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HEALTH SERVICES RESEARCH PERSONNEL: DEMAND, SUPPLY, AND ADEQUACY OF TRAINING RESOURCES E ~ izabeth McG ~ Ann * INTRODUCTION Health services research is an applied field that has as its domain all aspects of the health care delivery system. The ultimate goal of health services research is to provide the information base necessary to design a health care delivery system capable of maximizing the health of the population within the resource constraints imposed by the public and private sectors. The subjects of this research field include the training of health professionals; the process by which services are delivered; outcomes of care; methods by which patients pay and health professionals are reimbursed for care; the quality, efficacy, effectiveness, and appropriateness of services; and the interrelationships of these components. Health services studies may be methodologic, descriptive, analytic, or experimental, which implies a range of requirements for trained personnel. The demands for individuals trained in health services research come from academe, government, and the private sector. Given the complexities of the health care delivery system, the field relies upon researchers trained in numerous disciplines, as well as those capable of bringing disciplines together to work cooperatively. Figure 1 illustrates broadly the domains of health services research. U.S. Population --------> Service Delivery -a --> Outputs Health Needs System --Demographics --Culture --Morbidity --Mortality --Efficacy --Effectiveness --Efficiency --Equity --Quality FIGURE 1. A framework for health services research. --Expenditures --Health transitions --Satisfaction * The opinions expressed in this paper are the author's and do not necessarily reflect those of either the Committee on Biomedical and Behavioral Research Personnel or the National Research Council.

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Much of health services research looks at the relationship between the needs of the population and the delivery of services. The gaps between the demands for and supply of health technology often are studied in order to formulate approaches to closing the gaps. Finally, health services research examines the output of service delivery system as an indicator of system performance. The two outputs that have been the principal focus of research are expenditures on care and the health transitions (increments and decrements to health) that result from the application of service delivery system technologies. Others have argued that patient satisfaction with care also should be assessed. Economists, statisticians, and econometricians have developed tools for examining expenditures, whereas clinicians and psychologists have studied the health transitions and satisfaction. The diversity of questions formulated and analyzed by health services researchers makes it difficult to develop a neat taxonomy of the field. In an effort to explain through example, the remainder of this paper describes the training of individuals engaged in health services research, the various pathways used to produce these researchers, the current levels of support for training, and future events that might affect the demand for health services research personnel. At the conclusion of the paper, the question of the adequacy of these mechanisms for producing enough well-trained health services researchers for the near term is discussed. Throughout, many questions are raised for which there are not adequate data to arrive at an answer. These questions are raised not to frustrate the reader but to suggest avenues for a more systematic inquiry into the demand for and supply of health services research personnel. WHO CONDUCTS HEALTH SERVICES RESEARCH? Defining the requirements for health services research personnel is a complex task, for by its nature health services research is an interdisciplinary field requiring individuals trained in a variety of disciplines, as well as individuals who are capable of bringing disparate disciplines together to examine questions about the delivery of health services. Because there are no certification or licensing requirements, it is difficult to estimate the number and types of individuals who currently are conducting health services research studies. In this section four indicators of the types of individuals who constitute the health services research community are provided. One indicator comes from the membership of the Association for Health Services Research (AHSR), the professional society for such personnel. Table 1 gives the distribution of AHSR's 76

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membership by discipline. As the table demonstrates, the membership includes a wide variety of disciplines; these have been categorized for presentation purposes into more aggregate groupings and originally included more than 40 named disciplines. The top three disciplines are medicine (18.1 percent), economics (13.2 percent), and public health (12.7 percent). No single discipline is dominant. The educational background of the membership provides another illustration of the training received by those currently practicing in the field and is displayed in Table 2. About half of the members hold a research doctorate degree; about 21 percent are physicians or other health professionals; almost 20 percent have masters degrees; and the remainder have bachelors degrees, are in training, or did not specify their training in the membership survey. The institutional affiliations of members illustrate the variety of professional settings in which health services research personnel operate. Table 3 provides a distribution of the membership by the institutional affiliation of the individual. The greatest proportion of members are located in university settings (46.5 percent), followed by health care delivery or private health industry organizations (almost 27 percent). Other private organizations (e.g., consulting firms) and government employees make up 10.8 and 5.2 percent, respectively, of the membership. Finally, the publications that comprise health services research demonstrate the variety of topics considered and disciplines required to conduct such studies. The AHSR has an award each year for the best article in the field. Table 4 shows a listing of the titles, journals,ffirst author, and discipline of the articles thit were nominated for 1988 Article of the Year. Health services research is conducted by persons who have been trained in a variety of disciplines. Most of the studies are interdisciplinary in nature and require a team of individuals who can work together to solve the complex methodologic and conceptual issues posed by the subject matter. The articles shown in Table 4 provide one indicator of the variety and type of topics addressed by leading health services researchers and some sense of the disciplines involved. The extent to which the field is interdisciplinary is understated because only the first author is shown. Many of these projects included physicians, social scientists, and methodologists (e.g., statisticians). TRAINING FOR HEALTH SERVICES RESEARCH As suggested from the above discussion, the training currently received by those who are conducting health services research covers a variety of disciplines and degrees; therefore, 77

