EXECUTIVE SUMMARY

The subject of this report is the nation's future need for biomedical and behavioral research scientists and the role the National Research Service Awards (NRSA) program can play in meeting those needs. The report has been prepared under the auspices of P.L. 93-348 (as amended), the National Research Act of 1974, which specifies that the Secretary of the Department of Health and Human Services shall request that the National Academy of Sciences conduct a continuing study of the nation's need for biomedical and behavioral scientists, the subject areas in which they are needed, and the kinds and extent of training which should be provided them. This is the tenth in the continuing series of reports to the National Institutes of Health (NIH) and the U.S. Congress on this subject.

The committee's deliberations and recommendations centered on three major activities. First, a Panel on Estimation Procedures was established to provide numerical analysis of educational and employment prospects and national needs for biomedical and behavioral research personnel. The panel concluded that existing mathematical models are inadequate to predict need and their recommendations for alternative strategies are presented in Chapter 2. Second, the committee convened a public hearing to gather views from a broad constituency associated with NRSA programs. Both written and oral testimony were considered by the committee and our conclusions are reflected in the recommendations that follow. 1 Third, the committee met as a group on four separate occasions and, as a panel of experts, discussed and debated information and recommendations. The consensus of these meetings forms the basis for the recommendations included in this report.

Through all the deliberations, one theme was constant: although the NRSA program may be relatively small as regards total numbers of trainees (less than 15 percent of the total number of graduate students training in the biomedical and behavioral sciences are supported by NRSA funds in any year), it is enormously powerful in its ability to change research emphases and to attract the highest quality individuals to research careers. It is viewed as a prestigious, highly competitive program. It is clear that initiatives, if introduced through the NRSA program, could have a powerful impact on intended new research directions or constituencies. In other words; the force of the NRSA program in determining research initiatives and directions in programs is enormous and clearly out of proportion to the relatively small place it occupies in the total research training portfolio.

ESTIMATING NATIONAL NEEDS FOR RESEARCH SCIENTISTS

The committee recognized early in its work that defining the nation 's needs for biomedical and behavioral scientists is difficult and imprecise. However, the committee also recognized there are certain forces and opportunities that will have an impact on the needs for research personnel and, therefore, cannot be ignored. These include health care reform, major advances in fundamental research, and the demands of the marketplace. Recommendations for establishing the size and scope of the NRSA program represent the committee's best judgment concerning the continuation of a strong, health-related, scientific work force based on a consideration of these forces and opportunities.

Health Research as a National Priority

The expansion of national support for health research that occurred over the past few decades may be expected to continue although at a slower rate. Reapportionment of research and development funding between academia and industry has had and will continue to have an important



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EXECUTIVE SUMMARY The subject of this report is the nation's future need for biomedical and behavioral research scientists and the role the National Research Service Awards (NRSA) program can play in meeting those needs. The report has been prepared under the auspices of P.L. 93-348 (as amended), the National Research Act of 1974, which specifies that the Secretary of the Department of Health and Human Services shall request that the National Academy of Sciences conduct a continuing study of the nation's need for biomedical and behavioral scientists, the subject areas in which they are needed, and the kinds and extent of training which should be provided them. This is the tenth in the continuing series of reports to the National Institutes of Health (NIH) and the U.S. Congress on this subject. The committee's deliberations and recommendations centered on three major activities. First, a Panel on Estimation Procedures was established to provide numerical analysis of educational and employment prospects and national needs for biomedical and behavioral research personnel. The panel concluded that existing mathematical models are inadequate to predict need and their recommendations for alternative strategies are presented in Chapter 2. Second, the committee convened a public hearing to gather views from a broad constituency associated with NRSA programs. Both written and oral testimony were considered by the committee and our conclusions are reflected in the recommendations that follow. 1 Third, the committee met as a group on four separate occasions and, as a panel of experts, discussed and debated information and recommendations. The consensus of these meetings forms the basis for the recommendations included in this report. Through all the deliberations, one theme was constant: although the NRSA program may be relatively small as regards total numbers of trainees (less than 15 percent of the total number of graduate students training in the biomedical and behavioral sciences are supported by NRSA funds in any year), it is enormously powerful in its ability to change research emphases and to attract the highest quality individuals to research careers. It is viewed as a prestigious, highly competitive program. It is clear that initiatives, if introduced through the NRSA program, could have a powerful impact on intended new research directions or constituencies. In other words; the force of the NRSA program in determining research initiatives and directions in programs is enormous and clearly out of proportion to the relatively small place it occupies in the total research training portfolio. ESTIMATING NATIONAL NEEDS FOR RESEARCH SCIENTISTS The committee recognized early in its work that defining the nation 's needs for biomedical and behavioral scientists is difficult and imprecise. However, the committee also recognized there are certain forces and opportunities that will have an impact on the needs for research personnel and, therefore, cannot be ignored. These include health care reform, major advances in fundamental research, and the demands of the marketplace. Recommendations for establishing the size and scope of the NRSA program represent the committee's best judgment concerning the continuation of a strong, health-related, scientific work force based on a consideration of these forces and opportunities. Health Research as a National Priority The expansion of national support for health research that occurred over the past few decades may be expected to continue although at a slower rate. Reapportionment of research and development funding between academia and industry has had and will continue to have an important

