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Strengthening Research in Academic OB/GYN Departments (1992)

Chapter: 2 IS THERE A PROBLEM?

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Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
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2
IS THERE A PROBLEM?

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

Support of Research and Training in Departments of OB/GYN

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

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

available to indicate either past levels of support or changes in distribution, but some OB/GYN department chairs feel that the pharmaceutical industry has become a more significant source.2 There are also indications that private foundation support, which played an important role in stimulating research in departments of OB/GYN in the past, has diminished in recent years.

The Role of Foundations

According to an inventory of private agencies that contribute to population research,* a small number of foundations—the Ford, Rockefeller, and Andrew W. Mellon foundations—have for years dominated the private funding scene. The Hewlett Foundation, created in 1966, entered the inventory in 1985. The Population Council, which is included in the inventory, is itself a research organization that solicits funds to support its work. However, it also supports investigators—mainly overseas—who collaborate with the council in fertility and contraception work.**

Between 1976 and 1985, several trends in foundation support were notable. Reproductive processes and contraceptive development both lost ground, losing 34 percent and 6 percent in funds, respectively. There was also a large shift of funds to the social and behavioral sciences (a gain of 224 percent) and smaller but nevertheless substantial gains for contraceptive evaluation (184 percent) and population research centers (98 percent).3 These trends suggest that OB/GYN departments may have been losers, since the largest gains appear in areas in

*  

 The term population research is not synonymous with the research activities appropriate to departments of OB/GYN. In the following discussion it is defined as "studies of the nature, determinants, and consequences of population characteristics and dynamics and the development of basic data and methods for such population analysis. Physical, biological, psychological, cultural, social, economic, geographic, historical and political factors may all be included in population studies" (U.S. Department of Health and Human Services, National Institutes of Health, Public Health Service, Inventory and Analysis of Federal Population Research, Fiscal Year 1988, Washington, D.C., 1990). Many population research projects are conducted in departments other than OB/GYN. Moreover, OB/GYN departments receive research support from foundations that are not included in the inventory. Nevertheless, this inventory is the best available indicator of trends in foundation support for the areas of science undertaken by departments of OB/GYN.

**  

The Population Council was a major grant-giving organization in the 1950s and early 1960s. There tier it became mainly a research organization funded by foundations, NIH, and other government agencies in the same way that other research organizations and universities are funded.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

which other departments have a major stake. The area most specific to OB/GYN—that is, reproductive processes—experienced the greatest loss.

Private foundations have also made significant contributions to the training, development, and support of OB/GYN academic manpower. The principal foundations involved have been the Mary R. Markle Foundation; the Josiah Macy, Jr. Foundation; the Rockefeller, Ford, and Mellon foundations; and, more recently, foundations formed by OB/GYN professional groups. The history of the contributions of these organizations is detailed in Appendix A. The foundations played an important role in stimulating the research careers and bringing to prominence many of today's leaders in academic OB/GYN. It is particularly useful to note the contributions of the Macy and Mellon foundations, which provide good examples of the impact of foundation giving and of the factors that may cause a change in the programs these foundations support.

The program of the Josiah Macy, Jr. Foundation focused specifically on the furtherance of reproductive biology through faculty development, conferences and seminars, and support of research time for medical students. In the 1950s and 1960s, funds flowed into selected medical schools and to individuals in residency programs. There were also funds for interdisciplinary research. The program supported faculty fellows and postdoctoral fellows, many of whom later became distinguished contributors to their discipline. When the program ended in 1966, about 50 people had received training support; by 1979, 15 of the 50 were department chairs. Also of importance were the Macy-sponsored conferences, at which new directions for reproductive science were presented, discussed, and refined. It is estimated that between 1955–1970 the Macy Foundation allocated $6.4 million to the development of academic OB/GYN research.4 Its heavy involvement in OB/GYN came to an end with a change in leadership within the foundation.5

Another foundation that formerly made important contributions but that has today diminished its involvement is the Andrew W. Mellon Foundation. Beginning in 1977, the foundation attacked the problem of world population growth through research aimed at contraceptive development. It helped support talented investigators entering the reproductive sciences and brought a number of young molecular biologists into the field. Major grants were awarded to 17 reproductive biology centers, supporting the development of more than 200 young M.D. and Ph.D. investigators and untenured faculty. A 1986 review of the program noted that Mellon funds were particularly valued by departments because of their flexibility—the money could be used to support individuals at crucial early phases of their careers, to bring into the centers people of various backgrounds to create multidisciplinary research teams, or to undertake areas of contraceptive investigation that NIH could not fund.6 These young investigators

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

were starting to make important contributions to the field when the decision was made in 1989 to wind down the program. It is currently funded at $1 million per year, down from the former level of $2.5 million.

In 1980, the Mellon Foundation also started providing reproductive research project grants, often to institutions with Mellon reproductive biology center grants. Roughly $1.2 million per year was allocated to these grants, which were discontinued in 1989. It is estimated that between 1977 and 1988 the Mellon Foundation contributed a total of $27.5 million to reproductive biology, including support of young investigators.7 Reasons for the reduction in Mellon support of the field of reproductive research are complex, but interviews with foundation staff indicate that contributing factors include a sense that few of the investigators who were supported have continued working in areas related to contraceptive development and that the project money was an add-on to NIH funds for work similar to NIH-supported research. In general, the foundation concluded that its greater strength lay in the humanities rather than in the biomedical field, a view reinforced by new leadership at the foundation. Moreover, discussions between scientists and foundation staff did not yield a focus that closely matched the foundation's goals, so it decided to transfer funds to applied research and other areas in the population research field.8

Islands of strength in OB/GYN research and leadership exist today in part because of the efforts of these foundations. They invested in OB/GYN research and the development of research personnel, and the flexibility of that money was particularly valuable as an adjunct to more regulated government support. The withdraw of the support that was so important in developing OB/GYN research leaders has generated fears that, as the generation of leaders whose development was assisted by the foundation programs approaches retirement, a vacuum in research leadership will become apparent. Whether it was within the power of those in OB/GYN to persuade the foundations to maintain their investment in reproductive sciences is uncertain. To some extent foundation policies are driven by external events, and to some extent by factors internal to the foundations such as a change in leadership. Moreover, foundations choose priority areas in many different ways: through internal priorities, personal contacts, and advisory committees.9 Some foundations seek underfunded areas in which their support can make a difference, which may today represent an opportunity for OB/GYN.

In addition to awards specifically for reproductive sciences or to support individuals trained in OB/GYN, which have suffered a major decline in number and in level of funding, foundations today offer awards for which eligibility is less constrained and for which young OB/GYN investigators may be eligible. For example, the Searle Scholars Program awards three-year grants of $180,000

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

to individuals in the first or second year of their first appointments as assistant professors. The idea is to identify promising investigators at an early and crucial stage in their careers. Since its inception in 1980, the program has made 191 awards—mainly to basic science investigators, according to the program director, who notes that the selection committee seeks evidence of a departmental commitment to the candidate. This, he believes, is more often found for basic than for clinical scientists. Other foundations that give substantial awards to young biomedical investigators in many fields include the Lucille P. Markey Charitable Trust, which supports 16 individuals per year, and the David and Lucille Packard Foundation and the Pew Charitable Trusts, each of which supports 20 individuals per year.10

Other Private-Sector Training Support

Today, much private-sector support of OB/GYN training comes from industry, although OB/GYN professional associations and their foundations also contribute. ACOG has identified a total of 14 awards currently being made by the private sector, including some substantial fellowships:

  • The James Kennedy Fellowship Award of the American Association of Obstetricians and Gynecologists Foundation (the funding arm of the American Gynecological and Obstetrical Society) provides $40,000 per year for two years for fellows and requires a $15,000-per-year institutional commitment. This postdoctoral award targets individuals who need research training to move toward an investigative career. The program began in 1984 and had awarded a total of 17 fellowships by July 1990. Thirteen of these fellows attended a retreat in June 1990 at which an impressive summation of their research activities was presented.11

  • The Berlex Foundation offers one or two scholarships per year with a stipend of $50,000 plus $10,000 for laboratory support for an individual who already has a record of independent research.

  • ACOG has joined with Ortho Pharmaceutical Corporation to provide two $30,000 fellowships annually, to be awarded to an ACOG fellow or junior fellow identified as progressing toward academic OB/GYN. The award is meant to allow the recipient to undertake an investigative project and basic research training.

