The continuing dilemma in clinical investigation and the future of American health care: A system-wide problem requiring collaborative solutions

American medicine faces a paradox: on the one hand, decades of basic science research have produced fundamental insights into disease mechanisms. On the other, there has rarely been a more difficult environment for the training and employment of clinical investigators, who perform the research that translates basic biomedical knowledge into practical 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 recruiting, training, and retaining these scientists (e.g., time-consuming training, inadequate emphasis on clinical research in medical school, fewer 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 problem, the authors stress the importance of (1) carefully defining the major subtypes of clinical investigation (i.e., physiologic investigation, outcomes research, and clinical trials) and noting which are and which are not endangered; (2) understanding the potential solutions to the problem that have been offered in the past; and (3) defining and hopefully marshaling a coalition of those institutions whose resources are currently available to address the problem and that have an important stake in its solution: academic health centers, the National Institutes of Hearth, health care providers, foundations and educational societies, medical schools, and industry. The authors stress that finding solutions to the current problem are a shared responsibility that must be carried out, for without well-trained and innovative clinical investigators, the social contract of biomedical research - to keep society well - cannot be fulfilled.