1
Context and Issues

STUDY CONTEXT AND HISTORICAL DEVELOPMENTS

Advances in biomedical, clinical, and behavioral research have significantly contributed to increased human life span and well-being over the past century, and the support and guidance of the National Institutes of Health (NIH) has had a significant role in enabling this research. Among the major benefits of this research have been vaccines for polio, measles, mumps, Streptococcal pneumonia, Hemophilus meningitis, and a host of other infectious diseases; insulin treatment for diabetes and sophisticated instruments for monitoring glucose levels in the blood; medications to control blood pressure and serum cholesterol; medical and surgical procedures for the treatment of heart disease, including cardiac valve and whole organ transplants; antiretroviral drugs for the treatment of AIDS; and increasingly successful treatments for cancer. The successful completion of the Human Genome Project has led to a plethora of new insights and experimental strategies for understanding major, chronic human diseases at the most fundamental levels and has led to continuously growing numbers of diagnostic tests based on genome, proteome, and metabolome arrays as well as to new types of powerful and targeted treatments. These advances are already transforming our understanding of human physiology and pathophysiology and redefining with far greater specificity and precision our understanding of, and approaches to, complex human diseases. Not only are these advances transforming the practice of medicine, but also they have enabled new, quantitative whole-organism approaches to the study of health and disease by providing the scientific and technological foundation for the burgeoning new discipline of systems biology.

The behavioral and social sciences in recent years have benefited from a tremendous leap in the sophistication of methods and tools, leading to a realistic expectation that useful and effective answers to fundamental questions central to disease prevention and health promotion will result from investing in research training in these areas. At the level of human behavior, the behavioral and social sciences produce knowledge about health issues such as drug and alcohol abuse, obesity, violent behavior, smoking, maintenance of drug treatment regimens, stress management, ability to cope with illness, and health decision-making. At the level of society, the economics of maintaining health and delivering health care can significantly benefit from the research that is carried out in this area.

As these sciences have been maturing, our society has come to realize the absolute necessity of the research findings they produce for the understanding and the treatment and prevention of its health problems. To capitalize on these often-transformational changes requires a highly trained work force that is capable of contributing in increasingly multidisciplinary teams that span scientific domains from biology, chemistry, and physics to engineering, informatics and mathematics. Continuing to invest in the training of this workforce is to invest in the health and well-being of this country.

RESEARCH TRAINING AT THE NATIONAL INSTITUTES OF HEALTH

The history of clinical and research training at the NIH dates back to the naming of the NIH in 1930, when Congress also authorized the first research fellowships in the biological and medical sciences. The ensuing decades have witnessed dramatic growth not only in the NIH budget but also in the number of institutes, the disciplines encompassed, and the mechanisms for funding. From 1975 to 2008 the National Research Service Award (NRSA) program has provided traineeship and fellowship support at the predoctoral level for about 40,000 graduate students in the biomedical, behavioral and social, and clinical sciences. At the postdoctoral level, during this period about 31,000 trainees and fellows were supported across the same broad fields.



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1 Context and issues Study CoNteXt aNd hiStoriCal develoPmeNtS investing in research training in these areas. At the level of human behavior, the behavioral and social sciences produce Advances in biomedical, clinical, and behavioral research knowledge about health issues such as drug and alcohol have significantly contributed to increased human life span abuse, obesity, violent behavior, smoking, maintenance of and well-being over the past century, and the support and drug treatment regimens, stress management, ability to cope guidance of the National Institutes of Health (NIH) has with illness, and health decision-making. At the level of had a significant role in enabling this research. Among the society, the economics of maintaining health and delivering major benefits of this research have been vaccines for polio, health care can significantly benefit from the research that is measles, mumps, Streptococcal pneumonia, Hemophilus carried out in this area. meningitis, and a host of other infectious diseases; insulin As these sciences have been maturing, our society has treatment for diabetes and sophisticated instruments for come to realize the absolute necessity of the research find- monitoring glucose levels in the blood; medications to ings they produce for the understanding and the treatment control blood pressure and serum cholesterol; medical and and prevention of its health problems. To capitalize on these surgical procedures for the treatment of heart disease, includ- often-transformational changes requires a highly trained work ing cardiac valve and whole organ transplants; antiretroviral force that is capable of contributing in increasingly multi- drugs for the treatment of AIDS; and increasingly success- disciplinary teams that span scientific domains from biology, ful treatments for cancer. The successful completion of the chemistry, and physics to engineering, informatics and math- Human Genome Project has led to a plethora of new insights ematics. Continuing to invest in the training of this workforce and experimental strategies for understanding major, chronic is to invest in the health and well-being of this country. human diseases at the most fundamental levels and has led to continuously growing numbers of diagnostic tests based reSearCh traiNiNg at the on genome, proteome, and metabolome arrays as well as NatioNal iNStituteS of health to new types of powerful and targeted treatments. These advances are already transforming our understanding of The history of clinical and research training at the NIH human physiology and pathophysiology and redefining with dates back to the naming of the NIH in 1930, when Congress far greater specificity and precision our understanding of, and also authorized the first research fellowships in the biological approaches to, complex human diseases. Not only are these and medical sciences. The ensuing decades have witnessed advances transforming the practice of medicine, but also they dramatic growth not only in the NIH budget but also in the have enabled new, quantitative whole-organism approaches number of institutes, the disciplines encompassed, and to the study of health and disease by providing the scientific the mechanisms for funding. From 1975 to 2008 the National and technological foundation for the burgeoning new disci- Research Service Award (NRSA) program has provided pline of systems biology. traineeship and fellowship support at the predoctoral level for The behavioral and social sciences in recent years have about 40,000 graduate students in the biomedical, behavioral benefited from a tremendous leap in the sophistication of and social, and clinical sciences. At the postdoctoral level, methods and tools, leading to a realistic expectation that use- during this period about 31,000 trainees and fellows were ful and effective answers to fundamental questions central supported across the same broad fields. to disease prevention and health promotion will result from 

