2
IS THERE A PROBLEM?

The previous chapter noted perceived difficulties in supporting research and in training research personnel in obstetrics and gynecology (OB/GYN). This chapter moves from perception to more solid ground by examining objective indicators to establish whether a problem exists. There are three ways to answer the question. The first measure is the level of external support for research and research training in academic departments of OB/GYN, primarily from the National Institutes of Health (NIH) but also from the private sector. The second involves the structural characteristics of departments of OB/GYN, specifically, whether OB/GYN departments differ from other clinical departments in ways that might indicate that problems exist or that might constitute a cause for alarm. The final measure is a research agenda for OB/GYN, the size and depth of which indicate unmet needs for research and promising avenues of investigation with great potential for repaying increased investment in OB/GYN research.

Support of Research and Training in Departments of OB/GYN

Sources of funding for research in departments of OB/GYN include the federal government, foundations, the academic institutions within which the departments exist, the departments themselves, and industry. The Institute of Medicine (IOM) was fortunate in that the American College of Obstetricians and Gynecologists (ACOG) and the Association of Professors of Gynecology and Obstetrics (APGO) include questions in their joint survey of academic manpower that enabled the committee to gain an understanding of the overall level of research support in departments of OB/GYN and the relative contribution of each of the above sectors. Responses from all 136 approved U.S. medical schools indicated a total of $142.2 million in research funds from all sources m 1990. The principal source of research support was the federal government ($77.5 million, or 54.5 percent), followed by institutional support ($26.4 million, or 18.6 percent), industry ($19.3 million, or 13.5 percent), and foundations and other sources ($19.1 million, or 13.4 percent).1 No data axe



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Strengthening Research in Academic OB/GYN Departments 2 IS THERE A PROBLEM? The previous chapter noted perceived difficulties in supporting research and in training research personnel in obstetrics and gynecology (OB/GYN). This chapter moves from perception to more solid ground by examining objective indicators to establish whether a problem exists. There are three ways to answer the question. The first measure is the level of external support for research and research training in academic departments of OB/GYN, primarily from the National Institutes of Health (NIH) but also from the private sector. The second involves the structural characteristics of departments of OB/GYN, specifically, whether OB/GYN departments differ from other clinical departments in ways that might indicate that problems exist or that might constitute a cause for alarm. The final measure is a research agenda for OB/GYN, the size and depth of which indicate unmet needs for research and promising avenues of investigation with great potential for repaying increased investment in OB/GYN research. Support of Research and Training in Departments of OB/GYN Sources of funding for research in departments of OB/GYN include the federal government, foundations, the academic institutions within which the departments exist, the departments themselves, and industry. The Institute of Medicine (IOM) was fortunate in that the American College of Obstetricians and Gynecologists (ACOG) and the Association of Professors of Gynecology and Obstetrics (APGO) include questions in their joint survey of academic manpower that enabled the committee to gain an understanding of the overall level of research support in departments of OB/GYN and the relative contribution of each of the above sectors. Responses from all 136 approved U.S. medical schools indicated a total of $142.2 million in research funds from all sources m 1990. The principal source of research support was the federal government ($77.5 million, or 54.5 percent), followed by institutional support ($26.4 million, or 18.6 percent), industry ($19.3 million, or 13.5 percent), and foundations and other sources ($19.1 million, or 13.4 percent).1 No data axe

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Strengthening Research in Academic OB/GYN Departments available to indicate either past levels of support or changes in distribution, but some OB/GYN department chairs feel that the pharmaceutical industry has become a more significant source.2 There are also indications that private foundation support, which played an important role in stimulating research in departments of OB/GYN in the past, has diminished in recent years. The Role of Foundations According to an inventory of private agencies that contribute to population research,* a small number of foundations—the Ford, Rockefeller, and Andrew W. Mellon foundations—have for years dominated the private funding scene. The Hewlett Foundation, created in 1966, entered the inventory in 1985. The Population Council, which is included in the inventory, is itself a research organization that solicits funds to support its work. However, it also supports investigators—mainly overseas—who collaborate with the council in fertility and contraception work.** Between 1976 and 1985, several trends in foundation support were notable. Reproductive processes and contraceptive development both lost ground, losing 34 percent and 6 percent in funds, respectively. There was also a large shift of funds to the social and behavioral sciences (a gain of 224 percent) and smaller but nevertheless substantial gains for contraceptive evaluation (184 percent) and population research centers (98 percent).3 These trends suggest that OB/GYN departments may have been losers, since the largest gains appear in areas in *    The term population research is not synonymous with the research activities appropriate to departments of OB/GYN. In the following discussion it is defined as "studies of the nature, determinants, and consequences of population characteristics and dynamics and the development of basic data and methods for such population analysis. Physical, biological, psychological, cultural, social, economic, geographic, historical and political factors may all be included in population studies" (U.S. Department of Health and Human Services, National Institutes of Health, Public Health Service, Inventory and Analysis of Federal Population Research, Fiscal Year 1988, Washington, D.C., 1990). Many population research projects are conducted in departments other than OB/GYN. Moreover, OB/GYN departments receive research support from foundations that are not included in the inventory. Nevertheless, this inventory is the best available indicator of trends in foundation support for the areas of science undertaken by departments of OB/GYN. **   The Population Council was a major grant-giving organization in the 1950s and early 1960s. There tier it became mainly a research organization funded by foundations, NIH, and other government agencies in the same way that other research organizations and universities are funded.