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there are a variety of formal and informal ways in which individuals become trained. Thus, the discussion of training considers each of these approaches to training separately: 0 disciplinary degree programs (e.g., programs that grant a professional or research degree in a traditional discipline such as economics); 0 interdisciplinary training programs (e.g., public policy, health services research); postdoctoral training programs; and 0 on-the-job training (e.g., socialization of research personnel into the field of health services research). Because the scope of health services research is broad, most individuals probably are trained in a narrow aspect of the field and then receive socialization into broader issues through some combination of additional work (e.g., postdoctoral studies) or by learning on the job. Whether this is the most efficient means of producing such personnel remains an open question. DISCIPLINARY DEGREE PROMS Currently, most individuals engaged in health services research have received their training primarily from disciplinary degree programs, including economics, quantitative methods (e.g., statistics, operations research, epidemiology), sociology, psychology, management (e.g., business, accounting, planning), and so on. It seems likely that for the foreseeable future, the field of health services research will continue to draw upon individuals with disciplinary degrees for a majority of its personnel. Clearly, the degree requirements for these programs already are well established, and the principal issues for this group of potential researchers are as follows: the type and amount of training necessary to acquire health services research skills and the extent of migration between disciplinary and interdisciplinary research and methods for influencing . . . mlgratlon. Although health services research is interdisciplinary and depends upon the skills and knowledge of investigators who have received different training, as the field has become more mature, it has developed its own language and information base. For health services research to be conducted efficiently and effectively (i.e., to avoid reinventing the wheel), individuals who wish to engage in this research must be socialized into the field in some manner. The two most common mechanisms-- 78

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postdoctoral training and on-the-job training--are discussed below. Most formal training programs take about 2 years, whereas on-the-job training has a less specific time frame. The amount of time required probably depends upon an individual's prior training, experience, and aptitude for learning new applications. One of the difficulties in estimating the number of persons currently engaged in or capable of performing health services research is that a majority of individuals have the potential of migrating in and out of the field. Further, some may spend only a portion of their professional time in health services research, while spending the remaining time in some other activity (e.g., medical practice or other disciplinary research). Migration may have the advantage of providing a niexib~e work force capable of expanding and contracting to meet the demands of the marketplace. The impact of migration on the supply of personnel is an issue that is particularly relevant to interdisciplinary research. Because little is known about the effects of such labor-market patterns, an investigation of the role of migration on the demand and supply of health services researchers should include attention to the following questions: o What is the minimum amount of time that must be spent in health services research in order to produce high- qua~ity research? O Is migration between health services and other research fields desirable? O What are the implications of migration for the quality of research produced? Having this potentially large source of human energy on which to draw for new health services research talent raises the question of the mechanisms by which such individuals might be attracted into the field. The attractiveness of any career path depends upon at least two factors: the financial viability of that avenue as compared to competing alternatives and the relative importance of the probJems-under study. The funding for health services research is small relative to biomedical research; thus, among those who have biomedical research as an alternative, health services research probably is not as attractive. However, those who are competing for research funding in the behavioral sciences may find health services research relatively attractive. If research funding in this area expands, one might expect greater numbers of persons to be drawn into the field. Other mechanisms, such as Career Development Awards, that provide a stable source of funding for new entrants to the field while they develop a research track record provide an appropriate means of attracting new talent into this field. Such awards are not widely available for health services research 79