  • There are in addition a number of smaller professional association/industry grants that provide start-up funds for research projects, as well as some monies for training support.12

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

It is estimated that approximately six to eight physician/scientists are being trained annually in these major programs supported by the private sector.13

Many of these programs have their roots in assessments from inside the discipline that academic research needs enhancement and that a vitalized research effort would upgrade the status of OB/GYN.14 The initiatives have resulted in a small but significant body of awards to further the development of investigators. The future magnitude of professional and industry support of OB/GYN research training will depend on a continuing sense in the discipline that an enhanced research capability would benefit it generally, both in terms of the status of academic OB/GYN and in the quality of clinical practice.

Voluntary Health Agencies

Voluntary health agencies—often founded by the friends and families of individuals with a particular disease—sometimes use their funds for disease-related research and training. They can make important contributions to the careers of scientists by supporting fellowships, initial research, and other career development awards. Voluntary health agencies do not, however, usually make long-term commitments to research.15 OB/GYN departments are well positioned to tap into the resources available from these agencies since OB/GYN interests overlap to some extent with the interests of three of the largest—the American Cancer Society, the March of Dimes-Birth Defects Foundation, and the National Easter Seal Society. Data on the level of OB/GYN funding by such voluntary health agencies are not available; however, each of the three agencies mentioned above was included in lists of sources of support received by the committee from chairs of departments of OB/GYN.

FINDINGS: The committee found cause for alarm in the diminution of foundation support for the development of OB/GYN research personnel and for OB/GYN research. Foundations played a vital role in preparing many of the current leaders of the field, and without this support there may not be enough well-prepared individuals to step into leadership positions when the current generation reaches retirement age. Today only approximately 11 young investigators each year benefit from major private-sector training awards, including those supported by the joint public/private Reproductive Scientist Development Program but excluding those who are awarded other NIH training

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

support. Increasing the number of available awards by at least another six would return significant benefits to OB/GYN research.

RECOMMENDATIONS: OB/GYN leaders should take the initiative in demonstrating to foundation and voluntary health agency trustees and other representatives, to leaders of professional associations, and to relevant foundations of industrial corporations, ways in which expanded support of training for OB/GYN investigators would be a worthwhile investment. The purpose of such investments would be to ensure that sufficient research personnel are available to allow OB/GYN to fulfill its promise of improving women's health, contraception, and pregnancy outcomes. The committee encourages foundations to develop programs for OB/GYN, such as the former Josiah Macy, Jr. Foundation program, the current Searle Scholars Program, or other foundation efforts that can be regarded as models with characteristics that may be worth emulating.

OB/GYN leaders should seek additional research support from the types of organizations mentioned above. The promise of the research, together with a willingness to adapt research programs to correspond to foundation priorities, will provide powerful arguments that have a chance of salvaging some lost foundation support. By the same token, decision makers in foundations that are concerned with the development of scientific personnel—or with population problems, women's health, cancer, pregnancy outcomes, and other topics that OB/GYN is well positioned to address—should be aware of the role that their support of training and research could play at this crucial time in the development of OB/GYN research.

The committee also recommends that the American College of Obstetricians and Gynecologists and the Association of Professors of Gynecology and Obstetrics continue to include in their manpower survey questions on sources of research support received by departments of OB/GYN. This information will for the first time allow tracking of the level of research activity in departments of OB/GYN.

Federal Support

A 1980 report on the status of academic obstetrics noted that ''federal funding of research in academic departments of obstetrics and gynecology in the

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

United States has never been substantial, and the situation is not different today.''16 That sentiment might be echoed in 1992.

The discussion below focuses on NIH support of departments of OB/GYN. * Other federal agencies also contribute, but their support is difficult to identify and is not thought to be sizable.17 A survey of departments of OB/GYN in 1990 revealed a total of $77.5 million in federal research funds.18 NIH data indicate that, of this amount, $45.7 million (59 percent) came from NIH, and there are reasons to believe that the NIH contribution exceeds 59 percent. (For example, the figure omits awards that flow to academic departments but that are awarded to other entities, such as hospitals.) Staff at federal agencies outside of NIH agree that their funding of research in departments of OB/GYN is limited. In 1989, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) provided $1.6 million in research funds.

Trends in NIH Support of Departments of OB/GYN NIH funds flowing to departments of OB/GYN increased from $6.9 million in 1968 to $16.1 million m 1978 and to $45.7 million in 1990 (this latter figure represents a slight decline from the $46.5 million awarded in 1989). In constant dollars, however, the increase over the 1968–1989 period was 74 percent; it was 43 percent between 1978 and 1989 (Figure 2-1). Since the average amount of money per award increased over time, the number of awards has not grown at the same rate as dollar support. Thus between 1980 and 1989, the dollars going to departments of OB/GYN more than doubled, while the number of awards increased by less than 5 percent, more closely reflecting the real-dollar increase.

Departments of OB/GYN very slightly increased their share of the overall NIH budget. Their share of the NIH funds going to departments of medical schools has remained virtually unchanged. During the 1980s the NIH budget increased by 150 percent, while OB/GYN departments gained 190 percent. OB/GYN departments maintained their share of NIH medical school support at 1.4 to 1.5 percent between 1968 and 1989, although they received less than might be expected on the basis of faculty size: 3.8 percent of all medical school faculty are in departments of OB/GYN, but they were awarded only 1.5 percent of the NIH funds going to medical schools.

*  

 The following discussion of the NIH role is, unless noted otherwise, based on a background paper by Robert A. Walkington, which is published as Appendix B of this report and to which the reader is referred for additional information. The data for this paper were extracted from the NIH data systems specifically for this study.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

Figure 2-1: NIH support of departments of OB/GYN, current and constant (1968) dollars

SOURCE: Special tabulation by NIH.

An important element in the extent of support, at any given time, of specific areas of science or of specific disciplines relates to the fortunes of the NIH institute that provides the funds. Because public and congressional perceptions of the importance of the health or science issues undertaken by each institute have varied over time, budget appropriations for individual institutes do not always parallel overall NIH budget growth.

Historically, the National Institute of Child Health and Human Development (NICHD) has been the major NIH supporter of departments or OB/GYN, providing between 55 percent and 70 percent of NIH support since 1968. NICHD has received approximately 6 percent of total NIH funds since 1978, and departments of OB/GYN have increased their share of NICHD funds from 5.4 percent in 1978 to 7.5 percent in 1989.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

The National Cancer Institute (NCI) has been the second largest NIH supporter of OB/GYN departments. However, the NCI contribution fell from 31 percent of total NIH funds going to departments of OB/GYN in 1978 to 9 percent ($4.6 million) in 1989. Although NCI's share of the total NIH appropriation has itself fallen substantially, NCI is still by far the largest institute, accounting for more than 20 percent of NIH's 1989 funds.

NIH offers many types of research and research training awards. Research grants absorb the largest proportion of NIH funds, a proportion that has risen from 77 percent of total NIH support awarded in 1980 to 84 percent in 1989. Awards to departments of OB/GYN followed a similar trend: research grants increased from 90 percent to 92 percent of OB/GYN awards over the same period. The largest component of this group of awards is the category of investigator-initiated awards (RO1s). Also included in the group of awards are First Independent Research Support and Transition (FIRST) and New Investigator Research awards, both of which can be pivotal support for young investigators; Research Program Project grants; and research center grants, which play a role in solidifying the research efforts of a department and ensuring the presence of a new generation of investigators. NIH also supports research training at both the pre- and postdoctoral levels. This aspect of NIH activities has experienced a relative decline, falling from 6.6 percent of the NIH extramural budget in 1980 to 4.3 percent in 1989. Again, the trend for departments of OB/GYN is similar, with training support falling from 3 percent of NIH support of departments of OB/GYN in 1980 to 1.3 percent in 1989.

In sum, departments of OB/GYN have made a very small gain in terms of share of NIH resources, but the funds they receive remain an extremely small component not only of the NIH budget as a whole—which is to be expected—but also of the budget of NICHD, the institute that has the mandate to improve reproductive health. Closer examination of the data causes a greater sense of alarm about how OB/GYN departments are faring. The following sections take such a look, viewing the state of NIH support of departments of OB/GYN from three perspectives: the types of awards applied for and received by departments of OB/GYN, the academic degrees of investigators, and how OB/GYN departments compare with some other clinical departments.