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0 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES BoX 1-1 research training at the National institutes of health The origins of research training at NIH date to 1930, when the Ransdell Act changed the name of the Hygienic Laboratory to the National Institute of Health (a single institute at that time) and authorized the establishment of fellowships for research into basic biological and medical problems. While the harsh economic realities of the Great Depression imposed constraints, this legislation marked a new commitment to public funding of medical research and training. The National Cancer Act of 1937, which established the National Cancer Institute (NCI) within the Public Health Service (PHS), funded the first training programs targeting a specific area. This legislation supported training facilities and the award of fellowships to outstanding individuals for studies related to the causes and treatment of cancer. In 1938, 17 individuals received fellowships in cancer-related research fields, such as biochemistry, physiology, and genetics. NCI became part of NIH with the passage of the Public Health Services Act of 1944—the legislative basis for NIH’s wartime and postwar expansion of research and training programs and, more generally, for a major federal commitment to support biomedical research. This expansion was supported by legislative actions that converted existing divisions within NIH to institutes and centers and the establishment of new institutes or centers, each with field-specific training and research missions. In particular, the first of these laws—the National Heart Act of 1947—established the National Heart Institute and changed the name of the National Institute of Health to the National Institutes of Health. Throughout the 1940s, 1950s, and 1960s there was substantial growth in the NIH budget, with annual increases averaging 40 percent from 1957 to 1963 (with dollar increases ranging from $98 million to $930 million). This funding raised the number of grants to academic institutions and enabled greater federal assistance in both the construction of research facilities and the establishment of fellowship and training programs for research personnel; it even allowed for limited investment in the support of research in foreign countries. The growth in research and training support slowed in the late 1960s, to about 6 percent annually, with a consequent decline in the number of research grants, both foreign and domestic, and a curtailment of facilities construction. Support in the 1970s reflected public and congressional interest in specific diseases. Legislation provided increased funding for such research areas as cancer and pulmonary and vascular disorders, and the eleventh institute on the NIH campus, the National Institute on Aging (NIA), was estab- lished in 1974. The NIA also brought a new perspective to NIH in that it was authorized to support not only biological research but also social and behavioral research. While funding for research in targeted areas was welcomed at NIH, this also meant that research in less visible areas tended to decline. Institutes such as the National Institute for General Medical Sciences and the National Institute of Allergy and Infectious Diseases saw annual average reductions of about 10 percent. By the early 1970s, training support was authorized through the different institutes and centers by 11 separate pieces of legislation. However, in its fiscal year 1974 budget recommendations, the administration proposed the phasing out of research training and fellowship programs over a five-year period by making no new awards and honoring only existing commitments. The reasons it cited for this proposal were that the need for such programs and the manpower trained by them had never been adequately justified, people trained in these programs earned incomes later in life that made it reasonable to ask them to bear the cost of their training, large numbers of those trained did not enter biomedical research or continue their training, alternative federal programs of support for this training were available, and the programs were not equitable because support was not available equally to all students. The administration’s proposal met with virtually universal opposition by members of the nation’s biomedical research community. As a result, the administration revised its position and proposed a new, but smaller, fellowship program at the postdoctoral level. This proposal also met with objections, and in 1974 Congress enacted the National Research Act (P.L. 93-348), which amended the Public Health Services Act by repealing existing research training and fellowship authorities and consolidating them into the National Research Service Award (NRSA) program. The legislation authorized sup- port for individual and institutional training grants at the predoctoral and postdoctoral levels, with the stipulation that an individual could be supported for no more than 3 years. Moreover, to safeguard against some of the cited abuses of the former programs, it restricted training support on the basis of subject-area shortages and imposed service obligations and payback requirements. In the years since the National Research Act was signed, the law governing the NRSA program has been modified several times in order to include new areas of research training and to establish funding levels for selected disciplines. The first change came in 1976, when Congress extended the program to encompass research training in nursing. Then, in 1978, Congress expanded the NRSA program to cover training in health services research. In 1985 the program was enlarged once again to include training in primary care research. Specific funding targets for training in health services and primary care research were established with the Health Research Extension Act of 1985, when Congress required that 0.5 percent of NRSA funds be allocated to each of the two fields. The same law directed that funds for training in health services research be administered by the Agency for Health Care Policy and Research and its successor, the Agency for Healthcare Research and Quality. Research training in primary care originally came under the purview of NIH but in 1988 was delegated to the Health Resources and Services Administration by Congress after concerns were raised that NIH was interpreting the meaning of “primary care” too broadly. Funding levels for training in health services and primary care research were increased to 1 percent of the NRSA budget with the passage of the NIH Revitalization Act of 1993, and these two fields remain the only ones for which specific funding levels have been established by law. SOURCE: NRC. 2005. Advancing the Nation’s Health Needs: NIH Research Training Programs. Washington, DC: The National Academies Press, pp. 5-7.

