3
CAREER CHOICES

Chapter 2 narrowed the focus of concern from investigative capabilities in general to physician investigators in obstetrics and gynecology (OB/GYN). Basic scientists in OB/GYN departments are heavily involved in research and are quite successful in the competition for research funds, although there are indications of a decline in their success rate toward the end of the 1980s. Physicians are far less involved in research, as might be expected, given their clinical responsibilities. However, the number of physicians who successfully compete for research support is small, as is the number of physicians in the training pipeline who are likely to be able to compete in today's and tomorrow's research environment. There is no denying the importance of basic scientists to the biomedical research endeavor generally, as well as for OB/GYN. Many models can be cited of the relationship between basic and clinical scientists in clinical departments—individuals with complementary expertise who work together synergistically. Such models may include ones in which basic scientists provide the underpinnings on which clinical scientists build, basic scientists bring research expertise to the department that the physician investigators lack, or clinical and basic scientists conduct investigations in the same department but with little or no communication. Moreover, there are physician/scientists whose interest and training have extended so far into basic science that theft work is indistinguishable from the work of the Ph.D. scientist.* Attracting and retaining excellent basic scientists require a clinical department to overcome the fear of the basic scientist that he or she will be considered second-class by his or her

*  

 The importance of the interaction between basic and clinical research in reproductive medicine is stressed in a paper by Lawrence D. Longo, ''Fundamental and Clinical Research and Patient Care: A Triad for Progress in Reproductive Medicine,'' American Journal of Obstetrics and Gynecology 1988; 59(1):6–12.



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Strengthening Research in Academic OB/GYN Departments 3 CAREER CHOICES Chapter 2 narrowed the focus of concern from investigative capabilities in general to physician investigators in obstetrics and gynecology (OB/GYN). Basic scientists in OB/GYN departments are heavily involved in research and are quite successful in the competition for research funds, although there are indications of a decline in their success rate toward the end of the 1980s. Physicians are far less involved in research, as might be expected, given their clinical responsibilities. However, the number of physicians who successfully compete for research support is small, as is the number of physicians in the training pipeline who are likely to be able to compete in today's and tomorrow's research environment. There is no denying the importance of basic scientists to the biomedical research endeavor generally, as well as for OB/GYN. Many models can be cited of the relationship between basic and clinical scientists in clinical departments—individuals with complementary expertise who work together synergistically. Such models may include ones in which basic scientists provide the underpinnings on which clinical scientists build, basic scientists bring research expertise to the department that the physician investigators lack, or clinical and basic scientists conduct investigations in the same department but with little or no communication. Moreover, there are physician/scientists whose interest and training have extended so far into basic science that theft work is indistinguishable from the work of the Ph.D. scientist.* Attracting and retaining excellent basic scientists require a clinical department to overcome the fear of the basic scientist that he or she will be considered second-class by his or her *    The importance of the interaction between basic and clinical research in reproductive medicine is stressed in a paper by Lawrence D. Longo, ''Fundamental and Clinical Research and Patient Care: A Triad for Progress in Reproductive Medicine,'' American Journal of Obstetrics and Gynecology 1988; 59(1):6–12.

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Strengthening Research in Academic OB/GYN Departments peers. Suggestions for overcoming problems include the creation of joint appointments between basic and clinical departments and tenure-track appointments for basic scientists in clinical departments; there have also been calls for education of basic scientists in pathobiology.1 However, since the identified weakness in OB/GYN relates to physician/scientists rather than basic scientists, this chapter focuses on factors related to the decision of physicians to enter and sustain an investigative career in OB/GYN. Many of the problems and barriers confronted by physician/scientists in departments of OB/GYN axe common to most clinical departments—for example, the decision to forgo a higher income in order to focus on research. For these factors, this chapter explores whether there is a quantitative difference between OB/GYN and other specialties. Other factors, such as the impact of federal research policy or NIH structure, are unique to OB/GYN. Career Pathways The roots of an individual's career choice may be found at an early age, but the question of early science education has wider implications than this study, Similarly, research experiences during medical school are strongly associated with postgraduate research involvement.2 A group that examined ways of expanding the supply of clinical investigators made the following statement: During medical school, the first critical career decisions are made that determine whether an individual may become a clinical investigator. If interest in research is stimulated and sufficiently nurtured in medical school, it is likely that a student will select postgraduate training that is academically oriented and offers the opportunity to continue the research experience.3 This committee is convinced that the medical school years are crucial for generating scientific curiosity and the enthusiasm that will carry an individual through training to a career of independent investigation. However, because these years come before the physician chooses a specialty, this report emphasizes them only lightly. The majority of physicians enter medical education intending to become full-time practitioners. Academia employs only a fraction of physicians, and for those physicians research is often not their primary activity. The expansion in

