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A renaissance in reproductive endocrinology and infertility
A renaissance in reproductive endocrinology and infertility Robert L. Barbieri, M.D. Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts
Assisted reproductive technology (ART) is catalyzing a renaissance in reproductive endocrinology and infertility (REI), manifested by the rapid growth of new technologies, such as intracytoplasmic sperm injection, oocyte cryopreservation, preimplantation genetic manipulation of embryos, and embryonic stem cell biology. Because of advances in ART, REI will be a vibrant and growing discipline, both in academic and independent practice settings, for many decades. (Fertil Steril威 2005;84:576 –7. ©2005 by American Society for Reproductive Medicine.)
A “renaissance” is a period of vigorous artistic and intellectual activity. Arguably, we are in the midst of a renaissance in reproductive endocrinology and infertility (REI). Never before has so much new technology and translational research been generated in a field related to obstetrics and gynecology in such a short period. The renaissance in REI is being catalyzed by assisted reproductive technology (ART). Advances in ART, such as intracytoplasmic sperm injection, oocyte cryopreservation, preimplantation genetic diagnosis, and embryonic stem cell biology are major catalysts for this renaissance. The future for REI, both in academic practice and independent practice, is exceptionally positive. Dr. Soules’ thesis (1) is that there are serious systematic problems within academic REI programs and that ART has contributed to these problems. In his article, he lists a number of operational problems that are not specific to academic REI but are challenges for many procedure-based specialties. For example, inefficient billing systems, unnecessary layers of administrative bureaucracy, and excessive institutional overhead are not problems unique to REI programs but rather are problems that can systematically undermine the performance of all types of clinical practice, in both academic and nonacademic settings. Reproductive endocrinology and infertility faculty complain about these problems, but so do cardiologists, orthopedic surgeons, and dermatologists. It is important for the leaders of medical centers to ensure that administrative functions are highly efficient and effectively support the practice of busy clinicians. If they do not, then successful clinicians, especially those who are procedure-based, will migrate to better practice settings. Of all the fields of medicine, the migration to better and more efficient practice settings seems to be most intense in the field of orthopedics, for which orthopedic hospitals have arisen throughout the country.
Received February 11, 2005; revised and accepted February 11, 2005. Reprint requests: Robert Barbieri, M.D., Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115 (FAX: 617-277-1440; E-mail: rbarbieri@ partners.org).
576
Some of the problems listed by Dr. Soules (1) are specific to REI. For example, in many obstetrics and gynecology residency programs, rotations on REI are much shorter than they were 15 years ago. Consequently, there is minimal contact between REI faculty and obstetrics and gynecology residents. This can create a gulf between them, thereby reducing job satisfaction for REI faculty dedicated to teaching residents. However, there are many teaching opportunities for REI specialists in departments of obstetrics and gynecology, including such leadership roles as the medical student clerkship director, the residency program director, or the associate program director. Specialists in REI often take lead roles in teaching medical students and residents about such diseases as endometriosis, myomas, and ectopic pregnancy. In addition, there are unlimited opportunities for academic REI specialists to participate in teaching by leading or participating in continuing medical education courses and writing clinical articles. The super-specialization in REI, much of it caused by ART, has created some distance between REI divisions and the main general obstetrics and gynecology faculty within academic departments. Dr. Soules (1) is concerned that REI specialists in academic departments might have low morale. However, some surveys of obstetrician– gynecologists report that clinicians in academic practice settings are slightly more satisfied with their careers than physicians in private practice settings (2, 3). Not every practice setting is prepared to take full advantage of the potential of ART. For example, in some state university systems, key ART personnel, including nurses, administrative assistants, and embryologists, are unionized. Consequently, specialized work rules might make it difficult to efficiently manage a 7-day-per-week clinical operation, such as an ART program. These difficult problems are dwarfed by the great potential in ART. In addition, in some academic settings, institutional leadership has not recognized the importance of REI and the critical role it plays in ensuring the success of the institution’s maternal–fetal medicine practice, genetics practice, and neonatal intensive care unit.
