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1. Introduction and Summary Abstract Research training programs sponsored by the federal government serve several functions: they attract able students to research careers by providing stipends, tuition, and allowances; they encourage better training environments at colleges and universities through institutional allowances that support faculty, equipment, and interdisciplinary programs; and they contribute to the nation's research enterprise by promoting the flow of well-trained young scientists into research careers. These are worthy goals, and the training programs, filtered through the peer review process, appear to have been successful in achieving them. Assessing the appropriate level of training to be provided under the National Research Service Award (NRSA} programs--the task of this study--involves consideration of these objectives together with the career and employment prospects of the trainees. Currently we are facing a period in which faculty expansion will likely be curtailed by falling enrollments and slower revenue growth, but increased replacement demand is expected to be generated by higher rates of attrition due to death and retirement. Industrial demand for Geoscientists is increasing and biotechnology firms expect academia to train the personnel they need to sustain this growth. The main issue is how to achieve the proper balance between maintaining the strength of the nation's biomedical and behavioral research effort, and adjusting the flow of young scientists entering the field to the number of research and teaching positions that are expected to become available in the next few years. During the 1970s, training funds declined sharply relative to research funds and currently amount to less than 6 percent of research expenditures of the administering agencies--NIH, ADAMBA, and Division of Nursing, HRSA--down from 17 percent in 1971. It is the committee's view that training funds should not be further reduced. The nation must begin to plan for the 1990 decade when many current faculty members will reach retirement age and college enrollments will once again start to increase. 1

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2 The issues addressed in this report are those presented to the National Academy of Sciences (NAS) by Congress in the 1974 Act that reauthorized the research training programs of the National Institutes of Health (NIH), the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), and by subsequent amendment, the Division of Nursing of the Health Resources and Services Administration (HRSA). Congress asked the NAS to monitor the biomedical and behavioral fields, to assess the national need for research personnel in these fields, and to determine the kinds and extent of training that the government should provide. This report examines the system under which biomedical and behavioral scientists are trained for research careers in this country and the government's programs that support such training. Those programs consist of training grants and fellowships that are designed to supplement the government's research programs in the biomedical and behavioral fields by providing support to predoctoral and postdoctoral students and their institutions. The goal of the training programs is generally to strengthen the research effort, and they-do so by encouraging young scientists to pursue research careers, by selecting the best qualified candidates for support, and by fostering the development of a strong training environment through competition and the peer review process. From the very inception of these programs in 1937, the interdepen- dence of research and training was recognized. The National Cancer Act of 1937 established the National Cancer Institute within the National Institutes of Health and gave it authority for supporting both research and training in matters relating to the causes and treatment of cancer. The wisdom of that linkage within our universi- ties was acknowledged recently by Donald Kennedy, President of Stanford University, who noted that the government could have followed the German model and established quasi-independent laboratories with support from the industrial sector, or it could have created a network of government laboratories. That it did neither guaranteed that new discovery and the training of the next generation of discoverers would take place in the same locations, thus establishing one of the great strengths of American science. That strength is well recognized in Europe; at the 1977 Nobel awards, when Americans swept the prizes for the first time, our thoughtful Swedish colleague Sune Bergstrom pondered the phenomenon and finally attributed it to the 'democracy of American science.' He meant the fellowship of the bench--the system of apprenticeship that is built upon the coexistence of research with research training. (Kennedy, 1985)

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3 COMMITTEE'S APPROACH TO ASSESSMENT OF NATIONAL NEED In response to its congressional charge, this committee and its predecessors have compiled a substantial data base on national trends in enrollments, degrees, employment characteristics and funding in the biomedical and behavioral fields, developed analytic models of the training system, and made projections of demand for these scientists over the short term. By means of follow-up studies, we have also examined the subsequent career achievements of former trainees and fellows. Comments and suggestions from the scientific community have been solicited at public meetings following the publication of each report. A summary of the last public meeting in May 1984 is presented in Appendix F. In this report, we present the latest available data on the components of the system and update the projections to 1990. The complete data base is published in Appendixes A through C. A chapter is devoted to each major area of this study, which we have defined as clinical sciences, basic biomedical sciences, behavioral sciences, health services research, and nursing research. Our definition of each area is presented in Appendix D. The taxonomy is based on the fields that contribute to each area, not on the types of degrees held by the contributors. Chapter 3 includes the results of the second survey of personnel needs in the biotechnology industry. The committee's basic approach has been to examine the systems that have evolved in this country for preparing the students for careers in biomedical and behavioral research and by which they received support for their research as independent investigators and teachers. These systems function somewhat differently in each of the major areas of concern. In the basic biomedical sciences, the typical route to a research career consists of about 7 years of graduate study leading to the Ph.D. degree, followed by 3 years of postdoctoral training. The behavioral fields, nursing research, and health services research are somewhat similar to the biomedical fields, except that postdoctoral training is less typical. In the clinical sciences, research-oriented physicians usually complete 4 years of medical school, 3 years of residency training, and 2 or more years of research training before they begin to compete for research support. Postdoctoral research training is often sought by dentists and veterinarians who intend to pursue research careers. The committee believes that a solid understanding of how the systems have functioned in the past and how they can be expected to function in the next few years is essential to an assessment of training needs. There are some components of the training system that are vital to our assessment. Among these are the length of the postdoctoral training period, the percentage of newly hired faculty members who have some postdoctoral research training, the percentage of postdoctoral trainees who subsequently choose academic careers, and the proportions of predoctoral students and postdoctoral trainees that should be supported under NRSA programs. Each of these components is considered along with our projections of faculty demand within the relevant chapter--clinical sciences, basic biomedical sciences, or behavioral sciences. Identifying and quantifying these critical