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effect on employment prospects for biomedical and behavioral scientists, although the effect will vary by field, as we discuss elsewhere in this report. We expect continued national support for basic biomedical and behavioral research. However, research supported by federal funds may be expected to be closely relevant to social and economic needs and more readily adaptable for use in the private industrial sector. Furthermore, as society shifts away from product-intensive industries toward a service-oriented industrial base, the role of research in improving the quality and reducing the costs of health services will be closely scrutinized. Unknown Effects of Health Care Reform As forces converge to shape and change the delivery of health care in the United States, we expect a dramatic effect on research training. On the one hand, the potential flattening of reimbursement for clinical care will curtail a revenue stream (clinical income) that, in many medical schools and academic health centers, subsidizes the support for research training. A reduction in this revenue stream may shrink research training opportunities in academic health centers. On the other hand, increased emphasis on the maintenance of health, the outcome and quality of care, and the assessment of the impact of technology provide unique opportunities for prevention and health services research. Other changes in health care reform stress the need for increased activity in areas related to behavioral, nursing, and health services research. Advances in Research It is difficult, of course, to gauge the effect of the advancement of science on personnel needs. On the basis of our familiarity with the goals of the NRSA program, the range of expertise among our committee members, and the contributions of many individuals participating in our deliberations throughout the year, we have identified some fruitful areas of inquiry that also have the potential of engaging young scientists in careers that are both productive and rewarding. Major advances in basic biomedical and behavioral research are ripe for application to address the causes, diagnosis, and treatment of human disease. These major research findings also provide the opportunity to bring new technologies to the marketplace. Demand of the Marketplace Employment conditions for biomedical and behavioral scientists were relatively robust throughout the 1980s. Dramatic changes have occurred, however, with regard to sector of employment with a greater fraction of Ph.D.s employed in industry and other nonacademic jobs than in earlier years. The nation's need for research scientists has also been affected by demographic changes: the number of individuals from racial and ethnic minority groups is increasing but not as fast as might be expected given federal efforts to encourage the participation of minorities in this area. The work force of the future will consist of an increasing proportion of women and minorities; it is important that these changes are reflected in the biomedical and behavioral science work force. RECOMMENDATIONS Considering the major forces that have an impact on national needs for research and the unfolding of the research career, the committee recommends the following changes in the NRSA program to meet those needs. Stipends Raise the real value of stipends to more competitive levels by fiscal 1996: approximately $12,000 per year for predoctoral awardees and approximately $25,000 for postdoctoral awardees with less than 2 years of research experience. Maintain the real value of these stipends (i.e., the nominal value adjusted for inflation) through annual increases of 3 percent per year (the assumed annual rate of inflation). It is disturbing to note that stipend levels for predoctoral trainees in the NRSA program have remained unchanged since 1991 at $8,800 taxable salary per year. The existing structure of a $700 monthly stipend is simply not sufficient. Many state university stipends start at $11,000 and the National Science Foundation currently pays $14,000. Hence, we recommend an increase in the inflation-adjusted value of predoctoral stipends to $12,000 by fiscal 1996 to provide an incentive for graduate students not only to seek but also to complete training at the doctoral level. Postdoctoral NRSA awardees do not fare much better, earning approximately $18,600 in their first year of training and $19,700 in their second. It becomes very difficult at this important period of training to entice a clinician or Ph.D., already burdened with debt, into research training. Thus, the committee recommends that the NRSA stipends at the first-year postdoctoral level be increased to $25,000 in inflation-adjusted dollars by fiscal 1996. This expansion in stipend support should be achieved through the addition of funds to the current NRSA training budget (Appendix H).

