Tomorrow's Leaders
Maintaining the Pipeline of Pediatric Specialists

BY MARK SHWARTZ

SPRING 2007 -- Dramatic advances in diagnostics and treatment in recent years have transformed pediatrics into a highly specialized discipline. Today, Lucile Packard Children's Hospital is staffed by pediatricians representing dozens of clinical subspecialties--from adolescent medicine to vascular surgery. Many of these physicians are nationally recognized leaders who seamlessly combine first-rate clinical care with groundbreaking research in their field.

"As childhood illnesses become more complex, there's a growing need for people with in-depth knowledge in sub-areas of pediatrics," says Charles Prober, MD, senior associate dean for medical education at the Stanford School of Medicine. "Take cancer, for example. You want children with cancer to be taken care of by pediatric oncologists. Likewise, advances in pediatric cancer therapy are going to be made by subspecialists in that field." 

Three More years

Prober acknowledges that it takes a special kind of person to become a pediatric subspecialist--a dedicated individual who, after four years of medical school and a three-year residency, is willing to take on a minimum of three additional years of subspecialty training with little financial reward. About two dozen fellowships are available at Packard in a variety of pediatric subspecialties, including cardiology, neonatology, and neuro-oncology. Maintaining a pipeline of new subspecialists is essential for the future of pediatric medicine, he adds. 

In a recent survey of medical students, the American Academy of Pediatrics found that concern over rising educational costs has led to declining interest in pursuing pediatric subspecialty careers. "The average medical school debt in the United States is approximately $150,000," notes Prober. "A pediatric fellow typically earns about $50,000 a year--far less than you could earn if you directly entered pediatric practice." 

Medical schools also have difficulty finding steady sources of funding for subspeciality fellowships, he adds. "Philanthropy is clearly an important source, especially through endowments," Prober says. "An endowed fellowship says to the prospective fellow, we believe in you so much that we're going to support you for the entire duration of your fellowship. That means you can pay attention to your training instead of spending time each year applying for support." 

Recruit and Retain

Those who've finished their fellowships often pursue academic-research careers at medical centers, such as Stanford. But retaining new faculty can be a challenge, says Michael Longaker, MD, MBA, director of children's surgical research at Stanford Medical School. "The first five years are critically important in the development of a physician-scientist," explains Longaker, the Deane P. and Louise Mitchell Professor in the School of Medicine. "Everyone is pulling for their time. Their department wants them to take on more patients, and they also have a tremendous teaching load. Therefore, it's essential to provide additional resources that allow them to pursue their research interests." 

To address the problem, Packard has established an endowed faculty scholars fund for outstanding junior faculty subspecialists. Through this endowment, young faculty scholars receive two-to-five years of additional financial support, which allows them to take time off from their clinical routine to conduct innovative research or immerse themselves in subspecialty training. "In these times, when NIH research dollars are very tight, the faculty scholar program offers us a novel way to recruit and retain promising new subspecialists," Longaker says. "Tomorrow's stars are really built on how much success they have at the launch of their career." 

Economic incentives, along with the Hospital's close ties to Stanford and Silicon Valley, will continue to draw future leaders to Packard, adds Prober: "We have an extraordinarily innovative academic community that has demonstrated leadership in computer technology, biotechnology, and other areas. It will attract those who want to connect to this rich environment." 

Sonia Partap, MD 
Beverly and Bernard Wolfe Fellow in Neuro-oncology 

Sonia Partap, MD, monitors Marcos Mendoza's progress as he recovers from neurosurgery to treat a brain tumor. The excercises allow her to measure improvements in his hand-eye coordination.

For as long as she can remember, Sonia Partap has wanted to be a doctor. "My parents are physicians from India," says the St. Louis native. "My father is a psychiatrist, my mother is a pathologist, and my sister was in medical school when I was in high school, so growing up I was surrounded by medicine." 

While completing a combined BA/MD degree program at the University of Missouri-Kansas City, Partap began gravitating toward pediatrics. "Kids are much more resilient than adults," she says. "I was inspired by their spirit." 

After graduating from medical school in 2000, Partap entered a two-year residency program in pediatrics at Brown University, followed by a three-year residency in adult and child neurology at the University of Washington in Seattle. In 2005, she was selected as the first Beverly and Bernard Wolfe Fellow in Neuro-oncology at Stanford, a three-year fellowship supervised by Paul Fisher, MD, the Beirne Family Director of Neuro-Oncology at Packard Hospital.

"Sonia has superb clinical acumen and great compassion," says Fisher. "The Wolfe fellowship has allowed her to take on novel interdisciplinary training in oncology, radiology, radiation oncology, and pathology, which will put her far ahead of other clinicians starting their careers in pediatric neuro-oncology. With such unique clinical experience and some additional training to come in epidemiology research, we are preparing Sonia to become a leader in the field in years to come." 

