Summary

INTRODUCTION

This report is the twelfth in a series on monitoring the changing needs for biomedical and behavioral research personnel in the United States. The task of assessing and predicting the status of research personnel over the entire spectrum of health sciences is daunting. The need for improved health care in the nation remains a priority. This need can only be met by research in health areas over a broad and continually expanding venue. Research and research training are national as well as international in scope and personnel.

The Statement of Task for the committee is as follows: “A committee will advise the National Institutes of Health (NIH) on issues regarding research personnel needs in the basic biomedical sciences, behavioral and social sciences, clinical sciences, oral health, nursing, and health services. The committee will gather and analyze information on the employment of research scientists in these fields and on the need for educating additional researchers. The committee will deal broadly with the training needs and direction of the Ruth L. Kirschstein National Research Service Award (NRSA) program, as dictated by congressional legislation and with the process to assess the needs. The report will examine long-range trends and identify training needs through 2010.”

The research enterprise is divided into three major areas: basic biomedical, behavioral and social sciences, and clinical research. The scope of these areas is discussed in the body of the report and will not be dwelt on here. In addition, oral health, nursing, and health services are considered separately because of their special needs. However, it should be recognized that these divisions are arbitrary and broad. The boundaries are not sharp and are continually evolving. Furthermore, the crossing of these boundaries is crucial for the development of new ideas and fields. For this reason, a separate chapter is devoted to interdisciplinary and emerging fields. Finally, major advances in research require a continual input of new personnel with fresh ideas, so career development is an essential part of the overall picture.

FINDINGS AND RECOMMENDATIONS

For the three major areas considered, workforce models were developed that include extrapolations of new Ph.D.s and M.D.s entering the market and job availability through 2011. The results of this modeling cannot be taken literally. First, the data available to analyze the current situation are approximate at best. Second, extrapolation into the future requires information that exists only up to 2003: the world and national economy; the budget available for research; the state of the world in general with regard to war, disease, and immigration policies; and unanticipated advances in science. A particularly speculative issue is the role of foreign scientists in the health research enterprise, due to recent changes in immigration policy in this country and changes in research support in foreign countries. However, the research workforce tends to adapt to changing conditions, a tendency that in the long run works to bring the workforce’s needs and demands into equilibrium. Taking into account workforce models and all other known factors, this committee finds the following: (1) the system is currently in reasonable balance, and (2) despite the emergence of new and unanticipated factors over the next six years, the system will adapt toward a balanced state unless major policy changes are made in the patterns of federal research support. This means that unemployment among trained researchers should remain low and that most of the trained personnel will remain in science.

A quantitative assessment does not ensure a successful research enterprise. Quality is an essential ingredient for progress. In this regard, the NRSA program plays a unique role. Although these awards support only a small fraction of the students and postdoctorals being trained, they set the standards for the entire research training establishment. In addition, they attract high-quality students into research and into fields of particular need. The record of success of



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Advancing the Nation’s Health Needs Summary INTRODUCTION This report is the twelfth in a series on monitoring the changing needs for biomedical and behavioral research personnel in the United States. The task of assessing and predicting the status of research personnel over the entire spectrum of health sciences is daunting. The need for improved health care in the nation remains a priority. This need can only be met by research in health areas over a broad and continually expanding venue. Research and research training are national as well as international in scope and personnel. The Statement of Task for the committee is as follows: “A committee will advise the National Institutes of Health (NIH) on issues regarding research personnel needs in the basic biomedical sciences, behavioral and social sciences, clinical sciences, oral health, nursing, and health services. The committee will gather and analyze information on the employment of research scientists in these fields and on the need for educating additional researchers. The committee will deal broadly with the training needs and direction of the Ruth L. Kirschstein National Research Service Award (NRSA) program, as dictated by congressional legislation and with the process to assess the needs. The report will examine long-range trends and identify training needs through 2010.” The research enterprise is divided into three major areas: basic biomedical, behavioral and social sciences, and clinical research. The scope of these areas is discussed in the body of the report and will not be dwelt on here. In addition, oral health, nursing, and health services are considered separately because of their special needs. However, it should be recognized that these divisions are arbitrary and broad. The boundaries are not sharp and are continually evolving. Furthermore, the crossing of these boundaries is crucial for the development of new ideas and fields. For this reason, a separate chapter is devoted to interdisciplinary and emerging fields. Finally, major advances in research require a continual input of new personnel with fresh ideas, so career development is an essential part of the overall picture. FINDINGS AND RECOMMENDATIONS For the three major areas considered, workforce models were developed that include extrapolations of new Ph.D.s and M.D.s entering the market and job availability through 2011. The results of this modeling cannot be taken literally. First, the data available to analyze the current situation are approximate at best. Second, extrapolation into the future requires information that exists only up to 2003: the world and national economy; the budget available for research; the state of the world in general with regard to war, disease, and immigration policies; and unanticipated advances in science. A particularly speculative issue is the role of foreign scientists in the health research enterprise, due to recent changes in immigration policy in this country and changes in research support in foreign countries. However, the research workforce tends to adapt to changing conditions, a tendency that in the long run works to bring the workforce’s needs and demands into equilibrium. Taking into account workforce models and all other known factors, this committee finds the following: (1) the system is currently in reasonable balance, and (2) despite the emergence of new and unanticipated factors over the next six years, the system will adapt toward a balanced state unless major policy changes are made in the patterns of federal research support. This means that unemployment among trained researchers should remain low and that most of the trained personnel will remain in science. A quantitative assessment does not ensure a successful research enterprise. Quality is an essential ingredient for progress. In this regard, the NRSA program plays a unique role. Although these awards support only a small fraction of the students and postdoctorals being trained, they set the standards for the entire research training establishment. In addition, they attract high-quality students into research and into fields of particular need. The record of success of

