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OCR for page 55
CHAPTER FIVE
PHYSICIAN- SCIENTISTS
Training in the clinical sciences is critical to maintaining
our country's leadership in the translation of basic discover-
ies to meaningful patient care. As the nation demands more
primary care of our physicians, we must not lose sight of
the tremendous advances that have been made by individu-
als using basic approaches to explore interesting and sig-
nif~cant clinical problems.
Clinical research includes a spectrum of investigation.
At one end, it is represented by the use of basic scientific
approaches and tissue samples from patients or normal indi-
viduals to generate fundamental insights into the disease
process. At the other end, it is represented by studies in
which whole patients, normal volunteers, or populations of
subjects each serve as He laboratory.
The clinical investigator generally has an M.D. or other
health professional doctorate, although the committee rec-
ognizes that basic scientists also participate in clinical in-
vestigation. The committee has based its assessment of na-
tional need on the fact that most government-sponsored
research in He clinical sciences is performed in medical
schools or academic health centers (Appendix Table F-22~.
The ability of medical schools to conduct clinical research
depends largely on the continuing availability of clinical
faculty with strong research skills. The future availability
of well-prepared clinical research faculty has come into
question by a number of authors (Ahrens, 1992;
Fredrickson, 1993; IOM, 1994~. Given continuing national
concern over the future supply of skilled clinical investiga-
tors, we have restricted our analyses in this chapter to the
need for physician-scientists.2
Previous National Research Council (NRC) study com-
mittees have focused on the special role that He physician-
scientist has played in bringing clinical insights to bear in
the laboratory and in translating new knowledge into the
context of medical practice (NRC, 1981~. Almost all NRC
55
committees that have addressed research training needs in
the clinical sciences have observed that there continues to
be a shortage of physicians willing to prepare for research
careers. Many committees have focused on He very real
effects of competing-and more lucrative-opportunities
available in private practice as a reason for this trend (NRC,
1978~. More recently, some committees have observed that
changes occurring in the way medical schools finance their
operations and structure Heir faculties simply does not pro-
vide an environment conducive to preparation for a research
career (NRC, 1985~. We concur and provide evidence else-
where in this chapter suggesting that upcoming changes in
the national support for health research and health care re-
form may further erode research and research-training op-
portunities in academic health centers.
In addition to these contextual variables, we believe the
nature and timing of National Research Service Award sup-
port may directly effect the success of recruiting physicians
into research careers. On the basis of information gathered
by the National Institutes of Health (NIH), we believe that
the Medical Scientist Training Program (MSTP) may be
especially effective in launching individuals into research
careers. This program was established in 1964 to permit
individuals to pursue the M.D. and the Ph.D. degrees con-
currently. The MSTP program has consistently had a high
proportion of graduates involved in research and actively
contributing to He advancement of the clinical sciences.
(See also, Appendix A for a summary of available outcome
studies.)
Opportunities for careers in clinical research abound.
Our continuing challenge is to stimulate interest of clini-
cians in contributing to that effort, and He NRSA program
can clearly play a role relative to that goal.3 In the sections
that follow, we will review some of the more exciting ad-
vances in clinical science that create He need for a continu
OCR for page 56
MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
ing research effort, summarize the current market for these
scientists, and recommend specific changes in the NRSA
program that may be effective in expanding the cadre of
physician-scientists needed at this time.
ADVANCES IN CLINICAL SCIENCE
Advances in clinical science have been enormous and
include, but are not limited, to the following:
· Identification of the genetic defect in various genetic
disorders, including cystic fibrosis. Cystic fibrosis is the
most common genetic disorder in Caucasians, affecting 1 of
every 2,000 children. The disease is characterized by pul-
monary infections and pancreatic insufficiency and is due
to a cellular defect in the development of secretions. The
genetic defect associated with the disorder is found in chro-
mosome 7. This discovery allows three major advances.
First, it allows genetic counseling within families. Second,
it has allowed a determination of the product of the gene.
