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History of Academic Medicine The Vietnam War and Medical Research: Untold Legacy of the U.S. Doctor Draft and the NIH "Yellow Berets" Sandeep Khot, MD, MPH, Buhm Soon Park, PhD, and W.T. Longstreth, Jr, MD, MPH Abstract Purpose during 1953-1973. Using databases, Associates were also more likely to hold From the outbreak of the Korean War in they compared later academic positions positions at top-ranked medical schools, 1950 through the end of the Vietnam of associates with those of nonassociate to fill leadership roles in the NIH, and to War in 1973, many American physicians peers who also entered academia and win prestigious awards and honorary were inducted into military service identified associates with prestigious society memberships. through the Doctor Draft. Some fulfilled awards or honorary society their obligations by conducting clinical memberships. research in the National Institutes of Conclusions Health (NIH) Associate Training Program Results The physician-scientists trained in the The cadre of physician-scientists (ATP) and later labeled themselves trained in the ATP during the Doctor "Yellow Berets." The authors examined selective ATP were highly qualified individuals who received training and Draft rose through the academic ranks the history of the ATP and its influence networking opportunities not available to to leadership roles and continued their on NIH associates' future careers. others. They were approximately 1.5 productive scientific collaborations. Method times as likely as nonassociates to Their legacy continues to have Via interviews with former associates and become a full professor, twice as likely to implications for medical research today, archival research, the authors explored become chair of a department, and three particularly for training programs in the training and collaboration in the ATP times as likely to become a dean. clinical research. W ith the outbreak of war in Korea in 1950, the U.S. Congress approved an War. The Doctor Draft required all physicians and dentists aged 51 and were not exempt from the draft; instead, once they were drafted by the Army, the amendment to the Selective Service Act younger to register and authorized the Navy, or the Air Force, they were of 1948 to expand the federal president to make special "calls" for assigned to the NIH.' Although clinical government's authority to draft certain medical, dental, and allied health associates' official duty was to provide physicians. This legislation, generally specialists. An unexpected consequence care to patients in the Clinical Center, known as the Doctor Draft, affected the of the Doctor Draft was the rise of they were allowed to pursue their own career development ofmany male physician—scientists in the United States medical research interests under the medical school graduates for more than as the National Institutes of Health supervision of NIH intramural scientists.' two decades, until the end of the Vietnam (NIH) provided a few thousand talented With this novel addition of a substantial young doctors with the opportunity to research component to subspecialty pursue medical research as a means of training, the NIH soon became the Dr. Mat d assistant professor. Department of fulfilling their military obligations and to premier place to train Neurology. University of Washington, Seattle, be trained as clinical investigators rather physician—scientists. Washington. than solely as skilled practitioners.' The Dr. Park is associate professor and erector. NIH envisioned creating a cadre of Escalation during the Vietnam War Graduate Program of Soence and Technology Kona Advanced Institute of science and Technology, physician—scientists who would make important contributions to fundamental Although all doctors were subject to draft Daegon. Korea. and former associate historian, Office of NM History, National Institutes of Health. medical research and bring new scientific calls, less than 10% of new medical Bethesda, Maryland. discoveries to the bedside.? school graduates served in the military Dr. Longstradi is professor. Department 01 during the Vietnam War.' Most of those Neurology. University of Washington, Seattle, drafted served in the reserves or the PHS, Washington. Background which included training programs such Correspondence should be addressed to Dr. Khot. The NIH Associate Training Program as the ATP. In the late 1960s, however, Department of Neurology, Harbornew Medical (ATP) started in 1953 when several dozen the Defense Department's medical Center, 325 Ninth Avenue, Box 359775, Seattle, WA 98104-2470; telephone: (206) 744-3251; fax: (206) hand-picked medical graduates came to workforce needs increased considerably 744.8787; e.mail slhotOuw.edu serve in the newly created NIH Clinical as the number of U.S. military personnel Center as clinical associates. The clinical in Vietnam escalated from 16,000 in 1964 Mad Med. 2011;86:502-508. First published online February 21. 