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Strengthening Research in Academic OB/GYN Departments the number of full-time faculty in clinical departments that has occurred in the past three decades is mainly a response to increased clinical care activities and does not primarily reflect an increasing supply of investigators.4 Several factors that are examined in the next section, such as the impact of debt and the duration of training, can affect a physician's decisions at any of the mining points on the career pathway. These factors are often interdependent. For example, an individual's level of debt is likely to have a bearing upon his or her attitude to the difference in income between an academic career and a career in private practice. Indebtedness might also affect the decision to embark on a lengthy training period that postpones the date at which higher incomes can be secured. Debt The extent to which an individual's level of indebtedness at various stages of education plays a role in decisions about the next stage of a career is not made completely clear by available studies. In particular, there is little information on the role of debt in the decision to enter a career in investigation.* One pertinent survey of third-year residents, mainly of the medical school class of 1987, showed that 59 percent of residents who had plans for postdoctoral research training indicated that their current levels of debt influenced those plans, "presumably negatively," according to the author.5 In addition, the impact of debt repayment is felt more strongly later in a career, and additional debt is likely to be incurred. OB/GYN residents appear to graduate from medical school with somewhat greater debt than other specialists. The average 1989 debt of prospective OB/GYNs ($45,757) was exceeded only by physicians entering emergency medicine ($48,709), physical medicine ($47,792), and surgical subspecialties ($46,162).6 OB/GYN and emergency medicine had the highest proportion—16 percent—of medical school graduates with debt levels in excess of $75,000, compared with an average of 11 percent for all specialties.7 In addition, between 1986 and 1989, the average level of debt for those intending to enter *    Available evidence deals with the relationship between debt levels and specialty choice, and indicates that only a weak relationship exists. However, much of this work was completed before high levels of debt became common for graduates of medical school; thus the full effect might not yet have been observed (U.S Department of Health and Human Services, Report to Congress on an Analysis of Financial Disincentives to Career Choices in Health Professions, Washington, D.C., Health Resources and Services Administration, Bureau of Health Professions, November 1986).

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Strengthening Research in Academic OB/GYN Departments OB/GYN increased 31 percent, compared with an average of 26.5 percent for all medical students. One indication of the possible impact of indebtedness is the income level needed to repay the debt. Taking into account the repayment schedules of the different types of loans a medical student is likely to use, as well as the definitions formulated by lending agencies of "comfortable" repayment-to-income ratios, a physician owing $50,000 must earn nearly $79,000 per year five years after graduation to comfortably repay the debt; it is "difficult" with an income of only $52,653.8 For the 16 percent of OB/GYN residents who graduate from medical school with more than $75,000 in debt, clinical practice may look very attractive compared with academia. In 1988, OB/GYNs under the age of 36 had an average net income of $131,500, but nearly $146,000 would be needed to "comfortably" repay a debt of $75,000.9,10 By contrast, a full-time M.D. instructor earned, on average, $58,100 in 1988–1989 ($68,000 in 1990–1991), and an assistant professor averaged $104,300 ($121,500 in 1990–1991).11 For the would-be investigator who takes a research fellowship after subspecialty training, income during those years is likely to be well below the $75,000 needed for comfortable repayment of a $50,000 debt. If additional debts are recurred during this subsequent training, they will cause greater repayment difficulties.* Another economic consideration relating to debt is the security of an income stream. The physician entering academia is quite likely to be deterred by the combination of high debt, relatively low income, extended training, and the perception that grant funding and continuing support of untenured junior faculty are uncertain. It is reasonable to conclude that individuals faced with repaying substantial debt will, in general, gravitate toward employment that provides enough of an income to make repayment less rather than more painful. OB/GYN department chairs and others in the specialty provided many anecdotes of individuals whose ability or willingness to continue on the path of investigation was destroyed by the burden of debt. Given the relatively small number of people with the perseverance, intellectual curiosity, and talent needed for investigation, the effect *    This point was emphatically made in a letter received by the committee: "Another issue which raises its head is the necessity for [research trainees] to take out loans during this period of training. One of our current fellows who has just completed training has loam outstanding of approximately $140,000. With the reality that sub-specialists are commanding salaries in execs of $150,000 per year in the private practice arena, and frequently realize multiples of that of two or three fold, it is difficult for one to accept further funding at $40,000 per year when they consider their outstanding loans and commitment to their families."

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Strengthening Research in Academic OB/GYN Departments is significant when even a few of those with the necessary qualifies are deterred from research by the burden of debt. It is particularly disturbing if such debt results in the loss of one of the few OB/GYNs who have already accomplished research training. Mechanisms that provide relief of debt—usually either forgiveness or repayment deferral—are well established as ways of diminishing economic barriers to entry into a field or of encouraging new entrants. The conviction that an economic incentive would help stimulate investigation in contraception and infertility lies behind a proposal in the current NIH reauthorization that would repay $20,000 of the educational loans of a professional for each year that he or she agrees to conduct research with respect to contraception or infertility. Forgiveness mechanisms can also be designed with payback requirements to prevent abuse and to increase retention in research. For example, the Public Health Service offers National Research Service Awards (NRSAs) that axe repaid by research or teaching for a time equal to the duration of NRSA support minus 12 months.12 FINDINGS: Debt, when viewed in the context of the accumulated weight of the many other deterrents to an investigative career, does result in the loss of talented individuals to the pool of OB/GYN investigators. The anecdotal evidence, their own experience, and data on specialty choice and debt repayment burdens, together with the very small number of OB/GYN physicians in the research training pipeline, convinced committee members that there is a need for a program that would decrease the deterrent effect of debt repayment. In the current funding climate, however, it is unrealistic to expect the public sector to be solely responsible for the costs of a program to provide debt relief for investigators in OB/GYN. The beneficiaries of strong research capability include not only the public but also the academic departments, the profession of OB/GYN, and the pharmaceutical industry. All of these entities should therefore participate in supporting a program to reduce the debt burden for young investigators. To ensure cost-effective use of resources, such a program should be restricted to young investigators of proven talent and should include mechanisms to ensure that recipients at least attempt to make a significant scientific contribution. RECOMMENDATION: The committee recommends that a program to alleviate the burden of debt (e.g., loan forgiveness, deferral of repayment,

