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OCR for page 18
2. Clinical Sciences
As of 1982, the market opportunities for clinical
investigators continued to be favorable, with medical
school faculties still growing and providing places
for young scientists interested in research careers.
The immediate problem remains one of recruiting
physicians to undertake research training. In the
longer term our projections indicate that the
s~cuar~on Is likely to undergo appreciable change.
With the possibility of a physician surplus
developing, the number of medical schools will stop
increasing, enrollments will stabilize or decline, and
faculty growth will be slower, thereby reducing the
number of positions available for new entrants into
the clinical investigator pool. At the same time,
greater financial uncertainty in medical schools is
likely to aggravate the long-standing difficulty of
attracting and retaining high-quality clinical
investigators. The problem appears to be related more
to the difficulty of obtaining funds for research than
to the availability of training positions. Despite
reduced employment opportunities, however, shortages
of clinical investigators are likely to persist for
the next few gears.
INTRODUCTION AND OVERVIEW
Clinical investigation, as defined by the Committee, includes
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 animal studies by scientists identifiable as
clinical investigators on the basis of their other work. Clinical
investigation is generally performed in academic health centers. In
that environment collaboration with basic scientists is facilitated,
appropriate resources for human studies are available, and multi-
disciplinary teams are at hand to provide skills needed for comparative
assessment of old and new methods. Accordingly, the Committee's
assessment of demand for clinical investigators is focused on the
18
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19
medical school sector. The latest data on medical school enrollment,
as well as faculty professional fee income, and clinical R and D
expenditures' in constant 1972 dollars, suggest that this market
continued through 1982 to exhibit a relatively strong demand for
clinical investigators (Table 2.1~. Highlights of the new data
presented in Table 2.1 are as follows:
.
demand for faculty in clinical departments continued to
be strong
· clinical R and D expenditures rebounded sharply in 1980
after a decline in 1979, but have fallen back since then
.
professional fee income continues to be one of the
fastest growing revenue items in medical schools, and
now far exceeds the level of clinical R and D
expenditures
· the number of physicians applying for NIH research
grants has increased in the last 5 years, but the number
of grants awarded on behalf of M.D. principal
investigators has not changed appreciably.
A point of particular interest in the most recent (1982) data is
the finding that the number of full-time faculty in clinical
Clinical R and D expenditures are estimated by applying a
correction factor to total R and D expenditures reported by the
Association of American Medical Colleges. The correction factor for
any year is the proportion of total NIH obligations that goes to
support clinical research, using NIH's Central Scientific
Classification System as the basis for characterizing individual
research grants. Financial data are given in constant 1972 dollars
unless noted otherwise.
2 Faculty in this report means academically employed, regardless of
tenure status or rank. In a medical school, full-time faculty refers
to faculty whose salary is paid either in full or in part by the
medical school or its affiliated institutions and hospitals. Included
are faculty on both strict and geographic full-time. Strict full-time
medical school faculty are those who receive their entire professional
income as a fixed annual amount from funds controlled by the medical
school or its parent institution, who devote their full time to
programs of the medical school, and whose professional activities are
under the direct auspices and control of the medical school.
Geographic full-time medical school faculty are those who receive a
guaranteed base salary, all or most of which is paid from funds
controlled by the medical school, but who may earn income from
professional activities, who conduct all of their professional
activities in the institution paying the base salary, and whose
professional activities are under the direct auspices and control of
the medical school.
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21
departments has grown somewhat faster than expected over the past 3
years, apparently financed by higher than anticipated levels of both
faculty fee income and clinical R and D expenditures. Full-time
clinical faculty was up 17.9 percent in 1982 from the 1979 level--an
average growth rate of better than 5 percent per year. There are
indications, however, that the market outlook for the next 5 years may
be changing, as described below. Slower growth in the medical
education complex can be anticipated.
Piefe~ionalFeeIncomein Medico Schools
During the early 1960s, professional fee income generated by
faculty members grew steadily at more than 10 percent per year in real
terms. But starting in 1968, a dramatic upswing occurred. These
funds grew at an annual rate of more than 25 percent, and overtook
funds for clinical research as a source of revenue for medical
schools. The latest data show a 15 percent real increase in 1982 over
1981. Although fee income in most schools is the only part of the
departmental budget that has been increasing, the prospect for
clinical faculties to generate additional revenue seems clouded. The
impact of cost containment devices, such as the diagnosis-related
group (DRG) Medicare prospective payment plan, as well as increased
competition between teaching hospitals and community physicians, make
it unlikely that this source of institutional revenue will continue to
grow at its previous rates.
ClinicaIR and D Expenditures
Approximately half of total medical school revenues were derived
from research funding in the late 1960s. By contrast, such funds now
amount to one-fifth of total revenues. Clinical R and D currently
accounts for about 38 percent of total biomedical R and D expenditures
(Appendix Table All. In constant dollar terms, estimated clinical R
and D expenditures dropped $7 million in 1981 and rose only $5 million
in FY 1982. Its real growth rate over the past 7 years has averaged
about 3 percent per year. The Committee foresees a somewhat slower
growth rate through 1988.
