This study addresses a concern, expressed inside and outside the discipline of obstetrics and gynecology (OB/GYN), that women's health is suffering because of weakness in the research capabilities of academic departments of OB/GYN. This concern often focuses on three indicators of weakness:
the relatively low level of funds that flow from the National Institutes of Health (NIH) to departments of OB/GYN;
the dearth of departments that possess a sufficient cadre of investigators to generate a vital research environment; and
some special characteristics of the discipline, and of the environment in which it operates, that are thought to make it particularly difficult to attract talented individuals into res h careers or to stimulate and sustain research.
There is also a larger fear that important health problems, some of which could potentially be solved with an intensified research effort, are not receiving the research attention they need and deserve. If this were true, it would be reason for concern since research that might be undertaken in these departments has great potential for improving the health of women of all ages and for improving the outcomes of pregnancy. Indeed, this work might have an enormous social impact on present and future generations. A few examples of large-scale problems that could be ameliorated by increased OB/GYN research include the following:
the percentage of infants born weighing less than 2,000 grams, which has remained at about 7 percent through the 1980s;
pregnancy-reduced hypertension that complicates about 2.6 percent of deliveries and increases the risk of poor outcomes for the mother and child;
ectopic pregnancies that have increased every year since 1970 and have a fatality rate of 42 per 1,000 cases;
infertility that affects about 10 percent of married couples who want children; and
an epidemic of sexually transmitted diseases, including 4 million cases annually of chlamydial infection and 24 million people in the United States infected with human papillomavirus, many types of which axe associated with cervical carcinomas and severe dysplasia.
Research that provides solutions or partial solutions to some of these problems has the potential to generate significant reductions in health expenditures. For example, an Institute of Medicine committee1 conservatively estimated that, based on the costs of care in the early 1980s, a reduction in the rate of low birthweight from 11.5 percent to 9 percent just in women aged 15 to 39 years who receive public assistance and who have less than 12 years of education would save $188.2 million in the first year alone. Subsequent heavy health care, education, and other expenditures are incurred to care for the frequent long-term morbidity and disability sequelae of low-birthweight babies.
Origins of the Study
IOM Planning Committee
Questions about the state of research in obstetrics and gynecology (OB/GYN) departments arise in a troubling context: epidemics of sexually transmitted diseases and teenage pregnancy, lagging improvement of infant mortality, and the advent of new reproductive technologies such as in vitro fertilization. This context demands that serious attention be paid to OB/GYN research capabilities.
In 1988, the Center for Population Research of the National Institute of Child Health and Human Development asked the Institute of Medicine (IOM) to convene a committee to assess whether women's reproductive health would be better served if a stronger research base were developed in OB/GYN departments and whether IOM might usefully undertake a study to determine how to strengthen that research base. The planning committee convened by IOM noted the interdependence of several relevant factors: accomplishing needed research depends on the availability of human resources and funding, but generating a cadre of investigators depends on training programs, the quality of
mentors, the alternatives available to potential researchers, and, perhaps most importantly, the funding available to support research careers.
The planning committee examined the problems of a career in academic research, which include the impact of debt accumulated during medical school and specialty training, the financial cost of choosing an academic life, and the difficulties OB/GYN departments experience in finding protected time to allow the transition to independent investigator status. It also found that clinical investigators in OB/GYN must compete for funds with full-time investigators in basic science departments, as well as with clinical investigators in other medical departments. On the topic of funding, the planning committee surmised that the ''relatively sparse'' support OB/GYN receives from NIH might stem from the lack of an institute devoted to OB/GYN research, as well as from the ethical issues raised by some reproductive research.
