Editoria ls··------- ------Pulmonary Research Training-A Changing Scene Since the middle ages, when the great universities of Paris and Montpellier, Bologna and Padua, Oxford and Cambridge were the milieu in which early biomedical science was nourished and from which the early great leaders in anatomy and medicine emerged, graduate training has been a tradition in all civilized societies. While this tradition has persisted and expanded, there have been changes in social needs and economic constraints that now raise questions: Who should be trained? For what purpose? By whom? At whose expense? These issues about postgraduate training encompass all aspects of medicine and biomedical science. But they are of particular concern to the pulmonary academic community, which untill970 had no focal point for its programs. Indeed, the pulmonary field is only now beginning to tap the rich resources of the fundamental disciplines, disciplines with so much to contribute to elucidating the problems of pulmonary disorders. And only since 1972 have opportunities been available to improve and expand pulmonary academic medicine and to extend these benefits into the community. Since its inception, the National Institutes of Health (NIH) has been committed to postdoctoral research training as essential to the development and maintenance of a responsive, highquality national program in both clinical and health-related fundamental research. Not alone in this effort, NIH activities have been paralleled by those of other federal agencies, private foundations, professional societies, voluntary agencies, and other nonfederal organizations. From 1937, when the National Cancer Act authorized establishment of training facilities and fellowship awards, the NIH role in training expanded until the late 1960s. Training expenditures increased as new institutes developed within the NIH and reached an all-time high of $168 million in 1968. While NIH funds allocated to research training activities have remained fairly constant since then, the "real" dollars have actually decreased as a consequence of inflation. Of even greater impact on postgraduate train-
ing than the reduction in actual dollar expenditures are the changing attitudes within the federal government. In the early 1970s, the Office of Management and Budget began to require specific justification for all training and fellowship programs. President Nixon's budget message to Congress in 1973 recommended no new starts for research training grants and fellowships at the NIH, a recommendation that elicited strong opposition from both the scientific community and the Congress. To temper this criticism, the "Weinberger Fellowship" permitted research training for individuals but prohibited training grants to institutions unless specific needs could be identified. The National Research Service Award (NRSA) Actl passed by the Congress in July 1974 recognizes that " ... the success and continued viability of the Federal biomedical and behavioral research effort depends on the availability of excellent scientists and a network of institutions of excellence capable of producing superior research personnel ... ," and that " ... graduate research assistance programs should be the key elements in the training programs of the Institutes of the National Institutes of Health .... " While providing for National Service Awards to individuals, or to institutions for individuals, the Act limits such awards to subject areas for which a need for personnel has been determined through "a continuing study." Moreover, the Act includes a "payback" requirement that must be discharged by the recipient of the award, either through service requirements specified in the Act or through financial reimbursement to the United States according to a formula. The challenge of the NRSA Act resides in the language of Section 473 (a), which identifies the types of information to be obtained through 1 Public Law 93-348 National Research Act, Title I, National Research Service Award, October 1974. Copies may be obtained by writing to Senate Document Room, Room S-325, Capitol Building, Washington, D.C. 20510.
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME Jl3, 1976
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"a continuing study" required to justify National Research Service Awards in specific subject areas. In addition to establishing " ... the Nation's overall need for biomedical and behavioral research personnel ... ," the study must -identify subject areas in which personnel are needed, the number of personnel needed in each subject area, and the kinds and extent of training that should be provided to personnel in the subject area; -assess current training programs, both those conducted under the NRSA Act through Institutes at the :"'IIIH and other programs available for similar training; -determine (to the extent feasible) whether current training programs would be adequate to meet the identified needs if programs under the NRSA Act were terminated, and also what modifications in both NRSA and other current training programs are required if the needs for personnel in specific subject areas are to be met. In conformance with Section 473 (b) (1) of the NRSA Act, the National Research Council of the National Academy of Sciences is examining resources and needs relative to biomedical manpower, as required under Section 473 (a), which is summarized above. Although the importance of such a study is not in question, its achievement is a formidable task, requiring data not yet available as well as the development of appropriate procedures for analysis and interpretation. To provide continuity to NIH training programs under the NRSA Act, the Institutes were invited, as an interim arrangement, to make their own assessments of subject areas in which training opportunities are needed. The Division of Lung Diseases of the National Heart and Lung Institute identified biochemistry, cell biology, immunology, genetics, and bioengineering as subject areas with special relevance to the pathogenesis, diagnosis, and management of a spectrum of pulmonary diseases from acute to chronic. Because investigators in these basic disciplines only rarely perceive the problems of pulmonary diseases to which their expertise can contribute, the Division's NRSA program emphasizes interdisciplinary training. Physicians conversant with clinical manifestations of pulmonary disorders are encouraged to receive training in basic disciplines and, conversely, basic scientists are encouraged to train in clinical settings where they can acquaint themselves with pulmonary diseases, especially emphysema and
