Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 19
2. Clinical Sciences
Abstract
Important changes are taking place in the way
medical schools are financing their operations and
structuring their faculties. There is now more
emphasis on revenue-generating patient care and
relatively less on research. This shift has brought
with it a corresponding restructuring of faculty
composition and activity. Physician members of -
clinical departments are finding it more difficult to
compete successfully for NIB research grants but
Ph.D.s have gained appointments in clinical
departments at a rapid pace and have increased their
share of research grants. Physicians are applying for
research grants at about the same rate as a decade ago
but are having less success in obtaining them.
In dental schools, the financial arrangements are
quite different. State and local government
contributions are the dominant source of revenues and
have become increasingly important as the federal
contribution has been drastically curtailed. Tuition,
accounting for over 20 percent of total revenue in
dental schools compared with less than 6 percent in
medical schools, highlights some important differences
between medical and dental education. In contrast to
medical education in which residents and fellows
receive salary or stipend during training, many dental
trainees in advanced specialty programs must pay
tuition and receive no financial support from federal
or other sources.
Clinical faculties in both medical and dental
schools have continued to expand, financed by growth
in total revenue. The committee believes that more
newly hired clinical faculty members should have some
research training if the professional schools are to
maintain their clinical research capability.
19
OCR for page 20
20
INTRODUCTION AND OVERVIEW
In this chapter we look ahead to 1990 and try to estimate the
research training levels in the clinical sciences under the NRSA
programs that would satisfy national needs as perceived by the
committee.
The basic premise upon which the committee's assessment of national
need has been developed is that the government's research training
program serves as an adjunct to its research program and should be
administered to ensure the availability of an adequate number of highly
trained scientists to conduct that research. This has led to consid-
erations of how large the research effort will be in the future and
how many scientists will be needed to support it. Since most of the
government-sponsored research in the clinical sciences is performed in
medical, dental, and veterinary schools by faculty members, the
committee has concentrated mainly on an analysis of these groups.
It is well known that health professions schools generally do not,
and perhaps should not, prepare their students for research careers.
Preparation for a research career has normally been a postdoctoral
phenomenon since medical school and residency training provide little
or no opportunity for the acquisition of research skills. But since
physicians and dentists have a unique role to play in clinical
investigation, some provision must be made for providing them with the
requisite tools for a research career. Most often it is during a two
or three-year period of postdoctoral training that the necessary
research background is acquired. The question that concerns us in
this study is how many clinical scientists should receive postdoctoral
research training each year under NRSA programs? That depends in part
on the number of clinical faculty positions in medical and dental
schools, which in turn depends on enrollments and the availability of
funds from research grants, tuition, faculty practice plans, and other
sources. We will examine the trends in these variables from the early
1960s to date and then make projections of some of the key items
through 1990.
MEDICAL SCHOOL TRENDS
Recent trends through 1983 in medical school enrollments, faculty,
and financing are summarized in Table 2.1 and are presented in more
detail in Appendix Tables A1-11.2. Here are some highlights:
· Enrollment in graduate medical education programs (residents
and fellows) continued to expand sharply even though the number
of medical school graduates slowed noticeably. Undergraduate
Investigators in the clinical sciences are seen as consisting
mainly of physicians and dentists. It should be noted, however, that
the committee's overall concept of a clinical investigator includes
other health professionals, such as veterinarians and scientists
holding the Ph.D. or equivalent degrees, whose principal activity is
in the clinical sciences.
OCR for page 21
OCR for page 23
OCR for page 24
OCR for page 25
OCR for page 26
OCR for page 27
OCR for page 28
OCR for page 29
OCR for page 40
OCR for page 41
OCR for page 42
OCR for page 43
OCR for page 44
OCR for page 45
OCR for page 46
OCR for page 47
OCR for page 48
OCR for page 49
OCR for page 50
Representative terms from entire chapter:
dental schools
A'
·c}
of
-
·
-
·
o
Ed
·
~
·~
in
Em
v
Oc ~ o >
or ~ ~
~ ~ c'
22
.
.
medical school enrollment showed very little growth since 1981
as expected, but the total of undergraduate and graduate
enrollments jumped in FY 1982 in both public and private
schools as a result of the increases in graduate programs.
Instead of proceeding at modest growth rates for a few years as
expected, reported professional service income in medical
schools had huge gains in FY 1982 and again in FY 1983. This
revenue source increased by 16 percent in FY 1982 and 21
percent in FY 1983 after adjusting for inflation. The
committee does not anticipate continued growth at these high
rates.
Clinical R and D expenditures in medical schools were about as
expected, increasing moderately from 1980 to 1983.
· The growth of full-time faculty in clinical departments
moderated somewhat from earlier years, but there was a sizeable
jump of over 6 percent in 1982. The strong surge in service
income for that year indicates that the faculty expansion was
probably due more to clinical than to research activities.
Medical School Enrollments
For purposes of this study, we consider medical school enrollments
to be composed of medical students plus residents and fellows in
affiliated hospitals.
The number of medical students has increased only slightly since
1981, as expected, but the number of residents and fellows had larger
than expected gains between 1981 and 1982 which more than offset the
leveling off of medical students (Table 2.1, line 4~. The net result
is that total medical school enrollment increased at an annual rate of
3.2 percent from 1981 to 1983--about the same growth pattern exhibited
since 1976.