Fertility and Sterility姞 Vol. 84, No. 3, September 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2005.02.047
Research in academic medical centers has tended to become more “professionalized,” with most research being performed by scientists with at least a 75% commitment to their research programs. It is very difficult to maintain momentum in a research program unless the key personnel spend the vast majority of their time nurturing the research. Physicians who allocate 75% of their time to clinical practice and 25% to research can be successful with clinical research, especially if they collaborate with full-time investigators. There are great opportunities for research in REI because the field is evolving so rapidly and because the biology of reproduction is so rich with research possibilities. A major challenge to physicians committing 75% of their time to research is that, in general, research faculty is compensated at a lower rate than clinical faculty. For example, in 2002– 2003, the Association of American Medical Schools reported that the median salary for an associate professor was $90,000 in basic sciences and $201,000 in obstetrics and gynecology (4). Many clinicians are not enthusiastic about targeting their compensation to the range earned by full-time research faculty. My thesis is that the practice of REI in all settings— academic and independent practice—will flourish during the next 50 years because of scientific and technical advances in ART. Rather than being a detrimental factor, ART is an important catalyst for the expansion of REI programs. For example, advances in ART technology, such as intracytoplasmic sperm injection, oocyte cryopreservation, preimplantation genetic diagnosis, and embryonic stem cell biology, will continue to generate additional indications for REI interventions requiring the training of additional REI specialists and creating exciting growth within the field. In addition, these novel technologies drive the growth of translational research programs. The contrast in the optimism and vigor displayed by REI specialists vs. general obstetrician– gynecologists is great. At national meetings of REI specialists morale is high, and it is clear that the field is growing and healthy from both a clinical and translational research perspective. In contrast, at meetings of general obstetrician– gynecologists morale seems low, and there is significant concern that the professional liability issues will make it difficult to practice. The professional liability risk is at least 100% greater for obstetricians than for reproductive endocrinologists. In some surveys, one in seven general obstetrician– gynecologists reported that they have closed their obstetric practices because of stress in the practice environment. I know of very few certified reproductive endocrinologists who have completely closed their practices because of harsh practice conditions. The greatest problem in 21st century medicine is hidden from the view of most patients and physicians. The greatest problem in 21st century medicine is the nationwide lack of sufficient capital for investment in clinical and research program development, major equipment, and construction. The lack of adequate capital in medicine is best demonstrated by the shocking shortage of hospital beds that has
Fertility and Sterility姞
developed in the United States. In an environment plagued by inadequate capital, many academic medical centers are refocusing their efforts on core programs that are capable of generating the significant positive margins necessary to accrue more capital. These core programs often include cardiovascular care, oncology, and neurosciences. In a “capitalstarved” environment, many important programs will be short-changed and will not receive the equipment, space, and program development funds they rightly deserve to be vibrant and successful. This is a general problem that affects many medical practices but which might be especially problematic for REI, for which capital needs are great. It is important for departments of obstetrics and gynecology to make every effort to secure the capital resources necessary for the success of an academic REI program. Luckily, in many academic centers, grateful patients and their families are willing to provide donations that help to sustain the capital needs of an REI program. Here is a thought experiment for academic leaders in obstetrics and gynecology: would you prefer that ART programs be housed within the department of obstetrics and gynecology, or would you prefer that ART programs be housed within the department of urology or the division of endocrinology in the department of medicine? Reproductive endocrinology and infertility, both in academic and independent practice settings, will continue to attract the best and the brightest in obstetrics and gynecology. During the most recent fellowship match, there were more than three highly qualified applicants for every fellowship position. Why is REI attracting so many high-quality candidates for fellowship? Because REI is a vibrant and growing field. The advanced scientific technology used in the field, especially the technology associated with ART, is highly attractive to residents considering careers in a gynecology specialty. The outstanding translational research opportunities are very attractive to residents considering clinical research careers. It is clear that with imagination and a strong work ethic, every obstetrician– gynecologist can be sure to have a long and rewarding professional career, either in academic or independent private practice, if they choose to complete a fellowship in REI. Reproductive endocrinology and infertility is healthy and growing in both academic centers and independent practice. REFERENCES 1. Soules MR. Assisted reproductive technology has been detrimental to academic reproductive endocrinology and infertility. Fertil Steril 2005; 84:570 –2. 2. Kravitz RL, Leigh JP, Samuels SJ, Schembri M, Gilbert WM. Tracking satisfaction and perceptions of quality among U.S. obstetricians and gynecologists. Obstet Gynecol 2003;102:463–70. 3. Horger EO. Practice activities and career satisfaction among fellows of the South Atlantic Association of Obstetricians and Gynecologists. Am J Obstet Gynecol 1993;169:239 – 44. 4. Association of American Medical Colleges. Report on medical school faculty salaries, 2002-2003. Washington DC: Association of American Medical Colleges, 2004.
