DEPARTMENTAL AND LEADERSHIP ISSUES
Departmental Issues in Expanding Research Capabilities
Leaders able to convince others of the importance of obstetrics and gynecology (OB/GYN) research must emerge from the academic departments themselves and from among those individuals whose job it is to develop the research base of the discipline and nurture the next generation of clinicians and investigators. There is wide variation among departments of OB/GYN, both in their commitment to investigation and in their academic standing within their medical centers. Most knowledgeable people would agree that a small minority of OB/GYN departments are leaders in academic OB/GYN investigation and that these departments have a reputation for excellence in the medical center complex in which they operate. These departments, with a cadre of outstanding investigators, including basic scientists, are also the only ones that are considered able to provide an excellent environment for training the next generation of investigators.
Most academic departments of OB/GYN do not rank highly in the academic pantheon of their medical centers, but they nevertheless provide excellent clinical training and health care.* Indeed, such departments will, and should, remain at the heart of OB/GYN education. A number of departments fall between these two extremes: some attract consistent but relatively modest levels of research
support; others are mounting an effort to move up the curve of investigative excellence. Given the limited number of young investigators and the limited financial support available for such progress, a careful strategy of strengthening the latter departments—those that are the most ready and interested in joining the ranks of the major players—is the approach most likely to be successful. Tills strengthening is an intrinsic piece of the process that must occur if OB/GYN research is to become a more vital part of the nation's research armaments. That is to say, funding from such agencies as NIH will not be forthcoming unless the human resources are available.
Because departments of OB/GYN are virtually unstudied, the committee was forced to rely on the opinions of eminent individuals in the field to gain a sense of both the barriers to progress and the possible solutions.
The barrier cited most frequently and most forcefully by the chairs of academic OB/GYN departments was the need to generate income from clinical care, which represents a major problem when attempting to ensure that faculty have time for research.* Moreover, the dynamics of the situation, with reimbursement tightening and clinical care demanding ever more time, were perceived by many to be exacerbating an already dire situation. The following are some of the comments the committee received:
The major problem facing departments attempting to establish or even maintain an existing research presence is the ever increasing demand to generate practice dollars to support these activities in a department. As costs increase while reimbursement for services and availability of grants dollars diminish, more and more faculty effort must be shifted to clinical care. Thus both the time necessary for productive investigation and the money necessary to support it is eroding at an accelerating pace. It becomes a Catch 22 situation.
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In most departments of OB/GYN, the clinical obligations of faculty axe extremely burdensome. This is a function of the large number of obstetric-gynecologic patients in the ambulatory areas as well as within the hospital setting as they relate to the number of faculty members in smaller OB/GYN departments. Many young OB/GYN investigators come out of scientific training programs with skills enabling them to compete but simply don't have the time to do so because of the clinical workload. Departments of OB/GYN do not have the luxury of providing 10–11 months of protected time for research and 1–2 months of attending, as is done in many departments of medicine and pediatrics. Department chairs are placed in a position of having to ensure high quality clinical care and teaching at the expense of faculty research time.
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Since coming to this university ... I have attempted unsuccessfully to generate a change in emphasis from clinical practice to a balanced approach of research and teaching along with clinical practice. It is my opinion that this department is not unique in [needing to emphasize] clinical practice ... in order to maintain the economic viability of the department. In a low population density state with limited tax base, public funding of higher education including medical schools is marginal at best. In such an environment the very existence of departments is threatened by the economic challenge of trying to retain excellent clinical faculty to carry out the teaching mission of the department, with research taking an ever-decreasing role.
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Because of [the low level of federal research support] departments must seek other sources for funding and generally end up with commercial funding through pharmaceutical companies, equipment manufacturers and the like, or from inside dollars if they have sufficient clinical income that they can develop research programs within the Department. In each of these cases the long-term support is not likely. The commercial companies tend to end support at the point that sale of product is possible. Inside funding depends so much on clinical care
that it becomes a Catch 22. If sufficient time is devoted to clinical care to provide dollars, there is not time left for good research.
