RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES

Committee to Study the National Needs for Biomedical, Behavioral, and Clinical Research Personnel

Board on Higher Education and Workforce

Policy and Global Affairs

NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES Committee to Study the National Needs for Biomedical, Behavioral, and Clinical Research Personnel Board on Higher Education and Workforce Policy and Global Affairs

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 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 project was supported by Contract/Grant No. DHHS-5294, Task Order #187 between the National Acad - emy of Science and the National Institutes of Health, Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the Committee to Study the National Needs for Biomedical, Behavioral, and Clinical Research Personnel and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13: 978-0-309-15965-4 (Book) International Standard Book Number-10: 0-309-15965-2 (Book) International Standard Book Number-13: 978-0-309-15966-1 (PDF) International Standard Book Number-10: 0-309-15966-0 (PDF) Library of Congress Control Number: 2011921184 Additional copies of this report are available from The National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Suggested citation: National Research Council. 2011. Research Training in the Biomedical, Behavioral, and Clinical Research Sciences. Washington, DC:The National Academies Press. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its con - gressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advis - ing the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Committee to Study the NatioNal NeedS for BiomediCal, Behavioral, aNd CliNiCal reSearCh PerSoNNel Roger Chalkley (Chair), Senior Associate Dean of Biomedical Research Education & Training Affiliation, Vanderbilt School of Medicine William Greenough (Vice Chair), Swanlund Professor and Director, Center for Advanced Study, University of Illinois in Urbana-Champaign David Korn (Vice Chair), Vice Provost for Research and Professor of Pathology, Harvard Medical School Charles Bertolami, Dean, College of Dentistry, New York University Thomas Daniel, President, Celgene Research Susan Fiske, Eugene Higgins Professor of Psychology, Princeton University Margaret Grey, Dean and Annie Goodrich Professor, Yale University School of Nursing James S. Jackson, Daniel Katz Distinguished University Professor of Psychology and Director, Institute for Social Research, University of Michigan Joan M. Lakoski, Associate Vice Chancellor for Academic Career Development, University of Pittsburgh Schools of the Health Sciences Keith Micoli, Post Doctorate Program Manager, New York University Langone Medical Center Mark Pauly, Bendheim Professor, Health Care Systems Department, Wharton School, University of Pennsylvania Larry Shapiro, Spencer T. and Ann W. Olin Distinguished Professor, Executive Vice Chancellor for Medical Affairs, and Dean of the School of Medicine, Washington University in St. Louis Edward Shortliffe, President and Chief Executive Officer, American Medical Informatics Association Donald Steinwachs, Professor and Director, Health Services Research and Development Center Bloomberg School of Public Health, Johns Hopkins University Valerie Wilson, Executive Director, Leadership Alliance. and Clinical Professor of Community Health, Brown University John Wooley, Associate Vice Chancellor for Research, Office of Chancellor and Academic Affairs, San Diego Supercomputing Center, University of California, San Diego Allan Yates, Professor Emeritus of Pathology, Former Associate Dean of Graduate Education, Ohio State University (Deceased August 2010) Consultants J. Chris White, President, ViaSim Corporation Rodolfo A. Bulatao, Research Consultant National academies Staff Charlotte Kuh, Deputy Executive Director, Policy and Global Affairs Division Peter Henderson, Director, Board on Higher Education and Workforce (BHEW) James Voytuk, Study Director and Senior Program Officer, BHEW Mark Regets, Senior Program Officer, BHEW Michelle Crosby-Nagy, Research Associate, BHEW Sabrina Hall, Program Associate, BHEW 

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Board oN higher eduCatioN aNd WorkforCe William E. Kirwan (Chair), Chancellor, University System of Maryland F. King Alexander, President, California State University, Long Beach Susan K. Avery, President and Director, Woods Hole Oceanographic Institution Carlos Castillo-Chavez, Professor of Biomathematics and Director, Mathematical and Theoretical Biology Institute, Department of Mathematics and Statistics, Arizona State University Jean-Lou Chameau, President, California Institute of Technology Rita Colwell, Distinguished University Professor, University of Maryland College Park and The Johns Hopkins University Bloomberg School of Public Health Peter Ewell, Vice President, National Center for Higher Education Management Systems Sylvia Hurtado, Professor and Director, Higher Education Research Institute, University of California, Los Angeles William Kelley, Professor of Medicine, Biochemistry, and Biophysics, University of Pennsylvania School of Medicine Earl Lewis, Provost, Executive Vice President for Academic Affairs, and Professor of History, Emory University Paula Stephan, Professor of Economics, Andrew Young School for Policy Studies, Georgia State University Staff Peter Henderson, Director, Board on Higher Education and Workforce i