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in general; most fall within more specialized areas of inquiry and tend to be aimed at physician researchers. Health services research also may be attractive to some because of the policy significance of the issues addressed. There is considerable interest in government and the private sector regarding issues of patient health outcomes, the appropriateness and quality of medical care, and the cost- containment potential of alternative delivery systems. Because both the public and private sectors are seeking answers to complex questions, the opportunities for working in an area of high visibility have expanded. This will appeal to those who are interested in applied rather than more theoretical fields of ~ 1nqulry. INTERDISCIPLIN=Y TWINING PROMS Interdisciplinary training is a relatively new--and increasingly important--avenue for producing health services researchers. Perhaps the most familiar programs are in public policy, public health, and health services or health policy research. In these programs students are introduced to a variety of methodologic approaches and taught the strengths and weaknesses of different methods for answering particular research or policy questions. This type of training introduces the individual to the contributions that can be made by different disciplines, which may be necessary in order to manage a team of researchers with different backgrounds. The interdisciplinary training may be general (e.g., public policy) or specialized (e.g., health services research). Because there are few such programs, each one is almost a unique case, and it is difficult to generalize about the advantages and disadvantages of each approach. Perhaps it is most important to know that both paths exist and that both are likely to produce some high-quality individuals capable of conducting health services research projects. As these fields develop, however, this may become a more efficient and effective means of producing health services research personnel. For those in interdisciplinary programs, the major issues are the following: o the availability of such training programs relative to the number of applicants; o the ability of such programs to attract high quality students; and o career opportunities that are open to graduates of these programs. Currently, there is no information on any of these three issues. What would be required in order to answer these 80

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questions is a comprehensive listing of interdisciplinary training programs and a survey of them. Admissions data combined with interviews of program directors could be used to answer the first two questions. In particular, it would be helpful to know what types of individuals are likely to pursue these programs (e.g., recent college graduates, individuals with related job experience, individuals making career changes) and how they compare with typical applicants to graduate programs in the disciplines from which health services research draws. The third question might be best addressed through a survey of alumni of these interdisciplinary training programs. Because these programs are relatively new, it is unlikely that one could piece together a career history (e.g., one that follows individuals from graduation through retirement), but early career paths could be documented. It is important to note that a variety of career opportunities are available to individuals trained in interdisciplinary research. Because many research results may suggest needed changes in policy, there are benefits to having trained individuals who are responsible for policy formulation and implementation. POST~CTO"L TWINING PROGRESS Individuals trained in either disciplinary or interdisciplinary programs may require additional career development such as that offered in postdoctoral training programs. These programs may serve different purposes, depending upon the background of the individuals entering the program, but all should enhance the qualify of research produced and provide research experience that will advance the careers of these persons. For those with professional degrees (e.g., medicine, law), the postdoctoral program may serve to introduce the individual to research methods. For persons with doctoral training in a specific discipline, the postdoctoral training program may provide an opportunity to specialize in health services research. For those with interdisciplinary degrees, the postdoctoral program may offer additional experience in designing and managing research projects. Each of these functions is important, and because of the multiple pathways into health services research, each will continue to serve a purpose in the future. The issues in this area are: 0 What are the key components of successful postdoctoral training in health services research? O What is the demand for positions in these programs relative to the availability? o Do such programs influence the career paths of their graduates? 81