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 CONTEXT AND ISSUES Career development Programs more likely both to publish and to apply for and receive grants from the NIH.1 Graduates from a non-MSTP dual-degree pro- While the education and training of graduate students and gram were also found to be highly productive. postdoctoral fellows prepares individuals to do research, the Most recently, a report by Brass et. al. has provided strong NIH recognized the need for programs that would help such evidence for the success of this approach in supplying a individuals go on to establish strong and productive research dedicated and well trained cadre of clinician biomedical sci- careers. In the 1980s they initiated programs (the K awards) entists.2 This report examined the graduates of 24 M.D./Ph.D. to facilitate the transition from trainee to research scientist programs including 4 that were not receiving NIH MSTP and to give established scientists the opportunity to pursue support. Twenty of the programs were among the 42 receiving new research directions. These programs had two goals: MSTP support. Their finding that 82 percent of the program (1) to provide Ph.D. scientists with the advanced research graduates are doing research and have funding is consistent training and additional experiences needed to become inde- with that of the NIH study of MSTP graduates. An important pendent investigators, and (2) to provide holders of clinical observation was that program graduates pursue a broad range degrees with the research training needed to conduct patient- of research areas and that many are conducting translational oriented research. and patient-oriented research as well as basic research. Already such individuals are making major contributions dual degree training both in terms of new discoveries and also in infusing research strength into major clinical departments in medical schools The Medical Scientist Training Program (MSTP) was across the country. By any criteria this program can now be established by the National Institute of General Medical judged a success. In Chapter 3 we recommend an expansion Sciences (NIGMS) in 1964 to fund research training lead- of the program and encourage that it be diversified to a degree ing to the M.D./Ph.D. degree in order to better bridge the into non-bench-oriented disciplines. gap between basic science and clinical research.. Graduates complete the dual degree in about 8 years. Composing only minority Programs at the Nih about 2.5 percent of medical school graduates, M.D./Ph.D.s annually receive about 33 percent of the NIH grants made NIH has been active in the recruitment of underrepresented to physician-scientists—attesting to their impressive level minorities into careers in research for nearly 40 years, work- of research productivity. Indeed, by 2004 the number of ing through a constellation of support mechanisms targeted first-time M.D./Ph.D. applicants for NIH R01 grants approxi- at specific populations under the Minority Access to Research mately equaled the number of M.D. first-time applicants Careers (MARC) program and the Minority Biological even though the total populations of M.D.s and M.D./Ph.D.s Research Support (MBRS) program. are vastly different. In 2009, 10.5 percent of tenured or Both the MARC and the MBRS programs are housed in tenure-track faculty held dual degrees, and they made up NIGMS, which encourages cooperation with the other parts 11.1 percent of the clinical department faculty and 8.7 per- of the institute and regularly promotes MARC and the MBRS cent in basic sciences department faculty. program activities through conferences and other events. In The dual-degree program started in 1964 with three M.D./ addition, there are special initiatives that promote training Ph.D. programs—at the Albert Einstein College of Medicine, and career development for minorities, such as the Bridges Northwestern University, and New York University—with 66 to the Doctorate Program, which provides support to institu- trainees; by 2009 the program had grown to include more tions to help students make the transition from master’s to than 2,000 M.D./Ph.D. trainees at more than 75 institutions Ph.D. programs. Minority graduate students working toward nationwide, supported by a complex mix of federal plus the Ph.D. or M.D./Ph.D. degree are also supported through diverse institutional and extra-institutional funding sources. the MARC program by F31 fellowship awards. The full MSTP graduates receive training in a diverse set of fields, range of minority programs for graduate students and post- including not only the biological sciences but also the chemi- doctorates housed in NIGMS and other institutes is described cal and physical sciences, social and behavioral sciences, in detail in Chapters 4 and 5 of the 2003 National Research economics, epidemiology, public health, computer science, Council (NRC) report3 Assessment of NIH Minority Research bioengineering, biostatistics, and bioethics. and Training Programs, Phase . Although the fact that the program is expensive has repeat- edly led to concerns about whether it is justified in terms of the overall outcome, several reports suggest that the MSTP has National Institute of General Medical Sciences, 1998. Available at 1 delivered on its promise to create a strong workforce of physi- http://publications.nigms.nih.gov/reports/mstpstudy/. Brass, L. F., M. H. Aabas, L. D. Burnley, D. M. Engman, C. A. Wiley, 2 cian scientists. In 1998 NIGMS published a matched sample and O. S. Andersen. 2010. Are MD-PhD Programs Meeting Their Goals? An study that compared individuals who completed a MSTP pro- Analysis of Career Choices Made by Graduates of 24 MD-PhD Programs. gram with those who had an M.D., Ph.D., or M.D. /Ph.D. from Academic Medicine 85(4):692-701. a non-MSTP program and found that MSTP recipients were NRC. 2005. Assessment of NIH Minority Research and Training Pro­ 3 grams, Phase . Washington, DC: The National Academies Press.

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES BoX 1-2 history of minority Programs at the Nih In 1972, at about the same time that the NRSA program was established, the Minority Schools Biomedical Support program—under the admin- istration of the NIH Division of Research Resources—began awarding grants to faculty and students at minority institutions. That same year research awards were made to minority faculty under the Minority Access to Research Careers (MARC) Visiting Scientist and Faculty Fellowship program, and in 1974 MARC was officially established within NIGMS as a formal program to stimulate undergraduates’ interest in biomedical research and to assist minority institutions in developing strong undergraduate curricula in the biomedical sciences. In 1977 the MARC Honors Undergraduate Research Training (HURT) program was established, and in 1981 the MARC Predoctoral Fellowship program was created to provide further incentive for gradu- ates of the HURT program to obtain research training in the nation’s best graduate programs. These programs continue today with some modifications, such as the replacement of the MARC HURT program with the MARC Undergraduate Student Training in Academic Research program, which is designed to help meet the need for continual improvement in institutional offerings. Other additions have included the Post-Baccalaureate Research Education Program Award, MARC Faculty Predoctoral Fellowships, MARC Faculty Senior Fellowships, MARC Visiting Scientist Fellowships, and MARC Ancillary Training Activities. As the MARC programs have been growing, the Minority Schools Biomedical Support program also has been evolving. When eligibility for the program was expanded in 1973, it was renamed the Minority Biological Support program; its name was changed again in 1982 to the Minority Biological Research Support (MBRS) program in order to reflect its research scope. This MBRS program was transferred to NIGMS from the Division of Research Resources in 1988, and the NIGMS established the Minority Opportunities in Research (MORE) program branch to serve as the focal point for efforts across NIH to increase the number and capabilities of minority individuals engaged in biomedical research and teaching. In 1996 the MORE Faculty Development and Initiative for Minority Student Development awards were established, and in 1998 the Institutional Research and Academic Career Development Award was announced to encourage postdoctoral candidates’ progress toward research and teaching careers in academia. SOURCE: NRC. 2005. Advancing the Nation’s Health Needs: NIH Research Training Programs. Washington, DC: The National Academies Press, p. 7. NatioNal reSearCh ServiCe aWard Program programs are overseen by awardee institutions rather than by individual research mentors, and this allows for the imple- In its almost 40-year history, the National Research mentation of trans-institutional standards for trainee stipends Service Award (NRSA) program has provided more than and benefits, mandated instructional programs in such foun- 160,000 training slots in the biomedical, behavioral, and dational areas as the responsible conduct of research (RCR), clinical sciences to students and young investigators. This the ethical conduct of human and animal subjects research, has been accomplished through a combination of individual and sundry career development and counseling programs fellowship awards and institutional training grants. Over the addressing such topics as grant writing and reviewing, pub- 10-year period from 1998 to 2007, trainees were to be found lication practices, mentorship, laboratory management, and in some 258 universities, research institutes, and teaching preparation of resumes. hospitals. As the NIH and the Public Health Service (PHS) Institutional training grants assure institutional ownership have grown over the past quarter of a century, the NRSA of, and responsibility for, the quality of trainees and their program has evolved to include new fields in the basic bio- training programs as well as making available professional medical sciences, such as genome research and neuroscience, and career development services that may not otherwise be and has expanded to support training in such clinical sciences accessible to trainees on individual fellowships. In other as communication disorders, health services, primary care, words, in order to gain support for a training grant applica- oral health, and nursing. tion, each institution has to review and strengthen all of its Institutional training grants, which fund the education of approaches to graduate education, a process from which all about 83 percent of NRSA participants, are widely regarded students benefit, not just those specifically supported by the as one of the best avenues for learning the theories and training grant. techniques of biomedical and behavioral research.4,5 These Individual fellowships, which support almost 18 percent of NRSA recipients at the predoctoral level and 35 percent at the NRC. 1995. Reshaping the Graduate Education of Scientists and Engi­ postdoctoral level, are also awarded on a competitive basis and 4 neers. Washington, DC: National Academy Press. provide what is often a first step toward professional inde- NRC. 1998. Trends in the Early Careers of Life Scientists. Washington, 5 pendence. Fellows develop their own proposals and, once an DC: National Academy Press.