Enro ~ ents
After more than 30 years of expansion, the nation's medical
schools are showing some decline in applications and enrollments. The
total of medical students, residents, and clinical fellows has grown
at an average annual rate of only 3.2 percent since 1979. Hit
simultaneously by steep borrowing rates and substantial tuition
increases, student indebtedness continues to grow. Perhaps because of
rising costs, as well as possibly changing perceptions of alternative
career options, the number of medical school applicants for the
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22
1981-82 academic year was 16 percent below that of 1972-73, and the
entering class of 1~ 2-83 numbered about 100 fewer' students than in
the preceding year (Rorcok, 19833. Based on survey responses from all
medical schools, the expectation is for net decreases in first-year
enrollment of 47 and 85 in 1983-84 and 1984-85, respectively {AAMC,
1~ 33. Moreover, the possibility of a physician surplus seems to rule
out an expansion of medical education in the foreseeable future. Some
growth in the number of residents may occur, however, despite evidence
of recent reductions in available positions because of cost
constraints. This may result from incentives for expansion of
graduate medical training contained in the Medicare prospective
payment plan recently passed by Congress.3 Also, with the growing
complexity of medical services, prolongation of training programs and
increase in number of residency years are a possibility.
MAINTAINING THE FLOW OF
NEW CLINICAL INVESTIGATORS
' The future vitality of clinical investigation depends upon the
medical schools' ability to maintain a flow of qualified physician
investigators. One measure of the flow is the number of new M.D.
principal ' investigators on NIB research grants. Although the number
of newly hired physicians in medical schools has more than doubled
since 1965, the number of new M.D. principal investigators has
remained at roughly 400 (Bryll, 1983~. The proportion of physicians
among all first-time principal investigators has gone down from 29.3
percent in 1977 to 24.2 percent in 1980. The number of physicians and
other professional doctorates participating in NIB research training
programs hasidec~ined on average by more than 6 percent per year since
1975 {Table 2.1, line la).
A no-growth situation in medical schools could have serious
implications for the future demand for physician investigators.
Inasmuch as NIH-supported principal investigators are in large part
members of medical school faculties, the future demand is linked
closely to the hiring of new faculty which, in turn, is dependent on
net increase in faculty size and number needed to replace losses due
to attrition. Our projections have shown that a cessation of growth
in size of faculty would reduce faculty hiring by more than half (NRC,
1975-81~. New M.D. principal investigators have in recent years
constituted only 10-15 percent of the number of anew hires.--a finding
consistent with the fact that only 20-25 percent of physician anew
3 In addition to a medical education pass-through, Congress also
doubled the current adjustment for indirect teaching costs. With the
new adjustment, teaching hospitals will receive additional payment of
12-13 percent for each 0.1 increase in the residents-to-beds' ratio.
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23
hires. have had postdoctoral research trainings Because medical
schools include the vast majority of physicians holding academic
appointments, a decline in hiring of new faculty will affect the
demand for new M.D. investigators far more than other new researchers.
Further, the increasing dependence of medical schools on practice
income is likely to favor the recruitment of clinically-or~ented
physicians over physician investigators for the limited number of
faculty openings.
MONITORING THE CLINICAL INVESTIGATOR POOL
The:Committee has for several years been tracking the number of
physicians reporting research as a primary activity to the American
Medical Association (AMA). These data have been used as an indicator
of shifts in interest in research careers on the part of physicians.
A consistent annual decrease since 1968 has been followed since 1975
by a steady increase. The latest available data show almost a 6 per-
cent rise in 1980 over 1979 (Table 2.1~. This pattern does not
conform to data compiled by the Committee on the number of physicians
participating in NIH research training programs, nor is it compatible
with other indications of physicians' research activities available
from the Association of American Medical Colleges. Efforts are
underway to identify the causes of the discrepancy.
The need to know much more about the population of clinical
investigators has prompted the Committee to consider the establishment
of a system by which such information could be readily obtained. As a
first step, a roster could be established that would include
physicians, dentists, veterinarians, and other health professionals
with interest or training in research. The data files on NIH/ADAMHA
trainees and fellows and principal investigators maintained by the
Committee could be combined with the AAMC'S Medical School Faculty
Roster, the Dental School Faculty Roster, and files maintained by
various professional societies to form a composite data base that
would include almost all clinical investigators. Samples could be
drawn from the population for use in periodic surveys of research
activity, sources of support, training background, and other
information vital to the task of monitoring this important pool of
scientists. The cooperation of the AMA, AAMC and other professional
organizations would be required in developing this project. -
4 The percentage of all new-hired M.D.s with postdoctoral research
training fell from 28 percent in 1970 to a low of 20 percent in 1979,
with a subsequent rise to 25 percent in 1981 (Sherman and Bowden,
1932~.
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24
SHORT-TERM RESEARCH TRAINING
The Committee in its 1979 report welcomed NIH's resumption of
support for short-term research training as an important step in '
helping'to revitalize interest in the pursuit of clinical investigation
careers. Data from a Committee-sponsored study suggest that if the
necessary number of clinical investigators is to be maintained,
undergraduate medical students should be provided the timpani
opportunity to acquire firsthand knowledge of the excitement of
working in a research laboratory (AAMC, 1981b). This is consistent
with the findings of another study that indicates that research career
decisions had largely been made during undergraduate medical school
years (Davis and Kelley, 1982~.
