CHAPTER EIGHT

HEALTH SERVICES RESEARCH PERSONNEL

Health services research is an interdisciplinary field of research that seeks to understand the impact of organizational characteristics, financing, health personnel, and technology on the use of health services, quality of care, patient outcomes, and cost. The field draws on a wide range of disciplines, including biostatistics, epidemiology, sociology, health economics, medicine, nursing, engineering, management, and psychology. Its national importance is broadly recognized by providers, administrators, employers, insurers, and state and national policymakers who are seeking solutions to problems of escalating health care costs, erosion of access to care, concerns about the quality of care, and the overall health status of Americans. This field provides the information that is being used to design health care reform proposals and will be the source of information on the impact of any future health care reforms.

In recognition of increasing need for policy-relevant information that comes from health services research, the Agency for Health Care Policy and Research (AHCPR) was established in 1989 as an organizational locus for federal leadership and funding. In addition, health services research studies are funded by institutes at the National Institutes of Health (NIH) in specific disease categories, by the Department of Veterans Affairs, by Centers for Disease Control, and by private foundations and the health industry. Levels of funding have increased dramatically over the past 5 years, escalating the demand for well-trained researchers who can work in interdisciplinary teams.

The committee recommends that training in health services research be given higher priority and an increased allocation of National Research Service Award (NRSA) positions. In 1992, AHCPR had 92 positions, or approximately 0.5 percent of all NRSA awards. The NIH Revitalization Act of 1993 increased the allocation of NRSA awards to AHCPR to 1 percent, or approximately 180 positions in 1993. It is recommended that this be increased over the period 1994-1996 to 360 positions. Initially, priority should be given to increasing postdoctoral training opportunities as predoctoral training opportunities are expanded.

ADVANCES IN HEALTH SERVICES RESEARCH

Health services research has expanded our understanding of organizational and financial factors that affect access to care, appropriateness of services, quality, cost, and patient outcomes. Methods have been developed and applied for comparing the cost and effectiveness of alternative diagnostic and treatment technologies and for assessing the impact of health services on health status and quality of life. Advances in health services research have influenced the direction of national and state policies and have contributed to dramatic changes in the health care industry over the past decade. The rate of change in health care is ever increasing and the demand for new information on the impact of policy options and the effects of past changes is growing. The current national discussions regarding health reform are sharpening policymakers' understandings of the need for accelerating the investment in health services research and in its dissemination.

Organization and Financing

Health services research provides information on the quality and cost of alternative types of health care organizations. For example, health services research provides policy-relevant information on health maintenance organizations (HMOs) and other managed-care arrangements. Research has shown HMOs to be effective in controlling costs and providing high-quality care. However, research has also shown the rate of inflation in health care costs in HMOs to



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CHAPTER EIGHT HEALTH SERVICES RESEARCH PERSONNEL Health services research is an interdisciplinary field of research that seeks to understand the impact of organizational characteristics, financing, health personnel, and technology on the use of health services, quality of care, patient outcomes, and cost. The field draws on a wide range of disciplines, including biostatistics, epidemiology, sociology, health economics, medicine, nursing, engineering, management, and psychology. Its national importance is broadly recognized by providers, administrators, employers, insurers, and state and national policymakers who are seeking solutions to problems of escalating health care costs, erosion of access to care, concerns about the quality of care, and the overall health status of Americans. This field provides the information that is being used to design health care reform proposals and will be the source of information on the impact of any future health care reforms. In recognition of increasing need for policy-relevant information that comes from health services research, the Agency for Health Care Policy and Research (AHCPR) was established in 1989 as an organizational locus for federal leadership and funding. In addition, health services research studies are funded by institutes at the National Institutes of Health (NIH) in specific disease categories, by the Department of Veterans Affairs, by Centers for Disease Control, and by private foundations and the health industry. Levels of funding have increased dramatically over the past 5 years, escalating the demand for well-trained researchers who can work in interdisciplinary teams. The committee recommends that training in health services research be given higher priority and an increased allocation of National Research Service Award (NRSA) positions. In 1992, AHCPR had 92 positions, or approximately 0.5 percent of all NRSA awards. The NIH Revitalization Act of 1993 increased the allocation of NRSA awards to AHCPR to 1 percent, or approximately 180 positions in 1993. It is recommended that this be increased over the period 1994-1996 to 360 positions. Initially, priority should be given to increasing postdoctoral training opportunities as predoctoral training opportunities are expanded. ADVANCES IN HEALTH SERVICES RESEARCH Health services research has expanded our understanding of organizational and financial factors that affect access to care, appropriateness of services, quality, cost, and patient outcomes. Methods have been developed and applied for comparing the cost and effectiveness of alternative diagnostic and treatment technologies and for assessing the impact of health services on health status and quality of life. Advances in health services research have influenced the direction of national and state policies and have contributed to dramatic changes in the health care industry over the past decade. The rate of change in health care is ever increasing and the demand for new information on the impact of policy options and the effects of past changes is growing. The current national discussions regarding health reform are sharpening policymakers' understandings of the need for accelerating the investment in health services research and in its dissemination. Organization and Financing Health services research provides information on the quality and cost of alternative types of health care organizations. For example, health services research provides policy-relevant information on health maintenance organizations (HMOs) and other managed-care arrangements. Research has shown HMOs to be effective in controlling costs and providing high-quality care. However, research has also shown the rate of inflation in health care costs in HMOs to

