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5 . CLINT CAL SC] ENCES Mode rn c ~ ini ca ~ i nve s t ig ati on i s ba sed or the concept that the d eve lonmen ~ of e f f ectiv" mea sures to prevent or treat human is Iness requires a knowledge of the manifestations of a di spasm, as well as an understanding of its cause and mechani sms. That understanding, in turn, i s derived from fundamental principles of biology. Future contributions to the solution of heal th problems may well be expected from the cling cad scientist firmly grounded in both cling cal medicine and modern biology. For purposes of this report, clinical Investigation involves individual s with ~ he M.D., D.D. S., D.V.~., and other health professional degrees, and inch viduals with the Ph. D. degree who work in this area. The most productive clinical research is often performed by investigators whose observations at the bedside or in Ah" clinical laboratory have furnished stimulus f or their studies. Through their dual expertise, Cal inical scientists are uniquely equipped to investigate the applicability of new biome di c a ~ knowl e ~ ge to ~ i se a s e problems i n mar. . Equally important, although less frequently emphasized, is their capacity to develop new knowledge, which is subs equent ly exit c ited by the ba s i c: bi omed ice l s cienti st . For example, most of the plasma components required for normal blood coagulation were d~ scovered by clinical investigators who studied patients with hemorrhagic di sorders . Vitamin B ~ 2 ultimate! y emerged from the observed action of ~ iver extract in pernicious anemia. Many other examples, new and old, could Joe cited to document the bi di rect iona ~ f ~ ow o f in f orma ti on betwe en c li ni c al an ~ ba s ic biomedical scientists. Upon receipt of the M. D. degree, physicians generally pursue several years of clinical training as resident physicians. Even the most outstanding education and training in clinical medicine does not prepare physicians for careers in research. Their grasp of human biology and di sease mechanisms i s adequate for the diagnos i s and treatment of patients, but is rarely of such a detailed or sophisticated nature to provide more than the most general scientific background for specific research endeavors. Most of them will have had no training in the discipline of the aboratory, in the des ign and e xecution of experiment s, in the understanding of complex instruments, or in the use of research techniques. In short, if they are to become ~0

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serious and productive research scientists, they need to be trained for a second career. For the potent al Cal inical investigator, the option of further training competes with practice opportunities in which starting salaries of $35, 000-$4S,000 may not be unusual. In addition, the ma jor finding of a recent study is that the f inancial return to the post-M. D. who has uncle rtaken training prior to accepts ng regular empl oyment on a medical Vacua ty or as a researcher at NIH i s less than for the physician in private practice (schef fler, ~ 975) . Training in each of the three career situations is shown to prod uce a n e conomic ne t lo s s to the trai ne e over a ~ i f etime . Moreove-, the pre sen ~ va lue of ~ he net ~ os s i s quite large, increases with length of training, and varies by specialty. Market forces wi ~ ~ not draw thi s groun of potentia inve stigators into res earch. Another form of financial deterrent, documented in interviews with training program directors, is instability of support (AAMC, 1977). A recurrent pattern of fiscal uncertainty has emerged in recent years, which can be ascribed in part to ~ eggs ative delays or to attempts to cut back traditional forms of research training support. The training year generals y begins on July 1. Most resident physicians start to make plans the preceding October, when, as a result of fiscal uncertainty, it is difficult to assure prospective trainees that funds will be available for the coming July. Moreover, the young post-M. D. is frequently reluctant to enter a training program when the outlook is uncl ear for support to complete the training or for support of research at the end of the training period. Another financial disincentive reported by training program directors is the unrealistically low fellowship stipend. At current levels, many first-year rem ear ch fellows earn less than they di ~ in the pre ceding yea r a s res idents . There are increase ng indications ~ hat the young physician may be turning away from clinical research as an attractive career option. Physician-investigators represented 43.9 percent of all first-tire principal investigators on NIH research grants in FY ~ 966 (Douglass and James, ~ 973; Challoner, ~ 976) ~ That percentage dropped to 22.3 percent in FY 1975,. Concomitantly, there was also a decrease in absolute numbers of physicians as f irst-time pro ncipal investigators from 47 ~ to 30 5, even though the total number of grants from which these percentages are ~ erived had i no rea se ~ over the same pe ri od of time . Although it is possible that some of these M-D. 's were receiving support on program pro ject and center grants, the change is consistent with a steady reduction since ~ 9 68 in both the actual numbers and percentage of active physicians reporting their activity to the AMA as being primarily research-related (Table 5. 1} . In addition to the financial deterrent, other factors contribute to the apparently declining attractiveness of a

