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a. ADMINISTRATIVE ISSUES AND POLICY CHANGES SHORT-TERM TRAINING The Co~ittee has followed wi th interest the steps NIlI has taken in planning and impl ementing the provi sion of the MRSA leg islation permitting the use of up to 4 percent of ap- propriated funds for short-term training programs. Al- though a few short-term training programs for pre-Ph.~.' s and post-Ph.D. ~ s have been supported prior to this new pro- vision, it is noteworthy that now recipients will be able to take up to three 3-month training sessions wi shout being subject to the payback requirement. NIH currently plans to use most of these f unds to provide heal th professions stu- dents with an exposure to research problems and techniques (Appendix C) in the hope of attracting some of these stu- dents into careers in cl inical research . The Committee en- dorses such a program for heal th professions students, but bel ieves that shor t-term training programs in other areas should not be expanded significantly until additional funds are made ava il able . The Committee believes that establishing a short-term training program for heal th professions students can be an important step in helping to revisal ize the interest of these students in pursuing cl animal research careers. In its 1978 Report (NRC, 1975-1978; pp. 101-103 ), the Committee noted that recent cliff iculty in attracting heal th profes- sions students into research careers is the resu1 t not only of financial disincentives but also of a lack of first-hand experience in a research activity dur ing the period of pre- doctoral training and residency. Flaking such experiences available through short-term training programs should enable students to test their interest and ability in research. Students who confirm their interest can then pursue with confidence a research training pathway. Those who discover little interest or ability in research can resume their training as practitioners without incurring the obligations of payback. Such sorting will also allow the valuab1 e training resources of training grants and fellowships to be directed to those heal th professions students with confirmed interest and abil ity. The 3-month program for predoctoral students will not augment the diminishing supply of physician investigators. For this purpose it may be highly desirable, even necessary, to provide a more substantial exposure to research during the physician' s residency period by offering ~ or more full years of research training to medical doctors who are so inclined. Those who have a positive experience would be in a better position to decide about further research training following completion of the residency. It is worth noting that opportunities to interrupt a residency with research exper fence would serve to reduce the long hiatus in research training for M.D./ Ph.D. program graduates who otherwise enter standard residency programs. 44

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The utilization of this short-term training mechanism to introduce health professions students to research suggests that other obj ec t ives , research areas, and types o f studen ts may also benefit from this kind of program. In the basic biomedical sciences, where the supply of researchers is not a problem, there already exists a few examples of short- term programs that have been designed to provide opportu- nities to acquire current research techniques ~ for example, at the Marine Biological Laboratory at Woods Hole, Massa- chusetts and the Cold Spring Harbor Laboratory, New York). The short-term training mechanism could also play a role with respect to nursing researche The Committee has learned that the Health Resources Administration's Division of Nurs ing hopes to develop a short-term training program in ad- i t ion to the ex i s t ing inst i but tonal research tra in ing gran t program. The purpose of this program would be to encourage nursing facul ty to become more active in research. The Com- mittee endorses this proposal and offers two suggestions: first, that the program permit individuals to participate for two or three consecutive summers; and ~ second, that prom gram policy permit the use of short-term training support in a broad range of institutions with ongoing research activi ties rather. than be restricted to only those institutions that currently have research tra ining grants O ~~ STI PEND LEVELS In its 1977 Report (NRC, 1975-1978; pp. 180-181), the Com- mittee noted that the absence of any increase in stipend Iesrels since 1974 has seriously eroded the economic position of trainees and fellows O The Committee pointed out that a continuation of this situation could result in difficul ties in recruiting individuals for research training and in enabling trainees and fellows to pursue their work on a fu11time basis without diverting their attention from mat- ters of training to those of subsistence. In recommending that stipend levels be raised, the Committee advised that increases should be effected through additional funding rather than by reducing the recommender] number of trainees and fellows to be supported. The Commi t tee notes that Congress and DHEW have addressed this problem this year and have done much to correc t the underlying inequi ty . DHEW has approved a pi an for raising stipend levels, effective July 1, 1980 (Appendix C ~ . Under the approved pi an, predoctoral st mends wi 11 in- crease from $3,900 to $5,040 ~ a 29 percent increase) and beginning postdoctoral stipends will increase from $10, 000 to $13,380 ( a 33 percent increase) . These increases are consistent with the Committee's 1977 recommendation for an 42

