APPENDIX A
PREPARING FOR THE TWENTY-FIRST CENTURY IN THE REPRODUCTIVE SCIENCES:

The History and Present Status of Research Training in Obstetrics and Gynecology

LAWRENCE D. LONGO*

Division of Perinatal Biology

Departments of Obstetrics, Gynecology, and Physiology

Loma Linda University School of Medicine

". . . the development of our departments [of obstetrics and gynecology] has demonstrated beyond question the critical importance of research efforts and the presence of investigators, for the intellectual health and successful function of our teaching programs"

(Douglas, 1976).

Above the mantel at his home at 13 Norham Gardens, Oxford, Sir William Osler, Regius Professor of Medicine at Oxford University, had a tryptych with paintings of three great physicians: Thomas Linacre, Thomas Sydenham, and William Harvey. Linacre stood for learning in the classics, Sydenham for practice, and Harvey for science (Cushing, 1925). The physician-scientist embodies these three facets of the scientifically educated clinician, who in addition to his role as a healer, advances the scientific frontiers of medicine.

Today, biomedical research is in the midst of an era of discoveries focused on the cellular and molecular basis of living systems and disease states. Advances at the molecular level in genetics, regulation of cell function,

*  

 Prepared for the Institute of Medicine Committee on Research Capabilities of Academic Departments of Obstetrics and Gynecology.



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Strengthening Research in Academic OB/GYN Departments APPENDIX A PREPARING FOR THE TWENTY-FIRST CENTURY IN THE REPRODUCTIVE SCIENCES: The History and Present Status of Research Training in Obstetrics and Gynecology LAWRENCE D. LONGO* Division of Perinatal Biology Departments of Obstetrics, Gynecology, and Physiology Loma Linda University School of Medicine ". . . the development of our departments [of obstetrics and gynecology] has demonstrated beyond question the critical importance of research efforts and the presence of investigators, for the intellectual health and successful function of our teaching programs" (Douglas, 1976). Above the mantel at his home at 13 Norham Gardens, Oxford, Sir William Osler, Regius Professor of Medicine at Oxford University, had a tryptych with paintings of three great physicians: Thomas Linacre, Thomas Sydenham, and William Harvey. Linacre stood for learning in the classics, Sydenham for practice, and Harvey for science (Cushing, 1925). The physician-scientist embodies these three facets of the scientifically educated clinician, who in addition to his role as a healer, advances the scientific frontiers of medicine. Today, biomedical research is in the midst of an era of discoveries focused on the cellular and molecular basis of living systems and disease states. Advances at the molecular level in genetics, regulation of cell function, *    Prepared for the Institute of Medicine Committee on Research Capabilities of Academic Departments of Obstetrics and Gynecology.

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Strengthening Research in Academic OB/GYN Departments immunology, and developmental biology have created opportunities in the reproductive sciences. In addition, novel approaches to the prevention, diagnosis, and treatment of reproductive diseases are appearing. Despite conceptual and technological developments, however, there exists a crisis in academic obstetrics and gynecology in both research and in research training. In part, this is due to forces external to the specialty–economic, ethical, political, and social. But there is also a dearth of physician-scientists and clinical investigators who can contribute to advances in the reproductive sciences and serve as role models for students, house staff, and others. In sum, too few obstetricians and gynecologist are being adequately trained to pursue research opportunities. Thus, for academic obstetrics and gynecology, current circumstances present a paradox. Never before have the opportunities been so great–and the resources so limited (Martin, 1991). Departments of obstetrics and gynecology are increasingly confronted by the need to provide highly technical clinical care, to perform manifold social functions, and to maintain large, private practices to generate income. Biomedical scientists in these departments are coming under growing pressure to justify their research. As obstetrics and gynecology approach the twenty-first century, the clinical investigator, particularly the physician-scientist, is seriously threatened by an increasingly sophisticated research enterprise, decreased time for careful thought and work, and diminishing federal and private resources for support. In the coming years, the future of obstetrics and gynecology as a whole will depend, in great part, on the health and well-being of its academic departments. In turn, the state of these departments depends, in considerable measure, on their role in research in the reproductive sciences. As Jack Masur, former director of the Clinical Center at the National Institutes of Health, (NIH) observed, "Hospitals with long traditions of excellence have demonstrated abundantly that Research enhances the vitality of teaching. Teaching lifts the standards of service, and Service opens new avenues of investigation." (This statement appears at the entrance to the main auditorium in the NIH Clinical Center.) This paper explores the roles of the private sector and more briefly those of the National Institutes of Health in helping to produce research leaders in obstetrics and gynecology.