This information will provide a rational approach to devel-
oping drugs to correct He defect. Finally, it will allow
studies that attempt to replace the defective gene with a
normal one in tissues that are affected. Indeed, such so-
matic gene therapy has already begun.
e Identification of the gene associated with bowel can-
cer. Very recently, two separate groups of investigators
demonstrated a genetic defect localized to chromosome 2,
which is associated with hereditary nonpolyposis colon can-
cer. The gene involved appears to control DNA repair, and
a defective gene seen in patients with colon cancer leads to
instability of cellular DNA. This research is a spectacular
example of the different ways in which basic research can
lead to clinical advances. In one laboratory the research
developed from studies performed in yeast and bacteria that
examined how these organisms repair DNA and the genetic
defects associated with DNA instability. In another labora-
tory there is a long history of studies in humans examining
genetic defects associated win a variety of colon cancer
syndromes. In other words, this remarkable advance in our
understanding of colon cancer came from distinct pathways,
one originating from basic studies of normal mechanisms in
bacteria and yeast and He over from more clinically ori-
ented studies looking at abnormal grown and differentia-
tion of colon cells. These studies will allow Be develop-
ment of reagents that can be used to screen for colon cancer.
· Creation of an animal model for ankylosis spondylitis
by using transgene methodology. Ankylosis spondylitis is
a syndrome Hat predominantly affects joints of the spine.
Approximately two decades ago it could be demonstrated
that the disease was significantly associated with a specific
HLA type, HLA-B27. Indeed, 90 percent of patients win
ankylosis spondylitis had He HLA-B27 genotype. In an
56
attempt to demonstrate the nature of He association between
the gene and the disease, investigators established a rat
model in which the human HLA-B27 gene was inserted by
using aansgene methodology. In some of Be animals a
disease developed that mimicked human ankylosis
spondylitis. These animals not only provide a model for
determining just how He gene influences Be expression of
the disease but also for deciding what other factors may be
involved. They also provide a model for studying the effec-
tiveness of various forms of therapy.
The importance of clinical research to advancing our un-
derstanding of clinical disorders is captured in a recent edi-
torial in Science written by Editor-in-Chief Daniel E.
Koshland Jr. (1993~:
In the 1980s and l990s NIH researchers, intramural and
extramural, performed the first trial of gene therapy in
humans, proved the effectiveness of methotrexate for
treating rheumatoid arthritis, developed new methods for
growing skin to repair burns, showed that control of glu-
cose levels slows progression of diabetes, showed effec-
tiveness of cholesterol reduction in the prevention of
heart disease, demonstrated an effective treatment for
spinal cord injury, found a new drug for Parkinson's
disease, showed that aspirin and coumadin lower the risk
of stroke, developed methods of hypertension control
that have reduced heart attacks and strokes by more than
50 percent, and so on for many other discoveries.....
These followed many earlier discoveries, including the
polio vaccine, the measles vaccine, hormone replace-
ment therapy, fluoride to prevent tooth decay, to name a
few. We are living longer, we are living with less pain,
we are living with less cost to alleviate health deficien-
cies than any previous generation because of the find
ines of health researchers In the not-so-distant past,
smallpox epidemics killed 25 percent of the inhabitants
of towns that were invaded by the virus. Today we are
storing the last traces of the virum because that dread
disease has been eradicated from the Earth.
Clearly, this partial list of clinically relevant discoveries
supports the practical value of clinical research. lThe United
States is the world leader in clinical research and we must
make a renewed commitment to retain this leadership. The
recommendations of this report should allow us to remain
in this position of preeminence.
ASSESSMENT OF TO CURRENT MARKET
FOR CLINICAL SCIENTISTS
Degree Production and Career Patterns
Clinical scientists work in a variety of settings but pri-
marily in academic heals centers. Between 1981 and 1991,
the number of full-time faculty employed in clinical depart
OCR for page 57
PHYSICIAN-SCIENTISTS
meets grew by about 38,000 to just over 59,000 (Appendix
Table F-23), suggesting that the market for clinical scien-
tists remained relatively robust throughout He 1980s.
Degree Production
The major source of new physician-scientists is the
nation's medical schools. The most readily available infor-
mation about patterns of enrollment and degree production
is He Association of American Medical Colleges (AAMC).
Data from AAMC (Appendix Table F-23) reveals Hat medi-
cal school enrollments remained essentially flat between
1981 and 1991 at about 65,000 students. The number of
medical degrees awarded each year also remained level at
about 15,500 per year in the 1980s.
Career Patterns
Few data sets are available for sorting out the unique
patterns of research careers among physician-scientists. The
American Medical Association provides information about
the number of physicians primarily engaged in research
(Appendix Table F-23~- which fluctuated between 16,000
and 23,000 between 1981 and 1990. But these figures may
also include trainees in graduate medical programs. Per-
haps more telling is the trend in success rates of M.D.s who
apply to the National Institutes of Health which peaked at
about 45 percent in 1987 and has leveled off at about 37
percent (on average) thereafter (Appendix Table F-23~.
