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2 CHAPTER An Historical View The instinct of the scholar to carry his educa- tion as far as he can at the centers of learning in his field is as old as the uni- versity itself. Thomas Aquinas in the 13th century left the University of Naples for Paris and Cologne to study under Albertus Magnus. To get the best training in medicine available in the 16th century Andreas Vesalius went from Louvain to Paris and thence to Padua, "that most famous university of the whole world,"1 as he called it. In more recent times, Ernest Rutherford, recip- ient of the best education his native New Zealand could give, seized the oppor- tunity of a grant for further study to pursue research in physics in England under J. J. Thomson. At its best, postdoctoral education represents an ancient prescription for excellence. Beginnings of Doctoral and Postdoctoral Research in the United States The men who developed the American university as a teaching and research institution a century ago intended it to be a place where learning would con- tinue through a man's lifetime. Teachers and students alike were to learn by Andreas Vesalius, De Humani Corporis Fabrica, 1543, the preface. 7

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8 AN HISTORICAL VIEW doing research. Attainment of the PhD was not to be any sort of stopping point. "What are we aiming at?" asked Daniel Coit Oilman in his inaugural address as first president of Johns Hopkins in 1876. He answered, in part: "The encouragement of research; the promotion of young men; and the ad- vancement of individual scholars, who by their excellence will advance the sciences they pursue, and the society where they dwell."2 President Oilman offered twenty fellowships annually to attract and sup- port young men starting research careers. The first fellows chosen in 1876 in- cluded four who already had their PhD's.3 The others were candidates for the doctorate but all had the same long-range objective. As a fellow of the fol- lowing year recalled, "The Johns Hopkins fellowship in those days did not seem a routine matter, an every-day step in the regular process toward a doc- torate or a professorship, but a rare and peculiar opportunity for study and research, eagerly seized by men who had been hungering and thirsting for such a possibility."4 The faculty also were encouraged to develop as creative scholars. The psy- chologist G. Stanley Hall, a professor at Johns Hopkins before he became the first president of Clark University, thought that Oilman "nowhere showed more sagacity than in applying individual stimuli and checks, so that in this sense and to this extent he was a spiritual father of many of his faculty, the author of their careers, and for years made the institution the paradise and seminarium of young specialists. This made stagnation impossible, and the growth of professors there in their work was, I believe, without precedent."5 When Hall opened Clark University in 1889 he said boldly: "We are a school for professors, where leisure, method, and incentive train select men to higher and more productive efficiency than before."6 At the University of Chicago, founded in 1890, President William Rainey Harper ventured to limit the claims of classroom teaching on a faculty mem- ber's time. "It is proposed in this institution," Harper wrote, "to make the work of investigation primary, the work of giving instruction secondary."7 For the sake of research, heavy teaching loads were avoided and arrangements were made to excuse faculty members from their teaching duties entirely from time to time. The commitment to research also found expression in the titles of appointments. The faculty was formally divided into scholars, fellows, and docents as well as instructors, lecturers, and professors. Quoted by W. Carson Ryan, Studies in Early Graduate Education, No. 31, Carnegie Foundation for the Advancement of Teaching, New York, 1939, p. 28. 3 John C. French, A History of the University Founded by Johns Hopkins, The Johns Hopkins Press, Baltimore, 1946, p. 41. 4Fabian Franklin, The Life of Daniel Coit Oilman, Dodd, New York, 1910, p. 228. 5 Quoted by Ryan, op cit., p. 39. 6Ibid., p. 48. ''ibid., p. 126.

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9 BEGINNINGS OF DOCTORAL AND POSTDOCTORAL RESEARCH The eighties and nineties was a period of rapidly rising student enrollments across the nation and of run-away growth in PhD programs. Graduate enroll- ments grew tenfold. In 1877-78 only a handful of institutions granted the PhD. Their graduate population totaled little more than four hundred. By 1896-97 there were 146 PhD-granting institutions with a collective graduate enrollment of 4,392. The pressures of expansion subjected the universities to financial strains that made it difficult to give strong support to postdoctoral and faculty research. At the 1901 meeting of the recently constituted Associa- tion of American Universities, Dean Harry P. Judson of Chicago commented on the support that fellowships had given to doctoral study and lamented that "the number of research fellowships offered to those who have made the doc- torate is as yet inconsiderable." He urged the endowment of "a considerable number of research fellowships... to be granted only to those who have al- ready on foot an investigation which promises results."8 Four years later he fought a proposal that Chicago balance its budget by increasing teaching loads; if it took this course, he argued, it would "... sink to the level of the many institutions which, while really large colleges, are adding a small portion of advanced work in the hands of overburdened teachers."9 There were those who felt that reasonable teaching loads were the key to the matter, rather than fellowships. At the seventh annual meeting of the As- sociation of American Universities in 1906, a morning was devoted to the topic, "To what extent should the university investigator be relieved from teaching?" President David Starr Jordan of Stanford offered the view that there was too much conceit of research—"not all who talk of research, even in Germany, shall enter the kingdom"—but he concluded: The university should recognize the necessity of research to university men, and in a much greater degree than is now the case in any American university. It should provide for this by furnishing all needed appliances, material, books, clerical help, art.sts, assist- ants, leisure, and freedom. . . . Men should not be encouraged to undertake research in order to gain professorships. Rather they should gain professorships in order to make research fruitful. A university need not provide for research fellowships or research professorships.10 In his annual report for 1910, the President of the Carnegie Foundation for the Advancement of Teaching, Henry S. Pritchett, looked critically at the contribution of the growing graduate student population to research. The graduate school had its rise ostensibly in a desire to promote research. As a matter of fact, it is engaged in the main in training teachers who desire degrees. The develop- 8Association of American Universities, Journal of Proceedings and Addresses, First and Second Annual Conferences, 1900 and 1901, pp. 40, 41. 9Quoted by Richard J. Storr, Harper.s University: The Beginnings, University of Chicago Press, Chicago, 1966, p. 353. 10Association of American Universities, Journal of Proceedings and A ddresses. Seventh Annual Conference, 1906, pp. 25, 28, 29.