The committee noted in its 1983 report {p. 22) the possibility
that graduate medical programs might expand. The latest data give
evidence that this has been happening. Since 1981, the number of
medical school graduates increased by only 0.4 percent per year, but
the number of residents and clinical fellows increased by 5.4 percent
per year. The reasons are unclear but may have to do with the influx
of U.S. foreign medical graduates and a lengthening of the residency
years due to the growing complexity of medical services.
We expect medical student enrollment to decline by about 1 percent
per year on average between 1983 and 1990 (Figure 2.1~. That
expectation, however, may be conservative in light of the decline
since 1982 in size of the 20-24 year age group--the population from
which medical school applicants are drawn. Coincident with this
change, a 9 percent decrease occurred in the number of applications
for the 1985-86 entering class, compared with the preceding year.
23
140
130
120
110
100
90
80
70
60
40
30
20
10
_ Actual
Pro jec ted
.
Total Medical I`
School Enrol l meet'
/
~~ Medical Students
~ ~ ~ x
~ Residents and Fellows
I
1__ 1 ,1
60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90
F I SCAL YEAR
O I , , , , , ~ ~ ~ , 1 1
FIGURE 2.1 Medical students, residents, and clinical fellows, 1961-83, with projections to 1990. See
Appendix Table Al.
OinicalR and D Expenditures
Since 1980, estimated expenditures for clinical R and D in medical
schools have increased moderately after adjustment for inflation
(Table 2.1, line 2a21. The average increase--2.1 percent per
2 Our estimate of clinical R and D is based on the percentage of NIH
obligations that is classified as clinical. For the past three years
this percentage has held steady at 38 percent. We apply this
percentage to total R and D expenditures in medical schools as
compiled by the AAMC to arrive at estimated clinical R and D funds.
my ~ Stim ,____--
_/;~t !-lYo/~ )
e
"` '3
' REV
A,
24
year--was about what the committee had anticipated in its last
report. We expect these funds to continue on a moderate growth path
of about 0.5 percent per year in constant dollar terms between 1983
and 1990 (Figure 2.2~.
Up to 1980, private medical schools have had higher levels of
research expenditures than public schools in the aggregate {Appendix
Table Alp. But since then, public schools have overtaken private
schools with respect to these expenditures. This is partly due to the
fast growth in the number of public schools. Clinical R and ~ in
public schools grew at an annual rate of 3.7 percent since 1980 as
compared with only 0.5 percent per year in private schools.
Nevertheless, private schools remain generally more research-
intensive than public schools, as measured by research expenditures
per school. Average clinical R and D expenditures were just over $3
million per school in private schools in 1983 compared with about $2
million per school in public schools (Appendix Table Ash.
ProfessionalSewiceIncome
Perhaps the most striking recent development is the renewed upward
surge in service income generated by medical school faculty practice
plans in 1982 and 1983 due mainly to the expansion of patient care
activities in clinical departments. This revenue source, which grew
quite rapidly in the early 1970s, appeared to be growing more
moderately in the late 1970s. But in 1982 it climbed 16 percent over
1981 and 21 percent in 1983 after adjusting for inflation (Table 2.1,
line 2b).
Because of changes being implemented in Medicare and Medicaid
programs and the likely adoption of similar cost containment measures
by other health insurers, we do not expect this rapid growth to
continue. Our best guess is for real growth of about 3.5 percent per
year through 1990 (Figure 2.3~.
Both public and private schools showed strong gains. On a per
school basis, service income grew in real terms by about 10 percent per
year in both public and private schools since 1981 {Appendix Table Ash.
TotalMedicalSchoolRevenue
Service income and federal research funds contributed over half of
all medical school revenues in 1983 (Table 2.2~. Another large
portion came from state and local government sources. Tuition
contributed only a small amount to total revenue--less than 6 percent
in 1983--but it is second only to service income in rate of growth.
Increases in tuition--18.5 percent per year since 1971--and steep
borrowing rates have contributed largely to the growth in student
indebtedness. Despite a study finding suggesting that financial
pressures do not influence career choice by internists (Block and
Swisher, 1980), medical student indebtedness, as noted in several
committee reports, may nevertheless operate as a deterrent to their
pursuit of research training.
25
a_
3 _
an
~4
' 2 -
~_
1
o
_ Actual
_______ Projected Pri va te School s ,, Ala, Astir\ __
ye '. '~l 1 School s ~
% '_
% ~t ,g~_5r
xx - - - ~
xx ~ ,' Publ ic School s
kSt)lol or ~
--'' Mi ddl e Est . ( O . 5%/yr . )
as ___________
----__L°~_ES t - (-1 Fly
62 64 66 68 70 72
74 76 78 80 82 84 86 88 90
F I SCAL YEAR
FIGURE 2.2 Clinical R and D expenditures per school in U.S. medical schools, by control of institution,
1962-83, with projections to 1990 (1972 $, millions). See Appendix Table A9.
11:
10>
Of
~ L
3 L
Projected / ~ <3.$10l1~-'
~ ,',-' Low Estimate (OYc/yr. )
Private Schools ~ x~ /~~~~~~~~~~~~~~~~~-~~~
Ail /, Al l Sc hoof s
ox / ~
Of f Publ ic School s
_
If_
Dye
O L . , ~
62 64 66 68 70 72 74 76 78 80 82 84 86 88 90
FISCAL YEAR
FIGURE 2.3 Professional service income per school reported by U.S. medical schools, by control of
institution, 1962-83, with projections to 1990 (1972 $, millions). See Appendix Table A9.