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Numerical Recommendations Between fiscal 1991 and 1993, the total number of NRSA awards grew from just over 14,000 to over 15,000 ( Summary Table 1). The basic biomedical sciences were estimated to have the largest fraction of support in fiscal 1993 at about 9,633 awards, followed by 3,000 awards in the clinical sciences [excluding 822 awards for combined M.D.-Ph.D. training through the Medical Scientist Training Program (MSTP)]. To meet the nation's future needs for biomedical and behavioral scientists, we believe the overall NRSA program should expand from 15,112 slots in fiscal 1993 to 16,260 slots in fiscal 1996, with that growth occurring mainly through modest expansion of NRSA support for research training through the MSTP program, in the behavioral sciences, oral health research, nursing research, and health services research (Summary Table 2). With full implementation of the recommendations that follow the number of NRSA awards would have expanded by about 10 percent between 1993 and 1996 with support for basic biomedical sciences representing 59 percent of the total in 1996, behavioral sciences about 9 percent of the total, the MSTP program 6 percent, other clinical sciences (including oral health research) 20 percent, nursing research 3 percent, and health services research 2 percent. Recommended changes in the size and scope of the NRSA program within each broad field are summarized below. Basic Biomedical Sciences Maintain the annual number of predoctoral awards in the basic biomedical sciences at 1993 levels, or approximately 5,175 awards, and the number of post-doctoral awards at 3,835. On the basis of input from a wide variety of sources about current and anticipated market conditions and in consideration of pressing national research needs, the committee endorses the continuation of federal support through predoctoral awards in the basic biomedical sciences (see Chapter 3). The committee is concerned, however, that the current low levels of stipend support will not attract the most talented students to careers in research. To underscore the depth of our concerns, we recommend that predoctoral awards in the basic biomedical sciences be maintained at fiscal 1993 levels until further assessment of funding priorities and national needs can be made. The committee recognizes that these recommendations are made in an era of fiscal restraint. Should additional funds become available for predoctoral research training in the basic biomedical sciences, NIH might wish to consider expanding NRSA support in this area. Postdoctoral research training is also an important component in the preparation of productive investigators in the basic biomedical sciences. Postdoctoral training increases the technical skills of the doctoral-level scientist and ensures the success of their independent research careers. Here, too, the committee is concerned that persistent low-level stipends may discourage qualified applicants from seeking postdoctoral training through the NRSA support. Thus, to permit NIH to introduce further and more realistic changes in stipend levels at the postdoctoral level, the committee recommends that the number of postdoctoral awards be maintained at fiscal 1993 levels. Again, however, should additional program funds become available for postdoctoral research training in the basic biomedical sciences, NIH might wish to increase the number of these awards. Behavioral Sciences Increase the annual number of NRSA awards for research training in the behavioral sciences from 1,069 to 1,450 between 1993 and 1996. On the basis of continuing gains being made by behavioral scientists in areas of national interest and on anticipated demand for behavioral research relative to health goals, the committee urges the continued expansion of federal support through predoctoral awards in the behavioral sciences (see Chapter 4). Predoctoral awards permit the preparation of investigators familiar with the broad range of research techniques and theories that characterize doctoral preparation in the behavioral sciences. As is the case in other areas, the committee is concerned that current low stipend levels for NRSA awardees do not attract the most able scientists to research careers in health-related fields. Thus, the committee has tempered its call for expansion in total support from 672 predoctoral awards in fiscal 1993 to 900 by fiscal 1996 in recognition of the competing need to increase stipend support. Postdoctoral research training through the NRSA provides the nation with an unusual mechanism for attracting the most skilled scientists to address areas of national need. Because of differences in the evolution of research careers, postdoctoral research training has played a greater role in some behavioral science fields than others. Nonetheless, postdoctoral study increases the technical skills of the investigator and strengthens the pool of talent available to the nation for research. Thus, the committee recommends that the number of postdoctoral trainees and fellows supported annually in the behavioral sciences increase from approximately 349 awardees in fiscal 1993 to 500 in fiscal 1996. Clinical Sciences Increase the number of MSTP awards from 822 in 1993 to 1,020 by 1996 and the number of postdoctoral