Competition for NIH Funds

To assess how OB/GYN departments are doing in gaining NIH support, the committee compared their applications with applications from departments of internal medicine, pediatrics, surgery, and radiology. Departments of internal

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

medicine were chosen for this purpose because they are the largest of all the clinical departments and are widely considered to be leaders in research capabilities. Pediatric departments were selected because pediatrics is a major focus of interest for NICHD; thus those departments share with OB/GYN some dependence on that institute. Surgery was chosen because it shares a technical orientation with OB/GYN—a characteristic that is also thought to affect the likelihood of success in NIH funding. Finally, departments of radiology were chosen because they are similar to OB/GYN in research intensity as measured by the percentage of faculty who are principal investigators (PIs) on NIH and ADAMHA grants. Although radiology faculty are more numerous than OB/GYN faculty, the two departments are nevertheless closer in size than the other departments chosen. Internal medicine had nearly six times as many full-time faculty as OB/GYN in 1988, while pediatrics and surgery had more than twice as many. Other departments or subspecialties might provide more appropriate comparisons, but data problems prohibited analysis.

All Competing Applications In the decade 1980–1989, the five clinical departments submitted a total of 46,148 competing applications to NIH (Table 2-1). Fifty-nine percent were submitted from departments of internal medicine (which have 44 percent of the full-time faculty in the five departments), 15 percent by departments of pediatrics (with 19 percent of faculty), 13 percent by departments of surgery (with 17 percent of faculty), 7 percent by departments of radiology (with 13 percent of faculty) and 6 percent by departments of OB/GYN (with 7 percent of faculty). Thus departments of internal medicine submitted a disproportionately large number of applications in relation to faculty size; OB/GYN, pediatrics, and surgery submitted a roughly proportional number; and radiology was slightly underrepresented. However, on a per capita basis, physicians in departments of OB/GYN submitted fewer applications than M.D.s from three of the other four departments (Table 2-2).

The success rate (percentage of applications funded) varied from 37.6 percent for internal medicine to 26.5 percent for OB/GYN. The differences in success rates among OB/GYN and the other departments, except for surgery, are statistically significant. The low relative success rate of OB/GYN departments became more acute toward the end of the decade.

Analysis by degree reveals that the success rate of applications from Ph.D.s in departments of OB/GYN was significantly lower than the success rates of Ph.D.s in departments of medicine and radiology. The differences in success rates for Ph.D.s among departments of OB/GYN, pediatrics, and surgery were

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

TABLE 2-1: Success Rates of Competing Applications Submitted to NIH by Departments of Obstetrics and Gynecology, Internal Medicine, Pediatrics, Radiology, and Surgery, 1980–1989

Department

Number of Applications

Number of Awards

Success Rate (%)

All Applicants

Obstetrics/Gynecology

2,669

706

26.5

Medicine

27,240

10,242

37.6*

Pediatrics

6,801

2,105

31.0*

Radiology

3,335

1,111

33.4*

Surgery

6,117

1,742

28.5

Total

46,162

15,866

34.4

M.D.s

Obstetrics/Gynecology

1,013

245

24.2

Medicine

17,684

6,962

39.4

Pediatrics

4,327

1,134

32.7*

Radiology

920

278

30.2*

Surgery

3,522

1,059

30.1*

Total

27,466

9,956

36.3

Ph.D.s

Obstetrics/Gynecology

1,473

416

28.2

Medicine

7,126

2,428

34.1*

Pediatrics

1,794

478

26.7

Radiology

2,127

745

35.0*

Surgery

2,038

547

26.9

Total

14,558

4,614

31.7

* Significant at 95% confidence level when compared with OB/GYN.

SOURCE: Special tabulation from NIH.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

TABLE 2-2: Per Capita Competing Applications Submitted to NIH by Selected Departments, 1989

Department

Total Faculty

M.D.s and M.D./Ph.D.s

OB/GYN

1.1

0.5

Internal Medicine

1.9

1.4

Pediatrics

1.1

0.8

Radiology

0.8

0.3

Surgery

1.2

0.7

 

SOURCES: Calculated from U.S. Medical School Faculty, "The Numbers Book," 1989 Washington, D.C., Association of American Medical Colleges, 1989; special tabulation from NIH.

not significant; indeed, OB/GYN departments, with a 28.2 success rate, were not far off the average of 31.7 for all five departments. However, in the latter years of the decade, the success rate of Ph.D.s in OB/GYN departments fell below that of the other departments.

Applications submitted by M.D.s from departments of OB/GYN fared significantly worse than those from any of the comparison departments. Compared with an average success rate of 36.3 percent for the five departments, OB/GYN's 24.2 percent success rate was significantly lower than each of the other four departments, including surgery, which was the next lowest at 30.1 percent. Thus it is apparent that the major portion of the weakness observed in the overall success rate of departments of OB/GYN is attributable to applications from M.D.s.

But success rates only tell part of the story. To win awards, applications must be submitted, and physicians in departments of OB/GYN submit relatively small numbers of applications per capita.

Investigator-Initiated Research The RO1 grant is the heart of the NIH extramural program. It is the traditional award for investigator-initiated research and in 1989 represented almost two-thirds of all NIH research grants.

The pattern observed above for all awards is repeated for RO1s: Ph.D.s from departments of OB/GYN have better success rates than their M.D. colleagues; M.D.s in departments of OB/GYN have a significantly lower success rate than each of the comparison departments. Thus research proposals from

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

M.D.s in particular, and to a lesser extent from Ph.D.s in departments of OB/GYN, are relatively unsuccessful in the competition for the important RO I research grants.

There are distinctive differences among the five departments in the proportion of RO1s submitted by M.D.s, despite similar proportions of M.D.s and Ph.D.s on their faculties. During the 1980s, almost two-thirds of RO1 applications from internal medicine and pediatrics came from M.D.s; for surgery, roughly one-half were from M.D.s, for OB/GYN, one-third, and for radiology, one-quarter. Thus access to RO1 funds for departments of OB/GYN was enhanced by the number of submissions from the more successful basic scientists.

Beginning Research Awards NIH offers research grants that are designed to help beginning researchers move from trainee status to independence. These First Independent Research Support and Transition (FIRST) awards support an investigator's initial independent effort and help in the transition to attaining an RO1. Departments of OB/GYN submitted few applications—a total of 165—for FIRST awards between 1980 and 1989; only 51 of the applications were from M.D.s. Since the success rate was significantly worse than that of each of the comparison departments, OB/GYN also received only a small number of FIRST awards—29 in total, 4 for M.D.s. Only radiology had a similarly low number of applications.

FIRST awards are small—for five years, with no more than $350,000 in total—but they help the investigator who must prove his or her worth before winning traditional types of NIH support.* The poor showing of departments of OB/GYN in general and of their M.D. applications in particular is disconcerting—the inability of M.D. investigators in departments of OB/GYN to win these awards may indicate weakness in younger es hers that bodes ill for the future. The low number of applications may indicate a lack of research interest in the younger generation that also has serious implications for the future.

NIH makes other awards that provide useful support for young investigators. For example, small grants (RO3s), often in the $20,000–$25,000 range, are well suited to investigators who are developing the preliminary data

*  

 The level of support on an NIH FIRST award does not fully cover the salary of a physician/investigator, nor does it cover the total cost of the research. The department chair must therefore make a significant additional investment of departmental funds in the investigator.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

needed for an RO1 application. Between 1987 and 1989, departments of OB/GYN submitted seven applications for RO3s—four from M.D.s and three from Ph.D.s. One M.D. was awarded an RO3. Thus it appears that another award of potential, if limited, use is not receiving much attention from OB/GYN.

Research Training NIH offers training support in two forms: fellowship awards to individuals and training grants to institutions, which then make awards of traineeships to individuals they select. Differences in success rates for these awards among the five comparison departments axe small and not statistically significant. Again, however, OB/GYN departments submit few applications and therefore win few awards. During the 1980s, OB/GYN submitted a total of 194 applications, 56 of them from physicians. This translated into only 84 awards, of which 24 went to physicians. Of the comparison departments, only radiology had comparably small numbers. Research training is the precursor of careers in investigation, and the paucity of awards does not bode well for future OB/GYN research manpower.