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4 components of the system provides a rational basis for determining the appropriate numbers of federally-supported traineeships and fellow- ships in these fields. One aspect of this study is quite clear--the universities and health professional schools are the locus of most biomedical and behavioral research and training sponsored by the government. The effectiveness of those programs therefore depends heavily on the availability of trained and qualified researchers among the faculty members of these institutions. Faculty members are supported by funds generated by tuition, research grants and contracts, state and local government contributions, and increasingly in medical schools by revenue from faculty practice plans. The latter has taken on an especially important role over the past 10 years as the medical schools strive to maintain revenues in the face of rising indirect costs and slower growth in enrollments, research funds, and other sources of revenue. Income from medical service plans displaced federal research grants and contracts as the largest source of funds for medical schools in the late 1970s and now accounts for over 30 percent of total revenue (AMA, 1960-84~. From the point of view of clinical research, the growth of income from medical service activities is a disturbing trend because it means that the emphasis in clinical departments of medical schools has shifted away from research toward service activities. As faculty vacancies occur, they tend to be filled by physicians whose interests are primarily in providing patient care in an academic setting rather than in research. Some basic scientists with Ph.D. degrees have moved into clinical departments to support the research and teaching activities as physicians in those departments turn more to service programs. But the pressure on medical school faculties to generate income means that young physicians may be required to perform service at the expense of research. Partially to counterbalance this growing tendency for medical schools to concentrate on service rather than research activities, this committee has recommended in the past and continues to recommend that more research training opportunities be made available to aspiring clinical investigators. The training system should be adjusted so that a higher percentage of recruits to clinical faculties will have some research training experience. A postdoctoral appointment as a trainee or fellow is the typical mode of acquiring such experience for physicians, veterinarians, and dentists. Furthermore, the knowledge base in the biomedical sciences has expanded rapidly in recent years and this has imposed additional requirements on training. A postdoc- toral appointment of about 3 years duration is now generally required because the complexity of biomedical science has increased and the array of instrumentation that must be mastered has developed rapidly. Also the boundaries between fields are disappearing (new fields such as immunogenetics and neurovirology are emerging) and it is mainly during the postdoctoral period that many bioscientists begin the process of integrating related fields with their own. The training programs are designed to complement research programs by developing the training environment and maintaining an adequate supply of well-trained scientists. The level and distribution of training funds provided by NRSA programs should be determined so as to

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5 achieve a stable and efficient system. Sharp year-to-year variations in training levels are unnecessarily disruptive. Demand expected to be generated in the academic and other sectors must be compared with the anticipated supply. Demography, funding trends, and alternative sources of support for training are all considered in our projections and analyses. A diversified array of disciplines contributes to the biomedical and behavioral sciences, ranging from mathematics and engineering to the clinical sciences. This diversity should be encouraged--excellent research often is produced in non-traditional areas--and the peer review system should be relied upon to select the best applications. Underlying all of these considerations is the perception that the effectiveness of the government's biomedical and behavioral research programs depends on the continual infusion of young scientists trained in the latest techniques of a science making startlingly rapid advances. RECENT RESEARCH DEVELOPMENTS Biological science has undergone a remarkable transformation in the past 3 or 4 decades. It has changed from a descriptive to an analytical and mechanistic field with a capacity to probe ever finer levels of organization. The growth in understanding of living things has been sufficiently dramatic and pervasive to justify use of the term "revolution" to describe the evolving state of modern biological science. Molecular biology began as a discipline that combined the theories and methods of biochemistry, microbiology, and microbial genetics. The more recent advent of the recombinant DNA technology permitted direct study of the genes of higher organisms, including man. It became possible to observe their structure, to determine how they function as blueprints for fashioning the cellular machinery, and to decipher the controls on their operation. As described by Baltimore (1984), this startling technology could be used ". . . as a molecular microscope with which to peer into the details of genes and as a factory able to synthesize the product encoded by the genes." The past decade witnessed other revolutionary advances in science and technology. One of the most interesting developments, for example, has been the detection and isolation of oncogenes, dominant genetic elements that apparently exist in the chromosomes of every human cell and in the cells of numerous other organisms. Oncogenes appear to play a central role in the malignant transformation of normal cells. Approximately 15-20 percent of all human tumors have been shown to contain oncogenes in their DNA. Increased understanding of oncogenes and how oncogene-encoded proteins work may make it possible to anta- gonize their functioning and to reverse the process of carcinogenesis. Enriched by new tools and understanding of biochemistry, molecular genetics, and cell biology, immunobiology has become a fertile source of insights. Because of the chemical specificity of immunologic reactants and their products, researchers and clinicians have been provided with powerful and versatile techniques, such as radioimmuno-