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Strengthening Research in Academic OB/GYN Departments Training Paths Innovative developments and advances in obstetrics and gynecology have resulted from research in the basic sciences. During the 1950s and 1960s, following their residency training, many individuals who sought academic careers spent several years in a basic science department or a research-oriented clinical department. A few of these individuals were supported by the Markle Scholar Program or the Macy Foundation; many were funded by the National Institutes of Health (see the later discussion below). In the 1970s, with the advent of subspecialty programs (gynecologic oncology—1972; maternal and fetal medicine—1973; reproductive endocrinology—1973; [Randall, 1989]), many individuals completed 2 or 3-year programs in these fields before joining academic departments. In a few cases, they also spent a year or two in research. Thus, a generation of well-trained clinical subspecialists joined academic departments with little or no experience in either laboratory or clinical research. For physicians-scientists, it has become increasingly important to spend 2 or 3 years in basic research training (IOM, 1985). Some individuals participate in basic research as part of their M.D./Ph.D. physician-scientist training program. Recent reports have described some aspects and relatively long-term results of the Duke (Bradford et al., 1986), Washington University (Frieden and Fox, 1991), and other (Martin, 1991) M.D./Ph.D. programs. Private Foundation Funding for Research Training: 1950 to 1985 The Markle Scholar Program: A Case Study Between 1948 and 1974, the John and Mary R. Markle Foundation supported the Program of Scholars in Medical Science.* The foundation itself was begun in 1927 by John and Mary R. Markle "to promote the advancemeat and diffusion of knowledge … and promote the general good." From 1936 to 1947, the foundation's chief activity was to provide small grants-in-aid for medical research. With the end of World War II, expenditures for medical research by the federal government increased dramatically, dominating national research funding. Thus, in 1946, the newly *    The discussion of the Markle Scholars Program is based on Strickland and Strickland (1976).

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Strengthening Research in Academic OB/GYN Departments appointed executive director, John McFarlane Russell, after spending a year visiting 30 medical schools in the United States and Canada and consulting with other educators and scientists, concluded that the foundation could provide a unique service and contribute to medical science by supporting people who wanted to remain in academic medicine. The scholarship would permit a young medical researcher to ''earn a bit more, have tenure long enough to prove his worth, ... have a respectable academic appointment and a nationally recognized title, [and] adequate laboratory facilities and equipment for his research'' (Russell, 1947). The concept of the program was support of outstanding young academicians who showed great promise, rather than the funding of research projects. Initially, the foundation provided $5,000 per annum for up to 5 years to supplement support by the scholar's institution. The purpose of the program was "to improve medical education and research by giving both recognition and financial support to bright young teachers, investigators, and administrators, and helping them to prepare for positions of leadership in academic medicine." By providing funds so that the medical school, in a variety of ways, could enrich the opportunities and resource of those selected, the foundation hoped to contribute toward the improvement of medical school faculties. Of the 506 individuals selected, only 17 were obstetrician/gynecologists (Table A-1). This figure contrasts with 162 in internal medicine and subspecialties, 110 in surgery, and 61 in pediatrics. The selection process had three steps: (1) initial nomination by the medical school; (2) selection of finalists by regional committees of distinguished laymen, who evaluated individuals on the basis of values and motivation; and (3) final appointment of the scholars by the foundation's board of directors. The medical schools nominated one person per year, choosing an individual who was considered truly committed to research and/or teaching in clinical or basic science. Schools nominated their brightest and best young "stars." The sponsoring institution was also required to make a significant and continuing commitment to the scholar. The selection committee was chosen for its perceived abilities in picking individuals who would be leaders and in "judging them as human beings." At the annual 3-day selection meeting, candidates were evaluated on "breadth of character, personality, and potential leadership." This selection process, which was thought by some to be a great strength of the program, would today probably be seen as placing an excessive emphasis on personal qualities.

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Strengthening Research in Academic OB/GYN Departments TABLE A-1: Markle Scholars in Obstetrics and Gynecology: 1951–1974 Name Institution Year Commenced Gordon W. Douglas, M.D. New York University 1952 Leo J. Dunn, M.D. Medical College of Virginia 1964 John R.G. Gosling, M.D. University of Michigan 1960 Perry A. Henderson, M.D. University of New Mexico 1969 Edward H. Hon, M.D. University of Southern CA 1955 John B. Josimovich, M.D. University of Pittsburgh 1964 Theodore M. King, M.D., Ph.D. Johns Hopkins University 1967 Kermit E. Krantz, M.D., Litt D. University of Kansas 1957 William A. Little, M.D. University of Miami 1962 James A. Merrill, M.D. University of Oklahoma 1957 Robert W. Noyes, M.D. Stanford University 1953 Robert I. Merritt, M.D. Saint Catharines Hospital 1956 Landrum B. Sherries, M.D., Ph.D. Columbia University 1951 Donald P. Swartz, M.D. Albany Medical College 1958 John D. Thompson, M.D. Emory University 1957 James C. Warren, M.D., Ph.D. Washington University 1961 Richard Wilson, M.D. University of Toronto 1962   SOURCE: Strickland and Strickland (1976). Although initially intended for only 10 scholars per year, the program proved so popular that within a few years, 20 to 25 individuals were being appointed annually. In 1950, the annual stipend was raised to $6,000, and in 1958 it was raised to $7,500. Grant money was often used for partial salary support, laboratory and library expenses, and travel. In general, the foundation required only brief annual financial statements from the institution and reports by the scholar at the end of the second and fifth years. At the end of an individual's 5-year scholarship, the executive director of the program or his associate, visited the young academician and prepared a report on his or her progress and contributions. Because the overall purpose of the Markle Awards was to improve the standards of academic medicine, considerable attention was given to medical education. Thus, although many scholars spent much of their time in research, the majority devoted 25 to 50 percent of their time to teaching. A feature of the Markle program was a series of annual 2-day meetings in which the scholars and other educators discussed key issues related to medical education. These meetings, organized and run by the scholars themselves,

