.

Feldman: There are more and more of us.

Foote: You can always add on more years of training. I did internal medicine pediatrics residency at Duke and then stayed on for 3 years of pediatric cardiology training. I am actually on a T32 this year. Between Duke and UNC, there's a clinical pharmacology T32, so that's supported my research for the year. DCRI also has a designated clinical research fellowship with some didactic training and seminars.

I’m planning to get back more into the clinical world next year, doing 2 years of pediatric critical care fellowship. My goal clinically is to work in the pediatric cardiac ICU after those years of training. From a research standpoint, I’ll focus on clinical pharmacology and some clinical trial design to improve outcomes in critically ill babies and children.

Harrington: It sounds like we still haven't figured out how to dose drugs in children.

Hernandez: We're getting better. There are multiple FDA label changes now.

Foote: I think we're getting up to 100, so hoping to continue that trend, especially as we get newer drugs, such as the biologics that have been shown to have really good efficacy in adults, making sure we're carrying over that benefit to the pediatric population.

Harrington: We heard from Beth that she's interested in predominantly being on the clinical side but having an important component of her life that allows her to do scholarship. What's your intention? Is it that, mostly as a clinical person with some research, or is it mostly as a researcher? What are you looking at doing?

Foote: I’m still trying to shape exactly what that looks like. I think right now my next step is certainly the clinical training and then I think looking toward applying for an early-career award.

If we can talk about what potential mechanisms that would be, maybe the traditional route of an NIH K award. I think I’ll be looking at industry-sponsored career development awards as well, to really fund the early years in faculty to allow you to have your own research career.

Unanswered Questions in Clinical Practice

Harrington: If I remember, Adrian, you had an AHA fellowship and a faculty award when you first joined the faculty at Duke. What are you thinking these days, Adrian, for what makes a clinician scientist? Beth and Henry are taking similar but not quite the same paths. What do you think it takes to train someone to be a clinician investigator?

Do you think that the current funding environment might influence how you think about that? My podcast last month was with Jeff Kuvin, from the ACC, and we talked about what it takes to train a cardiologist these days.

Hernandez: I think one of the things that's been around for decades is, those clinician investigators, that come across a common question for which there wasn't an answer. Bob, you remind me of my first grant, an AHA grant, which was around noncardiac surgery.

When I was on the consult service, I saw all these heart failure patients and we were making up answers in terms of providing recommendations for how to handle their scenario going through noncardiac surgery.

It was around that time that I was also reminded by someone we all know and admire, a mentor of mentors, Dr Eugene Braunwald, that when he was an intern, he would keep a diary of the questions that he would encounter that didn't have an answer. You see this commonly, where people do that and then over their years they aim to address those problems, all the time saying, hey, there's a clinical question that we don't really have an answer to. Is it worthy to go answer it?

I saw this today in rounds, with one of our colleagues, Chris Granger, quizzing some folks, and realizing that we didn't have an answer on something. I think that drives a lot of research.

Uncertainty Over How to Pay for Research Time

Harrington: For me, it's been one of the fun things of cardiology, that despite being a very evidence-driven specialty, the vast majority of the decisions we make all the time, as evidenced by the guidelines, are not supported by a terribly high level of evidence.

I tell the fellows all the time, "Don't worry; there are plenty of questions that our generation didn't answer." In all my years in the cath lab, it never ceased to amaze me when you would ask some fellow, "What are you interested in doing?" They would throw out some question and I would say, "Wow, that's a great question. How come we never thought of that before?"

Beth, one of the things you have to figure out is how to pay for your time. You have to go work for guys like Adrian, who are very tough.

Hernandez: Or Bob.

Feldman: I technically do work for Bob, I think.

Harrington: You have to work for mean guys like me. We're always wondering, how do you pay for your time? Your clinical time pays for yourself. If you're a good doctor and you're seeing patients —inpatient or outpatient — but have to figure out a way to pay for your research time, how are you approaching that, Beth?