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6 assays. In addition, hybridoma-derived monoclonal antibodies promise to revolutionize many aspects of biology and medicine through their ability to identify almost any molecular structure that can be purified sufficiently to be used as an antigen. Fundamental knowledge in the neurosciences has expanded along a broad front from cellular and molecular aspects to mechanisms of perception, learning, and emotion. The ingenious application of new technologies has hastened analysis of structural organization of the nervous system, and a detailed topography of the functional anatomy of the brain is close at hand. The chemical mechanisms by which some cells communicate, as well as the modes of action of many neuro- transmitter substances, are now understood in considerable detail. From that knowledge will emerge therapies for disorders associated with abnormalities in specific neuro-transmitter systems. Research on the relationship between stress and other physical problems has produced some significant results. Studies of hypertension have shown that psychosocial factors are highly correlated with hypertensive episodes; psychosocial factors may also be important in the earlier stages of the disease and may play a role in the etiology of high blood pressure (Kaplan, 1980~. Along with genetic factors, behavioral factors such as dietary salt intake, obesity, and psychological stress have been linked to the initiation of high blood pressure. Experimental studies involving animals have found that the brain participates at some stage in the increase of blood pressure levels. A series of experiments with rats demonstrated that conflict in learning situations was related to the development of the hypertensive state (Friedman and Dahl, 1975; Friedman and Iwai, 1976). Studies in a new interdisciplinary research area, psychoneuro- immunology, have found that stress-responsive hormones can alter the components of the immune response (Ader, 19811. The psychosocial influences on immune function have important implications for the body's defenses against malignancy. Other studies, involving laboratory animals (Amkraut and Solomon, 1977), and human subjects (Kasl et al., 1979), have found that psychosocial factors are related to susceptibility to infectious diseases. The biological revolution has been fueled in part by the merging of innovative instrumentation, such as lasers, large-scale integrated circuits, and computers, with fundamental insights into the nature of the living cell. Biomedical applications of lasers include laser cytofluorometry, a technique for separating cells according to size, shape, and reflective properties, and their further sorting according to, for example, their shape and DNA content--all within minutes. A further illustration of evolving instrumentation technology is positron emission tomography (PET). This provides a non-invasive means for visualizing the metabolism of the human brain during normal activi- ties, such as hearing, speaking, or thinking, and in diseased states in which there are deficits in sensory, motor, or cognitive processes. Still another technology which opens up new approaches to basic biomedical problems is electron spin spectroscopy. This is a particularly sensitive tool which can be used to measure phenomena

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7 such as oxygen uptake in tissue and electron transport activities involved in intracellular energy processes. Recent refinements permit spectroscopic measurements on single muscle fibers or small numbers of cells without sacrificing resolution or sensitivity. This rich harvest of knowledge and new technologies has made it possible to ask more sophisticated and penetrating questions. Investigators can now move with assurance in experiments that only 10 years ago would have been considered to lie almost in the realm of science fiction. In this context, the President's Biomedical Research Panel observed in its 1976 report: "There do not appear to be any impenetrable, incomprehensible diseases . . . the questions are at last here, and explorations in search of the answers are under way. n The following examples attest to the soundness of that observation. Researchers have developed increasingly detailed "maps" of human chromosomes, which identify the individual sites of the genes responsible for particular genetic defects. Gene mapping has now identified the chromosomal sites for more than 35 such genes responsible for specific genetic disorders, such as sickle cell disease. Several years ago, for example, the site of the defective gene responsible for a common form of muscular dystrophy was pinpointed, thereby setting the stage for efforts to isolate it and to determine the nature of the molecular defect that causes this degenerative disease. Also, a genetic marker closely linked with the gene that causes Huntington's disease has been located on the short arm of human chromosome 4. This landmark discovery is a critical first step toward developing a test for presymptomatic detection of carriers of this fatal, late-onset disorder, and ultimately reducing its incidence. . Progress has been made toward treatment of some of the genetic diseases. Investigations currently underway with respect to the Lesch-Nyhan syndrome presage developments in other areas. Specifically, scientists have recently cloned the gene for HGPRT--the enzyme missing in Lesch-Nyhan--and have injected it into cultures of cells derived from Lesch-Nyhan patients, where the cloned gene corrected the deficient function. Lesch-Nyhan syndrome, which causes severe psychomotor retardation and early death in one of every 50,000 male births, may therefore be the first candidate for gene therapy in humans, with other similar genetic metabolic diseases to follow. As in the case of molecular genetics, the last decade has witnessed a remarkable leap in understanding what receptors do and how they work. Receptor research has

