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APPENDIXES i

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APPENDIX A - HISTORICAL OVERVIEW1 For nearly 20 years, the National Research Council (NRC) has played an active role in the ongoing review of training opportunities available to individuals seeking ad- vanced preparation in the biomedical and behavioral sci- ences. During this time, the NRC has issued nine reports which describe the optimal structure of the National Re- search Service Awards Program (NRSA) given national re- quirements for health-related research scientists and avail- able training opportunities. The historical summary that follows reports information in three areas: (1) a brief history of NIH support for re- search training in the biomedical and behavioral sciences, including trends in support of the NRSA program; (2) an overview of the analytic contributions of previous NRC study committees; and (3) a summary of findings from stud- ies evaluating the outcomes of the NRSA program con- ducted under the auspices of previous NRC committees. LINKING HEALTH RESEARCH WITH TRAINING The National Institutes of Health (NIH) were authorized as early as 1930 to support the training of health scientists. Specifically, Public Law 71-251, the "Ransdell Act", for- mally established the "National Institute of Health" as a federal agency and directed the agency to recognize the training of scientists as one of its major responsibilities. Under the terms of the Act, individual scientists could be designated to receive "fellowships" for duty at the National Institute of Health or to conduct investigations at "other localities or institutions in this and other countries" (Lenfant, 19894. It was the enactment of the National Cancer Act of 1937 (P.L. 75-244) that established the first disease-specif~c in- stitute at NIH and led to the formation of the fast major program of fellowship support by the U.S. government. The 95 National Cancer Act instructed the NIH to provide stipends or allowances to "the most brilliant and promising research fellows from the United States or abroad ... for training and instruction in technical matters relating to the diagnosis and treatment of cancer" (P.L. 75-244~. Initial training efforts focused on postdoctoral research fellows and clinical train- ing for physicians "to improve their capability in diagnosis and therapy" (Ahrens, 1992~. Federal interest and involvement in biomedical and be- havioral research increased dramatically after World War II largely as a result of the demonstration during the war of the immediate and beneficial impact of well-organized ba- sic and clinical research in meeting "national needs" (NRC, 1976~. Congress concluded that human health and well- being of all Americans would benefit from the infusion of substantial sums to support research conducted by highly skilled investigators, and the Public Health Service Act of 1946 (P.L. 79-487) provided explicit authority for grants to support the training of research scientists. Thus, with the establishment of each institute, the authority was granted for the institute to train individuals in the diagnosis, preven- tion and treatment of disease. The fundamental assumption which links federal responsibility for research to a responsi- bility for training is that the quality of research depends on the talents of individuals attracted to a career in research. Initially, the scientists needed for the health research ef- fort were trained at the postdoctoral level, either as a result of attracting scientists from other fields to new subject areas or as a result of a need to further hone the skills of talented graduates. However, owing to the increasing demand for well-prepared research scientists, federal interest in the training of biomedical and behavioral scientists expanded in the 1950s to include the support of graduate students at the predoctoral level. "Grantee institutions" were permitted significant latitude in the management of predoctoral train

