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APPENDIX F Summary of Public Meeting, May 10, 1984 The committee held a public meeting on May 10, 1984 to receive comments from the scientific community on issues discussed in the 1983 report. Fifteen witnesses presented statements. Their names and those of the organizations they represented are listed below in order of appearance: Speaker 1. Elizabeth Short 2. Stanley Hazen 3. Emanuel Donchin 4. Michael Pallak 5. Robert Carson 6. Myron Genel 7. William McGivney 8. Barbara Redman 9. Gerald D. Shockman 10. David Rabin 11. Gordon Kaye 12. George Bohrnstedt 13. Matthew J. Freund and Donald W. Light 14. William Jolly 15. John Marshall Organization Association of American Medical Colleges American Association for Dental Research Federation of Behavioral, Psychological and Cognitive Sciences American Psychological Association Council of Graduate Departments of Psychology Association of Program Directors, General Clinical Research Centers American Medical Association American Association of Colleges of Nursing American Society for Microbiology Association of Teachers of Preventive Medicine Association of Anatomy Chairmen Professor and Chairman of Sociology, Indiana University American Association of Colleges of Osteopathic Medicine American Institute of Biological Sciences National Center for Health Services Research Summaries of each presentation are provided below. The complete statement of each speaker is available upon request to the committee. 240

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241 E1 i ~;~h~th Short. Man l. The appropriateness of a market model for estimating demand for researchers requires no justification. It is regrettable, however, that personnel requirements cannot be defined realistically to reflect revolutionary opportunities in biomedical science. The market for basic scientists in clinical departments of medical schools should continue to be monitored closely by the committee. NIH-supported post M.D. trainees/fellows who have not sought faculty positions may be involved in formal clinical trials, and hence, may not have been lost to research. This may account in part for the consistent increase of physician-researchers reported by AMA since 1975. 4. It will become more difficult to project practice income in medical schools, owing to the uncertain impact of the DRG-based prospective pricing system and its extension to non-Medicare beneficiaries. In estimating needs for trainees in the clinical sciences, why not, as a parameter, substitute for the 35 percent of M.D. faculty accessions who have had postdoctoral research training the 63 percent of M.D. faculty shown by the Faculty Roster to be doing at least some (10 percent or more of professional time) research? 6. The committee's suggestions for monitoring the clinical investigator pool,. . . i.e. establishment of a computerized roster. . . seem worthwhile. 7. The use of a 2-year postdoctoral research training period for physicians-scientists in estimating the recommended number of clinical sciences trainees should be reexamined for the 1985 Report. The increasing sophistication of biomedical research would seem to demand a longer apprenticeship. Stanley Hazen, D.D.S. Dr. Hazen lauded the committee's current concern with training needs in dental research. He urged that special consideration be given to the following issues: 1. Extension of eligibility to dental schools to participate in the MST program. 2. Increase of stipends for dental and medical trainees in short-term research training (T-35) programs.

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242 3. Permitting dental students to spread 3-month short-term research training over an entire academic year. 4. Establishment of a 5-year training program to produce dentist-scientists. Emanuel Donchin, Ph.D. 4. The committee's recommendation that the erosion of predoctoral training be halted was strongly endorsed. The Federation hoped that the committee, in the development of future recommendations, would extend the interpretation of its charge beyond a market analysis of the availability of jobs. That emphasis consecrates the status quo, and it provides a poor guide for planning an educational enterprise whose time constant is measured in decades. The committee was asked to undertake a close examination of alternate data bases, with specific emphasis on disaggregating data in order to determine the state of affairs in different disciplines and across different classes of institutions. With respect to levels of quality, he noted that the data on hand aggregate the statistics for all Ph.D.-granting institutions, whereas the bulk of active researchers in the behavioral sciences have been trained in a relatively small number of institutions. The committee should consider the consequences of its recommendations as a critical aspect of its work. Response by NIH/ADAMHA to the recommendations should be carefully monitored. In addition, the agencies, the public, and Congress should be alerted to dangerous trends that may occur as the unintended results of a rigid and inadequately funded implementation of its reports. The Federation pledges its readiness to cooperate in assessing the impact of various training support policies. Michael S. Pallak, Ph.D. . 1. The Association believes that the committee's charge includes a responsibility to inform Congress explicitly regarding the implications for research training inherent in levels of funding below those needed to implement NAS recommendations. Some seven months after release of the 1983 report, the agencies appear to have taken no steps in the direction of making available the 650 predoctoral and 540 postdoctoral awards recommended by the committee in the behavioral sciences field.