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Advancing the Nation’s Health Needs NRSA holders in obtaining research funding is impressive. The results of the training efforts in the nation are self-evident: this country continues to be a world leader in health-related research. While recognizing the success of these awards in promoting research, it is important to maintain a diverse support pattern for training. Research grants not only provide a viable alternative, they also fill a special niche in their own right. They provide personnel to carry out the research specified by funding agencies. These personnel may not be eligible for the NRSA, and research grants provide an alternate entry into the research enterprise. The most obvious examples are foreign scientists. Many foreign scientists remain in this country and make important contributions to training and research. This is beneficial to both the research community and the nation. In this regard, the committee is greatly concerned that current immigration policies will make the interchange of scientists and students with the rest of the world increasingly difficult. Based on the balance with regard to output of trained personnel, job opportunities, and overall quality, the committee’s primary recommendation for the three major areas is that the total number of NRSA positions awarded should remain at least at the fiscal year 2002 level. Furthermore, the committee recommends that future increases be commensurate with the rise in the total extramural research funding at NIH in the biomedical, clinical, and behavioral and social sciences. The year 2002 is specified because it is the most recent year for which data were available to the committee. Despite this single recommendation for the three areas, the committee recognizes that each area has considerations that merit special mention. For example, in the basic biomedical and behavioral and social sciences, it is important to maintain focus on basic research. Although the ultimate goal of NIH is improved health care, the committee believes that critical breakthroughs are usually founded on basic research rather than highly applied research. Clearly applied research has an important place in the research training portfolio, but broad training in basic concepts is essential. The application of lessons learned from basic science to health-related problems requires training in translational areas, and this should be a focus of the clinical sciences. Ideally, physicians are best equipped to do this research but may be unlikely to pursue research because of the heavy debt load M.D.s incur in medical school. To alleviate some of the above concerns, the committee recommends that the size and scope of the Medical Scientist Training Program (MSTP) be expanded at least 20 percent and that the scope be expanded to include the clinical, health services, and behavioral and social sciences. This program has proved remarkably successful in attracting outstanding physicians into research. Although the program is expensive, a modest expansion would serve the nation well. Furthermore, expansion of the scope would permit the behavioral and social sciences, for example, to participate more fully in the program. The expansion of scope should not be at the expense of the current MSTP support for basic biomedical research. In addition, the committee recommends that training grants be established for physicians to learn the skills necessary for clinical investigation. These programs can be part-time programs for physicians that would lead to a master’s degree. The shortage of physicians to carry out clinical research is already critical and will worsen if positive steps are not taken. The behavioral and social sciences receive considerably less research funding from NIH than the basic biomedical sciences and correspondingly less research training support. Many of the nation’s health problems are not just physiological in nature and need to be addressed by research in the behavioral and social sciences as well. Consequently, the committee recommends that each NIH institute and center incorporate the behavioral and social sciences into its training portfolio, including institutes and centers that have not emphasized these disciplines in the past. Although the need for research in oral health and nursing is apparent, both areas have difficulty providing an environment that fosters research as a career and in finding high-quality trainees interested in pursuing a research career. The long-term solution to this problem will require significant changes in traditional schools of dentistry and nursing. To attract trainees into oral health research, the committee recommends that all required years of the D.D.S./Ph.D. program be funded by the National Institute for Dental and Craniofacial Research (NIDCR) (analogous to the highly successful MSTP) and that the loan forgiveness program require documentation of time spent in research and scholarly success. This committee also recommends that the NIDCR design and implement programs intended to increase the number and quality of dental school applicants who are committed to careers in oral health research. In the case of nursing, the committee recommends that a new institutional research training grant (T32) program be established that focuses on rapid progression into research careers. Criteria might include predoctoral trainees who are within eight years of high school graduation, not requiring a master’s degree before commencing with a Ph.D., and postdoctoral trainees who are within two years of their Ph.D. These modest recommendations for oral health and nursing are intended only as starting points for these professions to move more strongly into research and research training. A growing need exists to shorten the interval between research advances in biomedical science and the ability to apply these advances effectively to improve the health of the public. Thus, more effective health care delivery practices are required. Because of this need, health services research training should be expanded and strengthened within each NIH institute and center. In addition, the training programs of the Agency for Healthcare Re-