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APPENDIX A =~ ~ O D 0N ~ O0\ ~ Q Z ~ I ~3 ~ l E to Z 1o .= a, be) D t, c, to to ~so at Go At ~ ch ~oo oo ~ Go Go Hi At At ~ - - - ~ - - - o ~8 ch - ~ to t~1 on ~ -, ~ to co _ ~ ~ co [~ 0 1 so ~ . ~ ~ to ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ o ~ ~ tr, t-) ~ Cal -~ ~ ~4 0 Cal~ t~ ~hi ~ ~_ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~1 ~ ~ ag , ~ ~ a, O ~ ~ ~ ~ ~ ~ ~ ~ ~ O ~ ~ ~I ~ _ _ - - - O ~ ~ ~ ~ ~ ~ ~ - ~ ~I ~ O {Q O ~ z z z z c~ - - ~ ~ ~ ~ ~ - c~ ~ m' c) ~ - ~ a1] o ~ O ~_ ,,` ~ 2 E, ~ o E ~ ~ ~ ~Z Z 3 .e D ~m .l . . - V, ~ ~ Z Z z z z ~ ~ ^ ~ ~ - O ~ ~ ~ ~ ~D C) ~o ~ ~o ~ ~ ., O ~ ko ~ ~ ~ ~ O ~ ~ ~ C~ t~ ~ ~ d. ~ d. ~ _ ~ _I _ _ _ O - ~ O ~ 00 ~ 00 ~ ~ ~ ~ ~ C~ ~ ~ O ~ c~ ~ ~ - u~ C~ d- ~ d- ~ ~ ~ ~J \0 0\ C~l C~ ~ O ~ M0 ~ ~ ~ ~ ~ ~ ~ ~ ~ oo O _ _ ~ c~ - ~ - -I - ~ C~ C~ ~ da _ _ _ ~ ~ _ ~ _ ~ ~ ~ _ _ ~4 _ _ ~ _' oo ~ ~ ~ ~ ~ _ ~ o O ~ ~ ~ ~ - ~ ~ ~ _ _ _ Z Z C~ 0 0 ~ ~ O O O ~ C~ ~ ~ ' de O ~ ~ ~ ~ ~ O ~ ~ c~ ~ ~ ~ ~ ~ O O - c~ - ~ ~ ~ ~ ~n ~ ~ - ~ c~ ~ ~ c~ 0 ^ O - - O O O O O O O ~ ~ - - ~ C~ d. ~4 - - - - ~ ~ - ~ - - - - - 4 ~ ~ (o ~ ~ ~ ~ ~ ~ S ; , ~ ~ ~ ~ ~ ~ ~ ~ ~ oo ~ C 1 ~ - - - - - - - - ~ - - - - - - - - ~ ~ ~ o ~ oo - ~ ~ oo ~ ~ ~ ~ ~ o oo ~ o d- - \0 0 ~ ~ ~ ~ O ~ C~ O ~ ~ C~ ~t mI oo - d ~ C~ oo - oO Ox ON t- ~ m] ~} ~ 0 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ o o ~ 00 00 ~ ~ oo ~ a' ~ oo oo ~ ~ ~ 0\ ~ _1 _ - 00 ~ 0 _ ~ ~ ~ ~ ~ ~ oo ~ 0 - C~ 00 00 04 00 00 00 oo oo 00 oo o~ ~ C~ cr, as ~ ~ o~ ~ cr, o~ cr ox cr cr, _ _ _ _ _ _ _ _ _ ~ _I ~ _ _ _ _ _ _ 96 cr~ cr - o U] _ ca o _ e o

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APPENDIX A ing grants being allowed to select trainees without prior review by the National Institutes of Health. Thus, in the 1950s, the basic pattern of the "institutional training grant" was developed. Over the years, the expansion of the na- tional biomedical and behavioral research effort and the at- tendant demand for scientists and teachers led the NIH train- ing effort to expand even further. By 1969, the number of trainees supported under the original training authority reached 16,000 in that year alone: By 1971,19IH training grants and fellowships supported or assisted 37.5 percent of the nation's full-time graduate stu- dents in the medical sciences and 21 percent in the life sci- ences. However, in its presentation of the fiscal year (FY) 1974 budget, the administration made an attempt to elimi- nate the award of all new training and fellowship grants (Lenfant, 1989~. Of the 13,000 NRSA positions that were awarded in FY 1992 by NIH and ADAMHA, the great preponderance were as trainees on NRSA institutional training grants (84 per- cent) (Figure A-1~. Only 2,200 or 16 percent of the awards were made as fellowships.4 Predoctoral fellowship support was restricted to just over 500 recipients and these primarily in the behavioral sci- ences and health services research. At the postdoctoral level fellowships represent about one-quarter of all awards ~ig- ure Am. The overall budget for NRSA support has grown in real or current dollars (Figure A-3) but remained steady in con- stant dollars. As a share of the NIH/ADAMHA R&D bud- get, NRSA support has declined from a high of about 9 percent in 1980 to about 5 percent in 1993 (Figure A-4. Total Positions = 13,890 Congress responded by creating a new training author ity: the National Research Service Award Act of 1974 (P.L. 93-3484. With this act, Congress established a new pro gram of support for advanced study in the biomedical and Fellow_ behavioral sciences. This program differs from otherpro- (2;6% grams of federal support in important ways. Perhaps most important is the notion that the National Research Service Award (NRSA) augments federal support for "graduate re search assistance" by restricting awards to "only those sub ject areas for which there is a need for personnel". Thus, the NRSA program did not spring full-blown in 1974; it represented a dramatic new direction in a long history of federal support for the training of health scientists. Total - 7,495 The NRSA Program Fellows~ in.. ,,. ~ .... When the National Research Service Awards program was established in 1974, a "novel element" (NRC, 1975) was introduced into federal programs of support: the legis- lation stipulated that these awards should be restricted to subject areas for which there is a need for personnel. Sub- sequently, amendments to the National Research Act of 1974 and administrative reorganization led to the addition of such fields of advanced research preparation as nursing research and primary care research. In 1976, the National Institutes of Health and the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) together provided 11,550 research training positions through the NRSA program (Table A-1. The program peaked ini- tially at 12,830 awards (in FY 1978) and declined to a low of 11,450 awards in 1986. Since 1986, the program has expanded to its current estimated level of 14,000 awards in FY 1993. Recommendations from He National Research Council throughout this period have generally called for a larger program of support than that provided by the U.S. Congress, although certain detailed recommendations have often been adopted by NIH/ADAMHA.3 97 1 1~ Fellows (2,201 ) | HI Trainees (11,689) | FIGURE A-1 Number of research training positions on NIH and ADAMHA fellowships and training grants, FY 1992. SOURCE: National Institutes of Health, special tabulations, 1993. Fellows f ~$ ~- ( 1, 674) go I; ~ $: 26% ~ ~ ~ \~ ~ Trainees ~ ~ ~ Trainees \: ~ ~ (6 989) ~ ~ ~ ~ ~ ~ ~ ~? (4 721 ) a 93 % ~~ ~ 74 % FIGURE A-2 Number of fellows and trainees as a proportion of all predoctoral and postdoctoral NIH and ADAMHA training po- sitions, FY 1992. SOURCE: National Institutes of Health, special tabulations, 1993. $300 ~ _ ._ /~ .