Market Forces
There are several influences on the availability of ca-
reers in clinical research. These influences, called market
forces, range from how we have traditionally trained clini-
cal researchers to outside industrial and governmental
spending trends. As the nation begins to develop a new
system of health care delivery, these market forces will be-
come increasingly important.
Academic Health Centers
An academic health center can be defined as a medical
school working in conjunction with a teaching hospital and
at least one over health professional school to achieve mu-
tually agreed upon goals for education, research, and provi-
sion of clinical care. Approximately 68 percent of NIH
R01 support goes to these academic health centers. Aca-
demic health centers therefore constitute the major sites at
which heal~-related research and research training are car-
ried out. Moreover, a significant amount of their support
for research is derived from income obtained for the provi-
sion of clinical care. This income stream is threatened by
57
changes in healthcare reform Hat place academic heals
centers at a disadvantage with regard to the cost of provid-
ing medical care. This presents a Treat to He market not only
for training but also for support of trained investigators.
Pharmaceutical and Biotechnology Industry
Uncertainties in health care reform has forced industry
to be exceedingly cautious win expenditures, and in some
cases to lay off large numbers of employees. This posture
clearly stifles innovation. One of the first areas to feel the
effects of budgetary constraints is research. This soft side
of the market has to be balanced by the fact that there are
tremendous opportunities for the development of unique
agents to Heat significant clinical disorders.
Cap on Domestic Spending
The federal deficit, budget reconciliation, and a cap on
domestic spending indicates that support for research and
training will have to compete for many other high-priority
areas supported by the domestic budget. This scenario is
one in which the NIH budget is likely to grow at a rate
certainly not greater and probably somewhat less than the
biomedical research price index.
Emphasis on Increasing the Training of Generalists
There clearly is an enormous pressure nationally to in-
crease the proportion of generalists in medicine and de-
crease the proportion of specialists. Heretofore, significant
research training and research activity has occurred in asso-
ciation win specialties, particularly the medical specialties.
Indeed, some view the problem in the imbalance of general-
ists to specialists as a result of overemphasis on research
spending. This, therefore, provides a diminished en~usi-
asm among some to further increase funding for research or
research training.
OUTLOOK FOR CLINICAL SCIENTISTS
In addition to market forces, there are factors that influ-
ence the demand for clinical scientists. These demand indi-
cators are expenditures for clinical research and develop-
ment (R&D) in medical schools; professional service
income in medical schools; total revenue; budgeted vacan-
cies in medical schools, both in clinical and basic science
departments; and the clinical faculty/student ratio.
Expenditures For Clinical Research and Development
From 1985 to 1990, expenditures for clinical R&D in
medical schools increased moderately. The average in
OCR for page 58
MEETING THE NATION9S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
crease was about 13 percent per year. An estimate of the
amount of support for clinical R&D in medical schools is
needed to refine the model of demand for clinical faculty.
An estimate of clinical R&D expenditures in medical
schools was derived by using the proportion of total NIH
obligations used to support clinical research. From 1969 to
1989 this proportion increased by 60 percent (Appendix
Table F-22).
Since 1980 public medical schools have had higher lev-
els of research expenditures than have private schools. This
is partly due to the fast grown in the number of public
schools. Clinical R&D in public schools grew at an annual
rate of 7 percent since 1980 as compared with only about 4
percent per year in private schools. However, private
schools remain more research intensive as indicated by re-
search expenditures per school. Average clinical R&D ex-
penditures were $14.6 million in private schools in 1990
compared win $10.2 million in public schools (Appendix
Table F-24).
Professional Service Income
Service income generated by medical school faculty has
continued to grow. From 1989 to 1990 service income gen-
erated by medical school faculty grew 14 percent and from
1990 to 1991 this income grew 13 percent (figures adjusted
for inflation in 1987 dollars). This has increased as medical
schools have become very successful in providing clinical
care. Thus, medical schools have come to depend on the
clinical income to support their research and educational
. .
missions.
Total Medical School Revenue
Service income and federal research funds contributed
over half of all medical school revenues in 1991. Another
large portion came from state and local government sources.
Tuition contributed only about 4 percent in 1991. With an
average yearly tuition increase since 1985 of about 6 per-
cent, medical student indebtedness, as noted by several
testifiers at the public hearing, may operate as a deterrent to
their pursuit of research training. The rates of total rev-
enues have grown at an average yearly rate of 14 percent
since 1986.