Career Development NIH offers several types of career development awards to support the training of scientists with clear potential who require additional training to reach independence. Some of these awards are for physicians only, some target individuals at particular stages of their development, and others target specific areas of work. The total number of investigators winning career development awards has not changed much over the past decade; however, there has been a shift away from Ph.D.s. toward M.D.s through an expansion of clinical investigator awards, which provide opportunities for medical scientists who will pursue research in areas of interest to the awarding institute. In addition, there axe two new programs for physician/scientists: one provides individual support and the other offers an institutional award for newly trained physicians to train in multidisciplinary programs.

As with research training awards, departments of OB/GYN, between 1980 and 1989, experienced success rates for career development awards similar to the rates of the four comparison departments. But, like radiology, OB/GYN submitted few applications; thus only 21 career development awards (18 to physicians) went to departments of OB/GYN during the decade. However, the number of individuals whose training has been supported exceeds the number of awards because the Reproductive Scientist Development Program (RSDP),

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

previously called the Reproductive Scientist Training Program, which takes in three physician trainees each year, is counted as one award.

The RSDP was developed in response to a perceived shortage of OB/GYNs with research expertise. Designed to give outstanding clinically trained individuals the basic research training in cell and molecular biology that would allow them to become competitive for research grants, the award was modeled after one developed in pediatrics. An individual is eligible for an RSDP award after completing residency training or a clinical fellowship. An awardee enters a laboratory to work with an outstanding mentor and to learn basic science skills, as well as to participate in research. This phase of the training program was originally expected to last two years; however, some trainees have requested and received support for a third year in the laboratory. Following the years of basic research, trainees spend three years as junior faculty members in the department of OB/GYN that originally sponsored them, with a guarantee of at least 75 percent time spent in research under a preceptor. The RSDP is funded by NIH and by $25,000 per year each from the American College of Obstetricians and Gynecologists, the American Fertility Society, the American Gynecological and Obstetrical Society, the Association of Professors of Gynecology and Obstetrics, Ethicon Incorporated, and GynoPharma Incorporated.

The first three trainees entered the RSDP in 1988 and presented their work in 1990 at a meeting of the Society for Gynecologic Investigation. The quality of the trainees is impressive, and the number of outstanding candidates has grown each year. Many members of the OB/GYN community believe that the RSDP represents the most hopeful endeavor for training new investigators that the discipline has seen for many years.

Although NIH data do not document the number of physicians in departments of OB/GYN who received research training and career development support from NIH in the past decade, according to one estimate the total for the decade is only 50 people.19

During the past year NICHD has changed the terms under which it grants the Clinical Investigator Award, an award for physicians who have completed clinical training and have had between three and seven years of postdoctoral training. Providing salary support of up to $50,000 per year, plus $10,000 for supplies, the award is designed to help an investigator work on a defined problem under the auspices of a sponsor and to assist in the investigator's transition to independence.20 Previously NICHD granted the Clinical Investigator Award for only three years; now up to five years of support may be awarded. This extension can make a significant difference for young

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

investigators struggling to prepare themselves to compete on their own for grant support.

The ability to adapt awards to respond to changing needs or other circumstances is a strength of the NIH system. Thus, for example, the Physician Investigator Award was established in response to a perceived need to enhance the supply of physicians engaged in research. This year the National Heart, Lung, and Blood Institute initiated a new award to replace its Physician Scientist and Clinical Investigator awards. The change was made ''to allow greater flexibility in developing a program suited to the experience and capabilities of the candidate." Thus the holder of the award may integrate research and subspecialty clinical training, interrupt the grant to continue clinical training, or develop a program that is suited to his or her level of research experience.21 The ability of NIH institutes to creatively tailor awards to try to accomplish specific outcomes, not only for career development awards but also for training and research grants, should not be underestimated.

"Umbrella" Grants These multiproject grants include research centers, such as the General Clinical Research Centers (GCRCs) and Specialized Centers, as well as Program Project Grants. They involve large numbers of researchers, are often targeted to interdisciplinary areas of work, and can support both core and ancillary activities such as animal facilities, epidemiology units, or hospital beds used for the research—depending on the type of award. They provide funding mechanisms for the development of junior staff, for specialized research nurses and dieticians, and for research facilities for inpatient and outpatient studies. Many have laboratories with advanced technologies.22 GCRCs are valued for the resource brought together that facilitate clinical research for investigators and subjects.

"Umbrella" grants are sometimes initiated when NIH—often at the behest of Congress—makes an announcement of the research area in which an institute wants to fund a center; generally NIH staff work closely with the applicant institution's staff during the development of applications. Once granted, the award is closely monitored by NIH staff. In general, these grants are awarded to institutions that have a proven track record in research (most of the investigators on center grants are also RO1 awardees) and are therefore thought to be able to sustain these large-scale efforts.

There is tension between the level of funding for RO1s and the number of centers funded by NIH, partly because the funding of one decreases the funding of the other. On the other hand, academic departments value the flexibility of

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

center grants; investigators between RO1s may be supported on such grants; interdisciplinary synergy between basic and clinical scientists is easier to generate; and center funds usually prove to be more stable, longer term support than other types of NIH funds. There are also differences between center grants and RO1s in terms of the work that can be accomplished. One observer noted that more clinical, innovative, and risky research is accomplished with center grants. In particular, research requiring three to four years to obtain data is more likely to be undertaken in the more stable context of a research center. Finally, the prestige attached to having a center can be used to stimulate contributions from nonfederal sources and to attract distinguished scientists to the departments.

Several awards of this umbrella type that pertain to OB/GYN research topics have been made. An example is the Specialized Centers (P50) awards for perinatal research centers, which include centers that focus on, for example, diabetes and pregnancy or premature labor. The Pregnancy and Perinatology Branch of NICHD supports six current P50 grants, of which two axe m departments of OB/GYN and four in departments of pediatrics. Other awards axe Research Project Cooperative Agreements, under which a maternal fetal medicine unit network and a neonatal intensive care unit network are supported. These networks were established in response to the notion that much obstetric and neonatal clinical management were not based on strong evidence of efficacy; groups were asked to design clinical trials to compare various clinical management approaches.

Departments of OB/GYN have fared differently depending on the type of umbrella grant they sought. The number of Program Project Grants awarded by NIH has increased over the past decade, but OB/GYN departments have not shared in this expansion. OB/GYN departments submitted only 28 Program Project Grant applications during the decade (one-quarter the number submitted by radiology, the department with the next fewest number of applications) and were awarded 13 grants. However, of the 33 applications for research center grants that were submitted by OB/GYN departments, 24 gained awards, for a success rate of nearly 72 percent—the highest among the five comparison departments. The high success rate for these awards (compared with many other NIH awards) is partly due to the understanding of departments that it is futile to apply unless a critical mass of investigation is already being conducted, and partly due to the consultation that takes place between NIH staff and applicants before the application is submitted.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

FINDINGS: The committee finds cause for acute concern about the research capabilities of physicians in departments of OB/GYN. Ph.D.s in departments of OB/GYN who apply for NIH funding have success rates comparable to the rates of Ph.D.s from some other clinical departments, but the submissions from physicians in departments of OB/GYN are sparse and fare poorly in the competition for NIH funds. In response to this weakness, the committee focused its recommendations on ways of developing and strengthening physician investigators in departments of OB/GYN, enabling them to compete more successfully for NIH funds in the future.

RECOMMENDATIONS: NICHD program staff should exercise to the fullest extent possible their ability to target training support to expand the number of research training opportunities for physicians in OB/GYN.

Chairs of departments of OB/GYN should work with NIH staff to improve the success rate of applicants for FIRST awards. FIRST awards are particularly useful mechanisms in this regard, since their average length exceeds that of RO1s and applicants under 36 years of age have the best success rate.

The committee believes that survival of the Reproductive Scientist Development Program is essential for the future health of OB/GYN research. Professional groups and the private-sector organizations that support the Reproductive Scientist Development Program should ensure its stability through a long-term commitment of resources. Because of the importance of the program NICHD should continue support of the Reproductive Scientist Development Program.

The committee also recommends that NICHD tailor another career development award to OB/GYN physicians. This award should be flexible in terms of the type of training it provides and the timing of training, as is the Clinical Investigator Development Award of the National Heart, Lung, and Blood Institute. And because the supply of research manpower in OB/GYN is of great concern, the committee also recommends that NIH develop a system to track OB/GYNs who are receiving federal training and career development support.