chronic bronchitis, fibrotic and immunologic pulmonary diseases, pediatric pulmonary diseases, pulmonary vascular diseases, and respiratory failure. How the questions posed by the NRSA Act relate to problems faced by the pulmonary community in general and the Division of Lung Diseases of the National Heart and Lung Institute in particular are briefly discussed below. A 1972 survey2 conducted by a committee of the American Thoracic Society and the American College of Chest Physicians in collaboration with the subspecialty Board on Pulmonary Diseases of the American Board of Internal Medicine assessed the availability of and need for professional pulmonary manpower. The report states: ... as has been documented convincingly by the results of this survey, there is a serious discrepancy between the number of chest physicians currently being trained, and the number of chest physicians needed now and desired in the future. A follow-up study in 1975, conducted at the request of the President of the American Thoracic Society by an Ad hoc Committee to Survey Pulmonary Disease Manpower, compared manpower availability and needs with the 1972 survey. The report states: The severe shortage of physicians and scientists involved in teaching, patient care and research related to pulmonary disease persists. Although the total number of faculty in departments of medicine and pediatrics has increased during the last four years, the number of available funded positions has increased proportionately more; thus the total number of vacancies is more than twice as great now as in 1971-72. In addition to the question of numbers, the 1972 report spoke to other issues: The association of the basic scientist with the clinical physician is therefore a particularly vital and fruitful one, which the Committee feels should be categorically acknowledged and supported. Interdisciplinary research among scientists from fields such as biochemistry, pharmacology, immunology and anatomy, performed in laboratories and in clinical units, is unquestionably the best investigative approach to the current mysteries concern· 2 Survey of Professional Manpower in Pulmonary Diseases, November 1972: Prepared for National Heart and Lung Institute by Manpower Survey Committee of the American Thoracic Society and the American College of Chest Physicians.
EDITORIAL
ing the cause and treatment of many chest diseases. Obviously, future medical school faculty members cannot be trained satisfactorily at those same institutions which need them most owing to the lack of training resources, but will have to go elsewhere for such training. Taken together, this inform ation suggests that training for medical school faculties should be concentrated in the few large training centers which already have demonstrated capabilities ....
Pending the report of the National Research Council, and development of systematic approaches to identifying subject areas where training is needed, the Division of Lung Diseases supports pulmonary training through such NIHwide mechanisms as the National Research Service Award to individuals and institutions, and the Research Career Development Award. In addition to the needs (discussed above) that are being addressed through the NRSA program, the Division is meeting other needs (identified in the report of the 1972 manpower survey) through special initiatives. These support activities, designed to strengthen the academic environment in which pulmonary training is provided and to foster pulmonary research by competent young investigators, are the Pulmonary Academic Award Program, initiated December 1970; the Young Investigator Pulmonary Research Grant Program, initiated August 1973; the National Pulmonary Faculty Training Program, initiated December 1974. The intent of the Pulmonary Academic Award is to make the pulmonary specialty more attractive and at the same time to provide all medical students with a more challenging pulmonary curriculum. Limited to one for each school of medicine or osteopathy that qualifies, the award provides a salary for a pulmonary physician who will commit his or her major effort for a period of 5 years to teaching, planning, and implementing a pulmonary curriculmn for medical students. The award also provides the opportunity for the recipient to expand his or her knowledge of pulmonary diseases and teaching methodology, and to meet regularly with other Pulmonary Academic Awardees to discuss problems of mutual concern. To enable physicians and scientists to pursue a project of their own design, the Young Inves· tigator Pulmonary Research Grant provides modest support for a 2-year period for a project that can be completed within that time. This pro-
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gram is not limited to investigators from basic disciplines, but one of its important objectives is to attract such investigators into pulmonary-related research. The Division's newest program, the National Pulmonary Faculty Training Program, is designed to enable junior faculty from medical schools that do not have outstanding training opportunities in pulmonary diseases to obtain such training at centers that have an exceptional tradition in pulmonary research training. A small number of grants have been awarded to such exceptional Training Centers (announced in the REVIEW, September 1975). A competition is now in progress to enable schools to sponsor candidates who will receive training at one or more of these centers. The changing scene for pursuing pulmonary research and academic training and the challenge this presents to the biomedical community are briefly described above. The challenge is in reality an opportunity, an opportunity for the pulmonary community to present its evidence and defend its requests. But the evidence must be convincing, the requests realistic. The past bipartite relationship between the NIH and the pulmonary community that it serves is now a tripartite relationship, with an additional body, represented by the National Research Council of the National Academy of Sciences, charged with continuing assessment of both what is required and the effectiveness of what is being done. That the pulmonary community is well able to meet the challenge is evidenced by the forward-looking manpower surveys of 1972 and 1975 that were undertaken by the American Thoracic Society and the American College of Chest Physicians. The pulmonary community and the NIH must persist in and refine this effort by providing continuing and realistic assessments of pulmonary manpower requirements as well as critical evaluations of existing training programs to determine whether they meet their objectives. Parallel to these efforts must be assessments of the social scene to determine the need for, and availability of, pulmonary care. And finally, the pulmonary community must find innovative ways to match available resources to community and individual needs. CLAUDE LENFANT
JAY MosKoWITZ Division of Lung Diseases National Heart and Lung Institute