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243 3. 4. The estimated number of predoctoral awards available for 1983 was 475, which is far short of the actual number in 1981 (639) and the number recommended for 1987 (650~. The 475 awards, however, include about 100 awards to undergraduate students, which should not be equated with support for predoctoral research training in behavioral sciences. The committee should request that agency data on predoctoral awards be broken down by graduate and undergraduate categories. It was suggested that postdoctoral data provided to the committee by NIH/ADAMHA be arrayed by length of award. An undetermined number of the postdoctoral awardees in 1983 were short-term trainees...i.e., support for a period of three months. Except for the foregoing concerns about implementation, the Association fully supports the committee's 1983 recommendations. Robert Carson Ph.D. Dr. Carson lauded the committee's recommendation for a return to the 1981 level of predoctoral trainees. He suggested the following: 1. Against the certainty of insufficient funds to achieve NAS target figures, the committee nevertheless should set a priority on an immediate increase in predoctoral awards. 2. 3. The Council disparages the committee's reliance on market analysis. Preferably, the committee should attempt to assess personnel needs necessary to exploit knowledge gains in areas that will be important in the future. There is justification for considering psychology separately from other behavioral science disciplines in the committee's analyses and recommendations. Incentives should be provided for Ph.D.s to pursue medical training through a program similar to that of the new Physician Scientist Award. Provision of clinical training for Ph.D.s with backgrounds in behavioral science also merits consideration. Regardless of changes in the number of undergraduate psychology majors, enrollment in psychology courses remains constant. Moreover, the reported decline in majors can be ascribed to the choice of a date for baseline. For example, psychology majors were at an all-time high during the early to mid-70s, owing to "an excessively romanticized humanism" in that era.

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244 Myron Genel, M.D. 1. The committee should pay particular attention to the unique problems and patterns of research and training that pertain to "true'' clinical research....i.e., first two categories in the Landau typology. 2. The committee's recommendations should be interpreted with an awareness that the NIH-IMPAC classification of research with human subjects does not distinguish the subset involving a significant "hands on" physician-subject interaction. 3. The Cuca study in the October 1983 issue of Clinical Research, . which deals with difficulties in obtaining grant support for human subjects research underscores the need for more rigorous training of young physicians embarking upon a research career. The GCRC's Clinical Associate Physician program was described as response to that need. - 4. 5. Also needed are more innovative approaches to research training. For example, programs should incorporate a core curriculum in experimental design, data analysis, computer science, and basic laboratory methods applicable to human subjects studies of almost any kind and subspecialty interest. Also meriting attention in this connection is a new training program at Yale, which is funded by NIADDK and NICHHD. The committee should also monitor the pilot programs at the University of Michigan's School of of Public Health and the Mayo Graduate School of Medicine. 6. The Association will be pleased to share with the committee the conclusions and recommendations emerging from its November 1984 conference on training and sustaining clinical investigators. Among the participants will be Dr. William N. Kelley and Dr. James B. Wyngaarden. William McGivney, Ph.D. Representing the American Medical Association, Mr. McGivney extolled the 1983 Report. He expressed agreement with the recommendations for the basic biomedical and clinical sciences fields, including the committee's observations on employment of bioscientists in the nonacademic sectors. He stressed the role of adequate and long-range federal support as a means of influencing the selection of biomedical research career paths by young scientists. Barbara Redman, Ph.D. - 1. Commends the committee for a comprehensive and useful report. 2. Only a tiny proportion of national expenditures for biomedical research and training is dedicated to research on nursing problems.