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Preface This analysis of the workforce needs in the biomedical, institutions in order to integrate research training with the social and behavioral, and clinical sciences began in May active conduct of research. 2008, when the storm clouds on the financial horizon were By comparison, the research workforces in the behav- developing. We had our second meeting in late September ioral and social sciences and the clinical sciences are much 2008 in the midst of the financial meltdown. This has made different. These research workforces are harder to quantify the business of making projections into the future a very since many of those holding doctorate degrees turn to private uncertain business indeed. The attempts to do just that were practice after receiving their research degrees or else to other nonetheless carried out by the workforce committee, which positions that do not rely on their research potential. With met to review what data were available (not as much as some qualification, the total number of U.S. doctorates in the one might wish) and to formulate recommendations to the behavioral and social sciences workforce is about 95,500, National Institutes of Health (NIH) and the Congress as to with over 47,100 in academic positions, about 32,800 in what changes might best lead to continued vigor in what has industry (including individuals who are self employed), been a great experiment in the training of biomedical scien- 8,700 in government, and 6,900 in other employment sectors. tists for over 35 years now. The ideas behind the recommen- There are only about 9,000 postdoctoral fellows included in dations were debated and analyzed by experts in the many these figures, and while they contribute to the research enter- areas toward which we were expected to direct our scrutiny. prise, they are usually not part of a large research group. The Eventually a broad consensus was attained, and that forms clinical sciences workforce is different still, since it is made the basis of the recommendations in this document. up of doctoral fellows with either a Ph.D. in a clinical field The basic biomedical sciences workforce itself numbers or a specific professional degree. Many of these postdoctoral s ome 120,000 personnel with doctoral degrees mostly fellows will be recruited into faculty positions. In nursing, for from U.S. institutions. These individuals are distributed example, a shortage in faculty in the near future will lead to primarily among academia (62,000), industry (29,000), and pressure to increase the number of Ph.D.s who can contribute government or nonprofit organizations (12,000). Although in this regard. Again, unlike the basic biomedical workforce, it is somewhat of an oversimplification, the workforce graduate students and postdoctoral fellows make up a small can be considered as being composed of two groups, one subset of the overall clinical research workforce. consisting of the 57,000 workers who are advanced in their The committee identified a number of important issues, careers and are mainly involved in managing or direct- and in this overview we mention the most pressing, upon ing research (61 percent of the 90,600 non-postdoctoral which we dedicated a considerable amount of discussion researchers), and the other consisting mainly of graduate time. These most pressing issues are: (1) the job situation for students (25,000) and postdoctoral fellows (26,000). In postdoctorates completing their training, (2) questions about some academic fields and some government laboratories the continued supply of international postdoctorates in an the latter group provides much of the hands-on aspect of increasingly competitive world, (3) the need for equal, excel- the research conducted. In other words the trainees them - lent training for all graduate students who receive NIH fund- selves are an integral and key component of the workforce. ing, regardless of whether it is from the National Research In fact, after World War II the federal government made the Services Award (NRSA) program or through R01 support, deliberate decision to fund basic research through academic and (4) the need to increase the diversity of trainees. ii

