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Conclusions and Observations for Philanthropic Funders Private philanthropy has an important role to play in biomedical research. All interviewees at site visits and recipients of Markey Trust awards noted the enormous benefit of flexible and generous philanthropic awards, funds Mat were not available from other sources. In 2000, 56,582 foundations made grants totaling $27,610,000,000 (Foundation Center, 2002, p. 50~. Grant dollars for medical research were in excess of $842 million dollars in that year, but more dollars might be available if a good case could be made for the value of private invest- ments in biomedical research. Wealthy individuals contributed in addi- tion more than $160 billion in charitable giving in 2001 (AAFRC Trust for Philanthropy, 2002), only a fraction of which went to biomedical research. The Markey Trust is a good example that could be used to encourage additional private contributions in this area. Markey Trust charitable contributions to biomedical research had the following attributes: Awards were restricted to biomedical research and training. Funds were dispersed over a 15-year period in a limited-term trust. Administrative costs were minimized to less than 5 percent of the Trust's total assets, placing most of the dollars into grant making rather than staff monitoring and ongoing program management. Awards were not prescriptive and award administration was flex- ible, leaving institutions and awardees to make such decisions as how to spend funds and the length of time for the award. 35

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36 BRIDGING THE BED-BENCH GAP Awards were not open to all institutions but were restricted to a list developed by the trustees based on their view of the research environ- ments in institutions. These institutions were then invited to apply for General Organizational Grants. Invited proposals were peer reviewed. The Markey Trust adopted a multilayered system to review the General Organizational Grants. First, Markey administrative staff screened the proposals to ensure that they were within the scope of the request, were complete, and were worthy of further consideration. Second, Robert Glaser, the Trust's medical director, reviewed applications to assess the feasibility of the research and the appropriateness of the proposed budget. Finally a panel of renowned scientists, including members of the National Academy of Sciences or the Institute of Medicine, reviewed the applications. In general, award amounts were relatively large so as to produce an impact on institutional behavior, facilitate organizational change, and enable training programs to be established. Long-term viability was the goal, and it was often achieved through the leverage of additional funds from other sources once the Markey seed money was in place. For ex- ample, the first two General Organizational Grants awards were made to the University of California, San Francisco, for $13,750,000 and to Rock- efeller University for $5 million. The training grants awarded to programs to provide research exposure to young physicians were typically $2.5 million. Awards to provide clinical exposure to Ph.D. scientists were somewhat higher, with some awards reaching $5 million. The most innovative programs went to institutions that created new approaches to providing Ph.D.s with experience in clinical research. In the words of Irwin Arias (2003), "1he goal is to have Ph.D. graduates who can function in the interface between basic science and disease and col- laborate with physician-investigators who work in the interface between the patient and basic science." The Committee urges that other private funders consider this as an area for grant making. Evaluation of the projects was complicated by several factors. The Committee found that these programs could not be definitively evaluated because the funded programs did not have similar objectives, approaches, or attributes. Progress reports that were required by the foundation did not have a required format so that the reports were not consistent, vary- ing considerably in length, precision, and amount of detail. Most impor- tantly the programs were not required to track or monitor the progress of trainees beyond the completion of the program so that the lack of out- come data limited the Committee's ability to assess the success of differ- ent training approaches. Future funders of graduate training programs should ensure that a comprehensive program evaluation and prospective