Budgeted Faculty Vacancies
Total budgeted medical school faculty vacancies have
grown at an average yearly rate of about 6 percent since
1989. The major growth of vacancies is in He clinical sci-
ence departments. There has been a steady decrease of fac-
ulty vacancies in He basic science departments with a high
58
of 801 budgeted vacancies in 1985 to the 1991 low of 643
vacancies.
Faculty/Student Ratio
Enrollments, revenue, and clinical faculty size are the
basic elements in assessing personnel needs for He clinical
sciences in medical schools. The ratio of clinical faculty to
enrollment is largely determined by He funds available to
support faculty.
Priority Fields
Clinical investigation requires practitioners to stay
abreast of developments in both medicine and science, each
of which is in constant acceleration and often the two do
not track in parallel directions (Fredrickson, 1993~. Obser-
vations from the study of patients lead to the development
of hypotheses, which lead, in turn, to scientific experimen-
tation. Interest in the patient is always paramount, but sci-
entific experimentation runs the risk today of taking the
clinical investigator away from the bedside to the clinical
laboratory. Ahrens (1992), in particular, has decried the
reductionist direction of clinical investigation, suggesting
that patient-oriented research is seriously imperiled. We
concur with Ahrens view that more emphasis should be
placed on the preparation of investigators familiar with the
experimental paradigms associated with patient-oriented re-
search. At He same time we recognize that laboratory-
based clinical investigation has a significant and continuing
role in He national health effort. However, from our review
of the literature, and on He basis of our expert judgement,
we cannot help but conclude that there is indeed a dearth of
individuals adequately trained to perform patient-oriented
or population-based research.
With the development of new therapies and diagnostic
procedures, there is an urgent need to train individuals who
can carry these advances into the clinic so that Heir effec-
tiveness can be measured and made available to the nation.
NRSA funds, either through individual NRSA fellowships
or programmatic training grants, can play an effective role
in promoting the specialists that are needed.
The MSTP also represents a priority field. Established
in the 1960s, this program has been especially attentive to
the essential training requirements for clinical investigation.
A 1992 study of graduates of the Johns Hopkins
University's M.D./Ph.D. program found that all of those
who had completed their training were actively involved in
research: 81 percent in academia, 14 percent at research
institutes, and 5 percent in the biotechnology industry
(McClellan and Talalay, 1992. See also Bradford et al.,
1986 and Frieden and Fox, 1991~.
NIH has also analyzed information about first-time ap-
plicants for research grants (R01) and prior research train
OCR for page 59
PHYSICIAN-SCIENTISTS
ink experience (Appendix Table F-25~. They found that in
1989 nearly 60 percent of individuals holding joint M.D./
Ph.D. degrees and applying for research support had re-
ceived formal research training Trough support provided
by NIH; this value was 47 percent for Ph.D. applicants and
42 percent for M.D. applicants. Furthermore, among first-
time NIH grant recipients in 1989, 68 percent of the M.D./
Ph.D. recipients had had previous NIH supported research
training experience compared win 55 percent of the grant
recipients holding Ph.D. degrees and 52 percent of those
holding M.D. degrees (Appendix Table F-26~. We con-
clude that continued and expanded support of the MSTP
program will yield He cadre of active and successful physi-
cian-scientists so sorely needed for the national research
effort today.
ENSURING TEW DIVERSITY
OF HUMAN RESOURCES
Issues remain regarding He recruitment of minorities to
faculty and He retention of all M.D. investigators re~ard-
less of ethnicity and gender. In addition to improved re-
cruitment, there must be specific attention given to the re-
tention of women as clinical investigators and faculty.
Extending the tenure clock and having on-site day-care are
two examples of ways to facilitate their retention.
Race and Ethnicity
Medical school faculty reveal a race/ethnicity mix simi-
lar to the basic biomedical sciences (AAMC, 1992~. Be
cause most of the U.S. population will soon be a mixture of
races over than white, the market will demand a more
widely representative pool of researchers. About 13 per-
cent of the faculty are members of minority groups and the
largest share of these workers is Asian (Table 5-1~. Table
5-1 displays the medical school faculty by rank and
ethnicity: of the professors, 87.6 percent are white, 5.7
percent are Asian, and 2.4 percent declined to respond; of
the associate professors, 82.5 percent are white, 7.9 percent
are Asian, and 3.1 percent declined to respond; of the assis-
tant professors, 77.5 percent are white and 8.6 percent are
Asian, and information was missing on 4.8 percent; of the
instructors, 72 percent are white and 9.4 percent are Asian,
and information was missing on 7.4 percent. Although 13
percent of the entire faculty represent minorities, this mix is
generally not yet reflected in higher faculty ranks.