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TABLE 5 .1 Current Trends in Supply/Demand Indicators in the Clinical S ciences Average Annual Growth Rate 1971 1975 1971-75 Supply indicators: Professional doctorates participating in NIH · ~ training programs: Total in training 4~726a 3~360 -8.2% New starts 1~541 1,S49 (1973) 0.3% (1971-73) Proportion of clinical trainees spending full _ . _ . time on research - 15.6% (1973) 15.4% (1977) -0.3% (1973-77) Demand indicators: Total R and D expenditures in medical schools (1967 $) $393 million $490 million 5.7% Medical service funds (1967 $) $ 94 million $193 million 19.7% Budgeted vacancies: Clinical departments 982 1,564 12.3% Basic science departments in medical schools 508 609 4.6% Labor force: M.D.'s primarily engaged in research 10,898 7,944 -7.6% Full-time faculty in clinical departments 1S,451 26,280 9.2% Enrollment: Medical students 40,487 53~143 7.0% Other medical student - equivalents 57 r 525 89,095 11.6% Total 98,012 142 r238 9.8% . Includes an unknown percentage of trainees who were in predominantly clinical training programs.' In a selected sample of eight medical schools interviewed by the AAMC in 1977. SOURCES: AMA (1963-76), JAMA (1960-75?, NIH (1976 data book). 112

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career in clinical research. Testimony at the public meeting of the Committee emphasized the effect of increased emphasis on the training of primary-care physic clans. From time of entry into medical school, students are exposed to social pressure to pursue careers in direct pat lent care, especial ly in the primary-care fields. These laudable social goal s reduce even further the already small number of students we th a potential interest in research and teaching. Even in the most r~search-oriented medical institutions only1O to 12 percent of medical students have chc~sen research careers {Public Health service, 1976b, ~,.131. Moreover, there is evidence to suggest that academic careers are viewed with increasing disfavor by students and house officers (AAMC, 1977~. There is an absence of data to document or to measure the changes that may be occurring in the supply of clinical investigators. Unlike internships and residencies, fed lowships and other advanced training programs in the clinical sciences are not approved by an accreditation body with record-keeping responsibilities. In addition, there is no common nomenclature for the various types of trainees, who may be called senior residents, fellows, postdoctoral trainees, etc. No systematic study of the number in trains ng or their sources of support has been conducted, although a number of specialty groups have looked at parts of the problem. To that end, under the Comma ttee' s sp on sor sh ip, the AAMC undertook re c ent ~ y to e x amin e va riou s aspects of the sub ject, such as problems of nomenclature and dPf~nit~on, number and distribution of research trainees by specialty, variation in stipends, mix of professional active +~ es, and sources of support. The AAMC, in a preliminary report, has de scribed a method of estimating the number of advanced clinical trainees engaged in research. The method makes use of two data sources from an Institute of Medicine study (IOM, ~ 9 7 6 ~ : ~ ~ ~ the Nat ~ oral Survey Questionnaire and ~ 2 ~ the House Of f icer Activity Analysis . The f ormer measured the total number of trainees in certain broad specialty areas in eaching-hosp' gal respondents . The latter consisted of a og-diary study of the professional activities of house stat f (including fellows) at a sample cuff 9 6 of the se teaching hospitals. By determining the proportion of research trainees in the sample hospitals and applying it to the number of trainees in the national survey, an estimate was made of both the number of research trainees and the number of full-time equivalent research trainees--2,657 and · , 74 6, respec ~ ively. The information from the Institute of Medicine is app] icable to the ~ 9 7 4- 75 academic year . There are no earlier or later data with which to make comparisons to determine the changes that may be occurring with respect to research activities by clinical science trainees. The AAMC is therefore attempting through interviews with training ~3

