now believe that the triple-threat is no longer feasible and that a clinician can focus on being outstanding in only one, or possibly two, of these areas. This chapter explores the number of faculty available for performing clinical research, examines some of the barriers to careers in clinical research, and suggests some solutions for overcoming the impediments to these career paths.

ENVIRONMENT FOR CLINICAL RESEARCH

Clinical research can be conducted in numerous sites, but the primary locus of most clinical research has been the academic medical center. There are currently 126 accredited allopathic medical schools in the United States, 14 of which are free standing and 112 of which are affiliated with a university. In addition, some academic medical centers are closely affiliated with schools of nursing, pharmacy, or allied health. To trace the course of development to the modern academically based clinical research environment, it is useful to reflect on the history of academic medical centers.

Prior to this century, medical education was the province of voluntary private practitioners. Over the past 100 years, medical education in the United States has undergone vast changes. At the turn of the century there were approximately 155 medical schools in the United States and Canada, and there were three predominant models: the hospital-based clinical model, in which students were trained through programs similar to apprenticeships; the university-based model; and the proprietary or for-profit schools (Burke, 1992). In 1910 Abraham Flexner published a report, "Medical Education in the United States and Canada," based on personal visits and surveys of medical schools (Flexner, 1910). By the time Flexner issued his report, the university-based teaching model was beginning to gain broad acceptance in the United States. Flexner endorsed this model and recommended that the responsibility of medical education be delegated to full-time faculty members who would also be involved in advancing knowledge in medical science as well as training physicians. Moreover, Flexner's description of the for-profit medical schools and the low educational standards of these schools led to the closure of many schools and reforms in a large number of the schools that remained. Flexner's report may thus have served as the catalyst for the shift to staff clinical departments with full-time faculty. This change to full-time faculty in the university-based medical centers, combined with an academic organization similar to those in the other parts of universities, made the medical school more like the rest of the university, with a greater emphasis on scholarly achievement (Fye, 1991).

Largely as a result of the Flexner report, the number of medical schools in the United States dropped to 80 by 1925. Following World War II, the number of medical schools began to rise again as a result of a variety of forces. In 1940 there were about 2,800 full-time medical school faculty. By 1950, the number



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