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immed i a te cos t-o f- l iv ing increase, and the Commi t tee notes that the plan will do much to compensate for the effects of inflation over the last 5 years. The implementation of this plan of stipend increases faces certain cliff icul ties that are traceable to the current provisions for NIH funding. In November 1979 Congress passed a con t inuing revel ut ion, ef f ec t ire through September 1980, which allows the NRSA program $33 mill ion more than FY 1979. The "additional" $33 million, however, was not a net increase in the total NTH budget, but rather an instruction to reprogram funds from other purposes to the support of training. Such a reprogramming scheme was clearly intended by the Congress to assist training but not to reduce re- search grant support. The reprogramming was to be ef fected on an institute by institute basis. For most institutes with relatively large research contract programs, this reprogramming adjustment is being accompl ished by shif ting between these two categories . The Institute of General Medical Sciences, however, has found it impossible to make this adjustment. This Institute has the largest predoctoral training program in NIH. It makes two- thirds of all NIH predoctoral awards, and it has a compara- tively small research contract program from whose resources it might draw to increase stipends . The Committee understands that the NIGMS may have to reduce the number of predoctoral trainees to be supported in 1980 by as much as 20-25 percent in order to provide the newly increased levels. A few training programs may not be renewed; and most of the continuing programs will have fewer trainees than in 197 9 . Thus, the outlook for support of predoctoral trainees in 1980 is for an NIH-wide reduction of approximately 13 per- cent in number of positions, wi th al most all of this reduc- tion taking place through NIGMS programs. ADAMHA also was not provided with any additional funds to implement the planned increase in stipends, and this will resul t in a reduction of approx imately 14 percent in the number of positions that can be supported in FYl980. The Committee hopes that this significant reduction in predoctoraI training in 1980 will be a transient, temporary phenomenon. The Commi t tee i s pi eased the t Congress and DHEW have recognized the problem of stipend levels and urges that Congress provide appropriate levels of funding for research training while avoiding unintended, but serious, inequities and disruptions such as those which appear to be occurring. A particular problem with regard to stipend level s has been the case of the potential physician investigator. In addition to the considerable gap in lifetime earnings, there is a growing gap between the incomes of house staff and research trainees. The situation raises the possibil ity of estabI ishing a differential stipend policy that would take into account those areas where market disincent Ives are 43

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particularly acute. The Commi t tee recognizes that differen- tials might have other disadvantages and wil ~ devote further attention to this issue when addi tional data on f inancial and other disincent Ives, currently being sought, become avail ablee INSTITUTIONAL SUPPORT COMPONENT OF THE TRAINING GRANT DREW has recently announced a modification of the procedure for determining the max imum level of award for the institu- t tonal support component of the training grant O The pre- vious administrative procedure, insti tuted wi th the beg in- ning of the NESA program, used a formula which allotted a maximum of approximately 25 percent of the total of each training grant award for institutional support. Under that procedure private universities received larger sums for their institutional support than did public institutions be- cause the tuition costs, which are significantly higher in private schools, were included in the base amount of the training award to which the 25 percent fo ~ foul a was appl fed . The new procedure, to commence on July I, 1980,- will be based on a maximum allotment per trainee--$3,000 per predoc- toral and $5,000 per postdoctoral trainee. The overall amount of support budgeted for institutional purposes is not expected to change markedly. The result of this ad justment, however, will be to redress the imbalance that has existed between public and private universities in the amount awarded for institutional support. The Committee is pleased that the present inequitable condition has been corrected, but believes that in the new procedure greater flexibi] ity should be available to meet the training needs of individual programs. It is proper that agencies require each appI icant to justify the amount of institutional support needed . In this regard, there is no more reason in the case of any ind ividual program to impose an absolute ceil ing than there is to impose an absolute floor on the institutional support component. While the agencies, of course, must place some overall ceiling on the amount of funds available for this purpose, the distribution of these funds to ind ividual programs should be based on program-justified needs and not on a universal ceiling. This position is consonant with that expressed by the U. S . House of Representatives (197B, p. 33), which urged greater flexi3oi1 ity in the distribution of such funds. The Committee recommends that greater fiexibil ity be incorporated in the procedure for distributing the institu- tional support component of training grant funds. Agencies should permit waiving the rigid ceiling of 33,000 per pre- 4aS