Structural Characteristics of Departments of OB/GYN

Data on the relative success of departments of OB/GYN in competing for NIH funds are one indicator of a possible problem in their research capabilities.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

A different set of indicators pertains to the departments themselves: how they differ from other clinical departments, the relative intensiveness of their research efforts, the composition of the departments in terms of the academic degrees of faculty members, and theft ability to provide a healthy research environment.

Overview of Faculty in Clinical Departments of Medical Schools

The number of faculty members in the clinical departments of U.S. medical schools grew by 69.5 percent between 1978 and 1989, from almost 29,000 to a little over 49,000 (see Table 2-3). However, not all departments shared equally in this expansion. Departments of internal medicine led the way with a growth rate of 86.1 percent, widening the gap in size between internal medicine and all other clinical departments. At the other end of the spectrum are the departments of physical medicine, which are small (only 561, or 1 percent of clinical faculty members in 1989) and which experienced a relatively meager growth of 24.4 percent between 1978 and 1989. Departments of OB/GYN are relatively small and slow-growing: their 1989 total faculty size of 2,383* was below the 3,167 average and represented only 5 percent of total clinical faculty. Theft growth of 58.3 percent between 1978–1989 was below the 69.5 percent average.

Composition of Faculty by Degree The principal factors driving faculty size are teaching load and clinical duties—research is usually secondary. The number of Ph.D.s in a department is considered an indicator, albeit an imperfect one, of research activity. In 1986, Herman and Singer remarked that ''the major efforts of clinical investigation have moved from the bedside, where patient contact and research were closely linked, toward the basic science laboratory and its emphasis on cell culture, enzyme systems, and animal models." This, they posited, accounted for the growth in the number of full-time Ph.D. faculty appointments in clinical departments—up from 3,500 in 1972 to 5,900 in 1982. The authors suggested that Ph.D.s may have been recruited to compensate for the failure of M.D.s to maintain their share of the total research effort.23

*  

 According to a survey conducted by ACOG, there were a total of 2,952 full-time faculty members in departments of OB/GYN in July 1990. This survey of all OB/GYN departments has been repeated at intervals since 1977. It documents an increase in faculty of 90 percent since 1977 and 22 percent between 1986 and 1990—a higher rate of growth than that shown by data from the Association of American Medical Colleges (AAMC) discussed in the text. The committee used AAMC data in this section because they allow comparison with other departments.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

TABLE 2-3: Change in Number of Faculty Members in Clinical Department, 1978–1989

Department

1978

1989

Percent Change

Anesthesiology

1,579

2,777

75.9

Dermatology

262

379

44.7

Family Practice

1,098

1,581

44.0

Internal Medicine

7,558

14,065

86.1

Neurology

1,088

1,706

57.0

OB/GYN

1,505

2,383

58.3

Ophthalmology

594

1,093

84.0

Orth. Surgery

477

772

61.8

Otolaryngology

419

572

36.5

Pediatrics

3,327

6,009

80.6

Physical Medicine

451

561

24.4

Psychiatry

3,661

5,405

47.6

Public Health

712

1,187

66.7

Radiology

2,524

4,003

58.6

Surgery

2,893

5,270

82.2

Other

791

1,305

65.0

Total

28,939

49,068

69.5

 

SOURCES: C. R. Sherman et al., On the Status of Medical School Faculty and Clinical Research Manpower 1968–1990, NIH Publication No. 82-2458. Bethesda, Md., National Institutes of Health, 1981; Association of American Medical Colleges, U.S. Medical School Faculty, "The Numbers Book," Washington, D.C., Association of American Medical Colleges, 1989.

Table 2-4 shows changes in the type of degree held by faculty of clinical departments between 1978 and 1989. The proportion of faculty with the Ph.D. or M.D./Ph.D. degree grew from 18.1 percent to 21.2 percent; because of substantial overall growth in faculty, this translates into significant numerical growth—from 3,859 in 1978 to 10,436 in 1989. There is wide variation in the presence of Ph.D.s and M.D./Ph.D.s in clinical departments, from only 13 percent of anesthesiology faculty to 45 percent of departments of public health. OB/GYN departments, with faculty rosters that are 14.3 percent Ph.D. and 5.4 percent M.D./Ph.D., were not far off the average for clinical departments of 15.7 percent and 5.5 percent, respectively. Departments of OB/GYN are close

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

TABLE 2-4: Change in Degrees of Full-Time Faculty, 1978 and 1989, as Percentage of Department Faculty

 

M.D.

M.D./ Ph.D.

Ph.D./ O.H.D.*

Other

Department

1978

1989

1978

1989

1978

1989

1978

1989

Anesthesiology

88.9

82.5

4.6

7.0

4.2

6.0

2.3

4.4

Dermatology

71.6

78.6

6.1

7.1

17.5

11.9

4.8

2.4

Family Practice

66.5

73.7

1.6

1.5

13.5

17.8

17.4

7.0

Internal Med.

85.4

80.8

4.7

6.5

7.1

9.5

2.8

3.1

Neurology

73.3

67.8

6.4

9.4

14.6

18.5

5.7

4.3

OB/GYN

78.1

74.1

5.0

5.4

12.2

14.3

4.7

6.2

Ophthalmology

65.5

63.0

6.6

6.3

22.1

23.9

5.8

6.8

Orth. Surgery

84.7

78.1

4.4

3.1

7.5

11.0

3.4

7.8

Otolaryngology

53.3

53.3

2.5

4.9

28.5

32.2

15.7

9.8

Pediatrics

80.4

78.4

3.3

4.8

10.0

10.6

6.0

6.0

Physical Med.

51.0

62.2

2.4

3.0

17.6

18.5

29.0

16.2

Psychiatry

55.5

54.2

2.5

3.8

29.5

33.1

12.5

9.0

Public Health

36.7

40.8

2.8

3.9

38.4

41.4

22.1

13.9

Radiology

72.8

71.1

3.7

4.5

15.7

18.2

7.8

6.1

Surgery

82.2

80.1

5.7

5.2

8.4

11.1

3.7

3.6

Other

59.6

31.0

1.8

3.8

19.3

59.1

19.3

7.0

Total

74.8

73.2

4.1

5.5

14.0

15.7

7.1

5.6

* Other health doctorate.

SOURCES: Comparison of Characteristics of U.S. Medical School Salaried Faculty in the Past Decade, 1968–1978, Publication No. NO1-OD-8-2116, Washington, D.C., U.S. Department of Health, Education, and Welfare, Public Health Service, 1979; Association of American Medical Colleges, U.S. Medical School Faculty, "The Numbers Book," Washington, D.C., Association of American Medical Colleges, 1989.

to the average clinical department in both the direction of change and the makeup of their faculty. Therefore, to the extent that the presence of faculty with basic science degrees indicates that departments are structured to undertake research, departments of OB/GYN are positioned to compete in the research arena.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

Age and Gender Composition of Faculties A body of empirical work, mainly pertaining to nonphysician scientists, suggests that there is at least a weak relationship between age and research productivity, as measured by publications.24 The best available data on physician investigators come from a 1980 survey by the Association of American Medical Colleges (AAMC), which queried physician faculty listed in its Faculty Roster System. The data were analyzed to determine variations in time spent in research and in numbers of publications as they relate to age.25 These data indicate that research productivity as measured by time spent in research does not peak at the same time as productivity measured by volume of publications. By both measures the latest peaks are at about 45 years of age.

Analysis of 1988 data from the AAMC Faculty Roster System (Table 2-5) indicates that the age distribution of physicians in departments of OB/GYN is similar to that of all physician clinical faculty. Indeed, the age distribution of the physician faculty of each of the five clinical departments analyzed is remarkably similar, suggesting that any differences in the research productivity of departments are not due to the age of physician faculty.

The relationship between gender and research activity is also unclear. Over the past decade, extensive note has been taken of the underrepresentation of women in the scientific work force and of differences in career trajectories for women in science compared with men.26 Women scientists in general publish roughly 50 percent fewer papers than male scientists of the same age, and differences in publication rates increase with age.27 This study, however, is concerned with academic scientists in general, and with physicians in particular—a segment of the scientific work force about which only a little is known.