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program direct ors, to determine whether cat inical science trainee research activitie s have changed over a f ire-year period. The data from the study, as wel ~ as issues emerging from interviews with numerous representatives of academic medical centers (e. g., training program directors, department chairmen), wit ~ be included in the Committee's 1978 report. OUTLOOK FOR THE CLINICAL SCIENCES The availab~ ~ data substantiate the impressions of a continued strong demand for cod Decal investigators and a diminishing amount of re search activity on the pant of the physician population. From ~ 97 ~ through ~ 975, the latest year for which data are available, the number of physicians reporting research as ~ heir primary activity has declined by more -hen 7 percent annually (Table 5.1 ) . At the same time, the indicators of demand fc'~ clinical inve stigators continue to move upward. R and D expenditures n medical schools are expanding at more than 5 Percent per year, medical student enrollment is up more than 7 percent per year, and total medical school enrollment including graduate student enrollment in basic scam ences programs, nursing programs, and students in the ails ed health professions, is Growing even faster. In ~ he following sections a model is presented for estimating the future needs for cot inical faculty in medical schools. In developing this model, it is recognized the' many cling cal faculty members are not engaged in clinical research, and that the involvement clef cling Cal faculty in patient care activities ~ s both significant and increasing. The recer ~ sharp inc rease s in medi cal school f unds derived f rom service and patient care activities reinf orce the impression that many full-time cog nical faculty members may be spending relative ~ y Mitts e time in clinical investigation. This is because of the many demands now placed on university medical centers and teaching hospitals to become more ~ evolved in the health care system of their local community es. At this stage of the development of the model, it Is not pass ible to mea sure the impact of increasing patient care activity or; the demand for clinical focus ty, important as it has been. What can be observed in the data is that changes in medical s chool en Boll meets, and federal R and D expenditures by those school s, have been correlated with changes ire total clini cal faculty. Thi s refl e cts in part recent increases in the number of medical schools as well as prog re s s ive growth o f enrol iment i n exi sti ng s choo Is . Thu s this relationship, while not an absolute guide to future needs for the reasons cited, does provide a useful departure point for developing pro Sections of future need based on a ~~ 4

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simplified set of assump~ions.t For purposes of this mcdel, "clinical faculty" is used synonymously with "clinical investigators," although in reality it is recognized that many clinical faculty members do not engage in research to any signfican~ degree. Further work with this model will attempt to refine this point as the data permit. The essential variable to be predicted by the model is the size of the clinical faculty in medical schools (CF). Enrollment is incorporated into the model by forming the ratio of clinical faculty to medical students {CF/M). As noted above, a strong relationship between this ratio and real R and D expenditures in medical schools has been observed over the 1961-75 period and forms the basis for making projections of future clinical faculty needs. Projections to 1982 have been made under different assumptions about medical student enro, ~ ment and R and D expenditures ~ n medical schools. A high, middle, and low assumption has been made ~ n each case. Figure 5. ~ i 1lustrates the past behavior of the variable s and shows the effects of these assumptions. Tab, e 5.2 shows the pro jected size and growth rate of clinical faculty under the nine assumptions due to faculty expansion alone. Provision must also be mad" for replacement needs, in Table 5.3, using Cartt~r's (1976) estimated annual attrition :rate of 1.3 percent of total faculty. Under the highest combination of assumptions (IA}, which the committee believes are quite improbable, the pro jected annual increase in clinical faculty would be about 3,750 individual s, or Fore than a 9 percent annual growth rate. Under the midd1 e set of assumptions (TIB), approxima ely 2,000 new clinical faculty members would be needed each year, which is about the average annual increment ~ n cat inical faculty that has occurred since 1971. Under the low set of assumptions {IIIC), an estimated 750 new clinical faculty members Scum be needed each year up to ~982. The Committee believes that the lower pro j actions of future demands for clinical faculty resume ting from the above assumptions seem more realistic. Continued increase in medical school enrollment with a level ing-off in five-seven years is foreseen. The increase will be stimulated by capital ion payments under the renewed heal th manpower legislation, the activation of ~ O schools now in the planning stage, growth to full enrollment of approximated y ~ O new schools already in operation, and the mandatory absorption of U.S. students attending foreign medical schools. Nevertheless, it seems unlikely that the rate of increase experienced in the last five years will be sustained. In its present state of development, the model presented above contains features that limit the precision of its estimates. The question has been raised, for example, whether the growth in fu]~-time clinical faculty can be fully explained by medical student enrollment or research ~5