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of predoctoral trainees under NRSA institutional grants . (This change in pot icy does not apply to individual Fellowship awards. ~ Accordingly, as of this date, predoctoral individuals may be appointed during any years s) of their graduate training,. as long as such appointments are cons i s tent wi th the s tat utory max imum of f ive years of predoctoral support under the Na t tonal Research Service Award Act. ThiS change is appl icable to currently supported programs, as wel l as those funded in the f uture . Program Directors are strongly encouraged to provide stipends in the f irst and second years of graduate work only in cases where promising students ~ especially women and minorities) would not have suf f icient resources to enable them to pursue their training on a full-time basis, and such students have expressed their commi tment to pursue research careers in areas related to alcohol ism ~ drug abuse, or mental heal th . The Committee is hopeful that abol ition of the 2-year re- striction will enhance the recrui tment and retention of well-qua, if fed first- and second-year students in research careers relevant to the goals of ADAMHA. With respect to their efforts to develop targeted research-training programs that would recruit members of minority groups into research careers, ADAMHA has also announced a new program of support2: ADAMHA has initiated a Minority Access to Research Careers ~ MARC) program modeled on the MARC program of the National Institute of General Medical Sciences at NTH.... We have high hopes that these mechani sms will help to assist institutions with substantial minority enrol ~ ment in the training of greater numbers of scientists and teachers in f ields relating to alcohol i sm. drug abuse, and mental heal th . The Committee commends ADAMHA on the signif icant stridestaken these past months to enhance the availabil ity of NRSA support to minority-group members, women, and stu- dents from disadvantaged backgrounds. The Committee shares the hope expressed by Dr. Kit erman that these actions will enhance the representation of these individual s in the scientific labor force and in the national alcohol, drug abuse, and mental health research effort. 46

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CLINICIANS IN MENTAL HEALTH RESEARCH In its 1978 Report (NRC, 1975-1978: p. 79), the Committee explored for the first time some of the barriers to the re- cruitment of clinicians into mental health research. Among the factors identified by the Committee was the separation of federal support for research training and cl inical train- ing as a result of the enactment of the NRSA authority. Specifically, the Committee observed: When the NRSA Act required that a distinction be made between clinical training and research training, ADAMHA, which had long provided support for both types of training through NIMH, estab- lished guidelines by which existing awards could be assigned to either the clinical or the research training category "as the preponderance of evi- dence" from the grant applications suggested. Since the release of its 1978 Report, the Committee notes that former Representative Paul Rogers (D-Fla. ~ clarified the intent of the NRSA authority relative to pro- viding research training opportunities to clinicians when he introduced the Biomedical Research and Training AInentiments of 1978 ~ see note ~ to Chapter 2 of this Report) . The Com- mittee welcomes this clarification of intent. It recognizes the real ity of introducing cl inicians, including cl inical psychologists and psychiatrists, to research during the course of their cl inical professional training and g ives the agenc ie s fl ex ib i l i ty to prov id e appropr i a te suppor t under e i ther tra in Fig author i ty . 3 HEALTH SERVE CES RESEARCH UNDER THE NRSA AUTHORI TY The Committee is pleased that its earlier recommendations in this area have had a far-reaching impact. The Commi thee notes specif ically that its recommendation to expand the NRSA authority to include the NCHSR has been real ized. The Health Services Research, [lealth Statistics and Medical Technology Act of 1978 (PL 95-623, Section 3 ~ a) ~ 3 ~ ~ amended the previous authority to permit the use of NRSA support for training in heal th services research4: The Secretary shall, through the National Center for Heal th Services Research, the National Center for Heal th Statistics, and the National Center for Heal th Care Technology and using National Research Service Awards and other appropriate author i ties, undertake and suppor t 47

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training programs to provide for an expanded and con t i nu i ng suppl y 0 f ind iv id ua 1 s qual i f i ed to perform the research, evaluation ~ and demonstra ~ Lion pro jects set forth in sections 305' 306, and 309. The Committee is hopeful that this expl icit extension of the NRSA authority to inc] ude the NCHSR will result in a more stable "federal commitment to the total heal th services research effort" (NRC, 1975-1978 1977 Report, pa 129 48

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NOTES ~ . Memor and um f rom Adm i n i s tra tor, ADAMHA, to ADANHA NRSA Research Training Program Directors and Potential Research Training Grant and Fellowship Applicants, December 19, 1979. 2 . Or . Gerald K] erman, ADAMHA Administrator, munication to Dr. Henry Riecken, January 3, 1980 . personal com- 3. The Committee notes that the NRSA guitlel ines issued jointly by NIH and ADAMHA in 1976 and now the cl conical training guidel ines issued by NIMH in 1979 both contain language that permits under either authority support of clinical and research activities to the extent required to fulfill the principal purpose of the training program. 4. This amendment makes research training support mandatory rather than permissive, and extends the NRSA authority to include the National Center for Heal th Statistics and the new Of f ice of Heal th Technology in add i t ion to the NCHSR . 49