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Strengthening Research in Academic OB/GYN Departments targeted fellowships or awards that eliminate the need to incur further debt, etc.) be established for physicians qualified in the specialty of OB/GYN who have demonstrated a serious intention to pursue a career in research. Since this program is targeted to only the few most promising individuals, its costs will not be great and should be borne by a consortium of OB/GYN professional associations, the pharmaceutical industry, academic departments of OB/GYN, and the Public Health Service. The program should be structured to identify the most promising individuals in need of assistance and should include mechanisms to encourage retention in research of individuals assisted by the program. Foregone Earnings For most physicians, the decision to pursue an academic or investigative career means that their income will be substantially below that earned in clinical practice. It is often claimed that it is particularly difficult to attract physicians into academic positions in OB/GYN because, as a relatively high-earning specialty, the difference between academic income and alternative earnings is greater than the difference that occurs for other specialties. Data do not support this contention, although they do confirm the existence of an income gap between academia and other forms of physician activity (Table 3-1).* Young physicians from OB/GYN, internal medicine, and surgery who enter academia earn only approximately 80 percent of the income earned by all physicians in those specialties. The size of the income gap is different at various ages, but for OB/GYN, internal medicine, surgery, and radiology, academic earnings are between 53 percent and 90 percent of the specialty earnings up to age 65. Of the six specialties for which data were available, psychiatry and pediatrics do not show a consistent earnings deficit for those physicians who enter academia. In sum, the income deficit for OB/GYNs is as great as but no greater than that experienced by other specialties, although the gap may nevertheless deter talented individuals from an academic research career. *    The income differential between practice and academia is likely to be larger for subspecialists than for generalist OB/GYNs.

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Strengthening Research in Academic OB/GYN Departments TABLE 3-1: Percentage of Net Income of Academics in Relation to That of All Physicians in the Specialty   Age   < 36 36–45 46–55 56–65 > 65 OB/GYN 80 % 53 % 70 % 87 % N/A Internal Medicine 80 63 71 85 132 % Psychiatry N/A 87 104 125 111 Surgery 80 57 73 89 145 Pediatrics 114 79 83 102 N/A Radiology 90 66 69 77 N/A   SOURCES: Calculated from data in Socioeconomic Characteristics of Medical Practice, 1989, ed. Martin L. Gonzales and David W. Emmons, American Medical Association, Chicago, Ill.; William C. Smith, Jr., Report on Medical School Faculty Salaries, 1988–89, Association of American Medical Colleges, Washington, D.C.; and special tabulation of data from the Faculty Roster System of the Association of American Medical Colleges prepared by Paul J. Friedman, M.D., Professor of Radiology and De, an for Academic Affairs, University of California, San Diego. Assuming some parallel between the choice of a specialty and the choice of a career in research, evidence on the role of expected income in a physician's choice of specialty may be viewed as surrogate data. Surveys of graduating medical school students and some econometric analyses generally indicate that future income is not an important factor in specialty choice.13,14 But one study found a correlation between the median net income of a specialty and the proportion of residency positions filled by U.S. medical school graduates.15 Another, using a sophisticated econometric analysis, found that the effect of potential income differs for female and male physicians—in general, the higher the potential income, the higher the probability of selecting the specialty; but the choices of female physicians axe inversely related to potential income. This does not mean that women physicians are averse to money, but that there may be other factors associated with lower-paying specialties that axe of greater interest to women than foregone income.16 This latter finding implies that OB/GYN, in which more than 45 percent of residents in 1989 were women,17 has a substantial pool of individuals for whom nonfinancial factors may be of prime importance. If the imagination of this group can be captured by the excitement of research, and if research offers

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Strengthening Research in Academic OB/GYN Departments the job conditions they consider important (which might include such characteristics as flexible scheduling), the income differential between research and practice might be less problematical for OB/GYN than for specialties in which women play a lesser role. Moving from quantifiable to anecdotal evidence, a much clearer picture emerges. Many academician believe that the extended training of the M.D. investigator, during which incomes are relatively meager,* together with the large incomes that can be earned in clinical practice in OB/GYN, make even the generous offerings of academia seem paltry. The average salary of a full-time assistant professor in a department of OB/GYN was $125,500 in 1990.18 However, department chairs attempting to hire newly qualified subspecialists believe that an initial salary of at least $150,000 is needed to lure promising investigators to academia.** Although individuals with an academic or investigative bent find professional rewards in teaching, research, or academic administration that counterbalance financial sacrifice, it is clearly unrealistic to expect too large a sacrifice. FINDINGS: OB/GYN, like other clinical departments, loses investigators because of the discrepancy between practice and academic income. There is little appreciable difference in foregone income between OB/GYN and the other specialties for which data were available. Since the specialty choices of female physicians are driven less by income considerations than by other factors, the high proportion of women in OB/GYN may work to the advantage of the field. But to realize this advantage, departments must,identify the characteristics of an academic and research life that are attractive to women and offer choices that fulfill the lifestyle needs of women. *    Recognizing the impact of meager stipends on the willingness of individuals to undertake research training, a 1989 task force that evaluated NIH biomedical research training programs proposed that trainee stipends be increased to levels comparable to those of house staff salaries ("Review of the National Institutes of Health Biomedical Research Training Programs, October 1989"; National Institutes of Health). NIH is expected to implement this recommendation in the near future. **   An additional problem noted by OB/GYN department chairs is that the salaries paid to faculty are so far in excess of the salary support of research grants that significant additional amounts must be found, which usually requires that the faculty member devote substantial time to clinical practice. This issue is discussed more fully later in this chapter. Committee members also noted that the higher salaries paid to M.D.s can alienate Ph.D.s, making it difficult to generate and maintain a creative training and working environment.