26
Even with the disparate growth rates of the various components in
Table 2.2, total revenue has been quite stable. In fact it has grown
at a steady rate of about 5.5 percent per year since 1965 after
adjustment for inflation (Figure 2.4), and we expect continued growth
through 1990, but at a slower rate of about 3 percent annually.
The contrast between dental and medical school finances is quickly
apparent by comparing the sources in Tables 2.2 and 2.3. Whereas
medical schools depend heavily on service income and research funds,
the main sources in dental schools are state and local governments and
tuition. This fact has important implications in this study because
it bears on the types of activities engaged in by faculty in these
schools. Medical service income is generated largely through medical
school faculty practice plans whereas clinic income in dental schools
is largely generated in student clinics. A1SO' the tradition of
research in medical schools is much stronger than in dental schools,
but the rapid growth of service income in medical schools portends rel-
atively less emphasis on research, especially in clinical departments.
TABLE 2.2 Trends in U.S. Medical School Revenues ($ millions
Fiscal Year
1971 1976 1981 1982 1983
$ % $ % $ % $ % $ %
Federal Research 438 25.6 823 24.3 1,446 22.5 1,578 21.9 1,655 20.2
Other Federal 322 18.8 398 11.7 396 6.2 415 5.8 415 5.1
State and Local Gov't. 323 18.9 808 23.8 1,452 22.6 1,617 22.4 1,784 21.8
Tuition and Fees 63 3.7 156 4.6 346 5.4 413 5.7 482 5.9
Medical Service 209 12.2 609 18.0 1,850 28.8 2,140 29.7 2,626 32.1
Other Income 358 20.9 595 17.6 935 14.6 1,054 14.6 1,216 14.9
TOTAL 1,713 100.0 3,389 100.0 6,425 100.0 7,217 100.0 8.179 100.0
a The data in this table may not agree with others shown in this report. This table was derived by the AMA by combining
indirect cost recoveries with the associated sponsored programs, and by segregating the service components in federal, state,
and local government and nongovernment sponsored programs from the nonservice components. These service components
generally involve contracts for provision of medical service in hospitals.
SOURCE: American Medical Association (JAMA, September 28, 1984, p. 1536).
TABLE 2.3 Trends in U.S. Dental School Revenues ($ millions)
Fiscal Year
1972 1976 1981 1982
Revenue Source $ % $ % $ % $ %
Federal Research 18 9.2 26 7.5 45 7.4 47 7.2
Other Federal 37 18.9 57 16.4 36 5.9 24 3.7
State and Local Gov't. 68 34.7 145 41.7 296 48.8 314 48.2
Tuition and Fees 36 18.4 58 16.7 116 19.1 147 22.6
Dental Clinic 21 10.7 39 11.2 74 12.2 82 12.6
Other 16 8.2 23 6.6 40 6.6 37 5.7
TOTAL 196 100.0 348 100.0 607 100.0 651 100.0
SOURCE: American Dental Association (1969-84).
27
50
45
40
35
30
an
on
. 25
J
20
15
10
5
o
Actual
Projected
Private Schools Age -
<3OIol At )
,`~ '~- Low Estimate (0%/yr. )
~ A I I School s
,,
5~
Publ ic School s
64 66 68 70 72 74 76 78 80 82 84 86 88 90
FI SCAL YEAR
FIGURE 2.4 Total revenue per medical school, by control of institution, 1964-83, with projections to
1990 (1972 $, millions). See Appendix Table A11.2.
THE CHANGING FINANCIAL STRUCTURE OF MEDICAL EDUCATION
occurred
were the
A striking change in the pattern of financing medical schools has
in the past 15 years. In 1971, federal research programs
dominant source of funds--accounting for over 25 percent of
total revenues. Gradually during the 1970s, aggregate revenues from
research were overtaken by medical service income and state and local
government contributions. By 1983, service income generated by
faculty practice plans accounted for almost 33 percent of total
revenue and had become the largest single source of funds. Federal
research funds had fallen far behind at about 20 percent of revenues.
Although federal research funds are still the major source of support
in some research-intensive medical schools, they have nevertheless
declined as a percent of total revenues even in those institutions,
concurrent with a rise in the proportion of dollars derived from
patient care (Rosenberg, 1985~. Another important change during the
1970s was the decline of capitation grants and their ultimate
termination in 1982.
28
Increasing dependence on medical service income has a potential
for eroding institutional commitments to research and clinical
scholarship. This dependence results in less time to prepare grant
proposals, collect data, write papers, and generally makes it more
difficult to compete successfully for grant support. In past years,
some revenue derived from patient care has been made available to
support research activities in clinical departments. But as pressure
builds to restrain the growth of Medicare/Medicaid expenditures and
cost sharing becomes more widespread in private health insurance
plans, patient care revenues will face more intensive competition for
their disbursement among departmental activities, and research is
likely to suffer. Privately controlled schools are at particular risk
in that respect because they do not receive large state and local
government contributions. Publicly controlled schools are able to
partly cushion the loss of federal funds with increased appropriations
of state/local government monies e For most private medical schools,
these funds are a relatively minor source of support. Consequently,
their reliance on professional service income is more compelling.
