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2. CLINICAL SCIENCES
The Committee def ines clinical investigation as research on patients;
on samples derived from patients as part of a study on the causes,
mechanisms, diagnosis, treatment, prevention, and control of disease; or
on laboratory animals by scientists identif table as clinical
investigators on the basis of their other work. As a mode of scholarly
inquiry, clinical investigation takes many forms. It may consist of the
systematic observation of individual patients in a controlled environment
or large-scale clinical trials involving thousands of subjects and the
pooled effort of investigators in multiple institutions. It includes
carefully controlled studies to elucidate the mechanisms of disease, or
epidemiolog ic research to uncover leads as to the etiology of disease.
An essential aim of clinical investigation is to translate new knowledge,
through applied research, into new technology and modes of treatment, as
well as the validation of new technology through clinical trials.
The clinical investigator] generally teas an M.D. or other health
professional doctorate. The Committee recognizes that basic scientists
also partic mate in clinical investigation. As part of the clinical
investigation team, they have a multifaceted role that may range f ram
studying isolated tissue components derived from patients to close
collaboration with a physician-investigator in research requiring
experimental manipulation of human subjects and their environment.
Moreover, they often help to ensure the application of state-of-the-art
technology to clinical investigation. While such participation is to be
encouraged, there will always be an overriding need for the physician
investigator who is uniquely prepared to recognize research opportunities
presented by human disease, to formulate researchable questions, to
design experiments for answering those questions, and to perform
personally the work entailed in those experimental designs. In many
cases it will be necessary to study patients intensively, permitting the
clinical situation to guide the nature of the questions, as well as the
manner of seeking their answers. In addition, legal, ethical, and
regulatory constraints establish the primacy of the physician in clinical
investigation. In short, the physician investigator has a very special
role both in bringing clinical insights to bear in the laboratory and in
translating new knowledge into the context of medical practice.
Given this irreplaceable role, the Committee reiterates its concern
over the precipitous decrease in postdoctoral training of physicians. As
can be seen in Table 2.1, the number of persons with a health
professional doctorate receiving training under NIH training programs has
declined in both absolute numbers and as a percentage of total
postdoctoral trainees/fellows supported by NIH from 1911 to 1979. While
some of the decline can be attributed to the elimination of predominantly
23
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TABLE 2.1 Distribution of NIH Postdoctoral Trainees and Fellows by Degree Type, 1971-79a
Year Total M.D.,sb Ph.D.'sb
1971 # 7,532 4,631 2,901
% 100.0 61.5 38.5
1972 # 7,AgS 4,466 2,927
% 100.0 60.4 39.6
1973 # 5,466 3,612 1,854
% 100.0 66.1 33.9
1974 # 6,313 3,522 2,791
% 100.0 55.8 44.2
1975 # 5,957 2,874 3,083
% 100.0 48.2 51.8
1976 # 4,884 1,950 2,934
~ 100.0 39.9 60.1
1977 # S,~gS 1,906 3,389
~0 100.0 36.0 64.0
1978 # 5,683 1,954 3,729
~0 100.0 34.4 65.6
1979 # 5,613 1,923 3,690
% 100.0 34.3 65.7
aThese data represent individuals who actually served in NIH-supported traineeship or fellowship positions. Thus
these counts may differ slightly from those shown in Chapter 1 which represent awards, not individuals on duty.
Includes Fogarty Inten~abonal Center programs.
b`'M.D." and `'Ph.D." Also include equivalent doctorate degrees. Persons with bow M.D. and Ph.D. degrees are
shown under 'M.D.".
SOURCE: National Institutes of Health (1966-81).
clinical training programs early in that period, the decrease in more
recent years probably reflects a diminished interest in research careers
On the part of the young physician ~ see p. 28) . The Committee believes
that the dec line has serious implications for the f uture of patient-
centered and disease-oriented research.
24
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THE TRAINING OF PHYS ICIAN INVESTIGATORS
With the movement of clinical medicine "from anecdotal empiricism to
an approach based on analysis and experimentation, n clinical
investigation has become the bridge between basic and clinical science
(Tinier, 1980~. In that process it has become enormously sophisticated
and complex. It is appropriate therefore to ask how the young physician
acquires the diverse scientific and clinical skills needed for a
successful career in clinical investigation.
Clinical research training is heterogeneous in nature, duration,
sources of support, and degree of formality of the training experience.
The newly trained physician investigator is not the product of a distinct
course of study, such as the curriculum leading to the M.D. degree or
graduate medical education programs aimed at eligibility for primary
specialty board certif ~cation. Although the physician enters research
training most commonly at the end of the last year of the residency
program, there are many points along the continuum of medical education
at which the decision for a research career may be made. Individuals
enter research training at different stages of their educational and
professional careers and with varying amounts of research experience.
Moreover, there is a diversity of paths for transition f rom the trainee
pool to the community of productive clinical researchers.
Medical School
Despite this diversity, the development of a clinical investigator in
most cases beg ins in medical school where research opportunities can take
several forms. Some medical students receive their f irst exposure to
research by repeating classical experiments in basic science or by casual
laboratory interactions with faculty members. Other students may develop
a f irsthand acquaintance with the laboratory through summer extramural
experiences, such as research fellowships. Short-term training for
periods of up to 3 months, for example, is currently supported by NRSA
institutional awards for 964 trainees in 65 health professional schools.
In some medical schools fellowships similar to the former NIH
Post-Sophomore Re search Fellowships are available to spec tally selected
students. These awards provide an opportunity f or a student to inter rupt
regular coursework with a f ull year of advanced study and research.
Students who have developed a strong interest in research during
their premedical education have an opportunity in three-quarters of
United States medical schools to combine medical and graduate studies in
programs leading concurrently to the M.D. and Ph.D. degrees (M.D./Ph.D.~.
A selected subset of 24 medical schools have 6 year dual degree programs
funded through the NRSA Medical Scientist Training Program of the
National Institute of General Medical Sciences. Another source of
potential clinical investigators is comprised of students who enter
medical school with the Ph.D. degree (Ph.D./M.D.~. The postgrad-
uation research plans of this group are compared in a later section of
this chapter, with those of concurrent M.D./Ph.D. 's and medical students
who do not earn a Ph.D. degree.