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CONCLUSIONS ED OBSERVATIONS FOR THE PH~HROPIC FUNDERS 37 monitoring of outcomes is part of the overall design of the project. The Committee was, however, able to assess the long-term viability of pro- grams and how the viable programs were funded. Over half of the pro- grams continued operation beyond the five years of Markey funding- three of the six programs that were evaluated at the workshop and two of the three programs whose sites were visited. During these site visits and at the workshop, program staff stressed the importance of large front-end funding to firmly establish the program. Moreover, continuing programs leveraged other sources of funding (e.g., NIH and intramural funds). Listed below are attributes common to many of the strong programs funded by Markey. Most of these elements were identified through the site visits and the workshop that was convened to consider the training programs for Ph.D. students. These observations represent the Commit- tee's observations following an examination of Markey records, the site visits, the workshop, and Committee members' collective experiences and are not based on objective data. All General Organizational Grants recipi- ents were not visited nor were all participants in the workshop. The Committee's observations emphasize the experiences of the recipients whose sites were visited or who attended the workshop. These elements of successful programs may seem almost self-evident and have been iden- tified by other reports, but the Committee believes it is useful to list them to guide future investments in training or organizational change. Leadership. Programs that require collaboration among departments and that bridge the basic and clinical sciences must have strong institu- tional leadership by department chairs and deans to enable organiza- tional change to occur. Mentoring. Successful training is dependent on the presence of excel- lent mentors. Dual mentors (one a basic scientist, the other a clinician scientist) may be crucial for both physicians and Ph.D. scientists who train in translational research. Identification of Candidates. A competitive process and early identi- fication of excellent candidates are essential to recruiting the best trainees. Defined Program. A carefully structured program with attention to elements of training, defined course work, mentoring, networking oppor- tunities, and research experience was found in programs that the Com- mittee considered to be excellent Protected Time for the Physician Trainees. Time must be protected from the additional responsibility of patient care if the physician-scientist is to obtain sufficient training to enable hun or her to compete with their Ph.D. colleagues in research productivity. Sustainability. As expected, training programs that have endured were able to obtain funding to continue from other sources or from their

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38 BRIDGING THE BED-BENCH GAP institutions. For training grants five years of support may not be sufficient time for outcome data to demonstrate the efficacy of the program. Philan- thropies that fund training programs should consider longer periods of support. This could be done by combining large front-end levels of sup- port with partnering with other potential funders from the beginning or by working with the institution on plans for the sustained support of the programs when grant dollars end. Several Trust training programs have been sustained after Markey funds were depleted (e.g., both programs at the University of California, San Francisco; Washington University in St. Louis; and Columbia Univer- sity College of Physicians and Surgeons, all of which tailored their pro- grams to emphasize translational research). lohns Hopkins University developed a new degree program that concentrated on translational re- search and has succeeded in obtaining extramural funding from the NIH. In these four programs the Markey award was a catalyst in changing the focus of training for a cadre of students. Tufts University had established their program in translational research before receiving Markey funding. This program is ongoing and continues to produce scientists versed in disease-oriented research. Funds to sustain these programs have come from different sources. For example, intramural funding is used at Washington University and the programs at the University of California, San Francisco; endowment funds have been channeled into the program at Columbia University; and extramural funding has been obtained by Johns Hopkins University. The Committee recognized that for many of the recipient institutions the Markey award was one of a number of training grants awarded from a wide range of funding sources. When Markey funds were expended and not renewed, the institution turned to other sources to continue the train- ing of graduate students or physicians, in some cases reflecting the new goals of the follow-on funder. The NIH and a number of philanthropic organizations have made major new investments in training and sustaining physician-scientists both to develop new investigators and to retain existing investigators in research. Because these are new programs, no outcome data are available. On the other hand, few if any funders have attempted to support training for Ph.D.s to better translate basic science into clinical applications. Based on the findings above, the Committee can draw several conclu- sions about the operations of the Markey Trust. The terms of Mrs. Markey's will were fulfilled through the vision and focus of the trustees. Over $500 million was distributed to fund bio- medical research in a 15-year period.

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CONCLUSIONS ED OBSERVATIONS FOR THE PH~ANTHROPIC FUNDERS 39 The funds were distributed appropriately for training and organi- zational change. The Markey Trust took funding risks with potential rewards, and many of them paid off in the form of institutional changes and better training opportunities. Concerning me General Organizational Grants program, the Com- mittee simply could not evaluate the General Organizational Grants pro- gram quantitatively in view of the heterogeneity in its central theme and the absence of more stringent reporting of the necessary data. In the fu- ture, funders should build such evaluation processes into their grants. Despite the above limitations, the Committee was strongly of the subjective opinion that this program was an invaluable asset to the par- ticipating institutions.