Age
Figure 5-1 shows He distribution of U.S. medical school
faculty by age. Out of a total of 70,187 faculty, 57.6 per-
cent are ages 40-49 and 25 percent are ages 30-39. Table 5-
2 indicates that of those aged 40-49, 22.4 percent are full
professors, 55.3 percent are associate professors, 39.1 per-
cent are assistant professors, and 29.9 percent are insauc-
tors. Of those aged 30-39, 0.3 percent are professors, 8.1
percent are associate professors, 45.8 percent are assistant
professors, and 51.8 percent are instructors. Of the M.D./
Ph.D. graduates, 39.8 percent are ages 40-49 and 25 percent
are ages 50-59 (Table 5-3~. Only 15.6 percent M.D./Ph.D.
graduates are ages 30-39.
TABLE 5-1 Distribution of U.S. Medical School Faculty by Rank and Ethnicity
Professor
EthnicityNumberHoNumberHoNumber SoNumber %
Native American240.1130.122 0.111 0.2
Asian1,0655.71,3347.92,300 8.6590 904
Black19313191.9778 2.9300 408
Mexican American280.1410.2114 0.419 0.3
Puerto Rican960.51460.9247 0.988 104
Other Hispanic2581.42551.5461 107129 201
White16,39687.614,00882.520,838 77054,512 72
Refused4462.45313.1843 301156 2.5
Missing2151.133421,293 408465 704
Total18,72110016,98110026,896 1006,270 100
Associate
Professor
Assistant
Professor
Instructor
a Declined to respond.
SOURCE: Association of American Medical Colleges (1992~.
59
OCR for page 60
MEETING THE NATION'S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
Total = 70,187
30-39 (1,420) 2.0%
(17,521) 25.0%
60-69
(8,082) 1 1 .5%
Missing
(1,493) 2.1%
FIGURE 5-1 Dis~ibubon of U.S. medical school faculty by age.
SOURCE: Association of American Medical Colleges (19921.
TO NRSA PROGRAM IN
TElE CLINICAL SCIENCES
50-59
(15,091) 21.5% Every NRC study committee has noted Cat recruitment
of qualified clinical researchers poses special challenges.
Under 30 Physicians, dentists, and veterinarians enjoy several at~ac
,(215) 0.3% live career alternatives. The vast bunk of Ph.D. trainees
pursue research careers, but only one-~ird of postdoctoral
M.D. trainees have followed that path, with most entering
medical practice instead. Part of Me reason is that prepar-
ing clinical specialists for practice in shortage fields has
been an explicit purpose of the NIH funding programs.
With that goal now substantially met, however, Me commit-
tee doubted the need for continued subsidy to clinical train-
ing for practice.
TABLE 5-2 Distribution of U.S. Medical School Faculty by Degree and Age
Age
Professor
Number % Number
Associate
Professor
%
o
801
55.3
25.1
9
1.3
1.1
100
Assistant
Professor
Number
_
12314
10512
2286
790
129
807
268g6
%
0.2
45.8
39.1
8.5
2.9
0.5
3
100
Number
102
3248
1875
533
168
25
319
6270
Instructor
%
1.6
51.8
29.9
8.5
2.7
0.4
5.1
100
Under 30
30.39
4049
50-59
60~9
70+
Missing
Total
SOURCE: Association of American Medical Colleges (1992~.
o
62
4185
7835
5526
1038
75
18721
o
0.3
22.4
41.9
29.5
5.5
0.4
100
o
1375
9397
4265
1S32
220
192
16981
TABLE 5-3 Distribution of U.S. Medical School Faculty by Rank and Age
Age
Under 30
30-39
4049
50-59
60~9
70+
Missing
Total
. .
M.D. Ph.D./O.H.Da M.D.-Ph.D./M.D.-O.H.D.a Other
Number % Number % Number % Number
. . . .
60
12114
15235
8786
5203
971
456
42825
0.1
28.3
35.6
20.5
12.1
2.3
101
100
58
3715
7976
4652
1995
268
237
18901
0.3
19.7
4202
24.6
10.6
1.4
1.3
100
a O.H.D.: Other health doctorate.
b Other: Faculty with non~octoral/no degree or missing degree data.