2011 associates were selected from physicians to more than 543,000 in 1968.5 1n 1967, doi: 10 1097IACM.06013e31820f fed? who applied to serve at least two years in Congress responded by imposing Supplemental digital content for this article is the U.S. Public Health Service (PHS) restrictions on exemptions available to available al httpi/linkshwYcom/ACADMED/A43. Commissioned Corps. These physicians physicians seeking deferments, which led 502 Academic Medicine, Vol. 86, No. 4 /April 2011 Copyright O by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. EFTA_R1_02029405 EFTA02689759  History of Academic Medicine about 6,000 of the 9,000 doctors graduating from medical school each year to be drafted by the Department of Defense." Selective Service director Lewis Hershey used the conscription policies to create a comprehensive workforce policy he called "channeling," where men were directed through "pressurized guidance" I into desirable civilian and military pursuits considered to be in the national E interest' "From the individual's E viewpoint," commented Hershey. "he is z standing in a room which has been made uncomfortably warm. Several doors are open, but they all lead to various forms of recognized, patriotic service to the nation." DoesorOnat Kasen e Vows More than 700 doctors, dentists, and we L I 1 1 1 wit I I L L I I I I L I I I other health care professionals could 1110 Ina Wes 1112 1916 ere ere 90ra 1912 nes late 1014 satisfy their military obligation each year through service in the PHS Year Commissioned Corps.° The NIH used the channeling policy to recruit highly Figure 1 The number of new physicians accepted into the NIH Associate Training Program from its inception in 1953 to its end in 1992, with the period of the U.S. Doctor Draft and the U.S. sought-after medial school graduates involvement in the Korean and Vietnam wars noted. eager to pursue careers in academic medicine. As U.S. involvement in the war Pike." recalled William Eaton, who was influence on academic medicine in the escalated, more physicians sought to an NIII investigator in 1968.9 Although years following their NW training. A fulfill their military obligations through the associates did not use the term previous survey found that, in 1998, work at the NIH, and the number of themselves during the war, when many 23.6% of the professors of medicine at applicants and the size of the ATP grew.' adopted it years later, it took on an ironic Harvard Medical School and 21% at In 1965, the year that the first U.S. connotation. Bernard M. Babior, a Johns Hopkins University School of ground troops landed in Saigon, 153 research scientist who trained at the NIH, Medicine were former NIH associates.' physicians reported to the ATP to fulfill used the term wryly in a poem he wrote Our goal %r this study is to demonstrate, their military obligation. The following to the NIH scientist Earl Stadtman in using both qualitative (archival research year, the number of new associates 1990': and oral history) and quantitative (data jumped to 178, and by 1970, it increased matching) methods, that a substantial to 206. In 1973, the year a peace Whereas my draft board said to me, "IA: portion of the young physicians who settlement in Paris led to a ceasefire in I from ascetic Boston made my way Bethesdawards, to Stadtman's realm secure fulfilled their military obligations Vietnam. the number of new associates through service in the NW ATP during To soldier for a while in the Yellow Beret. peaked at 229 (Figure 1).' the Doctor Draft went on to assume Examining the influence of the "Yellow leadership roles within U.S. academic The "Yellow Berets" Berets" medicine as a result of the high-level The term "Yellow Berets" was used in a training and networking opportunities After completing their military derogatory manner during the Vietnam available to them at the NIH. The ATP obligations in the ATP, many NIH War to contrast draft dodgers with the during this period, we will demonstrate, associates returned to U.S. medical elite Green Berets—the U.S. Army was the most important source of schools and helped form academic Special Forces—in a period beset by physician—scientists for a generation. faculties that developed clinical ongoing strife and civilian antiwar research training programs. "All of the protests. Its origin is not clear, but it was professors wanted to have their best used in a 1966 Bob Seger song, "Ballad of Method students come here," recalled Joseph E. the Yellow Baer": Rath'o who was director of intramural Qualitative analysis Fearless cowards of the USA research at an NIH institute during the Bravely here at home they stay Doctor Draft, "because they knew that As part of a John 1. Pisano Travel Grant They watch their friends get shipped away they would be here for two or three awarded by the Office of NIH History in The draft dodgers of the Yellow Beret. years and then probably come back to 2001, one of the authors (SS.) their university." interviewed selected associates who "To our amusement we PHS officers entered the ATP during the period of the were called 'Yellow Berets' by the officers The former NIH associates, the "Yellow Doctor Draft (1950-1973) about their from the naval hospital