25
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Residency
The pattern for including a researab experience within a standard
residency varies considerably among clinical specialties. Some
residencies, including a number of surgical specialties, routinely
include from 3 months to 1 year of clinical research experience. The
rationale, however, is to prepare clinicians who can keep abreast of
advances in the specialty, rather than to produce clinical investiga-
tors. By contrast, research experience is no longer considered as part
of the general training requirements in other specialties such as
pediatrics and internal medicine. During the period of residency, as a
general rule, the young physician will have had little or no training in
the discipline of the laboratory, the design and execution of
experiments, and the understanding of complex instruments and research
technology. In short, to become a productive investigator, he/she needs
to start a second and new career.
Post-Residency
; . ~-
......
. .
Research training has traditionally been intermixed with clinical
specialty training for most physicians who later pursued careers in
academic medicine. This ref. lects the fact that many clinical research
activities must be conducted in patient care settings. In internal
medicine, for example, research-oriented residents completing the general
program subsequently entered subspecialty training, e.g., cardiology,
gastroenterology, rheumatology, etc., with the goal of additional
certif ication in that subspecialty and acquisition of research
experience. Many of these subspecialty fellowship programs received
support from federal training grants. Recent debate over the need for
additional subspecialists has prompted questions by federal and other
funding agencies as to whether it is appropriate for public funds to be
used for research training provided in connection with subspecialty
training. This has resulted in diminished funding of subspecialty
fellowships which, in turn, has reduced the number of opportunities for
training in clinical investigation.
At the end of the residency, physic fans with research training in
their background can work as postdoctoral research fellows under
individual preceptors. NRSA fellowships are well-suited as a support
mechanism for this purpose. Such support is particularly applicable to
g raduates of joint M. D . /Ph. D . prog rams, most of whom take at least 3
years of residency training in ~ clinical specialty. Residency
schedules, however, are relatively inflexible, permitting little or no
contact with laboratory research during this period. This discontinuity
makes reentry into the laboratory extremely difficult, especially in
light of the rapid pace of conceptual and methodologic advance in
biomedical research. To compete successfully as a physician investi-
gator, a postdoctoral fellowship in a basic or clinical research
laboratory is virtually a necessity. Most physicians emerging from
residency programs, unlike post-Ph.D. trainees who have already been in
the laboratory for several years, are not adequately prepared to write
research fellowship proposals. For them 2 or 3 years of individually
tailored training in either a basic science or clinical department would
be needed to accomplish the coursework, seminar participation, and
independent study/research for a career in clinical investigation.
26
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DETERMINANTS OF CAREER CHOICE
The Co~Tunittee in previous reports noted the increasing indications
that young physicians may be less likely to view clinical investigation
as an attractive career option. Various factors presumed to be affecting
their career decisions were highlighted, including testimony at a public
meeting on the effect of increasing national emphasis on the training of
primary care physicians. Recognizing the need for a clearer insight into
the underlying attitudes and values, the Committee assigned hi gh priority
to research in this area. Since publication of its last report, three
studies commissioned by the Committee for this purpose have been
completed.
Career Plans of Medical Students
The f irst study, which was carried out by the Association of American
Medical Colleges, was based on a December, 1979, survey of all medical
school seniors who expected to graduate in 1980 (AAMC, 1981b). Included
in this survey were questions on choice of various career paths, as well
as attitudes toward research. The responses were matched with records of
answers provided by each student to a questionnaire administered with the
Medical College Admissions Test (MCAT), the individual ' s MCAT scores, and
with records from the application for admission to medical school.
Students were asked to indicate their f irst, second, and third pre-
ference for alternative careers in research, clinical practice, and
administration. For purposes of analysis, respondents were assigned on
the basis of their f irst and second choices of career alternatives to
three groups--"Research Firsts, n "Research Seconds, " and "Non-Research-
ers. n Research was checked as the f irst choice of 21. 8 percent of
respondents; 12.2 percent checked research as their second choice but not
as f irst; 66. 0 percent checked only clinical practice as f irst and second
choices. From a comparison of the three groups, some of the f indings
were as follows.
Test Scores
The groups differ signif icantly in their mean MCAT scores.
Research Firsts" and "Research Seconds" had the highest and second
highest mean for all four {Verbal, Quantitative, General, and Science)
tests.
Gender
There was no statistically signif icant difference between the sexes
regarding preferences for research career. "Research Firsts" and
Research Seconds" both had virtually the same distribution of males and
females as in the total group of respondents.
Experiences During Medical School
Somewhat less than one-quarter of all respondents reported having
participated in a research project as an investigator during medical
school. Grouped according to career plans, 45. 3 percent of "Research
Firsts" and 24.2 percent of "Research Seconds" reported such an
experience, compared with 16. 3 percent of the "Non-Researchers. "
similar pattern can be observed with respect to publications.
27
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Approximately 15 percent of all respondents had been sole or joint
authors of research papers during their undergraduate medical years.
For the three groups the percentage were Research First.,. 31.4 percent;
Research Seconds, " 15. 0 percent; and ~Non-Researchers, ~ 10 percent.
Debt
The data do not indicate that anticipated accumulated debt at
graduation from medical school operates as a disincentive to choice of
research career.
Factors Inf luencing Research Career Choice
Respondents were asked to indicate the relative inf luence each of
nine factors played in their consideration of research involvement in
their ensuing medical careers. The three factors of highest importance
to both Research Firsts" and Research Seconds. were: opportunity to
work in the academic community, challenge of search for new knowledge,
and research experience while a premedical or medical student. These
f actors were substantially more important, however, to "Research Firsts.
than to "Research Seconds, n who scaled them all to be of "moderate,
rather than "ma jor, " inf luence. A fourth factor, "availability of
research training support, ~ was scaled to be of "moderates importance to
"Research Firsts and HResearcb Seconds and of "minor. inf luence to
"Non-Researchers. n2 Finally, all three groups rated as being of Minors
or No importances four factors proposed by many observers as hypotheses
to explain the declining entry of physicians into research training.
These factors were: uncertain availability of research funds after
completion of training, increasing f rustrations of researchers in
conducting clinical research, f inancia1 disadvantages of a researob
career, and obligation to pay back research training support by continued
research activity.
Plans of M.D./Ph.D. 's and Ph.~./M.D. 's
Ninety-eight percent of graduates of the NTH-sponsored Medical
Scientist Training Program (MSTP) indicated research careers as their
first choice, compared to 90 percent of other M.D./Ph.D. 's. Ph.D. 's who
subsequently earn the M.D. degree are about half as likely as concurrent
M.D./Ph.D. 's to select a research career first (53 percent), but they are
over twice as likely to choose research as are 1980 graduates earning the
M.D. degree only (21 percent).