Finally, the planning committee decided that an important research agenda in OB/GYN exists that is not receiving sufficient attention, and that academic departments of OB/GYN are the appropriate locus of this research. In the current funding climate, however, and with only the existing cadre of OB/GYN investigators, this research agenda is unlikely to receive the attention it deserves. Moreover, the planning committee found strong and widespread disquiet about the state of OB/GYN research, sufficient to conclude that further investigation of the causes and possible ways to improve the situation was justified. Thus, it recommended a full study by IOM.2
The Charge to the Committee
The Committee on Research Capabilities of Academic Departments of OB/GYN was charged with studying the perceived weakness in research and the related shortage of investigators who can build on the successes of the past and contribute to the reproductive sciences in the future. In particular, the committee was asked to determine whether there is an actual as well as a perceived weakness and if so, to identify its causes and potential remedies. To respond to the first part of the charge—determining whether a weakness exists—the committee was also asked to judge whether there was an important research agenda, suited to the unique capabilities of departments specializing in OB/GYN, that currently was not being undertaken. If there was such an agenda, the committee was to describe it. This research agenda would then serve two purposes: (1) to demonstrate that there are promising areas of research whose pursuit is likely to have a beneficial impact on the health of
women and their children and (2) to provide decision makers with guidance for setting priorities for research investments. If the committee found cause for concern about research conducted in departments of OB/GYN, it was to examine factors that could affect the state of research conducted by obstetrician/gynecologists, including
the role of NIH and other funding sources in supporting academic departments of OB/GYN, facilitating research in those departments, and developing high-caliber research personnel;
the career paths of OB/GYN physician investigators; and
the roles of major actors in academic health centers.
This examination was expected to reveal barriers to improvements in research and to result in recommendations by the committee of ways to enhance the research capabilities of departments of OB/GYN.
The Committee's Interpretation of Its Charge
The broadest interpretation of this charge would encompass not only the many areas of research likely to promote women's reproductive health but also those areas relevant to related conditions—for example, postmenopausal neoplasia, which is possibly related to estrogen deprivation—regardless of the academic department in which such work is conducted. At the other extreme, the committee could confine its examination to research performed by physicians certified in the specialty of OB/GYN and conducted in academic departments of OB/GYN. The committee took a middle position, based on the notion that departments of OB/GYN represent the primary locus of research intended to improve women's reproductive health and ameliorate the impact of the many diseases and conditions that affect reproductive organs and that are related to different stages of a woman's reproductive life cycle. Investigators in many academic departments outside of OB/GYN are involved in work that pertains to these topics, but attempting to encompass those investigators and their work in the scope of this study would require careful definition of the research areas to be included, lacking generally accepted, clear-cut boundaries of responsibility, the results of this effort would generate controversy among specialties without clarifying their roles in specific research areas in which overlap appropriately occurs. Many research topics could reasonably be undertaken in departments of OB/GYN or in other departments, but factors such as the greater availability
of particular expertise or of a particular patient population often decree that one department is preferable to another. In this report, "OB/GYN research" means research most advantageously conducted in academic departments of OB/GYN. At the heart of this activity are investigators trained in the specialty of OB/GYN, who often collaborate with investigators from other disciplines and with nonphysician investigators, who bring essential knowledge and techniques to bear on questions that belong in OB/GYN departments.
The committee viewed its charge as encompassing three major tasks:
developing indicators of the research strengths of academic departments of OB/GYN to assess whether a problem exists (Chapter 2);
developing a research agenda for OB/GYN that would both contribute to the resolution of the question of whether a problem in OB/GYN research exists and provide priorities for future research (Chapter 6).
OB/GYN research confronts some difficulties that spring from the particular characteristics of the specialty (such as its surgical and procedural orientation) and its environment. But many of the difficulties are similar or identical to those confronted by any medical discipline that endeavors to generate or sustain a serious clinical research effort. Thus, although the committee did not set out to solve the broader problems of clinical research, its deliberations were illuminated by information about the experience of clinical research in general, and to some extent its analyses and recommendations apply also to other disciplines. In making its recommendations, the committee has tried to take an approach that will help departments of OB/GYN nourish a strong research environment for the future, recognizing that the development of the necessary infrastructure and personnel requires a long-term commitment and cannot be rapidly achieved.