across Rockville Berets," arc said to have had a defining experiences and the training they Academic Medicine, Vol. 86, No. 4 /April 2011 503 Copyright O by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. EFTA_R1_02029406 EFTA02689760  History of Academic Medicine received in the ATP. as well as how the We also examined active faculty independence granted to associates and a opportunities they had to collaborate and appointments in 2007 by the research unique sense of collaboration within the network led to their later positions and intensity of medical schools, as ATP. "There was an incredible number of successes. These unstructured oral measured by 2003 fiscal year great immunologists around so it was like interviews were tape-recorded by S.K., expenditures for federal research grants (being] a kid in a candy store," recalled transcribed by NIH staff, and reviewed and contracts reported to the Liaison Anthony Fauci,21 an NIH associate who for accuracy by the interviewees. The Committee on Medical Education. entered the ATP in 1968 and went on to transcripts arc archived at the Office of Finally, in July 2007, using online become director of the NIH Institute of NIH History. Another author (B.S.P.) databases, we performed a name-by- Allergy and Infectious Diseases. "I conducted research on the origins of the name matching process to document learned this from this person and that ATP when he was an associate historian membership in two honorary from that person and that's how I taught in the Office of NIH History biomedical research societies—the myself immunology." (2004-2007). He used a wide range of National Academy of Sciences" and the archival sources, including materials Institute of Medicinel'—as well as to The design of the Clinical Center on the available from the U.S. National Archives identify recipients of the President's NIH campus also provided a unique and Records Administration, the Office National Medal of Science" and Nobel opportunity for associates both to see of the Director at the NIH, and the laureates.'° We used the online NIH patients and work in research Foundation for Advanced Education in almanac to screen high-ranking laboratories immediately adjacent to the the Sciences. positions at the NW in a similar center. "If you wanted to get an fashion.'' experience in clinical medicine where you Quantitative analysis could apply bedside observation to The University of Washington laboratory bcnchwork, the (ATP] was not In 1997, NIII staff created a database of institutional review board approved this study. the only program that you could come to individuals who entered the ATP, using the index cards prepared for each but it was built for that," noted Dr. physician at the time of entry. These Fauci.23 "This was built for the sole Results purpose of 'bench to bedside and cards included the physician's medical school and year of internship. (For Qualitative findings on training and 'bedside to bench.'" The clinical training examples, please see Supplemental networking opportunities in the ATP provided exposure to a wide variety of Digital Figure I, http:filinks.1ww.corn/ diseases for which associates could pose Our historical research showed that the questions and test their hypotheses in the ACADMEDIA43.) During database men, and the few women, selected as NIH creation, efforts were made to reduce laboratory. associates were top-quality physicians from transcription errors and improve the the outset. In the ATT's early years, accuracy of information abstracted Training medical doctors in basic promising graduates ofmedical schools on sciences research was a formidable task, from the original cards. Records on the East Coast were recruited via the "old associates in the early years of the ATP however. "Unlike the university-trained boys network,"' but the competition PhD candidate," former NIH director are incomplete, so we focused our became increasingly fierce as the analysis on the associates who entered ►ames Shannon remarked (in 1957), application procedure was formalized and "these individuals IMDsl have little or no the program from 1955 through 1973. opened to the public. In 1963, for instance, training in research methodology, only 53 of the 1,464 physician applicants We used these database records to match procedure, and theory, and so they are (3.62%) were selected to be associates." NIH associates who graduated from U.S. handicapped in proceeding effectively to Donald Frederickson,'" one of the first medical schools from 1955 through 1973 advanced research."" A group of NIH's associates in 1953 and, later, NIH director, to names listed in the Association of commented on the competition: "The best, intramural scientists seized on the American Medical Colleges (AAMC) the absolute cream, all applied. The art of opportunity to produce a new generation Faculty Roster database as of December picking, out ofa whole group ofqualified of physician—scientists by offering the 21, 2007. The Faculty Roster is the only people, those who might become successful associates after-hours science courses that national database with appointment data scientists was extremely difficult." were not widely available in U.S. medical on individual full-time faculty members schools. In 1954, they formed the since 1966.