Comparison with Earlier Graduates
The AAMC Graduation Questionnaire has been administered annually
since 1978. Comparable data on career pref erence are also available f rom
a questionnaire sent to the entire graduating classes of a sample of 28
medical schools in 1960. Responses to these questionnaires, taken
together, permit an assessment of chang ing student attitudes toward
resea rch ca ree r s.
The classes of 1960, 1978, 1979, and 1980 compare as follows:
Graduation Class
1960
1978
1979
1980
28
Percent Favoring Research Careers
39.0
22.4
20.3
21.8
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There is no clear trend in the last 3 years, but for all 3 the level of
research interest is noticeably less than it was in 1960. The percentage
of graduating seniors in the 3 recent years who will fulf ill their
expressed plans is unknown, but it would have to be a high proportion to
equal the level of researab participation of the Class of 1960. 3
Economic Incentives/Disincentives
Scheffler ~1975), in an earlier study using 1971 income data,
presented empirical estimates of the rate of return or loss to post-M.I).
trainees in biomedical science who subsequently pursue careers as faculty
members of a medical school, researchers at NIH, or employees in private
industry. In each of the career paths the trai ning produced an economic
net loss to the trainee over his/her professional lifetime relative to
the alternative of a career in private practice. Moreover, the
discounted value of the net loss was relatively large. 4 The loss
varied substantially by specialty f ield and increased with the length of
post-M.D. training. Under sponsorship of the Committee, the author has
updated his earlier work and has applied a similar method of calculation
to physicians, dentists, and veterinarians (Scbeffler, 1981~. In
general, the results of the later study show that the net lifetime
economic loss, in teens of 19 79 income data, is less than that reported
earlier.
For the three professions there was net loss in income assoc ~ ated
with postdoctoral training. Training was assumed to last 2 years, with
stipends at 1980 NIH levels and a discount rate of 12 percent.
Physicians pursuing a career at NIH sustain a lifetime economic loss of
about $170, 000, which is $100, 000 more than the loss incurred by medical
school faculty on a base salary. Dentists employed at NIH stand to
forego about $111,000 in lifetime income in comparison to dental practice
careers, with little economic differences between NIH employment and
dental school faculty careers. {3sing different discount rates, the same
comparisons yield the following results in terms of lifetime economic
loss:
Physic fans
at NIH
at Medical School
Dent i sts at NIH
Lifetime Economic Loss
D i scount Rate
12% 8% o%
~ _ _
$170, 000 $242, 000 $645, 000
$ 70, 000 $127, 000 $239, 000
$111, 000 $164, 000 $550, coo
Compared to physicians and dentists, veterinarians have small
economic losses, whether employed by the f ederal government or a
veterinary school. The economic losses varied considerably by spec tatty
for physic fans undertaking 2 years of postdoctoral training and selecting
~ career either at NIH or on a medical school faculty ~ see Appendix Table
A9) . The largest economic loss--$241, 000 at the 12 percent discount
rate--would be incurred by anesthesiologists choosing an NIH career.
Psychiatrists would realize an economic gain of approximately $25, 000 as
medical school faculty members (base salary plus supplemental earnings),
but ~ contrast would lose $34, 000 in a career at NIH. For several
specialties, such as radiology, obstetrics/gynecology, and internal
29
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medicine, NIH careers produce an economic loss of over $155,000,
averaging 2.8 times the losses to medical faculty. Comparing the losses
in 1971 and 1979, the author found that for f ire of the seven specialties
studied, the economic losses increased for employment at NIH, whereas for
f ive specialties, losses declined for employment at medical schools over
this period.
The percent of loss accruing during the f irst ~ years following
postdoctoral training is also of some interest. This derives f rom the
fact that some individuals may select careers using a shorter time
horizon because they do not assume they will remain in this career path.
Based on the same rate of return methodology as for the earlier
calculations, 42 percent of the loss in a NIH career accrues during the
first 5 years after training, while 61 percent of the career loss accrues
for employment at a medical school (base salary).
How large would postdoctoral research training stipends need to be,
it was asked, to reduce to zero the economic losses calculated for
physicians, dentists, and veterinarians? In other words, what size of
stipend would make the monetary rewards in each of these careers
equivalent to those in private practice? Scheffler's analysis suggests
that physicians who pursue a research career at NIH would need to receive
a training stipend of about $63,000 per year for 2 years In order to
reduce their economic losses to zero in comparison to careers in medical
practice. For those employed in medical schools, it would be about
$30,000 per year. Current stipend levels are about $16,000. To produce
the same ef f eat for dentists employed at NIH or on a dental school
faculty would require a stipend in excess of $50, 000. Veterinarians
would need a stipend level of about $25, 000.
The suitability of rate of return models has been criticized on
grounds that earnings are only part of the determinant of rational
personal investment in human capital. Few people choose a career solely
on the consideration of earnings. Instead, most give greater weight to
their anticipated overall career satisfaction. A significant part of the
return on training may in fact be personal satisfaction of dedicated
biomedical research scientists as they enhance their knowledge and
skills. Also, as noted elsewhere in this chapter, many consider the
challenge of the search for new knowledge to be a nonpecuniary benefit
tbat more than offsets the higher remuneration obtainable from clinical
practice. Thus, to the degree that nonpecuniary benefits of careers in
biomedical science offset the monetary aspects, the measured rate of
return to investment in post-.. training will have little consequence
in influencing the decision to undertake research training. In sum, the
effect of ignoring the career satisfaction aspect of training in
calculating private rates of return is to underestimate the rate of
return to investment in training.
Research Careers in Internal Med. ic ine
Under Committee sponsorship, researchers at Michigan State University
have studied the factors inf luencing choice between careers in academic
medic ine and private practice. Responses to a mail questionnaire were
received from more than 200 physicians, representing a national sample of
those who had completed their subspecialty training in internal medicine
by June, 1979, who had already decided for or against going into academic
medicine, and who were regarded by their training program directors as
possessing the qualifications for a career in academic medicine. The
sample was designed to provide an approximately equal distribution of
academic and nonacademic deciders.
