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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

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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.

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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.

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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,

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.