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Strengthening Research in Academic OB/GYN Departments considered such topics as "The Teacher in Medical Education," "Science and the Humanities," ''Academic Medicine and Public Policy," "Medicine in a Changing Society," and ''Scholarship Versus Society's Needs: A Conflict in Academic Medicine." Because these presentations and discussions were not published, it is difficult to ascertain their impact on medical education or academic medicine. Although originally intended as a postfellowship program in medical research, by the 1960s, the program's emphasis had evolved to one of nurturing individuals for leadership in medical education. In 1961, NIH initiated its program of Research Career Development Awards (RCDA) and Research Career Awards. Some have suggested that the 5-year RCDA program was modeled after the Markle scholarships. In the years that followed the establishment of the NIH awards, it became increasingly clear that the Markle program no longer played the key role it once had in keeping first-class minds in research. This change was reflected in the modification of the title of the program in 1962: from "Scholars in Medical Science" to "Scholars in Academic Medicine." One impetus for this shift was a perception that, with the development of federal programs to support young investigators, there was perhaps an overabundance of researchers. Thus, before his retirement from the foundation, Russell elected to terminate the program. The last group of scholars was chosen in 1969 (their awards continued until 1974). In assessing the strengths of the program, in addition to the financial support, important elements that have been identified by some observers include the program's flexibility and the unresricted nature of the money. Overall, the awards provided a stimulus to excellence and achievement. For the scholar and the institution he or she represents, the Markle Award was a major recognition and a key to growth and stability in academic medicine. Russell himself did not believe that the true impact of the awards could ever be assessed. Near the program's end, it was determined that 96 percent of the scholars had remained in academic medicine. Merlin K. Duval, a Markle scholar (1956–1961) who served as assistant secretary for health and scientific affairs in the Department of Health, Education, and Welfare, was quoted as saying, "The greatest strength of the Markle Program was that it served as an example of a premise that has subsequently been adopted by both private foundations and the Federal Government: to wit, one gets a great deal more out of investing in a man than in a subject". The Markle program is said to be a model for the Milbank Memorial Foundation Awards (given from 1964 to 1969), and the Robert Wood Johnson Foundation Clinical Scholars and Health Policy Fellowship programs, as well as the programs of the Commonwealth Fund and Carnegie Corporation.

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Strengthening Research in Academic OB/GYN Departments A measure of the program's import is the variety of leadership positions that the scholars assumed. For instance, as of 1975, the Markle ranks included a Nobel laureate, 3 university presidents, 7 vice presidents, 2 vice-chancellors, 1 provost, 11 medical school deans, 14 associate deans, 134 departmental chairpersons, and numerous other top administrators. However, the nominees who were not selected for the program but who remained in academic medicine advanced up the academic ladder as rapidly as the Markle scholars in rank and salary. Almost 80 percent of the scholars interviewed maintained that they would have remained in academic medicine even without the Markle Award. It might be questioned, therefore, to what extent the program had a major impact on the entry of young scientists into academic medicine, or their retention or advancement. For more than a quarter of a century, Markle scholars have symbolized leadership in American medical education. Many believe that the program has also made an impact on medical research, although quantifying that contribution is impossible. In sum, it is believed that the program benefited academic medicine and medicine in general "far in excess of the small amount of money the Foundation [contributed] to this large field". Josiah Macy, Jr. Foundation In 1955, the Josiah Macy, Jr., Foundation. recognizing the need for a scientific approach to obstetrics and gynecology and the requirement of laboratory training for full-time academicians elected to devote "at least the next ten years" to the area of reproduction. The goal was to develop reproductive biology as the basic science of academic obstetrics. A key figure in this decision was Howard Canning Taylor, Jr., chairman of Columbia University's College of Physicians and Surgeons and a figure of wide influence both within and outside the specialty (Bowers and Purcell, 1980). This program initially sponsored training at three centers: Columbia, Harvard, and Washington universities. Later, the departments of obstetrics and gynecology at Boston University, Cornell, Johns Hopkins, Michigan, Northwestern, Oregon, Pennsylvania, Yale, and the University of Uruguay (Montevideo) were included in the program. To accomplish its goals for reproductive science, the foundation established a program of faculty development, conferences and seminars, and medical student research. The three original departments of obstetrics and gynecology chosen for the program were encouraged to expand r search in the reproductive sciences. To achieve this, the Macy foundation provided the following to selected individuals