SOURCE: Association of American Medical Colleges (1992~.
60
600
1529
960
586
131
31
3838
o
15.6
39.8
25
15.3
3.4
0.8
100
, . .
96
1092
1625
693
298
50
769
4623
i
2.1
23.6
35.2
15
6.4
1.!
16.6
100
OCR for page 61
PHYSICIAN -S CIENTISTS
In its first report in 1975, the committee found the avail-
able data on clinical researchers to be wholly inadequate to
its needs, and it declined to recommend any change in ex-
isting levels of funding: 140 predoctoral and 3,340
postdoctoral clinical sciences trainees. Beginning with the
1976 report, the committee began to grapple in earnest with
the scope of its task. On the basis of unique value and the
special demands of clinical research and the fact that pro-
fessional schools do not ordinarily prepare students for ca-
reers as researchers, the committee concluded that
postdoctoral clinical trainees should generally receive their
support in the form of training grants made to professional
schools, which permit these institutions to build in a short
time the critical mass of students and web of resources nec-
essary for high-quality programs.
Evidence available in the early 1970s suggested that, un-
like the burgeoning supply of Ph.D. researchers, the pool of
M.D. investigators was shrinking while demand was grow-
ing steadily. Despite 6 percent annual grown in medical
school faculties, the American Medical Association figures
showed a significant drop since 1968 in the number of nhv-
sicians engaged primarily in research. Therefore, the com-
mittee recommended funding a total of 2,800 postdoctoral
traineeships and fellowships, up 10 percent from the num-
ber funded in 1975. It also praised the MSTP, initiated in
fiscal year 1964, which supported students in combined 6-
year M.D./Ph.D. courses. The committee recommended
funding 600 MSTP traineeships, up 19 from the 581 funded
in 1975.
Win the next several reports beginning in 1977, the com-
mittee began exploring why the number of physicians-sci-
entists was dropping. Although both enrollment and R&D
funding were rising rapidly at medical schools, many estab-
lished clinical faculty members were spending relatively
little of their time conducting research. In response to this
fin ding, the committee detailed a number of factors that it
believed might discourage physicians from undertaking re-
search careers:
· the risk of failing at an untried field after demonstrat-
ing the ability to succeed in medical practice,
· the loss of income as compared to practice,
· a growing perception among students that patient care
has greater value than research,
· social pressure on students to enter primary care
fields, and
· an image that paperwork and red tape inhibit research-
ers more than in the past.
In addition, the committee noted a discrepancy between the
medical training calendar and the NIH grant cycle. Physi-
cians who were planning for residencies to begin in July
had to do so as early as the preceding October, many months
before NIH announced its training awards.
61
In view of these circumstances, He committee continued
through the 1970s to recommend 2,800 postdoctoral
traineeships and fellowships in clinical sciences. It also
continued to praise He MSTP awards as a highly effective
method of producing clinical researchers, recommending
incremental increases in He program.
By 1979 the committee's warnings appeared to have had
an effect. Presidents of four leading societies discussed He
threat of clinical investigator shortage in major addresses,
as did a conference at He University of Chicago. Various
agencies had already begun trying to counter the shortage.
NIH, for example, had expended and modified its grant
mechanism to ease the transition from medical school to
research training and then to independent research. A 1978
amendment to the NRSA Act encouraged students to do
short-term research under 3-month grants not subject to
payback.
Several other developments that pointed toward a
brighter outlook were an increase in the number of physi-
cians reporting research as a major activity, an increase in
the number of clinical science traineeships and fellowships,
and survey results showing that medical students were
growing more interested in research. The committee main-
tained its recommendation of 2,800 postdoctoral awards.
During the early 1980s the committee continued to rec-
ommend holding the number of awards stable at 2,800.
Market opportunities for clinical investigators continued to
be favorable, win medical school faculties still growing
and providing places for young scientists interested in re-
search careers. The immediate problem was the recruit-
ment of physicians to undertake research Raining. The com-
mittee was concerned about a looming physician surplus,
which would probably slow the growth of medical school
enrollments and faculty and in turn reduce the positions
available to new clinical researchers. Even win fewer open-
ings, however, Be committee believed that clinical investi-
gator posts would remain hard to fill.
In 1985 He committee recommended a rise in He num-
ber of NRSA awards. It believed Hat demand would grow
faster than expected, in part because of increasing attrition
from an aging faculty pool.