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8 . resulted in rapid and sensitive methods of following drug responses of healthy and diseased cells. Tests based on estrogen receptor determinations provide guides in the selection of alternative treatments for human breast cancers. Receptor studies have already contributed to the development of drugs with psychopharmacologic importance, and of propranolol for the treatment of hypertension. Moreover, the potential exists for a new generation of drugs of natural or synthetic origin that are much more specific in their actions and whose pharmacology will be understood at a molecular level. Concentrated effort on vaccine development is yielding positive results. Scientists have been able to combine vaccinia virus, previously used to immunize against smallpox, with genetic material from hepatitis B virus. This hybrid vaccinia virus has been shown to stimulate in rabbits the production of significant amounts of antibody to hepatitis B antigen. The technique has subsequently been used to combine vaccinia virus with genetic material from influenza virus, from rabies virus, and from genital herpes virus. The prospect of a single recombinant vaccine to protect individuals against many diseases represents an entirely new approach to mass immunization that may have enormous worldwide implications. These examples are only a sample from a broad array of advances in biological sciences. But they indicate that the nation's past investment in biomedical and behavioral research and training has produced a powerful system for the development of these sciences. To maintain the momentum, talented students in universities and professional schools must be attracted to research careers by the provision of continual opportunities for training with established scientists, and adequate research funds must be made available to young investigators at the early stages of their career development. TRAINING AND RESEARCH FUNDING TRENDS Expenditures for the NRSA training programs totaled about $190 million in 1983, or less than 6 percent of the research expenditures of these administering agencies--NIH, ADAMHA, and Division of Nursing, HRSA (Table 1.1~. With the exception of 1973 when funds were impounded, training budgets have fluctuated in a fairly narrow range since 1971 compared with other health expenditures. Consequently, after adjustment for inflation, training funds have declined by almost 6 percent per year since 1971. By contrast, national research expenditures have increased over this period by 3 percent per year, and national health care expenditures by more than 5 percent per year in real terms.

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NIH/ADAMHA/HRSA Expenditures 9 TABLE 1.1 NRSA Training in Relation to Some National Health Expenditures, FY 1971-83 (1972 $, billions Research Training Relative to: National R&D Health Care National R&D Grants Research Nat'l. Health Nat'l. Grants & Fiscal Expenditures Health R&D and Contracts Training Care Expend. Health R&D Contracts Year (1972 $) (1972 $) (1972 $) (1972 $) (%) (%) (%) 1971 87 3.3 1.0 0.18 0.20 5.3 17.0 1972 94 3.5 1.2 0.18 0.19 5.1 15.0 1973 97 3.5 1.1 0.12 0.13 3.5 10.8 1974 100 3.8 1.4 0.18 0.18 4.8 13.1 1975 104 3.7 1.3 0.14 0.14 3.8 10.6 1976 112 3.8 1.4 0.11 0.09 2.7 7.4 1977 119 4.0 1.4 0.10 0.09 2.7 7.5 1978 124 4.1 1.4 0.11 0.08 2.5 7.3 1979 130 4.3 1.6 0.10 0.08 2.4 6.5 1980 140 4.4 1.6 0.11 0.08 2.5 7.1 1981 147 4.4 1.5 0.10 0.07 2.4 6.9 1982 156 4.5 1.5 0.08 0.05 1.8 5.7 1983 165 4.7 1.5 0.09 0.05 1.9 5.8 Annual Growth Rates 1971-83 5.5% 3.0% 3.3% - 5.7% - 10.9% - 8.2% - 8.6% a1972 dollars were obtained by using the U.S. Bureau of the Census Implicit GNP Price Deflator. See Appendix Table B7 for deflator. SOURCE: NIH (1966-84). See also Appendix Table D3. NATIONAL RESEARCH SERVICE AWARDS FOR 1983 AND 1984 In 1983, the three agencies that administer NRSA programs--the NIH, ADAMHA, and Division of Nursing, HRSA--awarded 11,579 full-time training positions under these programs (Table 1.2~. This was slightly lower than the 1982 level of 11,632, and also less than the 12,825 that had been recommended previously by this committee (NRC, 1975-81, 1981 report, p. 20~. The 1983 awards were about equally divided between predoctoral and postdoctoral awards. ~ ~ ~ ~ A small number of undergraduate awards were maue--almost all of them for the Minority Access to Research Careers (MARC) Honors uroaram. ~ ,__,_ An additional 1,518 awards were made in the Short-Term Training Program, primarily to health professional students. Training grant positions far outnumbered fellowships, accounting for over 83 percent of all awards.