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 CONTEXT AND ISSUES award has been made, are generally accorded a great deal of The relative numbers of trainees at the predoctoral and autonomy in pursuing their educational and research goals. postdoctoral levels have varied over the life of the program. In the years since the NRSA program was established, More training was initially provided at the postdoctoral level, funding for research training has grown overall much more but by 2008, 55 percent of the trainees were predoctoral. slowly than the NIH budget. In 1975, when the NRSA The training mechanisms (i.e., trainee vs. fellow) have program began, it supported 3,752 graduate students and also changed. Although the growth in predoctoral training postdoctoral fellows, and this grew to 11,565 slots by 1980. has predominantly been at the individual fellowship level, Thirty-two years after this, when the NIH budget had grown in absolute terms the trainees still far outnumber fellows. In by more than 1300 percent (in nominal dollars), the NRSA contrast, the decline in postdoctoral training has been all at program supported only 13,790 slots per year. The level of the fellowship level (see Table 1-1). support has been approximately stable since 1995. It is impor- These numbers do not reflect the actual number of pre- tant to note that these numbers refer to available “slots” on the doctoral and postdoctoral trainees and fellows since an grants, and since a given student is often appointed for more individual may receive support for up to 3 years. In recent than one year, this measure of level of support overestimates years the average median time for a trainee has been 2 years, the actual number of students supported by this mechanism, which implies that the actual number of graduate students possibly by as much as two-fold. The NRSA provides but a who have received predoctoral support is less than the total small part of NIH’s total support for graduate education— in the table by a factor of about two. The average period for about 22 percent—while roughly two-thirds of the nation’s fellows is slightly longer at 2.2 years. In summary, this means graduate student support is in the form of Research Assistant- that about half of the 6,641 trainees in 2008 and a little over ships funded directly by NIH research grants. half of the 1,537 fellows in 2008 should be counted as also TABLE 1-1 NRSA Trainees and Fellows, by Broad Field, 1975-2008 FY 1975 1980 1985 1990 1995 2000 2005 2006 2007 2008 Basic Biomedical Sciences Predoctoral Trainees (T32) 1,009 4,184 4,026 4,701 5,095 4,628 4,845 4,516 4,937 5,390 Predoctoral Fellowship (F30, F31) 27 21 80 123 411 400 862 962 1,074 1,154 Postdoctoral Trainees (T32) 474 2,200 2,128 2,232 2,191 2,310 2,598 2,463 2,386 2,475 Postdoctoral Fellowship (F32) 1,106 1,982 1,583 1,483 1,679 1,598 1,365 1,374 1,291 1,284 Total 2,616 8,387 7,817 8,539 9,376 8,936 9,670 9,315 9,688 10,303 Behavioral and Social Sciences Predoctoral Trainees (T32) 208 655 501 619 505 451 506 522 421 416 Predoctoral Fellowship (F30, F31) 125 74 41 58 101 207 214 183 154 147 Postdoctoral Trainees (T32) 32 368 392 398 411 465 460 401 350 301 Postdoctoral Fellowship (F32) 146 131 86 78 112 114 104 77 50 50 Total 511 1,228 1,020 1,153 1,129 1,237 1,284 1,183 975 914 Clinical Sciences (Excluding Health Services) Predoctoral Trainees (T32) 65 284 379 385 830 558 633 602 711 807 Predoctoral Fellowship (F30, F31) 3 2 8 153 108 123 190 209 222 228 Postdoctoral Trainees (T32) 346 1,408 1,714 1,287 1,553 1,467 1,893 1,930 1,872 1,968 Postdoctoral Fellowship (F32 ) 211 250 180 99 75 93 140 131 137 143 Total 625 1,944 2,281 1,924 2,566 2,241 2,856 2,872 2,942 3,146 Health Services Research Predoctoral NIH Predoctoral Trainees 0 3 10 11 6 0 20 27 28 28 NIH Predoctoral Fellows 0 0 1 1 4 8 14 7 8 8 AHRQ Predoctoral Trainees 0 0 8 22 19 3 71 67 76 71 AHRQ Predoctoral Fellows 0 0 0 0 0 0 1 2 1 2 Total 0 3 19 34 29 11 106 103 113 107 Health Services Research Postdoctoral NIH Postdoctoral Trainees 0 3 5 31 16 0 31 39 29 40 NIH Postdoctoral Fellows 0 0 1 2 1 1 4 3 3 5 AHRQ Postdoctoral Trainees 0 0 5 5 1 3 40 35 37 40 AHRQ Postdoctoral Fellows 0 0 0 3 0 0 2 2 3 2 Total 0 3 11 41 18 4 77 79 72 85 Total All Fields 3,752 11,565 11,148 11,691 13,118 12,429 13,993 13,552 13,790 14,555