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10 AN HISTORICAL VIEW ment of true research has had no relation to the enormous growth of the graduate school. Indeed, in many institutions the creation of a graduate school has practically put an end to research. ... In some graduate schools men who, in a perfectly natural way, would have developed into research men have been forced to give up the work of research in order to hold seminars and to find new themes for constantly growing armies of aspirants for the degree of doctor of philosophy. It is true that both the appre- ciation of research and the disposition toward research have grown in American colleges, but in no such proportion as the graduate school has grown, and the growth of one has had too little to do with the growth of the other.11 In 1913 the American Association for the Advancement of Science ap- pointed a Committee of One Hundred to consider the state of scientific re- search in America. It was a blue-ribbon group including representatives from the leading research institutions of the day. At a meeting the following year the chairman, Edward C. Pickering, pointed to the small sums appropriated by universities for research. "If a tenth of the money used for teaching was employed in research," he said, "Americans would soon take their proper places among the great men of science of the world." A subcommittee that included the surgeon, Harvey Gushing, and the geneticist, Thomas Hunt Mor- gan, suggested that ... in order to encourage the original minds in America, there should be more research professorships and research assistantships of high grade, which would raise their holders above the worry and inefficiency caused by financial need. . . . The finding of the really promising man (who must possess not only originality, but also sound judgment and in- tellectual honesty) is not easy, because it often involves the gift of prophecy on the part of the searcher. Nevertheless, it seems to us that all those in each of our larger institu- tions for learning who are really interested in research of the highest kind, either indi- vidually or grouped together as a voluntary committee, should keep their eyes open for persons possessing in high degree the happy combination of qualities desired and should urge upon presidents and governing boards the importance of supporting these persons so as to make it possible for them to yield their best fruit in discovery.12 Research in the Medical Schools Medical research was handicapped by the poor training received by many MD's. Abraham Flexner's famous report of 1910 on medical education in the United States and Canada is an eloquent account of the deplorable condition of undergraduate medical education at this time.13 At many schools students 11Sixth Annual Report of the President and of the Treasurer, The Carnegie Foundation for the Advancement of Teaching, 1911, pp. 104, 105. ^Science, February 26, 1915, Vol. XLI, No. 1052, pp. 316, 319. I3Abraham Flexner, Medical Education in the United States and Canada, Bulletin No. 4, The Carnegie Foundation for the Advancement of Teaching, 1910, p. 56.

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11 RESEARCH IN MEDICAL SCHOOLS got little grounding in the sciences basic to medicine and little exposure to clinical cases. The lecture theater played too large a part in medical education, the laboratory and ward much too small a part. Taking a year's appointment as a hospital intern was not yet the rule for young medical graduates. "House surgeons" and "house physicians," on the pattern of today's interns, were appointed at the New York Hospital soon after its inception in 1791 and at Bellevue in 1806, but during most of the nineteenth century the concept of the internship as an educational oppor- tunity made little headway.14 In 1904 the American Medical Association esti- mated that less than 50 percent of medical graduates took an internship before starting private practice.ls Those who sought the opportunity were, one ob- server said, the more studious element, "men of high and noble aspirations, intent on making records for themselves in their professional career; men with pronounced taste for the academic side of medicine."16 It seemed increasingly scandalous that a student could go directly from the lecture theater to the treatment of his first patient, and in 1905 the American Medical Association voted that an internship year should be a regular part of medical training. This did not make it so, however. It was five years before a medical school, the College of Medicine and Surgery of the University of Minnesota, made a year's internship a requirement for graduation. The first state to make it a requirement for practice, Pennsylvania, took the step in 1914. Even in 1920 only six states required it.17 But by this time the importance of an intern- ship year was gaining acceptance, and a decade later virtually every medical graduate served an internship, whether required of him or not.18 A year's internship, however, could not meet the needs of men who wished to achieve the highest level of medical competence. "Training for the higher clinical careers," wrote the distinguished Johns Hopkins pathologist, William H.Welch, in 1907, "requires a long apprenticeship after graduation from medi- cal school and after the ordinary hospital internship, and is best secured by prolonged service in a hospital as resident physician or surgeon under condi- tions which secure more thorough practical experience and better opportuni- ties for scientific study and investigation than those which now exist under the customary arrangement of the medical staff of our hospitals."19 Resi- dencies of this description were available at the Johns Hopkins Hospital and at some other university hospitals but they were few in total number. Many ^Internships and Residencies in New York City, 1934-37, Their Place in Medical Edu- cation, The Commonwealth Fund, 1938, p. 27. Journal of the American Medical Association, Vol. 43, August 13, 1904, p. 469. IS 16Ibid., Vol. 50, May 2, 1908, p. 1395. lllbid., Vol. 63, Sept. 19, 1914, p. 1049; Vol. 74, April 17, 1920, p. 1099. lsfbid., Vol. 99, August 27, 1932, p. 743. I9lbid., Vol. 49, August 17, 1907, p. 534.