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Strengthening Research in Academic OB/GYN Departments which other departments have a major stake. The area most specific to OB/GYN—that is, reproductive processes—experienced the greatest loss. Private foundations have also made significant contributions to the training, development, and support of OB/GYN academic manpower. The principal foundations involved have been the Mary R. Markle Foundation; the Josiah Macy, Jr. Foundation; the Rockefeller, Ford, and Mellon foundations; and, more recently, foundations formed by OB/GYN professional groups. The history of the contributions of these organizations is detailed in Appendix A. The foundations played an important role in stimulating the research careers and bringing to prominence many of today's leaders in academic OB/GYN. It is particularly useful to note the contributions of the Macy and Mellon foundations, which provide good examples of the impact of foundation giving and of the factors that may cause a change in the programs these foundations support. The program of the Josiah Macy, Jr. Foundation focused specifically on the furtherance of reproductive biology through faculty development, conferences and seminars, and support of research time for medical students. In the 1950s and 1960s, funds flowed into selected medical schools and to individuals in residency programs. There were also funds for interdisciplinary research. The program supported faculty fellows and postdoctoral fellows, many of whom later became distinguished contributors to their discipline. When the program ended in 1966, about 50 people had received training support; by 1979, 15 of the 50 were department chairs. Also of importance were the Macy-sponsored conferences, at which new directions for reproductive science were presented, discussed, and refined. It is estimated that between 1955–1970 the Macy Foundation allocated $6.4 million to the development of academic OB/GYN research.4 Its heavy involvement in OB/GYN came to an end with a change in leadership within the foundation.5 Another foundation that formerly made important contributions but that has today diminished its involvement is the Andrew W. Mellon Foundation. Beginning in 1977, the foundation attacked the problem of world population growth through research aimed at contraceptive development. It helped support talented investigators entering the reproductive sciences and brought a number of young molecular biologists into the field. Major grants were awarded to 17 reproductive biology centers, supporting the development of more than 200 young M.D. and Ph.D. investigators and untenured faculty. A 1986 review of the program noted that Mellon funds were particularly valued by departments because of their flexibility—the money could be used to support individuals at crucial early phases of their careers, to bring into the centers people of various backgrounds to create multidisciplinary research teams, or to undertake areas of contraceptive investigation that NIH could not fund.6 These young investigators

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Strengthening Research in Academic OB/GYN Departments were starting to make important contributions to the field when the decision was made in 1989 to wind down the program. It is currently funded at $1 million per year, down from the former level of $2.5 million. In 1980, the Mellon Foundation also started providing reproductive research project grants, often to institutions with Mellon reproductive biology center grants. Roughly $1.2 million per year was allocated to these grants, which were discontinued in 1989. It is estimated that between 1977 and 1988 the Mellon Foundation contributed a total of $27.5 million to reproductive biology, including support of young investigators.7 Reasons for the reduction in Mellon support of the field of reproductive research are complex, but interviews with foundation staff indicate that contributing factors include a sense that few of the investigators who were supported have continued working in areas related to contraceptive development and that the project money was an add-on to NIH funds for work similar to NIH-supported research. In general, the foundation concluded that its greater strength lay in the humanities rather than in the biomedical field, a view reinforced by new leadership at the foundation. Moreover, discussions between scientists and foundation staff did not yield a focus that closely matched the foundation's goals, so it decided to transfer funds to applied research and other areas in the population research field.8 Islands of strength in OB/GYN research and leadership exist today in part because of the efforts of these foundations. They invested in OB/GYN research and the development of research personnel, and the flexibility of that money was particularly valuable as an adjunct to more regulated government support. The withdraw of the support that was so important in developing OB/GYN research leaders has generated fears that, as the generation of leaders whose development was assisted by the foundation programs approaches retirement, a vacuum in research leadership will become apparent. Whether it was within the power of those in OB/GYN to persuade the foundations to maintain their investment in reproductive sciences is uncertain. To some extent foundation policies are driven by external events, and to some extent by factors internal to the foundations such as a change in leadership. Moreover, foundations choose priority areas in many different ways: through internal priorities, personal contacts, and advisory committees.9 Some foundations seek underfunded areas in which their support can make a difference, which may today represent an opportunity for OB/GYN. In addition to awards specifically for reproductive sciences or to support individuals trained in OB/GYN, which have suffered a major decline in number and in level of funding, foundations today offer awards for which eligibility is less constrained and for which young OB/GYN investigators may be eligible. For example, the Searle Scholars Program awards three-year grants of $180,000

