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3.4.1. Research training fellowships: the ideal start The experience of research funding agencies is that young doctors have not lost interest in research. There continues to be strong competition for the 150 or so research training fellowships available each year which provide around three years of well-designed, wellsupervised full-time research training; the ideal first step in the development of an academic career. Indeed, it is a widespread perception that in the last few years previous tenure of an externally-funded research training fellowship leading to a PhD or MD research degree has become the rule rather than the exception for new appointees to senior clinical academic appointments in the stronger disciplines. 3.4.2. Intermediate level fellowships: the next step for a few Although research-funding bodies have recognised the importance of post-doctoral research training in the career development of clinical academics (often abroad or away from base), opportunities for post-doctoral intermediate level fellowships are few in number. In part, this reflects the evolution of such fellowships as a means to maintain a cadre of very able young clinical scientists to serve as candidates for senior clinical fellow ships (see 3.4.3). However, the limited number of such awards also reflects their greater cost. Not only is the intermediate fellow’s salary provided for up to five years (during which time many fellows finish clinical training and are paid as honorary consultants) but also there is often the award of full consumable costs and technician support. Indeed, in highly sought-after intermediate fellowships styled as clinician scientist programmes, bodies such as the MRC and Wellcome Trust will allow significant time out of the research programme to continue/ complete clinical training - some five year Wellcome fellows may spend as much as 40% of their time in clinical work. Nevertheless, these privileges are for the few - although the MRC seeks to appoint nearly 50 research training fellows annually, recent years have seen about 10 clinician scientist appointments each year. The quality of intermediate fellows 12 Report of the Academy of Medical Sciences

is therefore very high; although intermediate level fellowships might be viewed as being broadly equivalent to clinical lectureships, we are aware of a number of intermediate fellows who have proceeded directly to clinical chairs. 3.4.3. Senior clinical research fellowships: the ‘jewel in the crown’ Each year a very small number (e.g. four per year at the MRC) of outstanding clinical scientists secure highly sought-after senior clinical research fellowships. These enable them to build internationally significant programmes of research over a five to 10 year period without the heavy clinical and teaching commitments typically borne by those in the senior clinical lecturer grade. Senior fellows are very attractive targets for proactive search committees seeking to fill chair vacancies. 3.5 Given research funding agency support, why should there be a problem in recruitment? It should be obvious that clinical academic medicine owes a large debt of gratitude to UK research funders but it may seem surprising that there is strong competition for fellowships on one hand, while on the other there is a dearth of senior candidates for university academic vacancies. A number of factors contribute to this apparent paradox: 3.5.1. Fellowships are limited in number Although career track analysis and workforce planning in clinical academic medicine are beset with a lack of hard data (see 3.6 below) it should be obvious that externally-funded career development programmes cannot meet demand. In the quite justifiable pursuit of excellence, research funders find it costeffective to concentrate on a small number of outstanding investigators; only 10 or so senior clinical fellows are appointed each year by the MRC, Wellcome Trust and other funders. This represents a very small stock of clinical scientists which cannot possibly ensure that all existing clinical chairs in 24 established undergraduate medical schools and the three new schools are kept filled, let alone fuel expansion of newer clinical academic disciplines.

The tenure-track clinician scientist: a new career pathway to promote recruitment