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be similar to more traditional fee-for-service care. This has stimulated innovations in managed care, some of which come directly from products of research, including the use of appropriateness criteria for making coverage decisions, advances in the design of management-information systems and analytic methods for monitoring quality indicators and cost, and methods for profiling providers to compare provider performance in terms of cost and quality. These methods are supporting a new generation of managed care that emphasizes the provision of effective high-quality care at a reasonable cost. Our knowledge of the impact of financial incentives on patient access to care, provider practice patterns, and organizational productivity come from health services research. For example, research has demonstrated the power of financial incentives and disincentives on patient care seeking and provider practice. Health services researchers developed the payment classification systems used by Medicare to pay hospitals (DRGs) and to pay physicians (RBRVs). Current research work is improving case mix and severity measurement in ambulatory care. These measures can be used to adjust payment to HMOs and other providers and represent long-term investments in health services research. Our understanding of public health issues regarding access to appropriate and needed services comes primarily from health services research. For example, information on the growing numbers of uninsured people and their characteristics has been critical to the formulation of health care reform proposals. Furthermore, studies have shown that insurance coverage is necessary, but frequently not sufficient to ensure appropriate access to care. High-risk populations will likely require special outreach services and health education to gain the full benefit of available services. These findings are beginning to clarify and redefine the future role of public health agencies under health care reform. Medical Effectiveness Research New initiatives to allow better understanding of the effectiveness of health care services are advancing knowledge regarding what works, for whom, and under what circumstances. The AHCPR is supporting a range of studies on specific conditions and procedures to encourage better understanding of variations in patterns of provider practice and their consequences for patient outcomes, both clinical and patient-reported. Validated measurement scales for patient-reported outcomes, including health status and satisfaction, are products of years of research. Studies of acute myocardial infarction, cataract surgery, low birth weight, coronary artery disease, joint-replacement surgery, and other common conditions are providing new insights into the effectiveness and efficiency of our current health care delivery system as measured by improvements in patient outcomes and cost. Among the products of this research are best-practice guidelines for specific conditions that are being widely disseminated to providers, insurers, and consumers to improve knowledge and state-of-the-art practice. Quality of Care and Patient Outcomes Research is contributing to new and improved methods for measuring quality of health services, including their impact on patient functioning, satisfaction, and quality of life. Quality of care is broadly conceived to include relevant characteristics of the organizational structure of the health care provider, the content of the care, and the outcomes experienced by individuals with specific health problems. One of the newer areas for research pertains to the use of patient-reported measures of outcomes in conjunction with clinical measures of outcome. Patient-reported outcomes information is being applied in organized efforts to improve the total quality of services, as well as being used by some regulatory authorities (e.g., the Food and Drug Administration) for assessing quality of life effects of new treatments. The conceptual framework for measuring quality-of-care, the measures being applied, and the integration of quality measurement in organized efforts to improve quality are based on what is being learned through health services research. Ethical and Legal Issues The advances in medical technology and the need to provide patients with state-of-the-art care have increased legal and ethical concerns. Research is clarifying the nature of ethical concerns with new technologies (e.g., genetic screening) and providing new understandings regarding the meaning of informed consent and effective procedures for obtaining informed consent. Among legal issues of greatest concern to providers has been the rapid escalation of malpractice claims and the overall cost of malpractice insurance. Research has shown the importance of effective provider-patient communication in reducing the occurrence of malpractice claims and has provided information that has helped shape malpractice reform legislation in several states. In conclusion, our understanding of the operation of the American health care system, its effectiveness, and its efficiency relies largely on the products of health services research. Advances in our conceptual understanding of the complexities of health care delivery, methods of measuring quality of care, cost, and patient outcomes and the development of policy-relevant information have been highly significant over the past 25 years. Even so, there are many questions unanswered regarding how best to organize and provide health care services to ensure the highest possible health status for all Americans at an affordable cost.