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245 Nursing research deals with sleep disruption, pain reduction, and stress management among other things, and has produced findings that have improved patient care while effecting s~gn~r~cant savings. Hospital acquired infections are a substantial health problem. Infection control practitioners (75 percent of whom are nurses) were proven effective in decreasing the occurence of these infections in a recent study. Support for nursing doctoral education is crucial to nursing research. A recent study showed an unmet need for 1,623 doctorally prepared nurse faculty. The number of NRSA fellowships in nursing research should be increased to 500 per year, the number of traineeships for graduate nursing students should be increased, and grants for nursing research should be increased to a comparable level with other types of research. Gerald D. Shockman, Ph.D. 1. Demand data from the survey of the biotechnology industry, cosponsored by the TOM committee and the Congressional Office of Technology Assessment, taken together with NSF data on manpower supply, demonstrate a "current shortage of certain types of biomedical scientists." The same data also justify concern that the shortage will worsen, unless remedial steps are quickly taken. In addition to microbiology/immunology, similar market forces relevant to the new biotechnology are observable in several other biomedical science disciplines..., i.e., cell biology, genetics, biochemistry. 3. The shortages foreshadow harm to research and graduate education in the biomedical sciences, and will ultimately erode the U.S. position in international biotechnology competition. The quality and quantity of faculty required to train a competent work force are points of particular vulnerability. 4. Aside from increases in trainees/fellows at the predoctoral and postdoctoral levels, a major push is called for to enhance the prestige and rewards of academic employment in these fields. Competition for the best minds is not only with the medical schools, but increasingly with industry. Anecdotal "data" suggest that the anticipated demand for appropriate B.S. and M.S. degree holders already equals or exceeds that for Ph.D.s in microbiology/immunology and related areas. The lure of higher salary in industry may be drawing off candidates for doctoral training, including some who have completed one or more years of graduate study.

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246 David L. Rabin, M.D. Dr. Rabin appeared on behalf of the Association of Teachers of Preventive Medicine, an organization of 700 M.D. and Ph.D. faculty in schools of medicine and public health. The Association is concerned with quantity and quality of personnel trained for prevention practice, as well as prevention and public health research, biostatistics, epidemiology, environmental health, and behavioral sciences. He alluded to the shortages of clinical prevention specialists that were projected by GMENAC and to the essentiality of federal support for residency programs. On the basis of data from the National Health Service of Scotland, he pointed to a need for 8,000 medically trained epidemiologists, as against a current supply of 1,000 epidemiologists, less than half of whom are medically trained. While the need for biostatisticians and epidemiologists has been recognized in previous reports of the committee, training support continues to be inadequate. He recommended that a national study be undertaken to define clinical and research needs to attain prevention goals. The results of such a study would facilitate the committee's setting priorities for research training. Gordon Kaye, Ph.D. Dr. Kaye described a continuing shortfall of personnel to fill faculty positions in departments of anatomy. He cited data since 1973, derived largely from the Association's biennial manpower survey, on the disparity between "job seekers" and "available positions." For the remainder of his presentation, he made the following observations. 1. Onerous teaching demands make it difficult for established faculty to keep up to date on research developments and to attract external funds. At the same time, it is difficult to find faculty candidates proficient in cell and molecular biology, who can also teach any of the subjects traditionally taught in anatomy departments. In a related vein, teaching for anatomy faculty in medical schools is no longer restricted to the first year, but now includes electives in the 3rd and 4th years. Also, the development of CAT and NMR scanning, ultrasonic lithotomy, etc., have made teaching in anatomy essential for house staff and clinical faculty. 3. In addition to categorical--predoctoral and postdoctoral-- training grants, there is need for advanced postdoctoral support to permit middle-level faculty to renew their technical armamentarium. A similar support program should be instituted to re-attract individuals, such as women with Ph.D.s, who have left academic employment.