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Strengthening Research in Academic OB/GYN Departments in a residency program: (1) salaries and research expenses for 2 years of research training in the basic sciences; (2) supplemental salary support on completion of that 2 year period and during completion of the residency; (3) and on completion of the residency, salary and funds for research while launching an investigative career. In addition, the foundation provided support for basic scientists to participate with obstetricians and gynecologists in multidisciplinary research. Ten individuals were chosen as Macy Faculty Fellows m Reproductive Biology (Table A-2), and about 30 Macy Postdoctoral Fellows in Obstetrics and Gynecology were partially supported at various schools (Table A-3). Fellowship awards were $15,000 per year for 3 years. In 1963, the Macy Foundation endowed professorships in obstetrics at both Columbia's College of Physicians and Surgeons and the Harvard Medical School (Macy Foundation, 1965 Annual Report). By 1966, when the Macy program ended, about 50 individuals had received some training support for an academic career in obstetrics and gynecology. By 1979 15 of them has become departmental chairmen (Bowers and Purcell, 1980). TABLE A-2: Macy Faculty Fellows in Obstetrics and Gynecology Fellow Institution John W. Choate University of Rochester Carlyle Crenshaw, Jr. Duke University John P. GustIon, Jr. Western Reserve Univ. Richard J. Hildebrandt University of Florida Cecil Jacobson George Washington University Robert B. Jaffe University of Michigan Theodore M. King University of Missouri Emmet J. Lamb Stanford University Jacques F. Roux Albert Einstein William Spellacy University of Miannesota   SOURCE: Josiah Macy, Jr., Foundation (1966).

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Strengthening Research in Academic OB/GYN Departments TABLE A-3: Macy Postdoctoral Fellows in Obstetrics Name Institution Karlis Adamsons, Jr. Columbia University Joseph J. Barlow Harvard Medical School Theodore C. Barton Harvard Medical School Jack N. Blechner University of Florida Arthur C. Christakos Duke University Charles Donald Christian University of Arizona Philip A. Coffman Center for Population Research/NICHD Robert Duemler Washington University Theodore Fainstat Northwestern University Ira C. Gall Washington University Donald Peter Goldstein Harvard Medical School Donald A. Goss Vanderbilt University John W. Grover Harvard Medical School Samir Hajj American University of Beirut Dennis Hawkins University of London Andre Hellegers Georgetown University Arthur Herbst Harvard Medical School Jaroslav F. Hulka University of North Carolina Howard N. Jacobson Harvard Medical School John B. Josimovich University of Pittsburgh Theodore M. King Albany Medical College Michael M. Levi Columbia University John L. Lewis, Jr. Cornell Medical College A. Brian Little Case Western Reserve Univ. William A. Little University of Miami Paul C. MacDonald University of Texas/Southwestern Med School Girgis Mikhail Jefferson Medical College Horst Naujoks Genetic Research Laboratory/University of Frankfurt

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Strengthening Research in Academic OB/GYN Departments Name Institution Harry Prystowsky University of Florida Ralph M. Richart Columbia University John G. Robertson University of Edinburgh Seymour L. Romney Albert Einstein School of Meal. Kenneth J. Ryan Case Western Reserve Univ. Hilton A. Salhanick Harvard Medical School Eugene C. Sandberg Stanford University John Joseph Sciarra University of Minnesota Wolfgang Tretter Columbia University John Urquhart University of Pittsburgh Raymond L. Vande Wiele Columbia University A. Stark Wolkoff University of Kansas David WuTakau Medical College, Taiwan Richard Wurtman Massachusetts institute of Technology Clement Yahia Harvard Medical School   SOURCE: Josiah Macy, Jr., Foundation (1966). An additional Macy contribution was a Summer Scholarship Program for medical student research in reproduction. Sixteen of these awards were made available annually to each of the 15 medical schools (Macy Foundation, 1956–60; 1980 Annual Reports). The Macy Foundation also sponsored an interdisciplinary conference program to facilitate communication among various fields and specialties. Over the course of two decades, the foundation organized more than 20 conference groups, each group holding five annual meetings (Fremont-Smith, 1957). Conference participants were limited to 25 individuals: 15 to 20 regular members attended the five annual conferences, and the balance were guests. In addition to conferences held on gestation during the 1950s, the Macy Foundation supported conferences on "Teaching the Biological and Medical Aspects of Reproduction to Medical Students" (Macy Foundation, 1966) and "Teaching Family Planning to Medical Students" (Macy Foundation, 1968).

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Strengthening Research in Academic OB/GYN Departments A conference hosted jointly by the Macy Foundation and the National Institute on Child Health and Human Development (NICHD), "The Current Status and Future of Academic Obstetrics," was of interest from the standpoint of research training in obstetrics and gynecology (Bowers and Purcess, 1980). In report after report, leaders in academic medicine in general and in obstetrics and gynecology in particular stressed (1) the extent of research opportunities in the reproductive sciences, (2) the paucity of well-trained physician-scientists in the specialty, and (3) the need to correct this imbalance. Norman Kretchmer, then director of NICHD, sum the situation: "Reproductive research and departments of obstetrics and gynecology would benefit mutually from more emphasis on training young investigators and on fostering cooperation and collaboration among diverse research areas" (Bowers and Purcell, 1980, pp. 55–57; see also pp. 33–39 and 164–167). Overall, between 1955 to 1965, the Macy Foundation allocated $5.37 million to develop talent in academic obstetrics and gynecology. From 1965 to 1970, it awarded an additional $1 million to help develop the field of reproductive biology and improve instruction in obstetrics and gynecology. Ford Foundation Increased interest in and enthusiasm for the reproductive sciences were spurred in the late 1950s and early 1960s by awareness of the problem of world population growth and by optimism about the potential contribution of the biological sciences to its solution. This optimism was base in large part on the successful development of oral contraceptives and the intrauterine device. During this period, the World Health Organization began its population program, the Population Council was founded, and NIH developed specific programs to support research in reproductive biology and fertility. Beginning in 1952, the Ford Foundation began to support research in the reproductive sciences, particularly in contraceptive development and safety; it also supported research and training in the social sciences relating to population issues and family planning programs in developing countries. At the end of that decade, it appointed a committee to determine the steps it should take to develop the scientific basis for a program in population control. The work of the committee led to the establishment of centers for studies in reproductive endocrinology and neuroendocrinology at several major universities. The foundation also provided considerable monies to the Population Council to support contraceptive development and demographic studies.

