The U.S. Public's Investment in Medical Research: An Evolving Social Contract.

Medical researchers and their institutions are operating under extraordinary financial stress. More than a decade after completion of the 5-year doubling of the National Institutes of Health budget, the medical research community must confront a significant loss in National Institutes of Health purchasing power and downward pressures in federal discretionary spending. In part, this trend results from a federal budget stalemate over the growth in entitlement programs, particularly spending on medical care. This article considers the changing nature of the federal investment in medical research and the potential for medical researchers and institutions conducting the full spectrum of research to improve health system performance and health equity. In our view, continued federal investments reflect an evolving social contract for research serving the public good; the term contract is used metaphorically to represent a figurative, implicit agreement between the scientific community and the public's representatives in government. Under this conceptual contract, the American people--who are ultimately the funders of research, research training and infrastructure--expect outcomes that lead to better health, security or other benefits. The evolving contract includes expectations for more accountability, transparency, sharing of results and resources, and better integration of research systems and cultures that used to take pride in boundaries and distinctions. We outline here some of the major movements of organizations realigning to social support, which are increasingly essential to sustain public investment in medical research.

Commentary: Putting evidence to work: an expanded research agenda for academic medicine in the era of health care reform.

The historic Patient Protection and Affordable Care Act (HR 3590) signed into law by President Obama has brought into sharp focus the need and opportunity for an expanded continuum of biomedical research. An updated research agenda must build on basic science and classical clinical investigation to place a more deliberate emphasis on patient- and population-outcome-oriented science and to apply science to help transform our current inefficient and expensive health care system into a more evidence-based system of effective, coordinated, safe, and patient-centered health care. If academic medicine is to play a leading role in this 21st-century transformation of health care through research, as it did in the 20th century, those in the community must think strategically about what needs to be done to be part of the solution for transforming the nation's health care delivery systems and prevention strategies, and the changes in institutional, organizational, and individual behaviors and values required to get there. Not all institutions will engage in the science called for in health care reform, but for those institutions with the interest, capacity, and resources to move forward, what is needed?

New physician-investigators receiving National Institutes of Health research project grants: a historical perspective on the "endangered species".

CONTEXT: Although concerns have persisted for decades about the production of new physician clinical scientists and their success in receiving and sustaining research supported by the National Institutes of Health (NIH), no comprehensive analysis documents the experiences of first-time investigators with an MD over a long period. OBJECTIVE: To ascertain the perseverance and comparative success of physician-scientists competing for NIH research (R01) grants awarded over 40 years. DESIGN, SETTING, AND PARTICIPANTS: A longitudinal, comparative study of all first-time applicants and recipients of NIH R01 grants between 1964 and 2004 stratified by the principal investigators' major degrees (MD, PhD, or MD and PhD) and their proposed involvement in research of humans or human tissues. MAIN OUTCOME MEASURES: Number of first- and second-time NIH R01 grant applicants and recipients by academic degree and by research type (clinical vs nonclinical). RESULTS: The annual number of first-time investigators with an MD only as NIH R01 grant applicants remained remarkably stable over 4 decades (41-year mean of 707 [range, 537-983] applicants). Among first-time applicants, those with an MD consistently had less success in obtaining funding (mean annual percentage [MAP], 28%) than either investigators with a PhD (MAP, 31%; P = .03 vs MD only) or both an MD and a PhD (MAP, 34%; P<.001 vs MD only and P = .002 vs PhD only). Among investigators who obtained a first R01 grant, those with an MD were consistently less likely (MAP, 70%) than those with a PhD (MAP, 73%; P = .04 vs MD only) or those with an MD and a PhD (MAP, 78%; P<.001 vs MD only and P = .007 vs PhD only) to obtain a subsequent R01 grant. First-time applicants with an MD were much more likely to propose clinical research (MAP, 67%) than applicants with an MD and a PhD (MAP, 43%) and applicants with a PhD only (39%). First-time applicants with an MD only who proposed clinical research were funded at lower rates than their MD-only counterparts proposing nonclinical research (23% vs 29%, respectively; P<.001). CONCLUSIONS: From 1964-2004, the number of physician-investigators applying for first R01 grants showed little net change. Physician-investigators consistently experienced higher rates of attrition and failure, even after receiving a first R01 grant, and those proposing clinical research were less successful in obtaining funding than physicians proposing nonclinical research.

Contributions of international medical graduates to US biomedical research: The experience of US medical schools.

International medical graduates (IMGs) constitute an appreciable fraction of full-time faculty at US medical schools and of principal investigators (PIs) on National Institutes of Health (NIH) research project grants. Information from the Faculty Roster of the Association of American Medical Colleges (AAMC) and from the NIH Consolidated Grant Applicant File (CGAF) was examined to assess IMGs' contribution to US medical school faculty and research. The study found that the number of IMG full-time faculty more than doubled over two decades-from 7,866 individuals in 1984 to 17,085 individuals in 2004, but that IMGs remained relatively stable as a share of physician full-time faculty (from 18.8 to 19.4%); the share is somewhat higher (20.0% of full-time physician faculty in 1984 to 23.7% in 2004) if faculty with degrees of unknown provenance are included. From 1984 to 2004, IMGs increased as a share of full-time physician faculty who are principal investigators on NIH research grants from 16.5% (540) to 21.3% (1,143). Including faculty with incomplete data on degree provenance, the corresponding IMG share increases to 18.0 and 24.0% respectively. Thus, IMGs comprise at least one-fifth and more likely one-fourth of all full-time faculty physicians who are PIs on NIH research project grants. The proportion of IMG full-time physician faculty who are in basic science departments is about twice that of their US/Canadian counterparts, as is the proportion of IMG physician PIs. Slightly fewer than half (48%) of full-time IMG faculty PIs pursue human subjects research (as coded by the NIH), while the majority of US/Canadian counterparts pursue human subjects research.