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Summary The importance of research for the improvement of health the biomedical sciences with the development of world-class and health care has been recognized both nationally and research institutions in foreign countries. The statement of internationally for many decades. In the United States the task for the committee is: most visible sign of this recognition is the strong and endur- A committee will advise the National Institutes of Health ing support for the National Institutes of Health (NIH). The (NIH) and the Agency for Healthcare and Quality Research creation of a research establishment that supports research (AHRQ) on issues regarding research personnel needs as they ranging from very basic to applied has yielded incredible relate to the administration of the National Research Service dividends in terms of improving the health care of the nation. Awards (NRSA) program. The committee will gather and Many of these improvements have a common theme: Very analyze information on employment and education trends fundamental basic research provided an understanding of of research scientists in the broad fields of the biomedical, human physiology that ultimately resulted in improved behavioral, and clinical sciences, and in the subfields of oral health care. In many cases, the basic research occurred health, nursing, and health services research. The analysis decades before its application and with no apparent applica- will take into consideration the demographic changes in the tion. Thus, the benefits of research to the health care of the United States, changes in disease pattern, and changes in nation are quite clear. scientific opportunity. The committee will deal broadly with the training needs and direction of the NRSA program as To continue to derive and extend these benefits, we require they relate to relevant federal research training policies, the a highly trained workforce. This workforce must have an impact of changes in the level of support for research and infusion of new people with new approaches on a steady training, and the emergence of cross-disciplinary research basis if it is to be successful. An investment in the training of areas. The analysis will include an estimate of the future this workforce is an investment in the health of this country. supply of researchers from the current and future population The introduction of the National Research Services Award of graduate students and postdoctorates, and the committee (NRSA) program in 1973 was a significant step in main- will make recommendations on the overall production rate of taining this workforce, and while it supports only a small research personnel in the biomedical, behavioral, and clinical fraction of the predoctoral and postdoctoral scientists in the sciences for the period 2010 to 2015 as it relates to the NRSA biomedical, behavioral, and clinical sciences, it has set the program. Separate consideration will be given to training standard for training, regardless of the sources of support. with respect to NIH dual-degree and career development programs, and NIH programs that are designed to address The legislation establishing the NRSA program also diversity in the research workforce. called for periodic review by the National Research Council of the program and evaluation of the national needs for Reflecting the broad fields identified in the statement research personnel, and this report is the thirteenth in the of task, the committee divided the research enterprise into resulting series. The task of assessing and predicting the three major areas: basic biomedical, behavioral and social status of research personnel is complicated by the need for sciences, and clinical research. These areas are discussed in accurate and complete data on the supply and demand of per- detail in individual chapters in this report. Additional chap- sonnel and by the effects of external forces. Examples of the ters are devoted to dentistry, nursing, and health services latter are downturns in the economy, the effect that national research, even though these can be thought of as subfields health care legislation will have on the clinical profession, of the major areas. An additional chapter addresses training and possible changes in the flow of international talent in 

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES issues that cut across the above fields. Recommendations are it became clear that recommendations that call for increases found in the individual chapters and are referenced here by in the NIH training budget are important and should be made number following the recommendation. for the health of the current and future research workforce in the biomedical, behavioral, and clinical sciences. Given the current and projected future economic environ- future WorkforCe ProJeCtioNS ment, it is unlikely that the NIH budget will allow for the For each of the three major areas considered—biomedical implementation of recommendations that require new exter- s ciences, behavioral and social sciences, and clinical nal