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Health Services Research: Work Force and Educational Issues Committee on Health Services Research: Training and Work Force Issues Marilyn I. Field, Robert E. Tranquada, and fill C. FeasTey, Editors Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1995

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National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, under Contract No. 282-94-2008; the Robert Wood Johnson Foundation, under Grant No. 24791; the Department of Veterans Affairs; and the Baxter Foundation. The views presented are those of the Institute of Medicine Committee on Health Services Training and Work Force Issues and are not necessarily those of the funding organizations. Library of Congress Catalog Card No. 95-71398 International Standard Book No. 0-309-05348-X Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, D.C. 20055 Call 800-624-6242 (or 202-334-3313 in the Washington metropolitan area) The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. Copyright 1995 by the National Academy of Sciences. All rights reserved. No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted' or otherwise copied for public or private use, without written permission from the publisher, except for the purpose of official use by the U.S. Government. Printed in the United States of America

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COMMITTEE ON HEALTH SERVICES RESEARCH: TRAINING AND WORK FORCE ISSUES ROBERT E. TRANQUADA,* Chair, Norman Topping/National Medical Enterprises Professor of Medicine and Public Policy, University of Southern California, Los Angeles, California PAULA K. DIEHR, Professor, Department of Biostatistics, University of Washington, Seattle, Washington DEBORAH A. FREUND, Vice Chancellor, Academic Affairs, and Dean of Faculties, Indiana University, Bloomington, Indiana WILLIAM T. FRIEDEWALD, Senior Vice President and Chief Medical Director, Metropolitan Life Insurance Company, New York, New York (resigned January 17, 1995) JOHN C. GREENE,* Professor and Dean Emeritus, School of Dentistry, University of California, San Francisco, California MERWYN R. GREENLICK,* Professor and Chair, Department of Public Health and Preventive Medicine, Oregon Health Sciences University, and Director, Kaiser Permanente Center for Health Research, Portland, Oregon ADA SUE HINSHAW,* Dean, School of Nursing, University of Michigan, Ann Arbor, Michigan DAVID A. KINDIG, Professor of Preventive Medicine, and Director, Wisconsin Network for Health Policy Research, University of Wisconsin-Madison School of Medicine, Madison, Wisconsin KENNETH W. KIZER, Professor and Chair, Departments of Community and International Health, School of Medicine, University of California, Davis, California (position at time of committee service, resigned October 24, 1994) KEVIN J. LYONS, Associate Dean and Director, Center for Collaborative Research, College of Allied Health Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania ALBERT G. MULLEY, Chief, General Internal Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts WILLIAM L. ROPER,* Senior Vice President and Chief Medical Officer. The Prudential Health Care System, Atlanta, Georgia DONALD M. STEINWACHS,* Chair and Professor, Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland BAILUS WALKER, Jr.,* Professor of Environmental and Occupational Medicine, and Associate Director, University Cancer Center, Howard University College of Medicine, Washington, D.C. * Member, Institute of Medicine . . .

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B1~RILYN J. FIELD, Study Di~c10r (Ann January 15,1995) JILL C. FEASLEV, Rese~cb Associate bang October 1, 1994) DONNA D. THOMPSON, A-ink~ive Assistant (1brougb Clay 5, 1995) hL`ll[LEEN N. LO~nt, Direc10r, Division of Health Care Services SUSAN TILt[L, Study tremor Obrougb January 15,1995) BLtHLA R. SECEDERS, A-ink~ive AssL1an1 (aher June 12,1995) NINA H. SP~uUILL, Financial Of Bcer 1V

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Acknowledgments The Committee on Health Services Research: Training and Work Force Issues wants to acknowledge those who assisted it in preparing this report. At the Agency for Health Care Policy and Research, James Cooper, the project officer, helped us in many ways. Donnarae Castillo, who is responsible for the National Research Service Award activities within the agency, patiently answered questions and compiled information on institutional and individual awards. Ralph Sloat helped us locate diff~cult-to-find historical information about earlier training activities. Julius Rosenthal at the Agency for Health Care Policy Research supplied information on dissertation research awards. At the Department of Veterans Affairs (VA), Shirley Meehan and Joseph Couch provided information on the Health Services Research educational programs at the VA. Within the National Research Council, Porter Coggeshall, Pamela Ebert- Flattau, Anthony DeSantis, and others provided information about the series of studies of biomedical and behavioral science research personnel that the Office of Scientific and Engineering Personnel has conducted since 1975. With support from the Pew Health Policy Program, Marion Lewin and Valerie Tate Jopeck, colleagues within the Institute of Medicine (IOM), contributed substantially to committee efforts to gain perspectives from private industry and state government. They helped organize a panel of industry representatives for the committee's March 1995 meeting in which the committee heard from Howard Bailit, Henry Bachofer, Carmela Dyer, Lawrence Lewin, and Bruce Steinwald. Marion Lewin also participated in telephone interviews with