ing than the reduction in actual dollar expenditures are the changing attitudes within the federal government. In the early 1970s, the Office of Management and Budget began to require specific justification for all training and fellowship programs. President Nixon's budget message to Congress in 1973 recommended no new starts for research training grants and fellowships at the NIH, a recommendation that elicited strong opposition from both the scientific community and the Congress. To temper this criticism, the "Weinberger Fellowship" permitted research training for individuals but prohibited training grants to institutions unless specific needs could be identified. The National Research Service Award (NRSA) Actl passed by the Congress in July 1974 recognizes that " ... the success and continued viability of the Federal biomedical and behavioral research effort depends on the availability of excellent scientists and a network of institutions of excellence capable of producing superior research personnel ... ," and that " ... graduate research assistance programs should be the key elements in the training programs of the Institutes of the National Institutes of Health .... " While providing for National Service Awards to individuals, or to institutions for individuals, the Act limits such awards to subject areas for which a need for personnel has been determined through "a continuing study." Moreover, the Act includes a "payback" requirement that must be discharged by the recipient of the award, either through service requirements specified in the Act or through financial reimbursement to the United States according to a formula. The challenge of the NRSA Act resides in the language of Section 473 (a), which identifies the types of information to be obtained through 1 Public Law 93-348 National Research Act, Title I, National Research Service Award, October 1974. Copies may be obtained by writing to Senate Document Room, Room S-325, Capitol Building, Washington, D.C. 20510.
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME Jl3, 1976
103
104
EDITORIAL
"a continuing study" required to justify National Research Service Awards in specific subject areas. In addition to establishing " ... the Nation's overall need for biomedical and behavioral research personnel ... ," the study must -identify subject areas in which personnel are needed, the number of personnel needed in each subject area, and the kinds and extent of training that should be provided to personnel in the subject area; -assess current training programs, both those conducted under the NRSA Act through Institutes at the :"'IIIH and other programs available for similar training; -determine (to the extent feasible) whether current training programs would be adequate to meet the identified needs if programs under the NRSA Act were terminated, and also what modifications in both NRSA and other current training programs are required if the needs for personnel in specific subject areas are to be met. In conformance with Section 473 (b) (1) of the NRSA Act, the National Research Council of the National Academy of Sciences is examining resources and needs relative to biomedical manpower, as required under Section 473 (a), which is summarized above. Although the importance of such a study is not in question, its achievement is a formidable task, requiring data not yet available as well as the development of appropriate procedures for analysis and interpretation. To provide continuity to NIH training programs under the NRSA Act, the Institutes were invited, as an interim arrangement, to make their own assessments of subject areas in which training opportunities are needed. The Division of Lung Diseases of the National Heart and Lung Institute identified biochemistry, cell biology, immunology, genetics, and bioengineering as subject areas with special relevance to the pathogenesis, diagnosis, and management of a spectrum of pulmonary diseases from acute to chronic. Because investigators in these basic disciplines only rarely perceive the problems of pulmonary diseases to which their expertise can contribute, the Division's NRSA program emphasizes interdisciplinary training. Physicians conversant with clinical manifestations of pulmonary disorders are encouraged to receive training in basic disciplines and, conversely, basic scientists are encouraged to train in clinical settings where they can acquaint themselves with pulmonary diseases, especially emphysema and
chronic bronchitis, fibrotic and immunologic pulmonary diseases, pediatric pulmonary diseases, pulmonary vascular diseases, and respiratory failure. How the questions posed by the NRSA Act relate to problems faced by the pulmonary community in general and the Division of Lung Diseases of the National Heart and Lung Institute in particular are briefly discussed below. A 1972 survey2 conducted by a committee of the American Thoracic Society and the American College of Chest Physicians in collaboration with the subspecialty Board on Pulmonary Diseases of the American Board of Internal Medicine assessed the availability of and need for professional pulmonary manpower. The report states: ... as has been documented convincingly by the results of this survey, there is a serious discrepancy between the number of chest physicians currently being trained, and the number of chest physicians needed now and desired in the future. A follow-up study in 1975, conducted at the request of the President of the American Thoracic Society by an Ad hoc Committee to Survey Pulmonary Disease Manpower, compared manpower availability and needs with the 1972 survey. The report states: The severe shortage of physicians and scientists involved in teaching, patient care and research related to pulmonary disease persists. Although the total number of faculty in departments of medicine and pediatrics has increased during the last four years, the number of available funded positions has increased proportionately more; thus the total number of vacancies is more than twice as great now as in 1971-72. In addition to the question of numbers, the 1972 report spoke to other issues: The association of the basic scientist with the clinical physician is therefore a particularly vital and fruitful one, which the Committee feels should be categorically acknowledged and supported. Interdisciplinary research among scientists from fields such as biochemistry, pharmacology, immunology and anatomy, performed in laboratories and in clinical units, is unquestionably the best investigative approach to the current mysteries concern· 2 Survey of Professional Manpower in Pulmonary Diseases, November 1972: Prepared for National Heart and Lung Institute by Manpower Survey Committee of the American Thoracic Society and the American College of Chest Physicians.