funds. A more realistic possibility is the reallocation of s ciences—the committee commissioned contractors to existing resources. It is not within the committee’s charge, develop workforce models using two different methods. nor did we have the information to recommend how funds One is a life-table model, similar to that used in the past within the NIH might be reallocated. The NIH is in the best two studies, and the other is a new approach that relied on a position to realign its agenda. Recognizing that reallocation systems dynamics model. Each model includes estimates of of existing funds is nearly inevitable, however, we have the numbers of new Ph.D.s and M.D.s entering the workforce identified the three most costly recommendations and placed and of the size of the workforce through 2016. The results of them in priority order. this modeling should be taken as approximations, because the data available to analyze the past and current status of reCommeNdatioN oN the NrSa PoSitioNS the workforce are incomplete, the career trajectories of new doctorates are not predictable, and most importantly, it is The primary task of recommending the number of NRSA impossible to judge the effects of the current major stresses positions for 2010-2015 was complicated by the inconclu - on the world and national economies, on the budget available sive results from the two models for projecting the future for research, and on the state of the world in general with workforce combined with the existence of major economic regard to war, disease, and immigration policies. uncertainties. Based on the ongoing need to maintain a The models predict substantial growth in the biomedical strong research workforce, the committee recommends that the total number of NRSA positions in the biomedical and clinical sciences and little growth in the behavioral and and clinical sciences should remain at least at the fiscal social sciences. The role that foreign scientists will play in year 2008 level and in the behavioral sciences should influencing the size of the job market in the biomedical and increase back to the 2004 level. Furthermore, future clinical sciences is significant, and changes in the level of adjustments should be closely linked to the total extra- participation among these foreign scientists could reduce the mural research funding in the biomedical, clinical, and predicted growth. The life-table model estimates a larger bio- behavioral sciences (3–1, 4–3, and 5–1). In recommending medical workforce in 2016 than does the systems dynamic model for scenarios with the greatest projected workforce this linkage, the committee realizes that in the case of a entrance. The differences in the workforce projections decline in extramural research, a decline in training would among the different scenarios are substantial, and it is dif- also be appropriate. ficult to predict which scenario will provide the best estimate, The year 2008 is the last year for which the most complete considering the status of the economy, the national debt, and data are available and represents the highest level of support research support. Unemployment among trained researchers in recent years in the biomedical and clinical sciences. In should remain low; however, in 2006 there was an increase contrast, 2008 support in the behavioral sciences declined in the number of postdoctorates in all sectors, and this may from the 2004 level. Bringing the level of support in the reflect a weakening of the job market as the NIH budget, after behavioral and social sciences in 2008 up to the level in its doubling, was essentially kept constant. 2004 would require the addition of about 370 training slots at a cost of about $15 million. Considering the importance of research in this area, a return to the previous level is eCoNomiC realitieS essential. When the study committee began its deliberations, the The highest quality of workforce is necessary for a suc- economy was showing the first signs of a downturn that cessful research enterprise. The NRSA program is important would deepen to a recession and dramatically affect employ- in this regard. Even if it trains only a small fraction of all the ment and economic development around the world. Spending students and postdoctoral fellows involved in research, these over the past decade and the cost of the stimulus package training programs set the standards for the entire research have significantly increased the debt of the federal govern- training establishment. In addition, they attract high-quality ment, and reports such as that from the U.S. Deficit Commis- students into research and into fields of particular need. sion predict massive reductions in U.S. spending. The extent The record of success of NRSA award holders in obtaining of any future cuts in the NIH budget—and, in particular, research funding is impressive, and the results of the nation’s the extent of cuts that affect training—is unknown. As the training efforts are self-evident: The United States continues committee reviewed the state of research training, however, as a world leader in research.