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Despite the multiple pathways into health services research and the variety of disciplines that participate, there may be a basic set of skills necessary in order to have a successful career in this field. Two important components in many health services research projects are a clinical perspective and methodologic expertise. These reflect the two levels at which analysis generally is conducted in such projects: at the doctor- patient level (clinical) and at the level of a particular group (policy). Physicians, by virtue of their medical training and experiences, can bring a clinical perspective to health services research, but, in order to contribute to the formulation of research questions and study design, they also must be trained in research methods. Physicians are trained to approach each patient as a unique case, rather than to take the aggregate approach to formulating questions and collecting data that are required for conducting research. Thus, most physicians require training in research methods to acculturate them to the language and framework for problem solving. Methodologic experts, on the other hand, provide a perspective on the design and conduct of research projects, but they may require socialization or training about the important clinical issues. For example, much interest has been expressed by Congress and others in devoting additional resources to patient-outcome research. A methodologic expert might be able frame the questions but would require assistance in designing a medical records abstraction form, including making decisions about the critical values (e.g., what diagnostic test result justifies performing coronary artery bypass surgery). Alternatively, a cardiologist could suggest the key outcomes of bypass surgery that might indicate whether high-quality care was being delivered, but he or she might require assistance from an epidemiologist or statistician to design a study to estimate the prevalence of quality problems. Estimating the demand for entry to postdoctoral programs should be approached in a manner similar to that suggested for interdisciplinary training programs. A comprehensive list of the postdoctoral programs and a survey of program directors that included information from admissions records would provide information on, for example, the number of qualified applicants turned down each year. It would also be useful to know what alternatives applicants to these programs are considering. Finally, although there seems to be logic in developing postdoctoral training programs, it would be useful to know the outcomes of these programs and whether they have any substantial influence on the quality and success of graduates: o Does postdoctoral training improve the ability of individuals to obtain research funding? 82

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o Are researchers who have been through such programs more likely to have articles accepted for publication? o o Are they able to publish in higher-quality journals? Are they more likely to stay in research careers? Answering these questions would require a survey of alumni and an examination of the backgrounds of successful and unsuccessful applicants for health services research funds. ON-THE-JOB TRAINING The final pathway into health services research is on-the- job training. Probably anyone who is conducting health services research has had some on-the-job training because it is a common means of career development. In the university setting such opportunities are provided through research assistantships or internships. Students may form mentor relationships with research supervisors, who in turn take responsibility for schooling the student in the methods and knowledge central to the chosen field of study. In all research settings this may be the method by which disciplinary-trained individuals are socialized into health services research (e.g., by serving as the economist on a health services research project). Reliance on this method of producing health services researchers is risky at best because the success of the approach depends upon the quality and commitment of those serving in a supervisory capacity. If the supervisor perceives his or her role as a teacher or mentor and is capable in either of those capacities, then the individual in training is more likely to have a successful experience. Many research projects, however, are constrained by tight budgets that may not allow for adequate learning opportunities. Motivated individuals may be able to learn even under such circumstances, but we would hardly want to depend upon this approach as the sole means by which such researchers are produced. HEALTH SERVICES RESEARCH REQUIREMENTS The field of health services research would be advanced by establishing some guiding principles about the requirements to become a health services researcher. From the taxonomy proposed in Figure 1, a first step could be taken to recommend areas of exposure. While there is no one pathway that should be required, it is reasonable to consider how we would want to train the next generation of researchers in this area. A proposed curriculum is outlined in Table 5 as an example of the areas of study recommended for those in health services research. Presumably, some researchers would be experts in one of the fields listed in the table, but they would also have been exposed through a 83

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combination of formal course work and research experience in some proportion (say two-thirds) of the other disciplines that contribute to leading health services research projects. The knowledge of these other fields is important both in formulating research strategies and managing projects that utilize multiple disciplines. 8OPPORT FOR HEALTH 8ERVICE8 ~SE~CE T"INTNG From the above discussion, it should come as no surprise that the field of health services research draws upon a variety of sources of funding for training. These sources include both public and private support. Those more easily identified are the sources dedicated to health services research training fellowships; clearly, this does not capture all of the funding sources for training those who become health services researchers. The AHSR maintains a directory of Health Services Research Organizations e The 1988 directory provides profiles on more than 80 health services research centers, including information on the number and funding for training fellowships. The appendix to this paper contains a listing of the predoctoral, postdoctoral, and other training support based on information provided in the directory. As can be seen from Table 6, the number of fellowships available for training in health services research is quite small. Although this number most likely underestimates the true number, it probably captures the majority of available fellowships in major institutions. It also should be emphasized that these numbers represent fellowships specific to health services research and do not include individuals receiving disciplinary training who may eventually enter health services research through other channels. It is also worth noting that these programs exist in only a few states (15 or 16), which suggests that access to these programs is limited geographically. California and Massachusetts have the largest number of institutions offering predoctoral and postdoctoral training programs. Financial support for these training programs comes from both government and private sources. FEDERAL SUPPORT A number of agencies within the federal government provide funding for both research and training activities. The most prominent agencies are within the Department of Health and Human Services (DHHS) and include the National Center for Health Services Research and Health Care Technology Assessment, the Health Care Financing Administration, the National Institute of Mental Health, and the National Institutes of Health. Outside DHHS, health-related research activities (although not necessarily health services research) are funded by the 84