Moreover, preoccupation with financing is likely to favor the
recruitment of clinician-teachers over physician-investigators as
expansion of the clinical faculty decelerates.
The trend for clinical departments to hire more clinicians and
fewer M.D. researchers has been reinforced by the growth of
subspecialization of practice in teaching hospitals and by the
increased professionalization of biomedical research. The training
requirements for independent investigators have become so technically
demanding that a physician, even after two or three years of a
research fellowship, is generally less well-trained for research than
the PhoD. who has been preparing for such a career since the
baccalaureate. There are also more Ph.D.s applying for NIH grants.
These facts help explain the drop in M.D. share of competing NIH
research grants, which fell from 36.1 percent in FY 1973 to 25.5
percent in FY 1983, compared with an increase from 53.4 percent to
65.5 percent over the same period for Ph.D.s (NRC, 1979-851. That
decline has been attributed to reduced award rates, rather than fewer
applications, by young M.D. investigators (Carter et al., 1983~.
Because of financial pressure it is understandable that clinical
departments are placing even greater emphasis on practice over
research, and/or recruiting Ph.D. scientists to help sustain a
significant level of research activity.3
THE MARKET OUTLOOK
Our approach to the task of estimating training needs in the
clinical sciences has been to try to estimate the demand for full-time
3 The issue of the recruitment of basic scientists in clinical
departments has been examined in detail by this committee and a
separate report on the subject will be published soon.
29
faculty in clinical departments of professional schools (medical,
dental, and veterinary) created by both expansion and attrition, and
then to determine what adjustments should be made to the training
system so that it produces the required number of trained researchers.
Similar approaches have been utilized for the biomedical and
behavioral sciences in Chapters 3 and 4.
To estimate demand due to expansion of faculty, we have developed
analytic models that relate faculty size to enrollments and revenue.
The panels associated with this committee make assumptions about the
future pattern of these two (exogenous) variables--enrollments and
revenue--which in turn are used to estimate future faculty size. This
produces estimates of demand due to expansion (or contraction) of
faculty, to which is added replacement demand created by faculty
attrition due to death, retirement, and other causes.
The dynamics of the system are vital to the committee's assessment
of need for training. As faculty vacancies occur, they will be filled
partially by new entrants to the supply of clinical scientists. Most
of them will be young physicians who aspire to careers in academic
medicine, but the evidence suggests that only a moderately small
portion (currently about 25 percent) of those individuals joining
clinical faculties in medical schools will have had postdoctoral
research training.
The number of newly hired faculty members with postdoctoral
research training is a critical parameter in the system because the
committee believes that the ability of medical schools to conduct an
effective clinical research program depends to a large extent on the
replenishment of clinical faculty by new entrants who have been
exposed to research techniques through a formal postdoctoral training
program of at least two years. It is also a part of the system over
which there can be some administrative control. The committee has
recommended that the training system be adjusted so that 35 percents
of all new hires to clinical faculty positions in medical schools
would have completed a period of formal postdoctoral research training.
With estimates of demand for clinical faculty, and with a target
level for the number of new hires with research training experience,
the committee can estimate the number of clinical science postdoctoral
trainees who should be in the pipeline each year. Three additional
parameters of the training system are needed to complete the analysis:
the appropriate length of the postdoctoral training period, the percen-
tage of postdoctoral trainees who select academic careers, and the
percentage of the postdoctoral trainees who should be supported under
NRSA programs. These will be discussed in more detail after the
projections of faculty demand are presented.
4 Although the committee believes that a substantially higher
percentage could be justified, it is aware that since 1970 the highest
figure achieved, even for M.D. new-hires in basic science departments
of medical schools, was 37 percent (Sherman and Bowden, 19821.
40
We expect dental enrollment to continue to decline until 1988 and
then flatten out through 1990. The best guess is for an average annual
decline of 2.8 percent per year between 1983 and 1988, with upper and
lower limits of -1.3 percent and -4.3 percent per year respectively.
After 1988, the market for dental practitioners is expected to improve,
mainly due to growing demand for dental care by the elderly. This is
likely to have the effect of stabilizing the enrollment decline in
dental schools.
Enrollment in public dental schools currently accounts for 57
percent of total enrollment, compared to 43 percent in private
schools. This, of course, reflects the widening gap between the
number of public and private schools. From 1961 through 1970,
enrollment in private schools was higher than in public schools. But
since 1970, public school enrollment has been greater and probably
will continue to be for quite some time in view of the appreciable
disparity in the number of schools in each category.
Dental School Faculty (Appendix Table A21)
Despite the downturn in dental school enrollments starting in 1982,
clinical faculty in dental schools has remained stable at around 3,700
full-time members since 1981. In contrast, full-time basic sci-
ence faculty in dental schools declined by over 6 percent since 1982.
The implication of these data is that funds necessary to maintain a
level number of clinical faculty have come mainly from increases in
clinic revenue, tuition, R and D funds, and state and local government
support. A discussion of these sources of revenue follows.