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ACKNOWLEDGMENTS / vi current and former state officials including Mark Chassin, Dennis Beatrice, Robert Crittenden, Robert Frank, Alan Well, Pamela Paul-Sheehan, Beth Kilbreth, and Richard Merritt. The committee also expresses its appreciation to the two dozen executives of health plans, consulting firms, and similar organizations who agreed to be interviewed by committee members about health services researchers in private industry. At the University of Wisconsin-Madison, Nancy Cross Dunham and Karen Tyler of the Wisconsin Network for Health Policy Research created the health services researcher database for the committee and drafted a report describing the method and results. That database is more comprehensive than any developed before. Alice Hersh, Suzan Meredith, and Jennifer Rotchford of the Association for Health Services Research provided considerable information including their membership files. As usual, staff at the IOM provided critical support for the work of the committee and project staff. They include Elizabeth Mouzon, Donna Thompson, Don Tiller, Nina Spruill, Susan Thaul, Dorothy Majewski, Sarah Reich, Claudia Carl, Mike Edington, and Richard Julian. An especially heartfelt thank-you goes to Mary Lee Schneiders who spent many long hours working through the complexities of database conversion and manipulation.

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Contents SUMMARY 1 INTRODUCTION AND BACKGROUND Origins of the Study, 14 Study Approach, 15 Definitions and Concepts, 17 Conclusion, 23 2 OVERVIEW OF HEALTH SERVICES RESEARCH A Brief Look Back, 26 Health Services Research Today and Tomorrow, 34 Conclusion, 41 3 THE HEALTH SERVICES RESEARCH WORK FORCE The Current Work Force, 44 The Future Work Force, 49 Conclusion, 54 4 EDUCATIONAL PROGRAMS, RESOURCES, AND ISSUES Educational Programs, 56 Funding for Education in Health Services Research, 63 Conclusion, 74 . . . V11 . 13 . 25 . 43 . . . . 55

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viii I CONTENTS 5 FINDINGS AND RECOMMENDATIONS Data Availability and Improvement, 77 Work Force Size and Characteristics, 78 Supply in Relation to Demand, 79 Training Programs, 80 Conclusion, 83 6 REFERENCES APPENDIXES 77 85 A A New Database on the U.S. Health Services Research Work Force . . 91 B Survey of Health Services Research Educational Programs 101 C Multistate Life Table Methodology and Projections 113 D Committee Biographies 121 Multistate Life Table Methodology and Projections TABLES AND FIGURES TABLES 1.2 4.1 4.5 A.1 1.1 Federal Expenditures for Health Services Research, FY 1994 and 1995 Appropriations, 22 Federal Expenditures for Health Services Research in Relation to Total U.S. Health Spending, FY 1970 and FY 1994, 23 Institutions Receiving National Research Service Awards from the Agency for Health Care Policy and Research, FY 1994, 58 4.2 Awards for Health Services Research Training, 1967-1994, 67 4.3 Recommendations for National Research Service Awards for Health Services Research by Committees of the National Research Council (NRC) or the Institute of Medicine (IOM), 1976-1994, 68 4.4 Funding of National Research Service Awards (NRSA) for Health Services Research, FY 1986-1994, 69 Key Features of National Research Service Awards Traineeships and Fellowships, 71 Number of Identified Health Services Researchers, by Region/State, 95 Recorted EmnloYment of Health Services Researchers (HSRs) by A.2 A.3 ~ . ~ Organizational Type, 96 Organizations Reporting Difficulties in Recruiting Ph.D.-Level Health Services Researchers in the Past Few Years, by Type, 97

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CONTENTS I ix Rank Order of Research Areas in Which Recruiting Difficulties Were Reported, 98 Number of Organizations Indicating Plans to Recruit Health Services Researchers in the Next Five Years, 98 A.6 Research Areas in Which Responding Organizations (n = 154) Expect to Recruit Health Services Researchers in the Next Five Years, 99 Doctoral and Postdoctoral Fellowship Programs in Health Service Research by Discipline and Degree Level, as categorized in the 1991-92 FHSR Directory, 103 Number and Percentage of Survey Respondents Indicating Typical Academic Backgrounds of Their Health Services Research Students, 109 B.1 B.2 B.3 B.4 FIGURES Number and Percentage of Survey Respondents Indicating Typical Work Backgrounds of Their Health Services Research Students, 110 Number and Percentage of Survey Respondents Indicating Core Courses for a Standard Health Service Research Curriculum, 111 B.5 Number and Percentage of Survey Respondents Indicating Source of Funding for Health Service Research Students' Stipends, 112 B.6 Number and Percentage of Survey Respondents Indicating Post-Training Employment Settings of Graduates in Health Services Research, 112 1.1 Health Services Research Work Force, by Function, 20 4.1 Funding for National Research Service Awards in health service research, fiscal years 1986-1994, 70

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Health Services Research: Work Force and Educational Issues

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