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Departments of Agriculture, Commerce, Defense, Education, Energy, Interior, Labor, and Transportation, as well as the Consumer Product Safety Commission, Environmental Protection Agency, Agency for International Development, National Aeronautics and Space Administration, the National Science Foundation, and the Veterans Administration. It is difficult to estimate what proportion of the health-related research conducted by these other agencies falls into the category of health services research. Such an estimate would require a separate study that has not yet been done, although it was recommended in the last report to Congress. The National Center for Health Services Research and Health Care Technology Assessment (NCHSR-HCTA) is one of the two agencies primarily responsible for funding health services research. Table 7 shows the allocation of funding for NCHSR- HCTA since 1986. Although current dollars remain stable, the real dollars available for such research have been declining since the inception of the center. Further, new money is being added in specific research areas (e.g., patient outcomes and AIDS research) rather than being made available for general research funding. In fiscal year 1988 NCHSR-HCTA funded 40 new grants in the following areas: o patient outcomes research; o AIDS-related projects; a rural hospitals; 0 emergency medical and intensive care; 0 prenatal care; 0 technology assessment; o role of market forces; o home health care; and o other policy concerns. Grants were awarded for periods of 1 to 5 years, although most grants were for 2 years. The total amount obligated was $8.6 million. NCHSR-HCTA also provides support for predoctoral and postdoctoral training. The agency has authority to award 10 to 20 dissertation grants annually to support individuals pursuing degrees in fields related to health services research while they write dissertations. The grants may be up to $20,000 annually and must be related to the current funding priorities of the agency. NCHSR-HCTA also has authority to award individual 85

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TABLE 3: Institutional Affiliation of AHSR Members, May 1988 Institutional Affiliation Proportion of Members (n = 1042) University Health care delivery Health industry Private organization Government Private Other foundation 46.5 15.6 11.3 10.8 8.2 1.2 6.4 SOURCE: AHSR, personal communication. 96

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TABLE 4: 1988 Nominations for AHSR Article of the Year First Author Title Degree and Discipline Journal Luft, H. S.* The Volume-Outcome Rela- Ph.D. Health tionship: Does Practice Economics Serv. Res. Make Perfect? Shortell, S. M. The Effect of Regulation, Ph.D. N. EngI. Competition, and Ownership Management J. Med. On Hospital Mortality Dubois, R. W. Hospital Inpatient Mor- M.D./Ph.D. N. EngI. tality: Is It a Predictor Public J. Med. Of Quality? Policy Chassin, M. R. Wennberg, J. E. Goldberg, H. I. Jencks, S. F. Does Inappropriate Use Explain Geographic Varia- tions in the Use of Health Care Services? Use of Claims Data Systems to Evaluate Health Care Outcomes: Mortality and Reoperation Following Prostatectomy A Randomized Controlled Trial of Academic Group Practice: Improving the Operation of the Medicine C] inic Bringing Excluded Psychi- atric Facilities Under the Medicare Prospective Payment System M.D. JAM A M.D. JAMA M.D. JAMA M.D. Med. Care *Winner of 1988 Article of the Year 97

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1 First Author Title Degree and Discipline Journal Soumerai, S. B. Feder, J. F. Shy, K. K. Sacks, H. S. Verbrugge, Young, M. J. Rossi, P. H. Warner, K. E. Payment Restrictions for Prescription Drugs Under Medicaid: Effects on Therapy, Cost, and Equity How Did Medicare's Pro- spective Payment System Affect Hospitals? Evaluating a New Technol- ogy: The Effectiveness Electronic Fetal Heart Rate Monitoring Meta-Analyses of Randomized Controlled Trials L. M. Exploring the Iceberg: Common Symptoms and How People Care for Them Do Cardiologists Have Higher Thresholds for Recommending Coronary Arteriography than Family Physicians? The Urban Homeless: Estimating Composition and Size Health and Economic Implications Tobacco-Free of a Society Sc.D. N. Engl. J. Med. Economics N. Engl. J. Med. Ph.D. Ann. Rev. Of Pub. Health Ph.D. N. EngI. J. Med. Ph.D. Med. Care M.D. Health Serv. Res. Ph.D., Science Sociology Ph.D., JAMA Economics SOURCE: Brook, R. H., Good for You and Me?", 1989. "Health Services Research: Academic Medicine. 98 Is It