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expenditures. An equally tenable explanation might be the expanded involvement of medical school s in Health Main finance O_ganizations, VA hospitals, and other patient- r=lated activities. Th~. s interpretation is reinforced by studies performed by the AAMC for the President's Biomedical Research Panel, which show that for the past decade, while there has been a 10 percent increase in real dollars for research, there has also been a 40 percent rise in patient- care income and a doubling of state support for teaching. The s e f indin gs ~ ead to ~ he i nf erenc e that the subs ~ antiart faculty expansion in academic medical centers was related to the provi sion of clinical car" and added responsibility for the teaching of other heal th professions students. For the s e rea son s, ~ he Commi ttee be ~ i eves it import ant in its future studies to distinguish between clinical investigators, as the essential variable to be predicted, and total clinical faculty. The variable used to measure R and D expenditures also presents a probe em. The Committee would like to measure only R and D expenditure s in clinical departments, but the data col lected to date are not that refined. Although the Committee recognizes the dif f iculty of f actoring out the clinical component of total ~ and D expenditures, it feels the effort to do so. would be justified by the improvement in the mode ~ and wi ~ ~ make such an ef f ort over the coming year. Inclusion in the model of factors accounting for age composition and faculty turnover rate would also add to its preen sion and usefulness in estimating demand. Attempts to improve and refine the model, as indicated above, will be supplemented by ef forts to test its ef f ectivenes s by compari son with estimates of clinica faculty growth obtained through a canvassing of Beans. The reservations concerning the present model place limitations on its precision for estimating future needs. It does provide, however, a guide to the direction the market for clinical investigators is likely to follow. Whether or not there are enough clinical trainees in the pipeline to fill the vacancies that are expected to occur under any of the assumptions is quit" difficult to determine with "he information now available. There is good information only about one segment of the pipeline, the NIH training programs. These programs are the major source of support for the training of clinical investigators, but a smaller amount of support is available f rom other sources, such as private foundations, institutional funds, state and local governments, and other federal agencies. The amount of the latter that is available for research training in the clinical sciences, rather than training for clinical practice, is unknown at this time. I f the number of individuals wi th prof ess i anal degree s participating in the NIH training programs is indicative of national patterns, then instead of a buildup of clinical postdoctorals, as in the biomedical and behavioral fields, ~ ~9

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there has been a gradual deck ine. The trend in the number of professional postdoctoral s entering the NIH training program has declined from 2, 006 new starts in ~ 968 to 1, 549 in ~ 973, a reduc Lion of 23 percent, or 5 percent annually (Tabl" 5. 4} . Al though ~ here is inadequate information on the total number of clinical research trainees In the pipeline, it would appear that clinical investigators are not being produced in suf f iciest quantity to satisfy the needs of medical school faculties. Budgeted vacancies (i. e., positions for which ~ budgetary provision sexists) in clinical departments have been increasing at more than ~ 2 percent per year since 1971. Furthermore, the pattern of vacancies in clinical departments is quite similar to the pattern of R and D expenditures in medical school s (in constant dog lars), indicating once again the relationship between research activity and the demand for clinical investigators (Figure 5. 2} . Numerical Levels The Committee in its ~ 976 report detected trends in supper y and demand that, if continued, could lead to shortages of qualified M. D. researchers. That possibility Ied the committee to recommend f or FY ~ 977 a ~ O percent increase in the number of trainees and fellows at the postdoctoral eve1, compared with the number funded by NIH/ADAM~ in FY 1975. The Comma -tee finds cause for concern in the fact ~ hat actual postdoctoral awards by NIH in the clinical sciences in FY ~ 976 provided for a total of 1, 682 trainees and fed lows, compared with the recommendation for 2,675, a reduce ion of 37 percent from the recommended level (Table 5. 5) . This decrease in the clinical sciences exceeded that for each of the other broad areas covered by the ~ 976 report. Informa ~ ion that would unequivocally account for this decrease is not available, a circumstance that serves to reinforce the committee's concern. Several factors merit attention in attempting to explain the reduction . First, there i s the po ssibi lity of nonutilization of traineeship positions. If positions were vacant, did the vacancies reflect a lack of qualified applicants or the effect of such factors as unrealistic timing of award notif ~ cations? The Co~runittee notes in this connection that there are reporting problems peculiar to institutional awards. To avoid confusion it is necessary to ~ i st ingui sh between po s itions a ~ Toted to the train ing program and actual appointments to these positions. Data for ~ 976, for example, mainly reflect numbers of ~raineeship positions awarded rather than individual appointments . Figures on ~ he ~ atter will generally not be available to the agencies before fall 1977, and hence it will not be known 120