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SUMMARY TABLE 1 Aggregated numbers of NRSA supported trainees and fellows for FY 1991, FY 1992, and FY 1993. a Fiscal Year   Type of Program TOTAL ALL FIELDS Basic Biomedical Sciences Behavioral Sciences Clinical Sciences Medical Scientist b Training Oral Health c Research Nursing d Research Health Services e Research 1991 TOTAL Total 14,085 9,021 902 2,894 783 218 255 12     Predoctoral 6,948 4,593 519 755 783 78 220 0     Postdoctoral 6,525 3,861 338 2,139 0 140 35 12     MARC Undergraduate 612 567 45 0 0 0 0 0   Trainees Total 11,850 7,199 775 2,814 783 186 93 0     Predoctoral 6,449 4,313 472 736 783 78 67 0     Postdoctoral 4,789 2,319 258 2,078 0 108 26 0     MARC Undergraduate 612 567 45 0 0 0 0 0   Fellows Total 2,235 1,822 127 80 0 32 162 12     Predoctoral 499 280 47 19 0 0 153 0     Postdoctoral 1,736 1,542 80 61 0 32 9 12 1992 TOTAL Total 14,607 9,317 908 2,970 806 213 257 94     Predoctoral 7,265 4,777 534 819 806 77 217 35     Postdoctoral 6,661 3,910 323 2,151 0 136 40 59     MARC Undergraduate 681 630 51 0 0 0 0 0   Trainees Total 12,365 7,477 790 2,887 806 178 103 82     Predoctoral 6,761 4,487 481 800 806 77 75 35     Postdoctoral 4,923 f 2,360 258 2,087 0 101 28 47     MARC Undergraduate 681 630 51 0 0 0 0 0   Fellows Total 2,242 1,840 118 83 0 35 154 12     Predoctoral 504 290 53 19 0 0 142 0     Postdoctoral 1,738 1,550 65 64 0 35 12 12 1993 TOTAL Total 15,112 9,633 1,069 2,974 822 224 236 96     Predoctoral 7,835 5,171 672 855 822 97 188 30     Postdoctoral 6,603 3,836 349 2,119 0 127 48 66     MARC Undergraduate 674 626 48 0 0 0 0 0   Trainees Total 12,819 7,740 930 2,877 822 201 112 79     Predoctoral 7,265 4,811 604 826 822 96 76 30     Postdoctoral 4,880g 2,303 278 2,051 0 105 36 49     MARC Undergraduate 674 626 48 0 0 0 0 0   Fellows Total 2,293 1,893 139 97 0 23 124 17     Predoctoral 570 360 68 29 0 1 112 0     Postdoctoral 1,723 1,533 71 68 0 22 12 17 NOTE: Data from IMPAC data system was prepared by the information and Statistics Branch, Division of Research Grants, and the National Institues of Health, RTSPO/OEP/OER. About 230 positions in FY 1991 and 576 positions in FY 1992 were not coded for disciplines in IMPAC datafiles. These positions were assigned to cluster disciplines using departmental affiliations and grant titles. a Units are full time training positions (FTTPs). Short term training positions are included, but the number of appointments have been divided by four to convert to FTTPs. b Positions designated as Medical Scientist Training Program (MSTP) for purposes of this table are all considered to be in biomedical disciplines. c Positions supported by the National Institute of Dental Research (NIDR). d Positions supported by the National Institute of Nursing Research (NINR). e Positions supported by the Agency for Health Care Policy and Research (AHCPR). f Includes 42 postdoctoral traineeships in 1992 for training in Primary Care Research supported through the Health Resources and Services Agency (HRSA). g Includes 58 postdoctoral traineeships in 1993 for training in Primary Care Research supported through the Health Resources and Services Agency (HRSA).