R and D Revenue (Table 2.3 and Appendix Table A22)
Dental school R and D revenue in constant dollars has been
generally rising since 1968 although there have been some rather sharp
drops--notably in FY 1969 and 1975--and some flat stretches. In
recent years there have also been some steep increases--real R and
increased by 14 percent in FY 1981 and by another 3 percent in FY
1982. Prior to 1981, real R and D revenue had increased at an average
annual rate of only 1 percent since 1968. Nevertheless, R and D funds
in dental schools are relatively minor sources of revenue, accounting
for only about 7 percent of total revenue in 1982 compared to 22
percent in medical schools.
Okidata published by ADA in its Annual Report on Dental Education for
1983-84 show full-time clinical faculty at 4,130 positions. This
number appears to be too high. Further examination by the ADA reveals
that a new method of collecting and tabulating the data in 1983-84
overestimated the number. A recheck by the ADA yielded a count of
3,688, which is more in line with other data.
41
The National Institute of Dental Research has formulated a 5-year
planning budget to exploit the scientific opportunities described in
its long-range research plan, "Challenges for the Eighties n (NIH ~
1983c). Although that budget incorporates an annual increase of 8
percent in constant dollars for extramural research, most of which
would be awarded to dental schools, the committee believes it realistic
to project an average increase of 3 percent per year in dental school
R and D revenue through 1990. Upper and lower limits are projected at
6 and 0 percent respectively.
Dental Clinic Revenue (Table 2.3 and Appendix Table A23)
In contrast to service income in medical schools, which stems
largely from faculty practice plans, clinic revenue in dental schools
is generated largely by students. Clinic revenue has had a dramatic
growth pattern during the past decade and probably is one of the keys
to understanding what has been happening in dental education during
the 1970s. Since 1968,-real clinic revenue has increased at a steady
pace of better than 7 percent per year--much faster than the growth in
real R and D revenue at less than 2 percent per year.
At the beginning of the 1970 decade, clinic revenue and R and D
revenue in dental schools were both at about the same level of $16
million per year in real terms. By 1983, clinic revenue at about 344
million was double the R and D revenue of about $22 million per year.
Both public and private dental schools have benefited from increased
clinic revenue but the growth has been somewhat faster in public
schools because of their higher rate of growth in predoctoral
enrollment.
We are projecting clinic revenue to increase between 0 and 4
percent per year in constant dollars through 1990, with a best guess
of 2 percent per year.
Tuition and Fees (Table 2.3 and Appendix Table A24)
Another factor that has played a substantial role in dental school
revenues since 1970 is tuition. In contrast to medical schools,
tuition in dental schools has been an important source of funds, and
in the past 10 years has become the second largest revenue source
behind state and local government funds.
Tuition revenue increases in private dental schools have been
especially sharp. In 1982, tuition revenue at 43 percent of total
revenue in private schools was by far the largest single source of
funds. In real terms it has increased at 8.3 percent per year in
private schools and 6.9 percent per year in public schools since 1968.
Our projections are for continued increases of between 2 and 12
percent per year through 1990, with a best guess of 7 percent per year.
42
State and Local Government Revenues (Figure 2.3 and Appendix Table A25)
We may infer from the ADA reports and the data in Table 2.3 that
state and local governments have always been the dominant source of
support for dental schools. Clearly since 1972, this source of funds
has taken on added importance as federal support has declined. In
1982, state and local government contributions made up nearly half of
all dental school revenues, up from about 35 percent in 1972. During
this same period, the federal government's share (excluding research
funds) declined from 19 percent to less than 4 percent. Most of this
decline is attributable to the elimination in 1982 of capitation
grants--a program designed to encourage the expansion of enrollment in
professional schools.
Modest increases are expected through 1990. Our best guess is for
2 percent per year real growth, with upper and lower limits of 4 and 2
percent per year, respectively.
Public schools, of course, rely more heavily on state and local
government support than do private schools. In 1982, state and local
governments contributed 64 percent of all public dental school revenue
and only 15 percent of private dental school revenue.
Nonetheless, the combined federal, state, and local government
contributions were still a smaller percentage of total revenue in 1982
than they were about 10 years ago. Dental schools have reacted to the
declining government support by increasing tuition and clinic revenue.
Medical school tuition has also increased rapidly but not nearly as
fast as medical service income.
Total Revenue (Figure 2.9 and Appendix Table A26J
The above sections describe the major revenue sources for U.S.
dental schools. As a result of these trends, real total revenue per
school grew at an average annual rate of 9.5 percent between 1968 and
1973. After 1973, the growth slowed to about 2 percent per year. As
a result of the expected increases in most revenue components--
especially tuition--the committee expects growth in total revenue to
continue through 1990 at about 4 percent per year, with upper and
lower limits on this estimate of 7 percent and 1 percent, respectively.
Average revenue in public dental schools has been consistently
higher than in private schools. Similarly, the faculty/student ratio
is higher in public schools--a fact that provides a basis for modeling
academic demand as explained in the next section.
43
10
9
8
7
6
5
4
3
2
1
o
-
1 _
68 70
Actual
Proj ec ted
Publ i c School s
__ ,- ___
__
.~ch°°~?
Pri vate School s
1 1 ' ~ l ~ , 1 , 1 1
72 74 76 78 80 82
PI SCAL YEAR
V<\0\~
,'
~,~S,(;
.~ ~
<~OlOly~
Low Estimate (1%/yr.)