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Strengthening Research in Academic OB/GYN Departments to individuals in the first or second year of their first appointments as assistant professors. The idea is to identify promising investigators at an early and crucial stage in their careers. Since its inception in 1980, the program has made 191 awards—mainly to basic science investigators, according to the program director, who notes that the selection committee seeks evidence of a departmental commitment to the candidate. This, he believes, is more often found for basic than for clinical scientists. Other foundations that give substantial awards to young biomedical investigators in many fields include the Lucille P. Markey Charitable Trust, which supports 16 individuals per year, and the David and Lucille Packard Foundation and the Pew Charitable Trusts, each of which supports 20 individuals per year.10 Other Private-Sector Training Support Today, much private-sector support of OB/GYN training comes from industry, although OB/GYN professional associations and their foundations also contribute. ACOG has identified a total of 14 awards currently being made by the private sector, including some substantial fellowships: The James Kennedy Fellowship Award of the American Association of Obstetricians and Gynecologists Foundation (the funding arm of the American Gynecological and Obstetrical Society) provides $40,000 per year for two years for fellows and requires a $15,000-per-year institutional commitment. This postdoctoral award targets individuals who need research training to move toward an investigative career. The program began in 1984 and had awarded a total of 17 fellowships by July 1990. Thirteen of these fellows attended a retreat in June 1990 at which an impressive summation of their research activities was presented.11 The Berlex Foundation offers one or two scholarships per year with a stipend of $50,000 plus $10,000 for laboratory support for an individual who already has a record of independent research. ACOG has joined with Ortho Pharmaceutical Corporation to provide two $30,000 fellowships annually, to be awarded to an ACOG fellow or junior fellow identified as progressing toward academic OB/GYN. The award is meant to allow the recipient to undertake an investigative project and basic research training. There are in addition a number of smaller professional association/industry grants that provide start-up funds for research projects, as well as some monies for training support.12

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Strengthening Research in Academic OB/GYN Departments It is estimated that approximately six to eight physician/scientists are being trained annually in these major programs supported by the private sector.13 Many of these programs have their roots in assessments from inside the discipline that academic research needs enhancement and that a vitalized research effort would upgrade the status of OB/GYN.14 The initiatives have resulted in a small but significant body of awards to further the development of investigators. The future magnitude of professional and industry support of OB/GYN research training will depend on a continuing sense in the discipline that an enhanced research capability would benefit it generally, both in terms of the status of academic OB/GYN and in the quality of clinical practice. Voluntary Health Agencies Voluntary health agencies—often founded by the friends and families of individuals with a particular disease—sometimes use their funds for disease-related research and training. They can make important contributions to the careers of scientists by supporting fellowships, initial research, and other career development awards. Voluntary health agencies do not, however, usually make long-term commitments to research.15 OB/GYN departments are well positioned to tap into the resources available from these agencies since OB/GYN interests overlap to some extent with the interests of three of the largest—the American Cancer Society, the March of Dimes-Birth Defects Foundation, and the National Easter Seal Society. Data on the level of OB/GYN funding by such voluntary health agencies are not available; however, each of the three agencies mentioned above was included in lists of sources of support received by the committee from chairs of departments of OB/GYN. FINDINGS: The committee found cause for alarm in the diminution of foundation support for the development of OB/GYN research personnel and for OB/GYN research. Foundations played a vital role in preparing many of the current leaders of the field, and without this support there may not be enough well-prepared individuals to step into leadership positions when the current generation reaches retirement age. Today only approximately 11 young investigators each year benefit from major private-sector training awards, including those supported by the joint public/private Reproductive Scientist Development Program but excluding those who are awarded other NIH training

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Strengthening Research in Academic OB/GYN Departments support. Increasing the number of available awards by at least another six would return significant benefits to OB/GYN research. RECOMMENDATIONS: OB/GYN leaders should take the initiative in demonstrating to foundation and voluntary health agency trustees and other representatives, to leaders of professional associations, and to relevant foundations of industrial corporations, ways in which expanded support of training for OB/GYN investigators would be a worthwhile investment. The purpose of such investments would be to ensure that sufficient research personnel are available to allow OB/GYN to fulfill its promise of improving women's health, contraception, and pregnancy outcomes. The committee encourages foundations to develop programs for OB/GYN, such as the former Josiah Macy, Jr. Foundation program, the current Searle Scholars Program, or other foundation efforts that can be regarded as models with characteristics that may be worth emulating. OB/GYN leaders should seek additional research support from the types of organizations mentioned above. The promise of the research, together with a willingness to adapt research programs to correspond to foundation priorities, will provide powerful arguments that have a chance of salvaging some lost foundation support. By the same token, decision makers in foundations that are concerned with the development of scientific personnel—or with population problems, women's health, cancer, pregnancy outcomes, and other topics that OB/GYN is well positioned to address—should be aware of the role that their support of training and research could play at this crucial time in the development of OB/GYN research. The committee also recommends that the American College of Obstetricians and Gynecologists and the Association of Professors of Gynecology and Obstetrics continue to include in their manpower survey questions on sources of research support received by departments of OB/GYN. This information will for the first time allow tracking of the level of research activity in departments of OB/GYN. Federal Support A 1980 report on the status of academic obstetrics noted that ''federal funding of research in academic departments of obstetrics and gynecology in the