30
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A notable f inditing was the absence of a signif ic ant difference between
the two groups in either current salary or aggregate debt. Moreover,
there were no apparent f inancial pressures inf luenc ing the career
choices. Respondents appeared to be fully aware of potential differences
in future income. Those moving into private practice expected higher
income than their academic colleagues both 3 and 10 years f ram the time
of the survey. Those choosing academic medic ine expected their income to
be about 30 percent less in 3 years than those in private practice, and
about 17 percent less af ter 10 years. Income expectations appeared to be
of moderate importance to those choosing a practice career and of
relatively minor importance to those selecting an academic career.
The study noted a primary emphasis on intellectual stimulation by
those selecting careers in academic medic ine. It is the importance of
intellectual stimulation, along with considerably g reater interest in
clinical research, that most clearly distinguishes those selecting
academic medicine. This is in contrast to those selecting practice, who
seem to be most oriented toward patient care and interaction, and who
also consider other f actors important such as personal autonomy,
availability of "call" coverage, ability to locate in one community, and
salary.
In rank-ordering the desirability of various career activities, the
biggest difference between the two groups was in the rating of primary
care. It was as though primary care was perceived as the reciprocal of
research. According ly, the f act of having made the choice of primary
care virtually excludes for that individual the possibility of performing
research.
D1 scusslon
The study of economic rate of retur n, c ited above, has documented
that the early and lifelong earnings of physicians in academic medicine
are less than comparable average earning s of physic fans in private
practice. This fact, plus a high level of debt accumulated before
graduation f ram medical school, have been commonly perceived to serve as
disincentives for following a research career. However, other studies
raise some question as to the extent to which f inancial factors, such as
debt burden and differential earnings, at current levels serve as
deterrents to selection of a research career. Certainly, one should not
forget that in the heyday of National Research Council fellowship support
for M.~. investigators, the relatively enormous income differential
between research and practice careers seemed not to operate as a
disincentive (Cain and Bowen, 19611. Moreover, income figures may be
deceptive, since averages for clinical practice can be distorted by the
earnings in a relatively few subspecialties. In addition, faculty
salaries in clinical departments have increased to a point where it is
not uncommon for a starting salary of an assistant professor to triple
the salary received in the last year of residency training.
Data from the Michigan State University study and from analysis of
the AAMC Graduation Questionnaire underline the key role of intellectual
stimulation as an incentive for a research career. Its importance as a
discriminant between academic and practice "deciders was the basis for a
recommendation in the MSU study that intellectual curiosity be emphasized
in the selection process for medical students and fellows.
31
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Data from comparisons of future physician researchers and
nonresearchers document the need for providing undergraduate medical
students with the time and opportunity to acquire f irsthand knowledge of
the excitement of working in a research laboratory. -This conclusion is
reinforced by a f inding f rom a study of factors affecting the career
decisions of more than 1,100 members of the American Society for Clinical
Investigation and the American Federation for Clinical Research (Davis
and Kelley, 1981) . The largest f Faction of respondents indicated that
their research career decision had been made during medical school and
that the most important events influencing this decision had occurred
during the same period.
In both the Michigan State University study and the AAMC survey of
graduating seniors, payback was seen not to have been a serious deterrent
to research career planning. In addition, the survey of successful
clinical investigators by Davis and Kelley showed that the payback
obligation was perceived to be a relatively minor factor in the
decision-making process. The f indings for n recent deciders" in internal
medicine may be f [awed, however, owing to the very small number of
respondents who had received NRSA training. Moreover, the AA~MC f inding
should be interpreted with some caution, inasmuch as the dec ision on
incurring a payback obligation was for most medical school seniors some 3
or more years in the future. Similarly, the results f ram the survey of
established investigators may have limited value, since they really
represent answers to hypothetical questions. In sum, although it is
possible that payback is less of a deterrent than is widely believed,
evidence for such a view remains inconclusive.
COMPARISON OF TRAINING PROGRAMS
The National Institutes of Health have for many years administered
both extramural and intramural research training programs for
physicians. In addition to postdoctoral traineeships and fellowships
(Tr~inees/Fellows), extramural funds hay'? supported since 1964 a Medical
Scientist Training Program {MSTP) in which trainees concurrently pursue
the M.D. and Ph.D. degrees. In addition, intramural funds support two
other research training programs. One is for Research Associates who
devote most of their time, under a preceptor, to laboratory research in
biomedical science. The second is for Clinical Associates who-
participate in both clinical . and laboratory research, as well as in
clinical activities under the immediate supervision of senior
investigators. The Medical Scientist Training Program averages 6 years
in length, compared with just over 2 years for the other three programs.
Given the decline since 1974 in numbers of physicians receiving
re search training, the continuing need for physic fan investigators, and
the limitations on NIH research training funds, the Committee considered
it important to compare output of these princ ipal routes for research
training of physicians. A recent study by the Association of American
Medical Colleges undertook such a comparison, usi ng the following output
measures: ~ a) percent of trainees who remain in research, ~ b) research
productivity in terms of publications and type of journals in which
papers are published, (c) rate of advance in academic or research
positions, and (d) success in competing for NIH research grants (AAMC,
19 Bib) . The 53 persons completing the Medical Sc dentist Training Prog ram
between 1968 and 1973 served as the reference group. For each of these
53 trainees, a comparable student who subsequently was trained during
32
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those years in each of the other three programs was identified. Abe
comparison student was of the same age and sex, entered the same (or a
similar) medical school with comparable undergraduate education, and had
comparable Medical Co' lege Admission Test (MCAT) scores taken at about
the same time.
The fourfold comparison revealed that:
( 1) All four programs were highly successful in producing
physician investigators. MST P bad the highest pro-
portion of graduates--74 percent--who could be
conf irmed as currently involved in research. Com-
parable figures for Research Associates, Clinical
Associates, and Trainees/Fellows were 58 percent, 58
percent, and 47 percent, respectively. When program
graduates engaged in other medical school faculty activity
are included, the percentages rise to 89 percent, 75 per-
cent, 68 percent, and 62 percent, respectively. As a
percent of graduates with known current career status,
94 percent of MSTP and 95 percent of Research Associates
were in research and teaching. Comparable percentages f or
Clinical Associates and Trainees/Fellows were 86 percent
and 83 percent, respectively.
2) By 19 81 a significantly larger proportion of MSTP graduates
than of participants in the three other programs had
attained tenured f acuity rank. About 42 percent of
MSTP graduates who had joined faculties achieved tenure,
compared with 17 percent of former Research Assoc iates and
Trainees/Fellows and 4 percent of Clinical Associates.