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TABLE 5.4 NIH Post-M.D. or Post-M.D./Ph.D. Trainees and Fellows, New Starts 1938-73a Year Trainees Fellows Total 1938-48 110 110 1949 117 117 1950 2 126 128 1951 9 60 69 1952 5 45 50 1953 0 90 90 1954 6 98 104 1955 3 107 110 1956 4 135 139 1957 111 168 279 1958 489 111 600 1959 720 152 872 1960 1182 228 1410 1961 1545 294 1839 1962 1873 278 2151 1963 1808 341 2149 1964 1752 337 2089 1965 1789 366 2155 1966 1786 277 2063 1967 1859 183 2042 1968 1772 234 2006 1969 1612 210 1822 1970 1547 139 1686 197i 1436 105 1541 1972 1431 93 1524 1973 1421 128 1549 from NRC (1975a). "M.D." includes all professional doctorates, e.g., M.D.'s, D.V.M.'s, D.D.S.'s, etc. "Ph.D." includes all academic doctorates, e.g., Ph.D.'s, D.Sc.'s, D.Ph.'s, etc. 12

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2000 1600 1200 800 400 o (a) Budgeted Vacancies / / ' ^ ~IinI=l ^, Depts. Science # I : I I I i lg62 1966 let lam 1966 lam FECAL YEAR 500 400 2 300 , 200 1 1 1 1 i 1 ,l O- lg62 lg66 lg70 lg74 FISCAL YEAR (b) R and D Expenditures in Medial Schools (1967 $) FIGURE S.2 Medk~ spool budgeted valances and R ad D expenditures Bawd on data Tom JAMA (1967 See Appends G.

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TABLE 5.5 Committee Recommendations for NIH and ADAMHA Predoctoral and Postdoctoral Traineeship and Fellowship Awards in the Clinical Sciences Fiscal Year Agency Awards and Committee Recommendations 1975 1976 1977 1978 1979 1980 1981 Actual awards Total 3095 2289 Pre 543 607 Post 2552 1682 1976 recommendations Total 3256 3400 3400 Pre 581 600 600 Post 2675 2800 2800 1977 recommendations Total 3500 3500 3500 Pre Post 2800 2800 2800 aFY 1976 awards were reported in 1977 subsequent to the release of the 1976 report of the Committee. 123

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until Then whether or not the position was filled by a post- M. D. trainee. Conch usicns regarding utilizaticn must therefore be withheld until Chat time. second, some NIB Institutes described their areas of interest in a way that may inadvertently have de-emphasi zed clinical research in +hei ~ NRSA program announcements. At least one In sti ~ u~eint~nt tonal ly followed this course in order to discourage applications for training for clinical practice. A ~ hird factor, but one which is not unique to the clinical sciences, is inadequate funding. The Committee is aware that di f f iculties arose in FY ~ 976 as a result of the need to opera' e under a continuing resolution. Fourth, an unknown number of post-M. D. awards may have been improperly classifier under the basic biomedical sciences, which showed an i ncrea se o f about 5 0 0 pos "doctoral awards f rom ~ 97 5 to 1976. In addition ~ o program data to be obtained from NIH/ADA^MHA, the Committee will in the coming year carefully examine the policy implications of payback provisions, disparities be' we en siren s' salaries and training stipend ~ evels, and social pressures for training in primary care as they impi nge upon ca re er cho ice i n c li ni ca ~ re s earch. Recommenda~ ion . In the absence of any evidence that would compel a change in its prey' ous findings, the Committee reiterates it s prior reco~runendation that 2, 800 postdoctora ~ tra inees and fellows be f unded in the cat inical sciences by the end of FY 1979, and that this level be maintained through FY ~ 981 . Since the average trainee is in training for about two years, this recommended level would produce approximately 1,400 trained clinical investigators per year, a number Chat is consistent with the lower estimates of demand. Recommendation . The Commi ttee recommends that program announcements be worded in a manner that expl icitly encourages applications for training in the clinical sciences . Trainee ships/Fellowships The greatest need, in the Committee ' s vi ew, is for high- quality trains ng programs specifically designed to offer rigorous scientif ic background necessary to produce a clinician with the skills of a productive research sc ienti st . The s e programs shou ld have academi c br eadth, organized academic content and requirements, and substantial 124