577
Assisted reproductive technology (ART) is catalyzing a renaissance in reproductive endocrinology and infertility (REI), manifested by the rapid growth of new technologies, such as intracytoplasmic sperm injection, oocyte cryopreservation, preimplantation genetic manipulation of embryos, and embryonic stem cell biology. Because of advances in ART, REI will be a vibrant and growing discipline, both in academic and independent practice settings, for many decades. (Fertil Steril威 2005;84:576 –7. ©2005 by American Society for Reproductive Medicine.)
A “renaissance” is a period of vigorous artistic and intellectual activity. Arguably, we are in the midst of a renaissance in reproductive endocrinology and infertility (REI). Never before has so much new technology and translational research been generated in a field related to obstetrics and gynecology in such a short period. The renaissance in REI is being catalyzed by assisted reproductive technology (ART). Advances in ART, such as intracytoplasmic sperm injection, oocyte cryopreservation, preimplantation genetic diagnosis, and embryonic stem cell biology are major catalysts for this renaissance. The future for REI, both in academic practice and independent practice, is exceptionally positive. Dr. Soules’ thesis (1) is that there are serious systematic problems within academic REI programs and that ART has contributed to these problems. In his article, he lists a number of operational problems that are not specific to academic REI but are challenges for many procedure-based specialties. For example, inefficient billing systems, unnecessary layers of administrative bureaucracy, and excessive institutional overhead are not problems unique to REI programs but rather are problems that can systematically undermine the performance of all types of clinical practice, in both academic and nonacademic settings. Reproductive endocrinology and infertility faculty complain about these problems, but so do cardiologists, orthopedic surgeons, and dermatologists. It is important for the leaders of medical centers to ensure that administrative functions are highly efficient and effectively support the practice of busy clinicians. If they do not, then successful clinicians, especially those who are procedure-based, will migrate to better practice settings. Of all the fields of medicine, the migration to better and more efficient practice settings seems to be most intense in the field of orthopedics, for which orthopedic hospitals have arisen throughout the country.
Received February 11, 2005; revised and accepted February 11, 2005. Reprint requests: Robert Barbieri, M.D., Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115 (FAX: 617-277-1440; E-mail: rbarbieri@ partners.org).
576
Some of the problems listed by Dr. Soules (1) are specific to REI. For example, in many obstetrics and gynecology residency programs, rotations on REI are much shorter than they were 15 years ago. Consequently, there is minimal contact between REI faculty and obstetrics and gynecology residents. This can create a gulf between them, thereby reducing job satisfaction for REI faculty dedicated to teaching residents. However, there are many teaching opportunities for REI specialists in departments of obstetrics and gynecology, including such leadership roles as the medical student clerkship director, the residency program director, or the associate program director. Specialists in REI often take lead roles in teaching medical students and residents about such diseases as endometriosis, myomas, and ectopic pregnancy. In addition, there are unlimited opportunities for academic REI specialists to participate in teaching by leading or participating in continuing medical education courses and writing clinical articles. The super-specialization in REI, much of it caused by ART, has created some distance between REI divisions and the main general obstetrics and gynecology faculty within academic departments. Dr. Soules (1) is concerned that REI specialists in academic departments might have low morale. However, some surveys of obstetrician– gynecologists report that clinicians in academic practice settings are slightly more satisfied with their careers than physicians in private practice settings (2, 3). Not every practice setting is prepared to take full advantage of the potential of ART. For example, in some state university systems, key ART personnel, including nurses, administrative assistants, and embryologists, are unionized. Consequently, specialized work rules might make it difficult to efficiently manage a 7-day-per-week clinical operation, such as an ART program. These difficult problems are dwarfed by the great potential in ART. In addition, in some academic settings, institutional leadership has not recognized the importance of REI and the critical role it plays in ensuring the success of the institution’s maternal–fetal medicine practice, genetics practice, and neonatal intensive care unit.