° We defined as The ATP helped foster an academic and Scientific Advisory Committee to decide "nonassociates" those medical school congenial atmosphere within the NIH "subjects and fields for formal courses, faculty who graduated during the same that was unusual for a government course level, appropriate curricula, time period as the associates but did not agency. A 1965 report to President faculty, admission requisites" for the NIH participate in the ATP. Using the Faculty Lyndon B. Johnson characterized the evening school.:3 The committee Roster database, we compared the NIH scientist as having "probably more comprised several institutes directors of associates and nonassociates on their 'academic freedom' than his university intramural programs and other leading highest academic positions achieved at counterpart"—with the freedom to scientists, including Robert W. Berliner, U.S. medical schools. Because PHS choose his research topics, freedom to Christian B. Anfinsen, Daniel Steinberg, Commissioned Corps positions seemed devote an his time to research, and Seymour S. Kety, Bernard Horecker, and to be reserved for draft-eligible men,n we freedom from the need to secure funds.2° DeWitt Stetten, ►r. As they came from completed the analysis with and without The decidedly nonbureaucratic academe. most of them already had women. environment led to a high degree of professional teaching experience. S04 Academic Medicine, Vol. 86, No. 4 /April 2011 Copyright O by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. EFTA_R1_02029407 EFTA02689761  History of Academic Medicine Moving a step further, the Scientific allowed to attend any of the lectures and training they received through the ATP. Advisory Committee proposed in 1956 to seminars they wished. Of the 2.791 associates who graduated create a "two-year program for people from U.S. medical schools between 1955 who have their MI) degree and intend to A separate third category, the staff and 1973, we identified 1,577 (56.6%) associate, was created in 1964 with the who later entered academic medicine, go into medical research as a career."" goal of training highly qualified The NIH created a new category of according to the AAMC Faculty Roster candidates to fill openings in various NIH research associates to designate the database. We identified a total of 27,821 programs. physicians in this program as fully nonassociates—namely, all other committed to research activities, in By that time, the NIH ATP was physicians in the Faculty Roster database contrast with the clinical associates who recognized as the place to get thorough who graduated during the same period— also had medical staff duties at the training in biomedical research in the who likewise entered academic Clinical Center. In designing the United States. "It was very difficult lat medicine during their careers. We program, the committee members other institutions! to give people very found that a greater proportion of studied other institution? curricula— meaningful clinical and research associates achieved higher academic especially that of the Rockefeller Institute opportunities," recalled Samuel Broder." positions compared with nonassociates for Medical Research, which had started an NIH associate who entered the ATP in (Figure 2). Faculty members who were accepting graduate students in 1953— 1972 and subsequently rose through the NIH associates were about one-and-a- and looked into Harvard Medical ranks to become director of the National half times more likely to achieve the School's effort to avoid too intensive and Cancer Institute. "Particularly in some position of full professor (ratio 1.57; too early specialization in training for fields where the NIH virtually was the 95% confidence interval ICI) 1.49- first-year medical students. They also only place in town, the only place in the 1.66), twice as likely to achieve the reviewed the nation's workforce for world, perhaps, that could do certain position of chair (ratio 2.0; 95% CI medical research—one of the NIH types of training programs." 1.78-2.24), and nearly three times as leadership's major concerns since the late likely to achieve the position of dean 1940s—and considered the possibility of Quantitative findings on the effects of (ratio 2.97; 95% CI 2.21-3.98). These designating medical research as a medical ATP opportunities on the careers of results were not substantially different specialty." NIH associates after excluding women from the Our quantitative study of the careers of associates (n = 4) and nonassociates The goal of the research associate NIH associates shows the effects of the (n = 2,939). program was to turn physicians into independent medical investigators who 50 • 3 were well grounded in modern scientific knowledge and methods. The committee members felt strongly that research ■ NIH associate n= 1.577 Ratio of NIH associates to nonassociateS 2.5 associates should "learn how to do 