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12 AN HISTORICAL VIEW MD's interested in advanced medical training sought it in Europe. Residencies at European teaching hospitals were advertised in the American medical journals. Some who wished to see more provision for advanced medical training in the United States looked to the graduate schools to provide it. The graduate schools, it was felt, had the necessary respect for research and, as institutions dedicated to scholarship, were in the best position to maintain scholarly stand- ards. In 1914 the University of Minnesota under President George E. Vin- cent (later president of the Rockefeller Foundation) initiated graduate degrees in medicine on the pattern of the university's graduate degrees in the arts and sciences. Six three-year teaching fellowships were established for the support of candidates. The following year the university signed an agreement with the Mayo Foundation in Rochester permitting students to work for the degrees in the clinics and laboratories of either institution. Thirty clinical fellows or resi- dents at the Foundation officially became fellows in the university. The gradu- ate work at Rochester was placed under the direction of a committee chaired by the dean of the graduate school.20 What was intended by graduate work in medicine was made clear in a re- port presented to the university regents: In graduate work of any kind research plays a large part. Originality and ability to con- duct investigation must be demonstrated. The studies of a medical graduate in any given specialty should consist of: (1) Further work in the fundamental sciences of anatomy, physiology, etc.; (2) adequate practice in the technical procedures of diagnosis and treat- ment; (3) a thorough acquaintance with the literature of the specialty and related branches; (4) original investigation relating to his specialty Investigators are trained by doing original work under critical and inspired leadership. This is the prime function of the graduate school.21 Development of the program was delayed by World War I but after the war it attracted large numbers of applicants. As many as one thousand applied annually to study at Rochester. About 60 a year were awarded fellowships. The great majority came for advanced training in surgery. Roughly one in six was interested in internal medicine. Only a scattering were interested in work in the basic medical sciences.22 By 1934 a total of 1,098 students had spent an average of four years on fellowship appointments at Rochester. Most had held fellowships that were service appointments in the clinic, at least in part; only 123 had held strictly research appointments. The program was not in- tended as preparation for academic work as against clinical practice. Neverthe- Helen Clapesattle, The Doctors Mayo, University of Minnesota Press, 1941, p. 643. Journal of the American Medical Association, Vol. 64, March 6 and June 12, 1915, pp. 790-794, 2009-2011. ^Journal of the American Medical Association, Vol. 74, March 27, 1920, p. 912.

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13 RESEARCH IN MEDICAL SCHOOLS less, 700 or so of the fellows later became teachers in medical schools and in other institutions.23 It appears that about half of them completed the require- ments for a degree in the graduate school, normally a master's degree but in some cases a PhD. Other advanced students received graduate degrees for their work at the university.24 Few graduate schools, however, followed Minnesota's initiative, and the medical schools were slow to devise any program beyond the MD. Lacking help from the universities, medical practitioners devised means of their own to promote higher levels of competence. As early as 1908 members of the Ameri- can Ophthalmological Society urged the desirability of a special examination for the certification of practitioners in their field. It was suggested that the So- ciety could require an advanced degree for membership, but this idea was not taken up. One objection, it is interesting to note, was that if the medical schools responded by starting advanced degree programs there would be as many standards for the degree as there were schools. The Society appointed a joint committee with the American Academy of Ophthalmology and Otolaryngology and the section on ophthalmology of the American Medical Association to look for a solution. In 1915 the committee recommended that the three groups establish together an examining board to certify to compe- tence in the specialty. It was hoped that the board's certificates, while they would have no legal standing, would become the recognized mark of profi- ciency in the field. The committee's recommendations were accepted, and in 1916 the first specialty board examinations in ophthalmology were held in Memphis, Tennessee. In due time other specialty groups followed the oph- thalmologists' example. A specialty board for Otolaryngology was set up in 1924, for obstetrics and gynecology in 1930, for dermatology and syph- ilology in 1932, and for pediatrics in 1933.2S Hospital service provided the means to prepare for the board examinations. The increasing complexity of medical techniques put hospitals more and more at the center of medical practice. Diseases which had once been treated by a visiting physician in the home were now best treated in the hospital. The hos- pital was no longer feared, as it had been in the nineteenth century, as an insti- tution of last resort, where a patient went when treatment at home failed. The number of hospital beds rapidly increased, creating a rising demand for resident house staff. A residency at a well-equipped hospital with a varied case load Association of American Universities, Journal of Proceedings and Address of the Thirty-sixth Annual Conference, 1934, p. 64. ^Bulletin of the University of Minnesota, The President's Report for the Years 1932- 1934, pp. 178,272, 278. 5Graduate Medical Education, Report of the Commission on Graduate Medical Educa- tion, Chicago, 1940, pp. 204-207; Journal of the American Medical Association, Vol. 65, Oct. 16, 1915, p. 1328; Vol. 68, March 10, 1917, p. 790.

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14 AN HISTORICAL VIEW could offer an excellent training to a young MD who wished to develop his competence, and hospitals looking for house staff organized their residencies to serve this second function. In 1925 the Council on Medical Education and Hospitals of the American Medical Association started listing residencies that they believed offered satis- factory educational opportunities. Its first list included only 35 hospitals, one of them a hospital in Paris. Many of the hospitals on the list were closely asso- ciated with medical schools, but others were not. Discussing the features it looked for in a satisfactory residency, the Council expressed the view that a hospital offering residencies in a specialty .. . should provide (a) review courses in anatomy, pathology and the other basic pre- clinical sciences. .. (b) clinics in which students can have the opportunity personally to examine patients. .. (c) courses of operative and laboratory technique; and (d)-to be assigned only when the student's previous training will warrant-assistantships in which, under the supervision of a physician who is recognized as an expert in the particular specialty, he can gradually assume responsibility in the diagnosis and therapeutic or op- erative treatment of the sick. Opportunity should be provided also for research work in the chosen specialty bearing on both the fundamental sciences and clinical fields. 26 In 1928, after a careful canvass, the Council published a list of 1,136 resi- dencies at 292 hospitals.27 Additions to the list during the next ten years doubled the number of approved hospitals and tripled the number of approved residencies. In 1939 the Council set forth in detail what it considered to be the essen- tials of an approved hospital residency or fellowship. A residency was defined as a service appointment "of one or more years following an approved intern- ship .. . designed primarily to meet the requirements for certification of special practice."28 It characterized a fellowship in this context as "a form of apprenticeship which in some cases is indistinguishable from a residency, al- though it usually offers greater opportunity for the study of basic sciences and research. Ordinarily a fellowship is a university rather than a hospital ap- pointment."29 The Council made no distinction in the essentials of a resi- dency or fellowship training program. Both residents and fellows, it thought, "should be given an opportunity to contribute to the hospital service by some investigative work. This may take the form of research in the hospital labora- tories or wards, summaries of medical literature, or the preparation of statis- tical analyses derived from the hospital record department. The members of the resident staff should likewise be encouraged to engage in teaching activi- 26.Journal of the American Medical Association, Vol. 85, August 22, 1915, pp. 595-598. 21 Ibid., Vol. 90, March 24, 1928, pp. 911, 920, 922-979. 9R Ibid., Vol. 112, March 11, 1939, p. 926. 29Ibid., April 8, 1939, pp. 1386-1392.