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Strengthening Research in Academic OB/GYN Departments RECOMMENDATION: Leaders in departments of OB/GYN should accommodate the nonfinancial working needs of investigators to facilitate and ensure their continued involvement in research. Duration of Training The effects of debt and foregone income are likely to interact with a third factor—length of training. Compensation for "trainees," whether as grants, fellowships, or salaries, is generally lower than for fully qualified individuals; therefore the amount of income foregone increases with the duration of training. If compensation is low enough, new debts may be incurred, particularly if family obligations grow as a physician/trainee marries and has children. Increases in the length of training thus have substantial financial implications that can influence career decisions. The concept of a physician/scientist conducting research at the bedside to evaluate the effect of a new procedure or drug is still valid today. However, advances in molecular biology and the increasing convergence of basic and clinical research have changed the nature of much research conducted by physicians and expanded its range. James Wyngaarden, in aa article entitled "The Clinical Investigator as an Endangered Species," defined the physician/scientist in terms of both training and activity: An individual thoroughly trained in clinical medicine and also thoroughly trained in a scientific discipline, and who, in addition, participates in both clinical and experimental endeavors as a career role. Thus, I refer to the physician who is simultaneously a serious scientist, and far less to the clinician who may occasionally do some research.19 This description is sufficiently broad to encompass physicians engaged in a wide spectrum of investigational activities, and it certainly fits the physician/scientist who is the focus of this report. Although the duration of training needed to fulfill various roles has not been specified, there is a strong relationship between the duration of postdoctoral training and later success in the competition for NIH support.20 This may be due in part to self-selection (those with greater commitment to research are likely to invest in longer training) and in part to the expertise gained during the

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Strengthening Research in Academic OB/GYN Departments extended training. Regardless of the reason, the finding speaks to a greater return on an investment in training if individuals commit to longer periods. There is little agreement on the best way to tram physician/scientists. Some believe that M.D./Ph.D. programs are the optimal approach, while others debate the timing of science and clinical components. Several models exist, most of which include a concentrated involvement in research for at least two years, supervision by an experienced research mentor, presence in an active laboratory, and resources for each support.21 Physicians who have completed clinical training—whether they have earned the M.D. degree or completed specialty or subspecialty training—are not prepared to enter a career in which investigation will be a major activity. They are not equipped with the methodological tools to conceptualize and design sound research protocols. Nor do they have sufficient basic science knowledge and training at the bench to undertake investigation in, for example, the molecular aspects of biology—if that is where their interests lie. Residency and subspecialty programs often encourage or require courses in statistics and the conduct and publication of a research project. A physician who has maximized such opportunities may be sufficiently prepared to undertake some uncomplicated clinical research, but there is general agreement that substantial additional training is needed to embark on an investigative career.* Specialty and Subspecialty Training in OB/GYN The conventional training path for an individual who intends to enter academia in OB/GYN starts with residency, which requires four years in a graduate medical education program that has been accredited by the Accreditation Council for Graduate Medical Education. Only 36 months must be spent in clinical OB/GYN, but in practice, the complete period is spent in clinical education. Certain regulations controlling the residency experience make it difficult for a resident to participate in research training: no assignment to another discipline that removes the candidate from daily contact with OB/GYN *    This statement should not be taken to imply that physicians reach residency or subspecialty fellowships without any research experience. Opportunities to at least initiate research training occur at early stages. Funded research opportunities of three months or longer are often available for medical students, and one study found that research experience varied by school with between 28 percent and 85 percent of students reporting research experience at the schools studied (Scott Segal et al., "The Association Between Students' Research Involvement in Medical School and Their Postgraduate Medical Activities," Academic Medicine 1990; 65:530–533).

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Strengthening Research in Academic OB/GYN Departments is allowed, and no more than six weeks' leave of absence may be taken in any one year.22 These rules make it impossible for an individual to undertake extended research training. However, approximately two years ago an element of flexibility was introduced whereby the American Board of Obstetrics and Gynecology, Inc. (the organization that controls the specialty certification examination and eligibility processes), allows ''modification of training to accommodate research for individuals preparing for academic careers.''23 This modification is granted on an individual basis and requires an application to the board from the individual and his or her program director before the residency starts. Specialty certification is followed by at least two and sometimes three years of subspecialty fellowship,"* and at least one year of practice as a subspecialist. The board established three specialty divisions in 1972: gynecologic oncology, reproductive endocrinology, and maternal fetal medicine, each with formalized advanced training. The purposes were to "improve the health care of women with special problems by: (1) elevating standards of education, (2) enhancing the recruitment of qualified physicians, (3) improving the organization and distribution of patient care, and (4) increasing basic knowledge."24 Although the extra years of subspecialty training may not be needed if an individual intends to pursue a career in research, the uncertainties of such a career cause many to believe that the physician must be fully qualified for a career in clinical practice. Academic departments and hospitals also often require subspecialty certification. In the past four years, the number of certified subspecialists who are full-time faculty has risen by 28 percent (160 individuals), and 109 schools have all three subspecialties represented on their faculties (only 5 schools have none).25 It is somewhat easier to fold research training into the subspecialty fellowship period than into residency—indeed, the fellowship requires that a thesis be accepted for publication in a peer reviewed journal. The third year of a three-year program concentrates on developing research skills. Only 10 of the 154 subspecialty programs are official (board-approved) three-year programs, but numerous additional programs require a three-year commitment.26 Anecdotes suggest that some programs, particularly in reproductive *    The committee is aware of at least one four-year fellowship program. The Division of Gynecologic Oncology at the University of California, Irvine, offers two years of research training in a basic science laboratory, either inside or outside the department (previous experience with only one year of basic research having led to the conclusion that a minimum of two years is needed). This is followed by the two-year clinical fellowship.