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fellows in the clinical sciences from 68 in 1993 to 160 in 1996. To achieve this expansion, we recommend that the annual number of postdoctoral trainees in the clinical sciences be decreased slightly from 2,051 to 1,805 between 1993 and 1996. Studies have consistently shown that a substantial fraction of graduates from the MSTP program remain productively engaged in research, often with greater success in securing research support than those M.D.s who pursue post-M.D. research training not leading to a doctorate (see Chapter 5). Current support for MSTP training provides for about 820 awards. Given the success of this program in contributing workers to the national research effort, we believe this program should be expanded to provide 1,020 awards by fiscal 1996. Furthermore, because of the urgent need for clinical scientists familiar with patient-based research techniques we urge the NIH to increase the number of postdoctoral NRSA fellowship awards from 68 in fiscal 1993 to 160 by fiscal 1996 to permit the preparation of patient-based investigators. To permit the expansion of the pool of MSTP trainees and postdoctoral fellows, we believe modest reductions should be made in the number of postdoctoral awards made through institutional training grants in the clinical sciences. NIH reports that 2,051 awardees were supported in fiscal 1993 through this mechanism. We believe a gradual decrease in the number of awards to 1,805 should occur by fiscal 1996. Remaining Fields Increase the number of awards in oral health research to 430 by 1996, in nursing research to 500 by 1996, and in health services research to 360 by 1996, to allow for their efficient absorption by the system after which the number of awards is stabilized at the new levels. Oral Health Research. There is an acute need for clinical dental researchers and oral health research workers in general. The National Research Council's 1985 report called for 320-400 new clinical dental research trainees annually, but the National Institute of Dental Research (NIDR) has been unable to carry out this recommendation because funds have not been available. A significant increment in training would substantially alleviate the shortage of oral health research personnel. There is need and rationale for a tripling or quadrupling the training of oral health researchers. Realistically, however, the need is better met incrementally rather than abruptly. The committee recommends, therefore, that the total number of training positions available for preparation in oral health research increase from approximately 224 positions in fiscal 1993 to 430 positions in fiscal 1996 and remain steady thereafter (see Chapter 6). The MSTP program offers an integrated program of medical and graduate research training leading to the combined M.D. and Ph.D. degrees. The success of that program, coupled with the demonstrated success of such joint degrees as the D.D.S./Ph.D. and D.M.D./Ph.D., suggests that oral health research would benefit from the development of a Dental Scientist Training Program (DSTP) that is analogous to the MSTP under the auspices of the NRSA legislation. The committee recommends, therefore, that one-quarter to one-half of the new positions available for training in oral health research in fiscal 1994 and beyond be used by NIDR to establish a DSTP program under the NRSA act. Nursing. With the proposed changes in health care reform, continued development of a strong scientific base in nursing research for practice is essential to prepare advanced practice specialists to care for the rapidly changing needs of high-risk and underserved patient populations (see Chapter 7). The committee recommends that the number of positions available for preparation in nursing research increase from approximately 236 awards in fiscal 1993 to 500 in fiscal 1996. These positions should be phased in on a yearly basis as properly qualified candidates and training sites present themselves. Because nursing research is a developing field of science, there is a critical need to have an increased number of highly trained nurse researchers at the cutting edge for nursing practice and health care. Support for research training must be expanded at the predoctoral level to allow further expansion at the postdoctoral level. As the number of NRSA positions increase by the year 1996, there should be a progressive shift toward an eventual balance between the proportion of funding for predoctoral and postdoctoral support. Health Services Research. Health Services research is a relatively young field that uses interdisciplinary approaches to examine the impact of organization, finance, and use of technology on the utilization, cost, and quality of care (see Chapter 8). This field of research will need to grow substantially to meet the ever-expanding demands for information by policymakers, administrators, providers, and consumers. The questions raised regarding what impact different proposals for health care reform will have on access, cost, and quality of care are largely questions that will be addressed by this field of research. To meet these needs, the committee recommends that the number of NRSA positions allocated to the Agency for Health Care Policy and Research (AHCPR) increase from about 96 in fiscal 1993 to 360 in fiscal 1996. Institutional training grants permit the development of