~$200 ~ ~ /~~~ constant dollars $100 - - $0 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~me '76 '77 '78 '79 '80 '81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 FIGURE A-3 NIH and ADAMHA research training budget, FY 1976-1993. NOTE: Current dollars are estimated. Constant dol- lars are based on the Biomedical Research and Development Price Index. SOURCE: National Institutes of Health, special tabula- tions, 1993.

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APPENDIX A lo% 8% ' it\ '80 '81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 FIGURE A-4 NIH and ADAMHA Paining budget as a percent- age of the budget for extramural research and development grants (estimates). SOURCE: National Institutes of Health, special tab- ulations, 1993. ESTABLISHING TEIE SCOPE OF TEIE NRSA PROGRAM The National Research Council has played an active role in advising the National Institutes of Health and the U.S. Congress on the appropriate mix of NRSA support given national needs for research scientists and employment op- portunities. The NRC has provided this advice since the enactment of the National Research Act of 1974. Nine re- ports were issued between 1975 and 1989. The 1975 report provided definitions for He key con- cepts basic to this study training grants, fellowships, insti- tutional support, end predoctoral end postdoctoral training- and discussed their relationship with the quality of biomedical and behavioral research conducted in this coun- try. A short history of the relevant federally supported pro- grams was provided along with a summary of career out- comes of former trainees and fellows who participated in them. The committee's second report (1976) assessed the cur- rent academic labor market and near-term outlook for bio- medical and behavioral scientists. In most of these fields, the committee found that an ample supply of Ph.D.s was available. In fact, because the rate of grown in biomedical and behavioral research and development (R&D) expendi- tures had slowed perceptibly since 1968, and because col- lege enrollments were expected to stabilize by 1980 while Ph.D. production continued at a high level, the committee concluded that a slower rate of growth in labor force in these fields was advisable. Accordingly, the committee rec- ommended a modest reduction in the number of federally supported predoctoral students in the basic biomedical and behavioral areas. Postdoctoral support, the committee believed, should be held constant in the basic biomedical sciences and increased in other areas. In the behavioral sciences, the recommended shift to predominantly postdoctoral training represented a significant reorientation of federal support and graduate Gaining patterns in this area. This recommendation was 98 developed partly in response to the growing need for more specialized investigators capable of dealing with He increas- ingly complex research questions in the area of behavior and health. On the other hand, the clinical sciences area was seen as needing increased support to help stimulate the flow of M.D.s into clinical research careers. These initial recommendations were intended to remain in effect until the committee' s impressions about the market could be con- f~ed or modified by further analyses and additional data. In 1977, the committee found evidence that newly trained biomedical and behavioral Ph.D.s were encountering in- creasing difficulty in obtaining permanent faculty positions. The number of these Ph.D.s on postdoctoral appointments (which the committee considers to be temporary positions) had been rising at a rate of over 13 percent per year between 1972 and 1975 in He biomedical sciences. Furthermore, the committee's 1977 Survey of Recent Doctorate Recipi- ents showed that more than 40 percent of these postdoctoral appointees in biomedical fields had prolonged their appoint- ments because they could not find suitable employment. These indications of a tight job market facing new Ph.D.s in these fields prompted He committee to