The sense of increasing dependence on clinical income is substantiated by data on medical school finances, which indicate that the problem is pervasive among clinical departments—in large part because of the salaries that must be supported. Revenues from medical services plans rose from 3 percent of total revenues in 1960–1961 to 27.4 percent in 1988–1989. Over the same period research revenues fell from 37.4 percent to 17.4 percent of total revenues.1,* Yet although service income has replaced research income as the leading source of revenues, it does not follow that clinical income provides much discretionary money that department chairs can use to support investigation. A survey of medical faculty practice plans in 1980 found that 42 percent of revenues went to direct physician compensation, 11 percent to physician fringe benefits, and 33 percent to operating expenses. Only 12 percent of the revenues were transferred for medical school or departmental use.2
To estimate differences among departments in their sources of support, the committee analyzed data from a survey of 34 medical schools during 1983–1985. Practice funds contributed approximately 30 percent of total OB/GYN department funds—less than the percentage of such funds in five departments (psychology, orthopedics, anesthesiology, ophthalmology, and radiology), approximately equal to that in two others (pediatrics and medicine), but still higher than in four other departments.3 Although OB/GYN departments are about average in the contribution of clinical income to departmental revenues, many OB/GYN chairs and other faculty members believe that OB/GYN has a particularly hard time generating this income. They note that although some services are lucrative, OB/GYN departments are relatively small, clinical earnings must support relatively high salaries and malpractice premiums, and OB/GYN coverage is particularly demanding of a practitioner's time. In addition, they say that the uncompensated care load for obstetrics is significant in many teaching hospitals.
Most of these complaints can be voiced by other specialties, but the convergence of these problems in OB/GYN is thought to create an especially
that the most crucial impact is on the ability of departments to difficult environment for research. Letters to the committee suggest develop and nurture young physician investigators by protecting their time during the critical early years of theft development as researchers:
Within an individual department, the biggest problem in developing new young faculty is in provision of the initial support. They must achieve major outside funding within two years or they must develop a clinical treatment program which supports their salary and overhead. Without such, most departments cannot continue support beyond two years and must ask the individual either to leave or change focus.
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Presently very few sources of salary support are available to new clinician investigators or basic researchers. Since the first two or three years after recruitment to a faculty position are the most crucial in determining the career path of most individuals, clinician-investigators might slide gradually into the clinical path if their time is not well protected and compensated for. Basic researchers might opt for industry where pay is more and the demands on their time are less.
Is the Past a Guide for the Future?
The history of the growth of today's leading OB/GYN res h departments exemplifies the importance of the role of the dean of the medical school. In many cases the dean was prepared to make an investment in developing a research-intensive OB/GYN department, sometimes because the school was attempting to become a major player in university research and was therefore investing in all clinical departments, at other times because OB/GYN lagged behind other departments and needed to be upgraded. In several cases the medical school investment was actually quite minor, either because a new chair brought major foundation funding with him or her or because foundation support was quickly obtained.
As noted in Chapter 2, the foundations that enabled these departments to grow to eminence in the past are not making similar contributions to reproductive science today. This does not mean that it is impossible to build a research department in today's environment. It does mean that department chairs must be very persuasive if they are to bring foundation funds into their
departments, whether for research training, space and equipment, faculty salaries, or research projects. It also means that department chairs must make the case for investment in OB/GYN research forcefully in the dean's office, where decisions are made that determine which departments will be the winners and which the losers in the allocation of resources.
A department of OB/GYN that seeks to transform itself into a first-rank research center must develop the infrastructure on which a research enterprise can be built. Components of this infrastructure include faculty capable of bringing the next generation into the mainstream of investigation. One way of accelerating the process is through investment in established investigators; another is to initiate interdepartmental ties that facilitate multidisciplinary learning and research. The challenge is to accomplish this development in an environment in which it is difficult to create the financial cushion needed to sustain faculty development. Nevertheless, OB/GYN department chairs suggested a number of solutions.
Several chairs believe that it is possible (although difficult) to increase the amount of money that the faculty practice plan contributes for the support of investigation. For this approach to succeed, a department leader with a strong, eloquent commitment to research is needed. Clinical faculty are unlikely to be enthusiastic contributors to the support of a group whose work they may not value and whose members may be perceived as competing with clinical activities in terms of status as well as resources. Accomplishing this cross-subsidy without alienating clinical faculty requires that the chair convince them that enhanced investigative capabilities would benefit the department as well as the discipline as a whole.