3) Research grant success rates at NIH did not appear to dis-
criminate among the four groups. MSTP graduates, Clinical
Associates, and Trainees/Fellows had higher approval rates
and better average priority scores than those for all
applicants. Judged by only a small number of appli-
cations, the pert onnance of former Research Assoc fates was
mixed--relatively low approval rate but excellent average
priority scores for approved applications.
4} Publication performance for graduates of the four training
programs showed marked differences in the quantity and sci-
entif ic depth of the articles they published. MST P gradu-
ates were the most prolif ic authors, having published 995
articles by 1981, compared with 716 articles by Research
Associates, 673 by Clinical Associates, and 408 by Trainees/
Fellows. All groups published articles in journals of all
four scientific "levels, '5 but the distribution by "level"
differed substantially. MSTP graduates and Research
Associates, for example, published predominantly in
journals characterized by a high degree of scientif ic rigor,
e. g ., Journal of Biolog ical Chemistry and American Journal
of Physiology. Former Clinical Assoc fates and Trainees/
Fellows published most f requently in journals, such as the
New England Journal of Medicine, which contain a mixture of
reports on clinical investigation and clinical observation.
Of the four groups of trainees, former Clinical Associates
published most f requently in journals emphasizing clinical
observation, e.g., the Journal of the American Medical Asso-
. . ~
c Dacron.
33
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500
40Q
Z 300
o
-
200
100
Actual
Projected
O ~ 1 1 1 1 1 1 1 1 1 1 1 1 1 1
62 64 66 68 70 72 74 76 78 80 82 84 86 88 90
FISCAL YEAR
FIGURE 2.1 Clinical R and D expenditures it
__ High Estimate (3%/yr.)
Middle Estimate (1%1yr.)
Low Estimate (-1%/yr.)
600
500
400
oh
Zo
J 300
200
100
Actual
- Projected
n medical schools {1972 A. See Appendix Table A7.
/ High Estimate ( t 2%/yr.)
! ~ Middle Estimate (6%/yr.)
; ~
l
/
/ ''
/~' _ _ Low Estimate (2%/yr.}
I . 1 I L I I ~ . _ I
62 64 66 68 70 72 74 76 78 80 82 84 86 88 90
FISCAL YEAR
FIGURE 2.2 Service income reported by medical schools (1972 A. See Appendix Table A7.
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1 0 :
OL
130
High Estimate (4%/Yr.)
~ ~ ~ Middle Estimate (2.5%/yr.)
1 10 _ '''
- Actual ~— --—— Low Estimate (0%/yr.)
_ 100 ~ ~ Projected >/
~ 90 _ / \
i3 '' Medical Students, Interns and Residents, and
~ 80 ~ / Clinical Fellows
Z 70 ~ / _ High Estimate (3%/yr.)
_~_ Middle Estimate (1.5%/yr.)
6 ~ '~~— —Low Estimate (0%lyr.)
0 50 _~ . ~;:
u, ~ Medical Students
40 _
30 _ _ ~,~`
_~ I nterns and Residents
20 _ ='
_ Clinical Fellows
LIT—~ 1 1 1 1 1 1
62 64 66 68 70 72 74 76 78 80 82 84 86 88 90
FISCAL YEAR
FIGURE 2.3 Medical students, interns and residents, and clinical fellows. See Appendix Table A6.
10O
90
80
70
60
50
40
30
20
10
o
—Actual
Projected
D _
_ Volunteer Faculty /
_ ~
_ /
'' High Estimate (5.2°/O/yr.)
'''__—Middle Estimate (2.8%/yr.)
_ _ ~ ~~~~ Low Estimate (-0.05%/yr.)
C ~! To; ~~ ~., _
Full-Time Faculty
-_
. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
62 64 66 68 70 72 74 76 78 80 82 84 86 88 90
FISCAL YEAR
FIGURE 2.4 Clinical faculty in medical schools. Faculty is defined here as a full-time appointment in a
clinical department regardless of tenure status. See Appendix Table A6.
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Second, the funds provided by Congress to encourage medical schools
to expand their enrollments (capitation grants), which have been
declining throughout the 1970' s, were rescinded for EY 1981 and have not
been reauthorized for FY 1982. On the other band, medical schools are
also under heavy financial pressure and are likely to resist any attempts
to reduce enrollments. The net effect, as seen by the Committee and its
Panel on Clinical Sc fences, is that the current growth in medical student
enrollment will not continue but will average about 1.5 percent per year
through 1985 (Figure 2. 3) .
The number of residents and clinical f ellows is almost as large as
the number of medical students and has been growing faster in recent
years. Therefore, the Committee assumes that the total number of medical
students, residents, and clinical fellows will grow at an average rate of
2.5 percent per year through 1985. The upper and lower limits on this
growth rate are assumed to be 4 percent and 0 percent, respectively.
Given these assumptions about future growth in the monetary and en-
rollment variables, the model produces the estimates of demand for
full-time clinical faculty through 1985 shown in Figure 2.4 and Table 2.4.
Under the most likely circumstances foreseen by the Committee (the middle
panel of Table 2. 4, assumptions II and B), full-time clinical faculty in
medical schools will grow to almost 40, 000 by 1985. This means an
average of about 1,000 new positions will be created each year due to
expansion of faculty and another 2, 000 vacancies still occur each year
because of attrition. Exactly how these estimated 3, 000 positions will
be f illed is crucial to determining the national needs for training
clinical scientists. For this we must know something about the dynamics
of f acuity accession and attrition in medical schools.
The Committee is fortunate to have recently received such information
from a study it commissioned the Association of American Medical Colleges
(AAMC, 1981b} to do. That study provided data on several topics
concerning medical school faculty, some of which are discussed elsewhere
in this report. Of immediate interest here are data on hiring of
clinical faculty members with research training background. Up to now it
has been assumed that all demand created by expansion and attrition due
to death and retirement would be filled by former postdoctoral trainees.
But the new data show that this is an unrealistic assumption. From
1975 to 1978 only about 21 percent of all new appointments in clinical
departments had postdoctoral research training.
The AAMC data also show that a signif icant amount of attrition f rom
medical school faculties (about 4 percent per year) takes place because
of changes in employment and causes other than death and retirement.
Attrition rates therefore have been modified in Table 2.4 to reflect this.