Limits on the Scope of the Study
Many factors impinge on the ability of a discipline such as OB/GYN to develop a research base, including private and federal arrangements for payment for health care, structural issues in the provision of health care, factors relating to the funding of medical schools and their constituent departments, and the content of undergraduate and graduate medical education. The committee
concluded that consideration of such broad factors was far beyond the task with which it had been charged. Similarly, the committee as constituted was not suited to examine structural change at NIH, such as the establishment of a women's center or institute, which would have repercussions beyond the scope of this study. In 1990, NIH instituted the Office of Research on Women's Health, with responsibility for monitoring progress in research on topics pertaining to the health of women. With NIH policies and structure relating to women's issues in a state of flux, recommendations for major structural change would be ill-timed. And because of a lack of adequate evaluations of past and present programs for the training of investigators, the committee was unable to answer important questions on this topic (such as how best to combine clinical skills and basic science training to ensure the maintenance and currency of both areas, or how to prepare investigators to take their place in a modern research environment).
The committee also recognized that a policy study in one area of biomedical research must be conducted with full awareness of the current climate of funding for biomedical research overall, since increased funding for one area may occur at the expense of other areas. However, although the committee's research agenda for OB/GYN stresses the importance of the recommended research advances to solutions of social and health problems and to the health care system, the committee was not in a position to evaluate the potential contributions of one research area compared with another. It therefore determined that such an evaluation was beyond the scope of this study.
There is widespread agreement that current policy, which in effect prohibits the use of federal funds for research on human embryos and fetal tissue, has inhibited advances in OB/GYN research. This has occurred because the major source of investigator-initiated research funding—NIH—is barred from supporting some specific areas of research that would be likely to contribute to the understanding and treatment of infertility, pregnancy loss, developmental disorders, and advances in contraception. To the extent that the policy represents a barrier to progress in OB/GYN research, it is pertinent to this study. For example, funding problems in these research areas are likely to discourage individuals who would otherwise have embarked on a research career in the reproductive sciences. This committee was not constituted, however, for an examination of the complex ethical and social issues related to embryo research, and the topic was therefore determined by the committee to be beyond its brief, apart from noting the negative effect of the policy on OB/GYN research. The significant societal benefits that would result from a resolution of the divisive issues that surround questions of embryo research and use of fetal tissue are laid out in three other Institute of Medicine (IOM) publications.3,4,5
Conduct of the Study
During the course of the study, the committee held four meetings to address the questions posed in its charge. To facilitate its work and make good use of the range of expertise on the committee, the group established two task forces: the Task Force on NIH and the Task Force on the Research Agenda.
To learn about the concerns of the OB/GYN academic research community, the committee sent a letter to the chair of each academic OB/GYN department in the United States and Canada. The chairs were invited to indicate their priority items for an OB/GYN research agenda, to describe difficulties they confront in attempts to develop research activities, and to comment on any other factors they wanted to bring to the attention of the committee. Replies were received from 50 individuals, some of whom responded as representatives of the leading OB/GYN professional societies.
The committee also commissioned background papers to provide analyses of topics of particular interest, two of which are published as appendixes to this report. To add breadth to the material available to the committee, IOM staff undertook a wide range of interviews with individuals in academic departments, funding agencies, and elsewhere. NIH was a major source of data, providing extensive information on applications and awards for research and training support. In addition, interviews with NIH staff contributed to the committee's understanding of structural issues at NIH.
In pursuing these approaches, the committee found that they illuminated not only specific aspects of research in OB/GYN departments but also general concerns about clinical investigation. Such concerns form an integral part of the background of the study and are discussed in the section below.
General Concerns About Clinical Investigation
Several commentators have expressed concern about diminishing interest and participation of physicians in biomedical research.6,7,8 Over a decade ago, one such report opened by saying, "Clear evidence now at hand demonstrates that there has been and continues to be a marked decline in the number of medical students and postdoctoral physician trainees intent upon pursuing careers in investigative medicine."9 This dismay evolved from the joint perception that clinical research is important and that support for such research (and the human resources to conduct it) may not in the future be sufficient, due to problems in recruitment, training, retention, and support of clinical investigators.
