NIH, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration to consider additional measures to bolster the training and retention of health care doctorates in clinical research, including those described in the following recommendations.

Recommendation 4-2. The NIH, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration should substantially increase opportunities for dual-degree training in fields related to clinical research.

The committee urges the agencies to work together to substantially increase opportunities for dual-degree training (whether M.D.-Ph.D., M.D.-M.P.H., or dual-degree programs targeted to dentists and other health care doctorates) in fields related to clinical research, such as epidemiology, psychology, and health services research.

Recommendation 4-3. The NIH, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration should take steps to reduce the economic barriers to clinical research careers faced by physicians, dentists, and other health care doctorates.

The committee urges the agencies to work together to (1) ensure that physicians and dentists in postdoctoral research training are fully informed of their options for loan deferment and (2) seek legislative authority to establish extramural loan repayment programs for those who pursue clinical research training and careers. In addition, the committee urges the NIH and the Agency for Healthcare Quality and Research to consider seeking legislative authority to raise the salary cap above current levels for physicians and other health care doctorates conducting clinical research.

Recommendation 4-4. The NIH, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration should take additional steps to improve their understanding of the training and career paths of clinical investigators.

Since the NIH began to monitor the number of clinical research grants it awards, its efforts have yielded some important new data on the clinical research workforce. Still, information on the training and career paths of physicians, dentists, and other health care doctorates is too limited to permit detailed analyses of the clinical research workforce.

Recommendation 4-5. There should be no growth in the aggregate number of Ph.D.s awarded annually in the fields traditionally associated with clinical research.

Given the considerable growth in the number of research doctorates awarded in clinical science fields since 1975, and the resulting expansion of the Ph.D. portion of the clinical research workforce, the committee finds no reason for Ph.D. production to increase outside of dual-degree programs.

Recommendation 4-6. The National Institute of Nursing Research should emphasize research training programs that foster earlier entry into research careers.

Delayed research training inevitably limits the length of an investigator 's research career and affects the supply of nursing faculty. The National Institute of Nursing Research may wish to consider redirecting a portion of its NRSA funds to programs targeting students entering the nursing profession (such as B.A.-to-Ph.D. programs) and recent nursing graduates.

Recommendation 4-7. The NIH, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration should increase their efforts to identify and support programs that encourage and prepare underrepresented minority students for careers in clinical research.

Although the number of underrepresented minority men and women earning Ph.D.s in the clinical sciences has grown over the last few decades, the NIH and its fellow agencies should increase their efforts to ensure that these trends accelerate. In addition, the NIH, the Agency for Healthcare Research and Quality, and the Health Resources and Services Administration should intensify their efforts to increase the percentage of minority physicians in research, which appears to be about half that of other careers in medicine.



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