Feldman: Honestly, that’s what's been the most stressful and most uncertain for all of us. Even today, because I knew I was doing this podcast, I asked some of my colleagues who are doing T32s, "What are you thinking? How is this going to affect all of us down the line?" To be honest, no one really knows.

For me, who's going to be doing research as more of a side of what I'm doing, what will pay for me is going to be, probably not 100%, but the vast majority of my clinical work. I think for me, the research will be on the side. If I need to apply for grants piecemeal as they come or as ideas come, I think that's what I will end up doing. If I end up getting into more research and if I need less and less clinical time, I think that's going to be more complicated for me going forward.

For what I end up doing, is there going to be industry support? Are there going to be additional grants I can apply to? I think it's going to come from everywhere, and I think no one knows.

Harrington: Having that ability to tap into multiple sources is a useful skill. For somebody like you who's interested in what I'll call health services or health policy, much of it is what you do as opposed to what a team around you does. There may be ways to be able to piece many things together.

Henry, how are you approaching this? You're on a T32 now and you have certain obligations on the T32, but the big obligation is to get trained. There’s not much deliverable in terms of a solid research project. How are you thinking of the future?

Foote: Certainly looking ahead to starting my very clinically heavy ICU fellowship, and thinking 2 years ahead when I’ll be trying to start an early faculty job, how to position myself.

Sometimes you get a couple years of not protected time, but some funding from your institution to allow you to work on grants until you get your own independent funding. There's uncertainty now in terms of how much flexibility institutions may have with discretionary funding to support early faculty that may suggest that you need to come with a greater percentage of your own funding.

Hernandez: One thing you both touched on is being able to address your own interests. One of the things about grant funding, whether it's through federal funding, nonprofits, or industry, is that it allows you to become your own boss. That's fun to have that chance to be your own boss for a certain part of your world.

Harrington: That's a good way to think of it. The reason you get to do what you want to do depends upon how much grant funding you can bring in to protect that time. That is the ongoing challenge.

Adrian, what are you seeing in terms of T32s? We certainly have lost T32s here at Weill Cornell, including a very large one that's been going on for 40 years. We've appealed for reconsideration, but losing the T32, to me, is one of the big blows because that affects the future. It may not affect today, but it affects the future.

Hernandez: Even before the past 6 months, we were seeing trends in T32s in terms of emphasis of new areas of science and how to incorporate innovative methods into training programs. We have lost T32s because they weren't there yet in terms of incorporating data science, for instance, or digital methods.

More recently, there have been losses in T32s because of a shift in federal priorities. Previously, some of the T32s had to meet priorities at that time to be funded. That shifted. We've seen those changes now. We wait to see what will translate into the future T32s, or programs like that, because certainly the investment in early careers has a long trajectory of impact. Small changes there get amplified literally over decades. I think that touches on one of your comments or worries about where things are right now.

Harrington: Yeah, that's one of the things that concerns me the most. For example, we accepted fewer PhD graduate students this year — substantially fewer. That's not going to create a problem today or even tomorrow. It's going to create a problem 5, 7, or 10 years from now as the PhD science workforce is needed. At Weill Cornell, we're not alone. Many of our peers have done that. I think you guys have done that, Adrian.

Hernandez: Yes. We have as well, at Duke. That will have downstream implications. That's one of the challenges around the so-called serendipity of science. You don't necessarily know where the next discovery will come from. If it was that easily planned, then that would be much easier, but that's not the case. It's creative minds in the right time being curious.

Harrington: Yeah. I like to call it curiosity-driven research because that's really what it is — people just having an interest. The example I've been giving all the time lately is the GLP-1 agonists. We started studying them because people were interested in the metabolism in lizards. I don't think people that started out with that had an idea that these would be some of the most important drugs in current history.

I'm going to ask each of you to close up. I'll start with you, Beth. Have the conversations about less funding and uncertainty coming out of Washington affected your thinking in terms of the future? Have they stressed you out?