Clinical research continues to be important, especially at a time when molecular biology is making impressive advances in understanding biological processes, precisely because clinical research provides the critical link between the new biology and patient care.10,11 Indeed, interdependence of all stages, from untargeted basic research through preclinical to clinical research and the development of medical technologies, makes each part of the process vitally important.12
Because the National Institutes of Health (NIH) is a major source of funds for investigation and training, and because it is the principal source of relevant data, discussion has often focused on the NIH role in support of clinical investigation and how physicians fare in the grant process at NIH.* In 1989, approximately 6.9 percent of the total NIH budget went to clinical trials, up from 5.5 percent in 1981. (These data do not include all clinical research, which can be more broadly defined to include, for example, studies using tissue from human subjects.) This amounted to $487 million in 1989, of which an estimated 14 percent of the total was spent in the NIH intramural program.13 Much of the growth was experienced by the National Institute of Allergy and Infectious Diseases, whose spending on clinical trials rose from $8 million m 1981 to almost $102 million in 1989. Most of this growth occurred after 1985, indicating the large impact of AIDS. Spending on clinical investigation by the National Institute of Child Health and Human Development (NICHD), the principal supporter of OB/GYN research, also grew rapidly—almost fivefold between 1981 and 1989—but started from a low level; by 1989, NICHD was spending $31 million on clinical trials.14
Some but not all studies corroborate the prevailing sense that clinical research grants are less likely than basic research to be funded.15 For instance, a study found comparable award rates for clinical and basic science applications for research project grants submitted between 1980 and 1989.16 It is suggested that investigators are deterred from submitting clinical research applications by their belief that funding is unlikely. Data illustrate a growing discrepancy between the volume of research activity of M.D. and M.D./Ph.D. investigators compared with Ph.D. investigators as measured by RO1 applications (an
imperfect surrogate measure since clinical trials are often funded by other NIH mechanisms).* For instance:
Between 1979 and 1989, the number of RO1 applications from M.D.s and M.D./Ph.D.s increased by 1.5 percent, compared with an increase of 16.3 percent in applications by Ph.D.s.17
The proportion of new rant applications from M.D.s dropped from 27.6 percent of total RO1 applications in 1979 to 25.9 percent in 1989.18 The supply of clinical investigators is also determined in part by the availability of training opportunities and by the ability of the investigator to gain support for subsequent research. The following data indicate relevant trends:
The number of physicians in research training programs sponsored by NIH decreased between 1969 and 1980. Despite growth in the 1980s the number of physicians NIH is able to support either partially or fully is still below the level of the late 1960s and early 1970s.19,20 However, many trainees of the early period did not opt for investigative careers. Because of changes in the programs, such as the introduction of a payback requirement for trainees who do not subsequently engage in research, the retention in research may be higher today.
Ph.D.s supported by NIH fellowship programs or NIH training grants are more likely than M.D.s to apply for research awards. According to a 1986 study, 62 percent of former NIH Ph.D. fellows applied for NIH or ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration) research grants, compared with 43 percent of M.D.s. For former NIH Ph.D. trainees the figure was 52 percent, compared with 17 percent for M.D. trainees.21
However, for the physicians who entered the competition for NIH funds the picture was relatively encouraging—at least compared with Ph.D. scientists. The success rate for research project grants submitted to NIH by M.D.s and M.D./Ph.D.s was slightly higher than the success rate for Ph.D.s in each year
Other data, however, indicate a decreasing, or at best flat, interest in research on behalf of physicians:
After rising from 11,929 in 1970 to 18,535 in 1983, the number of physicians reporting research activity fell to 16,941 in 1989; this represents a decline in the proportion of the U.S. physician population who report that they are engaged in research of from 3.6 percent to 2.8 percent.23,24
Despite possible flaws in data, a 1990 IOM committee concluded that there has been no growth in the number of physicians participating in research in recent years.25 Many factors are proposed as accounting for the diminished interest of physicians in clinical investigation:
the length of training and uncertainties about how best to tram a successful clinical investigator;
the level of debt with which physicians graduate from medical school;
a perceived decrease in the funding of investigation of clinical problems;
perceived instability in funding, which makes a career in research seem an uncertain undertaking;
the lure of more highly paid clinical practice;
pressures on academic departments to produce clinical practice revenues;
the inability of academic departments to nurture clinical investigators;
multiple demands on academic health center resources, which make it difficult to obtain the funds needed to protect the time of clinical investigators; and
the reluctance of third-party payers to pay the costs of care for patients participating in clinical research protocols.