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Strengthening Research in Academic OB/GYN Departments Nonetheless, many would argue that the past and present contributions of obstetricians and gynecologists to these advances are not what they should be. In fact, many leaders in reproductive research maintain that the quantity and quality of research in departments of obstetrics and gynecology are totally inadequate, and prospects for future improvement are dim. Thus, a challenge for obstetrics and gynecology is to increase and improve research and research training in the reproductive sciences. The following is intended to outline some fairly obvious yet important points that derive from the above analysis. Although most of what follows applies to physician-scientists, much of it also applies to clinician investigators. Importance of Research Training in the Reproductive Sciences Research training programs contribute to the nation's scientific capital of new insights, innovations, and paradigm shifts by promoting the flow of well-trained young scientists into research careers. Such training provides unique preparation for identifying research opportunities related to human diseases. Many of the challenges of clinically related research cannot be met by M.D.s employing Ph.D.s to do their laboratory work. Neither will many of the conundrums of the field be solved by scientists who lack a clinical background. This effort will require well-trained, first-rate physician-scientists and clinical investigators who bring both their clinical perspective and insights and their scientific skills to the new challenges of reproductive science. Thus, academic obstetrics and gynecology must propagate the physician-scientist and provide an environment of nurture and support. Because improved research training leads to increased scientific competence, over the long term it will lead to improved quality of research. Such career development, however, should not be left to happenstance. The number of obstetrician-gynecologists who apply for and receive NIH research grants is unacceptably low. A vital mission for the specialty is to educate additional reproductive physician-scientists. Because of the long training period required for a physician-investigator. current and future needs must be carefully considered. Unfortunately, there are no firm data on which to make such projections.

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Strengthening Research in Academic OB/GYN Departments Centers of Excellence By definition, a research-intensive department contributes important basic and clinical discoveries to the reproductive sciences. It also serves as an ''ecological habitat" for physician-scientists and clinical investigators. Finally, it is an environment in which medical students and house staff are stimulated to seek an academic career. Because the university is the locus of most reproductive research training, the effectiveness of that experience depends on the availability of qualified faculty research mentors. Thus, the loop of mentors working with trainees who in turn become mentors must be preserved and enlarged. It is evident that, however desirable it might be, each of the 120-odd departments of obstetrics and gynecology in the country neither can nor will make a major commitment to research. Nonetheless, in addition to the current dozen or so research-intensive departments, more centers of excellence must be developed. Forty such departments would only represent one-third of the total, yet could have an enormous impact on research and research training. For such centers to develop will require the leadership of visionary, hardworking chairmen/chairwomen and division heads with research experience and a commitment to such an agenda. Discovery of Potential Physician-Scientists Physician-scientists and clinical investigators for the reproductive sciences are often attracted to research as medical students or residents. Indeed, many students choose their residency on the basis of possibilities in this regard. In the past, the majority of such individuals have come from a handful of research-intensive departments (see later Addemdum). Mechanisms are needed to identify potential physician-scientists and to make more college students, medical students, and residents aware of opportunities and career paths in the reproductive sciences. Residency-Fellowship Training The clinical training of an obstetrician gynecologist subspecialist requires 6 or 7 years after award of the M.D. degree. Postdoctoral training in basic research requires an additional 3 or more years in the laboratory. Clinical investigator training demands at least 1 or 2 years in addition to the subspecialty

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Strengthening Research in Academic OB/GYN Departments fellowship. Combining these learning experiences to educate a physician-scientist or clinical investigator is thus a lengthy, demanding process. Research Training Development of a physician-scientist requires a committed individual, an outstanding mentor, an appropriate training duration, a learning environment with increasing responsibilities, and an in-depth rigorous research experience. An effective training program requires a minimum of 2, and preferably 3, years in the laboratory with 90 percent or more time devoted to research (IOM, 1985; Lenfant, 1989). Such programs should be structured with increasing responsibility. In addition, the trainee should maintain a close relationship with his or her mentor to inculcate the value system appropriate to the conduct of scientific research. Its developers hope that the Reproductive Scientist Development Program can serve as a model in this regard. Post-Research Training Perhaps the most critical period for the developing physician-scientist (and clinical investigator) is that of emergence from the status of a graduate student to that of an independent investigator. Such individuals must be provided with the right conditions for growth and development. These may include relief from debt and a reasonable income, guaranteed research support for 3 to 5 years, restricted clinical responsibilities, and freedom to concentrate on one's field of interest. Clinical Investigators The clinical investigator plays a key role in designing, conducting, and interpreting clinical trials, metabolic studies, drug evaluations, epidemiologic studies, and related research. There is consequently a need for more and better trained clinical investigators in obstetrics and gynecology. Leaders of subspecialty training programs and those responsible for their certification should work to improve meaningful research opportunities for subspecialty fellows. This will require looking beyond the ever-expanding technological arena to