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iii PREFACE the JoB SituatioN the best opportunities will come to those postdoctorates who have dedicated themselves to excellence. The biomedical workforce, then, is different from the The financial crisis not only has affected the process of the other fields in that a major component (perhaps as much as review of this committee, but also has clearly exacerbated a 50 percent) is composed of individuals who are in training number of issues that had been developing in previous years. primarily within an academic research environment. This A key issue concerns the likelihood of obtaining a position body of graduate students and postdoctoral fellows provides in the academic research environment. The age of retirement the dynamism, the creativity, and the sheer numbers that in academia is increasing significantly (see specific data in drive the biomedical research endeavor. As such, this group chapter 3). Furthermore, the financial issues of the past two is of enormous value to the country’s investments in obtain- years have substantially affected faculty 401(k) plans, and ing knowledge about the fundamental nature of disease pro- it seems unavoidable but that the consequence will be a cesses and in developing the means to correct malfunctions. further decrease in retirement rate until the retirement funds It has to be understood that, to a significant degree, the value have recovered some of the lost ground. A further result of of the trainees supported by the NIH lies more with their cur- the problems over the past two years is that universities in rent research output while they are trainees than with their general have not expanded their research activities, and this future career development. has put further stress on the availability of new positions. Indeed, the size of this component of the biomedical The net effect is that the previously tight job situation for research workforce is greater than the number needed to postdoctorates looking for teaching or research academic staff the current and estimated future openings in the pool positions is likely getting worse. of positions for academic principal investigators. As a result, Concern for the employment issues (some said the plight) the number of trainees hired and trained is determined by the of postdoctorates surfaced in the late 1990s as postdoctorates number of personnel needed to perform the work rather than found that the traditional paths for career development had the number needed to replenish retiring senior investigators, become less accessible. Some thought that perhaps this was who are involved mainly in administering their laborato- because postdoctorates were being held in the postdoctoral ries. This situation has been exacerbated in recent years by position beyond the time in which the training was complete. financial stresses and the understandable reluctance of older These issues were debated by distinguished groups, and this but healthy faculty members to retire. As a consequence, the led to the formation of the National Postdoctoral Association. primary regulator of the size of the student and postdoctoral One of the major goals of this organization was to impose workforce is not determined by anticipated specific employ- a time limit on the postdoctoral period in the hope that this ment needs in the generally older group of research managers would lead to the timely identification of a career position. and directors. Instead, it is governed mostly by the amount Indeed, many institutions promptly implemented policies of funds (mostly R01 grants) made available (primarily by forbidding the postdoctoral time period from being longer the NIH and other federal agencies) for the conduct of bio- than (usually) 5 years. The outcome was predictable: This medical research. approach did nothing to create new jobs or positions, but A direct corollary of this approach is that the workforce instead it probably led to postdoctoral fellows being reclassi- is constantly being replaced with new cadres of graduate fied as research (non-tenure-track) faculty, a type of position students and postdoctorates. Although some trainees do, of that mostly lacks individual space, intellectual independence, course, move on to employment as “independent investiga- or financial resources. This “faculty” position has been the tors” in academia or industry, this is definitely not the case for most rapidly growing one in medical schools over the past the majority of those completing their training—in contrast decade, and it has served to accommodate, in a somewhat to the situation 30 years ago. Certainly many of the graduates precarious position, significant numbers of Ph.D.s in mostly have, out of necessity, been highly creative in looking for clinical departments, where they remain subject to the vaga- new career outcomes, and in a sense this has also supported ries of NIH funding as well as to departmental strategic plans science within this country. However, the fact remains that and the funding exigencies of their senior faculty advisors. more recently this incredibly productive approach has gen- erated a significant number of individuals who leave bench iNterNatioNal PoStdoCtorateS science after completion of their training. No one disputes that the system has been incredibly successful in pushing Another consequence of the difficult economic times the boundaries of scientific discovery, but, at the same time, should also be considered. As is documented in Chapter it has compelled both individuals and institutions to be cre- 2, more than 50 percent of the postdoctorate workforce is ative in preparing for the wide range of so called “alternative made up of individuals who obtained their Ph.D. from other careers” that many of the graduates of the training programs countries. Indeed, one can make a strong argument that the now prepare themselves for. In this regard it is important influx of highly trained and creative foreigners has contrib- that institutions are honest with entering graduate students uted greatly to U.S. science over the past 70 years. However, as to what they may expect and that students recognize that the difficulty of obtaining jobs after the postdoctorate period