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES supported in a previous year, which indicates that the actual tively. One factor that may play a role in the difference is number of trainees is about 3,700 individuals per year. This that if students are not NRSA supported, they may have is consistent with NIH data on the number of Ph.D.s with significant teaching assistantship responsibilities, which may some form of NRSA support, which, allowing for attrition, contribute to a longer time to degree. stands at about 3,000 Ph.D.s. Following graduation, NRSA predoctoral trainees and The relative distribution of trainee support between the fellows were more likely to move quickly into research biomedical sciences (70 percent) and all the other areas positions. In fields where postdoctoral study was common, supported by the NRSA mechanism has changed little over 93 percent of the trainees and fellows reported having the years. However, the number of NRSA-supported trainees definite postdoctoral commitments, compared to 80 percent in the social and behavioral sciences has declined recently. of graduates in the same fields at non-NRSA institutions. Until 2000 the percentage of trainee slots in this area was It is difficult to report career path progression accurately, almost constant at 10 percent, but by 2007 it had fallen to since people move in and out of positions and postdoctoral 7.1 percent. In contrast, during this interval the number of appointments tend not to be for fixed time periods, but NRSA supported trainee slots in clinical training increased from trainees and fellows appeared to be more likely to move into 18 percent to 21.3 percent. faculty or research positions. About 37 percent of the NRSA recipients held faculty positions 7 to 8 years past the doctor- ate, compared to 16 percent from non-NRSA institutions. evaluation of the NrSa Program Also, 87 percent of previous NRSA trainees and fellows, A number of attempts have been made to quantify the compared to 72 percent from non-NRSA institutions, were value of NRSA training. In 1984, NIH conducted an exten- in research-related positions in academia, industry, or other sive evaluation of the program, with a follow-up evaluation research settings. in 1998. If one examines research grants and publications as These evaluations showed that NRSA trainees and fellows measures of research productivity, one finds that the NRSA graduated 3 months sooner than those without NRSA sup- trainees and fellows were more likely to have grants and port at the same institutions and 7 months sooner than their more publications. For example, among the 1981-1988 counterparts at institutions without any NRSA grants. In Ph.D.s who had applied to NIH by 1994 for research grant addition, nearly 58 percent of the NRSA trainees and fellows support, the success rate for NRSA recipients was 67 percent, had received their doctorate by the age of 30, as compared compared with 47 percent for non-NRSA institution gradu- with 38.9 percent and 32.3 percent for the non-supported ates. With regard to publications, NRSA predoctoral trainees doctorates from NRSA and non-NRSA institutions, respec- and fellows in the 1981-1982 cohort had a median number BoX 1-3 Nih evaluations of the NrSa Program A 1984 evaluation of formal NIH-sponsored research training (which included programs existing before the establishment of the NRSA) found that a larger percentage of participants in NIH training programs completed their doctoral programs and went on to NIH-supported postdoctoral training than among their counterpart trainees. Furthermore, those supported by the NIH during their predoctoral studies were more likely to apply for and receive NIH research grants, authored more articles, and were cited more often by their peers. At the postdoctoral level, both those appointed to institutional training grants and recipients of individual fellowship awards were more likely to pursue research careers than their colleagues without formal NIH research training, and the former were more successful by such measures of achieve- ment as obtaining research funds, publication, and citations by their peers. These differences were true for M.D.s with postdoctoral research training as well as for Ph.D.s. A follow-up to the 1984 evaluation of the NRSA Predoctoral Program was conducted in 1998, and many of the findings from the earlier study were found to still hold true. The 1998 study examined the characteristics of NRSA-supported doctorates between FY 1981 and 1992 against their Ph.D. counterparts at institutions with NRSA training grants who did not receive this type of support and at another group at institutions without NRSA grants.a The study found that 80 percent of the NRSA trainees or fellows received their Ph.D. from 50 institutions that ranked in the top quarter of all biomedical sciences programs, and nearly 60 percent received their degree from the top 25 institutions. The completion rate for students supported by the NRSA program was an estimated 76 percent and was comparable to that of other merit-based, national fellowship programs and of students in high-quality doctoral programs. National Institute of General Medical Sciences, 1998. Available at http://publications.nigms.nih.gov/reports/mstpstudy/. a

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 CONTEXT AND ISSUES of publications twice that of doctorates from institutions disciplinary research. Third, they establish innovative train- without NRSA grants, 8.5 publications as compared to 4. ing standards not only for NRSA awardees, but also for all Non-NRSA-supported Ph.D.s at NRSA institutions also had trainees, regardless of their mechanisms of support. This fewer publications by almost as large a margin, 5 publica- last point is of great importance, and, indeed, over the past tions as compared with 8.5. decade this may have been one of NRSA program’s most Such studies do not, of course, indicate whether the suc- important contributions. cess of former NRSA trainees and fellows reflects the train- A report published in 2006 by ORC Macro for the NIH ing they received, the selection process, or a combination examined the career achievements of NRSA postdoctoral of factors. In addition, as alluded to above, these data have trainees and fellows from 1975 to 2004. The results of this to be viewed with caution because a non-NRSA student in study were inconclusive. By some measures the trainees other funded positions such as an assistantship may have to had an advantage, and by other measures they did not. spend additional time in activities not directly related to his Most tellingly, the study concluded that after 12 years the or her research. Nonetheless, these findings do suggest that postdoctorates who received NRSA support were largely there are significant strengths and achievements within the indistinguishable from those who did not. Unfortunately the NRSA program at the predoctoral level. study is flawed: The postdoctoral pool is radically different In assessing the needs for training support in the bio- from the predoctoral pool in that more than 50 percent of the medical, behavioral, and clinical sciences, it is important to postdoctorates are internationals and thus unable to become understand the role of NRSA awards. Although, as indicated NRSA trainees because of the citizenship restrictions. Pre- above, NRSA awards support only a small fraction of the sumably, the international pool contains a significant number total number of trainees, the role of these awards in the train- of equally talented and creative individuals who are well ing process is extremely important for the following reasons: equipped to compete with the U.S.-trained postdoctorates, First, they serve to attract highly qualified people into bio- thus rendering any relative performance conclusions moot. medical research. As discussed above, a good example of this is the Medical Scientist Training Program (M.D./Ph.D.), NatioNal reSearCh CouNCil role iN aSSeSSiNg which has a well-established track record for launching phy- PerSoNNel NeedS sicians into productive—and often outstanding—research careers. Second, they have served over the years to direct the Study’s origins training into specific research areas, which have often been emerging areas for which other mechanisms may not be Since 1975, the NRC has issued regular reports on the available, such as molecular medicine, biophysics, and supply of biomedical and behavioral researchers in the United bioinformatics, and, as such, they have stimulated cross- States and the likely demand for new investigators. This con- BoX 1-4 National research Service award act of 1974 (P.l. 93-348) Sec. 472. (a) (3) Effective July 1, 1975, National Research Service Awards may be made for research or research training in only those subject areas for which, as determined under section 473, there is a need for personnel. Sec. 473. (a) The Secretary shall, in accordance with subsection (b), arrange for the conduct of a continuing study to— (a) establish (A) the Nation’s overall need for biomedical and behavioral research personnel, (B) the subject areas in which such personnel are needed and the number of such personnel needed in each such area, and (C) the kinds and extent of training which should be provided such personnel; (b) assess (A) current training programs available for the training of biomedical and behavioral research personnel which are conducted under this Act at or through institutes under the National Institutes of Health and the Alcohol, Drug Abuse, and Mental Health Administration, and (B) other current training programs available for the training of such personnel; (c) identify the kinds of research positions available to and held by individuals completing such programs; (d) determine, to the extent feasible, whether the programs referred to in clause (B) or paragraph (2) would be adequate to meet the needs established under paragraph (1) if the programs referred to in clause (A) of paragraph (2) were terminated; and (e) determine what modifications in the programs referred to in paragraph (2) are required to meet the needs established under paragraph (1). (c) A Report on the results of the study required under subsection (a) shall be submitted by the Secretary to the Committee on Energy and Commerce of the House of Representatives and the Committee on Labor and Human Resources of the Senate at least once every four years.

