THE CONTINUING DILEMMA IN CLINICAL INVESTIGATION AND THE FUTURE OF AMERICAN HEALTH-CARE - A SYSTEMWIDE PROBLEM REQUIRING COLLABORATIVE SOLUTIONS

American medicine faces a paradox: on the one hand, decades of basic s cience research have produced fundamental insights into disease mechan isms. On the other, there has rarely been a more difficult environment for the training and employment of clinical investigators, who perfor m the research that translates basic biomedical knowledge into practic al advances in patient cart. The authors explain the historical roots of this crisis and the lack of data about specific workforce needs for clinical investigators, discuss long-standing difficulties of recruit ing, training, and retaining these scientists (e.g., time-consuming tr aining, inadequate emphasis on clinical research in medical school, fe wer role models) and why these processes are becoming more difficult ( e.g., a coming flattening of federal support for research; the impact of managed care on academic health centers). In confronting this probl em, the authors stress the importance of (1) carefully defining the ma jor subtypes of clinical investigation (i.e., physiologic investigatio n, outcomes research, and clinical trials) and noting which are and wh ich are not endangered; (2) understanding the potential solutions to t he problem that have been offered in the past; and (3) defining and ho pefully marshaling a coalition of those institutions whose resources a re currently available to address the problem and that have an importa nt stake in its solution: academic health centers, the National Instit utes of Hearth, health care providers, foundations and educational soc ieties, medical schools, and industry. The authors stress that finding solutions to the current problem are a shared responsibility that mus t be carried out, for without well-trained and innovative clinical inv estigators, the social contract of biomedical research - to keep socie ty well - cannot be fulfilled.