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15 RESEARCH IN MEDICAL SCHOOLS ties, particularly in relation to the training of medical students, interns, and nurses." Residencies served well as a means of providing advanced clinical training but offered little opportunity to the man whose area of interest lay in the preclinical sciences. In 1920 the professor of physiology at Yale complained bitterly of the small encouragement given to men in these fields. Believing that the preclinical and clinical men on the staff of a medical school should work as a team, regarding each other as equals, he thought that "no man of the PhD variety should be allowed in the preclinical chairs." However, "no man of ability with the MD degree will in fact strive for them or stay in them, against the immensely greater opportunities and advantages offered now, and to be offered in even richer measure in the future, by the clinical departments. Unless something pretty radical is done and done soon, either these chairs will be filled by men with the PhD or they will be vacant. To get young men into the medical sciences through the avenue of the PhD," he continued, "is, under present conditions, a cruel proposition. They get in; they cannot get out, as an MD could; and there is then nothing for them to do but to accept the starvation wages, perhaps a half of the pay of men no older nor more loyal and industrious in the clinical chairs... it is more like a cemetery than a career."30 He spoke with feeling, as a PhD man himself. Widespread agreement that the preclinical sciences were in trouble led to the appointment of a committee by the National Research Council, then recently established, to study the situation. Information it received from preclinical department heads at 68 medical schools convinced the committee that there was indeed "a great paucity of satisfactory assistants in the pre- clinical departments," that "insufficient immediate and prospective financial support" was largely responsible, and that the shortage of assistants was "seriously hampering the development of the preclinical sciences, and, through them, of medicine as a whole." The committee offered a suggestion that had been made to it in a number of places, that preclinical departments should have at their disposal "a number of attractive assistantships and research fel- lowships so that a man who wished to obtain additional training in one of the fundamental medical sciences, either for the purpose of better preparing him- self for practice or for a post in a clinical department, would find no financial obstacle in his way." The committee speculated that "some of the men availing themselves of such appointments might become sufficiently interested to give up their first intentions and become full-time members of a department of a preclinical science."31 ., Vol. 74, May IS, 1920, pp. 1415, 1416. 31 Ibid., Vol. 74, April 17, 1920, pp. 1117-1122.

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16 AN HISTORICAL VIEW National Research Fellowships The National Research Council was established by the National Academy of Sciences in 1916 to help organize the country's scientific resources to meet the threat of war. Its work during World War I demonstrated its usefulness as an agency for coordinating scientific research, and in 1918 President Woodrow Wilson asked the Academy to perpetuate the Council as a peacetime institu- tion.32 One of the first peacetime tasks to which it turned was the task out- lined earlier by the Committee of One Hundred of identifying and encouraging young researchers in science. Discussions between the executive officer of the Council, Robert A. Millikan, and the president of the Rockefeller Foundation, George E. Vincent, on the merits of a national program of postdoctoral re- search fellowships led to a grant by the Foundation of $500,000 to be used by the Council over five years in support of research fellowships in physics and chemistry. The grant was announced in March 1919; the first 13 fellows were selected before the end of the year. The stated purpose of the fellowship was threefold: to open a scientific career to a larger number of investigators and to give investigators a more thorough training in research, to increase knowledge relating to the funda- mental principles of physics and chemistry "upon which the progress of all the sciences and the development of industry depend," and to create more favorable conditions for research in the educational institutions of the coun- try. On the last point the Council was most specific. National Research Fellows will be permitted to conduct their investigations at institu- tions that will cooperate in meeting their needs. These needs differ widely from those of students seeking only instruction. Able investigators, actively engaged in productive re- search, are needed to inspire and guide the work of the Fellows. Research laboratories, adequately manned with assistants and mechanicians, and amply supplied with instru- ments, machine tools, and other facilities, are indispensable, and funds to provide sup- plies and to satisfy the constantly recurrent demands of research must be available. Above all, there must exist the stimulating atmosphere found only in institutions that have brought together a group of men devoted to the advancement of science through pursuit of research. The fellowships were to be awarded preferably, but not exclusively, to United States citizens who had had the equivalent of doctoral training. Indi- viduals were to be appointed initially for one year but were to be eligible for reappointment. They were to devote themselves entirely to research, except that during the academic year they could devote up to one fifth of their time to teaching (including preparation time), if teaching would benefit them edu- cationally, or to attendance of advanced courses of study. It was hoped, by 32'National Research Council Bulletin, Vol. 1, Part 1, No. 1, 1918, pp. 22, 23.