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10 TABLE 1.2 Aggregated Numbers of NIH/ADAMHA/HRSA Traineeship and Fellowship Awards for FY 1983 and FY 1984a TOTAL ALL Biomedical Behavioral Clinical Nursing FIELDS Sciences Sciences Sciences Research FY 1983 TOTAL 11,579 6,929 861 3,665 124 Predoctoral 5,207 3,425 408 1,267 107 Postdoctoral 5,915 3,139 373 2,398 5 MARC Undergraduateb 457 365 80 0 12 Trainees 9,711 5,455 758 3,486 12 Predoctoral 5,010 3,363 381 1,266 0 Postdoctoral 4,244 1,727 297 2,220 0 MARC Undergraduateb 457 365 80 0 12 Fellows 1,868 1,474 103 179 112 Predoctoral 197 62 27 1 107 Postdoctoral 1,671 1,412 76 178 5 MARC Undergraduateb 0 0 0 0 0 FY 1984 TOTAL 11,469 6,992 859 3,498 120 Predoctoral 5,096 3,423 391 1,167 115 Postdoctoral 5,912 3,194 382 2,331 5 MARC Undergraduateb 461 375 86 0 0 Trainees 9,578 5,508 753 3,314 3 Predoctoral 4,863 3,339 364 1,158 2 Postdoctoral 4,254 1,794 - 303 2,156 1 MARC Undergraduateb 461 375 86 0 0 Fellows 1,891 1,484 106 184 117 Predoctoral 233 84 27 9 113 Postdoctoral 1,658 1,400 79 175 4 MARC Undergraduateb 0 0 0 0 0 a These are total numbers of awards for traineeships and fellowships. Data on the number of new starts for FY 1983 and FY 1984 are not available. Totals represent full-time positions only and do not include short-term traineeship and fellowship awards. In FY 1983 there were 1,518 short-term traineeships, of which 12 were prebaccalaureate, 1,394 were predoctoral, and 112 were postdoctoral. There were also 6 short-term fellowships, of which 3 were Predoctoral and 3 were postdoctoral. In FY 1984 there were 1,586 short-term traineeships, of which 12 were prebaccalaureate, 1,489 were predoctoral, and 85 were postdoctoral. There were also 4 short-term fellowships, of which 3 were Predoctoral and 1 was postdoctoral. See Tables 1.3 and 1.4 for further detail. b These are prebaccalaureate awards in the Minority Access to Research Careers (MARC) Honors Undergraduate Training Program. See Tables 1.3 and 1.4. SOURCES: Office of the Administrator, ADAMHA (6/15/84 and 6/10/85); Division of Nursing, HRSA (12/14/84); Division of Research Grants, NIH (4123185 and 7129185).

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11 In FY 1984, the number of full-time NRSA training positions totaled 11,469. This was down slightly from FY 1983, almost all of the drop coming in predoctoral awards. MARC Undergraduate awards were practically unchanged from FY 1983, and awards in the short-term training program rose somewhat to 1,586. For both FY 1983 and FY 1984, most of the training positions were allocated to the basic biomedical and clinical sciences, followed by behavioral sciences and nursing research. No awards were made by these agencies in the area of health services research. The actual and recommended distribution of awards by field is shown in the following table: FY 1983 FY 1984 Actual Recommended Actual Recommended . . . Biomedical Sciences 59.8% 58.1% 60.9% 57.9% Behavioral Sciences 7.4% 9.5% 7.5% 9.8% Clinical Sciences 31.7% 27.5% 30.S% 27.4% Nursing Research 1.1% 2.3% 1.1% 2.3% Health Services Research 0.0% 2.6% 0.0% 2.6% . . 100.0% 100.0% 100.0% 100.0% The 1983 and 1984 training awards by field, academic level, and mechanism are shown in Table 1.3 for NIH and in Table 1.4 for ADAMS. Note that these tables show only full-time training positions and therefore are not directly comparable to data in previous committee reports which include trainees in the short-term program. FINDINGS AND RECOMMENDATIONS Previous reports have made recommendations for training levels through 1987. Our recommendations in this report are directed to fiscal years 1988-90. The analyses leading to these recommendations in each major area can be found in subsequent chapters of this report. In general, we find that the NRSA training grants and fellowships are integral parts of the overall biomedical and behavioral research programs in this country and play key roles in maintaining the vitality of those programs. Among this committee's chief concerns expressed in its past reports have been the number of biomedical scientists serving in postdoctoral appointments for prolonged periods and the reduced number of academic positions that would likely result from declining enrollments in the 1980s. Those concerns were reflected in recommendations for a reduction in the number of predoctoral traineeships that should be provided under NRSA programs, and a stabilization of postdoctoral training levels through 1987. But the most recent data available to us indicate that the postdoctoral pool of biomedical scientists is beginning to decline, as is bioscience Ph.D. production. During the next ~ years, a large number of faculty