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 SUMMARY PrioritieS for other reCommeNdatioNS The MST Program has proved remarkably successful in With large CoSt imPliCatioNS attracting outstanding physicians into research. Although the program is expensive, we believe that a modest expansion In addition to the recommendation on the number of would serve the nation well. A recommendation to increase NRSA positions, there are several other recommendations in the size of the program was made in the previous NRSA this report that will require additional resources. Most call for study but was not implemented. The committee also recom- modest increases and could be accomplished by a shifting of mends, strongly, that this increase in the size of the MST resources within an institute or center. Three, however, would program be accomplished by increasing the total number of require significant additional funds. They are listed below in MST programs and thereby the number of students trained, priority order. In prioritizing these actions, the committee and not by expanding the size of existing MST programs. considered both their cost and their merits, along with likely Broadening the scope of MSTP training responds to the future constraints on the NIH budget. current national commitment to improve the effectiveness, efficiency, and accessibility of health resources, while con- ( 1) NIH should reinstitute its 2001 commitment to trolling costs. increase stipends at the predoctoral and postdoctoral levels for NRSA trainees. This should be done by bud- (3) NIH should consider an increase in the indirect cost geting regular, annual increases in postdoctoral stipends rate on NRSA training grants and K awards from 8 per- until the $45,000 level is reached for first-year appoint- cent to the negotiated rate currently applied to research ments, and stipends should increase at the cost of living grants. The increase in the rate could be phased in over thereafter. Predoctoral stipends should also be increased time (2–2). at the same proportional rate as postdoctoral stipends This would require a five- or six-fold increase in indirect and revert to cost-of-living increases once the comparison costs, or $191 million for the NRSA program at its current postdoctoral level reaches $45,000 (2–1). size and $338 million for K awards. There was not unanimity When fully implemented, the estimated annual cost of this within the committee on this recommendation because of recommendation would be about $80 million, or 10 percent of concerns about costs and the reduction in program size the NRSA budget. If phased in over four years, the $20 million that could result with a stagnant NIH budget. An increase dollar annual increase would be about 2 percent of the NRSA of $529 million is significant, even in light of the reason- training budget. This increase should not be accomplished by ing to have NIH share the full cost of administrating these reducing the number of individuals supported by the NRSA programs, but the committee wanted to record its support program. Despite the cost, the committee thought this increase for the measure and its hope that it could be implemented to be sufficiently important to give it the highest priority. at some point. It has been almost 10 years since NIH endorsed the Many of the requirements and support activities centered recommendation from the 2000 National Research Council in training grants—such as minority recruiting, education (NRC) report and subsequently instituted a plan to increase in the responsible conduct of research, and professional the minimum postdoctoral stipend to $45,000 with propor- development—have improved the overall tenor of graduate tional increases at the predoctoral level. But after a few years education immensely over the past decade. However, these of implementation, there were no compensation increases, activities cannot be covered by the current 8 percent indirect and in the past two years the increases were 1 percent. By cost allowance and therefore must rely on institutional funds. returning to its targeted minimum, the NIH would allow Similarly the K awards, which have served a tremendously NRSA stipends to be competitive and would retain the best important role in fostering the early career development of trainees in the program. The quality of the workforce can- both basic and clinical researchers, utilize the same facili - not be maintained without an appropriate level of support. ties as funded researchers and generate their own significant The President also sees this as an issue, and the 2011 budget administrative costs, yet have the same 8 percent indirect request for NIH included a 6 percent increase in stipend cost allowance. levels, although it was at the expense of a 1 percent decrease in the number of training slots. other reCommeNdatioNS (2) The size of the Medical Science Training Program training in responsible Conduct of research (MSTP) should be expanded by at least 20 percent, and more if financially feasible (3–4). NIH in 2009 issued a detailed policy outlining the Currently there are 911 MSTP slots at an average cost of agency’s expectations for training in the responsible conduct $41,806 per slot. An increase by 20 percent to about 1,100 of research (RCR), along with recommendations on how to slots would increase the MSTP budget by about $7.6 million, establish specific curricula. The requirement of RCR train- or 1 percent of the NRSA budget. If phased in over time, the ing within the T32 mechanism has led to the development impact would be less. of curricula and educational practices that should benefit