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ix PREFACE has discouraged domestic students from pursuing graduate women continue to be less represented among tenure-track and subsequent postdoctorate training. The shortfall required faculty in research-intensive universities.1 A series of studies to support the R01 workforce has been made up with inter- have suggested that this, in part, reflects the fact that women national scientist postdoctorates. The major source of such in general do not see a tenure-track faculty position as attrac- postdoctorates in recent decades has been China and India. tive and family friendly, and improvement is unlikely until However, in recent years China has been investing mas- universities change basic policies related to family issues. At sively in its research base, and it is now second in the world the same time we do see ever more women moving from the in research and development, and at the same time the U.S. postdoctorate period into non-tenure (research) track posi- share of new doctorates has dipped below 50 percent for the tions (AAMC data book 2010). first time. If the attractiveness of biomedical research con- The representation of ethnic and racial minorities in ducted in these foreign postdoctorates’ homelands were to graduate programs has increased quite dramatically in bio- exceed that of a stint in the United States, then the reservoir medical research, almost certainly in response to pressure from which we have driven (at least in part) our R01 research from the requirements of training grant applications. In for the past 30 years might well dry up. And because Ph.D. fact, the representation of such minority groups in graduate- training is a lengthy process we would not at present be able student and postdoctorate populations is approaching the to quickly replace this shortfall with homegrown Ph.D.s. If same proportion that these groups have represent among B.S. this process were to happen relatively suddenly (and given recipients. However, the appointment of minority groups to the economic uncertainties this is no longer a outlandish biomedical science tenure-track faculty positions has so far suggestion) the effect on biomedical research in this country not followed this trend, and, indeed, minority representation could be profound. in medical school basic science faculties has been static for 30 years. As with women, racial and ethnic minorities seem disinclined (AAMC data) to look for (or stay in) tenure- eXPortiNg traiNiNg graNt SuCCeSSeS to track faculty positions. In the past there might have been Nih-SuPPorted traiNeeS a criticism of hiring practices, but increasingly we have to The training grant mechanism has contributed to a number face the possibility that this is not the explanation for the of significant improvements in overall graduate education current situation and that some other critical issue related over the past two decades. These include improvements in to the satisfaction and stresses of a faculty career is now minority recruiting, more rigorous and extensive training coming into play. in the responsible conduct of research and ethics, increased emphasis on career development, more attention to out - data ColleCtioN comes, and the requirement for incorporating more quan- titative thinking in the biomedical curriculum. At schools One issue that surfaced time and again was related to with training grants these attributes unavoidably spill over data collection. In its training grant and fellowship applica- somewhat into those graduate programs, which might lack a tions, the NIH collects a wondrous amount of information. If training grant. However, without the pressures coming from entered into an appropriate database, this information would the training grants, schools could easily miss out on some provide the foundation for evaluating the effectiveness of of these benefits. the NRSA funding over time. Unfortunately, although the In practice the majority of students—including, of course, information probably exists (and is certainly collected), until all non-citizen students—are not supported by training recently it has been difficult to access, as it has existed mainly grants. These students are mostly supported by R01 grants. in the form of paper files and, more recently, as electronic The committee felt that all students and postdoctorates who “flat” files. The workforce committee is recommending that a are supported by NIH monies, either directly or indirectly, training database be established that would allow mining for should benefit from the best practices developed through the outcomes and comparison with training outside the NRSA training grant mechanism. There are many ways this might be mechanism (through R01 support). achieved, and the NIH should encourage universities and other Finally, the committee spent quite some time discussing institutions to develop these approaches in the ways they see as the actual process of conducting this review. In essence, most applicable to the culture at their own institutions. although one or two committee members were “holdovers” from the previous group, most of the members were new. It took at least two meetings to figure out exactly what was diverSity required and what the scope of the review was in order to Training grants have been promoting diversity for understand the nature of the charge to the committee. Then 20 years. In some ways they have now succeeded, though we evaluated the impact of the previous workgroup, and much remains to be done. In particular, the gender differ- ence has essentially disappeared for graduate students and, See http://www.americanprogress.org/issues/2009/11/women_and_ 1 recently, even among postdoctorates. However, it is clear that sciences.html.

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x PREFACE how that affected our goals. Thus it became apparent that We wish to thank the following individuals for their there was little continuity in the review mechanism, and, in review of this report: Irwin Arias, National Institute of Child essence, each newly constituted committee has to reinvent Health and Human Development; Wendy Baldwin, Popula- the wheel every time. This is inefficient. And so, guided by tion Council; Ralph Catalano, University of California, the retained members who reported that they experienced Berkeley; Charles Gilbert, Rockefeller University; R. Bryan the same problem four years previously, we have proposed Haynes, McMaster University; Hedvig Hricak, Memorial that a mechanism be developed at the NIH to evaluate the Sloan-Kettering Cancer Center; Marjorie Jeffcoat, Uni - recommendations and their implementation as appropri- versity of Pennsylvania; John Norvell (retired), National ate and to ensure that this ongoing process is forwarded to Institute of General Medical Sciences; Joel Oppenheim, New the new workforce committee at the very onset of the next York University; Jonathan Skinner, Dartmouth University; review process. and Nancy Woods, University of Washington. Although the reviewers listed above have provided many constructive comments and suggestions, they were not aCkNoWledgmeNt of revieWerS asked to endorse the conclusions or recommendations, nor This report has been reviewed in draft form by individuals did they see the final draft of the report before its release. chosen for their diverse perspectives and technical expertise, The review of this report was overseen by Georgine Pion, in accordance with procedures approved by the National Vanderbilt University, and Charles Phelps, University of Academies’ Report Review Committee. The purpose of this Rochester. Appointed by the National Academies, they were independent review is to provide candid and critical com- responsible for making certain that an independent exami - ments that will assist the institution in making its published nation of this report was carried out in accordance with report as sound as possible and to ensure that the report institutional procedures and that all review comments were meets institutional standards for objectivity, evidence, and carefully considered. Responsibility for the final content of responsiveness to the study charge. The review comments this report rests entirely with the authoring committee and and draft manuscript remain confidential to protect the the institution. integrity of the process.