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13 TABLE 1.4 ADAMHA Traineeship and Fellowship Awards for FY 1983 and FY 1984a Biomedical Sciences TOTAL Total Epidenuolo~ ALL Biomedical Biological and Behavioral Clinical I1ELDS Sciences Sciences Biestatistics Sciences Sciencesb FY 1983 TOTAL 1,106 388 276 112 576 142 P=docto~ 474 181 114 67 253 40 Postdoctoral 547 202 157 45 243 102 MARC Underclad.' 85 5 5 0 80 0 Trainees 957 317 212 105 ' 516 124 Predoctoral 417 152 89 63 226 39 Postdoctoral 455 160 118 42 210 85 MARC Undergrad.` 85 5 5 0 80 0 Fellows 149 71 64 7 60 18 Predoctoral 57 29 25 4 27 1 Postdoctoral 92 42 39 3 33 17 MARC Undergrad.C O O O 0 0 0 FY 1984 TOTAL 1,105 3% 296 100 541 168 Predoctoral 470 194 133 61 217 59 Postdoctoral 540 193 154 39 238 109 MARC Undergrad.C 95 9 9 0 86 0 Trainees 938 315 221 94 ~2 141 Predoctoral 402 162 105 57 190 50 Postdoctoral 441 144 107 37 206 91 MARC Undergrad.C 95 9 9 0 86 0 Fellows 167 81 75 6 59 27 Predoctoral 68 32 28 4 27 9 Postdoctoral 99 49 47 2 32 18 MARC Undergrad.C O 0 0 0 n ~ a These are total numbers of awards for tralneeships and feUowsh~ps. Data on the number of new starts for FY 1983 and FY 1984 are not available. Totals represent full-time positions only and do not include short-tenn tralneeship and fellowship awards. In FY 1983 there were 46 short-tenn tra~neeshipa, of which 12 were prebaccalaureate in behavioral sciences, 5 were Predoctoral in biological sciences, and 29 were postdoetonl (5 in biolo~pcal sciences, 24 in behavioral sciences). There were also 6 short-tenn fellowships, of which 3 were predoc~ (2 in biological sciences and 1 in behavioral sciences), and 3 were postdoctoral (1 each in biological sciences, epidemiology/bhstatistics, and behavioral sciences). IQ FY 1984 there were 22 short-term trameeships, of which 12 were prebaccalaureate in behavioral sciences, S were Predoctoral in biological sciences, and 5 were postdoctoral in biological sciences. There were also 4 short-term feUowships, of which 3 were Predoctoral (2 in by cat sciences and 1 In behavioral sciences), and 1 was postdoctoral in behavioral scienc. b Effete [Y 1981, ADAMHA has been using a different system for classifying their trainees and fellows. In prior years, ADAM reported training in health sernces research but none us clinical sciences. c These are prebaccalaureate awards in the Minority Access to Research Careers (MARC) Honors Undergraduate Research Trading Program. SOURCE: Office of the Ad~nistrstor, ADAMHA (6/15/84 and 6110/85).

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14 members will reach retirement age and consequently the need for young faculty to replace them will begin to increase. In addition, NRSA research training funds have declined since 1974, both in real terms and as a percentage of research expenditures, to a level below that previously recommended by this committee. As a consequence, the number of predoctoral trainees in the basic biomedical sciences supported in 1984 was 11 percent below the committee's recommended level and is on a steep downward slope. We therefore believe that the research training programs should be restored to the recommended number of positions by 1987, and then adjusted to meet the increase in demand expected to begin in the late 1980s. As shown in chapters 2-4, we have made projections of faculty demand under high, best-guess, and low assumptions. The range between the high and low projections in most cases is fairly wide, mainly because of the difficulties inherent in predicting future levels of academic revenues from R and D and other sources. Although we have based our recommendations on our best-guess estimates of expected demand, it must be recognized that these estimates could be thrown off by a number of factors including sudden changes in the hiring practices of universities and professional schools, shifts in federal funding patterns for biomedical research, and more radical revisions to Medicare/Medicaid and other health insurance programs. Our recommendations, based on our best estimates of the market situation expected to prevail in the next five years and considera- tions of how the training system should operate in each area, are presented below. Clinical Sciences The number of full-time NRSA postdoctoral traineeships and fellowships in the clinical sciences (excluding dental clinical research--see below) should gradually be increased from the current level of less than 2,400 to 3,000 by 1990. In order to encourage more talented physicians to undertake research training, 85 percent of these postdoctoral awards should De allocated to M.D.s. Dental research has not kept pace in recent years with remarkable developments in other clinical science sectors. One way to remedy that is to bolster the research training opportunities for entering faculty of dental schools where most dental investigation is conducted. Dental research training levels have fallen precipitously since 1980 and should be strengthened. The number of postdoctoral traineeships and fellowships in dental clinical research should be increased gradually from the 1984 level of about 100 to 320 by 1990. The Medical Scientist Training Program (MSTP), administered by the National Institute of General Medical Sciences (NIGMS), is considered to be one of the most productive mechanisms for training physician-scientists. However, the costs of MSTP as a