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Strengthening Research in Academic OB/GYN Departments increase training in epidemiology of reproductive problems, biostatistics, clinical research study design, clinical trials and protocols, and other such topics. The Role of Private Foundations The Markle Scholarship Program had an impact on the quality of academic medicine far out of proportion to the money it provided. Although this effect was particularly apparent in departments of internal medicine, pathology, pediatrics, and general surgery, it could also be seen in departments of obstetrics and gynecology. In addition, the Josiah Macy, Jr., Foundation and the programs of the Ford, Mellon, and Rockefeller foundations helped to strengthen some of the more research-intensive departments of obstetrics and gynecology. These programs demonstrated that a relatively small amount of money can have a significant impact in a field. As Smith (1989) has noted, the cost of training is extremely low in comparison with the ultimate investment in the scientific research of those who are supported. Private foundations and health-related corporations must collaborate in this enterprise. Industry and pharmaceutical companies profit from the discoveries of graduates of research training programs and should help to support such research training. Follow-Up An essential element of training the physician-scientist is long-term evaluation. Despite the enormous effort that has been put into research training, relatively little thought has been devoted to the outcome of training, or how the process could be optimized. Tracking mechanisms should follow the progress of trainees. In addition, a system should be established to review and assess periodically whether goals of the programs are being met. Such evaluations will build a body of knowledge in an area that, as yet, is still poorly understood. Conclusion As noted on a previous occasion, "the challenge that lies before us is to not rest on past achievements, but to look to the future. The problems we face are

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Strengthening Research in Academic OB/GYN Departments to use the future wisely, to use our talents wisely, and to use our funds wisely" (Longo, 1988). Training young obstetrician-gynecologists to pursue scientific problems at both the fundamental and clinical levels promises to continue to enlarge our understanding of all aspects of reproduction, including improved care for women and children. Addendum: Results of Survey of Former Scholars, Macy Fellows, and RCDA Recipients Only a few obstetrician/gynecologists have been Markle Scholars, Macy Fellows or have received Research Career Development Awards (see Table A-4 and A-5). In general, these individuals have achieved, or are continuing to achieve distinction in the profession. To obtain additional insights into the factors that influence physician-scientists in obstetrics and gynecology to choose a career in research and to identify the ingredients of a successful research program, the author sent a short questionnaire to each living obstetrician/gynecologist who was a former Markle Scholar (MS) or Macy Fellow (MF), or who had received a Research Career Development Award (RCDA) since 1975. Survey questions are given below. About half of the total group of these individuals replied (8 of 15 MSs, 8 of 10 MFs, and 7 of 8 RCDAs) for a total of 22 (one individual was both an MS and MF). Because the responses from individuals in three groups were so similar, they will be treated together. What follows is a tram of their responses with selected excerpts. General Background During what years did you hold your scholarship or fellowship? For Markle Scholars, this was from 1951 to 1974; for Macy Fellows, from 1956 to 1966; and for Research Career Development Award recipients, from 1975 to 1989. What was the subject of your research or scholarship during that period? Respondents were fairly evenly divided between reproductive endocrinology and maternal-fetal medicine (about 40 percent each) with a few

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Strengthening Research in Academic OB/GYN Departments individuals in oncology and other areas such as anatomy or immunology of reproduction. What individual or individuals was most important in affecting your decision to enter academic medicine? In what capacity did you know him or her? Almost without exception, the respondents gave the names of one or two key figures in obstetrics and gynecology who inspired them to excel. These included Allen C. Barnes, Nicholson J. Eastman, Charles H. Hendricks (mentioned by 3 persons), Arthur Hertig, William C. Keetel, Harry McGaughey, Joseph L. Seitchik, and Howard C. Taylor. In the reproductive basic sciences these included Leslie B. Arey, Donald H. Barron, and Ernst Knobil. Most of the respondents were either medical students or residents in about a dozen of the most research-intensive departments of obstetrics and gynecology when they came under the influence of these individuals. At what phase of your career did you make this decision? Again, about half of the respondents made their career decision while a medical student, and the other half while a resident. None were fellows. This result agrees with an Institute of Medicine report (1983) that decisions for a arch career are often made in medical school (see also Burns, 1984, and Cadman, 1990). What factors were most important in making that decision? The most common responses were the challenge of problems solving and intellectual stimulation and the desire to use newer approaches to solve biological questions m reproduction. One person recalled the stimulation received from Alpha Omega Alpha (national medical honor society) monthly meetings. Scholarly Productivity Please provide names and academic appointments of research fellows (both M.D.s and Ph.D.s) whom you have trained. List your major research grants, NIH, and other. Please list your other awards, honors, and distinctions. (for the above three questions you may wish to sent me a copy of your C.V.) What do you regard as your greatest contribution to academic Obstetrics and Gynecology? Replies to this last question centered on the theme of interesting students, residents, and fellows in research in obstetrics and gynecology. One person expressed it as "fostering curiosity in young people," while another phrased it as "not killing the dreams of the young!"