Starting in 1979 with 5 grantee institutions and 16 trainees, the
current program has increased to 60 institutions and 1,026 trainees in
FY 1982. As authorized in the 1978 amendments to the NRSA Act,
students could pursue training for periods up to 3 months during
summer and off-quarters without incurring a payback-obligation.
Training' supported by these institutional awards is not restricted to
a single' discipline or department. The potential for this type of
training has been enhanced by two developments since the Committee';s-
last report. Under the most recent amendments to the NRSA Act, the
payback obligation is now applicable only to awards in excess of 12
months, thereby increasing a program director's flexibility in
planning trainee's research experience. Also, waivers may now permit
the payment of short-term stipends within the regular (T-32) training
grants.
The Committee believes that specific recommendations on the
administration and size of this program should await the results' of an
evaluation. Accordingly, a two-pronged study is planned to determine
the fraction of trainees who maintain their interests in research and
who follow career pathways that include research activity. One
approach entails an examination of records of trainees from the
pre-NRSA era. In this connection, it is to be noted that NIB training
grants provided support for periods of 1-3 months to 12,6'45 '
individuals during the years 1960-1974. Subsequent postdoctoral
training, NIH/ADAMHA grant activity, academic appointments, and
publications will be scrutinized. The other approach will compare the
research plans of NRSA short-term trainees with'those of'their '
non-trainee classmates and graduates of the non-grantee institutions.
This area of the study will also involve analysis of responses to' the '
AAMC annual survey of graduating seniors.
MEDICAL SCIENTIST TRAM PROGRAM
The Medical Scientist Training Program (MSTP) supports combined
medical and scientific training leading to both the M.D. and Ph.D.
degrees. Sponsored by the National Institute of General Medical
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25
Sciences (NIGMS), the program has grown from 3 grantee institutions
and 17 trainees in FY 1964 to 23 institutions and about 700 trainees
currently. Based on an outcome study of the first 53 graduates of
MSTP with respect to research retention, rate of advance in academic
positions, research grant success, and publication performance, the
program has been successful (NRC, 1975-81, 1~ 1 Report).
Reflecting our enthusiasm for the program we have previously
recommended that high priority be given to protecting MSTP training
slots, should it become necessary for budget reasons to reduce the
overall number of NRSA trainees. That recommendation has been
implemented, even though the support of all research training has
generally been under severe restraint. Moreover, trainee slots have
been maintained at a time when total expenditures per ~graduate. have
become significantly higher on MSTP grants than on other predoctoral
training grants, reflecting both a larger annual per trainee cost and
a longer period of stipend support for MSTP participants.
In its 1979 report, the Committee called for a moratorium on
further expansion, pending the development of more analytic
information regarding the program. A study during the past year by
NIGMS staff indicates that the relative cost of MSTP has been rising
steadily over the last few years. Expressed as a percent of total
NIGMS funds for predoctoral training, the MSTP share has increased
from 16 percent in FY 1977 to 25-28 percent currently. Continuation
of this trend could place in jeopardy the support of regular
predoctoral programs, which, it should be emphasized, are essential to
the continuing vitality of MSTP. The need to curb this growth in
costs has therefore become a matter of great concern.
A reasonable means for ensuring an appropriate balance would be to
retain for MSTP over the near future a share of NIGMS predoctoral
training funds that does not exceed 25 percent. The Committee
believes that the suggested stabilization of relative cost can be
achieved without detriment to quality through introducing various
modifications in program administration. One such measure, limiting
the period of MSTP support for an individual trainee to a total of 6
years and authorizing discontinuity in support, became effective July
1, 1983. A direct effect of that change will be to encourage greater
flexibility on the part of institutions in the operation of their MSTP
grants. It should be feasible, for example, for program directors to
include within the training sequence periods of support from non-MSTP
sources, such as research grants and institutional remission of
tuition. In the Committee's view, these changes have the potential of
enhancing program output, i.e., to increase the number of graduates
per MSTP dollar by means of "freeing up" some trainee slots.
Reference was made earlier to a limited 1% 1 study sponsored by
the Committee regarding the quality of MSTP output. As the program
enters its third decade of operation, the Committee believes the tome
Is appropriate to undertake a study of broader scope. It would be
useful, for example, to obtain a comprehensive picture of costs,
training completion rates, post-training employment histories,
scientific accomplishment, etc.