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Strengthening Research in Academic OB/GYN Departments United States has never been substantial, and the situation is not different today.''16 That sentiment might be echoed in 1992. The discussion below focuses on NIH support of departments of OB/GYN. * Other federal agencies also contribute, but their support is difficult to identify and is not thought to be sizable.17 A survey of departments of OB/GYN in 1990 revealed a total of $77.5 million in federal research funds.18 NIH data indicate that, of this amount, $45.7 million (59 percent) came from NIH, and there are reasons to believe that the NIH contribution exceeds 59 percent. (For example, the figure omits awards that flow to academic departments but that are awarded to other entities, such as hospitals.) Staff at federal agencies outside of NIH agree that their funding of research in departments of OB/GYN is limited. In 1989, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) provided $1.6 million in research funds. Trends in NIH Support of Departments of OB/GYN NIH funds flowing to departments of OB/GYN increased from $6.9 million in 1968 to $16.1 million m 1978 and to $45.7 million in 1990 (this latter figure represents a slight decline from the $46.5 million awarded in 1989). In constant dollars, however, the increase over the 1968–1989 period was 74 percent; it was 43 percent between 1978 and 1989 (Figure 2-1). Since the average amount of money per award increased over time, the number of awards has not grown at the same rate as dollar support. Thus between 1980 and 1989, the dollars going to departments of OB/GYN more than doubled, while the number of awards increased by less than 5 percent, more closely reflecting the real-dollar increase. Departments of OB/GYN very slightly increased their share of the overall NIH budget. Their share of the NIH funds going to departments of medical schools has remained virtually unchanged. During the 1980s the NIH budget increased by 150 percent, while OB/GYN departments gained 190 percent. OB/GYN departments maintained their share of NIH medical school support at 1.4 to 1.5 percent between 1968 and 1989, although they received less than might be expected on the basis of faculty size: 3.8 percent of all medical school faculty are in departments of OB/GYN, but they were awarded only 1.5 percent of the NIH funds going to medical schools. *    The following discussion of the NIH role is, unless noted otherwise, based on a background paper by Robert A. Walkington, which is published as Appendix B of this report and to which the reader is referred for additional information. The data for this paper were extracted from the NIH data systems specifically for this study.

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Strengthening Research in Academic OB/GYN Departments Figure 2-1: NIH support of departments of OB/GYN, current and constant (1968) dollars SOURCE: Special tabulation by NIH. An important element in the extent of support, at any given time, of specific areas of science or of specific disciplines relates to the fortunes of the NIH institute that provides the funds. Because public and congressional perceptions of the importance of the health or science issues undertaken by each institute have varied over time, budget appropriations for individual institutes do not always parallel overall NIH budget growth. Historically, the National Institute of Child Health and Human Development (NICHD) has been the major NIH supporter of departments or OB/GYN, providing between 55 percent and 70 percent of NIH support since 1968. NICHD has received approximately 6 percent of total NIH funds since 1978, and departments of OB/GYN have increased their share of NICHD funds from 5.4 percent in 1978 to 7.5 percent in 1989.

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Strengthening Research in Academic OB/GYN Departments The National Cancer Institute (NCI) has been the second largest NIH supporter of OB/GYN departments. However, the NCI contribution fell from 31 percent of total NIH funds going to departments of OB/GYN in 1978 to 9 percent ($4.6 million) in 1989. Although NCI's share of the total NIH appropriation has itself fallen substantially, NCI is still by far the largest institute, accounting for more than 20 percent of NIH's 1989 funds. NIH offers many types of research and research training awards. Research grants absorb the largest proportion of NIH funds, a proportion that has risen from 77 percent of total NIH support awarded in 1980 to 84 percent in 1989. Awards to departments of OB/GYN followed a similar trend: research grants increased from 90 percent to 92 percent of OB/GYN awards over the same period. The largest component of this group of awards is the category of investigator-initiated awards (RO1s). Also included in the group of awards are First Independent Research Support and Transition (FIRST) and New Investigator Research awards, both of which can be pivotal support for young investigators; Research Program Project grants; and research center grants, which play a role in solidifying the research efforts of a department and ensuring the presence of a new generation of investigators. NIH also supports research training at both the pre- and postdoctoral levels. This aspect of NIH activities has experienced a relative decline, falling from 6.6 percent of the NIH extramural budget in 1980 to 4.3 percent in 1989. Again, the trend for departments of OB/GYN is similar, with training support falling from 3 percent of NIH support of departments of OB/GYN in 1980 to 1.3 percent in 1989. In sum, departments of OB/GYN have made a very small gain in terms of share of NIH resources, but the funds they receive remain an extremely small component not only of the NIH budget as a whole—which is to be expected—but also of the budget of NICHD, the institute that has the mandate to improve reproductive health. Closer examination of the data causes a greater sense of alarm about how OB/GYN departments are faring. The following sections take such a look, viewing the state of NIH support of departments of OB/GYN from three perspectives: the types of awards applied for and received by departments of OB/GYN, the academic degrees of investigators, and how OB/GYN departments compare with some other clinical departments. Competition for NIH Funds To assess how OB/GYN departments are doing in gaining NIH support, the committee compared their applications with applications from departments of internal medicine, pediatrics, surgery, and radiology. Departments of internal