EDITORIAL
ing the cause and treatment of many chest diseases. Obviously, future medical school faculty members cannot be trained satisfactorily at those same institutions which need them most owing to the lack of training resources, but will have to go elsewhere for such training. Taken together, this inform ation suggests that training for medical school faculties should be concentrated in the few large training centers which already have demonstrated capabilities ....
Pending the report of the National Research Council, and development of systematic approaches to identifying subject areas where training is needed, the Division of Lung Diseases supports pulmonary training through such NIHwide mechanisms as the National Research Service Award to individuals and institutions, and the Research Career Development Award. In addition to the needs (discussed above) that are being addressed through the NRSA program, the Division is meeting other needs (identified in the report of the 1972 manpower survey) through special initiatives. These support activities, designed to strengthen the academic environment in which pulmonary training is provided and to foster pulmonary research by competent young investigators, are the Pulmonary Academic Award Program, initiated December 1970; the Young Investigator Pulmonary Research Grant Program, initiated August 1973; the National Pulmonary Faculty Training Program, initiated December 1974. The intent of the Pulmonary Academic Award is to make the pulmonary specialty more attractive and at the same time to provide all medical students with a more challenging pulmonary curriculum. Limited to one for each school of medicine or osteopathy that qualifies, the award provides a salary for a pulmonary physician who will commit his or her major effort for a period of 5 years to teaching, planning, and implementing a pulmonary curriculmn for medical students. The award also provides the opportunity for the recipient to expand his or her knowledge of pulmonary diseases and teaching methodology, and to meet regularly with other Pulmonary Academic Awardees to discuss problems of mutual concern. To enable physicians and scientists to pursue a project of their own design, the Young Inves· tigator Pulmonary Research Grant provides modest support for a 2-year period for a project that can be completed within that time. This pro-
105
gram is not limited to investigators from basic disciplines, but one of its important objectives is to attract such investigators into pulmonary-related research. The Division's newest program, the National Pulmonary Faculty Training Program, is designed to enable junior faculty from medical schools that do not have outstanding training opportunities in pulmonary diseases to obtain such training at centers that have an exceptional tradition in pulmonary research training. A small number of grants have been awarded to such exceptional Training Centers (announced in the REVIEW, September 1975). A competition is now in progress to enable schools to sponsor candidates who will receive training at one or more of these centers. The changing scene for pursuing pulmonary research and academic training and the challenge this presents to the biomedical community are briefly described above. The challenge is in reality an opportunity, an opportunity for the pulmonary community to present its evidence and defend its requests. But the evidence must be convincing, the requests realistic. The past bipartite relationship between the NIH and the pulmonary community that it serves is now a tripartite relationship, with an additional body, represented by the National Research Council of the National Academy of Sciences, charged with continuing assessment of both what is required and the effectiveness of what is being done. That the pulmonary community is well able to meet the challenge is evidenced by the forward-looking manpower surveys of 1972 and 1975 that were undertaken by the American Thoracic Society and the American College of Chest Physicians. The pulmonary community and the NIH must persist in and refine this effort by providing continuing and realistic assessments of pulmonary manpower requirements as well as critical evaluations of existing training programs to determine whether they meet their objectives. Parallel to these efforts must be assessments of the social scene to determine the need for, and availability of, pulmonary care. And finally, the pulmonary community must find innovative ways to match available resources to community and individual needs. CLAUDE LENFANT
JAY MosKoWITZ Division of Lung Diseases National Heart and Lung Institute