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26
INVOLVEMENT OF PH.D. SCIENTISTS IN
CLINICAL INVESTIGATION
Implicit in the Committee's numerical recommendations for post-
doctoral training in the clinical sciences has been the recognition
that individuals with other than health professional doctorates engage
in clinical investigation. Indeed, early evidence of an appreciable
involvement of non-health professionals in clinical investigation
emerged from the Committee's 1976 survey of recent Ph.D. recipients in
biomedical and behavioral fields (NRC, 197ab). Approximately 31
percent of the respondents in that survey described themselves as
engaged in research that directly involved human subjects (or animals
in the case of veterinary science research) or samples derived
therefrom, as part of a clinically-oriented study. That such
involvement had been expanding became apparent from the Committee's
analysis of staffing patterns in NIH-funded clinical projects over the
1973-78 period.5 As can be seen from Figure 2.1, Ph.D.s were the -
50
40
30
LLJ
lo' 20
LLJ
10
o
73 74 75 76
FISCAL YEAR
Other
Professional s
`_ Ph.D.7
M.~D.s &
M.D./Ph.D.s
I I I I J
77 78
FIGURE 2.1 Participation of Ph.D., M.D., and other scien-
tists on clinical research grants sponsored by NIH, 1973-78.
Data are shown as percentage of total paid full-time equiva-
lent employment on the grants. See Appendix Table A15.
s An Annual NIH Survey, Manpower Report, collected data from
principal investigators regarding persons receiving salary from each
grant during those years. The NIH Central Scientific Classification
System was used in this analysis to identify clinical grants--i.e.,
those involving human subjects as individuals or as groups.
\
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27
only degree category of personnel to exhibit a relative increase in
full-time equivalent employment on those clinical research grants,
rising from 27 percent in 1973 to almost 3S percent in 1978.
In earlier reports, the Committee has commented on the declining
attractiveness of clinical investigation as a career option for the
young physician. It is to be noted in this connection that the
proportion of NIH postdoctoral research traineeship and fellowship
positions filled by M.D.s in 1981 was about one-half that in 1973
(Table 2.2~. Dur ing that period the number of Ph.D. bioscience
researchers increased substantially, with a net growth of 450 per year
in the pool of postdoctoral appointees in the academic sector (see
Chapter 3, Table 3.1~. AS will be noted below, a growing number of
Ph.D. scientists has moved into clinical departments of medical
schools (Appendix Table Ark. Under these circumstances, one of the
questions examined by the Committee concerned the extent to which the
steady increase in the postdoctoral training pool might be used to
mitigate a possible shortage of physician investigators. In this
section of the report, the Committee addresses that question.
Ph.D. Faculty Members with Appointments in
Clinical Departments of Medical Schools
The clinical departments of medical schools provide a useful
starting point for examining the role that Ph.D. scientists play in
clinical research. Not only is the preponderance of clinical
investigation in the United States performed at that site, but it is
also possible to chart in some detail the growing frequency of Ph.D.s
with faculty appointments in clinical departments. For example,
full-tzme faculty in clinical departments of U.S. medical schools,
including pathology departments, trebled between 1967-68 and 1981-82.
Compared to other degree types, only the Ph.D.s exhibited an increase
in share of the total. As a proportionate share of clinical
department faculty, Ph.D.s rose from 11.5 percent in 1968 to 15.1
percent in 1982 (Appendix Table Ark. The M.D., M.D./Ph.D., and
mother n groups all declined slightly in percentage terms during this
period.
The distribution of Ph.D. faculty in the clinical departments is
uneven. The top four departments in number of Ph.D.s--psychiatry,
internal medicine, pathology, and family practice--accounted for 61
percent of the total in 1981-82 (Appendix Table Arm. As a fraction
of the faculty of each clinical department, Ph.D.s ranged from about
5 percent in anesthesiology to over 31 percent in otolaryngology and
in psychiatry.
Do Ph.D. faculty members in clinical departments differ from their
counterparts in basic science departments in medical schools? In
terms of the same selected characteristics, how do they differ from
their physician colleagues? Relevant to these questions, three groups
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28
of medical school faculty members will be compared in the following
paragraphs:
1. Ph.D.s with primary appointments in clinical departments
2. Ph.D.s with primary appointments in basic science departments
3. M.D.s with primary appointments in clinical departments.
TABLE 2.2 Distnbution of NIH Postdoctoral Trainees and Fellows,
by Degree Type, 1971-81a
Fiscal
Year Total M.D.sb Ph.D.sb
.
1971 # 7,540 4,634 2,906
~ 100.0 6 1.5 38.5
1972 # 7,407 4,474 2,933
% 100.0 60.4 39.6
1973 # 5,478 3,630 1,858
5to 100.0 66.1 33.9
1974 ~ 6,364 3,551 2,813
~0 100.0 55.8 44.2
1975 # 5,971 2,884 3,087
~ 100.0 48.3 5 1.7
1976 # 4,910 1,970 2,940
% 100.0 40.1 59.9
1977 # 5,325 1,927 3,398
~ 100.0 36.2 63.8
Its,
1978 # 5,758 1,984 3,774
% 100.0 34.5 65.5
1979 # 5,814 2,005 3,809
% 100.0 34.5 65.5
1980 # 5,831 2,172 3,659
~0 100.0 37.2 62.8
1981 # 5,265 1,961 3,304
% 100.0 37.2 62.8
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 International Center
programs.
b"M.D." and "Ph.D." also include equivalent doctorate degrees. Persons with both M.D.
and Ph.D. degrees are shown under "M.D."
SOURCE: NIH (special tabulation, 10/7/82).