recommend an addi- tional 10 percent reduction from the number of predoctoral trainees in the biomedical sciences supported by He federal government in 1976. The postdoctoral recommendation was unchanged. Certain fields within the basic biomedical sciences ex- hibited evidence of better-than-average employment pros- pects and were cited as exceptions to the recommendation for reduced predoctoral support. The fields of biostatistics/ biomathematics and epidemiology showed no postdoctoral holding pattern and appeared to be attracting people from closely related fields, such as statistics, that are outside the biomedical sciences. For these fields, the committee rec- ommended no reduction in predoctoral support levels. In its 1977 report, the committee presented for the first time a systematic treatment of health services research train- ing needs, providing a definition for this emerging research area and a preliminary list of training difficulties that face it. In addition to calling for a continued expansion of mental heals services research Gaining, primarily at He predoctoral level Trough the programs of Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), the committee called for an extension of He NRSA authority to permit training in the general area of health services research espe- cially through the programs once provided by the National Center for Health Services Research (NCHSR). Nursing research training was officially brought under the purview of the study by amendments made to the NRSA Act in 1976 (~e Health Research and Health Services Amendments of 1976 or P.L. 94-278~. In its 1977 report, He committee provided He results of its survey of nurses who had completed Heir doctoral Gaining between 1971

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APPENDIX A and 1975. The findings suggested that opportunities for employment for doctorally trained nurses was favorable, and led the committee to suggest an expansion of research train- ing support, predominantly at We predoctoral level. The committee's 1977 report also discussed the issues of mid-career training and the participation of women and mi- norities in biomedical and behavioral research; the adminis- trative problems of the three-year limit on awards, the payback provision, announcement fields, and multidisciplinary awards; the education and training pro- cess by which most biomedical and behavioral scientists are produced; and the importance of federal support in sustain- ing the research training system. Most training grant programs were originally focused on the apparent need for increasing the number of well-trained research personnel. However, in developing a stable con- tinuing policy for government support of training programs in the biomedical sciences, the 1978 NRC committee con- cluded that it is essential to consider over effects that may be less obvious than the contribution of mere numbers. Many experienced observers believe, for example, that training grants have been just as important in improving the quality of Raining as in providing for increased numbers. The 1978 study committee identified four important uses of the institutional training grant: first, one of He most important uses of training grant funds is to provide research equipment and supplies for use by the trainees. Research training is unlike many other forms of education in that it cannot be learned solely from books. Much biomedical research depends also upon He availability of specialized apparatus, costing in the tens to hundreds of thousands of dollars. Many of these instruments require special training for their use, and it is the custom in good training laboratories to assign a high level technician to protect the apparatus from misuse and train the graduate students and visiting investi- gators in its proper handling. Such personnel are often at least partially paid from training grants and certainly play an essential role in the training process (NRC, 1978~. Second, training grants have almost certainly improved the quality of training by providing a portion of the salaries for additional faculty members. One of the major purposes of training grants has been to encourage interdepartmental training programs. The field of genetics provides an excellent example. In many institutions the geneticists may be found in several departments-plant geneticists in the botany department, animal geneticists in the zoology department, insect geneti- cists in the department of entomology, bacterial geneticists in the department of microbiology, and medical geneticists in the medical school and in universities with an agricul- tural