More Turns Than a Back Road: The Career Journey of an Academic Clinician-Scientist

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This document outlines the winding career path of Barbara Trautner, M.D., Ph.D. an academic clinician-scientist, emphasizing key pivot points, research evolution, and lessons learned. Dr. Trautner initially had a strong aversion to research, viewing it as isolating, lonely, cutthroat, competitive, and clinically irrelevant based on stereotypes and a negative undergraduate experience studying guppies for an 18-month thesis project. In college, the speaker preferred clinical medicine, seeing it as a team-based, compelling, and important endeavor focused on patient care.

After college, Dr. Trautner pursued medical school, residency in medicine, and an infectious diseases (ID) fellowship. During this period, clinical experience was 110% of her focus, and research was far from her mind. Personal milestones included getting married after medical school and having children at the end of residency and ID fellowship. A pivotal moment came in the second year of her ID fellowship when she needed to commit to a research project and mentor. Despite her reluctance, her attending, Dr. Robbie Darwish, encouraged her based on her stated interest in growing bacteria in the clinical micro lab. This led her to study catheter-associated biofilms on urinary catheters.

To join the faculty at Baylor as a clinician investigator, Dr. Trautner needed to secure external funding for her salary due to the institution's financial situation. This required obtaining a K award from the NIH, which provided protected time for learning to be a good clinician investigator. She also had to return to school to get a PhD to gain necessary molecular biology skills that were not available when she was in college, explaining to the federal government why she needed more career development support. Uninterrupted time on the K award was crucial for developing as an investigator; failure on this first training grant would hinder future funding opportunities. Her initial laboratory-based research, studying if inoculating a benign E. coli strain into bladders of chronically catheterized individuals could prevent infection, involve multiple career development awards, but ultimately show the benign strain was overgrown.

After five years as an assistant professor, Dr. Trautner sought a position as a VA infectious diseases physician, but a government hiring freeze necessitated obtaining a VA career development award. During this period, she became the ID fellowship program director, a role she enjoyed, though it required being on faculty for five years.

A significant career pivot occurred after receiving counsel from a section chief, David A. I. Ouzounis, who suggested applying for a mentored career development award. What the speaker heard, however, was that it would potentially allow her to avoid clinical rotations while pregnant, framing the grant writing process as a form of "paradise". The K award was funded, leading her to commit to a clinically relevant research project that involved growing bacteria and conducting small clinical trials. This work, including studying bladder microbiomes, sparked her concern about antibiotic stewardship and overuse, particularly in the spinal cord injured population where frequent antibiotic use was leading to increased bacterial resistance. This clinical concern became the basis for turning clinical observations into research facts. For example, research at the VA hospital revealed that about a third of treated catheter-associated UTIs lacked patient symptoms, a finding that has held true over time and in other hospitals.

Coming off her second career development award, Dr. Trautner faced a fork in the road. An opportunity arose to become the associate chief of medicine at the Houston VA. Driven by a dedication to VA healthcare and a desire to fix inefficiencies, she accepted the role to build a hospitalist program. As the second in command of a medical care line with 855 employees, she achieved significant accomplishments, including hiring the first hospitalists (starting with nine, based on a mix of available slots and a Lord of the Rings reference). Other successes included securing funding for the VA Chief Resident Quality and Safety Program, establishing a pickline team, hiring nurse case managers, and assisting numerous trainees with badges. However, despite these achievements, she felt she was "really pretty early career" and her research program was dying. She had trouble finding time for research, education, and had given up her continuity clinic (which she later resumed).

Inspired by Cheryl Sandberg's book Lean In, which suggested looking for sideways moves on the "jungle gym" if unhappy in a current role, Dr. Trautner sought a path that better utilized her skills and interests. This led to a pivot to the department of surgery, where she directed their clinical and health services research program and rebuilt her own research. In this role, she significantly built the research infrastructure, increasing staff in clinical research administration from a half-time grant manager to 28 people. She also mentored faculty and trainees and provided research education. Her research program flourished again, leading to funding for a larger grant for the "Kicking COTI" project, aimed at decreasing unnecessary urine cultures to reduce antibiotic use. This project was successful at the Houston VA and later expanded to multiple VA sites and is now being studied with ARC funding in 41 hospitals, investigating different methods of implementing the antibiotic stewardship intervention. Research on barriers to stewardship highlighted that smaller, lower-complexity VA hospitals face significantly more challenges compared to larger, high-resource ones.

Dr. Trautner’s research evolved beyond UTI-related stewardship to include non-prescription antibiotic use. Studies in Houston found that 30% of surveyed individuals had taken unprescribed antibiotics, obtained from friends, relatives, stores, markets, or even pets. Recognizing the need for alternatives to antibiotics, which become less effective with each use, her research mission expanded to include antibiotic-sparing approaches. She is now working with bacteriophage (fage) and has received necessary FDA approvals to begin a phase one trial of fage in the bladders of spinal cord injured patients.

The arrival of COVID-19 prompted another shift in research focus, driven by the mission to protect patients. Her clinical research team pivoted to conducting COVID clinical trials, despite the risks. Team members bravely consented patients in person, navigating challenges like collecting specimens from contagious individuals and overcoming logistical hurdles like a major freeze. The team contributed to trials published in prominent medical journals, including those on monoclonal antibodies and tocilizumab. These trials showed that monoclonal antibodies were less effective for inpatients but valuable for outpatients, though their specificity posed challenges with rapidly mutating viruses. The impact of their COVID trial work led to the creation of her current position as Director of Clinical Research at the Houston VA, focusing on bringing more investigators into clinical research and providing infrastructure support.

Reflecting on her journey, Dr. Trautner highlights lessons learned, particularly from a personal health challenge (stage 2B breast cancer) in 2016. Receiving her cancer diagnosis on the same day her research grant was funded reinforced the lessons that love is everything, meaningful work is essential, and you don't have time for anger.

Meaningful work, like her long-term research projects, provided purpose during treatment. She also emphasizes the importance of investing in work relationships, as many loved ones are colleagues with whom significant time is spent.

Dr. Trautner now views research as collaborative, social, supportive, and team-oriented, contradicting her earlier stereotypes. She believes clinical trials are a great way to start in clinical research, merging research skills and clinical care. She likes her work to a "wheel of UTI research," demonstrating how various aspects of an illness (pathogenesis, biomarkers, diagnosis, treatment, prevention, epidemiology, guidelines, implementation) can be studied in different settings and populations, making the field non-boring . The historical examples of Semmelweis and Lind are cited to underscore how crucial medical practices, like handwashing and using limes for scurvy prevention, were proven through observations akin to early clinical trials, despite initial resistance to the findings. Ultimately, Dr. Trautner expresses gratitude for her research teams and emphasizes that she is never lonely at work. She also notes the crucial support of good mentors and the necessity of resilience throughout her career journey.

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