During medical school, differences between men and women in their interest in research are slight. One study revealed that in 1987, the only activity during medical school in which men participated more than women was the authorship of published research—24 percent of men and 19 percent of women.28 Women lag only slightly in expressing an interest in having research as part of their career—of 1989 graduating medical students, 23.6 percent of the men and 21.2 percent of the women intended to take a research fellowship; 16.1 percent of the men and 13.5 percent of the women expected to be significantly involved in research.29 Evidently the discrepancies between men and women in this area appear after medical school.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

TABLE 2-5: Age Distribution of Physician Faculty (as Percentage of Departmental Faculty) of Selected Clinical Departments

 

Age

 

< 36

36–45

46–55

56–65

> 65

All Clinical Departments

13.8

41.4

25.7

15.1

4.0

OB/GYN

15.8

38.5

26.5

14.6

4.6

Internal Medicine

12.9

45.0

25.3

13.2

3.5

Psychiatry

13.8

38.5

25.0

18.0

4.7

Surgery

12.7

41.1

26.5

15.2

4.6

Pediatrics

13.1

47.0

24.6

12.6

2.7

Radiology

15.7

38.4

27.9

14.3

3.8

NOTE: Columns may not add to 100 due to rounding.

SOURCE: Special tabulation by Paul. J. Friedman, M.D., Professor of Radiology and Dean for Academic Affairs, University of California, San Diego; data taken from the Faculty Roster System, Association of American Medical Colleges.

Data on the advancement of women in academic medicine indicate that they have increased their representation in medical school faculty—from 13 percent in 1967 to 21 percent in 1990—and that female medical school graduates are more likely than their male equivalents to join medical school faculties. However, women advance more slowly through the faculty ranks: of the cohort of people who became faculty members in 1976, 25 percent of the men and 19 percent of the women were tenured or on a tenure track in 1987; 12 percent of the men were professors, as opposed to only 3 percent of the women.30

Clearly something is halting the progress of women through the academic ranks. One possibility is that, to the extent that academic advancement is based on research productivity, women are not equalling men. An analysis of internal medicine faculty members—the only available analysis of gender difference—indicated that in 1982 and 1983, 19 percent of men and 29 percent of women reported no research involvement; women were also less likely than men to have outside research funding and assigned research space.31 Moreover, 16 percent of the men and 29 percent of the women had not had research training, and 44 percent of the men and 55 percent of the women had not been the first author of an original article.32

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

However, a 1989 survey of physicians by the American Medical Association does not substantiate the notion of lesser research involvement by women: 2.8 percent of both male and female physicians in 1989 reported research as a major professional activity.33 Similarly, women who complete research training and apply for RO1 grants from NIH appear to be almost as accomplished as the men. Since 1980 women have averaged slightly poorer priority scores than men, but the difference in any one year was only from one to eight points, and in 1990 men and women had comparable success rates.34 On balance, however, the weight of the evidence suggests that women in science are generally less involved in research than are men (reasons for this axe discussed later in this report).

Table 2-6 substantiates the finding that women are clustered in lower level faculty positions. More importantly for this study, departments of OB/GYN have a substantially higher representation of women (23.7 percent)* than the average clinical department (19.6 percent). The only departments with a higher proportion of women faculty than OB/GYN are pediatrics, public health, and physical medicine; the proportion of women faculty in family medicine is similar to that of OB/GYN. In addition, nearly 55 percent of instructors in departments of OB/GYN are women; thus the future ranks of senior faculty will be pulled from a pool in which women axe in the majority.** The gender distribution in departments of OB/GYN is not likely to contribute in a major way to the current competitive weakness in OB/GYN research identified earlier in this chapter. However, this characteristic of OB/GYN departments suggests that attention to the needs of women seeking research careers would be an investment with a substantial return.

Research Intensiveness

How Much Time Do Faculty Members Spend Doing Research? A more direct indicator of the research strength of a department is the time faculty members spend in research activities. Unfortunately, data that would allow comparisons

*  

 ACOG survey data note that 29 percent of OB/GYN faculty are women. Again, the committee uses AAMC data since they allow comparisons with other departments.

**  

The pattern of NIH funding of women also indicates their increasing future role in research. Women hold about 18 percent of RO1 funds, 28 percent of FIRST awards, and 31 percent of NIH training grant funds (National Institutes of Health, Women in NIH Extramural Grant Program. Fiscal Years 1981 to 1990, Division of Research Grams, Bethesda, Md., 1991).

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

TABLE 2-6: Distribution of Medical School Faculty (as percentage of faculty at each level that are women) in Clinical Departments by Gender and Rank, 1989.

Department

Professor

Associate Professor

Assistant Professor

Instructor

Total

Anesthesiology

7.6%

17.9%

27.7%

26.0%

22.6%

Dermatology

7.9

16.3

35.5

36.8

21.5

Family Medicine

6.4

15.7

27.0

44.3

23.8

Internal Medicine

4.6

10.6

22.1

30.4

15.7

Neurology

5.0

16.3

19.7

34.5

15.8

OB/GYN

7.2

13.6

30.1

54.8

23.7

Ophthalmology

5.7

11.2

19.9

21.0

13.8

Orth. Surgery

0.9

7.5

10.2

21.2

8.1

Otolaryngology

2.2

14.8

22.4

49.1

17.1

Pathology (clinical)

8.9

19.6

30.0

43.9

21.6

Pediatrics

14.6

26.5

39.5

55.1

32.4

Phys. Medicine

12.1

30.6

36.9

49.5

34.1

Psychiatry

8.3

18.3

29.2

44.5

16.6

Public Health

12.1

20.7

40.0

55.1

30.1

Radiology

5.4

14.5

22.8

23.0

16.3

Surgery

1.6

5.9

12.6

20.5

8.1

Other Clinical

10.5

31.6

24.1

21.4

Total

6.3

15.0

25.7

37.0

19.6

 

SOURCES: Association of American Medical Colleges, U.S. Medical School Faculty, "The Numbers Book," Washington, D.C., Association of American Medical Colleges, 1989.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

among clinical departments are sparse. AAMC collects data on the activities of medical faculty, but only activities that consume more than 10 percent of a faculty member's time and without distinguishing between activities that consume, for example, 11 percent or 90 percent of time.

In 1983, to gain a better picture of medical faculty involvement in research, the Association of Professors of Medicine, in cooperation with AAMC, asked full-time faculty members in departments of internal medicine what percentage of time they spent in research.* In 1990, ACOG, at the request of this committee, added to its academic manpower survey a question asking whether faculty members spent 20 percent or more of their time in research. The results revealed that 34.5 percent of physician faculty (M.D. and M.D./Ph.D.) spent at least 20 percent of their time in research in 1990, compared with 45 percent of M.D. and 67 percent of M.D./Ph.D. internal medicine faculty, as recorded in the AAMC data for 1983. Ph.D. faculty in both internal medicine and OB/GYN departments are more involved in research than their M.D. colleagues6—90 percent of the internal medicine Ph.D faculty and 92 percent of the OB/GYN Ph.D. faculty spend at least 20 percent of theft time in research.35,36 Data from these two sources are not strictly comparable because of differences in sources of information and time of data collection and the difference between a specialty oriented toward surgical procedures and one oriented toward medicine. Nevertheless, the disparity between the two departments in research activity of physicians is suggestive. Departments of internal medicine, acknowledged leaders in research activity among clinical departments, appear to engage their physician faculty more heavily in research, which also reflects their relatively high success rate in competing for NIH funds (see above). The lesser involvement of OB/GYN in se h may also support the notion, current among OB/GYN leaders, that OB/GYN faculty maintain unusually large clinical practices.

Which Clinical Departments Are Research Intensive? The final characteristic examined here that may bear on the research capabilities of departments is the percentage of full-time faculty who are principal investigators on NIH or ADAMHA awards. This indicator functions as a proxy measure for the research intensity of departments. A 1988 AAMC study ranked departments of OB/GYN eleventh out of 17 clinical departments, with 9.8 percent of faculty as PIs, compared with an average of 14 percent for all clinical departments.

*  

 That study defined the following as active researchers: individuals who spend at least 20 percent of their time in research, who have authored or co-authored an original article or other significant research publication, and who have either external funding or assigned research space.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

Ophthalmology ranked first with 36.5 percent; family medicine was at the low end with 1.2 percent (Table 2-7).