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SUMMARY TABLE 2 Committee Recommendations for NRSA Trainees and Fellows for FY 1994 through 1999. a Fiscal Year   Type of Program TOTAL ALL FIELDS Basic Biomedical Sciences Behavioral Sciences Clinical Sciences Medical Scientist b Training Oral Health c Research Nursing d Research Health Services e Research 1994 REC. Total 15,415 9,640 1,195 2,975 890 260 340 115     Predoctoral 8,175 5,175 745 895 890 125 290 55     Postdoctoral 6,560 3,835 400 2,080 0 135 50 60     MARC Undergraduate 680 630 50 0 0 0 0 0   Trainees Total 12,975 7,745 1,040 2,875 890 200 130 95     Predoctoral 7,490 4,815 670 875 890 100 95 45     Postdoctoral 4,805 2,300 320 2,000 0 100 35 50     MARC Undergraduate 680 630 50 0 0 0 0 0   Fellows Total 2,440 1,895 155 100 0 60 210 20     Predoctoral 685 360 75 20 0 25 195 10     Postdoctoral 1,755 1,535 80 80 0 35 15 10 1995 REC. Total 15,835 9,640 1,325 2,910 955 345 420 240     Predoctoral 8,600 5,175 825 895 955 210 360 180     Postdoctoral 6,555 3,835 450 2,015 0 135 60 60     MARC Undergraduate 680 630 50 0 0 0 0 0   Trainees Total 13,165 7,745 1,150 2,780 955 230 160 145     Predoctoral 7,730 4,815 740 875 955 130 120 95     Postdoctoral 4,755 2,300 360 1,905 0 100 40 50     MARC Undergraduate 680 630 50 0 0 0 0 0   Fellows Total 2,670 1,895 175 130 0 115 260 95     Predoctoral 870 360 85 20 0 80 240 85     Postdoctoral 1,800 1,535 90 110 0 35 20 10 1996 REC. Total 16,260 9,640 1,450 2,860 1,020 430 500 360     Predoctoral 9,010 5,175 900 895 1,020 290 430 300     Postdoctoral 6,570 3,835 500 1,965 0 140 70 60     MARC Undergraduate 680 630 50 0 0 0 0 0   Trainees Total 13,355 7,745 1,260 2,680 1,020 265 195 190     Predoctoral 7,965 4,815 810 875 1,020 160 145 140     Postdoctoral 4,710 2,300 400 1,805 0 105 50 50     MARC Undergraduate 680 630 50 0 0 0 0 0   Fellows Total 2,905 1,895 190 180 0 165 305 170     Predoctoral 1,045 360 90 20 0 130 285 160     Postdoctoral 1,860 1,535 100 160 0 35 20 10 a Units are full time training positions (FTTPs). Short term training positions are included, but the number of appointments have been divided by four to convert to FTTPs. b Positions designated as Medical Scientist Training Program (MSTP) for purpose of this table are all considered to be in biomedical disciplines.