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39
enrollments, but that the effect is spread over several years. We use
a growth function of the following form to model these data:
CF/WS = ea-b/M +C
where: OF = full-time clinical faculty in U.S. medical schools
WS = 4-year weighted average of students, i.e.,
(WS) t=1/6 (St+2St-l+2St-2+St-3 ~
where S = total of medical students, residents, and
clinical fellows
M = 3-yr. weighted average of clinical R and D expenditures
plus professional service income per school (1972 $,
millions)
c = scaling constant: CF/WS = c when M = 0
a,b = parameters to be determined empirically
With this type of growth function, the percentage change in CF/WS
is assumed to increase proportionately to 1/{M2~. The function has
an inflection point at b/2 and is asymptotic to eat
Similar curves also were derived separately for public and private
medical schools. These are shown in Figure 2.8 along with the 95
percent confidence Digits in each case.9
Fitting this model to data from 1964-80, we get the following
estimates for the parameters: a = -0.98517; b = 0.% 32; c = 0.01. The
values were derived from 17 annual observations by a least-squares
regression procedure which yields an R2 of 0.932. R2--the
coefficient of determination--must lie between O and 1 and is a
measure of how well the assumed function fits the data, with R2 = 1
representing a perfect fit e The dotted lines in Figure 2.7 represent
the 95 percent confidence limits on the estimated curve. The curve is
asymptotic to CF/WS = 0.38 and has an inflection point at M = $0.5
million per school.
9 The functional form of these curves is the same as before (although
with different parameter values), i.e.: CF/WS = ea~b/M +c.
Parameter estimates for each case were also derived from 17 annual
observations between 1964 and 1980. These are as follows:
Public schools
a = -1.266
b = 0.8691
c = 0.05
R2 = 0.84
Private schools
a = -0.8088
b = 1.2892
c = 0
R2 = 0.93
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40
Note in Figure 2.8 that at low levels of clinical funds--below $2
million per school for example--the CF/WS ratios in both public and
private schools are quite similar. At levels above 32 million per
school, the ratios diverge, with private schools having substantially
higher ratios for the same level of clinical funds. This implies a
difference in emphasis between public and private medical schools with
regard to the way clinical funds are expended. One hypothesis it that
private schools tend to use the funds more for faculty support while
public schools tend to use the funds more for other purposes.
0.42
0.40
0.38
0.36
3 4 5 6
CLINICAL FUNDS PER SCHOOL (M), (1972 $, millions)
Private School'
Publ ic School s
*= Private Schools
61 = Publ i c School s
7 8 9
FIGURE 2.8 Clinical faculty/student ratio (CF/WS) vs. clinical funds per school (M), by control of
institution. The ratio is defined as follows: CF = full-time faculty in clinical departments of U.S.
medical schools; WS = 4-year weighted average of students, i.e., (WS)t = 1/6(St + 2St 1 + 2St 2 + St 3),
where S = total of medical students, residents, and clinical fellows. Clinical funds are defined as
clinical R & D expenditures (R) plus professional service income (P) in medical schools. M is defined
as a 3-year weighted average of R+P: Mt = 1/4~(R+P)t + 2 (R+P)t 1 + (R+P)t 2] . Solid line represents
a growth curve of the form Y = exp~a-b/x)+c fitted to the data for 1964-80. Broken lines represent
95~o confidence limits on the fitted curve. See Appendix Tables AS and A9.
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41
Assumptions
To use the model for projections, it is necessary to make
assumptions about the future behavior of the three elements that drive
the model--students, R and D funding, and professional fee income.
1. Enrollments: medical school enrollments, defined as medical
students, residents, and clinical fellows, are expected to
show no growth between 1982 and 1988. The upper and lower
visits on the expected growth rate are +2.5 percent per year
and -2.5 percent per year, respectively (see Figure 2.9~.
so
an
AL
120
110
100 _
90
o
-
~n
z
cat
o
cat
:~:
z
80
70
60
50
40
30
20
10
O ' I i , ,
60 62 64 66 68 70
_ Actual
-- Projected
-
Al l School s /
_: Publ ic _'
School s)/
_'
~;~!
--en ~ School s
hit,. ;~ ~ ~~ satyr.)
_e__________.
r
~~J
72 74 76 78 80 82 84 86 88
FISCAL YEAR
FIGURE 2.9 Medical students, residents, and clinical fellows, by control of
institution, 1961-81, with projections to 1988. See Appendix Table Al.
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42
2. Clinical R and D expenditures: the best-guess assumption is
for a 2 percent per year growth in these expenditures between
1981 and 1988 after adjusting for inflation. The upper and
lower limits are 4 percent per year and O percent per year,
respectively.(see Figure 2.10~.
so
4
2
1
o
Actual
Projected
Private J f
School s )~ /~
Off
~
W/~N
^/~
62 64
,_. High Estimate (4X/yr. )
_,
,_--' ~ ma- ME ddl e Estimate ( 2%/yr. )
- Low Estimate (0%/yr. )
Publ i c School s
66 68
70 72 74 76 78
FISCAL YEAR
80 82 84 86 88
FIGURE 2.10 Clinical R & D expenditures per school in U.S. medical schools, by control
of institution, 1962-80, with projections to 1988 (1972 $, millions). See Appendix Table A9.