Many of these factors have become more acute in recent years. The training of today's clinical investigator has of necessity become intense and extended, as vividly described below:
Without substantial postgraduate training in the biological sciences, the modern physician cannot readily enter the arena of sophisticated and competitive biological research. Since the clinical training of a physician is so intense, developing the skills that are necessary for an investigational career in biomedical research has also become very difficult. A fear of the laboratory often arises in young physicians who are long removed from working in a research laboratory or who have never been exposed to such work. Threatened with the loss of highly polished clinical skills and the prospect of isolation from the familiar clinical environment, these physicians are reluctant to enter laboratory research. Subspecialty fellowship training ought to provide an opportunity for research, but unfortunately the laboratory experience in most fellowships tends to be narrow, is usually focused on a single technique, and does not offer the broad-based kind of training in biomedical research that is necessary to encourage physicians to pursue a research career. Those who are willing to obtain in-depth training in the biomedical sciences must therefore turn to basic science departments. This in itself poses a threat and acts as a deterrent to most physicians considering a career in investigation.26
In the face of such obstacles, it is surprising that a large and increasing proportion of medical school seniors have indicated that their first choice of career would be as full-time academic faculty, teaching and conducting clinical research. The proportion indicating such interest has risen from 21.5 percent of respondents in 1981 to 28.8 percent in 1990.27,28 Unless attitudes to research and to financial rewards are changing, these data suggest that many of the deterrents to an investigative career take hold at a later stage. Perhaps the full impact of repaying educational debt does not come until after medical school is completed. Or perhaps a physician does not face the opportunity cost of an academic research career until confronted with the reality of supporting a family.
In addition to the years of clinical training, most physicians will require additional years of research training and education in basic science to enable them to compete for funds with Ph.D. Investigators.
It is imperative that the serious physician/scientist receive training in depth m a scientific discipline relevant to medicine. It is both inaccurate and arrogant to assume that the intensive professional training of a physician prepares him or her to compete in modern science with a scientist who has undertaken the rigorous discipline of a Ph.D. degree.29
Programs that have been established to prepare physician/scientists include the Physician-Investigator Fellowship Training Program in the Department of Medicine at the University of Pittsburgh School of Medicine and many similar programs; the Reproductive Scientist Development Program supported by NIH and private funds; federal and nonfederal M.D./Ph.D. programs; and NIH intramural positions and extramural training awards—particularly the Physician Scientist Award. However, there is no consensus on the best model for training physician/scientists, either in terms of preparing them to become competitive or in terms of efficiency—that is, maximizing the proportion of trainees who go on to productive careers in investigation. James Wyngaarden, former director of NIH, has acknowledged the problem in relation to NIH-sponsored training programs, which have variable success rates.30
Even after completing the formal training period, the potential investigator still needs support. To develop from research trainee to independent investigator requires time "protected" from the demands of teaching or clinical obligations. The academic department must in effect invest in the young investigator to ensure sufficient protected time. In a survey of young physician investigators, however, clinical and administrative activities were second only to lack of funding as factors that interfere with the performance of research, and lack of institutional support was felt to be a greater problem than the distraction of teaching duties.31 The importance of this support in allowing the investigator time to mature is revealed by NIH grant data: in the 1980s, the success rate for first-time applicants was relatively stable at just under 30 percent, but with repeated applications, 50 percent of applicants won awards.32 A department chair can thus expect that protecting the time of two new investigators to allow them to submit repeated applications will bring in, on average, one award.