______
84 86 88 90
FIGURE 2.9 Total revenue per school in U.S. dental schools, by control of institution, 1968-83,
with projections to 1990. See Appendix Table A18.
DEMAND FOR CLINICAL FACULTY IN DENTAL SCHOOLS
Given the behavior patterns discussed above regarding the
principal variables involved in dental education, the issue now
becomes one of trying to determine how they relate to one another.
Recall that the purpose of this analysis is to estimate the future
demand for full-time clinical faculty members in dental schools--and
ultimately to assess the need for training of dental clinical
investigators. The methodology that has been applied to a
corresponding analysis of medical schools involves the development of
a conceptual and empirical model of the interrelationships among the
variables. A similar approach will be applied here--the faculty/
student ratio is specified to depend on total revenue per school.
relevant data from 1970-83 are shown in Figure 2.10.
44
0.20
0.18
0.16
0.14
0.12
0.10
O.08
0.06
0.04
0.02
0.00
Pu bl i c School Is_
~~+Al 1 School s
eta
_~
~5
Private School s
0 1 2 3 4 5 6
TOTAL REVENUE PER SCHOOL (TS), (1972 $, millions)
FIGURE 2.10 Dental school clinical faculty/student ratio (CF/WS) vs. total revenue per dental
school (T/S). The ratio is defined as follows: CF = full-time faculty in clinical departments of U.S.
dental schools; WS = 4-year weighted average of students, i.e., (WS)t = 1/6(St + 2St 1 + 2St 2 +
St 3), where St = predoctoral, advanced specialty, and general purpose residency students in year t.
Solid line represents a growth curve of the form: Y = (K-C)exp(-ea~bX) + C with parameters K = 0.17,
C = 0.116, a = 5.388, b = 1.204. These were derived from 14 annual observations, 1970-83. See Ap-
nendix Tables A12, A13, and A18.
45
As in other bioscience areas, the observations form a nonlinear
pattern, suggesting that a constrained growth curve might provide an
adequate fit to the data. A Gompertz-type curve has been fitted to
the data and is shown as the solid line in Figure 2.10.~ 2
Using this model and the panel's assumptions about growth rates
through 1990, we may make estimates of demand for full-time clinical
faculty in dental schools (Figure 2.11~.
4,000
3,000
a:
LO
~4
z
i_
2, 000
an
LO
Cal
LO
Lo
~ 1 000
LO
=)
as
High Estimate (0.09%/yr ~
Actual ~~----_____ Middle Est.
------ Projected _ COO,, ~ "am · (-0~9~/yr. )
All School s em; by, '`
Publ i c Sc hoof s
_
-~4
- d'
,e,+~+.~.
.~. .~. ~ ~
Pri vate School s
~ .,,+ ~ ++ ~ +~+ +~+
.,e,+~+'*+
O ~ ~ · ~ ~ ~ . . . .
68 70 72 74 76 78 80 82 84 86 88 90
PI SCAL YEAR
FIGURE 2.11 Full-time faculty in clinical departments of dental schools, by control of institution,
1969-84, with projections to 1990. See Appendix Table A13.
2 The curve has the following mathematical form:
CF/WS = (K-C)exp[-ea~b(T)~+C
where: OF = full-time clinical faculty in U.S. dental schools
WS = 4-yr. weighted average of enrollments, i.e.,
WSt = 1/6 (St + 2St-1 + 2St-2 + St-3)
where: St = predoctoral plus advanced
specialty enrollments in year t,
T = total revenue per school in U.S. dental schools
(1972 $, millions).
a, b = parameters to be determined by the data.
K = asymptote: CF/WS ~ K as T If.
C = scaling constant
This function provides a good fit to the 14 annual observations
1970-83, with R2 = 0.95. The dotted lines in Figure 2.10 represent
the 95 percent confidence limits on the predicted values.
46
Under the panel's revenue assumptions, total revenue per school
would grow between 1 percent and 7 percent per year between 1983 and
1990, with a best guess of 4 percent per year. Combining these
estimates with the three assumptions about enrollment growth, we get
nine combinations of assumptions to consider. The projections of
faculty demand under each combination are shown in Table 2.6.
Under the combination of highest assumptions--I-A in Table 2.6--
full-time clinical faculty would grow to 3,810 from its 1983 level of
3,786 which gives a practically negligible number of new positions due
to expansion of faculty. But attrition due to death and retirement
would generate an estimated 60 positions and other attrition would
create another 190 vacancies for a total demand of 250 per year.
Under the best guess set of assumptions--II-B in Table 2.6--
faculty would decline slightly to about 3,550 by 1990. But attrition
would create 190 positions per year.
In the worst case envisioned by the panel--III-C in Table 2.6--
faculty would decline by about 90 positions per year, but attrition
would create about 150 vacancies per year for a net demand of about 60
positions per year.