As might be expected, research involvement varies by degree—11.1 percent of M.D.s, 24.3 percent of M.D./Ph.D.s, and 26.9 percent of Ph.D.s are PIs. Thus, M.D./Ph.D.s are generally more like Ph.D.s in their involvement in research. However, this generalization does not hold for OB/GYN. Both M.D. and M.D./Ph.D. faculty in departments of OB/GYN are below the average for clinical departments in the proportion of faculty that are Pis. On the other hand, Ph.D.s in departments of OB/GYN rank sixth of the 17 departments in the proportion that are PIs (32.2 percent) and are well above the 26.9 percent average.37 Clearly, to the extent that these data measure research intensity, departments of OB/GYN are among the less research-intensive departments, and their relative weakness in research capabilities can be attributed to the performance of their physicians.*

The research intensiveness of specialties can be analyzed on a different axis—the proportion of departments with significant outside research funding. There are two sources of data on this topic. The 1990 ACOG manpower survey revealed that only 9 of the nation's 136 academic departments of OB/GYN received more than $2 million in federal research funds. At the other end of the spectrum, 38 departments had no federal funds, and this number is larger for other sources of research funding.38

Data from NIH also indicate that research funding is clustered in a small number of departments. Between 1980 and 1989, approximately 70 departments of OB/GYN per year were recipients of NIH support. However, 10 departments received approximately 50 percent of the funds, and in 1989 only 4 departments had more than ten awards, while 15 had only one award. This concentration of funds in a small number of departments is somewhat more acute than generally occurs for NIH funds going to medical schools, where 20 schools received 50 percent of NIH funds in 1989.39

These indicators of research intensity suggest a weakness in departments of OB/GYN compared with other clinical departments, both in terms of the proportion of faculty that are PIs and in the concentration of research activity in a small number of departments. The existence of a critical mass of investigators is thought to be necessary to provide an environment in which science can thrive, and in which new investigators can be trained and exposed to role models in an atmosphere of scientific endeavor. These findings suggest

*  

 It should, however, be remembered that although NIH and ADAMHA are major sources of research funding, they are not the only sources. Data indicating the relative ability of departments to gamer other research support are not available, but departments of OB/GYN are thought to have relatively good access to pharmaceutical company research funds

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

that only a small number of departments of OB/GYN support a vital research effort or provide the necessary environment for the generation of new investigators.

TABLE 2-7: Ranking of Clinical Departments by Percentage of Full-Time Faculty Who Are PIs on NIH/ADAMHA Awards (1988).

 

Total Full-Time Faculty

M.D.

Department

No.

%PIs

No.

%PIs

Ophthalmology

1,014

36.5

650

25.7

Neurology

1,637

23.9

1,101

18.4

Dermatology

365

22.5

291

20.0

Internal Medicine

13,448

19.9

10,894

17.7

Pathology

1,152

17.0

656

13.9

Public Health

1,127

15.7

445

10.6

Other Clinical

69

14.5

21

19.0

Otolaryngology

543

14.2

296

6.4

Pediatrics

5,724

13.4

4,503

11.9

Psychiatry

5,244

12.1

2,858

8.1

OB/GYN

2,265

9.8

1,687

5.9

Surgery

5,031

9.5

4,038

7.0

Radiology

3,884

8.3

2,786

3.2

Orthopedic Surgery

730

7.8

569

4.4

Anesthesiology

2,649

3.5

2,186

1.6

Phys. Med/Rehab.

548

1.2

341

0.9

Family Medicine

1,539

1.2

1,127

0.7

Total/Average

45,969

14.0

34,449

11.1

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

 

M.D./Ph.D.

Ph.D.

Department

No.

%PIs

No.

%PIs

Ophthalmology

61

39.3

245

69.4

Neurology

148

37.8

315

35.6

Dermatology

22

40.9

43

34.9

Internal Medicine

875

31.1

1,261

33.9

Pathology

122

25.4

280

22.1

Public Health

48

14.3

472

25.0

Other Clinical

2

0.0

41

12.2

Otolaryngology

28

25.0

171

27.5

Pediatrics

275

28.4

614

21.8

Psychiatry

197

18.8

1,728

20.2

OB/GYN

126

13.5

320

32.2

Surgery

268

17.9

540

25.9

Radiology

169

13.6

696

29.0

Orthopedic Surgery

23

13.0

81

34.6

Anesthesiology

181

8.8

157

22.3

Phys. Med/Rehab.

18

5.6

97

6.2

Family Medicine

25

0.0

265

6.8

Total/Average

2,589

24.3

7,327

26.9

 

SOURCE: American Association of Medical Colleges, Medical School Faculty Roster (1988), linked with Information Management Planning, Analysis and Coordination records of research grants (NIH and ADAMHA) and contracts (NIH) that received funds during fiscal year 1987.

FINDING: Data pertinent to the present as well as the future research capabilities of OB/GYN departments indicate weakness. Time devoted to research by physicians is low, the proportion of faculty who are full-time investigators on NIH or ADAMHA grants is below average, and the number of departments with sizable research funding is small. The latter point indicates the small number of departments able to provide a suitable environment for training investigators. The strong and growing presence of women indicates that attention to differences among men and women in recruitment and retention in research will be important to the future health of the OB/GYN research enterprise. The committee's recommendations on these topics are found later in this report.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

A Research Agenda for Departments of OB/GYN

The research agenda (which is fully discussed in Chapter 6) provides a different sort of evidence of the need for expanded research efforts in OB/GYN, because it identifies areas of investigation likely to repay investment with improvements in the reproductive health of women and in the results of pregnancy.* To ensure that the research agenda fulfills its purposes, the following criteria were applied:

  • The research should contribute to the resolution of an important health problem. Importance can be defined in terms of high prevalence or incidence of a problem, in terms of the serious effect of the problem on individuals who experience it, or in terms of impact on the health care system where the costs of caring for the problem are incurred.

  • The research approach should be promising. That is to say, there is reason to think that following the selected avenue of investigation would provide solutions or that answering the question posed by the research is an essential step in finding a solution.

  • The research should be done in a department of OB/GYN or in collaboration with members of such departments. The mere fact that patients with OB/GYN should be a necessary element. Lack of interest by other specialties the problem are seen in OB/GYN departments is not sufficient justification. Rather, OB/GYN must be the discipline with the knowledge or skill needed to accomplish the research. If the research is interdisciplinary, would also be sufficient justification, since the work would not be accomplished if OB/GYN did not undertake it.

The committee followed several steps n developing the research agenda:

  • A letter was written to the chair of every U.S. and Canadian academic department of OB/GYN, asking for an opinion on priority areas for future research. Letters were also sent to leading OB/GYN professional associations. All committee members received copies of the replies, as well as a summary of the contents.

*  

 The research agenda developed by the committee does not stress the social, health care, and other cost savings that would be generated by research that eliminates or diminishes some of the problems listed. For instance, the high hospital costs of caring for low birthweight babies are only the tip of the iceberg of expenditures incurred as a result of the long-term morbidity and disability that are frequent sequelae.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×
  • A subgroup of the committee met to develop an initial list of research agenda topics, which was then reviewed, discussed, and revised by the full committee.

  • Taking into consideration the criteria listed above, committee members allocated priorities to each item on the research agenda, and items that received low priority scores were eliminated from the list.

  • Experts were asked to contribute background papers reviewing the current state of knowledge and identifying useful research approaches (see Appendix C for authors of background papers).

  • Using the background papers and their own expertise, committee members developed a research agenda. Readers are referred to Chapter 6 for the agenda, which covers the following topics:

    • Oocyte and follicular development in the ovary, including follicular formation; follicular atresia; follicular recruitment, selection, and dominance; corpus luteum function; and leukocytes, cytokines, and ovarian function.

    • Fertilization.

    • Fetal growth and development including embryology and congenital malformations; fetal growth and placental transport; congenital infection and substance abuse; perinatal research; and epidemiological research.

    • Preterm labor including preterm, premature rupture of the fetal membranes, complications of pregnancy that compromise fetal or maternal well-being independent of the onset of labor, preterm onset of labor, and preterm labor and infection.

    • Contraception including contraceptive implants, contraceptive rings, transdermal delivery, intrauterine devices (IUDs), oral conception, barrier methods, male contraception, antifertility vaccines, and medical abortifacients.

    • Infertility including epidemiology, cervical physiology and function, fallopian tube function, endometriosis, male infertility, and in vitro fertilization and new reproductive technologies.

