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APPENDIX D 68 the clinical sciences and health services research have been repeatedly mentioned by previous committees as deserving special attention. These trends seem to indicate chronic shortages, and deserve more attention than they have received to date. STATEMENT BY BRYAN E. MARSHALL, M.D. For approximately 20 years I have been involved in the research training of anesthesiologists at the University of Pennsylvania. A major part of this effort has been as Principal Investigator of a National Institute of General Medical Sciences Grant for Training in Anesthesia Research. The purpose of this grant is to train physician anesthesiologists to become competent researchers by providing 2 years of full time research fellowship after completion of residency and prior to joining a faculty. Our use of this grant has evolved considerably. At its inception 15 years ago, we recruited informally and developed a traineesâ program in our laboratories. Now our advertising, recruitment, and selection process begins 4 or more years before the training starts. Training is rarely conducted in our own laboratories, and the preliminary consideration of course work and practical training is established well before the fellowship begins. The aim is to have the trainee return to the Department to join already established research teams but now bringing a new area of expertise and collaboration to that team. My perspective is therefore drawn from this experience, and is based on research aimed ultimately at clinical problems concerning anesthesiology, intensive care, and pain management. Approximately 80 percent of graduates of this research training program are now on the faculty of major academic institutions, 10 percent are in hospitals affiliated with medical schools and only 10 percent are in private practice. Despite this reasonably successful outcome, I am concerned that many more clinical scientists âslip through our hands.âThe thesis I should like to advance here is that clinical scientists are in short supply, and that the cure for that situation may lie not so much in a broader recruitment effort, but in a serious effort to reduce wastage of potential candidates. Undoubtedly, the pressures on a clinician scientist are great, and it is easy to dismiss the problem of their short supply as there being simply too few such ambitious and multi-talented individuals presenting as potential trainees. Furthermore, although improvements in our educational system would undoubtedly provide a larger pool of candidates, that does not appear to be the major problem except in certain areas. Instead, it is one of wastage of the available candidates. This waste is encountered in three forms. For the research fields of my clinical horizons, the Postdoctoral Research Training Grant is the critical program. The most effective and efficient training for clinician scientists seems to occur when the clinical specialist training has been completed and the purpose and value of further research training is most clearly identified for specific career goals to be achieved. It is precisely at this point, however, that the sources of wastage are encountered. First, a disappointingly large number of highly trained individuals come out of Ph.D. and M.D./Ph.D. programs unsuited to continue research in their chosen clinical specialty. This may be because of disenchantment with attitudes conveyed in the basic science laboratories or because of lack of progress or poorly chosen projects. Not infrequently, the area of research training is very narrow and has no obvious application to problems of clinical relevance. Some may become overwhelmed by the gap between the single-minded concentration of Ph.D. training and the very generality of the M.D training. For those for whom the Ph.D. and postdoctoral training has occurred prior to a full M.D. program internship and residency, the time that has passed away from the laboratory may seem too long and the science that they once knew has advanced too much for them to catch up. In all of these instances, there is either distaste for further involvement in research or reluctance to undergo further research training to correct deficiencies. The outcome is often that the years of special research training are not utilized, and the money and time spent on training is wasted. This will continue as long as the Ph.D. and postdoctoral research training is routinely undertaken prior to completing the M.D. training, and the Ph.D. part of the M.D./Ph.D. program so heavily emphasizes research in pure basic science rather than in partnership with applied scientific disciplines. It is therefore suggested that some NRSA programs be restructured to encourage a full or modified Ph.D. training program for physicians, focused specifically on the development of clinician scientists, and that this be encouraged as a change in attitude in all medical