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Strengthening Research in Academic OB/GYN Departments Research Training in Obstetrics and Gynecology Many individuals distinguish between physician-scientists doing basic research in a clinical department and clinical investigators who perform more patient-oriented research. Do you believe that distinction should be made? Among respondents to this query, 15 states yes, 5 no, and 3 were of no opinion. there were no discernible differences in response by individuals in the three groups. If so, what is your perception of the current status and future needs of physician-scientists in academic Obstetrics and Gynecology? Despite the lack of unanimity of opinion to the previous question, the overwhelming response to this query was that there is a need for more clinical and basic science researchers, and a great need for 2 to 3 year ''junior scientist" post-subspeciality fellowships in both basic science and clinical research. One individual stated the need as 400 to 600 such investigators for the 130 or so medical schools. What do you believe to be the key elements in training physician-scientists? The points mentioned by respondents included good role models, a mentor who stimulates one to excel, broad-based laboratory experience, and protected time for research. Without exception, the respondents mentioned the need for stable financial support. One respondent also suggested that medical schools should reserve some admission positions for applicants who already have a doctoral or at least advanced research training. He also suggested that more medical students should be exposed to physician-scientists in departments of obstetrics and gynecology, so that potential recruits will be imbued with the excitement of research, problem solving, and research opportunities in reproduction. What do you believe to be the major problems in training new reproductive physician-scientists? Again, without exception, all respondents stressed the importance of money, both increased grant monies and stable funding for the long-term in research. Other issues mentioned included: the problem of relatively few academic departments being truly committed to research, the financial disparity between research and clinical practice, inherent conflict between clinical activity and fundamental research, "time consuming academic bureaucracies," and the "Lorelei-like attraction of private practice." What lessons would you care to share vis-a-vis research training in our specialty? What suggestions would you make as to how the needs for physician-scientists in obstetrics and gynecology can be met? Overall, there was a consensus on the seriousness of the problem, in that the specialty needs many more physician-scientists and clinical investigators. A key issue here was the

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Strengthening Research in Academic OB/GYN Departments need for increased funding for both research and research training. Several individuals suggested reviving something similar to the Markle/Macy scholarship programs to provide adequate support for the fellowships and training. One person emphasized that one must "do research you enjoy in an area that will be viable and that will sustain you for forty years, and stay current." Others stressed the need for more centers of excellence and more department chairs who are committed to academic research. A typical reply was the following: "Presently, most departments of obstetrics and gynecology do not have adequate research teams for training physician-scientists. The first priority should be directed toward creating such teams through developmental grants. Emphasis should be placed on encouraging young investigators to delve into new areas of research. A mix of M.D.s and Ph.D.s with dual appointments should also be encouraged. Developmental grants could be limited to 5 years or so, after which the group should apply to the regular funding agencies." Two other issues are of significance: Deans of medical schools, chairpersons, or directors of obstetrics and gynecology departments should be sensitized to the issue of the critical shortage of physician-scientists within the specialty. They should be encouraged to support more basic research within the clinical departments. Several respondents stressed the need to either create a separate residency-fellowship track to tram physician-scientists, with perhaps a Ph.D. option, or to modify subspecialty training by including more research. One person stated that "presently, subspecialty training emphasizes clinical competence and does not prepare the individual for competitive basic research funding. Most residents elect to pursue the recognized subspecialty, because this is the only option opened to them." Finally, a particularly thoughtful respondent mentioned that we "need a value system that rewards academic productivity."