The 1985 report also highlighted some important changes
in medical school financing that the committee feared might
further weaken clinical departments' commitment to re-
search. As revenue from patient care steadily climbed, the
committee believed that clinical faculty might find these
demands competing for the time needed to prepare propos-
als, collect data, write grants, and so forth. In addition, as
faculties grow less rapidly, medical school might favor hir-
ing clinician-teachers over physician-scientists.
The committee also examined factors affecting young
dentists' decision to pursue careers in clinical research. Al-
though, unlike physicians, dentists have ample opportuni
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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
TABLE 5-4 Aggregated Numbers of NRSA Supported
Trainees in Me Medical Scientist Training Program (MSTP)
for FY 1991 through FY 1993.
Fiscal Year
1991
1992
1993
Number of Predoctoral Trainees
783
806
822
NOTE: Based on estimates provided by the National Institutes of Health See
Summary Table 1.
ties for research during postdoctoral specialty training, only
a few trainees receive salaries and some must even pay tu-
ition. The committee recommended special consideration to
providing adequate support for training dentist-researchers.
In 1989 the committee noted that the number of NIH
traineeships and fellowships for clinical investigators
(whom it chose to call physician/scientists) had not in-
creased as fast as health-related R&D expenditures. The
percentage of M.D.s who were principal investigators on
NIH research grants had fallen, although the number of
M.D./Ph.D. principal investigators had remained constant
for the past decade.
The committee speculated that He demand for physi-
cian-scientists would increase in the future as health-related
R&D increased. However, given the lack of compelling
data about supply and demand and questions about the effec-
tiveness of physician research training, the committee rec-
ommended that the number of training positions remain the
same until current training programs could be evaluated.
RECOMMENDATIONS
The following recommendations are made to enhance
our excellence in physician-based research.
The Medical Scientist Training Program
In 1963, NIH granted funds to three institutions to sup-
port just under 20 individuals who pursued the M.D. and
Ph.D. degrees concurrently. Early NRC study committees
reported findings from studies that consistently showed that
a substantial fraction of MSTP awarders remain produc-
tively engaged in research, often with greater success in
securing research support than M.D.s who pursue post-M.D.
research training not leading to a doctorate.
Current support for M.D./Ph.D. Raining provides for
about 820 awards (Table 5-4~. Given the success of this
program in contributing workers to the national research
effort and the continuing and increasingly difficult problem
of attracting M.D.s without Ph.D. training to research ca-
reers, we believe this program should be expanded signifi-
cantly in the coming years (Table 5-5~.
RECOMMENDATION: To meet He nation's continu-
ing need for clinical investigators, the committee recom-
mends that the number of NRSA trainees supported
through the MSTP program be increased from 822 in
1993 to 1,020 trainees each year by the year 1996.
Individual Fellowships
Because of the urgent need for clinical scientists familiar
with patient-based research techniques, we urge NIH to in-
crease the number of postdoctoral NRSA fellowship awards
to permit the preparation of patient-based investigators.
RECOMMENDATION: The committee recommends
Hat NIH increase support for individuals to train in pa-
tient-based research by increasing He number of
TABLE 5-5 Committee Recommendations for Predoctoral
Tnuneeships In the Medical Scientist Training Program for
FY 1994 through FY 1999.
Fiscal Year Number of Predoctoral Traillees
1994
1995
1996
1997
1998
1999
890
955
1,020
1,020
1,020
1,020
~.
62
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PHYSICIAN - S CIENTI S TS
TABLE 5-6 Aggregate Numbers of NRSA Supported Trainees and Fellows in
Clinical Sciences for FY 1991 through FY 1993
Fiscal Type of Support
Year Level of Trading TOTAL Traineeship Fellowship
1991 Number of awards 2,894 2,814 80
Predoctoral 755 736 19
Postdoctoral 2,139 2,078 61
1992 Number of awards 2,970 2,887 83
Predoctoral 819 800 19
Postdoctoral 2,151 2,087 64
1993 Number of awards 2,974 2,877 97
Predoctoral 855 826 29
Postdoctoral 2,119 2,051 68
_
NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1.
postdoctoral fellowships in the clinical sciences from 68
in fiscal 1993 to 160 by fiscal 1996.