college, they may be found additionally in the depart- ments of agronomy and plant breeding. In many institu 99 lions, training grants have served to bring such scattered teachers together to provide broad training to graduate stu- dents and postdoctoral fellows in important fields that tran- scend departmental boundaries. More often than not, how- ever, some important disciplines may be missing, and training grant funds may be used to fill the gap on either a permanent or visiting basis (NRC, 1978~. The need for such additions to faculty is particularly impor- tant in rapidly advancing fields. Third, training grants contribute to excellence simply by providing an increased number of graduate students to a high-quality department. By careful adjustments of such support, a more equitable distribution of students may be effected without any net overall increase in numbers. Fourth, there has been so much discussion, bow among the public and in the Congress itself, about improving sci- entific communication, that perhaps one need only mention the importance of training grants in providing for the pur- chase of essential printed materials and forwarding the in- formation communication which is a critical part of He sci- entific process. Some special issues were addressed by the committee during the 1980s. For example, it explored the value of the Paining system in He biomedical sciences and also the at~ac- tion of women and minorities to the biomedical sciences. Value of the Training System In the 1983 report, the committee explored the value of NIH ~aineeships and fellowships by surveying the careers of past recipients. As expected, those supported by these highly coveted competitive awards had achieved an admi- rable level of success. In general, they attained their de- grees in less time, won postdoctoral awards more often, showed greater research productivity and experienced less difficulty in He job market than other scientists. Clearly, He committee felt, He awards programs contributed substan- tially to developing a cadre of highly capable investigators. Attraction of Minorities to Careers in Biomedical Research The Minority Access to Research Careers (MARC) pro- gram was created by the National Institute of General Medi- cal Sciences (NIGMS) in 1977 to attract talented minority students to the biomedical sciences. In the 1985 report, at He suggestion of NIGMS, the committee evaluated the MARC Honors Undergraduate Research Training Program. (See also Garrison, et al., 1985.) The committee reported that the program provides special training and research op- portunities to selected juniors and seniors at colleges and universities with substantial minority enrollments. The 800

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APPENDIX A alumni of Be program had achieved an excellent record of success, including a number of publications by undergradu- ate trainees. More Han 76 percent of MARC trainees went on to some form of graduate training, and nearly half pur- sued doctorates. Although most pursued medical or dental degrees, more than a third of the trainees responding fore- saw careers in research. All but a handful expected to pur- sue careers related to science or engineering. Attraction of Women to Careers in Biomedical Research The 1989 report expanded the committee's consideration of groups underrepresented in Be research pool to include women. Although the number of women receiving Ph.D.s had increased more rapidly than any racial or ethnic minor- ity except Asians, women remained markedly underrepresented among full-time research scientists. Non- Asian racial minorities showed even greater underrepresentation, by factors as great as 6 or 7. Such underutilization of the nation's pool of talent seemed par- ticularly regrettable in light of the dramatic improvement in the market for biomedical researchers, driven by rising de- mand in industry. The committee explored various possible reasons for these discrepancies. EVALUATING THE NRSA PROGRAM The National Research Service Award Act of 1974 poses questions of program outcome as part of He continuing study of national needs. Here the focus is on knowing what happens to awardees (e.g., Are they engaged in health re- search careers?. Questions concerning program effective- ness also are implied in the legislative authority. During 20 years of study, NRC committees assessing national needs in this area have looked occasionally at the matter of career outcomes and questions of program effectiveness. Chief findings are summarized in the pages that follow. Predoctoral Training for Ph.D.s Three major studies examined outcomes