3. Professional service income: the best-guess assumption is
for real growth (after adjusting for inflation) of 2 percent
per year from 1982 to 1988. Expected upper and lower limits
are 5 percent per year and -1 percent per year, respectively
(see Figure 2.11~.
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43
9f
8t
7
6:
3~
2:
1
o
-- Actual I,'
Projected ,,_ ,~ <2~0lyr )
Private ~ ~ - _iniate (~~%/yr.)
School scam ~ ~ School s
Ad// Publ icy)
,~ School s
3'q
I , . . . . . . . ~ . . ~
62 64 66 68 70 72 74 76 78 80 82 84 86 88
PI SCAL YEAR
FIGURE 2.11 Professional income per school reported by U.S. medical schools,
by control of institution, 1962-80, with projections to 1988 (1972 $, millions).
See Appendix Table A9.
Projections of Demand for Clinical Faculty to 1988
Given the Panel's assumptions about enrollments, clinical R and D
expenditures, and professional income in medical schools, we now use
the model to make projections of demand for clinical faculty.
Following our usual practice, projections are made for about 5 years
ahead of the report, so this year the projections go through 1988 as
shown in Figure 2.12 and Table 2.5.
Under the most optimistic assumptions about clinical R and D
expenditures and professional income (assumption I in Table 2.5),
these aggregated clinical funds would grow by 4.7 percent per year
through 1988 to about $11 million per school, driving the CF/WS ratio
to 0.35 from its current value of 0.33. The 98 percent confidence
fits on this estimate are 0.366 and 0.334, respectively. Since the
most optimistic assumptions attempt to define an upper limit on our
projections, we use the upper 95 percent confidence licit on CF/WS
(0.366) as the most optimistic estimate. We project academic demand
by using the most optimistic estimate of enrollment growth--2.5
percent per year (assumption A of Table 2.5--together with the
estimated CF/WS ratio of 0.366. This produces an estimated upper
limit for clinical faculty size of 49,640 members by 1988, for a
faculty growth rate of 3.9 percent per year.
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44
55
50
45
40
35
30
25
20
15
10
Actual
em-- Projected
Al l School s Ad/
/
Private Schools ID
o
INTO\{
Apia (;''
-'' Middle Estimate (1.3~/yr.)
-_ 1. 2X/~
Publ ic School s
, ,
60 62 64 66 68 70 72 74 76 78 80 82 84 86 88
FISCAL YEAR
FIGURE 2.12 Clinical faculty in U.S. medical schools, by control of institution, 1961-81,
with projections to 1988. Faculty is defined here as full-time appointments in clinical de-
partments regardless of tenure status. See Appendix Table A2.
About 1,620 positions would be created by expansion, with another
430 created by attrition due to death and retirement, and 1,900
created by other faculty attrition. The total number of clinical
faculty positions that would become available each year under these
high growth asssumptions is estimated at 3,950.
Under the middle or best-guess assumptions {IT-B of Table 2.5),
clinical funds would expand by about 2 percent per year through 1~8--
yielding ~ CF/WS ratio of 0.344--and enrollments would remain at 1981
levels. The best estimate of clinical faculty size under these
assumptions is 40,700, an increase of 500 positions per year or 1.3
percent per year over the 1980 level. Attrition from all causes would
add another 2,090 positions to give an estimated total annual demand
for clinical faculty of 2,590. This is the Committee's most likely
projection.
Under the low growth assumptions (III-C of Table 2.5), clinical
funds would expand very slightly to about $0.7 million per school by
1~8. Consequently, the estimated CF/WS ratio would be 0.336 with
upper and lower 95 percent confidence limits of 0.350 and 0.323,
respectively. Using the lower estimate of 0.323 to represent the most
pessimistic conditions, together with the lowest enrollment growth
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TABLE 2.5 Projected Growth in Medical School Clinical Faculty, 1980-88, Based on Projections of Medical
School Enrollment, Clinical R and D Expenditures, and Medical Service Income in Medical Schoolsa
Assumptions about Real R and D Expenditures and
Professional Service Income (in constant 1972 dollarsb)
in Medical Schools ($7.6 million per school in 1980)
I II III
Will expand at Will expand at Will decline
about 4.7~O/yr. about 2.05~0tyr. slightly by about
Assumptions about Medical Student Enrollment to $11.0 million to $8.9 million 0.7~O/yr. to $7.2
(medical students, residents, and clinical fellows) per school in per school in million per
(118,300 in 1981) 1988 1988 school in 1988
A. Will grow at 2.5%O/yr., Expected size of clinical faculty in
reaching 141,000 medicalschools (CF)in 1988 49,640 46,600 43,800
students by 1988 Annual growth rate in CF from
1980 to 1988 3.9 3.0~o 2.2~o
Average annual increment due to
faculty expansion 1,620 1,240 890
Annual replacement needs due to:C
death end retirement 430 420 400
other attrition 1,900 1,830 1,770
Expected number of positions to
become available annually on
clinical faculties 3,950 3,490 3,060
B. Will show essentially Expected size of clinical faculty
no growth from 1981 in medical schools (CF) in 1988 43,300 40,700 38,200
to 1988, remaining at Annual growth rate in CF from
118,300 students 1980 to 1988 2.1% 1.3% 0.5%
Average annual increment due
to faculty expansion 830 500 190
Annual replacement needs due tore
death and retirement 400 390 370