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Strengthening Research in Academic OB/GYN Departments medicine were chosen for this purpose because they are the largest of all the clinical departments and are widely considered to be leaders in research capabilities. Pediatric departments were selected because pediatrics is a major focus of interest for NICHD; thus those departments share with OB/GYN some dependence on that institute. Surgery was chosen because it shares a technical orientation with OB/GYN—a characteristic that is also thought to affect the likelihood of success in NIH funding. Finally, departments of radiology were chosen because they are similar to OB/GYN in research intensity as measured by the percentage of faculty who are principal investigators (PIs) on NIH and ADAMHA grants. Although radiology faculty are more numerous than OB/GYN faculty, the two departments are nevertheless closer in size than the other departments chosen. Internal medicine had nearly six times as many full-time faculty as OB/GYN in 1988, while pediatrics and surgery had more than twice as many. Other departments or subspecialties might provide more appropriate comparisons, but data problems prohibited analysis. All Competing Applications In the decade 1980–1989, the five clinical departments submitted a total of 46,148 competing applications to NIH (Table 2-1). Fifty-nine percent were submitted from departments of internal medicine (which have 44 percent of the full-time faculty in the five departments), 15 percent by departments of pediatrics (with 19 percent of faculty), 13 percent by departments of surgery (with 17 percent of faculty), 7 percent by departments of radiology (with 13 percent of faculty) and 6 percent by departments of OB/GYN (with 7 percent of faculty). Thus departments of internal medicine submitted a disproportionately large number of applications in relation to faculty size; OB/GYN, pediatrics, and surgery submitted a roughly proportional number; and radiology was slightly underrepresented. However, on a per capita basis, physicians in departments of OB/GYN submitted fewer applications than M.D.s from three of the other four departments (Table 2-2). The success rate (percentage of applications funded) varied from 37.6 percent for internal medicine to 26.5 percent for OB/GYN. The differences in success rates among OB/GYN and the other departments, except for surgery, are statistically significant. The low relative success rate of OB/GYN departments became more acute toward the end of the decade. Analysis by degree reveals that the success rate of applications from Ph.D.s in departments of OB/GYN was significantly lower than the success rates of Ph.D.s in departments of medicine and radiology. The differences in success rates for Ph.D.s among departments of OB/GYN, pediatrics, and surgery were

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Strengthening Research in Academic OB/GYN Departments TABLE 2-6: Distribution of Medical School Faculty (as percentage of faculty at each level that are women) in Clinical Departments by Gender and Rank, 1989. Department Professor Associate Professor Assistant Professor Instructor Total Anesthesiology 7.6% 17.9% 27.7% 26.0% 22.6% Dermatology 7.9 16.3 35.5 36.8 21.5 Family Medicine 6.4 15.7 27.0 44.3 23.8 Internal Medicine 4.6 10.6 22.1 30.4 15.7 Neurology 5.0 16.3 19.7 34.5 15.8 OB/GYN 7.2 13.6 30.1 54.8 23.7 Ophthalmology 5.7 11.2 19.9 21.0 13.8 Orth. Surgery 0.9 7.5 10.2 21.2 8.1 Otolaryngology 2.2 14.8 22.4 49.1 17.1 Pathology (clinical) 8.9 19.6 30.0 43.9 21.6 Pediatrics 14.6 26.5 39.5 55.1 32.4 Phys. Medicine 12.1 30.6 36.9 49.5 34.1 Psychiatry 8.3 18.3 29.2 44.5 16.6 Public Health 12.1 20.7 40.0 55.1 30.1 Radiology 5.4 14.5 22.8 23.0 16.3 Surgery 1.6 5.9 12.6 20.5 8.1 Other Clinical 10.5 31.6 24.1 — 21.4 Total 6.3 15.0 25.7 37.0 19.6   SOURCES: Association of American Medical Colleges, U.S. Medical School Faculty, "The Numbers Book," Washington, D.C., Association of American Medical Colleges, 1989.

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Strengthening Research in Academic OB/GYN Departments among clinical departments are sparse. AAMC collects data on the activities of medical faculty, but only activities that consume more than 10 percent of a faculty member's time and without distinguishing between activities that consume, for example, 11 percent or 90 percent of time. In 1983, to gain a better picture of medical faculty involvement in research, the Association of Professors of Medicine, in cooperation with AAMC, asked full-time faculty members in departments of internal medicine what percentage of time they spent in research.* In 1990, ACOG, at the request of this committee, added to its academic manpower survey a question asking whether faculty members spent 20 percent or more of their time in research. The results revealed that 34.5 percent of physician faculty (M.D. and M.D./Ph.D.) spent at least 20 percent of their time in research in 1990, compared with 45 percent of M.D. and 67 percent of M.D./Ph.D. internal medicine faculty, as recorded in the AAMC data for 1983. Ph.D. faculty in both internal medicine and OB/GYN departments are more involved in research than their M.D. colleagues6—90 percent of the internal medicine Ph.D faculty and 92 percent of the OB/GYN Ph.D. faculty spend at least 20 percent of theft time in research.35,36 Data from these two sources are not strictly comparable because of differences in sources of information and time of data collection and the difference between a specialty oriented toward surgical procedures and one oriented toward medicine. Nevertheless, the disparity between the two departments in research activity of physicians is suggestive. Departments of internal medicine, acknowledged leaders in research activity among clinical departments, appear to engage their physician faculty more heavily in research, which also reflects their relatively high success rate in competing for NIH funds (see above). The lesser involvement of OB/GYN in se h may also support the notion, current among OB/GYN leaders, that OB/GYN faculty maintain unusually large clinical practices. Which Clinical Departments Are Research Intensive? The final characteristic examined here that may bear on the research capabilities of departments is the percentage of full-time faculty who are principal investigators on NIH or ADAMHA awards. This indicator functions as a proxy measure for the research intensity of departments. A 1988 AAMC study ranked departments of OB/GYN eleventh out of 17 clinical departments, with 9.8 percent of faculty as PIs, compared with an average of 14 percent for all clinical departments. *    That study defined the following as active researchers: individuals who spend at least 20 percent of their time in research, who have authored or co-authored an original article or other significant research publication, and who have either external funding or assigned research space.

