training programs, this option may not be widely used, and even if it were used, additional training places financial and other burdens on a young physician.

Congress has authorized several educational loan repayment programs for M.D.s who enter clinical research training programs, for minority M.D.s who pursue clinical training, and for others pursuing designated career paths. There are perhaps a half-dozen different programs authorized, and the NIH has been vigorous in making these programs known to successful candidates. The explicit purpose of these programs is to mitigate educational debt burdens for M.D.s pursuing clinical research training. M.D. graduates from clinical research training programs (e.g., those receiving one of the several K awards) must have protected time to develop their independent research careers, an increasingly difficult situation in today’s increasingly competitive health care markets. Another obstacle is the limitation on salaries for NIH-funded physician-investigators. The cap is set annually set by Congress to be no more than that of an executive grade; this grade has varied in recent years between level II and level I. It is now set at $199,700, and although that is not an insignificant amount, it is below what many practicing clinicians or medical faculty can earn.

Dual-Degree Training

In addition to predoctoral and postdoctoral program support in the clinical sciences through the NRSA mechanism, dual-degree programs are another attractive option for health care professionals seeking clinical research training. The NIH currently, has three dual-degree training programs: (1) the Medical Scientist Training Program (MSTP), (2) individual M.D./Ph.D. fellowships, and (3) the Dental Scientist Training Program (DSTP).

These dual-degree programs are very attractive, because they provide students with several career options, and the level of educational debt that students are left with is much lower than that for regular M.D. students. The MSTP in the National Institute of General Medical Sciences (NIGMS) is the largest and oldest programs, dating back to 1964, and today it funds 880 students training at 35 medical schools and universities. An additional 31 MSTP trainees are supported by other institutes. Offering fellowships for M.D./Ph.D. training is more recent; they were instituted in 1989 by the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse to encourage dual-degree training in the areas of mental health, behavior, and neuroscience. The fellowship program is much smaller in scale, supporting about 140 new students each year. The latest type of dual-degree training to be introduced is the DSTP, which was created following the recommendations from the 1994 study of the NRSA program. The National Institute of Dental and Craniofacial Research supports about 90 dual-degree dental students through the T32 and F30 DSTP—in 16 different dental schools (only 2 of these schools do not have T32 DSTP trainees).

A student in a typical M.D./Ph.D. program begins intensive research training after the second year of medical school. At this point in their training, the students have had little exposure to clinical medicine and the challenges and research opportunities that are inherent therein. After three-plus years completing work required for the Ph.D. degree, the students return to the medical curriculum for the third and fourth years. For dual-degree graduates who elect to pursue full clinical specialty training, an additional three to five, or more, years typically ensue before the individuals can turn their attention fully to research. At that point, to begin an additional formal program of clinical research training is unappealing.

The M.D./Ph.D. programs were envisioned as a way to bring more M.D.s into clinical research, but in practice relatively few participants receive research training in clinical research methods, and only about 20 percent of the M.D./Ph.D.s actually go on to pursue clinical research careers. Educational debt does not appear to be the reason, because their debt averaged about $15,000 in 2006. Many have argued that these programs are not effective in training clinical researchers because of their structure. An analysis in 1996 of the fields of study chosen by MSTP participants found that nearly 60 percent of graduates from the late 1980s and early 1990s had their Ph.D.s in five basic science fields: biochemistry, neuroscience, molecular biology, cell biology, and pharmacology. As a consequence the work they were exposed to in their Ph.D. program was focused on basic research, and this attracted them to a research career in the biomedical sciences. As a result in their subsequent research careers, MSTP graduates focused almost entirely on laboratory-oriented research, albeit typically in clinical departments and in areas of relevance to that clinical discipline, and they sought NIH funding for such research projects at the same rate as Ph.D.s.

Recognizing this problem NIGMS has recommended that institutions provide broader opportunities within the M.D./Ph.D. training mechanism. The institute issued new guidelines for the MSTP that urged medical schools with such training grants to extend their programs in order to give students “a breadth of doctoral research training opportunities” in fields including computer science, the social and behavioral sciences, economics, epidemiology, public health, bioengineering, biostatistics, and bioethics. However, most M.D./Ph.D. programs have been slow to respond, and there has been little change in the descriptions of the programs. And in most cases, the basic structure of two years/three years/two years persists.

In addition to formal dual M.D./Ph.D. programs, other approaches are being tried to attract M.D.s to clinical research. Examples include master’s level programs in specific clinical areas, which are becoming popular in some research-oriented medical schools and which may be designed to provide academic formal training in such areas as quantitative and methodological principles of medical

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