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES data management all students and postdoctorates being trained in biomedical, health sciences, and behavioral research. Accordingly, all Are NRSA awardees more successful and productive in graduate students and postdoctoral fellows who are sup- their subsequent careers than others? Competitive initial ported by the NIH on Research Program Grants (RPGs) and renewal applications for these programs contain an should be required to incorporate certain additional enormous amount of information, but no systemic approach “training grant-like” components into their regular has been developed to capture this information for rigorous, academic training program. These should include RCR data-driven analysis. This problem will become all the more training, exposure to quantitative biology, and career acute if trainees supported on R01 grants become a part of the guidance and advising (2–3). overall database. The need for a modern data recording and management system is desperate, and such a system should be diversity implemented without delay. The NIH should collect reliable data on all of the educational components that it supports The demographics of this country are changing, and in such a manner that this information can be stored in an underrepresented minorities (URMs) are approaching a easily accessible database format. Such data might consist majority of the citizenry. The NIH is committed to increasing of important components of the training grant tables, as the diversity of the health sciences workforce through many well as retention and subsequent outcomes (2–6). programs, such as the Minority Access to Research Careers In the same vein, applications for training grant support and Minority Opportunities in Research programs in the require many detailed data tables, some of which are largely National Institute of General Medical Sciences (NIGMS), irrelevant to the proposal award process. The committee and the number of URM students in biomedical graduate recommends that the data tables be reviewed and a programs has increased from 2 percent in 1980 to 11 percent determination made, in consultation with the awardee today. However, in 2009 minority representation was 2 per- community, as to which are really essential for reviewing cent for tenured and tenure-track medical school faculty in the proposal and which should be incorporated into the basic science—the same as in 1980—and was 4 percent for databases (2–7). non-tenured or non-tenure track faculty. Graduate student and postdoctoral training programs that educate and Program evaluation and future Coordination train students who are funded by RPGs should be subject to the same expectations for diversity of trainees that are One aspect of training programs that has not been evalu- expected of training grants. Such programs should be ated to date is how the value of the research training was per- required to provide assurance on R01 grant applications ceived by the program director and the trainees themselves. that efforts are being made to increase diversity, though This information should be collected by an anonymous they will likely have to be at an institutional level (2–4). survey, where the only identifier would be the particular institute or center at which the NIH trainee was supported. k24 mentoring awards Specifically, a training evaluation questionnaire should be created so that all participants in the full range of The K24 mentoring award has been successful in develop- NIH-funded training vehicles can provide a confidential, ing the careers of clinical scientists and should be expanded unbiased evaluation of the program in which they were to the basic sciences. In addition, this mechanism could also trained. The intent of this recommendation is not to pro- be used to support diversity at the faculty level. The NIH vide additional information for the competitive renewal should expand the K24 mentoring award mechanism to of a particular program, but rather to allow the NIH include the basic sciences and adapt the K24 mechanism to evaluate the merit of all of its training approaches to provide the opportunity for established mid-career broadly (2–8). faculty to mentor early-stage investigators in the basic There should also be better communication between the sciences, including recipients of the the new R00 awards NIH and the NRC during the periods when the NRSA pro- (Phase 2 of the Pathways to Independence Award-K99/ gram is not in review. Such coordination would enhance the R00 Award). Additionally, the K24 award mechanisms information-gathering process and allow the committees at for both basic and clinical mid-career faculty should be the start of the review to complete their work more rapidly utilized to enhance institutional efforts to recruit and and efficiently. Greater continuity would benefit subsequent develop a diverse faculty. Specifically, the NIH should N RC committees in crafting recommendations and in d evelop a new category of K24 awards targeted to monitoring their implementation by the NIH. Accordingly, enhance the success of early-stage basic and/or clinical it is recommended that the appropriate office at the NIH investigators, or reserve a fraction of existing K24 awards involved in analyzing these recommendations should for mid-career applicants whose mentees will include one issue an annual report to the Director’s Advisory Com- or more URM faculty members (2–5). mittee on the status of review and implementation. After