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ASSESSMENT OF THE CURRENT MARKET FOR HEALTH SERVICES RESEARCH PERSONNEL The need for information coming from health services research is widely recognized and growing. The size and scope of the supply of highly trained researchers are not well documented but are inadequate in the view of the committee to meet the current or projected future needs. In this section, the available information on supply is presented. This is followed by a discussion of factors contributing to an expanding need for well-trained health services researchers. Supply of Health Services Researchers Health services research is problem-oriented: practitioners examine and evaluate the delivery of health care services in the United States. It is a distinct area of inquiry in which systematic methods are applied to problems of the allocation of finite health resources and the improvement of personal health care services. Individuals enter the field of health services research from a variety of backgrounds, including biostatistics, epidemiology and bioengineering, the behavioral sciences (anthropology, sociology, and psychology), the social sciences (economics, statistics, and urban planning), and other fields such as operations research, industrial engineering, public administration, health education, and medicine. The number of health services research personnel in the U.S. labor force is not known, although attempts have been TABLE 8-1 Distribution of Degrees Among Members of the Association for Health Services Research: 1992 Degree Number Doctorate 922 Masters 720 (Public Health) (247) (Other Masters) (473) Bachelors 78 Practitioner 601 (M.D. or D.O.) (448) (Nursing) (108) (M.S.W.) (17) (Other) (28) J.D. 24 TOTAL 2,345 a Source: Davidson, 1993 a Total exceeds 2,000 owing to multiple degrees of some members. made by the National Research Council (NRC) and others to describe the composition of certain segments of the labor force. 1 The composition of health services research is largely determined by the availability of support for research and development. Thus, no stable estimates of the number of individuals in the work force can be generated unless specialized surveys are conducted or special estimates are generated, as demonstrated by previous NRC surveys. Perhaps the best available estimate of the size of the health services research labor force is the membership of the Association for Health Services Research (AHSR), an organization established in 1981 to promote the field of health services research (Davidson, 1993). Although this most likely results in an undercount of the health services research labor force, studying the number of AHSR members and their characteristics is helpful in understanding the infrastructure of at least one segment of the labor force, a segment we might consider to be the “attentive” workers. 2 Composition of the Attentive Health Services Research Labor Force: 1992 About 2,000 individuals were members of AHSR in 1992. Of these, 100 were students and the remainder were drawn from medicine, public health, and research backgrounds. Most AHSR members hold doctoral degrees, whether research doctorates (922 members) or clinical doctorates (448 members) (Table 8-1). When asked to identify their discipline of specialization,