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Contents Summary 1 1 Context and Issues 9 2 Crosscutting Issues 21 3 Basic Biomedical Sciences 27 4 Behavioral and Social Sciences Research 51 5 Clinical Sciences Research 67 6 Oral Health 81 7 Nursing Research 97 8 Health Services Research 103 APPENDIXES A Committee Biographies 113 B Ruth L. Kirschstein National Research Service Award, Training Grants and Fellowships 119 C Classification of Ph.D. Fields 123 D Demographic Projections of the Research Workforce in the Biomedical, Clinical, and Behavioral Sciences, 2006-2016 125 E Demographic Projections of the Research Workforce in the Biomedical, Clinical, and Behavioral Sciences, 2006-2016 157 F Characteristics of Doctorates 177 xi

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figures, tables, and Boxes figureS 3-1 Full-time graduate enrollment in the biomedical sciences 1983-2008, 29 3-2 Biomedical Ph.D.s by year of degree and gender, 1970-2008, 29 3-3 Biomedical Ph.D.s by citizenship and race/ethnicity, 1973-2008, 31 3-4 Postdoctoral plans at time of doctorate, 32 3-5 Postdoctoral plans of minorities and non-minorities in the biomedical sciences, 33 3-6 Postdoctoral appointments in the biomedical sciences, 34 3-7 Academic positions of doctorates in the biomedical sciences, 1975-2006, 35 3-8 Postdoctorates in academic institutions, 36 3-9 Age distribution of tenured faculty 1993, 2001, 2003, 2006, 38 3-10 Percentage of tenured faculty in the biomedical sciences by 2-year cohort: Early career, 38 3-11 Biomedical employment by sector, 39 3-12 Percent employment by sector, 40 3-13 U.S. biomedical Ph.D.s employed in S&E fields by gender, 40 3-14 Percentage of female faculty in 2006 in the biomedical sciences by year of Ph.D. compared with the number of female Ph.D.s in the same year, 41 3-15 NIH funding of the Medical Sciences Training Program, 44 3-16 NIH support of graduate students, 47 3-17 Postdoctoral support in the biomedical sciences, 47 4-1 Percentage of college graduates that enroll as first-year graduate students by field in the behavioral and social sciences, 53 4-2 Gender of full-time graduate students in the behavioral and social sciences, 1979 to 2008, 54 4-3 Financial support of full-time graduate students in the behavioral and social sciences, 1979 to 2008, 55 4-4 Doctorates in the behavioral sciences, 56 4-5 Postdoctoral plans for clinical psychology and all behavioral and social science doctorates, 57 4-6 Percentage of the behavioral and social sciences doctorates by citizenship and race/ethnicity, 57 4-7 Postdoctoral appointments in the behavioral sciences, 58 4-8 Distribution of behavioral and social scientists in the workforce by gender, 59 4-9 Employment sectors in the behavioral and social sciences, 59 4-10 Age distribution of tenured behavioral and social sciences faculty, 60 4-11 Percentage of female faculty in 2006 in the behavioral and social sciences by year of Ph.D. compared with the number of Ph.D.s in the same year, 61 4-12 Academic employment in the behavioral and social sciences, 62 4-13 Female faculty positions in the behavioral and social sciences, 62 4-14 Federal sources of support in the behavioral and social sciences, 64 4-15 Types of support from the NIH in the behavioral and social sciences, 64 xii