There are still some important gaps in our knowledge of the system
that need to be f illed in as this study develops. Nevertheless
suf f ic lent data have accumulated to attempt a more rigorous estimate of
postdoctoral training needs based on the projections than has been
possible heretofore. Using the most likely projections from Table 2.4,
Table 2.5 shows how these estimates translate into estimates of the
number of clinical science postdoctoral trainees required to meet the
expected demand under certain conditions. At each step of the
calculation, the estimates are compared to the actual data where
ava i table.
Line 1 of Table 2. 5 shows the annual demand for full-time clinical
f acuity broken down into demand c reated by expansion, death and
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TABLE 2A Projected Growth in Medical School Clinical Faculty, 1980~85, Based on Projections of
Medical School Enrollment, Conical R ~d D Expenditures, and Medical Service Income In Medical
.S6hoolsa
Gumptions about Real R and D Expenditures
and Medical Sauce Income in Medical Schools
~ .
I II III
sump~don~ about Medi—1 Student Enrollment
(medical students, students, "d Clinical fellows)
Will expand at win expand at Will expand
about 8O6~/yr. about 4.0~0/yr. Lightly, about
to S964 ma- to S744 mil- Q8~/yr. to $616
lion ~ 1985 lion in 1985 million in 1985
wm grow at 4%/yr., Expected me of Minimal faculty
reacting 143,000 hi medical "hoofs (CF) m
students by 198S 1985 45,950 43,610 41,600
Annual grown rate in CF from
1980 to 1985 5.2% 4.3% 3.5%
Average annual mcremcnt due
to faculty expansion
Annual replacement needs due to:b
death and retirement
other attrition
Expected number of positions to
become available annuity on
clinical faculties
2,000 1,620 1,280
400 390 380
1,760 1,700 1,660
4,160 3,710 3,320
.
Be Will grow at 2.S%/yr.,
reaching 131,000
students by 1985
Expected Size of clinical faculty
m medical schools (CF) in
1985
Annual grown late in CP from
1980 to 1985
42,120 39,970 38,120
3.796 2.8%
2.0~o
-
Average eMnual inGrement due
to faculty expansion 1,370 1,010 700
Annual replacement needs due to:b
death and retirement 380 370 360
other attrition 1,670 1,620 1,590
Expected number of positions to
become available annually on
dinica1 faculties
3,420 3,000 2,650
C. WB1 Mow eaenlially Expected We of conceal faculty
no growth from 1979 to hi medical schools (CE) no
1985, leveling off at 1985
113,000 students Answer growth ram In CF from
1980 to 1985
36~320
1.1%
34,470
Oe 3%
32~870
~OeO54%
Average annual increment due
to faculty expansion 400 90 -170
Annual replacement needs due to: b
death ant retirement 350 340 330
other atbidon 1,550 1,510 1,470
Expected Rumba of positions to
become available annually on
clinical faculties 2,300 1,940 1,630
aFaculty in this table ~ defied as a [ull-~dme appointment In a conical department regardless of tenure status. These
projections are based on the following relationship:
(CF/S)t ~ exp(-LS9683~103440/Dt) + 0.13, where CF = give of conical faculty in medical schools; S = medical
students, residents, and clinical fellows; D = a weighted average of me last 3 years of clinical R and D expenditures
b plus medical ~ ce income in medical schools, be., Dt = 1/4(Dt + 2Dt_1 ~ Dt_2).
Based on an estimated replacement rate of 1.0% annually due to death and re~drement, and 4.4% annually due to
other athi~don. See A - octagon of American Medical Colleges (1981a).
\
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TABLE 2.5 Estimated Number of Clinical Research Postdoctoral Trainees Needed to Meet Expected
-Demand for Clinical Faculty Through 1985 Under Vanous Conditions
Actual (1975-78 average)
Projected
(1980~85)
Other
Total M.D.'s Ph.D.'s Degrees Total
1. Demand for full-time clinical faculty--annual
average:
a. due to expansion of faculty
b. due to death and retirement
c. due to other attrition
2. To reduce budgeted vacancies--annual average C
3. Demand for veterinary and dental school clinical
faculty
3,673 2,982
2,113 1,783
128 97
1,432 1,102
454
280
18
156
237
50
13
174
3,000
1,010
37oa
1,620b
150
(16% of med. school demand)d 500
4. Total annual accessionse 3,673 2,982 454 237 3,650
a. % with postdoctoral research training 21.4% 18.6% 55.9% - 35.0~o
5. Total accessions with postdoctoral research
Paining——annual average
6. Size of clinical saence postdoctoral pool--annual
average
Size needed to meet academic demand assuming a
2-yr. training period and portion of trainees seeking
clinical faculty positions is:
a 60~o
b. 50~o
7. Annual number of clinical science postdoctoral
trainees to be supported under NRSA programs:
a. if 50% of pool is supported under NRSA
b. if 60% of pool is supported under NRSA
(35% of all accessions)
3,000 - 5,000
2,310
1,280
4,270
5,120
2,140 - 2,560
2,560 - 3,070
aAssumes an attrition rate due to death and retirement of l.O~o per year.
bAssumes an attrition rate due to other causes of 4.4% per year.
CIn 1978 there were 2,011 budgeted vacancies in clinical departments of medical schools. The demand for clinical
faculty generated by the need to reduce this level to 1,000 by 1985 is about 150 per year.
dIn 1978 there were 3,544 full-time clinical faculty members in U.S. dental schools and an estimated 1,869 full-time
equivalent clinical faculty members in U.S. schools of veterinary medicine. This total (5,413) was 16% of the full-time
clinical faculty in U.S. medical schools. Thus the demand for dental and veterinary school clinical faculty is
estimated at 16% of medical school demand, or 500 per year.
eAccessions are defied as new hires or those who rejoin faculties from nonfaculty positions. Inter-faculty transfers
are not counted as accessions. Data on the percentage with postdoctoral research training were derived from newly
hired faculty members only, which are 85% of total accessions. We are assuming that the same percentage applies
to all accessions.
SOURCES: Data from 1975-78 taken from American Dental Association (1971-79a), Association of American
Medical Colleges (1980, 1981a), Association of American Veterinary Medical Colleges (1978). Projections were
derived by this Committee.
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retirement, and other attrition. The projections assume a 1.0 percent
death and retirement rate and a 4.4 percent attrition rate due to other
f actors.