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Strengthening Research in Academic OB/GYN Departments Ophthalmology ranked first with 36.5 percent; family medicine was at the low end with 1.2 percent (Table 2-7). As might be expected, research involvement varies by degree—11.1 percent of M.D.s, 24.3 percent of M.D./Ph.D.s, and 26.9 percent of Ph.D.s are PIs. Thus, M.D./Ph.D.s are generally more like Ph.D.s in their involvement in research. However, this generalization does not hold for OB/GYN. Both M.D. and M.D./Ph.D. faculty in departments of OB/GYN are below the average for clinical departments in the proportion of faculty that are Pis. On the other hand, Ph.D.s in departments of OB/GYN rank sixth of the 17 departments in the proportion that are PIs (32.2 percent) and are well above the 26.9 percent average.37 Clearly, to the extent that these data measure research intensity, departments of OB/GYN are among the less research-intensive departments, and their relative weakness in research capabilities can be attributed to the performance of their physicians.* The research intensiveness of specialties can be analyzed on a different axis—the proportion of departments with significant outside research funding. There are two sources of data on this topic. The 1990 ACOG manpower survey revealed that only 9 of the nation's 136 academic departments of OB/GYN received more than $2 million in federal research funds. At the other end of the spectrum, 38 departments had no federal funds, and this number is larger for other sources of research funding.38 Data from NIH also indicate that research funding is clustered in a small number of departments. Between 1980 and 1989, approximately 70 departments of OB/GYN per year were recipients of NIH support. However, 10 departments received approximately 50 percent of the funds, and in 1989 only 4 departments had more than ten awards, while 15 had only one award. This concentration of funds in a small number of departments is somewhat more acute than generally occurs for NIH funds going to medical schools, where 20 schools received 50 percent of NIH funds in 1989.39 These indicators of research intensity suggest a weakness in departments of OB/GYN compared with other clinical departments, both in terms of the proportion of faculty that are PIs and in the concentration of research activity in a small number of departments. The existence of a critical mass of investigators is thought to be necessary to provide an environment in which science can thrive, and in which new investigators can be trained and exposed to role models in an atmosphere of scientific endeavor. These findings suggest *    It should, however, be remembered that although NIH and ADAMHA are major sources of research funding, they are not the only sources. Data indicating the relative ability of departments to gamer other research support are not available, but departments of OB/GYN are thought to have relatively good access to pharmaceutical company research funds

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Strengthening Research in Academic OB/GYN Departments that only a small number of departments of OB/GYN support a vital research effort or provide the necessary environment for the generation of new investigators. TABLE 2-7: Ranking of Clinical Departments by Percentage of Full-Time Faculty Who Are PIs on NIH/ADAMHA Awards (1988).   Total Full-Time Faculty M.D. Department No. %PIs No. %PIs Ophthalmology 1,014 36.5 650 25.7 Neurology 1,637 23.9 1,101 18.4 Dermatology 365 22.5 291 20.0 Internal Medicine 13,448 19.9 10,894 17.7 Pathology 1,152 17.0 656 13.9 Public Health 1,127 15.7 445 10.6 Other Clinical 69 14.5 21 19.0 Otolaryngology 543 14.2 296 6.4 Pediatrics 5,724 13.4 4,503 11.9 Psychiatry 5,244 12.1 2,858 8.1 OB/GYN 2,265 9.8 1,687 5.9 Surgery 5,031 9.5 4,038 7.0 Radiology 3,884 8.3 2,786 3.2 Orthopedic Surgery 730 7.8 569 4.4 Anesthesiology 2,649 3.5 2,186 1.6 Phys. Med/Rehab. 548 1.2 341 0.9 Family Medicine 1,539 1.2 1,127 0.7 Total/Average 45,969 14.0 34,449 11.1

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Strengthening Research in Academic OB/GYN Departments   M.D./Ph.D. Ph.D. Department No. %PIs No. %PIs Ophthalmology 61 39.3 245 69.4 Neurology 148 37.8 315 35.6 Dermatology 22 40.9 43 34.9 Internal Medicine 875 31.1 1,261 33.9 Pathology 122 25.4 280 22.1 Public Health 48 14.3 472 25.0 Other Clinical 2 0.0 41 12.2 Otolaryngology 28 25.0 171 27.5 Pediatrics 275 28.4 614 21.8 Psychiatry 197 18.8 1,728 20.2 OB/GYN 126 13.5 320 32.2 Surgery 268 17.9 540 25.9 Radiology 169 13.6 696 29.0 Orthopedic Surgery 23 13.0 81 34.6 Anesthesiology 181 8.8 157 22.3 Phys. Med/Rehab. 18 5.6 97 6.2 Family Medicine 25 0.0 265 6.8 Total/Average 2,589 24.3 7,327 26.9   SOURCE: American Association of Medical Colleges, Medical School Faculty Roster (1988), linked with Information Management Planning, Analysis and Coordination records of research grants (NIH and ADAMHA) and contracts (NIH) that received funds during fiscal year 1987. FINDING: Data pertinent to the present as well as the future research capabilities of OB/GYN departments indicate weakness. Time devoted to research by physicians is low, the proportion of faculty who are full-time investigators on NIH or ADAMHA grants is below average, and the number of departments with sizable research funding is small. The latter point indicates the small number of departments able to provide a suitable environment for training investigators. The strong and growing presence of women indicates that attention to differences among men and women in recruitment and retention in research will be important to the future health of the OB/GYN research enterprise. The committee's recommendations on these topics are found later in this report.