A well-established strategy—and one strongly endorsed by chairs who wrote to the committee—for enhancing departmental research capabilities is the recruitment of basic scientists who bring essential knowledge and skills to the department and, ideally, work alongside OB/GYNs in collaborative efforts. Again, however, there are some problems: because the Ph.D. in a clinical department is sometimes viewed by his or her basic science peers as second class, it can be difficult to recruit first-rate Ph.D.s. It is often preferable for the departments of OB/GYN and the basic science department jointly to recruit the basic scientist and to secure a joint appointment. It may also be necessary to create equitable tenure evaluation criteria. These actions will help the basic scientist continue to develop by sustaining the connection with basic science
colleagues. In addition, for Ph.D.s in the department to augment the clinical research capabilities, rather than merely conducting basic research and increasing external research funding, a collaborative relationship must be established between the basic and clinical scientists. Success in such a plan requires a leader's commitment to collaboration and to development of creative ways of overcoming the natural segregation that would otherwise occur.
Another type of collaboration, one that received less emphasis in letters from department chairs but nevertheless represents a strategy for building research capacity, is interdepartmental collaboration. The many areas of mutual interest with other departments (including basic science departments), if fully exploited, can stimulate the research interests of young people in medical school and during their subspecialty fellowship years. Collaborative arrangements can also provide mentoring that is not available in the OB/GYN department, and potential young investigators can benefit from the laboratories of collaborating basic science departments. Collaborative activities can be building blocks for a department that does not yet have sufficient capacity to stand alone as a research entity: they can ensure a level of research activity while junior faculty move toward independence and the department establishes itself as a research center able to recruit investigators. Finally, interdepartmental collaboration can be used as the basis for creative and fundable protocols to address important clinical problems, and as the basis for training opportunities not available in an individual department. Obvious research areas with potential for interdepartmental collaboration include not only neonatology and endocrinology, but also epidemiology, statistics, and the behavioral sciences. The latter areas are particularly attractive, because important work remains to be done in them in relation to many OB/GYN issues and that work could be accomplished without major investment in laboratory space or equipment.
These strategies for building the research infrastructure—cross-subsidy, recruitment, and interdepartmental collaboration—require investments of time and departmental funds in varying combinations. To augment departmental funds, some chairs have established foundations that receive contributions from the public. These funds have helped in small but important ways, such as by carrying investigators for short periods of time between grants, by "buying" time for grant writing, and by protecting the time of young faculty.
FINDINGS: Academic departments of OB/GYN face particular difficulty in establishing and expanding their research capability. Other clinical departments are confronting the same problems as OB/GYN—the competing
claims of research and clinical services, growing constraints on reimbursement, large amounts of uncompensated care, and the struggle to protect the time of young investigators. The convergence of these circumstances in departments of OB/GYN creates a difficult environment for conducting research and developing new investigators. It is the responsibility of the chairs of OB/GYN depots to persuade the dean of the medical school, foundations, and others to invest resources in OB/GYN research; in this the chair is assisted to a sizable degree by the surge of interest in women's health issues. Strategies to establish an infrastructure for research include cross-subsidy (reserving a portion of clinical income to support investigation), recruitment (incorporating Ph.D. investigators into the departments), and collaboration (establishing interdepartmental mechanisms to facilitate interdisciplinary training and research).
RECOMMENDATIONS: Chairs of departments of OB/GYN should make a serious commitment to augment their research capabilities and to vigorously engage in informing medical school leaders and OB/GYN faculty of the potential of investment in research and research training. The committee recommends three specific strategies for increasing research activities:
increase the clinical income used to support research;
conduct important epidemiological and behavioral research that is relevant to OB/GYN; and
create interdepartmental research linkages.
Chairs should also, when possible, establish a foundation that can receive contributions from patients and other supporters, to be used to support young investigators and for other purposes that encourage research.