POSTDOCTORAL TRAINING NEEDS FOR DENTAL SCHOOL CLINICAL FACULTY
The final step in this analysis of demand for dental clinical
faculty members is to translate the projections derived above into
recommended levels of training under NRSA programs. The procedure for
this is to determine the size of the pool of trainees necessary to
satisfy the projected demand using certain assumptions about how the
training system works. The methodology is similar to that applied to
medical schools but the parameter values used in the medical school
analysis are probably inappropriate to apply to the dental training
system. For example, there is justification for using an appreciably
higher figure than 35 percent with respect to the annual average
proportion of clinical dental faculty accessions with postdoctoral
research training. One reason for a higher figure is the growing
tendency for dental schools to restrict tenured and tenure-track
appointments in clinical departments to individuals with a background
of advanced education (specialty or general practice residency) and
research training. In addition, any effort to build a capability to
exploit the opportunities that have opened up in dental clinical
investigation must start from a more fragile base of faculty research
involvement than exists in medical schools. It is relevant in this
connection that 57 percent of D.D.S. faculty in clinical departments
reported a less than 10 percent involvement in research in academic
year 1983-84 (AADS, 1985~. The comparable portion of M.D. clinical
faculty in 1982 was 37 percent {Herman and Singer, 1985~.
Clinical specialty training has traditionally been interwoven with
training for research for most dentists who subsequently enter careers
in teaching and research By contrast, a physician generally enters
research training after completion of a standard residency. Since the
residency offers the physician little or no opportunity for investi-
gative experience, research training is often incorporated into
47
TABLE 2.6 Projected Growth in Dental School Clinical Faculty, 1983-90, Based on Projections
of Dental School Enrollment and Total Revenue per Schoola
Assumptions about
Dental Student
Enrollment (dental
students, general
purpose residency, and
advanced specialty
graduate students:
23,587 in 1984)
Assumptions about Total Revenue per School
(in constant 1972 dollarsb) in Dental Schools
($5.4 million per school in 1983)
Will expand at
about 7%/yr.
to $8.7 million
per school in
1990
II
Will expand
at about 4%/
yr. to $7.1
million per
school in 1990
III
Will expand
at about 1%/
yr. to $5.8
million per
school in 1990
A. Will decline to 22,380 Expected size of clinical faculty in
students by 1990 dental schools (CF) in 1990 3,810 3,760 3,540
Annual growth rate in CF from
1983 to 1990 0.09% - 0.08% - 0.09~o
Average annual increment due to
faculty expansion - 30
Annual replacement needs due to:
death and retirements 60 60 50
other attritions 190 170 110
Expected number of positions to
become available annually on
dental clinical faculties 250 230 130
B. Will decline to 21,050 Expected size of clinical faculty in
students by 1990 dental schools (CF) in 1990 3,590 3,550 3,340
Annual growth rate in CF from
1983 to 1990 -0.7% -0.9% - 1.8%
Average annual increment due to
faculty expansion - 30 - 30 - 60
Annual replacement needs due to:
death and retirements 60 60 50
other attritions 180 160 110
Expected number of positions to
become available annually on
dental clinical faculties 210 190 100
C. Will decline to 19,780 Expected size of clinical faculty in
students by 1990 dental schools (CF) in 1990 3,380 3,340 3,150
Annual growth rate in CF from
1983 to 1990 - 1.6% - 1.8% -2.6%
Average annual increment due to
faculty expansion 60 - 60 - 90
Annual replacement needs due to:
death and retirements 50 50 50
other attritions 180 160 100
Expected number of positions to
become available annually on
dental clinical faculties 170 150 60
aFaculty in this table is defined as a full-time appointment in a clinical department regardless of tenure status. These projections
are based on the following relationship:
(CF/WS)~ = (0.054)exp[e5~388~204(TS)~] + 0.116, where CF = size of clinical faculty in dental schools;
WS = weighted average of last 4 years of enrollments, i.e., (WS)~ = ~/~(S~ + 2S~ ~ + 2S~ 2 + St 3),
where S = dental students plus GPR and advanced specialty enrollments; (TS)~ = total revenue per school in U.S.
dental schools in year t (1972 $, millions). See Appendix Tables A12, A13, and A18.
Deflated by the Implicit GNP Price Deflator, 1972 = 100.0. See Appendix Table A7.
CBased on an estimated replacement rate of 1.5% annually due to death and retirement. See AAMC (1981a).
Eased on high, middle, and low attrition rates of 5%, 4.5%, and 4%, respectively.
48
subspecialty fellowships. For the dentist, therefore, research
training is pursued in a period equivalent to a residency, while for
the physician it is most commonly a post-residency phenomenon.
Advanced education in one of the eight dental specialties takes
place predominantly in dental schools, and to a much lesser extent in
other institutions. By contrast, residency training to meet basic
specialty board requirements for physicians is not focused on the
university campus, but occurs primarily in teaching hospitals.
The primary mechanism used by NIH for research training of
dentists and physicians is the NRSA institutional training grant.
Because of the link between research and specialty training for the
dentist, it is far more likely to exceed the 3-year limit on NRSA
postdoctoral support and to require a waiver than is the case for M.D.
research trainees.
Dentists are faced with a serious disincentive to pursue training
as clinical investigators. Whereas the young physician receives a
salary and benefits as a hospital resident and subspecialty fellow,
similar payment for the newly graduated dentist is limited largely to
hospital-based training in oral surgery or oral pathology. Training
in the other specialties rarely provides compensation and may indeed
require tuition payment by the trainees. Consequently, NRSA training
programs for dentists commonly include support for a clinical training
component.