    • Premenstrual syndrome.

    • The brain and reproduction.

    • Menopause.

    • Oncology including ovarian cancer, uterine neoplasms, cervical cancers, vulvar malignancies, breast cancer, and trophoblastic disease.

    • Sexually transmitted diseases including preventing sexually transmitted diseases by developing clinically effective and safe vaccines: developing cost-effective tests for early diagnosis of STDs; developing new therapies where needed and new cost-effective antibiotics that are easily administered and sufficiently acceptable to maximize compliance; clarifying the natural history of genital infections; defining behaviors associated with the acquisition and spread of STDs; and characterizing the role of STDs in adverse pregnancy outcomes.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

Conclusion

From its review of the evidence in this chapter, the committee concluded that there is cause for concern about both the current and the future state of research in departments of OB/GYN. While it is appropriate that many departments of OB/GYN have, and preserve, a clinical focus, it is important to expand the number of departments that can succeed in the competitive research arena. In that way the committee's research agenda can be accomplished, and departments of OB/GYN can fulfill their potential for improving the health of women. The committee concluded that the highest priority is to build physician research manpower so that more departments of OB/GYN can successfully compete for, and effectively use, increased research support. The committee therefore focused its recommendations on ways of recruiting and sustaining OB/GYNs in investigative careers and on developing research capabilities in departments that, with some additional help, have the potential to equal the first-rank research departments of OB/GYN. Recommendations are found earlier in this chapter and in subsequent chapters of this report.

No one entity bears the responsibility for this effort; rather, players to implement the committee's recommendations are to be found at NIH, in the departments of OB/GYN, in other loci in the medical schools, in foundations, and, importantly, in the profession of OB/GYN itself from which must flow the leadership that is a prerequisite to the development of a strong research community in OB/GYN.

References

1. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology July 1991; 78(1):141–143.

2. Letters to the committee from chairmen of departments of obstetrics and gynecology.

3. Center for Population Research, National Institute of Child Health and Human Development, Bethesda, Md., Inventory and Analysis of Private Agency Population Research, 1984–1985. June 1988.

4. Longo, Lawrence D. Preparing for the Twenty-first Century in the Reproductive Sciences. Appendix A, this volume.

5. Telephone interview with Thomas H. Meikle, Jr., President, Josiah Macy Jr. Foundation, New York, New York, May 1991.

6. Haseltine, Florence P., and Campbell, Arthur A. The Impact of Fellowships Supported by the Andrew W. Mellon Foundation. Center for Population Research, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md., March 26, 1986.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

7. Longo, Lawrence D. Preparing for the Twenty-First Century in the Reproductive Sciences. Appendix A, this volume.

8. Telephone interviews with Carolyn Makinson. Program Associate for Population, The Andrew W. Melton Foundation, New York, New York, 1990–1991.

9. Institute of Medicine. Funding Health Sciences Research. A Strategy to Restore Balance, ed. Floyd Bloom and Mark Randolph. Washington, D.C.: National Academy Press, 1990.

10. Barinaga, Marcia. The Foundations of Research. Science 1991; 235:1200–1202.

11. Robert F. Creasy, Professor and Chairman, Department of Obstetrics and Gynecology and Reproductive Sciences, University of Texas Health Sciences Center at Houston, personal communication, July 1990.

12. American College of Obstetricians and Gynecologists. Fellowships and Awards. Wallin, D.C.: American College of Obstetricians and Gynecologists. January, 1991.

13. Longo, Lawrence D. Preparing for the Twenty-First Century in the Reproductive Sciences. Appendix A, this volume.

14. Ibid.

15. Institute of Medicine. Funding Health Sciences Research: A Strategy to Restore Balance, ed. Floyd Bloom and Mark Randolph. Washington, D.C.: National Academy Press, 1990, p. 57.

16. Kretchmer, Norman. Support of Academic Obstetrics: The Public Sector. In: The Current Status and Future of Academic Obstetrics. Report of a Conference Supported Jointly by the National Institute of Child Health and Human Development and the Josiah Macy, Jr. Foundation. ed. John Z. Bowers and Elizabeth F. Purcell. New York, New York: Josiah Macy Jr. Foundation, 1980.

17. Ibid.

18. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology July 1991; 78(1)141–143.

19. Walkington, Robert A. National Institutes of Health Support of Research in Departments of Obstetrics and Gynecology. Appendix B, this volume.

20. National Institutes of Health. The K Awards. Division of Research Grants, Bethesda, Md., undated, p. 59.

21. National Institutes of Health. Clinical Investigator Development Award. NIH Guide July 19, 1991; 20(28):6–10.

22. Vaitukaitis, Judith L. The Future of Clinical Research. Clinical Research 1991; 39(2):145–1561.

23. Herman, Samuel S., and Singer, Allen M. Basic Scientists in Clinical Departments of Medical Schools. Clinical Research 1986; 34:149–158.

24. See, for example, Levin, Sharon, G., and Stephan, Paula E. Age and Research Productivity of Academic Scientists. Research in Higher Education 1989; 30(5):531–549.

25. Sherman, C. R. et al. On the Status of Medical School Faculty and Clinical Research Manpower: 1968–1998. A report to the Clinical Sciences Panel of the Committee on a Study of National Needs for Biomedical and Behavioral Research Personnel, National Academy of Sciences, National Research Council. NIH Publication No. 82-2458. 1981, Bethesda, Md.: 1981. National Institutes of Health, Office of Program Planning and Evaluation, 1981.

26. National Research Council. Women: Their Underrepresentation and Career Differentials in Science and Engineering: Proceedings of a Conference, ed. Linda S. Dix. Washington, D.C.: National Academy Press, 1987.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
×

27. Zuckerman, H. Persistence and Change in the Careers of Men and Women Scientists and Engineers: A Review of Current Research. In: Dix, L. S. ed., Women: Their Underrepresentation and Career Differentials in Science and Engineering: Proceedings of a Conference. Washington, D.C.: National Academy Press, 1987.

28. Bickel, Janet. Women in Medical Education. A Status Report. New England Journal of Medicine 1988; 319:1579–1584.

29. Bickel, Janet. Unpublished tabulation from 1989 Medical Student Graduation Questionnaire. Association of American Medical Colleges, Washington, D.C.

30. Bickel, Janet. Women in Medical Education. A Status Report. New England Journal of Medicine 1988; 319:1579–1584.

31. Ibid.

32. Ibid.

33. Roback, Gene, et al. Physician Characteristics and Distribution in the U.S. Chicago, Illinois: American Medical Association, 1990.

34. National Institutes of Health. DRG Peer Review Trends Workload and Actions of DRG Study Sections, 1980–1990. Bethesda, Md.: Division of Research Grants, p. 81.

35. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology 1991; 78(1):141–143.

36. Gentile, Nancy O., et al. Research Activity of Full-Time Faculty in Departments of Medicine. Washington, D.C.: Association of Professors of Medicine and Association of American Medical Colleges, 1987.

37. Sherman, Charies R. Summary of 1987 NIH and ADAMHA Research Support to U.S. Medical Schools, by Academic Department and Degree of Principal Investigator. Bethesda, Md.: National Institutes of Health, Office of the Director, May 1. 1989.

38. Pearse, Warren H., and Graham, Kathleen K. Trends in Obstetric-Gynecologic Academic Manpower and Research. Obstetrics and Gynecology 1991; 78(1):141–143.

39. National Institutes of Health. Extramural Trends, FY 1980–1989. Bethesda, Md.: Division of Research Grants, Information Systems Branch, August 1990.

Suggested Citation:"2 IS THERE A PROBLEM?." Institute of Medicine. 1992. Strengthening Research in Academic OB/GYN Departments. Washington, DC: The National Academies Press. doi: 10.17226/1970.
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Research conducted in academic departments of obstetrics and gynecology could result in substantial improvements in the health of women and the outcomes of pregnancy.

Strengthening Research in Academic OB/GYN Departments determines whether such departments are capable of fulfilling this promise. The committee finds that these departments have a poor track record in their ability to compete for research funds and in the extent to which their faculty contribute to research. Adding to the problem are factors that deter OB/GYNs from a research career and a dearth of dynamic research leaders in the profession.

The volume explores reasons for this situation and makes recommendations to counteract them. Also included is an agenda of needed research.

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