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Strengthening Research in Academic OB/GYN Departments endocrinology, have a heavy research orientation, offering about 18 months of laboratory experience. As with the residency program, subspecialty training can be modified to accommodate individuals who are preparing for an academic career, provided a request is made before starting the program. Since only one such application has been received by the board,27 several conclusions are possible: that program directors have difficulty identifying prospective candidates before the start of the program, that there is no demand for the modification, or that the requirement for individual application is so cumbersome that it acts as a deterrent. Despite the apparent emphasis on research during the fellowship years, the experience of committee members and others suggests that two to three years of additional intensive research training is usually needed, both as preparation for a research career and to become competitive with others seeking RO1 support.* An exception to the academic's need for extensive research training would occur for individuals whose principal occupations would be clinical practice and teaching, with only a minor involvement in the conduct of bedside clinical research. In a presentation to the committee, the president of the American Board of OB/GYN emphasized that the encouragement of research is not included in the stated objectives and purposes of the board. Nevertheless, because program directors have urged flexibility that would allow research training to be interleaved with clinical training, the board allows exceptions to be made on an individual basis for those who want to incorporate research training into their education.28 Calls for greater flexibility have been heard for many years. In 1985 a symposium on the need for flexibility in academic OB/GYN residencies was held at the annual meeting of the American Gynecological and Obstetrical Society. Speakers reviewed past recommendations to allow several types of residency experiences to prepare OB/GYNs for several types of careers, including academia and research.29 Other speakers reviewed the obstacles to the pursuit of research, including a lack of exposure to research during residency, the additional time required to satisfy subspecialty requirements and engage in research training, and the difficulty in keeping current in and excited *    The extensive clinical requirements of subspecialty fellowships are cited by Robert B. Jaffe in "The Need for Flexibility in Preparing Clinician/Scientists for Academic Careers," American Journal of Obstetrics and Gynecology [April 1986; 154(4):778–790], as making it difficult to free up time for research. He notes the need of reproductive endocrinologists to gain expertise in tubal microsurgery and in vitro fertilization as examples of such time-consuming activities.

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Strengthening Research in Academic OB/GYN Departments about investigation during the long period of clinical education.30,31 The problem, according to the speakers, was that the burden of attaining high levels of expertise in both research and clinical care may be excessive; would it not be possible, they asked, to accept a narrower clinical competence for the limited number of people who will make research the primary focus of theft professional lives? The same problems are present today, and there is still no consensus on the "best" configuration of clinical and research training for an individual who is proceeding on the path to an academic research career. What is clear, however, is that the educational pathway defined by the board and the Residency Review Committee* discourages a smooth merging of residency and the subspecialty fellowship with the research training needed to achieve independent investigator status. Fast-Track Training for Researchers in Other Specialties It may be six to seven years after medical school before a would-be OB/GYN investigator starts intensive research training, and me to ten years before she or he is prepared to begin a career as an investigator. It is easy to believe that this lengthy process is a deterrent, both emotionally and financially. Many experts in other specialties believe that training should be shorter, and some specialty boards have instituted accelerated, or flexible, pathways for use by those entering research. For example, the American Board of Internal Medicine (ABIM) developed a Clinical Investigator Pathway as a response to national concern about a shortage of clinical investigators. The goal is to ease entry into research by permitting the trainee to return to the laboratory any time after finishing medical school, to become certified in internal medicine after only two years of residency training, and to be examined for board certification with his or her medical school graduation cohort. The trainee is then able to proceed into subspecialty training and research.32 A subspecialty examination can be taken six or seven years after medical school graduation, by which time a *    The Residency Review Committee accredits residency programs for a specified number of residents for each postgraduate year. Thus a program must get permission for a resident who has left the program for research training to rejoin it at a later date, because a program that has filled its residency slots will then have an excess when the individual returns. Moreover, in general, residency programs are not allowed simultaneously to run programs of different lengths—for example, offer a four-year and a five-year program that allows a year of research. To do this, a program must receive permission from the Residency Review Committee.

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Strengthening Research in Academic OB/GYN Departments candidate must have completed three years of full-time (at least 80 percent) research.33 An early (second year of residency) commitment by the program director of a faculty position or salary for the trainee is intended to ensure that only motivated and potentially talented residents are offered the special pathway. The history of attempts by ABIM to arrive at this pathway for clinical investigators indicates the difficulties in structuring an accelerated path that meets the goals of flexibility in the timing of clinical and research training, and reduction of the total training time. Earlier, ABIM instituted a "short track" that was intended to shorten the time to entry into subspecialty training. This track reduced residency time but lacked the current requirement that the saved time be spent in research. It was discontinued because it was used as a short-cut into subspecialty training by individuals who had no retention of entering into a career in clinical investigation. Another example, both of an effort to encourage research through a reduction of training time and of problems encountered on the way to achieving a workable program, is found in pediatrics. The American Board of Pediatrics (ABP) in 1978 established a Special Alternative Pathway for candidates who were directing their career toward academic medicine. The pathway cut a year from the training period for initial certification. As in internal medicine, however, the accelerated route was used by too many candidates who did not enter academia, and ABP is therefore considering its discontinuation.34 Because the ABP conceives of the generalist pediatrician as taking car of most clinical pediatric practice and of pediatric subspecialists as being academicians, it has extended subspecialty training from two to three years and added a research competency training requirement. There is today a "fast track" for candidates for subspecialty training who have demonstrated research competence, such as those with an M.D./Ph.D. This allows the candidate to eliminate up to one year of training and to waive the subspecialty research competency requirement.35 While pediatrics and internal medicine differ from OB/GYN in important ways—for example, the need to develop and maintain surgical skills makes it more difficult for OB/GYN to mesh clinical and research training—there are lessons to be learned from the search for ways to diminish the deterrent of excessively extended training. FINDINGS: The extended duration of training for a physician investigator in OB/GYN has a deterrent effect on some who would otherwise pursue a research career. The American Board of OB/GYN now allows individuals to apply for a waiver in the training; however, to date there have been few