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Advancing the Nation’s Health Needs search and Quality should be expanded, commensurate with the growth in total spending on health services research. Thus far this report has been somewhat restrictive in its definition of research fields. However, the committee recognizes that many important advances occur at the boundaries of traditional fields, and indeed the boundaries themselves are continually shifting. It is essential that NIH adopt a proactive stance in encouraging training in interdisciplinary and emerging fields. Given the importance of the institute structure of NIH, research training should be better integrated across all of the NIH institutes and centers. Broadly based research training should be an essential effort for all institutes and centers, rather than concentrated narrowly in a few. NIH itself must serve as a paragon for interdisciplinary research and training. Most importantly, training must be broad and deep so that trainees are equipped to move both within and between traditional fields. Several specific recommendations are made here to address some of the important issues in this regard. The NIH should target individual NRSAs in emerging fields, interdisciplinary areas, and specific fields of interest. Such applications should be given priority in the awards process, and special review panels should be used as needed. Furthermore, quantitative subject matter should be integrated into and required for training programs in all areas. Quantitative subjects include statistics, mathematics, physics, physical chemistry, computer science, and informatics. In this age of genomics and computers, the large amount of new information generated requires all scientists to be well versed in quantitative reasoning. Finally, the difficulty in identifying emerging fields and the importance of encouraging these fields as they emerge are noted. The committee recommends that a standing committee (proposed later in this summary) provide recommendations to NIH as to the identity of emerging research. The career development of research personnel requires serious attention. The time to degree is increasing, as is the age at which individuals enter the job market as independent investigators. This trend does not appear to be abating but may change if the research personnel system remains in balance in terms of output and job placement. The decline in the postdoctoral pool suggests this may be occurring. NIH should be proactive in promoting career development. In this regard the intent of the K awards program, which has the goal of supporting the development of scientists into independent investigators, including a period of supervised research, is applauded. However, the current system is sufficiently complex to discourage applicants. The committee recommends that career development grants (currently K awards) be maintained but be restructured such that fewer mechanisms are established and consistently implemented across NIH. Furthermore, the committee recommends that the restructured K awards include the following: (1) a transition award to span senior postdoctoral status and an independent research position; (2) beginning faculty awards to free certain classes of investigators from nonresearch duties; (3) senior scientist awards for the purpose of faculty moving into new research areas; (4) awards to allow faculty and other researchers to maintain research careers during periods when personal demands (e.g., child rearing) prevent full employment status; and (5) clinical science awards to provide research training for clinical faculty/personnel. There is particular concern that talented researchers are being lost from the pool because career development opportunities are not available for women during their child-rearing years. Although the number of women in medical research has increased, this has not been uniform across fields, and continual vigilance and encouragement are required. The status of individuals in nonfaculty positions needs to be improved, in general. Since the report on the status of postdoctorals, Enhancing the Postdoctoral Experience for Scientists and Engineers: A Guide for Postdoctoral Scholars, Advisers, Institutions, Funding Organizations, and Disciplinary Societies, was released in 2000 by the National Academies Committee on Science, Engineering, and Public Policy and because other groups are exploring this issue, it is not handled in detail here. However, employee benefits are a particularly important issue, especially health insurance. Therefore, the committee recommends that NIH develop a mechanism for support such that NRSA postdoctoral fellows receive the normal employee benefits of the institutions at which they are located. The number of underrepresented racial and ethnic minorities entering research across the entirety of medicine is disappointing. Since this subject is currently being reviewed in depth by another National Academies committee, detailed recommendations with regard to this issue are not provided in this report. However, it is the unanimous opinion of the committee that intervention must occur well before graduate/professional school. To assist in this process, the committee recommends that supplements to existing training grants be made available for the purpose of developing outreach programs for undergraduates and high school students from underrepresented minorities and for the secondary school teachers serving them. The general solution to this problem clearly will require action across all of society as well as the research establishment. The committee is greatly concerned with the decline in preparation and interest in science students have in the early stages of their education. If this trend continues, the supply of Ph.D. scientists may be insufficient to carry out vital health-related research. Therefore, it is recommended that NIH work with other federal agencies to find ways to encourage students at precollege levels to pursue training in technical, computational, mathematical, and scientific areas that are necessary precursors for careers in science.

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Advancing the Nation’s Health Needs Finally, the need for research in health areas is of sufficient importance, from health and economic perspectives, to the nation is discussed. The external environment changes rapidly, including job availability, crises in health care, and emerging fields. The committee recommends that a standing independent committee be created to monitor biomedical, clinical, and behavioral and social science research personnel needs, to evaluate the training of such personnel, to assess the number and nature of research personnel that will be required in the future, to assist in the collection and analysis of appropriate data, and to make recommendations concerning these matters to NIH. Such a committee would be established by and be advisory to NIH. In particular, there is a lack of data with regard to tracking career outcomes for individuals supported by NIH. The committee recommends that NIH implement a data collection system for tracking the career outcomes of its recipients of research training support. A minimum set of outcomes would include employment sector, involvement in research, and subsequent NIH awards. By necessity, this summary is brief; the points raised here are discussed in detail in the full report. Although continual monitoring and development are required, the medical research training establishment is in good health and the NRSA program has been critical for past accomplishments and will continue to be critical for achieving future goals.