Institutional Training Grants in the Clinical Sciences
To permit the expansion of the pool of MSTP trainees
and postdoctoral clinical science fellows, we believe mod-
est reductions should be made in the number of postdoctoral
awards made through institutional training grants. NIH re-
ports Cat 2,087 awardees were supported in fiscal 1992
through this mechanism (Table 5-64. We believe a gradual
decrease should occur in the number of awards (Table 5-7~.
This would be done to permit the expansion of He MSTP
program (described above).
RECOMMENDATION: The committee recommends
that He number of postdoctoral institutional aa~neeships
supported Trough the NRSA program in He clinical sci-
ences be slightly decreased from 2,051 to 1,965 between
1993 and 1996.
NOTES
1. Several studies, it must be added, have identified a lack of rigor-
ously trained individuals who know how to perform patient-based research
(e.g., Ahrens, 1992) as a special need at this time.
2. The clinical sciences are understood to include individuals holding
degrees in a variety of health professions including: medicine, veterinary
sciences, dentistry, nursing, clinical psychology, and social work. The
research training needs of clinical psychologists have been addressed in
chapter 4 of this report ("Behavioral Sciences"), dentistry needs are sepa-
rately addressed in chapter 6 ("Oral Health Research"), and nursing ad-
dressed in chapter 7 ("Nursing Research"). The committee did not address
research training needs in the veterinary sciences or social work, but rec-
ognizes that these fields contribute to the national research effort and merit
support through the NRSA program.
3. A recent report of the Institute of Medicine, Careers in Research:
63
Obstacles and Opportunities (1994) investigates ways to improve the qual-
ity of training for clinical investigators and delineates pathways for indi-
viduals pursuing careers in clinical investigation in nursing, dentistry, med-
icine and other health professions engaged in human research.
REFERENCES
Ahrens, E. H., Jr.
1992 The Crisis in Clinical Research: Overcoming Institutional
Obstacles. New York: Oxford University Press.
Association of American Medical Colleges (AAMC)
1992 U.S. Medical School Faculty: 1992. Washington, D.C.: Asso-
ciation of American Medical Colleges.
Bradford, W.D., S. Pizzo, and A.C. Christakos
1986 Careers and professional activities of graduates of a Medical
Scientist Training Program. Journal of Medical Education.
61:915-918.
Fredrickson, D.S.
1993 Clinical Investigation. Paper prepared for the Committee on
National Needs for Biomedical and Research Personnel.
Frieden, C. and B.J. Fox
1991 Career choices of graduates from Washington University's
Medical Scientist Training Program. Academic Medicine.
66:162-164.
Institute of Medicine (IOM)
1994 Careers in Clinical Research: Obstacles and Opportunities.
Washington, D.C.: National Academy Press.
McClellan, D.A. and P. Talalay
1992 M.D.-Ph.D. training at the Johns Hopkins University School
of Medicine, 1962-1991. Academic Medicine. 67(1):36-41.
National Research Council (NRC)
1975 Personnel Needs and Training for Biomedical and Behav
ioral Research. Washington, D.C.: National Academy Press.
1978 Personnel Needs and Training for Biomedical and Behav
ioral Research. Washington, D.C.: National Academy Press.
1985 Personnel Needs and Training for Biomedical and Behav
ioral Research. Washington, D.C.: National Academy Press.
1989 Biomedical and Behavioral Research Scientists: Their Train
ing and Supply, Volume I: Findings. Washington, D.C.: Na
tional Academy Press.
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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
TABLE 5-7 Committee Recommendations for Relative Distribution of Predoctoral
and Postdoctoral Tra~neeship and Fellowship Awards in Clinical Sciences
for FY 1994 through FY 1999
Fiscal Type of Support
Year Level of Training TOTAL Trameeship Fellowship
1994 Recommended number of awards 2,975 2,875 100
Predoctoral 895 875 20
Postdoctoral 2,080 2,000 80
1995 Recommended number of awards 2,910 2,780 130
Predoctoral 895 875 20
Postdoctoral 2,015 1,905 110
1996 Recommended number of awards 2,860 2,080 180
Predoctoral 895 875 20
Postdoctoral 1,965 1,805 160
1997 Recommended number of awards 2,860 2,680 180
Predoctoral 895 875 20
Postdoctoral 1,965 1,805 160
195~d Recommended number of awards 2,860 2,ou ~1bU
Predoctoral 895 875 20
Postdoctoral 1,965 1,805 160
In Recommended number or awards 2,860 ~,osu Lou
Predoctoral 895 875 20
Postdoctoral 1 965 1,805 160
64
Representative terms from entire chapter:
clinical sciences