Line 2 indicates that demand for an additional 150 clinical faculty
members per year is created by the need to reduce budgeted vacancies in
clinical departments. These have doubled in the past decade, and the
Committee views this growth as an indicator of shortages. It is
appropriate, therefore, to attempt to reduce budgeted vacancies in
clinical departments to 1, 000 in 1985 from their 1979 level of about
2, 000.
Line 3 is the estimated demand for clinical faculty at dental and
veterinary schools. This demand component is estimated to be 16 percent
of medical school demand, or 500 per year.
Line 4 is the sum of lines 1 to 3. This total, 3,650, is the
expected annual demand through 1985 under the conditions stated.
Line 4a shows the percentage of accessions having some postdoctoral
research training. The current figure of 21 percent represents a severe
deterioration in the research preparation of clinical faculty members.
Of the present faculty in medical specialties who graduated from medical
school between 1963 and 1967, more than 40 percent had postdoctoral
research training (AAMC, 1981b, p. 12~. The Committee believes it is
important to restore this percentage to near its former level in order to
maintain the research capability of medical schools.
Line 5 shows the estimated number of accessions needed with
postdoctoral research training assuming that 35 percent of all accessions
have this training. Note that transfers from one academic institution to
another are not counted as accessions.
Line 6 gives the estimated size of the current pool of clinical
research trainees (no hard data are available on the size of the pool).
Assuming a 2-year training period and a 60 percent yield, a pool size of
about 4,270 would be needed to produce the estimated 1,280 trained
clinical researchers required each year, i.e., 4,270 = (1,280 x 2~/ 0.6.
Finally, line 7 provides estimates of the number of clinical science
postdoctoral trainees to be supported by the NRSA program.
It is encouraging to note that the Committee's projections of faculty
demand are supported by the AAMC study. The findings in both cases are
quite close. The Committee projects an annual demand of about 3, 000
full-time medical school clinical faculty positions based on a likely
growth rate of almost 3 percent per year through 1985, while the AAMC
study, using age-specif ic attrition rates, conf irms that if faculty does
indeed grow by 3 percent per year, the annual demand for full-time
clinical faculty would be just over 3,100 per year (AAMC 1981b,
p. 253) .10
But clearly the new inf ormation the CoIIunittee has received has
required readjustment in some of the assumptions made about faculty
dynamics. Perhaps the biggest adjustment is in the previous assumption
that all demand for clinical faculty would be satisf fed by people with
research training experience. If the AAMC data accurately ref. lect the
current situation, only about one out of f ive new hires in clinical
departments has had research training. This fact also cautions against
equating research with an academic caree r, for it implies that the
majority of people choosing to become members of clinical faculties do
not have a research background. While it may be true that most clinical
researchers are also faculty members, these data strongly suggest that
only a minority of clinical faculty members have the inclination or
training required for a research career.
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Graying of the Faculty and Research Productivity
The relationship between age and research productivity tales on added
signif icance with the realization that faculties in most f ields are
likely to be static or show only moderate growth in the coming decade.
In one of the more important aspects of its study, the AAMC (1981a)
showed how research output varies with the age of the clinical
investigator. Peak productivity, as measured by the annual number of
publications in selective journals, is generally reached around
mid-career for most clinical investigators and thereafter declines. 11
These results suggest that medical school faculties tend to become less
productive as the age distribution increases. To prevent ag ing of
faculties, there must be a continuous infusion of younger members,
preferably with research training experience.
In the most probable c ircumstances foreseen by the Committee,
clinical faculty growth will average almost 3 percent per year through
1985. At this rate, the average age of clinical faculties frill increase
only slightly, and research output will increase at about the same rate
as faculty growth according to the AAilC report (AAMC, 1981b, p. 64~. But
should faculty growth be slower than expected in the next decade, a
signif icant amount of faculty aging will occur, with a resultant decline
in average productivity. The AAMC estimates that if there is no f acuity
growth f ram 1980 to 1990, the average research output of physicians in
medical schools will drop by more than 6 percent, and in surgical
specialties by almost 14 percent. The research training programs can
thus be viewed as a kind of insurance policy that tends to stabilize the
research capability of medical schools despite varying demographic and
economic conditions.
RECOMMENDATIONS
In view of the outlook for continued shortages of clinical scientists to
staff the faculty of medical schools and conduct clinical investigations,
arm the need to encourage physicians and other health professionals to
undertake research training in preparation for research careers, in the
sections below the Committee makes two recommendations for training in
the clinical so fences area.
Tra ineeships and Fe llowsh ips
Recommendation. The Committee recommends that 2, 400
traineeships and 400 fellowships be awarded annually for
postdoctoral research training in the clinical sc fences
f rom FY 1982 through FY 1985. The Committee also urges a
greater emphasis on f illing these training positions with
physic tans. Most of the f unding should be in the f arm of
training grants, which are particularly suited to meet the
needs of the physic fan whose doctoral training usually
involves only limited research participation, and, as pre-
viously recommended, approximately 15 percent for individual
fellowships.
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In recommending federal support of 2, 800 postdoctoral trainees and
fellows in the clinical sciences, the Committee is well aware of the fact
that not all of these awards will be made to physicians. It is
appropriate that some of these trainees will hold the Ph.D. and other
nonhealth professional doctorates, just as some M.D. ' s will receive
training under grants awarded to basic biomedical so fence departments.
Currently, physics ens hold about 70 percent of all the postdoctoral
traineeships awarded by NIH in the clinical sciences. 12 While it ~ s
cliff icult to def ine the optimal proportion, 85 percent may represent a
reasonable proportion of M.D. 's in the pool of clinical science trainees
and fellows supported under NRSA programs. It would be compatible, for
example, with the observed ratio of M.D. 's to total full-time faculty in
clinical departments of medical schools {AAMC, 1981a).
There are cliff iculties in achieving a prompt increase in the
proportion of clinical science training positions held by physicians.