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Strengthening Research in Academic OB/GYN Departments applications for waivers. Some specialty boards have established special pathways for investigators—evidence that they believe that benefit is derived from abbreviating clinical training for physician investigators. Committee members agreed that much of the education of a generalist OB/GYN is wasted when an individual selects a subspecialty; for instance, the OB/GYN oncologist neither delivers babies nor uses the reproductive endocrinology or genetics training that was required during residency. One alternative would be an academic track by which aa individual could select a subspecialty and research pathway after two years of residency, while others intending to enter general OB/GYN practice would continue through the third and fourth years of residency training. Numerous letters from chairs of departments of OB/GYN supported a reduction in training time through such means as creating a separate track for would-be investigators, reinforcing the perception that many in academia would support such reform. RECOMMENDATION: The committee recommends that the American Board of Obstetrics and Gynecology immediately reexamine training requirements for generalists and subspecialists in OB/GYN to ascertain whet the training programs are unnecessarily long. A reduction in the time needed to obtain subspecialist status would allow those interested in pursuing a career in research and academic OB/GYN to achieve their goal more quickly than is possible today. The committee suggests consideration of a pathway that offers the option of moving to subspecialty fellowships after two years of residency. The committee also suggests that the American Board of OB/GYN carefully examine and evaluate the arrangements that other specialty boards have made to accelerate training for those with a clear intention of embarking on a career in research. These arrangements are examples of options that should be considered. Women and Research Women have a substantial representation in academic departments of OB/GYN—particularly at lower academic levels—but in general, they have a lesser propensity than men to enter research. This is likely to increase the shortage of research personnel unless special efforts are made to encourage research careers for women and to meet their particular needs.

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Strengthening Research in Academic OB/GYN Departments Factors that encourage young physicians to pursue investigation as a career include early involvement in research, role models, an environment that contains other active investigators, and the support of mentors who facilitate socialization into research. These influences are needed regardless of gender, but some are difficult for women to attain, and there may be other aspects of the researcher's life that demand attention if more young women are to become engaged in a life of investigation.* Studies of stress among residents do not speak directly to the question of whether lifestyle conflicts deter women from res h careers. These studies do, however, suggest that there are critical stages in the development of a research career at which the path of women could be eased. One study found a correlation between residents' level of dissatisfaction and the hours worked outside the home by the spouse. This problem is likely to be more severe for women since male spouses often put in more time outside the home than female spouses. Women residents also spent substantially more time than male residents on household chores. Furthermore, many institutions lack formal mechanisms for handling the pregnancies of residents (only 57 percent of teaching hospitals have maternity leave policies), and this, too, can lead to disruption and stress.36 There is evidence that women in medicine feel that they must delay childbearing: 45 percent of respondents to a 1988 survey of women faculty in departments of medicine had theft first child after completing training. If childbearing is delayed, however, the demands of young children must be accommodated in the early phases of the academic career—years when tenure decisions axe made and when faculty members are under pressure to conduct productive research and publish their results.37 Although several researchers have reported that family responsibilities do not consistently reduce the publication rates and salaries of women scientists and engineers, data also suggest that assistance with family responsibilities, such as providing child care, helps women sustain full-time employment.38 Some institutions have initiated policies that effectively stop the tenure clock for a limited period. Such policies can provide women, and others who need to spend time at home with children, relief from some of the pressures of trying to excel in the home and in professional settings. For example, Yale University School of Medicine allows faculty with "pressing personal or professional commitments" to take a part-time appointment. The faculty member who *    A similar quandary has been identified in pediatrics where women constitute 43 percent of instructor- and assistant professor-level faculty [H. T. Abelson and Anne Bowden Raleigh, "Women and the Future of Academic Pediatrics," Journal of Pediatrics 1990; 16(5):829–833].

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Strengthening Research in Academic OB/GYN Departments chooses this route is allowed up to three additional years to achieve tenure, but is warned in the information guide of the school that laboratory experiments and patient care demands, as well as week-end and night call schedules, can cause conflicts with a "part-time" schedule.39 Studies of science and engineering students point to the isolation felt by women (and minorities)in science. Surveys reveal that women feel frustrated and discouraged, while men are more likely to report anger. Women report feelings of powerlessness, pressure, and isolation; their self-esteem is often lower than that of men of equal or lesser attainment. Women also report that they are not well integrated into student networks that disseminate important information.40 This can be particularly harmful if women fail to get information about training and funding mechanisms, or about what is needed to progress in academia. * To offset this isolation, women faculty have organized networks that are believed to be effective. For example, at the University of Michigan, women faculty formed a supportive group and established a Women in Science Program whose activities include publishing a resource directory and running a speaker's bureau.41 Part of the sense of isolation may come from a lack of women role models and mentors. The data reviewed in Chapter 2 indicate that even in departments of OB/GYN, which have relatively large numbers of women, women are not well represented at higher faculty levels. Thus young women faculty in OB/GYN lack role models and mentors of their own gender. The importance of mentors has been documented for students at many levels of education; for successful careers in science; for sponsorship for faculty positions in academia; for promotion, tenure, fellowships, and grants; and for, successful careers in business. Whether women do better with mentors of the same gender is not established. However, according to one report, women students who chose women role models looked for "the exemplification of a career woman's total lifestyle"; men in the same situation looked for role models with outstanding reputations.42 A survey of women with full-time appointments in academic departments of internal medicine revealed that 94 percent agreed that women medical students need role models of successful, tenured women faculty.43 The encouragement, support, and advocacy of a mentor will undoubtedly be *    Informal conversations with individuals interested in the progress of women in academia suggest that women are likely to be. come sidetracked by clinical care and teaching during the early faculty years, and are not well informed about the credentials needed to achieve tenure. This latter factor may contribute to the clustering of women in low academic positions; it also speaks to the need for mentoring.