associated with NRS A-sponsored predoctoral training (Coggeshall and Brown, 1984; National Research Council, 1976, 1977~. In general, He results indicated that NIH awardees distinctly outperformed Heir comparison groups in terms of greater involvement in research (e.g., receipt of additional postdoctoral research training, time spent in research, and grant application/award activity). These individuals also had somewhat better track records in carrying out high qual- ity research (as measured by citations). Similar to the re- sults of previous studies on the determinants of academic careers (Long et al., 1979; McGinnis and Long, 1988), 100 awardees did not experience any greater success in locating academic employment, once prestige of doctoral institution had been controlled. A more recent study (Coggeshall and Brown, 1984) of NIH predoctoral awards also attempted to, at least partially, control for the heterogeneity of training experiences and selectivity. Looking at those individuals who received their Ph.D.s in He biomedical sciences between 1967 and 1981, three study groups were compared: (1) those who received at least 9 months of NIH predoctoral support; (2) Hose who earned their degree from the same departments as the first group but who received 0-8 months of NIH support; and (3) those who graduated from departments that did not have NIH training funds. This strategy permitted two important considerations: (1) those departments receiving NIH funds, often the top-ranked departments in the biomedical sciences, apply the same criteria to accept students, and thus their source of predoctoral support, may be more similar in terms of individual differences (e.g., abilities); and (2) that stu- dents who are in departments with NIH funding programs but who are not supported by these funds for an extended length of time may benefit from certain resources accruing to NIH-supported departments. Postdoctoral Research Training for Ph.D.s Three major studies have focused on identifying the out- comes of NRSA-supported postdoctoral training, primarily those of biomedical scientists. In general, Dose with postdoctoral training, regardless of sponsor, outperformed on all measures compared to Rose who were supported for their predoctoral education but who did not choose to pur- sue additional postdoctoral study. More recent examinations of NIH postdoctoral training in the biomedical sciences have been carried out for 1967- 1977 Ph.D. recipients (NIH, 1986) and for 1961, 1966, 1971, and 1976 Ph.D. recipients in the biomedical sciences (Garrison and Brown, 1986~. Here He major comparison groups were (1) NIH postdoctoral trainees and fellows, (2) Ph.D.s who had likely received postdoctoral training from other sponsors, and (3) those who reported no plans for postdoctoral study at the time they received Heir degree. Substantial differences emerged between NIH postdoctoral awardees and those who indicated no plans for postdoctoral study; for example, Garrison and Brown (1986) found that NIH awardees were Free times as likely as the "no plans" group to have applied for NIH/ADAMHA research grants (56.9 percent versus 19.6 percent) and four times as likely to have been awarded a grant (40.0 percent versus 9.2 per- cent). This latter difference was reduced somewhat when only those who applied for grants were considered (70.3 percent of NIH awardees versus 47.1 percent of "no plans" groups). They also were more likely Han Hose with no

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APPENDIX A postdoctoral training to have obtained faculty appo~nunents 8-9 years after the Ph.D. (66.7 percent versus 52.7 percent) and, depending on He specific cohort examined, to have published more articles and received more citations per ar- ticle. A study by NIH (1986) revealed similar findings in terms of academic employment and research funding activity. As Garrison and Brown (1986) found, NIH awardees continued to outperform in terms of grant application activ- ity those individuals whose postdoctoral training was sup- ported via another source (56.9 percent versus 34.5 per- cent). Also, they were more likely to have been awarded a grant (40.0 percent versus 22.3 percent). This disparity de- creased substantially, however, when considering only Hose applying for such grants (70.3 percent versus 64.8 percent). There did appear to be some advantage in terms of aca- demic employment; tile percentage obtaining a faculty posi- tion was 66.7 percent for NIH awardees as compared to 56.7 percent for those with other types of postdoctoral ~ain- ing, but consonant win previous research McGinnis et al., 1982), this