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FIGURE 8-1 Disciplines of individual members (members with multiple disciplines are counted more than once), 1992. SOURCE: Association for Health Services Research, 1993. about one-third indicated that they work in what AHSR considers to be the social sciences, another third in the health professions, and the remainder in public health, public policy, or other health services research specialties. Among those classified as social scientists, about 33 percent work in economics, 15 percent in sociology, and 12 percent in psychology. About 22 percent (147 members) of the social scientists reported their discipline to be health services research, possibly reflecting the participation of that cohort of individuals formally trained in health services research in recent decades ( Figure 8-1). Employment Sector. Most AHSR members were employed in university settings in 1992 (Figure 8-2). However, a host of non-profit and propriety health services research firms and non-profit professional organizations offer employment to health services research personnel. In 1988, the AHSR, together with the Federation for Health Services Research published the Directory of Health Services Research Organizations. That directory remains “the only source of information on health services research centers in the United States” (Davidson, 1993). Changes in Composition Over Time While the lack of data sets prevent an analysis of the composition of the health services research labor force over FIGURE 8-2 Employment settings of members, 1992. NOTE: Data represents 98% of AHSR membership. SOURCE: Association for Health Services Research, 1993. time, the availability of previous work by the NRC (1977, 1985) suggests that comparative studies might be developed. Because of the dynamic nature of this “labor force” and the importance to the national health effort, the Committee believes that some investment in labor force studies of the health services research community would yield tremendous payoffs—and, given the direction of national interest in the improvement of health care delivery, will be increasingly sought in the coming years. OUTLOOK FOR HEALTH SERVICES RESEARCH PERSONNEL The President's proposal for health care reform as well as Congressional proposals are pressing for change in the American health care system to remedy problems of spiraling costs, eroding access for the uninsured and underinsured, and uncertainty regarding the uniform quality of services. Many aspects of these proposals draw on information derived from health services research, as discussed above. Market forces are already requiring the pharmaceutical industry to consider issues of cost-effective outcomes of treatment as part of their business. However, as efforts are made to predict the consequences of alternative health care reform proposals, it is evident that much more information is needed if we are to make informed policy choices. Congress and the president have recognized this need and have increased substantially the funding of health services research by federal agencies and are expected to continue to increase funding into the future. Parallel increases in the funding of health services research in the private sector are occurring and are likely to continue. Questions to which better answers are needed include a spectrum of issues that cut across all health care services. These include: Which models of health care organization and financing work best and how does this vary across populations with different socioeconomic, ethnic, and health status characteristics? What impact do alternative organizational models

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have on the provision of preventive services, acute and long-term care, and quality of care and costs? What are the effects of licensing and regulatory mechanisms on access to care, quality, and cost and how should these rules be changed, if at all? Which health care professionals, with what types of training, are needed to provide high quality and efficient primary care, specialty services, long-term care, and rehabilitative services? How can accountability be improved? Can a useful report card on quality of care and costs be provided to patients and consumers to assist in making informed choices? What are other mechanisms to improve accountability in the health care system? What would be the impact of global budget constraints? Are there other means for reducing the rate of cost increases while providing appropriate services to all who need them (e.g., eliminating inappropriate services and reducing administrative inefficiencies)? These and other questions are sharpening the issues that need to be addressed through interdisciplinary health services research and demonstration studies. As changes continue to occur in the provision of health care services, there will be growing needs for rigorous evaluations of the impact of innovations on the quality, cost, and patient outcomes of care. Evaluations studies can clarify positive and negative aspects of innovations in health care delivery as well as point to opportunities to introduce improved models of care. Numerous organizational and financing changes are being introduced by states that are seeking tailored approaches to health care reform. These state initiatives also will need information on which to shape policy and evaluate progress. The source of this information is the field of health services research. Future Employment Conditions The growing demand for health services researchers can be seen in multiple areas, including both public and private sectors. The AHCPR was created in 1989. Since then its budget for research has doubled and is expected to continue to grow as the demands for information relevant to health care reform increase. Other federal agencies fund health services research, but AHCPR is viewed as the lead agency. Among the NIH institutes, there are increasing commitments to health services research. NIMH, National Institute of Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse were mandated by Congress to spend 12 percent of their budgets in 1993 and 15 percent in 1994 and 1995 to support services research in their respective areas. In 1994 this will amount to over $200 million in research funding. Other institutes fund health services research but do not identify it as such. The National Cancer Institute, National Heart, Lung, and Blood Institute, and National Institute on Aging all have significant research activities concerned with the provision of services and the effectiveness of care within their categorical disease responsibilities. It is anticipated that health services research funding will grow to represent a small but significant proportion of NIH funding. NIH currently spends substantially more on health services research than does AHCPR and is expected to continue to be a major source of funding for studies concerned with the organization of services, treatment, and outcomes of care for individuals with specific diseases and injuries. In addition to NIH, other components of the Department of Health and Human Services fund health services research. The Centers for Disease Control are making new investments in preventive services research and the Office of Research and Demonstrations at the Health Care Financing Administration supports a substantial health services demonstration and evaluation research program. Other federal agencies also fund health services research, including the Department of Veterans Affairs, which has an expanding health services research program. The investment of private industry in health services research also is rapidly growing. Insurers are seeking improved methods for reviewing claims and profiling providers. Managed care organizations are investing in improved methods for monitoring services, provider practices, and patient needs. The pharmaceutical industry is assessing outcomes of care related to drug therapies by using health status instruments and is investing in cost-effectiveness studies to demonstrate the comparative benefits of treatment. Every indication is that these investments will increase as managed care organizations demand better information to guide decisions regarding preferred treatments, appropriateness of services for different patients, and their impact on total costs of care. The health care industry accounts for 14 percent of the gross domestic product and is growing, possibly reaching 19-20 percent of the GDP early in the next century. Not only is it a large domestic industry, it is a significant source of international trade. Methods and techniques developed in America (e.g., DRGs for hospital payment) are being adapted and used in many other countries. Health status measurement indices developed here are being translated and validated for use in other languages. There is general consensus that there are similar problems being faced by all nations as each attempts to meet the growing needs for heath care services. Our past investments in health services research have made us an international leader. Other countries have begun to make investments in this area because of their needs for information and the demonstrated success of the American investments.