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xiii FIGURES, TABLES, AND BOXES 5-1 Tenured and tenure-track faculty by type of medical school department, 1990-2009, 71 5-2 Full-time graduate enrollments in the clinical sciences, 71 5-3 Mechanisms of support for full-time graduate students in the clinical sciences, 72 5-4 Sources of internal and external support of full-time graduate students in the clinical sciences, 72 5-5 Doctoral degrees awarded in the clinical sciences, 74 5-6 Academic postdoctoral support in the clinical sciences, 1979-2008, 74 5-7 Employment sectors of the clinical workforce, 1973-2006, 76 5-8 Academic appointments in the clinical sciences, 1973-2006, 76 5-9 Tenure status of Ph.D.s in clinical departments in medical schools, 1980-2009, 77 5-10 Cumulative age distribution for the clinical workforce, 77 5-11 Age distribution of Ph.D.s on medical school faculty in clinical departments in 1989, 1999, and 2009, 78 5-12 Clinical postdoctoral researchers by degree type, 78 6-1 Dental caries among 5- to 17-year-olds, 82 6-2 Extramural grant support by type of academic institution, 83 6-3 Biomedical science and dental/clinical science full-time equivalent faculty, 1998-1999 to 2007-2008, 83 6-4 Average pre-dental GPA of first-year students, 2003-2004 to 2007-2008, 84 6-5 Proportion of NIDCR extramural training and career development support by type of academic institution, 84 6-6 Full-time and part-time and volunteer faculty at dental schools, 1997-2007, 87 6-7 Number of vacant budgeted faculty positions in U.S. dental schools, 1997-2007, 88 6-8 Net income from private practice of independent dentists, 2002-2006, 89 6-9 Net income from private practice dentists and dental faculty, actual and projected, 1990-2015, 89 6-10 Net income from the primary private practice of independent dentists by age, 2006, 90 6-11 Average total resident and non-resident cost for all four years, 1998-1999 to 2008-2009, 91 6-12 Average cumulative debt of all dental school graduates, 1990 to 2009, 91 6-13 Dental school graduates, 1998-2007, 92 6-14 Model of estimating the rate of return to an investment in a dental education, 94 6-15 Average earnings of dental specialists in various careers and average earnings of four-year college graduates, by age, 2000, 94 7-1 Training positions at the postdoctoral and predoctoral levels, 101 D-1 U.S.-trained Ph.D. workforce, in thousands, in three major fields, 1973-2006: quadratic trend and annual variations, 126 D-2 U.S.-trained Ph.D.s by employment status and major field, 2001, 2003, and 2006, 127 D-3 Sex ratio in the U.S.-trained workforce by major field and survey year, 1995-2006, 127 D-4 Differences in male and female employment in science relative to the sex ratio in the U.S.-trained workforce between 1973 and 2006, 128 D-5 Proportional age distribution of U.S.-trained workforce by major field, 1995-2006, 128 D-6 U.S.-trained and foreign-trained Ph.D. workforce, by major field and year, 129 D-7 Proportion foreign-trained in the workforce by age group and major field, 2006, 130 D-8 Ph.D. graduates from U.S. universities by major field, 1970-2007: quadratic trend and annual variations, 130 D-9 Annual growth rates for Ph.D. graduates by major field (five-year moving averages), 131 D-10 Ph.D. graduates who are U.S. citizens or permanent residents versus temporary residents, by major field, 1970- 2007, 131 D-11 Temporary-resident Ph.D. graduates and their proportion intending to stay in the United States, by major field, 1970-2007, 132 D-12 Temporary residents as a proportion of those Ph.D. graduates intending to stay in the United States, by major field, 1970-2007: quadratic trend and annual variations, 132 D-13 Numbers of male and female clinical and behavioral graduates, 1970-2007, 133 D-14 Median age among Ph.D. graduates by major field and sex, 1970-2007, 134 D-15 Proportion of graduates in the modal four-year age group, by median age and major field, 1970-2007, 134 D-16 Ph.D. graduates and NRSA predoctoral trainees and fellows by major field, 1970-2007, 135 D-17 Estimated workforce entrants: foreign-trained Ph.D.s and U.S.-trained citizens and temporary residents, by major field, 1990-2000, 136