OB/GYN Leadership and Research
In any medical field there are individuals and organizations that most people will agree represent the leadership of some aspect of that field, such as teaching, advanced clinical care, or research. It is from these people and groups that the rank and file take their cues as to the important issues, and from whom the
outside world learns of the contributions of the field to the rest of society. In other words, leadership can have both an internal impact (helping to determine the positions and priorities of members of the profession) and an external impact (helping to determine how the field is viewed and whether it is worthy of public support).
It takes a serious commitment by a critical mass of this leadership to change the ethos of a profession. OB/GYN seems to have lacked that commitment. This lack may reflect the priorities of a field in which caring for women and securing their reproductive health have taken first place. In this, OB/GYN differs little from other fields of medicine—patient care is, after all, the purpose of medicine. Where OB/GYN does differ from many fields of medicine is in the low level of interest in research—an activity that provides the foundations for improvements in patient care—shown by both its academic leaders and its professional organizations.
Few research-oriented academics have risen to leadership positions in OB/GYN's professional organizations and used those positions to champion the cause of expanded research capabilities. This circumstance mirrors the dearth of academic departments in which research is a thriving activity and a major focus. And if a significant group of academic leaders are not actively making the case for expanded research, it is not surprising that professional organizations, whose membership is predominantly practitioners, display a low level of interest in advancing research.
The emergence of natural leaders from the academic ranks and their ascent to positions of influence should not be taken for granted. The need to smooth the path for potential leaders from academic medicine was understood by the executive director of the John and Mary R. Markle Foundation in the mid- to late 1940s.4 The foundation therefore established scholarships for outstanding young academicians (including teachers, investigators, and administrators) that could be used for partial salary support and for laboratory, travel, and other expenses. Markle awardees were recognized by their peers as an elite group, and many of the scholars (17 out of 506 were OB/GYNs) became leaders in their fields. By one measure the program does not appear to have been effective (nominees who failed to get into the program advanced up the academic ladder as rapidly as the scholars, 80 percent of whom maintained that they would have remained in academic medicine without the scholarship), but it was viewed as such a success that it became the model for other awards. It is difficult to determine what made the program successful. Some suggest that the rigorous selection process, which included nomination and a commitment of support by the medical school, and a three-day selection meeting, was important. Others point to the annual two-day meetings at which scholars met with educators to
discuss issues in medical education, as well as the flexibility of the money and the honor of the award itself.
In sum, the leadership of academic OB/GYN can play a significant role m stimulating interest and investment in research. The assistance of a structured program to help those leaders emerge is invaluable.
Leadership and Its Impact Within the Discipline
Without strong leaders within the discipline of OB/GYN who accept responsibility for the furtherance of research capabilities, change is unlikely to occur. Lacking that leadership, OB/GYN will not overcome its reputation for lagging behind some other specialties in both financial and intellectual support of arch—and until that happens, OB/GYN will not attract the research-oriented young people needed to create and sustain a vital research capability.
The present situation has been described as a vacuum where research leadership ought to be, but there are encouraging, if small, signs that change is under way:
Groups such as the American College of Obstetricians and Gynecologists (ACOG) strongly supported the Reproductive Scientist Development Program, which indicates their willingness to invest in the next generation of investigators. It also signals to the OB/GYN community the belief of those at the forefront of the field that research is an important priority.
The Association of Professors of GyneCology and Obstetrics has reactivated its Council of University Chairs of Obstetrics and Gynecology (CUCOG), which is forming a committee to encourage research. This committee is expected to work with other organizations in developing and stimulating research in academia.
Of the 126 chairs who responded to a questionnaire about topics they would like to have addressed in management seminars, 88 expressed an interest in seminars on developing research programs.5
In another survey, department chairs identified research experience as among the qualities they lacked, reflecting an encouraging awareness of the need for research experience for those holding the position of department chair.6
Thus some OB/GYN groups are already moving in useful directions; yet even greater roles for them and others are feasible. For instance, they could (as some already do) hold meetings to showcase the latest research findings, and their annual meetings could increase the emphasis on research, on the work of
young investigators, and on exchanges between senior and junior investigators.