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES tinuing series of reports was initiated by the U.S. Congress should play a more important role in health care, the decline with the passage of the National Research Service Award Act in the relative share of graduate students funded by training of 1974,6 which consolidated the variety of research training grants, and the lack of promising research career options for activities then sponsored by the National Institutes of Health young scientists, among other concerns. These and other and the Alcohol, Drug Abuse, and Mental Health Administra- issues related to the state of the nation’s research workforce tion into a single, inclusive program: the National Research have to this day been the focus of considerable attention and Service Awards. discussion and the subject of numerous national meetings, In the same legislation, Congress decreed that National public policy studies, and congressional hearings. Research Service Awards be made only in areas for which Some of this activity was prompted by the 1994 “national “there is a need for personnel” and directed that the National needs” report itself and the subsequent response to it by Academy of Sciences be asked to provide periodic guidance the NIH, the Agency for Health Care Policy and Research on the fields in which researchers were likely to be needed (AHCPR), and the Health Resources and Services Admin- and the numbers that should be trained (see Box 1-1). The istration.7 Of the eight major recommendations put forth by present study is the twelfth completed by the NRC, the oper- the 1994 committee, the agencies focused on two: increas- ating arm of the National Academy of Sciences, the Institute ing the stipends for trainees and fellows, and evaluating the of Medicine, and the National Academy of Engineering. NRSA program. Although they did not require any new steps, the suggestions put forth in the 1994 report for main- taining training levels in the basic biomedical sciences and Past reports for increasing the numbers of underrepresented minorities To date there have been 12 assessments of the “national were also adopted. At the same time, however, recommen- need” for research personnel in the biomedical and behavioral dations for increasing the number of NRSA training grants sciences conducted by the NRC, and while the purpose of and fellowships in the behavioral and clinical sciences, oral these assessments was to provide NIH and the Congress with health, nursing, and health services research were not acted information that could be used to make budget decisions, the upon, prompting a congressional inquiry in the fiscal year manner in which the assessments should be conducted or the 1997 appropriations for the NIH. In explaining their actions scope of the investigation has been left to the discretion of to Congress, the NIH and the other agencies indicated that the NRC. Those who conducted the first assessment in 1974 they had focused on the highest priority recommendations chose to limit its study to the demand for faculty, as shaped and were likely to continue to direct additional research by federal support for university-based research and enroll- training monies to stipends until NRSA stipend levels were ments in higher education. It interpreted the faculty research comparable to other sources of research training support. areas broadly to include the basic biomedical sciences, the In the meantime, other reports on clinical research and behavioral sciences, the clinical sciences, and health services training were being issued. In its 1994 report Careers in research. In their first full-length report, issued the following Clinical Research: Obstacles and Opportunities,8 the Insti- year, committee members concluded that Ph.D. production tute of Medicine (IOM) recommended (a) further evaluating in the biomedical and behavioral sciences was more than clinical research training programs, (b) redirecting funds adequate to meet existing demand. to the most effective forms of clinical research training, In studies conducted from 1977 to 2002, subsequent (c) emphasizing training programs that provide an opportu- committees incorporated employment trends in industry, nity to earn an advanced degree in the evaluative sciences, government, teaching hospitals, and similar settings in their (d) increasing the number of M.D. /Ph.D. and D.D.S./Ph.D. assessments of the demand for biomedical research person- programs that train investigators with expertise in patient- nel. In 1985 and 1989, the committees recommended addi- oriented research, and (e) expanding initiatives that reduce tional research training in the basic biomedical sciences, due educational debt, either through tuition subsidies, as in the in part to increased demand from the biotechnology industry. case of M.D. /Ph.D. programs, or loan forgiveness. The 1994 committee advised that training in the biomedical In 1997 an NIH panel produced a report on the status of sciences be maintained at existing levels but called for an clinical research in the United States, including the recruitment increase in research training in the behavioral sciences. and training of future clinical researchers.9 The panel recom- The 1994 report also redefined the scope of its investiga- mended: (a) initiating clinical research training programs tion by highlighting a number of issues that were of par- ticular concern to the administrators of the NRSA program. NIH. 1997. Implementing the Recommendations in the 1994 Report 7 These included the growth of the Ph.D. population in the from the National Academy of Sciences: Meeting the Nation’s Needs for biomedical sciences, the decline in the number of physician Biomedical and Behavioral Scientists. Unpublished report to Congress. researchers, the recognition that the behavioral sciences Washington, DC: NIH. IOM. 1994. Careers in Clinical Research: Obstacles and Opportunities. 8 Washington, DC: National Academy Press. National Research Service Award Act of 1974, Public Law 93-348. 93rd NIH. 1997. Director’s Panel on Clinical Research. Report to the Adi­ 6 9 Congress, June 28, 1974. sory Committee to the NIH Director. Washington, DC: NIH.