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Strengthening Research in Academic OB/GYN Departments A Research Agenda for Departments of OB/GYN The research agenda (which is fully discussed in Chapter 6) provides a different sort of evidence of the need for expanded research efforts in OB/GYN, because it identifies areas of investigation likely to repay investment with improvements in the reproductive health of women and in the results of pregnancy.* To ensure that the research agenda fulfills its purposes, the following criteria were applied: The research should contribute to the resolution of an important health problem. Importance can be defined in terms of high prevalence or incidence of a problem, in terms of the serious effect of the problem on individuals who experience it, or in terms of impact on the health care system where the costs of caring for the problem are incurred. The research approach should be promising. That is to say, there is reason to think that following the selected avenue of investigation would provide solutions or that answering the question posed by the research is an essential step in finding a solution. The research should be done in a department of OB/GYN or in collaboration with members of such departments. The mere fact that patients with OB/GYN should be a necessary element. Lack of interest by other specialties the problem are seen in OB/GYN departments is not sufficient justification. Rather, OB/GYN must be the discipline with the knowledge or skill needed to accomplish the research. If the research is interdisciplinary, would also be sufficient justification, since the work would not be accomplished if OB/GYN did not undertake it. The committee followed several steps n developing the research agenda: A letter was written to the chair of every U.S. and Canadian academic department of OB/GYN, asking for an opinion on priority areas for future research. Letters were also sent to leading OB/GYN professional associations. All committee members received copies of the replies, as well as a summary of the contents. *    The research agenda developed by the committee does not stress the social, health care, and other cost savings that would be generated by research that eliminates or diminishes some of the problems listed. For instance, the high hospital costs of caring for low birthweight babies are only the tip of the iceberg of expenditures incurred as a result of the long-term morbidity and disability that are frequent sequelae.

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Strengthening Research in Academic OB/GYN Departments A subgroup of the committee met to develop an initial list of research agenda topics, which was then reviewed, discussed, and revised by the full committee. Taking into consideration the criteria listed above, committee members allocated priorities to each item on the research agenda, and items that received low priority scores were eliminated from the list. Experts were asked to contribute background papers reviewing the current state of knowledge and identifying useful research approaches (see Appendix C for authors of background papers). Using the background papers and their own expertise, committee members developed a research agenda. Readers are referred to Chapter 6 for the agenda, which covers the following topics: Oocyte and follicular development in the ovary, including follicular formation; follicular atresia; follicular recruitment, selection, and dominance; corpus luteum function; and leukocytes, cytokines, and ovarian function. Fertilization. Fetal growth and development including embryology and congenital malformations; fetal growth and placental transport; congenital infection and substance abuse; perinatal research; and epidemiological research. Preterm labor including preterm, premature rupture of the fetal membranes, complications of pregnancy that compromise fetal or maternal well-being independent of the onset of labor, preterm onset of labor, and preterm labor and infection. Contraception including contraceptive implants, contraceptive rings, transdermal delivery, intrauterine devices (IUDs), oral conception, barrier methods, male contraception, antifertility vaccines, and medical abortifacients. Infertility including epidemiology, cervical physiology and function, fallopian tube function, endometriosis, male infertility, and in vitro fertilization and new reproductive technologies. Premenstrual syndrome. The brain and reproduction. Menopause. Oncology including ovarian cancer, uterine neoplasms, cervical cancers, vulvar malignancies, breast cancer, and trophoblastic disease. Sexually transmitted diseases including preventing sexually transmitted diseases by developing clinically effective and safe vaccines: developing cost-effective tests for early diagnosis of STDs; developing new therapies where needed and new cost-effective antibiotics that are easily administered and sufficiently acceptable to maximize compliance; clarifying the natural history of genital infections; defining behaviors associated with the acquisition and spread of STDs; and characterizing the role of STDs in adverse pregnancy outcomes.

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Strengthening Research in Academic OB/GYN Departments Conclusion From its review of the evidence in this chapter, the committee concluded that there is cause for concern about both the current and the future state of research in departments of OB/GYN. While it is appropriate that many departments of OB/GYN have, and preserve, a clinical focus, it is important to expand the number of departments that can succeed in the competitive research arena. In that way the committee's research agenda can be accomplished, and departments of OB/GYN can fulfill their potential for improving the health of women. The committee concluded that the highest priority is to build physician research manpower so that more departments of OB/GYN can successfully compete for, and effectively use, increased research support. The committee therefore focused its recommendations on ways of recruiting and sustaining OB/GYNs in investigative careers and on developing research capabilities in departments that, with some additional help, have the potential to equal the first-rank research departments of OB/GYN. Recommendations are found earlier in this chapter and in subsequent chapters of this report. No one entity bears the responsibility for this effort; rather, players to implement the committee's recommendations are to be found at NIH, in the departments of OB/GYN, in other loci in the medical schools, in foundations, and, importantly, in the profession of OB/GYN itself from which must flow the leadership that is a prerequisite to the development of a strong research community in OB/GYN. References 1. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology July 1991; 78(1):141–143. 2. Letters to the committee from chairmen of departments of obstetrics and gynecology. 3. Center for Population Research, National Institute of Child Health and Human Development, Bethesda, Md., Inventory and Analysis of Private Agency Population Research, 1984–1985. June 1988. 4. Longo, Lawrence D. Preparing for the Twenty-first Century in the Reproductive Sciences. Appendix A, this volume. 5. Telephone interview with Thomas H. Meikle, Jr., President, Josiah Macy Jr. Foundation, New York, New York, May 1991. 6. Haseltine, Florence P., and Campbell, Arthur A. The Impact of Fellowships Supported by the Andrew W. Mellon Foundation. Center for Population Research, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md., March 26, 1986.