Fertility and Sterility姞 Vol. 84, No. 3, September 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2005.02.047
Research in academic medical centers has tended to become more “professionalized,” with most research being performed by scientists with at least a 75% commitment to their research programs. It is very difficult to maintain momentum in a research program unless the key personnel spend the vast majority of their time nurturing the research. Physicians who allocate 75% of their time to clinical practice and 25% to research can be successful with clinical research, especially if they collaborate with full-time investigators. There are great opportunities for research in REI because the field is evolving so rapidly and because the biology of reproduction is so rich with research possibilities. A major challenge to physicians committing 75% of their time to research is that, in general, research faculty is compensated at a lower rate than clinical faculty. For example, in 2002– 2003, the Association of American Medical Schools reported that the median salary for an associate professor was $90,000 in basic sciences and $201,000 in obstetrics and gynecology (4). Many clinicians are not enthusiastic about targeting their compensation to the range earned by full-time research faculty. My thesis is that the practice of REI in all settings— academic and independent practice—will flourish during the next 50 years because of scientific and technical advances in ART. Rather than being a detrimental factor, ART is an important catalyst for the expansion of REI programs. For example, advances in ART technology, such as intracytoplasmic sperm injection, oocyte cryopreservation, preimplantation genetic diagnosis, and embryonic stem cell biology, will continue to generate additional indications for REI interventions requiring the training of additional REI specialists and creating exciting growth within the field. In addition, these novel technologies drive the growth of translational research programs. The contrast in the optimism and vigor displayed by REI specialists vs. general obstetrician– gynecologists is great. At national meetings of REI specialists morale is high, and it is clear that the field is growing and healthy from both a clinical and translational research perspective. In contrast, at meetings of general obstetrician– gynecologists morale seems low, and there is significant concern that the professional liability issues will make it difficult to practice. The professional liability risk is at least 100% greater for obstetricians than for reproductive endocrinologists. In some surveys, one in seven general obstetrician– gynecologists reported that they have closed their obstetric practices because of stress in the practice environment. I know of very few certified reproductive endocrinologists who have completely closed their practices because of harsh practice conditions. The greatest problem in 21st century medicine is hidden from the view of most patients and physicians. The greatest problem in 21st century medicine is the nationwide lack of sufficient capital for investment in clinical and research program development, major equipment, and construction. The lack of adequate capital in medicine is best demonstrated by the shocking shortage of hospital beds that has
Fertility and Sterility姞
developed in the United States. In an environment plagued by inadequate capital, many academic medical centers are refocusing their efforts on core programs that are capable of generating the significant positive margins necessary to accrue more capital. These core programs often include cardiovascular care, oncology, and neurosciences. In a “capitalstarved” environment, many important programs will be short-changed and will not receive the equipment, space, and program development funds they rightly deserve to be vibrant and successful. This is a general problem that affects many medical practices but which might be especially problematic for REI, for which capital needs are great. It is important for departments of obstetrics and gynecology to make every effort to secure the capital resources necessary for the success of an academic REI program. Luckily, in many academic centers, grateful patients and their families are willing to provide donations that help to sustain the capital needs of an REI program. Here is a thought experiment for academic leaders in obstetrics and gynecology: would you prefer that ART programs be housed within the department of obstetrics and gynecology, or would you prefer that ART programs be housed within the department of urology or the division of endocrinology in the department of medicine? Reproductive endocrinology and infertility, both in academic and independent practice settings, will continue to attract the best and the brightest in obstetrics and gynecology. During the most recent fellowship match, there were more than three highly qualified applicants for every fellowship position. Why is REI attracting so many high-quality candidates for fellowship? Because REI is a vibrant and growing field. The advanced scientific technology used in the field, especially the technology associated with ART, is highly attractive to residents considering careers in a gynecology specialty. The outstanding translational research opportunities are very attractive to residents considering clinical research careers. It is clear that with imagination and a strong work ethic, every obstetrician– gynecologist can be sure to have a long and rewarding professional career, either in academic or independent private practice, if they choose to complete a fellowship in REI. Reproductive endocrinology and infertility is healthy and growing in both academic centers and independent practice. REFERENCES 1. Soules MR. Assisted reproductive technology has been detrimental to academic reproductive endocrinology and infertility. Fertil Steril 2005; 84:570 –2. 2. Kravitz RL, Leigh JP, Samuels SJ, Schembri M, Gilbert WM. Tracking satisfaction and perceptions of quality among U.S. obstetricians and gynecologists. Obstet Gynecol 2003;102:463–70. 3. Horger EO. Practice activities and career satisfaction among fellows of the South Atlantic Association of Obstetricians and Gynecologists. Am J Obstet Gynecol 1993;169:239 – 44. 4. Association of American Medical Colleges. Report on medical school faculty salaries, 2002-2003. Washington DC: Association of American Medical Colleges, 2004.
577