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Strengthening Research in Academic OB/GYN Departments enhanced if that individual has experienced and dealt with the family and time pressures and professional isolation of a woman in science. Young women also need role models who demonstrate that the demands of an investigative career are not incompatible with family life, that women can overcome the hurdles and establish successful investigative careers. It seems likely that a same-gender mentor could provide needed encouragement and sustained support that would help women overcome some of the inherent disadvantages they confront in pursuit of a career in science. FINDINGS: It is vital for the health of the OB/GYN research enterprise that women not be lost to research because of obstacles that can be overcome by the profession. Women are entering OB/GYN in substantial numbers and now represent nearly half of all OB/GYN residents. Although women may be less deterred than men by the difference in income between academia and practice, women attempting a career in research are confronted with gender-related obstacles. These include the absence of same-gender mentors and role models. In addition, women appear to lack ace to the networks through which important information regarding academic advancement is transmitted. Some of these obstacles can be ameliorated by actions within the scope of departmental leaders. RECOMMENDATIONS: The committee recommends that OB/GYN department leaders pursue ways to ameliorate the stresses that attend the life of women in science. In particular, the committee recommends that every effort be made to find women mentors and role models for women investigators, if not in the department of OB/GYN, then through networks of women physician investigators, across departmental lines, or at another medical school. Departmental leadership should emphasize the value it places on women accepting mentoring relationships with young women investigators. This should not, however, preclude mentoring relationships between men and women, which the committee also considers to be of major importance. The committee also recommends that department chairs, in institutions in which no provisions exist for extending time to tenure for individuals with pressing personal commitments, engage the institution's decision-making groups in an effort to initiate such a policy.

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Strengthening Research in Academic OB/GYN Departments Summary of Career Choice Factors Every individual who chooses to enter an academic investigative career engages in a number of trade-offs. On the positive side are the attractions of the intellectual stimulation of the academic environment, the excitement of research, and the status conferred by membership in the select club of higher education faculty. Additional benefits may include decreased clinical responsibilities and the rewards of teaching, as well as other factors. On the negative side are financial sacrifices that include lower earnings, greater difficulty in repaying debt, and greater insecurity owing to the uncertainty of grant funding and departmental support in the pretenure years. Another negative, which also involves financial loss, is the extended duration of training as an individual moves through residency, subspecialty training, and research training. These factors apply to those in academic research careers, regardless of specialty. However, OB/GYN appears to be at a disadvantage in comparison with other specialties. Graduates of medical school who intend to enter OB/GYN have relatively high levels of debt (although they do not forgo any more income by entering academia than do internists, radiologists, or surgeons). However, OB/GYNs undergo an extended period of education and are generally unable to combine research training with clinical training, unlike some other specialties whose boards have developed "fast tracks" or flexible arrangements for investigators. Finally, the high participation of women in OB/GYN can work both for and against the future supply of investigators. On the one hand, women physicians have been more willing than men to forgo income in order to gain some other desired end. On the other hand, women have entered science at lower rates than have men, and they have been less productive (in terms of publications) once the commitment was made. These differences may be due in part to the stresses of family life—in particular, responsibilities for childbearing and child care—that fall on their shoulders, and in part to a dearth of women role models and mentors, who could play an important role in the development and career trajectories of women physician investigators. In sum, OB/GYN is not especially disadvantaged in the income differential between practice and further training, in the burden of debt repayment, or in the duration of training. Nor is the risk of failure for an OB/GYN investigator substantially greater than for other specialties. However, the weight of each of these factors together is likely to discourage some talented physicians from pursuing a research career unless they are cushioned from these obstacles by sustained support. The committee believes that it is vitally important that

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Strengthening Research in Academic OB/GYN Departments individuals with the talent and inclination for research are identified early and that obstacles to their growth as investigators are diminished. Recommendations throughout this report are intended to facilitate the recruitment and retention of investigators in OB/GYN. References 1. Arias, Irwin M. Training Basic Scientists to Bridge the Gap Between Basic Science and its Application to Human Disease. Sounding Board. New England Journal of Medicine 1989; 321(14):972–974. 2. Segal, Scott, et al. The Association Between Students" Research Involvement in Medical School and Their Postgraduate Medical Activities. Academic Medicine 1990; 65(8):530–533. 3. Association of American Medical Colleges. Clinical Research Manpower. The Report of the Ad Hoc Committee on Clinical Research Training. Washington, D.C.: Association of American Medical Colleges, February 1980. 4. National Research Council, in collaboration with the Institute of Medicine. Biomedical and Behavioral Research Scientists: Their Training and Supply. Vol. 1: Findings. Committee on Biomedical and Behavioral Research Personnel. Washington, D.C.: National Academy Press , 1989. 5. Petersdorf, Robert G. Financing Medical Education. Special Article. Academic Medicine 1991; 666(2):61–65. 6. Park, Randolph. AAMC Data Report. Graduating Medical Student's Debt and Specialty Choices. Academic Medicine 1990; 65 (7):485–486. 7. Tabulation from the Association of American Medical College's 1989 Graduation Questionnaire. 8. Petersdorf, Robert G. Financing Medical Education. Special Article. Academic Medicine 1991; 66(2):61–65. 9. Ibid. 10. Smith, William C., Jr. Report on Medical School Faculty Salaries, 1988–89. Washington, D.C.: Association of American Medical Colleges, 1989. 11. Ibid. 12. National Institutes of Health. National Research Service Awards for Senior Fellows. Information Statement. Bethesda, Md., April 1989. 13. Association of American Medical Colleges. 1988 Graduation Questionnaire Results. Washington, D.C. 14. Yoder, Sunny G. The Influence of Economic Factors on Medical Students' Career Decisions. In: Medical Education and Societal Needs: A Planning Report for the Health Professions. Washington D.C.: Institute of Medicine; 1983. 15. Ebell, Mark H. Choice of Specialty: It's Money that Matters in the USA. Journal of The American Medical Association 1989; 262(12): 1630–1631. 16. Marder, William D., et al. Physician Supply and Utilization by Specialty: Trends and Projections. AMA Center for Health Policy Research. Chicago, Ill. American Medical Association, 1988, pp. 84–86.