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17 NATIONAL RESEARCH FELLOWSHIPS the award of the fellowships, "to confirm a number of the most promising workers in research by enabling them to continue their research work im- mediately after taking their doctorates, at which time it is believed they are best qualified to continue any fundamental research."33 In 1922 the Rockefeller Foundation and the Rockefeller-endowed Gen- eral Education Board, acting in concert, pledged $500,000 for similar fellow- ships in the medical sciences, with emphasis on the preclinical sciences. In 1923 the Foundation pledged $325,000 for fellowships in the biological sci- ences. All three programs were continued when the initial grants were spent, and they received repeated extensions thereafter. Until the advent of large-scale federal programs for postdoctoral education in the 1950's, the Rockefeller Foundation, through the National Research Council, provided the single most effective means for the development of young American scientists as creative investigators. The record of the National Research Fellowships is remarkable. A study made in 1950 of the 1,359 indi- viduals who had been fellows between 1919 and 1949 found that 65 had been elected to the National Academy of Sciences and 3 had won Nobel prizes.34 Several others have been Nobel prizewinners since. Of 500 scientists newly starred as leaders in research in the 1937 and 1943 editions of the directory, American Men of Science, more than half had been postdoctorals, most of them National Research Fellows. Eighty-five percent said that their postdoc- toral experience had contributed much to their later scientific achievement, 15 percent that it had contributed moderately. In saying so they attached as much significance to their postdoctoral as to their graduate work.3S There can be no question but that the National Research Fellowships played a major part in strengthening American science. Robert A. Millikan made the judgment in 1950 that the fellowships had been "the most effective agency in the scien- tific development of American life and civilization" in his lifetime.36 The Rockefeller Foundation's investment in the fellowships totaled about $5 million. Although the number of fellows appointed each year during the twenties and thirties now seems small, it constituted a significant percentage of all PhD recipients in those years. Figure 1 shows the percentage of PhD recipi- ^Proceedings of the National Academy of Sciences, Vol. 5, 1919, pp. 313-315; Bulletin of the National Research Council, Vol. I, 1919-1921, p. 24; Myron J. Rand, The Scien- tific Monthly, Vol. 73, No. 2, August 1951, pp. 71-73. 3 Myron J. Rand, The Scientific Monthly, Vol. 73, No. 2, August 1951, p. 79. 5Stephen Sargent Visher, Scientists Starred, 1903-1943, in American Men of Science, The Johns Hopkins Press, 1947, pp. 361, 530. 36R. A. Millikan, The Autobiography of Robert A. Millikan, Prentice-Hall, New York, 1950, p. 213.

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28 AN HISTORICAL VIEW States or abroad."55 The Institute appointed its first trainee in January 1938 and its first fellows later the same year. It was the beginning of a program of federal support for the medical sci- ences that has had a far-reaching impact on medical education in the United States. But it was a beginning without ceremony. No one seems to have thought that the National Cancer Institute might be the precursor of other national institutes, that it might be a precedent with important consequences. The annual budget authorized for it was small-$700,000. The Rockefeller Foundation was spending much more at this time for work in medicine. Congress was spending annually more than three times as much on the eradi- cation of tuberculosis in cattle. For a war on cancer, $700,000 must have seemed a small budget; certainly not enough to launch a revolution in educa- tion. The Surgeon General, Dr. Thomas Parran, contracted with hospitals and universities to carry out the training provisions of the Act. The first National Cancer Institute trainee went for'his training to the Western Reserve Univer- sity. Physicians were appointed for two years to receive eight months' special training in each of the fields of pathology, radiology, and surgery. As is the case in many postdoctoral training programs since, research training was not a component. Candidates for the program were required to have had not less than three years of hospital experience.56 By 1948, 111 trainees had held appointments of one to three years at 35 universities, hospitals, and research institutes. None trained at the National Cancer Institute itself. The character of the training, however, was set by the Institute. While many trainees subsequently satisfied the requirements of spe- cialty boards, and some received credit for degrees, this was not the purpose of the program. In 1949 the Institute issued its own certificate for completion of the training.57 Fewer fellowships were awarded than traineeships. Forty-three National Cancer Institute research fellows were appointed between 1938 and 1946. The fellowships were not restricted to physicians and several recipients were PhD's. The Act's authorization of fellowships "in the Institute" was not construed to mean that they had to be held at the Institute; although many of the early fellows held their awards at the Institute, many attended other institutions.58 55 National Cancer Institute Act, 1937, Chapter 565 of the 75th Congress, 1st Session. S6Journal of the American Medical Association, Vol. Ill, Dec. 17, 1938, p. 2314. 57R. R. Spencer, M.D., National Cancer Institute Program of Postgraduate Training for Physicians, Public Health Reports, June 17, 1949, Vol. 64, No. 24, pp. 750-756. 58Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1939, Washington, D.C., p. 83. Research Fellows of the Na- tional Cancer Institute, January 1, 1938-April I, 1958, P.H.S. Publication No. 658, U.S. Dept. of Health, Education, and Welfare, 1959, pp. 1-6.

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29 THE FEDERAL GOVERNMENT The National Cancer Institute Act provided for the appointment by the Surgeon General of a six-member National Advisory Cancer Council. However, it did not give the Council any responsibility for overseeing the fellowship and training programs. Responsibility for selecting training centers, trainees, and fellows rested effectively with the professional staff of the Institute. National Institutes of Health In 1944 Congress passed an act to consolidate the many existing statutes governing the Public Health Service and to revise its organization to meet the needs of a nation again at war. Many of the changes were administrative. The National Cancer Institute, for example, was made a branch of a division of the service called the National Institute of Health. Other changes were more far-reaching. An important provision gave the Surgeon General the power from then on to award fellowships in any field "relating to the causes, diagno- sis, treatment, control, and prevention of physical and mental diseases and impairments of man." 59 His authority to award training grants was still con- fined to the field of cancer. The establishment by Congress of other institutes on the pattern of the National Cancer Institute, however, soon extended his authority to other fields. A National Institute of Mental Health was established in 1946,60 and a National Heart Institute and a National Institute of Dental Research followed in 1948.61 Then in 1950 an omnibus medical research act authorized the Surgeon General to set up an Institute of Neurological Diseases and Blindness and an Institute of Arthritis and Metabolic Diseases, to set up still other institutes whenever he determined such action "necessary," and to award training grants in any institute so established.62 In 1948 the National Institute of Health, the administrative division to which the separate research and training institutes reported, was officially renamed the National Institutes of Health. Funding of the institutes by Congress kept pace with their growing number. Appropriations for fellowships of all kinds, predoctoral and postdoctoral, jumped from $45,000 in the fiscal year 1946 to $1.4 million in fiscal 1950. Appropriations for training programs during the same period increased from $25,000 to $6.4 million. NIHPostdoctoral Fellowships In 1945 NIH was encouraged to view its mis- sion broadly when it was asked to take over a number of medical research s9 Public Health Service Act, 1944, Chapter 373 of the 78th Congress, 2nd Session. 60Public Law 587, 79th Congress, 2nd Session. 61 Public Laws 655 and 755, 80th Congress, 2nd Session. 62Public Law 692, 81st Congress, 2nd Session.