Funding this protected time is increasingly difficult, however. Medical schools have become more dependent on service income, which in 1988–1989 repented 43 percent of revenues, compared with 12 percent in 1970–1971.33 But without sufficient protected time, the investigator finds it difficult to write
grant applications and pursue serious investigation, a situation that can discourage even those physicians who have completed research training and started on the road of investigation. As current NIH director Bernadine Healy has noted:
Teaching, research and practice are in aggregate the triple mission of the medical school, but the demands on the individual to be all three, the ''triple threat,'' must be questioned. As science grows more complex and practice more demanding, the individuals should be allowed to choose which of the three missions to uphold and should be appropriately secured and rewarded for doing that one mission well.34
Beliefs About Research and Academic Departments of OB/GYN
Departments of OB/GYN share many of the problems in generating research that confront most clinical departments, but there is also a sense that many of these problems are more acute in OB/GYN than in other specialties and that certain barriers unique to OB/GYN research compound these problems. Letters to the committee from chairs of OB/GYN departments reveal that they feel that they operate in an environment that is particularly discouraging to research. For example, several chairs felt that OB/GYN faculty must contribute relatively large amounts of time to clinical work to generate the income needed to sustain department and faculty salaries. This load is believed to be especially heavy in OB/GYN for several reasons:
the need to generate sufficient service income to cover the high salaries needed to attract to academia individuals whose earning potential in practice is large;
the high uncompensated care load borne by obstetrics; and
high malpractice premiums.
When the earning capacity of each faculty member is important, these factors hinder the ability of a department to develop young investigators and to support mature investigators between grants or during fallow periods, when writing grant applications takes priority.
Departmental chairs also mentioned some special problems faced by OB/GYN in competing for NIH funds. Without an NIH institute whose primary mission is the furtherance of OB/GYN research, OB/GYN lacks an institutional
focus at NIH. And within NICHD, the prime funder for OB/GYN research, there are few individuals who are specialists in the discipline. This fosters a feeling that OB/GYN research lacks supporters at NIH and, until recent months, in the Congress, too—the latter being a very significant body in determining NIH priorities. In addition, many believe that NIH study sections (which review grant applications) are not only biased against clinical research in general, but lack sufficient OB/GYN representation. OB/GYN representatives are also care on the councils that advise the various institutes.
In short, there is a feeling that it is particularly difficult to generate interest in a career in OB/GYN research and that individuals who desire such a career confront special problems. Few role models are available to stimulate interest in research; only a small number of the nation's academic departments of OB/GYN have the critical mass of researchers needed to engender a lively research ethos. The prolonged, clinically focused residency and subspecialty training periods are thought to deter the would-be investigator and impede the acquisition of scientific knowledge and research skills. Finally, the lack of federal funding for fetal research is thought to both curtail OB/GYN research activities and act as a deterrent to the pursuit of investigative careers in this area. This report will assess the reality of some of these perceptions, which are listed here to indicate the prevailing thoughts and perceptions that lie behind this study.
1. Institute of Medicine. Preventing Low Birthweight, Washington, D.C.: National Academy Press, 1985.
2. Institute of Medicine. Research Capabilities of Obstetrics and Gynecology. Report of a Planning Committee of the Institute of Medicine. Washington, D.C.: National Academy of Sciences, 1989.
3. Institute of Medicine. Medically Assisted Conception: An Agenda for Research. Washington, D.C.: National Academy Press, 1989.
4. Institute of Medicine. Science and Babies: Private Decisions, Public Dilemmas. Washington, D.C.: National Academy Press, 1990.
5. Institute of Medicine. Biomedical Politics, ed., Kathi E. Hanna. Washington, D.C.: National Academy Press, 1991.
6. Wyngaarden, James B. The Clinical Investigator as an Endangered Species. New England Journal of Medicine 1979; 301:1254–59.
7. Association of American Medical Colleges. Clinical Research Manpower. The Report of the Ad Hoc Committee on Clinical Research Training. Washington, D.C.: Association of American Medical Colleges, 1980.
8. Healy, B. Innovators for the 21st Century: Will We Face a Crisis in Biomedical-Research Brain Power? New England Journal of Medicine 1988; 319:1058–64.
9. Association of American Medical Colleges. Clinical Research Manpower. The Report of the Ad Hoc Committee on Clinical Research Training. Washington, D.C.: Association of American Medical Colleges, 1980.
10. Kelley, William N. Are We About to Eater the Golden Era of Clinical Investigation? Presidential Address before the Sixtieth Annual Meeting of the Central Society for Clinical Research. Chicago, Illinois, November 13, 1987. The Journal of Laboratory and Clinical Medicine 1988; 111(4):365–370.
11. Thier, Samuel O. Clinical Investigation in the 1980s: Perspective from the Medical School. Clinical Research 1980; 28:248–251.