other attrition 1,760 1,700 1,650
Expected number of positions to
become available annually on
clinical faculties 2,990 2,590 2,210
C. Will decline by 2.5~O/yr. Expected size of clinical faculty in
to 99,100 students by medicalschools (CF) in 1988 37,700 35,400 33,200
1988 Annual growth rate in CF from
1980 to 1988 0.3% -0.4~o -1.2%
Average annual increment due
to faculty expansion -130 -160 -430
Annual replacement needs due to:C
death and retirement 370 360 350
other attrition 1,640 1,590 1,540
Expected number of positions to
become available annually on
clinical faculties
2,140 1,790 1,460
aPaculty in this table is defined as a full-tune appointment in a clinical department regardless of tenure status. These projections
are based on the following relationship:
(CF/WS)t = exp (-1.681 3 - 1108.8/Dt) + 0.05, where CF = size of clinical faculty in medical schools; WS = weighted average of
last 4 years of enrollments, i.e., (WS)t = 1/6(St + 2St 1 + 2St 2 + St 3), where S = medical students, residents, and clinical
fellows; D = weighted average of last 3 years of clinical R and D expenditures plus medical service income per school, i.e.,
Dt = 1/4(Dt + 2Dt 1 + Dt 2). See Appendix Tables Al, A3, and A10.
Deflated by the implicit GNP Price Deflator, 1972 = 100.0. See Appendix Table A7.
CBased on an estimated replacement rate of 1.0~o annually due to death and retirement, and 4.4 annually due to other attrition.
See AAMC (198 la).
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46
assumption of -2.5 percent per year, we estimate clinical faculty size
under the worst-case conditions to be about 33,200 members--a decrease
of 430 positions per year from 1~ 0 levels. But attrition would
create an estimated 1,890 positions per year for a minimum net demand
of 1,460 positions.
Estimating Postdoctoral Support Levels
Under NRSA Programs
The final step in our quantitative analysis of the market is to
attempt to translate the projections of academic demand into
recommended levels of postdoctoral training under NRSA programs. This
step requires certain additional assumptions about how the system has
functioned in recent years with regard to postdoctoral training and
its sources of support.
The features of the system that must be considered in addition to
the projections of medical school faculty growth are as follows:
2.
5.
contributions to academic demand generated-by:
a) the need to reduce budgeted vacancies in
clinical departments
b} demand for clinical faculty in dental and
veterinary schools
the number of accessions to clinical faculty positions
who have (or should have} research training
3. the appropriate length of the research training period
4. the proportion of individuals in the research training
pipeline who aspire to academic careers
the proportion of support of the total pool of
clinical research trainees that should be provided by
the federal government.
In the absence of complete knowledge of the system, we must make
additional assumptions about these features--first presented in the
Committee's 1~ 1 report--in order to provide a quantitative basis for
the recommendations.
Using the projections of academic demand derived in Table 2.5, and
the same set of conditions specified in the 1981 report,-we calculate
in Table 2.6 the range of clinical science postdoctoral trainees that
should be supported by NRSA programs under the specified conditions.
Line 1 of Table 2.6 is a summary of the projections of academic
demand for the extreme cases and the best-guess estimate derived in
Table 2.5.
Line 2 is an estimate of the demand generated by the need to reduce
budgeted vacancies in clinical science departments of medical schools.
Line 3 provides an estimate of the demand for clinical faculty in
veterinary and dental schools--estimated at 16 percent of medical
school demand.
Line 4 shows the total annual demand for clinical faculty under
each set of conditions. Total annual academic demand is expected to
be between 1,860 and 4,750 positions with a best guess of about 3,170
· ~
positions ~
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47
TABLE 2.6 Estimated Number of Clinical Research Postdoctoral Trainees Needed to Meet Expected
Demand for Clinical Faculty Through 1988 Under Various Conditions
Projected Through 1988 Annual
High Middle Low Average
Estimate Estimate Estimate 1979-81
1. Demand for full-time clinical faculty-
annual average: 3,950 2,590 1,460 3,780
a. due to expansion of faculty 1,620 500 -430 1,830
b. due to death and retirements 430 390 350 360
c. due to other attrition b 1,900 1,700 1,540 1,590
2. Demand created by unfilled positionsC 170 170 170
3. Demand for veterinary and dental school clinical
faculty (16% of med. school demand)d 630 410 230
4. Total annual accessions (expected demand) 4,750 3,170 1,860
Total accessions with postdoctoral research
training-annual average (assuming 35~O of all
accessions have postdoctoral research training)e
6. Size of clinical science postdoctoral pool-
1,660 1,1 10 6s0
annual average 3,000-5,000
Size needed to meet academic demand assuming
a 2-yr. training period and portion of trainees
seeking clinical faculty positions is:
a. 60% 8,300 3,700 2,170
b. 50~O 9,960 4,440 2,600
7. Annual number of clinical science postdoctoral
trainees to be supported under NRSA programs:
a. if 50% of pool is supported under NRSA 4,150~,980
b. if 60% of pool is supported under NRSA 4,980-5,980
.