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30 AN HISTORICAL VIEW projects sponsored during the war by the Office of Scientific Research and Development. The following year it established a Research Grants Office to administer a continuing program of research grants. The new office was also made responsible for implementing the fellowship provisions of the Public Health Service Act of 1944.63 In 1947 a Central Qualifications Board was set up to coordinate the review of fellowship applications submitted in different fields. The Research Grants Office (renamed the Division of Research Grants) es- tablished three types of NIH fellowships: predoctoral, postdoctoral, and TABLE 2 Number of NIH Postdoctoral and Special Fellowships, Fiscal Years 1946-1967 Fiscal Year NIH Postdoctoral Fellows NIH Special Fellows Total 1946 2 2 4 1947 27 7 34 1948 119 20 139 1949 255 57 312 1950 268 38 306 1951 291 27 318 1952 222 17 239 1953 335 22 357 1954 426 36 462 1955 389 38 427 1956 342 39 381 1957 471 99 570 1958 482 94 576 1959 627 104 731 1960 822 159 981 1961 1,050 228 1,278 1962 1,211 276 1,487 1963 1,223 389 1,612 1964 1,190 425 1,615 1965 1,188 505 1,693 1966 1,237 537 1,774 19673 1,088 522 1,610 aData for 1967 are partially estimated and exclude fellowships awarded by the National Institute of Mental Health. Beginning in FY 1967 NIMH was separated administratively from the other National Institutes of Health. Data for earlier years include NIMH fellow- ships. Source: Data provided by the Career Development Review Branch, Division of Research Grants, NIH. 63 Annual Report of the Federal Security Agency, Section Four, United States Public Health Service, for fiscal year 1964, p. 299.

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31 THE FEDERAL GOVERNMENT special. The "special" category was intended for investigators who for some reason did not qualify naturally for a regular predoctoral or postdoctoral award. They might be men in highly specialized fields, distinguished foreign scientists who wished to spend a year doing research in the United States, or men with unusual qualifications. Table 2 shows the number of postdoctoral and special fellowships awarded by NIH. NIH Traineeships Unfortunately figures are not available on the number of postdoctorals supported on NIH training grants during the same period. The growth in dollar appropriations for training, predoctoral and postdoctoral, is given in Table 3. The following, however, is the number of postdoctoral trainees supported since 1963:64 Fiscal Year NIH Postdoctoral Trainees 1963 5,366 1964 6,042 1965 6,534 1966 6,861 The number of trainees and of fellows cannot be compared directly because many trainees hold other awards for short periods, for example, for a summer. TABLE 3 Appropriations for NIH Training Grant Programs, Fiscal Years 1946-1967 Fiscal Year Training Appropriation Fiscal Year Training Appropriation 1946 $25,000 1957 $28,075,000 1947 $250,000 1958 $32,932,000 1948 $2,810,000 1959 $49,902,000 1949 $3,930,000 1960 $74,673,000 1950 $5,415,000 1961 $110,000,000 1951 $6,652,000 1962 $118,506,000 1952 $7,392,000 1963 $154,139,000 1953 $8,184,000 1964 $172,602,000 1954 $10,813,000 1965 $181,311,000 1955 $11,051,000 1966 $209,896,000 1956 $14,502,000 1967 $224,486,000 Source: NIH Almanac, 1967, p. 74. 64Statistics prepared by the Resources Analysis Branch, Office of Program Planning, NIH.

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32 AN HISTORICAL VIEW It has been estimated that the 6,861 trainees supported in fiscal year 1966 held the equivalent of 5,300 year-long awards. The figure would probably be lower still if it included only awards held during the academic year or part of it and excluded awards held only during the summer. Even with this correc- tion, however, the number of postdoctorals on training grants far exceeds the number on fellowships. The large majority of postdoctoral trainees are MD's. In 1966 over 85 per- cent held the MD degree. Some also held a PhD, but less than 15 percent held the PhD alone. The NIH postdoctoral fellows are much more evenly divided between MD's and PhD's. In 1966 almost 45 percent of the fellows held the PhD degree or equivalent.65 The several institutes within NIH have pursued a variety of objectives in their training programs, and individual programs differ widely. Some programs, such as the original training program of the National Cancer Institute, are in- tended to provide training in needed clinical skills; others, to provide training in research. All the institutes, however, support research training to a greater or less extent. The National Institute of General Medical Sciences, established in 1962, is particularly concerned with basic research, but it has no monopoly in this area. Each of the other institutes supports basic research relevant to its mission. Unfortunately, it is not possible to determine from the available sta- tistics how many of the trainees supported by the several institutes are in re- search training programs and how many are in other sorts of training. Whatever the purpose of a training program, all the institutes follow the same criteria in selecting a hospital or university for a training grant. These criteria are "the significance and relevance of the proposed training program; [the] adequacy of the leadership, faculty, and facilities; and [the] training record of the institution and department concerned."66 An institution must apply for a training grant to receive one and is free to set its own educational policy in providing training but, in the absence of a clear institutional policy, NIH policies set the pattern. It has seemed to some in the universities that the universities have assumed too little responsibility. Robert E. Ebert, Dean of the Harvard Medical School in 1966, made the following statement: Although the University has become heavily involved in graduate [medical] education, it has no primary responsibility for this phase of education. The internship is the respon- sibility of the Council of Medical Education of the AMA. The Specialty Boards, as well as extra-university residency review committees, are responsible for the quality, content and length of residency training. The National Institutes of Health, through the mecha- 65 Joseph S. Murtaugh, Director, Office of Program Planning, NIH, in Proceedings of the Conference on Postdoctoral Fellowships and Research Associateships-in the Sciences and Engineering, National Research Council, 1967. 66 Administrative Policies Governing Training Grants of the National Institutes of Health, mimeographed manual, May 1, 1962, p. 5.