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15 share of total NIGMS funds for predoctoral training have been rising steadily. Since continuation of that trend would inevitably weaken the support of regular predoctoral programs, there is an urgent need to curb this growth in costs. To ensure an appropriate balance, we restate our earlier recommendation that MSTP's share over the near future not exceed 25 percent of NIGMS predoctoral training funds, with a target goal of 725 trainees by 1988. We believe that level should be maintained through 1990. 4. We endorse the short-term training program for health professions students and recommend its continuation. This program is designed to introduce students in medical, dental, and other health professions schools to research methods during summer and off-quarters. It provides predoctoral stipends for up to 3 months of support for research training without payback obligation. Minority Access to Research Careers (MARC) Honors Undergraduate Training Program This institutional grant program provides support to third and fourth year honors undergraduates at minority institutions. The program has grown from about 250 traineeships in 1980 to about 470 in 1983. About 75 percent of these positions were in the basic biomedical sciences, 20 percent in behavioral fields, and about 5 percent in nursing research. We recommend that the program be maintained at its current level for the next few years. Basic BiomedicalSciences Since 1980, the number of NRSA predoctoral awards in basic biomedical science fields has dropped by over 12 percent. With about 3,400 positions provided in 1984, the program has fallen well below the committee's recommended level. This program (excluding MARC undergraduate traineeships) should be restored to 3,750 positions in 1988 and then gradually increased to 4,150 awards by 1990.~ 2. Postdoctoral training awards in the basic biomedical sciences should be gradually increased from the 1984 level of about 3,200 to a level of 3,800 by 1990. Win previous reports, awards made in the Minority Access to Research Careers (MARC) Honors Undergraduate Training Program have been counted as predoctoral awards. Starting with this report. awards in that program will be shown separately.

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1 Behavioral Sciences Predoctoral training in the behavioral sciences should be restored to the 1981 level of about 550 traineeships (excluding the MARC undergraduate awards) by 1987 and maintained at that level through 1990. Postdoctoral training in the behavioral sciences should gradually increase to 540 awards in 1987 and then be maintained at that level through 1990. Health Services Research The committee has previously recommended that a modest training program be provided in health services research by the federal agencies under the NRSA authority, and that such authority be extended to the National Center for Health Services Research. In the early 1970s, the federal government provided support to over 800 health services research trainees and fellows per year (NRC' 1975-81~. At present there is no training being provided under NRSA programs that is identified by the federal agencies as health services research. We affirm our previous recommendations that 330 awards be made annually in this area through 1990. Nursing Research Research on problems arising in nursing is supported primarily by the Division of Nursing, HRSA, and to a lesser extent by the NIH, the Veterans Administration, and private organizations such as the American Nurses Foundation and the Robert Wood Johnson Foundation. But practically all training for nursing research is provided by a small NRSA program administered by the Division of Nursing. Funding for training under NRSA programs in the Division of Nursing increased in FY 1985 to almost 82 million, but the number of trainees and fellows supported is still below the level called for by this committee in past reports. Applications for fellowships in nursing research rose 50 percent in FY 1985 and are expected to increase another 30 percent in FY 1986. We recommend that nursing research training under NRSA authority be increased from the 1985 level of about 170 awards to 320 awards by 1990. Table 1.5 summarizes the committee's recommended number of awards by field, academic level, and mechanism for FY 1988-90. The estimated costs for the recommended programs are shown in Table 1.6.

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17 TABLE 1.5 Committee Recommendations for NIH/ADAMHA/HRSA Full-Time Predoctoral and Postdoctoral Traineeship and Fellowship Awards for FY 1988-9Oa Clinical Sciences Fiscal Year Type of Program 1988 TOTAL Total Predoctoral Postdoctoral MARC Undergrad.g TOTAL Basic Medical ALL Biomedical Behavioral Scientist FIELDS Sciencesb Sciencesc Program. 13,035 7,S10 5,470 3,750 7,095 3,400 470 360 1,190 725 550 725 540 0 100 0 200 To 200 o Other Dental Clinical Health Clinical Sciences Services Nursing Research Programs Researche Researchf 2,800 330 280 0 200 245 2,800 130 25 0 0 10 Trainees Total 8,715 4,110 1,030 725 170 2,400 260 20 Predoctoral 5,145 3,750 500 725 0 0 160 10 Postdoctoral 3,100 0 430 0 170 2,400 100 0 MARC Undergrad.g 470 360 100 0 0 0 0 10 Fellows Total 4,320 3,400 160 0 30 400 70 260 Predoctoral 325 0 50 0 0 0 40 235 Postdoctoral 3,995 3,400 110 0 30 400 30 25 1989 TOTAL Total 13,465 7,760 1,190 725 250 2,900 330 310 Predoctoral 5,540 3,800 550 725 0 0 200 265 Postdoctoral 7,455 3,600 540 0 250 2,900 130 35 MARC Undergrad.g 470 360 100 0 0 0 0 10 Trainees Total 8,910 4,160 1,030 725 210 2,500 260 25 Predoctoral 5,195 3,800 500 725 0 0 160 10 Postdoctoral 3,245 0 430 0 210 2,500 100 ~ MARC Undergrad.g 470 360 100 0 0 0 0 10 Fellows Total 4,555 3,600 160 0 40 400 70 285 Predoctoral 345 0 50 0 0 0 40 255 Postdoctoral 4,210 3,600 110 0 40 400 30 30 1990 TOTAL Total 14,195 8,310 1,190 725 320 3,000 330 320 Predoctoral 5,900 4,150 550 725 0 0 200 275 Postdoctoral 7,825 3,800 540 0 320 3,000 130 35 MARC Undergrad.g 470 360 100 0 0 0 0 10 Trainees Total 9,370 4,510 1,030 725 270 2,550 260 25 Predoctoral 5,545 4,150 500 725 0 0 160 10 Postdoctoral 3,355 0 430 0 270 2,-550 100 5 MARC Undergrad.g 470 360 100 0 0 0 0 10 Fellows Total 4,825 3,800 160 0 50 450 70 295 Predoctoral 355 0 50 0 0 0 40 265 Postdoctoral 4,470 3,800 110 0 50 450 30 30 a These are total numbers of full-time awards recommended. 1984. b Recommendations for biostatistics, community and environmental health, and other training fields not specifically shown in this table are included here. c It is assumed that 90% of behavioral science Predoctoral awards will be traineeships and that 80% of postdoctoral awards will be traineeships. These are full-time training positions only, 85% of which should be allocated to physicians. In addition, a program of part- time research training (up to 3 months per year) for health professions students during summer and off-quarters was authorized in 1978, with expenditures not to exceed JO of appropriated training funds. In FY 1983, 1,417 traineeships were made available under this short-term program. e It is assumed that 60% of these health services research awards will be Predoctoral and 40% will be postdoctoral. Of the Predoctoral awards, it is assumed that 80~o will be traineeships. Of the postdoctoral awards, it is assumed that 75% will be traineeships. f It is assumed that 90~o of these nursing research awards will be Predoctoral and 10% will be postdoctoral. g The Minority Access to Research Careers (MARC) Honors Undergraduate Training Program is for prebaccalaureate students. See Table 1.2 for actual numbers of awards made in 1983 and