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Strengthening Research in Academic OB/GYN Departments 17. Jolly, Paul, and Hudely, Dorothea M. AAMC Data Book. Statistical Information Related W Medical Education. Washington, D.C.: Association of American Medical Colleges, January 1991. 18. Association of American Medical Colleges. Report on Medical School Faculty Salaries 1990–1991. Section for Operational Studies. Washington, D.C.: Association of American Medical Colleges. 19. Wyngaarden, James B. The Clinical Investigator as an Endangered Species. Bulletin of the New York Academy of Medicine 1981; 57(6):415–426. 20. Task Forces for Review of the NIH Biomedical Research Training Program. Review of the National Institutes of Health Biomedical Research Training Programs. Bethesda, Md.: National Institutes of Health, October 1989. 21. American Psychiatric Press. Training Psychiatrists for the 90s: Issues and Recommendations, ed. Carol C. Nadelson and Carolyn B. Robinawitz. Washington, D.C.: American Psychiatric Press, Inc. 1987. 22. American Board of Obstetrics and Gynecology. Bulletin for 1991. Seattle Washington: American Board of Obstetrics and Gynecology, Inc. 23. Ibid. 24. Merrill, James A. (Sub)Specialization in Obstetrics and Gynecology: Results of a Survey by the American Board of Obstetrics and Gynecology. American Journal of Obstetrics and Gynecology 1987; 156(3):550–557. 25. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetrics-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology 1991; 78(1):141–143. 26. Telephone interview with staff American Board of Obstetrics and Gynecology, Subspecialty Division, July 1991. 27. Mishell, Daniel R., Jr., Chairman American Board of Obstetrics and Gynecology. Presentation to the IOM Committee on Research Capabilities of Academic Departments of Obstetrics and Gynecology. November 1990. 28. Mishell, Daniel R., Jr., President, American Board of Obstetrics and Gynecology. Presentation to the IOM Committee on Research Capabilities of Academic Departments of Obstetrics and Gynecology. November 1990. 29. Willson, Robert J. Flexibility in Obstetric-Gynecologic Residencies: Why Is It Necessary? American Journal of Obstetrics and Gynecology 1986; 154(4):777–778. 30. Jaffe, Robert B. The Need for Flexibility in Preparing Clinician Scientists for Academic Careers. American Journal of Obstetrics and Gynecology 1986; 154(4):778–780. 31. Hendrick, Charles H. Experience with Flexibility in an Academic Residency Program. American Journal of Obstetrics and Gynecology 1986; 154(4):780–785. 32. John A. Benson Jr., President, American Board of Internal Medicine, personal communication, July 1990. 33. American Board of Internal Medicine. Clinical Investigator Pathway. Portland, OR: American Board of Internal Medicine, 1990. 34. Thomas K. Oliver, Senior Vice President, American Board of Pediatrics, personal communication, July 1990. 35. American Board of Pediatrics. Certification in Pediatric: Cardiology, Chapel Hill, N.C.: American Board of Pediatrics, November 1989. 36. Cited in Bickel, Janet. Women in Medical Education. A Status Report . New England Journal of Medicine 1988; 319:1579–1584. 37. Levinson, Wendy, Tolle, Susan W., and Lewis, Charles. Women in Academic Medicine: Combining Career and Family. New England Journal of Medicine 1989; 321:1511–1517.

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Strengthening Research in Academic OB/GYN Departments 38. Committee on Women in Science and Engineering. Women in Science and Engineering: Increasing Their Numbers in the 1990s. A Statement on Policy and Strategy. Office of Scientific and Engineering Personnel, National Research Council. Washington, D.C.: National Academy Press, 1991, p. 59, 39. Yale University School of Medicine. Information Guide for Junior Faculty. Published under the auspices of the Office of the Deputy Dean, New Haven, Conn. April 1990. pp. 13–14. 40. Widnall, Sheila E. AAAS Presidential Lecture: Voices from the Pipeline. Science 1988; 241:1740–1745. 41. Committee on Women in Science and Engineering. Women in Science and Engineering: Increasing Their Numbers in the 1990s. A Statement on Policy and Strategy. Office of Scientific and Engineering Personnel, National Research Council. Washington, D.C.: National Academy Press, 1991. p. 63. 42. Erkut, Sumru, and Janice R. Mokros. Professors as Models and Mentors for College Students. American Educational Research Journal 1984; 21(2):399–417. 43. Combining Career and Family. New England Journal of Medicine 1989; 321:1511–1517.