relationship could be primarily accounted for by other factors (e.g., prestige of doctoral institution). Similar results were reported by NIH (1986~. Postdoctoral Training for M.D.s The role of postdoctoral training for M.D.s was exam- ined by the three studies discussed in the preceding para- graphs. However, He difficulty in interpreting the results resulting from problems encountered in drawing comparison groups resembling in both orientations and experiences M.D.s with NRSA-supported, postdoctoral research train- ing-is exacerbated by the fact Hat He vast majority of physicians do not follow research careers. In addition, iden- tifying reasonable comparison groups in these retrospective studies is furler complicated by He fact that existing data- bases for physicians typically are less complete than those for Ph.D. recipients. Differences between M.D.s with postdoctoral appoint- ments and those without postdoctoral Paining, some of which appear to be substantial, were found by the National Research Council (1976) for certain outcomes: employ- ment in medical schools and universities (40.9 percent ver- sus 7.4 percent, respectively); the average amount of time reported in conducting research (10.6 percent versus 2.6 percent); and numbers of publications and citations (e.g., 586.6 citations versus 10.3 citations per person for M.D.s aged 41-50~. By the use of additional comparison groups, a strong relationship between the existence and length of for- mal research training and outcomes also appeared a rela- tionship Cat has been supported by analyses of more recent trainees (Levey et al., 1988; Sherman, 1983a, 1983b, 1989~. In addition to the M.D. groups specified above, two other groups were identified: individuals who had earned both an 101 M.D. and a Ph.D. and who had or had not received postdoctoral Paining. With the exception of average time spent in research, the results showed a ranking among these groups in line win He amount of research training received. For example, the proportions employed in academic set- tings were 67.5 percent for M.D./Ph.D.s with postdoctoral appointments, 60.4 percent for M.D./Ph.D.s who did not pursue postdoctoral study, 40.9 percent for M.D.s who had NIH-supported postdoctoral appointments, and 7.4 percent for M.D.s with neither a Ph.D. nor postdoctoral training. On each of He four measures used in the study, He perfor- mance of M.D./Ph.D.s, regardless of whether they had been engaged in postdoctoral study, was higher than for those M.D.s who did not possess a Ph.D. The two remaining studies tried to draw comparison groups that addressed in some way selectivity issues. Rawer than looking only at all M.D.s without postdoctoral ~ain- ing, Garrison and Brown (1986) also identified another group of M.D.s who received Heir degree in 1965 or 1974, who reported Heir primary activities to be "research" or "paining," but who had not received postdoctoral research training. Looking at 1974 M.D.s only, Here were differ- ences between this group and NIH postdoctoral trainees and fellows. For example, those M.D.s win NIH-supported postdoctoral Gaining also were slightly more likely to have applied for NIH/ADAMHA research grants (18.6 percent versus 12.0 percent) and subsequently been awarded fund- ing (8.7 percent versus 5.5 percent). A comparison of these outcomes between M.D.s who had NIH postdoctoral fellowships and those who had un- successfully applied for these fellowships was performed by the NIH (1986~. Although both this study and He Garri- son and Brown (1986) study demonstrated that NIH fellows comprise a small and select group of M.D.s with NIH postdoctoral awards, this comparison is instructive, although still equivocal, in that it attempts to address some issues of selectivity. Looking at 1986 and 1971 M.D. recipients, the National Institutes of Health found that NIHfellows consis- tently outperformed their unsuccessful applicant counter- parts in terms of medical school faculty appointments (65.1 percent versus 43.5 percent) and NIH/ADAMHA applica- tion activity (27.4 percent versus 19.4 percent). Of those who applied for grants, 59.1 percent of He fellows versus 33.3 percent of He unsuccessful fellow applicants received an award. In general, all of the previously described studies on predoctoral and postdoctoral training have contributed to our knowledge about certain accomplishments of NRSA awarders. Because of unresolved problems with selectivity and heterogeneity of training experiences, however, no de- finitive evaluation study has yet been undertaken to provide strong evidence for the absolute effect of NRSA training on career outcome.