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 CONTEXT AND ISSUES aimed at medical students, such as M.D./Ph.D. programs for Charles Goldman published a paper using mathematical clinical research, (b) ensuring that postdoctoral training grants modeling to demonstrate that U.S. universities were over- include formal training in clinical research, (c) providing new producing Ph.D.s in fields such as engineering, mathematics, support mechanisms for young and mid-term clinical inves- and the biological sciences, thus creating a group of Ph.D.s tigators, and (d) taking steps to reduce the educational debt that was chronically underemployed. They concluded that of clinical investigators. Some of these recommendations had increases in research funding would be likely to worsen job already been put in place at NIH before the panel report was prospects for Ph.D.s and urged academic departments to completed. These included: (1) a program to bring medical bring the production of Ph.D.s into balance with the demands and dental students to NIH’s Maryland campus for a one of the labor market—not just the demand for research and to two years of clinical research training; (2) new NIGMS teaching assistants. guidelines for its M.D./Ph.D. program to encourage research In 1996 the Federation of American Societies for Experi- training in fields such as computer sciences, social and mental Biology convened a conference to discuss these behavioral sciences, economics, epidemiology, public health, topics, which concluded with participants opposing any bioengineering, biostatistics, and bioethics; and (3) three national regulation of the size of graduate programs. Instead, new career development awards for young and mid-career the participants called for data on employment trends to investigators focused on careers in clinical research. This be made available to students and for universities to “self- current report will again stress the value of additional training regulate” the size of their graduate programs. Institutions in informatics, social and behavioral sciences, epidemiology were urged to refrain from admitting graduate students in and biostatistics, and bioethics. order to meet needs for teaching or research assistants. Infor- In a related area, another Institute of Medicine committee mation about institutions that have aggressively reduced the published the results of a study on the training and supply size of their biomedical graduate programs is lacking. of health services researchers. In its 1995 report, Health Subsequently, an NRC committee examining the career Serices Research: Workforce and Educational Issues, the paths of young investigators issued a report in the fall of IOM committee endorsed the number of training positions 1998 that also called for restraining the rate of growth in the in health services research that had been recommended in the number of graduate students in the life sciences. In Trends 1994 “national needs” study. The committee also encouraged in the Early Careers of Life Scientists, the NRC committee the AHCPR to focus its training funds on areas in which noted that the number of Ph.D.s awarded annually might researchers were reported to be in short supply, such as already be too high and called for prospective students to outcomes measurement, biostatistics, epidemiology, health be better informed about research careers. The committee economics, and health policy, and to set aside a number of urged the government to consider restricting the numbers institutional training grants for innovative research training of graduate students supported by research grants and to programs. In response, the Agency for Healthcare Research emphasize research training via training grants and fellow- and Quality made “innovation awards” to 10 institutions ships, acknowledging at the same time that the number of in 1998 to support the design and implementation of new Ph.D.s produced is ultimately determined at individual and models of health services research training. campus levels. Just as clinical research training has been the subject of Although universities control the influx of graduate stu- multiple studies since the 1994 NRC report, so too has doc- dents into their programs, experience shows that they (unsur- toral training in the basic biomedical sciences; some of these prisingly) tend to include their specific workforce needs in studies have also encompassed the behavioral sciences. In a their calculations, and the data clearly indicate that they have 1995 study commissioned by the National Science Founda- not collectively restricted the growth of the graduate student tion, the NRC’s Committee on Science, Engineering, and pool. The fact of the matter is that the bulk of the creative Public Policy reviewed graduate education across the bio- work and discovery in the biomedical sciences is driven by logical, physical, and social sciences and engineering. The R01 grants to individual faculty members. These faculty report, Reshaping the Graduate Education of Scientists and members are under immense pressure to be productive, and a Engineers, urged universities to provide a broader range of workforce composed of trainees is vastly more effective than academic options and better career guidance for their students one composed of technical assistants. The trainee workforce and called for federal agencies to encourage this trend through is also much less expensive to the individual grant than senior training grants. Partly in response, new NIGMS training grant research personnel such as instructors or research faculty. guidelines encouraged graduate programs to provide oppor- It has to be recognized that this system has been enor- tunities for trainees to take internships in industry and gain mously successful over many years; it also has to be experience in teaching as well as to provide them with infor- acknowledged that if R01 support increases, then the number mation on the career outcomes of graduates and with seminars of trainees will ineluctably increase in lockstep, as happened on employment opportunities and career counseling. during the recent doubling of the NIH budget. And if there Shortly after Reshaping the Graduate Education of Sci­ are insufficient U.S. national trainees, then faculties will entists and Engineers was published, William Massy and aggressively look to international Ph.D.s to fill the gap. No

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8 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES amount of well-intentioned urging of institutions to self- tee concluded that training in the biomedical, clinical, and correct will change this equation. The important question behavioral and social sciences should remain at least at the to be asked is, If this is such a successful model in terms of 2003 level, and training after 2003 should be commensurate scientific progress and return to the taxpayers’ investment, with the rise in the total NIH extramural research funding then what responsibility do we have to these young men in the three fields. and women as they complete their contributions to research There were several reasons for the committee’s recom- during their training period? This will be addressed in the mendation concerning the level of NRSA support and for recommendations below. not changing the mechanisms for support. The committee The 2000 assessment of the need for research personnel, members examined the workforce from the perspective of which was begun in 1997, concentrated on the three broad its size, composition, and age distribution and concluded fields of biomedical, behavioral, and clinical research, with that it had been fairly stable over recent years. In addition, a dental, nursing, and health services research included in life-table analysis of the workforce in each of the three fields the third category. A major change from earlier reports showed no signs of over- or under-employment during the was the movement away from detailed recommendations period from 2005 to 2011. Degree production, specifically in on the number of individuals who should be trained under the biomedical sciences, had leveled off, and the size of the the NRSA program and the use instead of a demographic postdoctoral pool was declining. All of these factors led the life-table model, proposed in the 1994 report, to estimate the committee to believe that no change in the level of NRSA size of the workforce each year up to 2005. The life-table support was necessary. It did recommend an expansion of the model was adopted because previous models of supply and MSTP by 20 percent and the greater involvement of clinical, demand had proved unreliable for valid forecasts. The life- health services, and behavioral and social sciences in the table-based analysis considered such factors as the average program. age of current investigators in the biomedical and behavioral Other recommendations were made concerning the sciences, the number of Ph.D.s expected to join the work- structure of the NRSA program—in particular, to provide force in the years ahead, and the likely effect of retirements postdoctoral fellows with the normal employee benefits of and deaths. The committee supplemented this analysis by the institution and to use NRSA awards to target emerging reviewing such indicators of short-term demand as trends in and interdisciplinary areas of research. The committee made faculty and industry hiring and perceptions of the job market a strong recommendation to restructure the career develop- by recent Ph.D.s. The model was implemented for the bio- ment grants (K awards) to have fewer mechanisms and to medical and behavioral sciences and showed that the supply implement them consistently across the NIH. The recom- of doctorates, even if at a low level, would be much greater mendation also called for more flexibility in the manage- than the need for researchers during the projection period. ment of K grants to allow for transition awards from senior This finding prompted the committee to recommend postdoctoral status to independent research positions and that degree production be maintained at current levels in all for awards to allow individuals to maintain research careers three broad fields. It did, however, make recommendations during periods when personal demands prevent full employ- for increases in clinical research training related to patient ment status. care and in interdisciplinary research in the biomedical and The recommendations were generally not acted on by behavioral fields. Many of the committee’s recommendations NIH. This may in part be due to a set of recommendations concerned the administration of the NRSA program; the that came from another NRC committee concerning the NIH, in response to the report, established new guidelines for long duration of postdoctoral training in the biomedical stipends at the predoctoral and postdoctoral levels, supported sciences and the time it takes to become an independent the recommendation on early completion of doctoral and researcher. This issue was of prime importance at the NIH, postdoctoral education and training, and supported limita- and in response to the recommendations from this report the tions on the period of NRSA support at the predoctoral and NIH introduced the K99/R00 award, aimed exclusively at postdoctoral levels. Ph.D.s, to provide 5 years of support during the transition The study immediately preceding this one was begun from postdoctoral to faculty status. The aim of this program in late 2002, and the study report was published in 2005. was to maintain and increase a strong cohort of new, well- That study built on the 2000 assessment and used the same trained, NIH-supported independent investigators capable of life-table analysis to make projections from 2005 to 2011 in competing for NIH support. each of the main fields. Individual chapters in the report were devoted to oral health, nursing, and health services research, the CurreNt Study but no projections of the workforce were made in these areas since there were insufficient data. Because the numbers of The current study began in 2008 with the selection of individuals working in these areas are less than in the three an expert committee to guide the study. The first meeting major fields, a life-table model was considered impracti- was in the late spring of that year and was followed by six cal. In terms of workforce projections, the study commit- more meetings, with the last taking place in early 2010. The

