However, what constitutes scholarship is not clearly defined. Although Boyer has suggested a broadening of what constitutes scholarly activity, over the past few decades scholarship in biomedicine has become equated with research, particularly laboratory-based research that frequently allows rapid data collection and publication (Boyer, 1987). Scholarship is, in turn, measured by one's ability to obtain competitive grant funds and publish results in peer-reviewed journal articles (Abrahamson, 1991; Applegate, 1990). Laboratory investigators, who devote all their time to research, usually have protected time to pursue research that is secured by grant funds. Clinical investigators, however, less frequently have grants to support their salaries and protect a segment of time to perform research activity. Thus, defining reliable measures of scholarship based on research activities for clinical investigators is much more difficult than for bench scientists (Bickel, 1991; Bickel and Whiting, 1991).

Physician faculty in clinical departments have certain patient care responsibilities that are distinctly different from those of physicians in independent research institutes, private industry, or preclinical departments (Blackburn, 1979). Clinical research faculty are generally hired to care for patients and teach clinical medicine to students, house staff, and clinical fellows—demands that are not made on nonclinical faculty. The economic necessity of maintaining a clinical department in financial balance has placed a greater emphasis on the clinical care component of a department's activities (Chin, 1985). Although a large portion of medical school revenues were previously derived from research funds, a review of medical school financing demonstrates that a growing fraction of medical school revenues are derived from professional practice plans (Hughes et al., 1991). During the late 1980s the revenues from professional services began to exceed those derived from research sources (Figure 2-7) (Ahrens, 1992; Jolin et al., 1992).

Although junior faculty members are recruited with the expectation that they will develop creative lines of investigation, the pressures of starting an academic practice, building a referral base, and contributing to departmental coffers can be overwhelming (Applegate, 1990; Jones et al., 1985). Academic health centers have contributed to these pressures and problems by imposing expanded funding expectations on young physician-investigators. It is believed that these investigators can support themselves with clinical income while performing pilot research studies and until they gain grant support. This also reinforces the disincentive to pursue clinical research when funding appears tenuous and encourages young investigators to pursue more secure career opportunities in bench research.

The perception that laboratory-based research is more scholarly and leads more readily to promotion lures junior faculty away from patient-based research. Moreover, while NIH and industry provide substantial sums of money for large, multi-institutional clinical studies and clinical trials, the principal investigators



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