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Advancing the Nation’s Health Needs
stituting 37 percent of its total extramural research dollars). Among the successful innovations supported by these funds have been a nationwide network of general clinical research centers, where an estimated 9,000 researchers pursue a broad range of clinical research projects.5 Nevertheless, the past two decades have been particularly challenging for the funding of all health professions, and especially for the support of research activities in the clinical environment that are not clearly tied to specified funding streams. Clinical research has yet to achieve the breadth and depth of currency (double entendre intended) it deserves.
Meanwhile, a key element in developing the nation’s clinical research capacity is the building of a robust cadre of clinician-scientists able to realize the promise of 21st-century medicine. This objective depends, in turn, on continuing support, incentives, and educational and professional reforms throughout the existing clinical research workforce.
DEFINING THE CLINICAL RESEARCH WORKFORCE
The clinical research workforce is as diverse as the definition of the field. It is composed of individuals with doctorates in the basic sciences, graduates of professional degree programs, graduates of health sciences and public health programs, and dual- or multiple-degree holders covering a wide range of health care research. Given the broad role these scientists play in providing the nation’s health care—their research spans the spectrum from discovery to delivery—it is difficult to categorize them. For this report efforts will be made to identify individuals who fit the Graylyn definition. However, this definition is very broad. For example, it includes behavioral and social sciences research in the context of patient care, and it is difficult to separate this from the general area of health-related behavioral research that is addressed in Chapter 3. Many of them are involved in health services research (Chapter 7) and in other efforts that are increasingly interdisciplinary (Chapter 8). However, aspects of all these activities will be incorporated into the analysis of clinical research, as appropriate.
Apart from the problem of technically distinguishing the areas in which the clinical workforce conducts its research, it is also difficult to match these areas with workforce members’ credentials—current databases focus on the specific degree and field of training for individuals and not on their research areas. This problem has hindered prior studies of the National Research Service Award (NRSA) program to the point where only partial descriptions of the workforce were given and no demographic projection of future workforce was made.
For this assessment’s purposes, the basic workforce analysis will include Ph.D.s with degrees in the health fields listed in Appendix C, the fraction of the M.D. population in medical school clinical departments that conduct NIH-supported research, and doctorates with degrees from foreign institutions who are in some way identified as clinical researchers. This formula still does not capture the complete workforce, such as M.D.s in the non–medical school part of an academic institution or in industrial laboratories. Those doing clinical trials are also difficult to identify, as departments have different ways of allocating funds for clinical trials and of supporting associated researchers (from graduate students to postdoctorates to faculty). However, each of these groups will be included in the analysis when data are available. The nursing and dental workforces, as well as the health services researchers briefly mentioned above, will also be included in clinical research, but because each of these fields has its own special workforce issues, they will be examined separately in Chapters 5, 6, and 7.
The educational background of clinical researchers is difficult to assess in the same detail as that of biomedical and behavioral and social sciences since a small fraction of M.D. graduates enter the research workforce. However, data are available on the Ph.D. portion of this workforce, and these data can be analyzed. In particular, the graduate student population in the clinical departments of doctorate-granting institutions grew at an annual rate of 5 to 10 percent in the 1990s; it then leveled off until 2002, when there was growth of about 6 percent (see Figure 4-1). This growth pattern of the number of clinical research–oriented graduate students is much different than that of the biomedical sciences, whose population was virtually constant during the 1990s. Its growth in 2002, as in the other fields, may reflect a poor economy—where continued education is an alternative to the job market. It should also be noted that the growth was primarily caused by an increase in female graduate students and that nursing graduate students were excluded from the data (as most will not receive a doctorate).
The pattern of financial support for clinical science students is also quite different from that of the other fields (see Figure 4-2). Many more are self-supported, and research and teaching assistantships make up a smaller proportion. As is the case for the other broad fields, the number of graduate students supported on research grants has grown, while levels of assistantships, traineeships, and fellowships have been constant from the 1970s until now. The growth in self-support in 2002 is consistent with the general increase in graduate student populations and the limited forms of support available from external and institutional funds.
The growth in the graduate population is reflected by the number of doctorates in the clinical sciences, which increased by a factor of 5 from the early 1970s (see Figure 4-3). This increase is largely the result of growing participation by women. The proportion of male doctorates in the