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ENSURING DIVERSITY OF HUMAN RESOURCES There is limited information currently available on the supply of health services researchers. Efforts need to be made to improve the completeness of information on individuals being trained in health services research and actively involved in research careers. On the basis of available information, it appears that career opportunities are open for women and men in this field. However, there is no information available regarding ethnic minorities. It is recommended that efforts be made to expand opportunities for ethnic minorities to pursue education and careers in this field. The NRSA awards can be used to leverage increased diversity among individuals entering this field and this should be encouraged. Training of Health Professionals Another concern relates to the lack of active involvement of the full range of health professions in the conduct of health services research studies. Much of past research has focused on physician-provided services or those delegated by physicians to physician assistants or nurse practitioners. The breadth of research needs to be expanded to include services provided by the full range of health professions, including occupational therapy, optometry, podiatry, physical therapy, and social work. In addition, services provided by practitioners of alternative medicine need to be included. A recent national survey reported that one-third of all Americans have used alternative medicine services and paid for most of this care out-of-pocket. One way to increase the diversity of research on the full range of health services provided in this country is to attract practitioners in these professions into health services research careers. The NRSA awards should be used to accomplish this goal. THE NRSA PROGRAM IN HEALTH SERVICES RESEARCH The information on current NRSA awards and the recommendations for future award levels in health services research relate solely to those awards made by AHCPR. The numbers of awards and funding levels of the program within AHCPR are shown in Table 8-2. The numbers of awards have grown rapidly yet remain small relative to the total needs for health services researchers. The current AHCPR program funds about 35 predoctoral and 59 postdoctoral positions, up from only 12 postdoctoral awards in fiscal 1990. The AHCPR program is relatively young and has given priority to postdoctoral training, particularly of health professionals, as an efficient strategy for more rapidly expanding the numbers of qualified health services researchers. It is expected that this should change over time to give increased emphasis to predoctoral training of individuals for careers in health services research. This training may occur either in academic disciplinary departments that have the capacity to train in health services research or in academic health services research departments that draw together faculty representing the range of disciplines applied in this field. NRSA awards in the NIH institutes also support the training of some health services researchers. NIMH supports TABLE 8-2 Aggregated Numbers of NRSA Supported Trainees and Fellows in Health Services Research for FY 1991 through FY 1993       Type of Support Fiscal Year Level of Training TOTAL Traineeship Fellowship 1991 Number of awards 12 0 12   Predoctoral 0 0 0   Postdoctoral 12 0 12 1992 Number of awards 94 82 12   Predoctoral 35 35 0   Postdoctoral 59 47 12 1993 Number of awards 96 79 17   Predoctoral 30 30 0   Postdoctoral 66 49 17 NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1.