40 Nonassociate research more than to do research itself" n = 27,821 and that they should be brought into Percentage achieving rank close contact with accomplished scientists • 2 in specialized research fields. In particular, the committee stressed two 30 points: "The importance of having the Research Associatels) work on problems 15 of their! own choice rather than be 'servants' in the research problems of the 20 preceptor, and the importance of providing the students! with some integrated and organized basic knowledge as a foundation that would permit them 10 to do their own integrating of knowledge 05 later."24 Therefore, in their first year, research associates attended one- to two- hour formal lectures three days each week (on the basic medical sciences, organic 0 U Other Assistant Associate Full Chair • Dean 0 chemistry, physical chemistry, tracer professor professor professor methods, and so on). In their second year, they participated in a weekly, two- Highest rank achieved hour informal seminar and a weekly Figure 2 Comparison of the highest academic ranks achieved by NIH associates and evening conference. The rest of their time nonassociates who graduated from U.S. medical schools between 1955 and 1973 and ever held was spent in a laboratory with a any academic position. The results are displayed for NIH associates and nonassooates; the preceptor. Clinical associates benefited percentage of the total is indicated along the left y-axis, and the ratio is indicated by diamonds from the program as well; they were along the right y-axis. The overall chi-square is 577, P< .001. Academic Medicine. Vol. 86, No. 4 /April 2011 505 Copyright O by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. EFTA_R1_02029408 EFTA02689762  History of Academic Medicine With regard to the medical school and 2007 and make up a similar medicine. On entering academic research intensity of faculty members proportion of members of the National medicine, the NIH associates who active in 2007, we found that the 626 Academy of Sciences within the graduated from medical school during NIH associates were 34% more likely biomedical fields. Many of the NIH's top this era were more successful than their than the 6,038 nonassociates to be at leaders also had their start in the ATP, nonassociate peers at rising through the one of the top 10 schools (144 123%) including 4 directors and 10 institute ranks. Our analyses indicate that versus 1,034 117%]. ratio 1.34; 95% CI directors. Table 1 identifies those NIHI among those with any academic 1.15-1.56) and 47% more likely to be at associates who have won prestigious appointment, NIH associates were one of the top 20 schools (268 (43%) awards and held top NIH positions and better represented than nonassociates versus 1.755 129%), ratio 1.47; 95% CI provides an overview of their in the higher echelons of academic 1.33-1.63). Again, these results were membership in prestigious societies. medicine: They were about twice as not substantially different after likely to have been a chair of a excluding women from the NIH Discussion department and about three times as associates (n 0) and from likely to have been dean of a school. nonassociates (n = 460). The training that elite Among active faculty in 2007, NIH physician—scientists received in the associates were also more likely than Finally, past NIH associates account for unique atmosphere of the ATP during nonassociates to be at the top-ranked one ofevery six Nobel laureates in the Doctor Draft led to their continued research-intensive medical schools. The physiology or medicine between 1985 success and influence in academic success of the associates is also reflected by their representation among honorary societies and career Table 1 achievement awards. As former Career Achievement Awards, Membership in Honorary Medical Research associates continue to hold leadership Societies, and High-Ranking National Institutes of Health (NIH) Positions Among roles both in academic medicine and NIH Associates Who Entered the Associate Training Program From 1955 the NIH, they will likely keep exerting Through 1973 (Including Those Who Were Not Commissioned Officers) considerable influence on both the NIH's extramural research grant program and its intramural agenda. Award Beyond their personal successes in Nobel Prize in Physiology 9 of 50 Nobel laureates (1985- Richard Axel, 1. Michael Bishop, academic medicine, the associates also or Medicine 2007) Michael S. Brown, Alfred G. Gilman, Joseph L. Goldstein, created a network of physician-scientists, Eric R. Kandel, Fend Murad, as the collaborative efforts they Stanley B. Prusmer, Harold E. established during this time period Varmus continued after they returned to their National Medal of Science 10 of the 76 biological sciences 1. Michael Bishop, Michael S. respective universities. "Science is a social recipients (1985-2007) Brown, Stanley N. Cohen, enterprise, and it's this kind of informal Anthony S. Fauci, Joseph L. Goldstein, Eric R. Kandel, Philip college or interactions that determine the Leder, Paul A. Marks, Solomon directions (of science' and