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xi FIGURES, TABLES, AND BOXES D-18 Proportion that would have retired by age 66, from retirement rates in specified periods, by major field and sex, 137 D-19 Proportion that would have retired by each age, from retirement rates in specified periods: male biomedical Ph.D.s., 137 D-20 Proportional distribution of the workforce by initial employment status and status two years later: pooled 1993-2006 estimates for all fields combined, by sex, 138 D-21 Proportional distribution two years later of those in non-science jobs, by major field and sex, selected periods, 138 D-22 Past and projected trends in Ph.D. graduates under high-, medium-, and low-growth assumptions, by major field, 1990-2016, 139 D-23 Past and projected age distribution of male behavioral graduates, selected years, 140 D-24 Proportion temporarily resident among graduates entering the workforce in 2016, under various assumptions, 141 D-25 Alternative projections of foreign-trained Ph.D.s entering the workforce (contrasted with medium projection for U.S.-trained graduates), by major field, 2006-2016, 142 D-26 Workforce projections by major field and source of Ph.D., 2006-2016, 144 D-27 Projected sex ratio by major field and source of Ph.D., 2006-2016,145 D-28 Projected sex ratio of workforce and potential entrants by major field, 2006-2016, 145 D-29 Median age of projected workforce by major field, sex, and source of Ph.D., 2006-2016, 146 D-30 Projected age distribution of the workforce by source of training and major field, 2006-2016, 147 D-31 Projected proportions dying and retiring, compared to entering graduates as a proportion of the workforce, by major field and sex, 2007-2016, 147 D-32 Projected number and percentage of the workforce not in the labor force by major field, 2006 to 2016, 148 D-33 Alternative workforce projections by major field, 2006-2016, 148 D-34 Difference of alternative scenarios from the medium projection in percentage change from 2006 to 2016, by major field, 149 D-35 Difference of other projections from the medium projection in percentage change from 2006 to 2016, by major field, 150 D-36 Foreign-trained Ph.D.s as a proportion of the workforce in alternative scenarios, by major field, 2006-2016, 150 D-37 Median age in 2016 in alternative scenarios, compared with 2006, by major field and sex, 151 D-38 Percentage increases in the U.S.-trained workforce in past decades and alternative projections for the entire Ph.D. workforce for 2006-2016, by major field, 152 D-39 Index of research funding compared with indexed past and projected growth of the research workforce (2003 = 100), 153 D-40 Annual growth rates for biological and medical scientists for various periods from the Bureau of Labor Statistics and current projections for biomedical and clinical Ph.D.s., 154 D-41 Annual growth rates for psychologists, sociologists, and anthropologists for various periods from the Bureau of Labor Statistics and current projections for behavioral Ph.D.s., 155 D-42 Workforce annual growth rates, 2001-2006, as previously projected and as derived from surveys, by major field, 155 E-1 Total biomedical, behavioral, and clinical sciences workforces, 2006-2016, scenario 1, 158 E-2 Total biomedical sciences workforce, 2006-2016, 158 E-3 Total behavioral sciences workforce, 2006-2016, 159 E-4 Total clinical sciences workforce, 2006-2016, 159 E-5 Breakout of biomedical sciences workforce, 2006-2016, scenario 1, 161 E-6 Breakout of behavioral sciences workforce, 2006-2016, scenario 1, 162 E-7 Breakout of clinical sciences workforce, 2006-2016, scenario 1, 163 E-8 Breakout of biomedical sciences workforce, 2006-2016, scenario 2, 164 E-9 Breakout of behavioral sciences workforce, 2006-2016, scenario 2, 165 E-10 Breakout of clinical sciences workforce, 2006-2016, scenario 2, 166 E-11 Breakout of biomedical sciences workforce, 2006-2016, scenario 3, 167 E-12 Breakout of behavioral sciences workforce, 2006-2016, scenario 3, 168 E-13 Breakout of clinical sciences workforce, 2006-2016, scenario 3, 169 E-14 Model for U.S.-trained males in biomedical science for scenarios 1 and 2, 173 E-15 Model for U.S.-trained females in biomedical science for scenario 3, 174