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33 THE FEDERAL GOVERNMENT nism of its study sections, is responsible for the definition of [postdoctoral] fellowship training. It is true that members of medical faculties play important roles on all of these various councils and boards, but only in an extra-university capacity. Neither the profes- sion nor the universities yet regard any of these programs as the responsibility of medical faculties. We are impelled to ask if the University can continue to assume that half of the education of a physician is not its business. Should not the faculty review the various programs of postdoctoral instruction going on within or near its walls as it does its doc- toral program either for the PhD or the MD degree? Especially in the area of fellowship training, which presumably is training young men for academic medicine, the University must take a more direct responsibility. National Science Foundation In the development of the National Institutes of Health, events outran the ar- ticulation of policy. In 1944 President Roosevelt asked Vannevar Bush, direc- tor of the war-time Office of Scientific Research and Development, to prepare a report on the federal support of science after the war. In Science, The End- less Frontier, published in 1945, Dr. Bush recommended the establishment of a National Research Foundation, funded by the Congress "for promoting the flow of new scientific knowledge and the development of scientific talent in our youth." He submitted a report by a medical advisory committee under the chairmanship of Walter W. Palmer of Columbia University urging the desira- bility of a new agency to channel funds into medical research. In the opinion of the Palmer committee none of the existing agencies of the government was "sufficiently free of specialization of interest" to warrant assigning to it the broad mission of supporting medical research across the country. "The Federal agency concerned with medical research should be created de novo and be in- dependent of all existing agencies." Dr. Bush, opposed to a separate agency for medicine, recommended the establishment of a single agency serving all of science, with separate divisions for the medical and natural sciences.6 "Sci- ence is fundamentally a unitary thing. The number of independent agencies should be kept to a minimum." He urged that there should be another division for scientific personnel and education. It would support undergraduate scholarships and graduate fellow- ships, and also "fellowships for advanced training and fundamental research." He submitted a report by a committee under the chairmanship of Isaiah Bow- man of Johns Hopkins that recommended a program of postdoctoral fellow- ships "as a direct aid to research." The Bowman committee felt that the program 67Robert E. Ebert, Report to the President of Harvard University for 1965-66, p. 7. 68Vannevar Bush, Science, The Endless Frontier, A Report to the President, Washington, D.C., 1945, pp. 28-34, 43-54.

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34 AN HISTORICAL VIEW . . . should include awards for older men to enable really experienced investigators to develop and utilize their talents most effectively. . . . Research workers who have reached the status of assistant professor or above tend to remain in their own universities and their time available for research tends to become increasingly broken up. In theory, the sabbatical year gives an opportunity for intensive research or travel, but in recent years universities have been less and less able to grant such freedom from academic routine. The resulting immobility of the senior staff serves to isolate the intellectual life of a university. .. and the individuals concerned, lacking outside stimulation, may incline more and more to perfunctory performance of routine duties.... Fellowships large enough to meet the salaries of advanced academic personnel for periods of intensive re- search work at their own institutions or at other universities would be an effective means of attacking these problems. The Palmer committee also urged the need for fellowships and recommended that postdoctoral fellowships in the medical sciences be tenable for periods up to six years. The committee cautioned, however, against "the establishment of lifetime research professorships, or of protracted research fellowships, at the expense of Federal funds."70 Five years later Dr. Bush's recommendations were realized in the National Science Foundation. The Foundation received meager appropriations in its early days and it was two years more before it was able to mount a fellowship program. By this time the National Institutes of Health were well established as a fellowship agency. The National Science Foundation incorporated a Divi- sion of Medical Research but no funds were appropriated to the Foundation for the support of research in the medical sciences until 1959. The National Institutes of Health(NIH) quickly became the main channel of federal support in this area. The National Science Foundation's total budget has never matched the total budget of NIH, and it has never been as large a sponsor of research training. Table 4 gives the number of fellowships the Foundation has awarded over the years for the support of postdoctoral scholars in various categories. Career Awards in the Medical Sciences Conditions in the universities after World War II made an academic career in the basic medical sciences appear to be as unattractive as it had been after World War I. In 1948 the average maximum salary of instructors in the basic medical sciences who had spent three to five years in PhD training was about the same as the average wage of carpenters and bricklayers. The best they could hope for by way of promotion was a professorship paying $8,000 to 69Ibid., pp. 91, 92. nolbid., pp. 54, 58.

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35 CAREER AWARDS IN THE MEDICAL SCIENCES TABLE 4 Number of NSF Regular and Senior Postdoctoral Fellowships and Science Faculty Fellowships, 1953-1969 Year NSF Postdoctoral Fellowships (Regular) NSF Senior Postdoctoral Fellowships NSF Science Faculty Fellowships (for College Science Teachers) 1952-53 38 — 1953-54 42 — — 1954-55 79 — — 1955-56 70 — — 1956-57 96 52 — 1957-58 109 55 100 1958-59 161 76 216 1959-60 194 83 302 1960-61 180 75 285 1961-62 235 91 285 1962-63 245 92 325 1963-64 245 95 325 1964-65 240 96 325 1965-66 229 98 325 1966-67 230 95 326 1967-68 150 65 250 1968-69 120 55 223 Source: National Science Foundation, Annual Reports. $11,000. "It is little wonder," commented a Survey Committee of the Ameri- can Medical Association and the Association of American Medical Colleges, "that young physicians enter the clinical fields or the fields of research and industry instead of the medical basic sciences. ... The clinical departments offer to young men a much greater range of opportunity than do the medical basic sciences. In the clinical areas a man may teach, carry on research, and keep in touch with clinical medicine. If he is not successful in obtaining a full- time position on the faculty, he may work on a part-time basis, or he can enter the practice of medicine and work for the medical school on a volunteer basis. All this constitutes stiff competition for the medical basic science fields."71 To improve the situation for promising young teacher-investigators in these fields, the John and Mary R. Markle Foundation launched in 1948 a program of Grants for Scholars in Academic Medicine. The grants, paying $5,000 a year for five years were to enable universities to give nominated individuals the best possible chance of developing their full powers. An applicant univer- 71 John E. Deitrick and Robert C. Berson, Medical Schools in the United States at Mid- Century, Report of the Survey of Medical Education, 1953, p. 198.