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TABLE 5: Proposed Curriculum for Health Service Training Research Methods Substantive Knowledge Economics Quantitative methods (statistics, econometrics, operations research) Social science research methods (survey research, Epidemiology Demography psychometrics) Technology assessment Health professions training and supply Quality of care Health care financing Organization and service delivery Outcomes assessment 99

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TABLE 6: Institutions Participating in Health Services Research Training Category of Number of Number of Number of Training Fellowships Institutions States Predoctoral 216~ 26 15 Postdoctoral 80~ 23 16 Other2 __ 24 15 lithe number shown is a minimum; some programs indicate that the actual number varies from year to year. 2 Includes internships, midcareer training, master's level programs, ad hoc fellowships, research assistantships, independent study, and visiting scholars. 100

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TABLE 7: Funding for NCHSR-HCTA (in thousands of dollars) Category 1986 1987 1988 1989 1990* . . Research Federal funds $15,740 $17,277 $16,624 $17,112 $12,153 Trust funds 1,050 1,070 1,005 1,037 1,037 Program support 1,050 1,568 1,632 1,600 1,693 Outcomes research AIDS-related research -- 1,945 5,879 28,000 6,859 8,576 One-percent funds (NMES) 16,000 15,318 10,033 11,154 NRSA 1,296 1,323 1,300 Total $17,840 $35,915 $37,820 $43,843 $63,913 * Presiclent's budget. SOURCE: AHSR 101

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TABLE 8: Funding for the HCFA-ORD (in thousands of dollars) Category 1986 1987 1988 1989 1990i Federal funds2 $15,310 $10,000 $9,574 $9,880 $14,000 Trust funds3 14,370 18,000 18,000 17,233 19,760 Total $29,680 $28,000 $27,574 $27,113 $33,760 President's budget. Appropriated by Congress. 3 Set aside from trust fund collections by congressional action. SOURCE: AHSR. 102

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TABLE 9: VA Health Services Research and Development Field Programs, 1987 Region Projected Spending, 1987 Research Staff (FTEs) Affiliated VA Medical Universities Centers (no.) (no.) Northeast Mid-Atlantic Southeast and Southwest (3, 7) Great Lakes (4) Medical District 17 Medical District 22 Medical District 23 Far West t6) Northwest (6) $1,500,000 1,078,603 846,794 1,116,500 1,263,893 690,027 220,776 1,600,000 544,414 22.4 8.0 18.6 15.5 16.2 10.2 2.0 9.5 5.1 3 2 5 4 5 2 3 2 5 23 1 4 5 3 4 1 3 6 Total $8,861,007 123.0 31 50 SOURCE: AHSR, 1988 Directory . 103

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TABLE 10: Robert Wood;Johnson Foundation Clinical Scholars Program, 1987 - Number of Number of Year Program Funding Scholars Alumni Began UCLA $~9,29g 8 54 Ig75 UCSF/Stanford 274,223 11i 72 1969 UNC-Chapel Hill 256,370 7 53 1974 University of Pennsylvania 575,818 112 54 1974 University of Washington 374,187 93 i 61 1975 Yale University 137,123 73 47 1974 Total $1,890,020 53 341 Includes four VA fellows. 2 Includes one VA fellow. Includes two VA fellows. SOURCE: Robert Wood Johnson Foundation, 104 personal communication

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TABLE 11: The Pew Charitable Trusts Health Policy Program, 1987-1991 Current Program Grant Current Number of Program (millions of $) Fellows Alumni Type* Boston University/ Brandeis $2.3 13 25 1,3,4 Michigan 1.9 23 9 l RAND/UCLA 1.6 19 28 1,5 UC-San Francisco 1.6 9 39 2 Total 7.4 64 101 * 1 = predoctoral; 2 = postdoctoral; 3 = corporate fellows; 4 = associate; and 5 = midcareer. 105

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