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x FIGURES, TABLES, AND BOXES taBleS 1-1 NRSA Trainees and Fellows, by Broad Field, 1975-2008, 13 2-1 NRSA Stipends, 22 2-2 Number of Full-time Pre- and Post-Doctoral Research Training Slots Awarded, 25 3-1 Number of Ph.D. Students Enrolled in the Biomedical Sciences, Fall 2005, 30 3-2 First Year Enrollment in Biomedical Ph.D. Programs, 30 3-3 Citizenship of Doctoral Students in the Biomedical Sciences, Fall 2006, 31 3-4 Race/Ethnicity by Percent of Doctoral Students in the Biomedical Sciences, Fall 2005, 31 3-5 Average Time to Degree, 33 3-6 Postdoctoral Appointments in the Biomedical Sciences in Fall 2006, 35 3-7 Number of Programs with Foreign Postdoctorates and the Three Most Popular Countries of Origin in Fall 2006, 37 3-8 Tenure Status of Basic Science Medical School Faculty, 2002, 2005, and 2009, 37 3-9 Distribution of Medical School Faculty by Track and Gender, 2002, 2005, and 2009, 41 3-10 Compositions of M.D./Ph.D. Programs in United States by Race, 43 3-11 MCAT Scores, 45 3-12 First Year Support for Doctoral Students in the Biomedical Sciences, 45 3-13 Funding Across Graduate Studies in the Biomedical Sciences, Fall 2005, 46 3-14 NRSA Trainees and Fellows by Broad Field (Basic Biomedical Sciences), 1975-2007, 46 4-1 Number of Doctoral Students by Gender as Reported in 2006 for the Research-Doctorate Study, 55 4-2 Financial Support of Students in the Behavioral and Social Sciences in 2006 as Reported in the Research-Doctorate Study, 55 4-3 Average Median Time to Degree for the Doctorates 2004 to 2006 in the Behavioral and Social Sciences as Reported for the Research-Doctorate Study, 56 4-4 Postdoctoral Appointments in Research Departments in the Behavioral and Social Sciences in 2006 as Reported for the Research-Doctorate Study, 58 4-5 Median Age Cohort for the Biomedical Sciences and the Behavioral and Social Sciences, 60 4-6 NRSA Trainees and Fellows, by Broad Field (Behavioral and Social Sciences), 1975-2008, Fiscal Year, 63 5-1 NRSA Predoctoral Trainee and Fellowship Support in the Clinical Sciences (Excluding Health Services), 73 5-2 NRSA Postdoctoral Trainee and Fellowship Support in the Clinical Sciences (Excluding Health Services), 73 6-1 Vacant Positions by Primary Area of Appointment, 88 6-2 Immediate Plans upon Graduation, by Percentage of Respondents, 92 7-1 Nursing Doctorates from U.S. Institutions, 1997-2008, 100 7-2 Tenure and Rank Status of Nursing Faculty, 100 8-1 Setting of Primary Employment, 2008, 106 8-2 Primary Field of AcademyHealth Members, 2008, 106 8-3 Health Services Research Training Positions Funded by AHRQ and the NIH, 107 8-4 NIH Institute Health Services Research Budgets Health Services Research FY 2008 Estimate, 109 D-1 Workforce of U.S.-Trained Ph.D.s in Three Major Fields, by Sex and Employment Status, 2006, 126 D-2 Annual Growth Rates for Ph.D. Graduates in Three Major Fields, Selected Periods, 139 D-3 Linear Regressions for Sex Ratio Among Graduates on Year, 1995-2007, by Major Field, 140 D-4 Latest and Projected Proportions of Graduates Who Are Temporary Residents and Stay Rates (Proportions of Graduates Who Plan to Stay in the United States) by Citizenship Status, and by Field and Sex, 141 D-5 Projected Numbers of Ph.D. Graduates and Immigrating Foreign-Trained Ph.D.s in Alternative Projections, by Major Field, 2006-2016, 143 D-6 Projected Workforce in Three Major Fields, by Sex, 2006-2016, 144 D-7 Alternative Workforce Projections by Major Field and Source of Training, 2006, 2011, and 2016, 151

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xi FIGURES, TABLES, AND BOXES E-1 Biomedical Science Workforce Projections for All Scenarios, 160 E-2 Behavioral Science Workforce Projections for All Scenarios, 160 E-3 Clinical Science Workforce Projections for All Scenarios, 160 E-4 Breakout of Biomedical Sciences Workforce, 2006-2016, Scenario 1, 161 E-5 Breakout of Behavioral Sciences Workforce, 2006-2016, Scenario 1, 162 E-6 Breakout of Clinical Sciences Workforce, 2006-2016, Scenario 1, 163 E-7 Breakout of Biomedical Sciences Workforce, 2006-2016, Scenario 2, 164 E-8 Breakout of Behavioral Sciences Workforce, 2006-2016, Scenario 2, 165 E-9 Breakout of Clinical Sciences Workforce, 2006-2016, Scenario 2, 166 E-10 Breakout of Biomedical Sciences Workforce, 2006-2016, Scenario 3, 167 E-11 Breakout of Behavioral Sciences Workforce, 2006-2016, Scenario 3, 168 E-12 Breakout of Clinical Sciences Workforce, 2006-2016, Scenario 3, 169 E-13 Data for U.S.-Trained Ph.D.s, 170 E-14 Data for Foreign-Trained Ph.D.s, 171 E-15 Ph.D. Data Used in Scenario 3, 175 BoXeS 1-1 Research Training at the National Institutes of Health, 10 1-2 History of Minority Programs at the NIH, 12 1-3 NIH Evaluations of the NRSA Program, 14 1-4 National Research Service Award Act of 1974 (P.L. 93-348), 15 5-1 Recommendations from the Association of American Medical Colleges Task Force II Report,“Promoting Translational and Clinical Science: The Critical Role of Medical Schools and Teaching Hospitals,” 69