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 SUMMARY approval, such a report should be forwarded to the NRC Furthermore, the F30 awards have proven to be an effec- to be made available to the subsequent review commit- tive way for students in M.D./Ph.D. programs to gain NIH tees. In addition, the NIH may wish to invite external support for their activities. They also provide a means of experts to provide added insight into the analysis. There support for students at institutions that do not have an MSTP. are a number of ways that this could be done, but the Consequently, all institutes should be encouraged to exact mechanism is left up to the NIH (2–10). make F30 fellowships accessible to qualified M.D./Ph.D. students (3–7). Nontraditional outcomes Behavioral and Social Sciences Traditionally, a successful career in the biomedical sci- ences was defined as a research position in a university with The behavioral and social sciences receive considerably grant support from NIH or other funding organizations. less training support than the other two major fields, but While many trainees still aspire to this career goal, many their role in the nation’s health has become increasingly others use their biomedical training to provide other societal important. The lack of support may in part be due to the benefits—as researchers in the private nonprofit sector or lack of an NIH institute that focuses exclusively on basic in the pharmaceutical, biotechnology, and medical device behavioral and social sciences research. Much of the cur- industries; by inventing and developing new products; by rent funding is oriented toward the research areas of the teaching science in the secondary schools; and with careers categorical institutes, and this should continue since it links in intellectual property law, in finance, and in government behavioral and social sciences research to the missions of the service. To recognize these career paths, peer reviewers in institutes. However, training programs in basic behavioral evaluating training grant applications, especially com- and social sciences that cut across disease categories and peting renewals, should be instructed to broaden their age cohorts should be housed at NIGMS, which would conception of “successful” training outcomes to recognize be consistent with the NIGMS congressional mandate. nontraditional outcomes that meet important national Given its disciplinary expertise, the Office of Behavioral priorities and needs in the biomedical, behavioral, and and Social Sciences Research (OBSSR) should cooperate clinical sciences (3–2). in this effort. NIGMS will need funds and appropriate staff dedicated to this new effort (4–1). Similarly, in light of chronic and escalating concerns In addition, training programs in basic and traditional about the uneven quality of precollege science education and its effect on students’ career choices, one highly needed behavioral and social sciences that bear specifically on and extremely valuable outcome is for biomedical and particular diseases and specific age cohorts should be behavioral sciences trainees to teach middle and high housed in all the relevant institutes and centers. Given school science. The NIH and the Department of Educa- both its disciplinary expertise and its role in connecting tion should work to provide incentives that would attract institutes and centers (ICs), OBSSR should cooperate trainees into these teaching careers and lead a national in this effort (4–2). An earlier recommendation calls for dialogue to accelerate the processes of teacher accredita- expanding the MSTP to the behavioral and social sciences. In tion controlled by the individual states (3–3). parallel, the F30 program should also be extended to clini- cal behavioral scientists in M.D./Ph.D. programs (4–4). m.d./Ph.d. training Programs Clinical Sciences In addition to having their funding increased by 20 percent (3-4), MSTPs should be encouraged to include The earlier recommendation for the MSTP applies with basic behavioral and social sciences training relevant to equal force to the clinical sciences, since part of the train- biomedical and health sciences research (3–5). This is con- ing occurs in this area. However, the hope that M.D./Ph.D. sistent with the recommendations below to increase training programs would provide the transitional and clinical research programs in basic behavioral and social sciences across NIH workforce has not been completely fulfilled. On the other centers and institutes (4–1, 4–2, 4–4). hand, medical students and residents might be attracted to MSTPs should also be encouraged to intensify and research in these areas if they are exposed to the principles document their efforts to identify and recruit qualified of clinical research and given the training to carry out nontraditional, underrepresented groups (women and such research effectively. The NIH, in consultation with minorities). These efforts should be a factor in the evalu- academic medical leadership, should identify better ation of all requests for MSTP funding increases and training mechanisms for attracting medical students should be conditions for receipt of any MSTP funding into translational and clinical research and should fund increases. Success depends on having a critical mass pilot programs designed to implement promising new (rather than isolated examples) of underrepresented approaches to accomplishing that objective (5–2). While trainees in any given MSTP (3–6). the areas of oral health and nursing are considered subfields

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES post-D.D.S. phase (as opposed to the lower, predoctoral of the clinical sciences, and while health services research stipend levels). The feasibility of adaptations of the exist- is at least partially a subfield, these areas were considered ing Medical Science Training Program (M.D./Ph.D.) separately in this study. model to dental education—including full funding for eight or so years—should be explored (6–3). dentistry While dentistry is primarily practice-oriented, there is Nursing another career path that brings strong science to the problems of oral, dental, and craniofacial health. There is a need for a The nursing profession shares the same shortage of critical mass of investigators with a long-term commitment research personnel as dentistry, but for different reasons. to research in the oral health sciences. Consistent with the B ecause of the structure of their profession and their 2009 National Institute of Dental and