12. U.S. Congress, Office of Technology Assessment. Impact of Randomized Clinical Trials on Health Policy and Medical Practice . OTA-BP-H-22. Washington, D.C.: Government Printing Office, August 1983, p.4.
13. Kahan, James P., et al. The Decision to Initiate Clinical Trials of Current Medical Practice. Prepared for the National Center for Health Services Research and Health Care Technology Assessment; R-3289-NCHSR. Santa Monica, Calif.: The RAND Corporation, September 1985, p. 14.
14. National Institutes of Health. NIH Data Book 1990. NIH Publication No. 90-1261. Bethesda, Md.: National Institutes of Health, September 1990.
15. Cuca, J. A. Scientific, Social, end Other Factors in the Evaluation of Applications for NIH Research Grants. Unpublished doctoral dissertation, The Catholic University of America, Washington, D.C., 1990, pp. 36–37.
16. Vaitukaitis, Judith L. The Future of Clinical Research. Clinical Research 1991; 39(2):145–156.
17. National Institutes of Health. DRG Peer Review Trends. Workload and Actions of DRG Study Sections 1979–1989. Bethesda, Md.: Statistics and Analysis Branch, Division of Research Grants, p. 65.
18. Ibid., p. 67.
19. National Research Council/Institute of Medicine. Biomedical and Behavioral Research Scientists: Their Training and Supply. Vol. 1: Findings. Washington D.C.: National Academy Press, 1989, p. 43.
20. National Institutes of Health. NIH Data Book 1990. NIH Publication No. 90-1261. Bethesda, Md.: National Institutes of Health, September 1990.
21. National Research Council/Institute of Medicine. Biomedical and Behavioral Research Scientists: Their Training and Supply. Vol. 1: Findings. Washington, D.C.: National Academy Press, 1989, p. 72–73.
22. National Institutes of Health. Extramural Trends FY 1980–1989. Bethesda, Md.: Information Systems Branch, Division of Research Grants, 1990, p. 51.
23. Institute of Medicine. Funding Health Sciences Research: A Strategy to Restore Balance, ed. Floyd Bloom and Mark Randolph. Washington, D.C.: National Academy Press, 1990.
24. Roback, Gene, et al. Physician Characteristics and Distribution in the U.S. Department of Physician Data Services, Division of Survey and Data Resources. Chicago, Ill.: American Medical Association, 1990.
25. Institute of Medicine. Funding Health Sciences Research: A Strategy to Restore Balance, ed. Floyd E. Bloom and Mark A. Randolph. Washington, D.C.: National Academy Press, 1990.
26. Levey, Gerald S., Lehotay, Denis C., and Dugas, Marcus. The Development of a Physician-Investigator Training Program. Sounding Board. New England Journal of Medicine 1981: 305(15):887–889.
27. Association of American Medical Colleges. AAMC Data Book. Statistical Information Related to Medical Education. Washington, D.C.: Association of American Medical Colleges, January 1990.
28. Association of American Medical Colleges. 1990 Graduation Questionnaire Results. Washington, D.C.: Association of American Medical Colleges, 1991.
29. Smith, Lloyd H., Jr. Training of Physician Scientists. In Biomedical and Behavioral Research Scientists: Their Training and Supply. Vol. 3: Commissioned Papers. National Research Council/Institute of Medicine. Washington, D.C.: National Academy Press, 1989.
30. National Research Council/Institute of Medicine. Biomedical and Behavioral Research Scientists: Their Training and Supply. Vol. 1: Findings. Washington, D.C.: National Academy Press, 1989, p. 76.
31. Cohen, Richard A. Ensuring the Future for Physician Investigators. Presented at the Association of American Medical Colleges Spring Meeting, March 26, 1991, Savannah, Georgia.
32. The Scientist. Rejected NIH Applicants Should Keep Trying. The Scientist, October 17, 1988.
33. Association of American Medical Colleges. U.S. Medical School Finances 1988–89. Section for Operational Studies. Washington, D.C.: Association of American Medical Colleges, July 1990.
34. Healy, Bernadine. The Human Factor at the Endless Frontier. Circulation 1989; 79(4):965–959.