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opportunity for conduct of a research project under competent direction. The training programs, which may frequently be multidepartmental, should last sufficiently long to equip the trainee for a serious research career. Two or perhaps three years are required in most cases to accomplish the course work, seminar participation, and independent study and research necessary to produce a clinical investigator. The most effective support mechanism fox such programs is the institutional training grant. Aside from the general characteristics described in Chapter 1, it is particularly designed to meet the reeds of the post-M.D. whose doctoral ~ raining is ~ Smiled in research participation. For these individuals, the purpose of training in the cat inical science is more to instill the method ogles and techniques of research than ~ o expand or sharpen cools the' have already been acquired. That purpose i s best served through a mechani sm that strengthens the research environment by providing funds for courses, seminars, specie, lectures, and supple es and equipment. The ind i vidua ~ f e 1 low strip i s be tter suited f or the post- M. D. with pro or research experience. The more experienced apple icants can exercise greater latitude in selecting a training site, since the choice is no' restricted to departments with training grants. Al so, they ray have a more precise unhorse ending of their needs and the availability of training to meet these needs. A serious ~ imitation, however, is the time lag between apple icatior and award. This lag, recently aggravated by the requirement of prior revs ew by NIH/ADAMHA Advisory Councils, is about nine months. The disadvantage may be seen, for example, in the case of a third-year pediatrics resident, who rrus* decide not only in which problem area to train, but a Iso on a spon sor and re s ear ch pr o j ect approve mately a y ear be f ore training begins. An institutional training grant, by contrast, enables the program director to accept a suitable app, icant with a minimum of delay. In addition to the ~ ong lead time, the individual fellowship has a disadvantage in applying a sings e priority rating scale to the post-M. D. just entering research training and the post-Ph. D. prepared to function as a research associate. Recommendation. The Committee recommends that mos' of the NIH/ADAMHA funding for post-M.D.'s should be in the form of training grants. It recommends that the appropriate proportion of fellowships is between 15 and 30 percent, a range that is in keeping with the proportions observed in the last two years. 125

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Medical Scientist Training Program The Committee again took special note of the Medical Scientist Training Program, a course of study designed to provide combined med i Cal and scientific training leading to the award of both the M. D. and Ph. D. degrees. The program offers to a limited number of carefully selected trainees a background and persnec~i~re that are uniquely valuable in the conduct of biomedica ~ re search. Trainees are permitted an unusual degree of flexibility in developing their investigative interests. Discs plinary lines can be crossed to utilize, for example, the programs of a basic science department and the research ef f ort of a clinical specialty. Sponsored by the NIGMS, the Melt Cal scientist Training Program has expanded slowly since its start in ~ 96 4-6 5 to a total of 23 grants, which provide approximately 600 tray neeship positions. Combined-degree programs incorporate economies of teaching by eliminating duplication between medical and graduate curricula. As a result, most of the programs require six to seven years for completion. To date a total of 171 trainees have completed the program, most of whom are current ly e nga ged in c li ni Cal re sid~ncy training . Follow-up data have been gathered by NIGMS staff on 36 graduates who have applied for research grants or postdoctoral fellowships. The data indicate that one-half of these applications fell in the upper JO percent of priors ty scores for tines" categories of NIH award. The nature of th e re search that is like ly to be performed by scientists hod ding the combined degrees is cliff icult to predict, so nce they have access to both basic and clinical research activities. Limited experience to date would suggest an equal distribution between basic science and clin- Cal departments. The Committee believes that they can bring to a basic science department a point of view ~ hat or ~ he one hand facilitates relating their research to c, inical medicine and on the other hand allows expicration in depth of selected medical problems encountered initially at the bedside. An important benefit of this type of program, both to the individual trainee and to ~ he f acuity, i s the encouragement and provi Sian for interdisciplinary contacts between members of the basic science departments and those of the clinical departments. Recommendation. The Committee recommends annual increases of approximately ~ O percent for FY ~ 978 arid far FY 1979 in MSTP training positions, using the number of 600 authorized for FY ~ 977 as the base. These reccm~r.ended levels will accommodate the scheduled escalation of positions in current grants, as well as a modest increase in the number of institutions participating in the program.

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FOOTNOTE 1. This relationship is as fellows: CF/M = 0.13643 7.9739 x 10-. (MRSD_3), where CF = size of full-time clinical faculty in medical schools, M = medical student enrollment, and MRSD_3 = R and D expenditures in medical schools, lagged three years (millions of 1967 S). The multiple correlation coefficient for this regression equation based on data for the period 1961-75 is 0~98. 127