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Strengthening Research in Academic OB/GYN Departments 7. Longo, Lawrence D. Preparing for the Twenty-First Century in the Reproductive Sciences. Appendix A, this volume. 8. Telephone interviews with Carolyn Makinson. Program Associate for Population, The Andrew W. Melton Foundation, New York, New York, 1990–1991. 9. Institute of Medicine. Funding Health Sciences Research. A Strategy to Restore Balance, ed. Floyd Bloom and Mark Randolph. Washington, D.C.: National Academy Press, 1990. 10. Barinaga, Marcia. The Foundations of Research. Science 1991; 235:1200–1202. 11. Robert F. Creasy, Professor and Chairman, Department of Obstetrics and Gynecology and Reproductive Sciences, University of Texas Health Sciences Center at Houston, personal communication, July 1990. 12. American College of Obstetricians and Gynecologists. Fellowships and Awards. Wallin, D.C.: American College of Obstetricians and Gynecologists. January, 1991. 13. Longo, Lawrence D. Preparing for the Twenty-First Century in the Reproductive Sciences. Appendix A, this volume. 14. Ibid. 15. Institute of Medicine. Funding Health Sciences Research: A Strategy to Restore Balance, ed. Floyd Bloom and Mark Randolph. Washington, D.C.: National Academy Press, 1990, p. 57. 16. Kretchmer, Norman. Support of Academic Obstetrics: The Public Sector. In: 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. ed. John Z. Bowers and Elizabeth F. Purcell. New York, New York: Josiah Macy Jr. Foundation, 1980. 17. Ibid. 18. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology July 1991; 78(1)141–143. 19. Walkington, Robert A. National Institutes of Health Support of Research in Departments of Obstetrics and Gynecology. Appendix B, this volume. 20. National Institutes of Health. The K Awards. Division of Research Grants, Bethesda, Md., undated, p. 59. 21. National Institutes of Health. Clinical Investigator Development Award. NIH Guide July 19, 1991; 20(28):6–10. 22. Vaitukaitis, Judith L. The Future of Clinical Research. Clinical Research 1991; 39(2):145–1561. 23. Herman, Samuel S., and Singer, Allen M. Basic Scientists in Clinical Departments of Medical Schools. Clinical Research 1986; 34:149–158. 24. See, for example, Levin, Sharon, G., and Stephan, Paula E. Age and Research Productivity of Academic Scientists. Research in Higher Education 1989; 30(5):531–549. 25. Sherman, C. R. et al. On the Status of Medical School Faculty and Clinical Research Manpower: 1968–1998. A report to the Clinical Sciences Panel of the Committee on a Study of National Needs for Biomedical and Behavioral Research Personnel, National Academy of Sciences, National Research Council. NIH Publication No. 82-2458. 1981, Bethesda, Md.: 1981. National Institutes of Health, Office of Program Planning and Evaluation, 1981. 26. National Research Council. Women: Their Underrepresentation and Career Differentials in Science and Engineering: Proceedings of a Conference, ed. Linda S. Dix. Washington, D.C.: National Academy Press, 1987.

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Strengthening Research in Academic OB/GYN Departments 27. Zuckerman, H. Persistence and Change in the Careers of Men and Women Scientists and Engineers: A Review of Current Research. In: Dix, L. S. ed., Women: Their Underrepresentation and Career Differentials in Science and Engineering: Proceedings of a Conference. Washington, D.C.: National Academy Press, 1987. 28. Bickel, Janet. Women in Medical Education. A Status Report. New England Journal of Medicine 1988; 319:1579–1584. 29. Bickel, Janet. Unpublished tabulation from 1989 Medical Student Graduation Questionnaire. Association of American Medical Colleges, Washington, D.C. 30. Bickel, Janet. Women in Medical Education. A Status Report. New England Journal of Medicine 1988; 319:1579–1584. 31. Ibid. 32. Ibid. 33. Roback, Gene, et al. Physician Characteristics and Distribution in the U.S. Chicago, Illinois: American Medical Association, 1990. 34. National Institutes of Health. DRG Peer Review Trends Workload and Actions of DRG Study Sections, 1980–1990. Bethesda, Md.: Division of Research Grants, p. 81. 35. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology 1991; 78(1):141–143. 36. Gentile, Nancy O., et al. Research Activity of Full-Time Faculty in Departments of Medicine. Washington, D.C.: Association of Professors of Medicine and Association of American Medical Colleges, 1987. 37. Sherman, Charies R. Summary of 1987 NIH and ADAMHA Research Support to U.S. Medical Schools, by Academic Department and Degree of Principal Investigator. Bethesda, Md.: National Institutes of Health, Office of the Director, May 1. 1989. 38. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology 1991; 78(1):141–143. 39. National Institutes of Health. Extramural Trends, FY 1980–1989. Bethesda, Md.: Division of Research Grants, Information Systems Branch, August 1990.

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