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 CONTEXT AND ISSUES committee was charged, as were the past few, with the task funds. The only possibility was the reallocation of existing of examining the current workforce and projecting the need resources, and NIH was in the best position to realign their for additional personnel in the biomedical, behavioral and agenda. The committee debated how it could nevertheless social, and clinical sciences as they pertain to the research fulfill its charge and assist NIH in its decision making, and mission of the NIH. Individual chapters of this study report it concluded that in order to maintain the high standards of are devoted to these fields, and special attention was given to the programs and continue to attract the best students into the clinical fields of oral health, nursing, and health services research careers, it would go forward with its recommenda- research, with the inclusion of separate chapters, as required tions to improve training programs but would prioritize the in the Statement of Task. most important ones and identify the costs. In assessing the characteristics of the past and current The committee was unanimous in its recommendations workforce, datasets from the National Science Foundation and prioritization except for the one recommendation that and the Association of American Medical Colleges were called for an increase in the indirect cost rates for NRSA used. An additional dataset that became available near the awards (see below). end of the study came from the National Research Council Study of Research Doctorate Programs. The value of these reCommeNdatioN oN NrSa PoSitioNS datasets depended on whether the study fields were included in their taxonomy or data were collected on degree types. In The primary task of this committee is to recommend the particular, the clinical sciences posed a problem, since data number of NRSA positions for 2010-2015. Based on the need are not readily available on researchers with medical degrees, to maintain a strong research workforce, we recommend that and it is difficult to distinguish between basic and clinical the total number of NRSA positions in the biomedical and research in medical school departments. clinical sciences should remain at least at the fiscal year 2008 Projections for the size of the future workforce are pro- level and that in the behavioral sciences they should increase vided in Appendices D and E using a life-table model and back to the 2004 level. This increase will require the addition a systems dynamics model, respectively. The projections of about 370 training slots at a cost of about $15 million. were based on different estimates of researchers entering the The committee also recommends that future adjustments in workforce from doctoral programs and through U.S. immi- the number of NRSA positions be closely linked to the total gration and emigration. The task of projecting the workforce extramural research funding in the biomedical, clinical, and was particularly difficult because of the state of the current behavioral sciences. In recommending this linkage, the com- economy and the unknown future demand for researchers. mittee realizes that a decline in extramural research would imply that there should also be a decline in training. reCeNt develoPmeNtS PrioritieS for other reCommeNdatioNS When the study committee first met, the economy was With large CoStS imPliCatioNS showing the first signs of a downturn that would deepen to a recession and eventually dramatically affect employment In addition to the recommendation on the number of and economic development around the world. As the com- NRSA positions, there are several other recommendations mittee reviewed the state of research training in subsequent in this report that require additional resources. Most call for meetings, it became clear that a projection of the future modest increases and could be accomplished by a shifting of research workforce in the biomedical, behavioral, and clini- resources within an institute or center. Three, however, would cal sciences would be difficult to develop from available data require significant additional funds. They are listed below in and would furthermore be risky, given the uncertain duration order of priority. In prioritizing these actions, the committee and severity of the recession. The workforce was contracting considered both their costs and their merits as well as likely with a decline in industrial employment, especially in the future constraints on the NIH budget. pharmaceutical area, and academic institutions had slowed First, NIH should reinstitute its 2001 commitment to their expansion of faculty and research facilities in response increase stipends at the predoctoral and postdoctoral levels to the reduced values of endowments and state appropriations for NRSA trainees. This should be done by budgeting regular, as well as the overall economic uncertainty. At the same time, annual increases in postdoctoral stipends until the $45,000 faculty members were delaying retirement, and this in turn level is reached for first-year appointments, and stipends was reducing the hiring of junior faculty members. These should increase with the cost of living thereafter. Predoctoral and other conditions might call for a reduction in research stipends should also be increased at the same proportional rate training, even though enhancements to training programs as postdoctoral stipends and revert to cost-of-living increases would be of great benefit. once the comparison postdoctoral level reaches $45,000. Given the current economic realities, the committee The estimated annual cost when fully implemented would recognized that the NIH budget would not allow for the be about $80 million, or 10 percent of the NRSA budget. implementation of recommendations that would require new If phased in over four years, the $20 million dollar annual

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0 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES increase would be about 2 percent of the NRSA training bud- to the negotiated rate currently applied to research grants. get. This should not be implemented by reducing the number The increase in the rate could be phased in over time. This of individuals supported by the NRSA program. would require a five- or six-fold increase in indirect costs, Second, the size of the MSTP should be expanded by at or $191 million for the NRSA program at its current size, least 20 percent—and more, if financially feasible—with assuming that stipends amount to about half of the awards, an emphasis on clinical, behavioral, and social sciences in and $338 million for K awards. There was not unanimity the expansion. This program has been highly successful within the committee on this recommendation because of in producing researchers in basic biomedical, transitional, concerns about costs and the reduction in program size that and clinical research.10 Again, recommendations to increase could result with a stagnant NIH budget. An increase of MSTP training were made in previous NRSA reports, and $529 million is significant, even in light of the reasoning an increase was endorsed by NIH following the 2000 NRSA that NIH should share the full cost of administrating these report. Currently there are 911 MSTP slots at an average cost programs, but the committee wanted to record its support of $41,806 per slot. An increase by 20 percent to about 1,100 for the measure and its hope that it could be implemented slots would increase the MSTP budget by about $7.6 million, at some point. or 1 percent of the NRSA budget. Phasing it in over 4 years The committee had the option of putting forth recommen- would not have a significant impact on the budget. dations without prioritization, but it believed that guidance in Third, NIH should consider an increase in the indirect cost these difficult economic times would add to the weight and rate on NRSA training grants and K awards from 8 percent credibility of the recommendations. The National Institute of General Medical Sciences. 1998. Available at 10 http://publications.nigms.hix.gov/reports/mstpstudy/,