2,866
1,850-2,220 1,080-1,300
2,220-2,660 1,300-1,560
aAssumes an attrition rate due to death and retirement of 1.0% per year. See AAMC (1981a).
bAssumes an attrition rate due to other causes of 4.4% per year. See AAMC (198 la).
CIn 1981 there were 2,231 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 1988 is about 170 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 410 per year.
eAccessions are defined as new hires or those who rejoin faculties from nonfaculty positions. Interfaculty 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.
SOURCE: Table 2.5.
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48
Line 5 shows the number of clinical faculty positions to be filled
,; , . .. .. .
by individuals with postdoctoral research training experience assuming
that 35 percent of all accessions to academic positions will be former
postdoctoral trainees. In the best-guess case, this number is
estimated to be 1,110.
Line 6 indicates the size of the clinical science postdoctoral
pool required to supply the necessary number of individuals with
postdoctoral training under certain assumptions about the length of
the postdoctoral training period and the proportion of the pool
seeking academic employment.
If the appropriate length of postdoctoral research training in the
clinical sciences is 2 years, then the pool size needed to produce
1,110 trained scientists each year would be 2,220. If only 50 percent
of the trainees seek academic appointments after completing their
training, then the necessary pool size must be 4,440. We assume that
some support for postdoctoral research training is also available from
sources other than the NRSA programs. This is dealt with in line 7 of
this table.
Line 7 shows the estimated number of clinical science postdoctoral
trainees that should be supported annually by NRSA programs under
different assumptions about the proportion of total support provided
by that source. The resulting range is between 1,080 under the lowest
set of assumptions, and 5,~ 0 under the highest set. The best-guess
assumptions yield a range of 1,8S0-2,660 postdoctoral trainees in the
clinical sciences.
Long-Term Considerations
The foregoing analysis is an attempt to translate the Committee's
assessment of enrollments and funding in the next few years into
projections of academic demand for clinical faculty and ultimately
into training levels needed to satisfy that demand. Along the way we
are forced to make critical assumptions about how the system has
worked in the past and how it will work in the future. Clearly, the
end results are quite sensitive to these assumptions.
In effect, what has been done is to combine expert judgment of
future trends with a conceptual view of how the training system
operates and how clinical investigators are absorbed into academic
positions.
Although we may have identified in this analysis most of the
important features of the system that must be considered--attrition
rates, length of training period, proportion of support provided by
federal programs, for example--our knowledge of all the parameter
values in the system is admittedly incomplete. In recognition of
this, we have provided a fairly wide range of estimates. This is
partly a reflection of incomplete knowledge, but also reflects the
uncertainty inherent in any projection exercise.
These caveats notwithstanding, it seems clear that even under the
most optimistic set of assumptions made by the Committee, the size of
the clinical faculty in U.S. medical schools will not expand as fast
as it has in the recent past.
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49
The long-term problem then becomes one of how to maintain the flow
of quay ified new entrants into the field of clinical investigation in
the face of declining opportunities in the academic sector where most
clinical research is conducted. It is a basic premise of this
Committee that the maintenance of such flow is vital to the research
enterprise. A potential no-growth situation in medical schools will
tend to decrease this flow as well as the growth of clinical research
itself. This dilemma is created by both demographic and economic
factors. A projected surplus of physicians has served to preclude
further expansion of medical education for the next 10 years or so.
Economic conditions are not favorable for large increases in R and D
funding by the federal government. The ability of medical school
faculties to support themselves through revenue from practice plans
will be negatively affected by efforts to contain costs in medicate
and medicaid programs. This is the situation facing clinical research
as seen by the Committee and other observers. Victor Fuchs, a noted
health economist wrote recently:
"I am particularly concerned, for example, about what
will happen to medical research. Without research,
without advancing the state of knowledge, medicine
will begin to run up against blank walls. There is
only a limited amount of improvement in health that
can be purchased by increasing the number of
physicians or by adding hospital beds. The great
advances have always come from figuring out better and
newer ways of preventing or treating disease. Somehow
there has to be enough funds generated in medical
centers to support research and to employ faculty who
are actively engaged in research.. (Fuchs, 1982)
As noted earlier in this report (Chapter 1), this Committee
believes that the long-term problems facing clinical research will
arise more from insufficient funding of research than from a lack of
training opportunities. We agree with Fuchs when he says that ways
must be found in medical schools to support research activities. But
we have tried in this report to make the most realistic analysis
possible with the existing information. Our recommendations for
training in the clinical sciences acknowledge the continuing need to
attract and train physicians for research careers. Yet the overall
recommended level of training in the clinical sciences has been
formulated under our best judgment about the research opportunities
that are expected to become available within the next few years under
the most likely set of circumstances in medico education.
Representative terms from entire chapter:
clinical faculty