Although NIH represents the largest single source of support for
postdoctoral research training of physicians, a multiplicity of
private foundations, voluntary agencies, and industry-related
organizations underwrite the preparation of physician-scientists. By
contrast, the NIDR is essentially the only sponsor for the training of
dental investigators through its NRSA postdoctoral programs and
associated career development opportunities.
The parameters of a research training system for dental clinical
investigators and the calculations leading to estimates of
postdoctoral needs are laid out in Table 2.7.
Line 1 of Table 2.7 is a summary of the projections of demand for
dental clinical faculty from the model.
Line 2 is an estimate of the contribution to demand generated by
the need for clinical faculty in nondental institutions. This demand
is estimated to be about 10 percent of dental school demand.
Line 3 shows total annual demand under each of three revenue
conditions. In the best-guess case, we expect about 210 positions to
be available each year through 1990.
Line 4 shows the number of accessions to dental school clinical
faculties that should have some postdoctoral research training. Since
there are currently so few qualified dental clinical investigators, a
strong effort should be made to bolster the research capability of
dental schools. One way of doing this is to try to modify the system
such that about 1/2 of all newly hired faculty members in clinical
departments of dental schools have some postdoctoral research
training. Applying this factor, the best-guess case yields an
estimate of 105 new hires needed each year with research training.
49
TABLE 2.7 Estimated Number of Dental Clinical Research Postdoctoral Trainees Needed to
Meet Expected Demand for Dental Clinical Faculty Through 1990 Under Various Conditions
Projected Through 1990
High
Estimate
Middle
Estimate
Low
Estimate
Annual
Average
1981-84
1. Demand for full-time clinical faculty-
annual average: 250 190 60 340
a. due to expansion of faculty 30 - 90 130
b. due to death and retirements 60 60 50 40
c. due to other attritions 190 160 100 170
2. Demand for clinical faculty outside of
dental schools 25 20 10
3. Total annual accessions (expected
demand) 275 210 70
4. Total accessions with postdoctoral
research training- annual average
(assuming ~/z of all accessions have
postdoctoral research training) 140 105 35
5. Size of dental clinical science
postdoctoral pool annual average
Size needed to meet academic
demand assuming a 3-year training
period and portion of trainees
seeking dental clinical faculty
positions is:
a. 80% 520 400 130
b. 70% 600 450 150
6. Annual number of dental clinical
science postdoctoral trainees to be
supported under NRSA programs:
a. if 80% of pool is supported under
NRSA
b. if 90% of pool is supported under
NRSA
124
420-480 320-360 100-120
470-540 360000 120-130
a Assumes an attrition rate due to death and retirement of 1.5% per year. See AAMC (1981a).
b Assumes high, middle, and low attrition rates of To, 4.5%, and 4%, respectively.
c In FY 1982 there were 1,686 students enrolled in residency programs (specialty and general practice) in nondental school
institutions. These programs are usually taught by full-time program directors at those institutions, of which there were 309
in 1982. The demand for faculty generated by these programs is estimated to be about 104Yo of dental school demand.
Accessions are defined as new hires or those who rejoin faculties from nonfaculty positions. Interfaculty transfers are not
counted as accessions.
SOURCE: Table 2.6.
50
Line 5 gives the size of the dental postdoctoral research training
pool needed to supply the necessary number of trained dental
scientists assuming that the training period lasts three years and
allowing for some attrition from the pool to nonacademic positions.
There is little, if any, support for dental research training
available from sources other than the federal government. Therefore,
line 6 calculates the number of trainees needed in NRSA programs
assuming that these programs support 80 or 90 percent of the total
pool of postdoctoral trainees in dental research. In the best-guess
case, the range is between 320 and 400 postdoctoral trainees.
SUMMARY
Projections of demand for full-time clinical faculty in medical,
dental, and veterinary schools have been made through 1990, and then
translated into numbers of clinical science postdoctoral trainees
needed to satisfy this demand under specified conditions which define
the training system. The committee's best estimates are as follows:
Annual Number of Clinical
Sci. Postdoctoral Trainees
Needed Under NRSA Programs
For clinical faculty in medical
and veterinary schools: 2,250 - 3,240
For clinical faculty in dental schools: 320 - 400
Total: 2,570 - 3,640
This spread of estimates is partly due to the difficulty inherent
in making assumptions about the future levels of revenue, especially
at a time when medical schools are facing possible dramatic changes
brought on by demography, a potential physician surplus, and by
efforts to curtail the growth in medicare/medicaid expenditures. And
it is partly due to the fact that for the first time in more than 25
years, medical school enrollments are expected to decline while
revenue is expected to continue to grow. The effect of these
disparate trends on the size of clinical faculties cannot be
determined with any specificity, and this uncertainty carries over
into the assessment of training needs.
The committee's estimates of training needs through 1990 are
somewhat higher than previous estimates published in its 1983 report.
The principal reasons for this are, first, that we foresee faster
growth in the financial factor in the demand model {total revenue)
than we had projected through 1988. Second, we are recommending an
adjustment to the training system for clinical scientists wherein the
average length of the postdoctoral research training period is
increased from two to two and one-half years. Third, we estimate that
attrition due to death and retirement will begin to increase between
1983 and 1990 along with the age distribution of the faculty.
Finally, our examination of the training system for dental researchers
reveals that it is substantially different from the medical researchers
training system, and in our opinion deserves special consideration.