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training in mental health services research, and the National Institute of Alcohol Abuse and Alcoholism is now soliciting training grant proposals in alcohol services research. In addition, the National Institute of Nursing Research supports training in health services research and to a lesser extent so do other institutes. NRSA training supported by the institutes should be encouraged; the numbers of current trainees is unknown because the classification of training awards in behavioral, clinical, nursing, and oral health does not discriminate which programs and fellows are pursuing training in health services research methods and their application. RECOMMENDATIONS Program Size Health services research is critical to the future of health care delivery in this country. 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. 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 answered by this field of research (Table 8-3). RECOMMENDATION: The committee recommends that the number of NRSA positions allocated to AHCPR increase to 360 in fiscal 1996. These positions should be phased in yearly as properly qualified candidates and training sites present themselves. Traineeships and Fellowships The institutional training grant permits the development of innovative interdisciplinary research training programs, TABLE 8-3 Committee Recommendations for Relative Distribution of Predoctoral and Postdoctoral Traineeship and Fellowship Awards for Health Services Research for FY 1994 through FY 1999       Type of Support Fiscal Year Level of Training TOTAL Traineeship Fellowship 1994 Recommended number of awards 115 95 20   Predoctoral 55 45 10   Postdoctoral 60 50 10 1995 Recommended number of awards 240 145 95   Predoctoral 180 95 85   Postdoctoral 60 50 10 1996 Recommended number of awards 360 190 170   Predoctoral 300 140 160   Postdoctoral 60 50 10 1997 Recommended number of awards 300 140 160   Predoctoral 60 50 10   Predoctoral 60 50 10 1998 Recommended number of awards 360 190 170   Predoctoral 300 140 160   Postdoctoral 60 50 10 1999 Recommended number of awards 360 190 170   Predoctoral 300 140 160   Postdoctoral 60 50 10

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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 significant emphasis on 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. RECOMMENDATION: The committee recommends that individual fellowships represent about 45 percent of total NRSA support available through AHCPR in fiscal 1996, up from approximately 15 percent in fiscal 1993. NOTES 1. For example, in 1977 the NRC identified and surveyed about 900 individuals who had received support from the National Center for Health Services Research (NCHSR) between 1960 and 1976 and about 1000 individuals who had received research training support from NCHSR or Alcohol, Drug Abuse, and Mental Health Administration in the area of health services research between 1970 and 1977. About 77 percent of the former trainees and 81 percent of the former principal investigators were engaged in health services research at the time of the survey. (See NRC, 1977; Ebert-Flattau, 1981). 2. The concept of the “attentive” public was developed by Gabriel Almond, who applied it to understanding attitudes of Americans toward foreign policy issues (Almond, 1950). Jon Miller applied the concept to the formulation of science policy and has expanded the original conception into a broader model of political specialization (Miller, 1983). The concept is extended for use here to refer to those members of the health services research labor force sufficiently interested in being identified as members of the field to have become members of AHSR. REFERENCES Association for Health Services Personnel 1993 AHSR Membership Directory. Washington, D.C.: Association for Health Services Research. Almond, G. 1950 The American People and Foreign Policy. New York: Harcourt, Brace and Company. Davidson, B. 1993 Personnel Needs and Training for Health Services Research. Paper prepared for the Committee on National Needs for Biomedical and Behavioral Research Personnel. Ebert-Flattau, P. 1981 Some preliminary data on the health services research labor force in the United States. In Systems Science in Health Care, C. Tilquin (ed.), New York: Pergamon Press. Miller, J. 1983 The American People and Science Policy. New York: Pergamon Press. National Research Council 1977 Personnel Needs and Training for Biomedical and Behavioral Research . Washington, D.C.: National Academy Press. 1985 Personnel Needs and Training for Biomedical and Behavioral Research . Washington, D.C.: National Academy Press.