what gets H. Snyder, Harold E. Varmus done," noted Alan Schechter?. who Honorary medical became an associate in 1965. "The research society program here allowed one to plug into National Academy of 64 elected as members, 44 this informal college." Michael Sciences among the 250 active U.S. Gottesman:7 a former associate and the members in the biomedical current NIH deputy director for fields (as of July 2007) intramural research, felt that some Institute of Medicine 125 among the approximately associates "would have gone on to be 1,470 regular members (as of July 2007) successful in any case but most either wouldn't have had the opportunity or NIH position wouldn't have had the environment that Director of NIH 4 among 9 directors (1953- Donald S. Frederickson, fostered this kind of success." 2007) Bernadine Healy, Harold E. Varmus, James 8. Wyngaarden The high degree of later accomplishment Director of NIH institutes 10 among 122 institute Samuel Broder, Donald S. directors (1953-2007) Frederickson, Roberti. Levy, and success of the NIH associates is likely Richard 1. Hodes, Anthony S. related to many factors. These include the Fauci, Duane Alexander, Allen competition among young physicians to M. Spiegel, Robert L. DuPont, enter the ATP during the Doctor Draft. Frederick K. Goodwin, Gerald especially during the escalation of the D. Fischbach Vietnam War, which helped the program Directors for intramural 1 deputy director and 2 Clinical Michael Gottesman (deputy recruit a high caliber of physician—scientists research Center directors among 8 director), Robert S. Gordon, Jr, directors (1953-2007) and John I. Gatlin (Clinical who might not have applied during Center directors) peacetime. The ATP also offered 506 Academic Medicine, Vol. 86, No. 4 /April 2011 Copyright O by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. EFTA_R1_02029409 EFTA02689763  History of Academic Medicine centralized training of associates within especially those accepted during the science research diverged, leading to a the unique atmosphere of the NIH campus program's early years. Additionally, our shift in NIH funding and the bulk of and laid the groundwork for future matching of the list of associates to other biomedical research being done by networking related to research funding. lists may have been imperfect. We were specialized PhD scientists." An NM able to match 1,577 of the 2,791 panel in 1995 found that funding levels Although the ATP created opportunities identified associates (56.6%) to names in for clinical research were low primarily for many future academic medicine the AAMC Faculty Roster database. We because MDs were not applying in leaders, its selective admission process may have missed some; others may have sufficient numbers for NIH awards may have had unintended consequences not pursued full-time academic careers, compared with PhDs." The decline in for women and minorities. As noted may have turned to private enterprises, or NIH-sponsored MD grant holders was earlier, women were minimally may have stayed at the NIH. We have no thought to be partly related to clinical represented in the ATP during the easy means to identify the career paths of investigators' loss ofconfidence in Doctor Draft and were not accepted into these other associates. competing effectively for research the PHS because those positions seemed Conclusions funding." to be reserved for draft-eligible men"; we identified only seven female associates, Some may have referred to NIH Perhaps one of the greatest strengths of four of whom were included in our associates during and soon after the the ATP was its focus on the clinical Doctor Draft as "Yellow Berets," a label analysis. Also, the NIH did not collect aspect of scientific investigation, namely, that implies cowardice and avoidance of information on minorities during the translational research. A "dangerous patriotic duties and that dismisses their Doctor Draft. Lack of support for valuable contributions. Barry Kimball," decline"" in the numbers of physicians research and effective mentoring, both a 1964 NIH associate and former doing clinical research could have important strengths of the ATP, have president of the American Board of devastating consequences for bringing been noted as possible limitations on Internal Medicine, felt that active duty "basic-science breakthroughs into clinical women and minorities.202' The selective military personnel were resentful. "We application ('bench to bedside').""." In admission during the Doctor Draft may were doing our service obligation in a response to the perceived shortage of have precluded women and minorities way which maximally enhanced our own physician-scientists, the NIH from the networking opportunities for careers. Why wouldn't they resent us?" appropriated funds to support training research funding, which may have After the war, though, many NIH programs in clinical research, including contributed to their underrepresentation associates used the term as a badge of its Medical Scientist Training Program, in the higher echelons of academic pride with the understanding that t