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Strengthening Research in Academic OB/GYN Departments References Beeson, P.B. How to foster the gain of knowledge about disease. Perspect. Biol. Med. 23:S9–S24, 1980. Bowers, J.Z., and E.F. Purcell (eds.). The Current Status and Future of Academic Obstetrics. Report of a Conference Supported Jointly by the National Institute of Child Health and Human Development and the Josiah Macy, Jr., Foundation. New York, Josiah Macy, Jr., Foundation, 1980. Bradford, W.D., S. Pizzo, and A.C. Christakos. Careers and professional activities of graduates of a medical scientist training program. J. Med. Educ. 61:915–918, 1986. Bush, V. Science—the endless frontier: A report to the president. Washington, DC: United States Government Printing Office, 1945. Corner, G.W. A History of the Rockefeller Institute. 1901–1953, Origins and Growth. New York: Rockefeller Institute, 1964. Cushing, H. The Life of Sir William Osier. 2 vols. Oxford: Clarendon Press, 1925. Douglas, G.W. Centennial insights. Am. J. Obstet. Gynecol. 126:739–743, 1976. Ford Foundation. Annual Report, October 1, 1981, to September 30, 1982. New York: Ford Foundation, 1982. Ford Foundation. Annual Report, October 1, 1989 to September 30, 1990. New York: Ford Foundation, 1990. Fremont-Smith, F. The Josiah Macy, Jr., Foundation Conference Program. In: Gestation: Transactions of the Third Conference, Villee, C.A. (ed). New York: Josiah Macy, Jr., Foundation, 1957. Frieden, C., and B.J. Fox. Career choices of graduates from Washington University's Medical Scientist Training Program. Acad. Med. 66:162–164, 1991. Haseltine, F.P. and A.A. Campbell. The Impact of Fellowships Supported by the Andrew W. Mellon Foundation. Center for Population Research. Washington, D.C.: National Institute of Child Health and Human Development, 1986. IOM (Institute of Medicine). Personnel Needs and Training for Biomedical and Behavioral Research. Report of the Committee on National Needs for Biomedical and Behavioral Research Personnel. Washington, D.C.: National Academy Press, 1985. Lenfant, C. (Chairman, Steering Committee). Review of the National Institutes of Health Biomedical Research Training Programs. Bethesda, MD: National Institutes of Health, 1989. Longo, L.D. Fundamental and clinical research and patient care: A triad for progress in reproductive medicine. Am. J. Obstet. Gynecol. 159:6–12, 1988. Longo, L.D. A Short History of the Society for Gynecologic Investigation, 1953–1983. Los Angeles: The Society, 1983. Macy Foundation. Annual Reports. New York: Josiah Macy, Jr., Foundation, 1956–1960, 1965, and 1980. Macy Foundation. Report of a Macy Conference. Teaching the Biological and Medical Aspects of Reproduction to Medical Students. New York, Hoeber Medical Division, Harper & Row, 1966. Macy Foundation. Teaching Family Planning to Medical Students. New York: Josiah Macy, Jr., Foundation, 1968. Martin, J.B. Training physician-scientists for the 1990s. Acad. Med. 66:123–129, 1991. Mellon Foundation. Report of the Andrew W. Mellon Foundation, from January 1, 1985, through December 31, 1985. New York: Andrew W. Mellon Foundation, 1985.

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Strengthening Research in Academic OB/GYN Departments Mellon Foundation. Report of the Andrew W. Mellon Foundation, from January 1, 1990, through December 31, 1990. New York: Andrew W. Mellon Foundation, 1990. Messer, R.H., Pearse, W.H., and J.G. Fielden. Academic Manpower for Obstetrics and Gynecology in the United States. Obstet. Gynecol. 53:649, 1979. Mitchell, G.W. Professor of OB/GYN, University of Texas Health Science Center. Lever to Lawrence D. Longo, 2 November 1990. Movsesian, M.A. Effect on physician-scientists of the low funding rate of NIH grant applications. N. Engl. J. Med. 322:1602–1604, 1990. National Institutes of Health. Successor to the Hygienic Laboratory. Public Health Report 45:1409–1412, 1930. Pearse, W.H., E.C. Davidson, Jr., and J.G. Fielden. Trends in obstetric-gynecologic academic manpower—1980 . Obstet. Gynecol. 58:233–236, 1981 Pearse, W. H., Davidson, E.C., and J.G. Fielden. Trends in Obstetric-Gynecologic Academic Manpower-1983. Obstet. Gynecol. 65:147–150, 1985. Pearse, W.H., Fielden, J.G., and Donald M. Sherline Obstetric-Gynecologic Academic Manpower-1986. Obstet. Gynecol. 70:403–405, 1987. Pearse, W.H., and K.K. Graham. Trends in obstetric-gynecologic academic manpower and research. Obstet. Gynecol. 78:141–143, 1991. Randall, C.L. Developments in the Certification of Obstetricians and Gynecologists in the United States 1930–1980: The American Board of Obstetrics and Gynecology. Seattle, WA, American Board of Obstetrics and Gynecology, 1989. Russell, J. Informal Survey of Medical Education and Research, Madre Foundation, New York, New York, May 1947, pp. 12–14. Smith, L.H. Training of Physician/Scientists. Pp. 107–120 in Institute of Medicine: The 1989 Report of the Committee on National Needs for Biomedical and Behavioral Research Personnel, Vol. 3, Commissioned Papers. Washington, D.C: National Academy Press, 1989. Spellacy, W.N., S.A. Birk, and W.C. Buhi. A National Survey of Medical School Obstetrics and Gynecology Departments, 1965 to 1975. J. Med. Educ. 52:901–905, 1977. Strickland, T.G., and S.P. Strickland. The Madre Scholars: A Brief History. New York: The John & Mary R. Markle Foundation, 1976. Taylor, H.C., Jr. (ed.). The Recruitment of Talent for a Medical Specialty. A Report to the American Gynecological Society on the Problem of Procurement of Academic and Scientific Personnel for Obstetrics and Gynecology. St Louis: C.V. Mosby Co., 1961. Wyngaarden, J.B. The clinical investigator as an endangered species. N. Engl. J. Med. 301:1254–1259, 1979.

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