Future Concerns

Feldman: I would say yes and I would say no. I think, yes, it is stressful. It is stressful to think about what your future is going to look like. Because we both have been training for years at this point, we came up in a particular model and now that model's changing, and so that's going to come with some anxiety.

I think we're not all entrepreneurial in our mindset, but I think we are driven people and I think if we want to get something done, we're going to figure out how to do it. When I have ideas, we'll manage to get work done. I think research will endure and we can get creative, but I think the anxiety is always going to be there because of all the change.

Harrington: I like the idea of an entrepreneurial mindset, and I'm going to ask Adrian about that.

Feldman: It’s the consulting in me, you know?

Harrington: I really like it. Henry, how about you? Is it changing your ideas about where you're going to be going in the future?

Foote: My main sense of this is that there's just tremendous uncertainty. I have 2 years of pretty good certainty when I'll be in clinical training, and then we'll see where we are after that. I'm not having to make a decision now in terms of what the next 5 or 10 years will look like. I'll have another couple years to reassess. I think you alluded to this earlier, that in being a clinician scientist, the clinician part does give you a fair amount of stability. You're a little bit more able to tolerate uncertain other aspects.

Harrington: I think that's right. I think that the clinician scientist maybe worries about this a little less unless you're running a large research institute that's heavily dependent on federal funding. Adrian, how are you thinking about this?

Entrepreneurship has always been a hallmark of the DCRI, and thinking creatively about funding has been a hallmark of the DCRI. How are you thinking about it for both the near term, let's call it the next 1 or 2 years, and the intermediate term, in the next 3-5 years?

Hernandez: Over the years, we have really endorsed the concept of academic entrepreneurship. It's not an oxymoron. Many of the most creative ideas start in academia. How do we do that?

In the short term, one of the things that we've been privileged to have to answer the questions that are most important is a diverse portfolio of funding. I think that's really good because if you're answering really important questions, it'll be of interest to many different types of funders. That's something that we continue to double-down on.

Thinking about what may be next, what may be areas that funders are really interested in and highly creative areas of research or addressing really unmet needs. ARPA-H is a good example of that. They have a very different mindset in terms of what they're aiming to do, and doing so very rapidly. We're seeing what we can do there. That's just an example of the entrepreneurship in a new area.

Harrington: I really like that thinking. It's similar to what we're trying to do here, which is to figure out what are we good at and what should we double-down on as opposed to what do we like doing but maybe we're not best in class at. Should we just double-down on the things we are really good at?

The second is the diversification of funding. You really have to be creative in this era and go after many different types of funding. Though, making up that federal funding gap, I just don't think it's possible. We're going to have to think differently about what we do. It's too big a gap.

Hernandez: That's exactly right. For sure, those kinds of dollars, you have to be smarter and also think about how to become more efficient and address these different issues in different ways.

Harrington: I love talking to the three of you because it also raises, as Adrian has said, where's the puck going to be? The puck's going to be the burden of chronic disease. All of us are working in that space. We want healthier children, we want less heart failure, and in my world, we want fewer heart attacks and less acute coronary disease. We all have a large amount of work to do, and I think there's great opportunity to play a role in that space.

I want to thank the three of you for joining. This has been a fabulous conversation about early-career clinician scientists and what the future might hold. I want to thank Dr Beth Feldman, from Weill Cornell Medicine; Dr Henry Foote, from the DCRI and Duke University; and Adrian Hernandez, the director of the DCRI.

Thanks for joining me, and if you've been listening to this or reading the transcript, let us know if it met your needs. Is it something that we should expand on? Is it something that you have comments on? Please do leave us a comment or a thumbs-up if you really liked the show.

Thank you, everybody, and thanks for joining us here on Medscape Cardiology and theheart.org.

Robert A. Harrington, MD, is the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine and provost for medical affairs of Cornell University, as well as a former president of the American Heart Association. He cares deeply about the generation of evidence to guide clinical practice. When not focusing on medicine, Harrington dreams of being a radio commentator for the Boston Red Sox.