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Fiscal Year   Type of Program TOTAL ALL FIELDS Basic Biomedical Sciences Behavioral Sciences Clinical Sciences Medical Scientist b Training Oral Health c Research Nursing d Research Health Services e Research 1997 REC. Total 16,260 9,640 1,450 2,860 1,020 430 500 360     Predoctoral 9,010 5,175 900 895 1,020 290 430 300     Postdoctoral 6,570 3,835 500 1,965 0 140 70 60     MARC Undergraduate 680 630 50 0 0 0 0 0   Trainees Total 13,355 7,745 1,260 2,680 1,020 265 195 190     Predoctoral 7,965 4,815 810 875 1,020 160 145 140     Postdoctoral 4,710 2,300 400 1,805 0 105 50 50     MARC Undergraduate 680 630 50 0 0 0 0 0   Fellows Total 2,905 1,895 190 180 0 165 305 170     Predoctoral 1,045 360 90 20 0 130 285 160     Postdoctoral 1,860 1,535 100 160 0 35 20 10 1998 REC. Total 16,260 9,640 1,450 2,860 1,020 430 500 360     Predoctoral 9,010 5,175 900 895 1,020 290 430 300     Postdoctoral 6,570 3,835 500 1,965 0 140 70 60     MARC Undergraduate 680 630 50 0 0 0 0 0   Trainees Total 13,355 7,745 1,260 2,680 1,020 265 195 190     Predoctoral 7,965 4,815 810 875 1,020 160 145 140     Postdoctoral 4,710 2,300 400 1,805 0 105 50 50     MARC Undergraduate 680 630 50 0 0 0 0 0   Fellows Total 2,905 1,895 190 180 0 165 305 170     Predoctoral 1,045 360 90 20 0 130 285 160     Postdoctoral 1,860 1,535 100 160 0 35 20 10 1999 REC. Total 16,260 9,640 1,450 2,860 1,020 430 500 360     Predoctoral 9,010 5,175 900 895 1,020 290 430 300     Postdoctoral 6,570 3,835 500 1,965 0 140 70 60     MARC Undergraduate 680 630 50 0 0 0 0 0   Trainees Total 13,355 7,745 1,260 2,680 1,020 265 195 190     Predoctoral 7,965 4,815 810 875 1,020 160 145 140     Postdoctoral 4,710 2,300 400 1,805 0 105 50 50     MARC Undergraduate 680 630 50 0 0 0 0 0   Fellows Total 2,905 1,895 190 180 0 165 305 170     Predoctoral 1,045 360 90 20 0 130 285 160     Postdoctoral 1,860 1,535 100 160 0 35 20 10 c Positions supported by the National Institute of Dental Research (NIDR). d Positions supported by the National Institute of Nursing Research (NINR). e Positions supported by the Agency for Health Care Policy and Research (AHCPR).