The relatively small number of physician applicants for NIH postdoctoral
research fellowships and traineeships in recent years is one aspect of
the problem. Another is NIH' s lack of leverage for inf luencing the
change directly, since trainee appointments are the responsibility of the
individual training program director. It is nevertheless of critical
importance that NIH examine all possible means for augmenting the
physic fan component of the clinical sc fences training pool. For example,
consideration could be ~ iven to implementing a 1979 recommendation of the
Committee to offer a postdoctoral clinical research experience for MSTP
graduates, most of whom go on to a clinical residency. Since their
research training up to that point has generally been in teas ~ c sc fence,
such an experience would be advantageous as a bridge for those aspiring to
become clinical investigators. Since inclusion of a clinical research
component would requ' re support outside of the usual source of residency
funding, the Committee recommended consideration of a special type of
award for this purpose. To foster progress in this direction, the
Committee reiterates its suggestion that Spec ialty Boards and Residency
Review Committees be encouraged to develop training policies for the
clinical investigator that would lead to Board certification without
appreciably lengthening the training process.
Another suggested approach is to change NIH guidelines regarding
full-time involvement in traineeships and fellowships. A requirement
of less than full-time part icipation could attract women physicians
with research interests, who are temporarily out of the labor force.
Also, it could facilitate the combination of research and clinical
training within a given year of residency.
Medical Scientist Training Program
Initiated in FY 1964 with three grantee institutions and support
for 17 trainees, the Medical Scientist Training Program has
experienced uninterrupted growth. By PY 1976 it involved 18
institutions and 465 trainees. As a result of continued expansion
thereafter, endorsed with enthusiasm by the Committee, trainee enrollment
is now approaching 700. In its 1979 report, the Committee proposed a
ceiling of 725 trainees in the Program through FY 1982. Further
expansion, it was felt, should await the development of more analytic
information regarding the Program, including comparative costs of other
research training programs for physicians. As reported elsewhere in this
chapter, a start has been made toward assembling the information.
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Additional analyses are needed, however, to explore possibilities for
enhancing cost-effectiveness through administrative modifications in the
Program and to determine its optimal size In relation to the totality
of NIH training activities. Until these further analyses can be
made, and in view of the steady build-up that has occurred, the
Committee believes it prudent to retain the currently recommended
enrollment level through FY 1985.
Recommendation. The Committee recommends that an annual
·
enrollment of 725 trainees In the Medical Scientist
Training Program (MSTP) should be maintained through FY 1985
and high priority g iven to preserving this level should it
become necessary to reduce the overall number of NRSA trainees.
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NOTES
1. Unless otherwise Specified, the term clinical investigator refers in
this chapter mainly to physicians. It should be noted, however, that
clinical investigation under the Committee' s def inition is also performed
by other health professionals, e.g., dentists and veterinarians, as well
as by scientists holding the Ph.~. and equivalent degrees.
2. Since opportunity costs for physicians who pursue doctoral research
training are relatively high, it is reasonable to infer that a loss of
f ellowship and traineeship support could diminish the already small
proportion of medical school seniors looking to a resea rch career.
3. A study comparing career preferences at graduation with career
performance after 17 years was reported in 1979 (Sherman and Morgan,
1979~. Approximately 28 percent of 1960 medical school graduates bad
contributed to the medical and scientif ic literature by 1977. The study
also found that 44 percent of the 1960 graduates expressing research
plans did eventually conduct and publish research, and 8.3 percent of
those without research plans published research in addition to carrying a
medical practice.
4. A discount rate is an interest rate used to compute the value today
of a sum of money to be received in the future. For example, 1 dollar to
be received a year f ram now is currently worth about 89 cents at a
d i scount rate of 12 pe rcent .
5. For a full description of research n level" and its derivation, see
Narin ( 1976) and She rman and Morgan ~ 19793 .
6. The AMA data themselves present some conf licts. Although the number
of physicians reporting research as a primary activity has increased, the
number with unknown activity has increased even faster, which creates
some uncertainty about how to interpret these data. The increase in
research activity reported to the AMA is puzzling, since it goes in the
opposite direction of data the Committee has compiled on the number of
physicians participating in the research training programs of NIH.
Furthermore, since the AMA survey contains no standard def inition of
research activity, the interpretation is subject to wide variation among
the respondents, and in many cases it may differ from the Co~Tunittee' s
def inn' ~ on.
7. Patient fee income data are taken from AMA (1960-80) but are known to
be understated there because of the way medical schools account for such
funds. Some schools report all patient fee income, while others receive
and report only a f raction of the total. The remainder is channeled
through independent corporations and hence is not accountable be the
Dean's Office.
The difference between reported and actual fee income is unknown, but
the Committee's Panel on Clinical Sciences believes that more and more of
these funds are moving out of the schools' spheres of direct
accountabil ity.
8. The clinical faculty data used in this analysis are taken f rom the
annual surrey of medical schools conducted by the Liaison Committee on
Medical Education and published annually in the Journal of the American
Medical Association (AMA, 1960-80) . The def inition of clinical faculty
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used in that survey is an appointment in a clinical department at any
rank. Residents and f ellows are excluded unless actually serving as
faculty members. The definition does not mention tenure or tenure-track
positions, and so presumably all appointments, whether on the
tenure-track or not, are counted as f acuity.
9. The specific form of the model teas been developed from the additional
hypothesis that the ratio of full-time clinical faculty to medical
student enrollment (F/S) wi 11 vary in accordance with the amount of R and
D funds and fee income (M). But because of tenure and other limitations
on faculty hiring, the rate of growth in the _/S ratio in response to
increasing funds we 11 not be linear but will decrease as the funds
increase. This suggests a logistics or Gompertz-type relationship that
typif ies many growth processes. Fitting this model to the data for 1961
to 1978 produces the following specif ic f unctional form:
(F/S) t = e
where:
(-1. 6 - 103440/Mt) + 0.13,
F = full-time clinical faculty in medical schools;
S = medical student enrollment including residents and clinical
f ellows; and
M = weighted average of clinical R&D expenditures plus fee
income in medical schools (R); Mt = 1/4 (Rt+25t-1 +
Rt_2,
_ —
10. The data shown on p. 253 pertain to all full-time faculty in medical
schools, while the Committee's projections are for full-time clinical
faculty in medical schools only. Averaging the AAMC data over the years
1980-1985 and allocating proportionately to clinical science faculty
gives a projected annual need for 3,166 based on a 3 percent growth
estimate.
11. These results should be interpreted with caution. It is easy to
confuse "cohorts effects with age effects, e.g., older people may have
poorer publication records because the conditions under which they were
trained, recruited, and promoted may have differed substantially.
12. Spec ial tabulation prepared for this Committee by NIH, February 2,
1981, of trainees occupy) ng positions awarded in FY 1978.
51
Representative terms from entire chapter:
clinical faculty