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18 TABLE 1.6 Estimated Cost of Recommended NIH/ADAMHA/HRSA Training Programs, FY 1988-90 (millions of dollars Clinical Sciences TOTAL Basic Med. Short- Other Health Fiscal Type of ALL Biomedical Behavioral Sci. Term Clin. Services Nursing Year Program FIELDS Sciences Sciences Total Prog. Trainingb Postdoc. Research Research 1988 TOTAL 272.6 137.3 23.2 101.4 13.1 3.2 85.1 6.4 4.3 Trainees 173.1 58.0 19.9 89.8 13.1 3.2 73.5 5.1 0.3 Fellows 99.5 79.3 3.3 11.6 11.6 1.3 4.0 Predoctoral 84.6 54.4 7.4 16.3 13.1 3.2 2.9 3.6 Postdoctoral 183.3 79.3 14.8 85.1 85.1 3.5 0.6 MARC Undergrad.C 4.7 3.6 1.0 0.1 1989 TOTAL 284.9 143.8 23.4 106.4 13.4 3.5 89.5 6.5 4.8 Trainees 180.2 59.9 20.1 94.6 13.4 3.5 77.7 5.2 0.4 Fellows 104.7 83.9 3.3 11.8 11.8 1.3 4.4 Predoctoral 87.6 56.2 7.6 16.9 13.4 3.5 3.0 3.9 Postdoctoral 192.5 83.9 14.8 89.5 - 89.5 3.5 0.8 MARC Undergrad.C 4.8 3.7 1.0 0.1 1990 TOTAL 302.3 155.0 23.7 112.0 13.8 3.7 94.5 6.5 5.1 Trainees 190.9 66.4 20.3 98.6 13.8 3.7 81.1 5.2 0.4 Fellows 111.4 88.6 3.4 13.4 13.4 1.3 4.7 Predoctoral 95.2 62.7 7.8 17.5 13.8 3.7 3.0 4.2 Postdoctoral 202.3 88.6 14.9 94.5 94.5 3.5 0.8 MARC Undergrad.C 4.8 3.7 1.0 - - - 0.1 a Calculations were based on 1984 average cost figures derived from NIH data and assumed the following: 1) a 23.8% increase in Predoctoral stipends and a 36.3% increase in postdoctoral stipends for FY 1985, held constant for later years; 2) a 5% per year increase in tuition; and 3) maximum annual institutional costs of $1,500 for Predoctoral trainees and fellows, $2,500 for postdoctoral trainees, and $3,000 for postdoctoral fellows. The stipend increases became effective in FY 198S. b Estimate assumes 1,500 trainees for 1988, 1,600 trainees for 1989, and 1,700 trainees for 1990. c The Minority Access to Research Centers (MARC) Honors Undergraduate Training Program is for prebaccalaureate students. ESTIMATED TRAINING COSTS PER AWARD IN FY 1984 (dollars) Predoctoral Postdoctoral Prebaccalaureate Clinical Sciences Basic Behav- Med. Short- Health Behav- Health Biomed. ioral Sci. Term Services Nursing Biomed. ioral Clinical Services Nursing FY 1984 Sci. Sci. Prog. Training Research Research Sci. Sci. Sci. Research Research MARC Honors Undergrad. Trainees 12,385 11,579 15,276 1,833 12,385 12,385 22,236 22,425 22,858 22,236 22,236 Fellows 12,385 11,579 12,385 12,385 17,790 18,510 20,473 17,790 17,790 13,948a a This estimate applies to all fields.