Facilitating the encouragement of leaders to further research is not easily accomplished, but there are lessons to be learned from activities undertaken by another specialty—psychiatry. This specialty had identified a situation very similar to the one that confronts OB/GYN: a dearth of investigators and a need to recruit young people into research, to enhance federal and other research support, and to get the weight of the discipline behind efforts to accomplish these goals. In 1985, the American Psychiatric Association established an Office of Research. This office is attempting to elevate the profile of research in the discipline in many ways: it publishes a quarterly report that highlights research policy shifts, legislative issues, and relevant published reports; it also acts as an information resource listing grant opportunities, training opportunities, and research meetings, as well as featuring discussions of training issues and exciting research developments. The office is developing data bases on research opportunities, training, and mentoring; in addition, it serves as a center for information on grant writing, peer review processes, animal research guidelines, and other topics of interest to those competing for funds.7 The office sponsors research policy symposia and grant-writing workshops, and (in recognition of the role of legislative bodies in directing the allocation of science resources) it also helps government relations efforts by writing and distributing information for use as testimony on research issues.
FINDINGS: The discipline of OB/GYN has not developed a cadre of leaders for whom the stimulation of research is a primary mission. As a result, academic leaders struggling to develop research capabilities have an uphill battle. They must, for example, convince their own faculty that they, and the discipline as a whole, will benefit from efforts to support research—an important concept when financial sacrifices are demanded. The committee is heartened by recent initiatives that encourage research in OB/GYN and by academic leaders who express awareness of the need to encourage investigation. Much, however, remains to be done.
RECOMMENDATIONS: OB/GYN professional organizations should create opportunities for expanding research and for stimulating young members of the profession to view investigation as an exciting and valued activity. Useful mechanisms include special sessions at annual meetings and providing funds for interested residents to attend such meetings. In
addition, these organizations should combine resources to establish an office whose mission would be the encouragement of OB/GYN research. The Office of Research of the American Psychiatric Association is an interesting model.
The committee also recommends that a foundation set up a program to assist the advancement of potential research leaders. The Markle Scholars Program, the Macy program (described in Chapter 2), and other efforts to develop academic leaders should be examined to determine which of their characteristics should be replicated.
Leadership and Its Impact Outside the Discipline
A vital research enterprise is sustained both by the discipline itself and by the public and private groups that provide financial support. Leaders from the discipline must make the case for funding of research—in the words of an Institute of Medicine/National Academy of Sciences report,
not as an entitlement but as an investment ... scientists [must] convey to the public and to Congress the powerful message of the value of support of biomedical research—its benefits for public health, its contribution to America's commercial viability, and its contribution to the richness of our culture.8
This message is pertinent to any sphere of science attempting to secure its share of research funds.
For better or for worse, congressional involvement in research decision making is growing. Not only does Congress appropriate the federal research money, but it increasingly ties that money to specific goals and activities.9 If OB/GYN is to increase the contribution of federal funds to its research areas, it must participate in the education of those who influence appropriations. This requires that the leaders of the profession emphasize the role of OB/GYN research in the resolution of important problems.
The rise of federal funding of research in areas such as AIDS, cancer, and Alzheimer's disease illustrates the role of patient advocates, research leaders, and others. A case study of the rise of the Alzheimer's movement notes the necessity of raising both scientific and public awareness of the disease, and the significance of the associated social and health problems. One of the leading players in the movement to raise the level of support for Alzheimer's disease
research said that they had to make Alzheimer's disease a ''household word''; another noted that, since Congress pays more attention to popular media than to scientific journals, it was important to use the media to disseminate research success stories. An equally important factor in the success of these efforts was the interaction of a wide range of groups including an advocacy organization, representatives of the National Institute on Aging, the media, representatives of Congress, and the neuroscientists who were interested in promoting the research.10
The 1990s offer an unprecedented opportunity for OB/GYN because of increasing public interest in women's health issues, an interest that OB/GYN leaders can tap into. Beginning with the June 1990 testimony of the General Accounting Office (GAO) before the Subcommittee on Health and the Environment of the House Committee on Energy and Commerce, in which the GAO commented on the National Institutes of Health's (NIH) implementation of a policy on including women in clinical trials, questions have been raised in the press, in Congress, and at lit about whether the nation's research enterprise is doing justice to women's health. The prominence being given to these issues strengthens the case for investing federal funds and medical school resources in departments of OB/GYN.