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APPENDIX A NOTES 1. Material for this section has been drawn from a variety of sources, including work commissioned by the study committee in 1992 and pro- vided by Ms. Judith Grumstru~Scott and Ms. Beryl Benderly. Sections have also been drawn from previous NRC study committee reports, most notably that of the 1978 study committee. The last section on evaluation issues is drawn from a paper by Dr. Georgine Pion commissioned by the 1989 NRC study committee. 2. In October 1992, the research components of the three institutes of ADAMHA joined the National Institutes of Health. 3. For example, earlier study committees called for a shift from predoctoral to postdoctoral support in the behavioral sciences, which has occurred. 4. The relative diminution of the fellowship mechanism within the NRSA program is an interesting feature of the history of the NRSA pro- gram. The 1974 authorization specified that not less than 25 percent of total support should be directed to fellowship support; the fraction has declined to 15 percent in recent years. REFERENCES Ahrens, E.H., Jr. 1992 The Crisis in Clinical Research: Overcoming Institutional Obstacles. New York: Oxford University Press. Coggeshall , P. E. and P.W. Brown 1984 The Career Achievements of NIH Predoctoral Trainees and Fellows. Washington, D.C.: National Academy Press. Garrison, H.H. and P.W. Brown 1986 Career Achievements of NIH Postdoctoral Trainees and Fel- lows. Washington, D.C.: National Academy Press. Garrison, H.H., P.W. Brown and R.W. Hill 1985 Minority Access to Research Careers: An Evaluation of the Honors Undergraduate Research Training Program. Wash ington, D.C.: National Academy Press. Lenfant, C. 1989 Review of the National Institutes of Health Biomedical Re search Training Programs. Bethesda, Maryland: NIH. Levey, G.S., C.R. Sherman, N.O. Gentile, L.J. Hough, T.H. Dial, and P. Jolly 1988 Postdoctoral research training of full-time faculty in academic departments of medicine. Annals of Internal Medicine 109:414-418. 102 Long, J.S., P.D. Allison, and R. McGinnis 1979 Entrance into the academic career. American Sociological Review 44:816-830. McGinnis, R., P.D. Allison, and J.S. Long 1982 Postdoctoral training in bioscience: Allocation and outcomes. Social Forces 60:701-723. McGinnis, R. and J.S. Long 1988 Entry into academia: Effects of stratification, geography, and ecology. In Academic Labor Markets and Careers, ed. D.W. Breneman and T.I.K. Youn. New York: Falmer Press. National Institutes of Health (NIH) 1986 Effects of the National Research Service Award Program on Biomed~cal Research and Teaching Careers. Bethesda, MD: NIH. National Research Council (NRC) 1975 Personnel Needs and Training for Biomedical and Behav ioral Research. Washington, D.C.: National Academy of Sci ences. 1976 Research Training and Career Patterns of Bioscientists: The Training Programs of the National Institutes of Health. Wash ington, D.C.: National Academy of Sciences. 1977 Personnel Needs and Training for Biomedical and Behav ioral Research. Washington, D.C.: National Academy of Sci ences. 1978 Personnel Needs and Training for Biomedical and Behav ioral Research. Washington, D.C.: National Academy of Sci ences. Sherman, C.R. 1983a Notes on the NIH Role in Support of Postdoctoral Research Training of Two Groups of Physicians. (Available from Charles Sherman, NIH, 9000 Rockville Pike, Bethesda, MD 20092.) 1983b Training and Manpower Development. Presentation at the Meeting of the Advisory Committee to the Director, NIH, Bethesda, MD. 1989 The NIH Role in the Training of Individual Physician Fac ulty: A Supplementary Analysis. (Available from Charles Sherman, NIH, 9000 Rockville Pike, Bethesda, MD 20092.)