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innovative interdisciplinary research training programs, an essential feature of research in this area. However, given the anticipated growing demand for skilled specialists in health services research, the committee concludes that AHCPR should place emphasis on the award of individual fellowships in the next few years in order to encourage qualified individuals with some experience in the area of health care policy to pursue advanced training. Minority Access to Research Careers Hold Minority Access to Research Careers (MARC) awards constant at fiscal 1993 levels, or approximately 680 awards, pending the outcome of the present NIH evaluation study. The NRSA program plays an important role in attracting minority group members to careers in the basic biomedical and behavioral sciences. This is achieved primarily through the MARC program (see Chapter 3 and Chapter 4). The core of this program is the Honors Undergraduate Program launched in fiscal 1977 to support college juniors and seniors (see, for example, Garrison et al., 1985). In fiscal 1993 about 674 slots were set aside by NIH for preparing of MARC undergraduates, most for training in the basic biomedical sciences. The committee is aware that NIH recently launched an 18-month study of the career outcomes of MARC program graduates. The committee endorses this effort and recommends a continuation of support for the MARC program at fiscal 1993 levels until the NIH assessment is complete. It is well documented that certain minority groups (African Americans, Hispanics, Native Americans) are vastly underrepresented in the biomedical and behavioral sciences. To address this problem, the obvious solution should be to increase opportunities for these groups to receive training in biomedical and behavioral sciences. This can only be accomplished by providing research training opportunities through such programs as MARC. It will be important that the NIH act swiftly to review and modify the size and scope of the MARC program in light of its findings. In recent years, the NIH has undertaken a number of important studies of minority research and training. 2 For example, the Office of Minority Health in 1993 reported on Phase I of an assessment of minority training programs (NIH, 1993). This report lays out a plan of action for reviewing NIH programs in this area and discusses the limitations of current NIH data collection procedures for tracking individuals who receive research and/or training support. 3 The range of programs to be addressed by this assessment is impressive, and includes such programs as: Minority Biomedical Research Support (MBRS), National Predoctoral Fellowship Awards for Minority Students, Minority Access to Research Careers (MARC), Research Centers in Minority Institutions (RCMI), and Research Supplements for underrepresented minority individuals. The committee looks forward to having more detailed information in the coming years on the outcome of these various assessments to facilitate the development of a fuller review of minority research training needs and the role of the NRSA program in meeting those needs. ENHANCING THE EFFECTIVENESS OF THE NRSA PROGRAM Flexibility in Career Training at the Postdoctoral Level Examine research training opportunities for women through the NRSA program and strengthen the role of postdoctoral support to assist women in establishing themselves in productive careers as research scientists. In May 1993 we convened a public hearing to invite suggestions for increasing the effectiveness of the NRSA program. Most of those testifying on the role of the NRSA program in recruiting women said that the NRSA program must be more flexible in the areas of reentry training, family leave, and geographic location of training sites. Committee members have also been concerned, however, that there is a clear disparity between the number of women receiving NRSA training and the number of recipients of NIH research grants (see Chapter 9). Women appear to be leaving science between the time they receive their doctorate and the time that they fully establish themselves in a research career track. The NRSA program can play a role in fostering the careers of these scientists. There is a need, then, to reshape NRSA awards at the postdoctoral level to encourage women to fully utilize their research talents. NRSA awards should allow retraining and career reentry to help women who have stopped out of research to update skills and move into emerging areas. Monitoring Progress Toward NRSA Goals Review NIH databases as management information systems and introduce changes in data collection, analysis, and dissemination to permit more effective tracking of NRSA award recipients. Emphasis should be given to the analysis of minority participation in research and training. New funds should be directed to the evaluation of NRSA program outcomes. Perhaps one of the most significant findings of this committee is the general lack of information about the outcome of the NRSA program given almost two decades of support. Very little serious evaluation of the NRSA program has

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been undertaken through NIH support except for a few student outcomes studies undertaken by earlier NRC committees. Nowhere is the need for accurate information more evident than in our inability to track the participation of underrepresented minorities in the biomedical and behavioral research effort. We cannot underscore strongly enough the need for follow-up information to assess program outcomes. In part, this involves the organization of existing files at NIH to permit the analysis of program outcomes (see Chapter 9). In part, the analysis that is needed will require serious review of data collection and analytic capabilities at the NIH and the development of new strategies to assess program outcomes. Improving the effectiveness of the NRSA program will require attention to issues not new to the research community. However, with the inevitable changes that will occur with health care reform and budget deficit reduction, NIH may find itself in a position of justifying its support for training programs. Well-designed career outcomes studies can provide the kind of feedback that is needed to assure that the NRSA program is both efficient and effective given constraints being placed on the federal funding effort. Future committees would benefit, furthermore, from more studies of the impact of NRSA support on the recipient institution's total pattern of training support. NOTES 1. The public testimony from the hearing will be available in a separate report, through the National Academy Press, Washington, D.C. 2. In addition to the studies described here, the Director of the National Institutes of Health has also commissioned a study of NIH efforts to recruit and retain minority scientists among its intramural staff. A report on that topic is being prepared by the Director' s NIH/EEO Executive Advisory Group. (Personal communication, 1994) 3. The NIH Minority Programs Evaluation Committee recommended changes in the NIH data system to permit more effective tracking of individuals, similar to the changes recommended by this committee (see Chapter 9). REFERENCES Garrison, H.H., P.W. Brown and R.W. Hill 1985 Minority Access to Research Careers: An Evaluation of the Honors Undergraduate Research Training Program. Washington, D.C.: National Academy Press. National Institutes of Health (NIH) 1993 Assessment of NIH Minority Research/Training Programs: Phase I. Bethesda , MD: National Institutes of Health.

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