"Brain tumors are one of the most common childhood cancers and, sadly, are the leading cause of cancer deaths in children," says Partap. "The development of effective new therapies will require improved diagnostic methods, increased understanding of tumor biology and risk factors, and novel clinical trial strategies. The Wolfe fellowship has provided me an unparalleled opportunity to develop the skills that I will need as I begin a clinical research career in pediatric neuro-oncology." 

Carolyn Chi, MD
Arline and Pete Harman Fellow

Carolyn Chi, MD, examines Gabriel Sanchez in the endocrinology clinic. The 10-year-old from Modesto received a pacemaker inplant to treat his heart condition and visits Packard regularly where doctors monitor his growth and development.

Carolyn Chi's passion for public health was kindled during her undergraduate years at Rice University. "I was majoring in sociology and biology and began doing research on the health care needs of AIDS hospice patients," she recalls. "It was a sociology professor who encouraged me to go into medicine." 

She eventually enrolled at Stanford Medical School and began focusing on children's health. "I prefer working with kids," she says. "They're very true patients. When they feel better, you know it: They're up playing, and they want to go home." 

In 2004, after four years of medical school and three years of residency training at Packard Hospital, Chi accepted a three-year fellowship in pediatric endocrinology, a subspecialty that focuses on glandular and metabolic disorders in children. 

"The first year of my fellowship was funded by the Department of Pediatrics," she says. "I was fortunate to obtain an Arline and Pete Harman Fellowship for the final two years. Without it, I'd still be applying for grants and trying to get funding." 

One of Chi's main areas of research is childhood obesity. "During my fellowship, I've been conducting a study on insulin resistance in obese adolescents with Darrell Wilson, MD, chief of pediatric endocrinology at Packard. There are a number of obesity-related health problems associated with insulin resistance, including type 2 diabetes, high blood pressure, and irregular menstrual periods." 

Chi also has been collaborating with E. Kirk Neely, MD, clinical associate professor of pediatrics, on a study evaluating the treatment of central precocious puberty--a pituitary gland disorder that triggers early puberty in children younger than 8. "The ultimate consequence for these kids is short stature," she explains. "Without treatment, a child may end up significantly shorter than their projected genetic height." 

The cause of central precocious puberty remains a mystery--one of many challenges that led Chi to pursue a fellowship in pediatric endocrinology. "Without fellowship training programs, there is no pipeline to produce specialists," she says. "So I'm extremely grateful to the Harmans and other donors. Ultimately, they're training doctors who will have the clinical skills to care for children with special needs and advance the field of medicine." 

Gregory Enns, MD
Arline and Peter Harman Faculty Scholar

One-year-old Gurshan Kaur-Gill, from Bakersfield, gets a check up from biochemical geneticist Gregory Enns, MD. The toddler suffers from an inherited metabolic disorder that can affect mitochondrial function in his cells.

When it comes to pediatric subspecialists, Gregory Enns, MD, is virtually in a class by himself. Enns is a biochemical geneticist--the only one at Packard and one of only a handful in California. He studies mitochondrial diseases: genetic disorders that interfere with energy-producing parts of the cell known as mitochondria. Each year, hundreds of children in the United States are born with mitochondrial diseases, often with devastating symptoms, such as mental retardation, seizures, deafness, heart damage, and liver failure.

"Mitochondria are basically cellular engines," says Enns, an associate professor of pediatrics, who joined the Stanford faculty in 1998. "They are critical for energy metabolism in all parts of our body, and they have been implicated in almost every disease process we know of--diabetes, cancer, neurodegenerative disorders, even aging. They also can be extremely hard to diagnose and treat." 

In 2006, Enns was named an Arline and Pete Harman Faculty Scholar. This special award provides Enns with three years of financial support to study new ways to identify and treat these illnesses. 

"As a faculty scholar, I can devote more time to science and research," he says. "The thrust of my work has to do with the fact that mitochondria not only generate energy for the cell, they also produce toxins, just like a car engine produces exhaust," he explains. "If mitochondria don't work right, they produce a lot of biochemical exhaust." 

The presence of toxic molecules in the bloodstream may be an indication of mitochondrial disease, he says. His goal is to develop a state-of-the-art blood test to detect these toxic biomarkers, giving pediatricians a reliable method of detecting and monitoring the severity of a child's mitochondrial diseases. Such a test also could be used to determine the efficacy of treatment. 

"Right now it is very difficult to determine how well a given treatment works," Enns says. "We'd like to have something that we can monitor and quantify, and with our biomarkers, I think we're onto something. I would say that support like the Harman Faculty Scholar Fund is absolutely critical, because it allows me to conduct translational research that can really have an effect on children's lives."