Craniofacial Research education process, nurses begin doctoral study at a much (NIDCR) strategic plan, the committee recommends several later time in life and take longer to complete the degree actions to increase the biomedical research workforce in than in other fields with more NRSA support. In response the oral health sciences. First, efforts should be made to to the graying of the profession, the T32 programs in achieve closer integration between schools of dentistry nursing should emphasize a more rapid progression into and the broader biomedical and health sciences research, research careers. Criteria for application should include practice, and education communities with the goal of predoctoral trainees who are within eight years of high generating new and vibrant research pathways and part- school graduation, streamlining the requirement for a nerships for students and faculty (6–1). nursing master’s degree in passing to the Ph.D. and pro- viding support for postdoctoral trainees who are within Second, financial support of dental students and post- doctorates with an interest in research is critical. NIDCR two years of completion of the Ph.D. (7–1). should establish research fellowships, including K awards, To increase research capacity for the existing work- and individual research awards to provide greater oppor- force, the National Institute of Nursing Research ( NINR) tunities for independent NIH research support for den- should (1) increase the number of mid- and senior- tists, as well as programs to fund non-dentists in Ph.D. career awards to enhance the number of nurse scien- programs in subject areas relevant to oral health and tists capable of sustaining programs of research, and also programs for internationally trained non-U.S. citizen (2) increase the length of support for K awards to five dentists seeking Ph.D. and postdoctoral fellowships. To years to be consistent with other institutes and centers accomplish this may well require that NIDCR rethink (7–3). The NINR budget is less than half that of any other its current priorities and may require additional funding. institutes that provide NRSA support and, because of that, Partnerships between NIDCR and other components of has difficulty balancing training and research support. In the academic health system need to be developed and consideration of the size of the NINR budget and the acute maintained based on recognition of the value added by need for nursing faculty, NIH should request additional the oral health sciences. The NIH-sponsored Clinical support from Congress to allow NINR to more closely and Translational Science Awards and Practice-Based meet this acute need (7–4). Research Networks should explicitly identify a collabora- As described elsewhere, the MSTP has proven to be ben- tive role for oral health research (6–2). eficial in attracting and sustaining a research workforce. In this regard, NINR should develop and pilot test a MSTP- Third, it is essential that some form of debt relief be like program to support clinical training at the Master of available to dental students who commit to pursue research Science in Nursing (MSN) or Doctor of Nursing Practice careers. Most students graduate with debt well over $100,000 (DNP) level for those nursing students wishing to be clini- and not unreasonably view dental practice as the only way to pay that debt. The committee recommends the develop- cian scientists (7–5). ment of programs that offer supplements for full or partial coverage of tuition or that offer loan forgiveness, health Services research or both, for the dental school component of combined D.D.S./D.M.D./Ph.D. programs. This would allow most Considering the critical need for health services research of the burden of the D.D.S./D.M.D. tuition to be covered at a time when the nation’s health-care system is undergoing for students who commit to long-term careers in dental extraordinary changes, the NRSA support for such training research. Enhanced stipends for graduate students at NIH is modest, less than half a percent at the predoctoral should be provided if fiscally feasible without causing stu- level and less than half of that at the postdoctoral level. dents to lose eligibility for low-interest student loans. In Health services research training should be expanded conjoined D.D.S./D.M.D./Ph.D. programs, when the clini- and strengthened within each NIH institute and center cal degree is awarded prior to the Ph.D., the NIH should (8–1). Also, the 1 percent of the NRSA budget that is now permit postdoctoral stipend levels to apply during the set aside is not sufficient for the training supported by the

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 SUMMARY AHRQ; AHRQ training programs should be expanded, an important component of the biomedical research enter- commensurate with the growth in total spending on prise in the United States—the standard that other nations health services research, including comparative effective- measure against. To sustain this preeminence, NIH training ness research (8–2). mechanisms must be nimble in responding to changes in U.S. immigration policy, changes in global employment opportu- nities for international graduate students and postdoctorates, CoNCluSioN growth in U.S. minority populations, profound changes in the In general, over the past 40 years the NRSA program health-care system, severe financial problems in U.S. higher has been of enormous benefit in training the workforce education systems, chronic inadequacy of science education responsible for the dramatic advances in the understanding of in K-12, and other conditions that may arise. Strengthening disease and has provided insights that have led to more effec- the NRSA and related training programs will help them meet tive and targeted therapies. The NRSA program has been these challenges.

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