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247 4. Funds should be made available for underwriting a year of full- time research training as part of the residency, rather than merely cutting the number of residency positions in response to changes in the financing of hospital care. The presence of such trainees in basic science departments could notably improve the likelihood of their participation in research, but also would enhance the scope of research in these departments. George W. Bohrnstedt, Ph.D. 1. My concern is that continued cutbacks being made in what are called "teaching costs" associated with training are begining to have a serious negative effect on our ability to do quality research training. In the past five years, the allowance for teaching costs on my training grant has declined from $30,000 to $10,000 per year, with no reduction in number of fellows and faculty participating in the program. 2. The term "teaching funds" is somewhat of a misnomer. These funds are used primarily for research needs of the trainees, e.g., the purchase of computer time, data entry costs, manuscript preparation, travel expenses for consultants, etc. 3. Sponsoring agencies should be advised that the reduction of these funds is likely to have an effect on the quality of research training we are all trying to provide. I believe we should return to a model that allows the applicant to provide and justify a teaching budget that is commensurate with a given research training program's needs. Matthew Freund, Ph.D. Dr. Freund spoke for the American Association of Colleges of Osteopathic Medicine. The 15 member-schools were the locus in 1982 for research totalling $9 million in support (including $6 million in federal funds). In addition, two D.O./Ph.~. training programs and two student summer research fellowship programs are currently active. He recommended that the committee's data base be extended to include information relevant to osteopathic medical schoools, and that representatives from their faculties and administration be considered for future committee and Panel appointments. Donald W. L ia ht. . Ph. D . 1. The committee's projections should transcend the marketplace constraints, particularly with respect to training personnel for health services research. For that field, 2 percent of recommended traineeship/fellowship awards could more reasonably approximate 7 percent. 2. It is important through NRSA to encourage the training of researchers with more applied interests in the clinical and behavioral sciences (underlining supplied).

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248 3. The scope of behavioral science should extend beyond psychology, and the training of behavorial scientists should in many cases take place directly in departments of the primary care specialties. 4. Post-Ph.D. training should increasingly be based on research which involves collaboration with clinicians. In line with trends described in chapter 2, some 12 Ph.D. researchers have been "seeded" in all the major clinical departments of his institution. William Jolly, Ph.D. 1. Inasmuch as undergraduate degrees and graduate enrollment in the biomedical sciences are declining, recruitment of predoctoral trainees should be stepped up, while maintaining current levels of NRSA postdoctoral support. 2. The persistently low unemployment rate for Ph.D. biomedical scientists should be regarded as an indication of continuing demand, despite market shifts between the academic and industrial sectors and among specialties within the two sectors. 3. Manpower shortages in bioprocess engineering are likely to have an important influence on the future development, commercialization, and adoption of biotechnology. 4. In light of the glamour of biotechnology, special efforts will be needed to avert shortages in other biomedical science areas. 5. Overall biomedical Ph.D. production will continue to be closely tied to federal research support levels. John Marshall, Ph.D. 1. The decline in grant support available from the National Center for Health Services Research is not indicative of a decline in the needs for health services research. The staggering growth in the nation's health costs generates a need for conceptual models, technology assessment, innovative methodology, and strategic data collection. 2. The capacity of the health services community to devise effective ways to assess technology, not only clinically, but in terms of costs and relative benefits is in a primitive state. Where will we find the young investigator with apporpriate skills?

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249 3. We are hopeful that the NCHSR will once again be able to sponsor centers of health services research with the aim of bringing together multidisciplinary skills and encouraging new approaches to policy-relevant areas like technology assessment 4. The NCHSR has endeavored to maintain its dissertation grant program and expects to continue to fund at least 20 grants per year. 5. Hard data on health services research personnel are probably among the most difficult to obtain in the health sector. The formation of the Association for Health Services Research provides a focal point for collection of such data.

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