OB/GYN suffers from several disadvantages compared with some other areas of medicine that have achieved increases in federal funding for their research. One is that OB/GYN research does not seek the cure of a specific disease and therefore does not have a natural constituency with which to work. The second is that there is no specific institute at NIH whose leadership is interested in advancing OB/GYN research broadly. (To the extent that the National Institute of Child Health and Human Development [NICHD] is the discipline's advocate at NIH, help is limited to the areas that fall within the NICHD mission [see Chapter 4].) And, importantly, the leadership of OB/GYN has not traditionally played a strong role in government relations and is not well prepared to enter the fray today.
Despite these obstacles, there are several encouraging signs. ACOG has upgraded its efforts in the legislative arena and contributes to the work of groups active in drawing attention to women's health research issues. In addition, members of Congress have proposed actions in many areas of women's health. Provisions of the Women's Health Equity Act include ensuring the inclusion of women in the study population of clinical trials; establishing a permanent Office of Research on Women's Health at NIH; and increasing funding for research on breast and ovarian cancer, osteoporosis, infertility, and contraception. Other initiatives establish three specialized centers for contraceptive development and two for infertility research. It is encouraging to note that NIH has received
applications for these centers from OB/GYN departments and that OB/GYN is involved in applications from other departments.
The Office of Research on Women's Health at NIH is developing a research agenda, which has had input from the OB/GYN community. In addition, Congress has been sensitize to the growing cadre of women who are becoming active in demanding funds for research directed toward improving their health. NIH has a new director, Bernadine Healy, whose voice and authority are urging greater gender equity in research. Such activities offer opportunities that can be grasped by OB/GYN leaders to establish OB/GYN as the locus of care for women, and its research as a major contributor to the solution of specified problems that affect women.
FINDINGS: The 1990s offer an opportunity to increase public awareness and funding for OB/GYN research. Because of OB/GYN's largely clinical orientation, however, strong advocates for research have not emerged. There has been a recent surge of interest in research to improve the health of women. This is reflected in a major new research initiative proposed by Bernadine Healy, director of NIH, the establishment at NIH of the Office of Research on Women's Health, and an array of legislative proposals from Congress. The emerging realization of a need to foster research on issues related to women's health offers an unprecedented opportunity to confirm the role of OB/GYN research in this area.
RECOMMENDATIONS: The committee recommends that individuals with a strong interest in research be represented in decision making positions in leading OB/GYN professional organizations. These OB/GYN organizations, in turn, should expand their efforts to educate decision makers about the potential of OB/GYN research and the importance of accomplishing the research agenda laid out in the next chapter of this report.
1. Association of American Medical Colleges. AAMC Data Book. Statistical Information Related to Medical Education. Washington, D.C.: Association of American Medical Colleges, January 1991.
2. Association of American Medical Colleges, staff communication, to the IOM Committee to Plan A Study of the Rose h Capabilities of OB/GYN. 1989.
4. The discussion of the Markle Scholars Program is based on a paper by Lawrence Longo, which appears as Appendix A in this volume.
5. George D. Wilbanks, President, Association of Professors of Gynecology and Obstetrics, personal communication, April 1991.
6. Bates, William G. Leadership Qualities of Obstetrical and Gynecological Department Chairmen of United States Medical Schools. Unpublished manuscript. Greenville Hospital System, Greenville, South Carolina.
7. Pincus, Harold Alan and Brenda Fasnacht. From the Office of Research. Psychiatric Research 1990; 5(1):2.
8. National Academy of Sciences/Institute of Medicine. Forum on Supporting Biomedical Research: Near-term Problems and Options for Action. Summary. Washington, D.C., June 27, 1990.
9. U.S. Congress, Office of Technology Assessment. Federally Funded Research: Decisions for a Decade. Summary. OTA-SET-491. Washington, D.C.: Government Printing Office, April 1991, p. 2.
10. Fox, Patrick. From Senility to Alzheimer's Disease: The Rise of the Alzheimer's Disease Movement. Milbank Quarterly 1989; 67:58–102.