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36 AN HISTORICAL VIEW sity and its nominees were to be considered together. The university's role was described as follows: It involves selecting outstanding men just as their training ends but before they make a scientific reputation; steeling them against tempting positions outside their chosen field of academic medicine; protecting them from being overloaded with teaching and adminis- trative responsibilities and contributing funds toward their support, or their research, or both. It is hoped that the security thus provided for five years will be sufficient for the Scholars to prove their ability and to become established as research workers and teachers... . The real interest of a medical school in encouraging scientific talent should be evident in the plan for the Scholar offered by the school when it makes a nomination. In the selection process, the plan of each school will be carefully analyzed so that nomi- nations received from schools unable or unwilling to carry out the purposes of the scheme will be eliminated. This does not mean that the financially less fortunate medical schools will be neglected. On the contrary some of the better candidates and most thoughtful plans, we hope, will come from such sources. Quality is not dependent on income or size.72 Sixteen Markle Scholars were appointed in 1948. Eighteen years later, 431 scholars had been appointed in 88 schools.73 The program still continues. A similar program of Grants for Scholars in Radiological Research was established by the James Picker Foundation in 1953, and in 1954 the American Cyanamid Company through its Lederle Laboratories Division established a program of Lederle Medical Faculty Awards.74 In 1956 NIH was prompted to establish its own program of five-year fellow- ships for investigators in the medical sciences. The need was described as follows: 1. There are well-recognized deficiencies in the training of physicians for careers in research. Rarely does a physician receive the rigorous training in research methodology that is typical of the PhD-type of training. Experiments devised by medical schools and designed to remedy this weakness for students who intend to enter research rather than the practice of medicine will be financed by N1H. 2. The state of the sciences basic to clinical medicine—the preclinical sciences-has for some time been a matter of concern among those who have thought extensively about medical research, medical education, and their interrelations. These fields are becoming progressively more important as the essential unity of biological and medical sciences with the physical sciences is expressed operationally in the design and execution of ex- periments. Despite unparalleled need for a vigorous effort in this field, research is not flourishing. The number of younger men of top caliber who aspire to research and teaching careers in medical schools is inadequate. 72The John and Mary R. Markle Foundation, 1947 Annual Report, pp. 6-10. 73/Wd., 1965-66 Annual Report, p. 51. 74Lederle Medical Faculty Awards, Eleventh Year, 1954-1965, April 1964;A Statement of General Principles in the Granting of the Fifteenth Annual Series of Lederle Medical Faculty Awards, 1968-1969. 75.Science, Vol. 124, No. 3233, December 14, 1956, pp. 1189, 1190.

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37 EPILOGUE The NIH career fellowships, called Senior Research Fellowships, were re- stricted to men in the preclinical sciences who, having had two years of post- doctoral training or experience, gave promise of a career in independent re- search and teaching and demonstrated "potential for development as an academic leader."76 In 1961 the fellowships, redesignated Research Career Development Awards, were thrown open to investigators in any of the sciences related to health-clinical as well as preclinical. In fiscal year 1964 a total of 747 individuals held these appointments. They included 191 in clinical medicine and dentistry, 466 in the basic medical and biological sciences, and 81 in the behavioral sciences. Epilogue These are some of the highlights in the development to date of postdoctoral education in the United States. This account is necessarily sketchy, and many programs that have made a significant contribution have been passed over. This is particularly true of the period since World War II. No account has been given of the postdoctoral fellowship programs of the Atomic Energy Commis- sion and of the Air Force Office of Scientific Research, of the Fulbright-Hays program, of the development of in-house postdoctoral research associateships at the National Institutes of Health and in other government research institu- tions, and of the programs of the many private foundations that, undaunted by the flow of federal money, have committed funds to support postdoctoral study. The postwar history of the Social Science Research Council fellowships, the re-establishment of a postdoctoral fellowship program for the humanities by the American Council of Learned Societies, and the recent entry into the field of the National Endowment for the Humanities are also an important part of the story. Equally important is the growing population of postdoc- torals supported by universities on research project funds. As shown in later chapters, such postdoctorals are now the largest segment of the total postdoc- toral population. How their numbers have grown cannot be told since no one has counted them previously. The pattern postdoctoral education has followed since the war was largely set in the prewar years. As we have seen, many of the problems that concern us now were problems then: the need to support young PhD's in creative re- 76'Grant and Award Programs of the Public Health Service, Vol. II, Policy and Informa- tion Statement on Training Programs, 1959, p. 21. ^Reference Tables on Persons Receiving Support from N.I.H. Extramural Training Pro- grams during Fiscal Year 1964, Public Health Service, 1966, Table 8, pp. 141-243.

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38 AN HISTORICAL VIEW search, the need to provide MD's with opportunities for research training, the balance of teaching and research, the influence of the sponsoring agencies, the responsibility of the universities. We are concerned in the following pages with a form of education that has developed over a long period, shaping itself in response to long-felt needs. It has had its setbacks, but it has survived the test of time.