- Email: [email protected]
The need for flexibility in preparing clinician-scientists for academic careers
778 Willson
and to recommend action steps that might be appropriate for the Society; (2) that a morning session during each annual meeting be devoted to discussion of a specific topic that concerns academic departments; (3) that the members of the Committee on Graduate Education and of the Program Committee cooperate in selecting the issue to be considered and in developing the program; and (4) that knowledgeable individuals, not necessarily Fellows of the American Gynecological and Obstetrical Society, be invited to prepare position papers to be presented and discussed during the session and that the papers and discussions be considered for publication with the scientific papers. We also recommended that the first such session be developed for the 1985 meeting and that the subject be "Flexibility in obstetric-gynecologic residencies: why is it necessary?" Obviously, the Council approved the suggestion. Finally, I should like to thank the members of both Committees who worked so diligently and effectively in gathering information on the issues and for their assistance in preparing the final reports. I also thank Drs. Jaffe and Hendricks for agreeing to prepare and present the papers today and to Drs. Merrill and Pitkin for their responses. They obviously share the concerns of the committee members.
The need for flexibility in preparing clinician-scientists for academic careers Robert B. Jaffe, M.D. San Francisco, California
Academic obstetrics and gynecology is not realizing its potential. With reproductive sciences at the cutting edge of contemporary biology, and with increased numbers of outstanding, highly motivated and well-educated physicians choosing careers in obstetrics and gynecology, the discipline is not attracting a commensurate increase in the numbers of these highly qualified individuals into the academic research component of the specialty. The reasons for this are many and varied. They include: (1) lack of sufficient, appropriate role models during house officer training; (2) a negative perception of the com-
From the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: Robert B. Jaffe, M.D., Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94143.
April,1986 Am J Obstet Gynecol
petitive and political aspects of academic medicine; (3) the discrepancy in income between academic medicine and private practice; (4) inadequate exposure to, and hence inadequate appreciation of, the intellectual excitement of academic investigative pursuits; and (5) inflexibility in the training programs in obstetrics and gynecology in most academic centers. It is these latter two interrelated factors that will be the focus of much of this discussion. Although the majority of comments will be directed toward residency training, the discussion will be extended briefly to a consideration of the need for flexibility in fellowship training as well. In many of the constituent disciplines of reproductive medicine and biology, reproductive science is, or should be, at the forefront. For example, in the field of endocrinology, over half of the articles in the two leading American endocrinologic journals deal with some facet of reproductive endocrinology. In the field of oncology, in which studies concerning normal and abnormal cell and tissue growth, oncogenes, and other aspects of cell biology have captured the imagination of fundamental biologists, gynecologic oncology has the opportunity to make meaningful strides. To a great degree, this potential has not as yet been realized. There are no academic obstetrician-gynecologists currently in the National Academy of Sciences, only three in the Institute of Medicine, and just two in the Association of American Physicians, and tellingly, none are members of the American Society for Clinical Investigation, the "Young Turks," who are under 45. In part because of (1) the excitement of contemporary reproductive biology, (2) a concern with important social issues, and (3) the attraction of being involved with both medical and surgical aspects of a discipline, as well as for a variety of other reasons, obstetrics and gynecology programs are attracting some of the brightest and best graduates of leading medical schools. Many of these individuals have had extensive research experience before beginning their house officer training. Yet relatively few pursue meaningful, academic investigative careers following their training. Of individuals who started Board-approved subspecialty fellowships that could have been completed before 1984, approximately 60% have full-time academic appointments. However, the number competing successfully for National Institutes of Health grants is very low compared to other academic disciplines. For example, in fiscal years 1983 and 1984, approximately 10% of National Institute of Child Health and Human Development extramural funding went to Departments of Obstetrics and Gynecology. Approximately half of the awardees held M.D. or M.D. and Ph.D. degrees. Thus about 5% of the awards of the National Institute of Child Health and Human Development and only 6% of its funds went to obstetrician-gynecologists. Of the total National
Volume 154 Number 4
Flexibility in academic obstetric-gynecologic residencies
Institutes of Health extramural budget, only 0.8% went to obstetrician-gynecologists. Although various forms of scholarship are essential, it seems clear that there needs to be greater emphasis on productive research as an integral part of a greater number of academic departments of obstetrics and gynecology. Several barriers exist for the pursuit of such research training. They include lack of significant exposure to contemporary research for the 4 years of residency training in many programs; a lack of first-hand experience in research by many of the leaders in obstetrics and gynecology; the presence of role models during residency training who spend most of their time in the clinical practice of obstetrics and gynecology; the additional time that would be required to satisfy subspecialty board requirements; and, for the individual with a strong research background, the 4-year period during which it is extremely difficult to keep current in and excited by contemporary investigative biology. For these reasons we proposed several years ago an alternate residency training program for selected individuals who were contemplating academic careers and who had significant previous research experience. This program, in which at least two individuals would have to be contemporaneously enrolled for logistic purposes, would intertwine clinical training and research during a 6-year period. It would involve primarily clinical residency training during the first 2 to 3 years following medical school. Thereafter, a year would be spent in the laboratory and, in the case of reproductive endocrinology, in gaining expertise in the clinical aspects of endocrinology and infertility. After this the individual would complete his or her clinical and research training in a manner sufficient to qualify both for the general boards in obstetrics and gynecology and, for those areas in which subspecialty boards are offered, in those subspecialty areas as well. Although there is a limited number of centers in which such a program could be established now, this number can and should be expanded if the model is successful. In my view the advantages of such a program are several: (1) the individual could stay in closer contact with the scientific aspects of the discipline without having to wait 4 years to renew that contact; (2) he or she would be guaranteed funding in advance for the fellowship experience as well as the residency; (3) research projects could be begun which could be continued dur-
suing traditional 4-year training programs; (2) loss of some continuity in clinical training and experience; (3) decrease in the development of the camaraderie that occurs as an individual goes through training with the same group of individuals; and (4), unless these are additional positions rather than just substitute positions, antagonism and jealousies by other house officers. Although these disadvantages are real, in my view the advantages markedly outweigh the disadvantages. However, the parent American Board of Obstetrics and Gynecology has not seen fit to give approval to such a program other than on a case-by-case basis. This is not feasible, since an applicant needs to know in advance, before making a decision about the location of his or her training program, that such an option would be available. In addition, program directors have to make decisions in advance so that they can plan appropriately for their training programs. It would seem that just as programs are approved for specialty and subspecialty training, selected programs also could be approved for this alternative form of training. Two examples might be illustrative. Our house officer training program has had two individuals in it, both of whom had similar backgrounds and both of whom showed excellent promise for academic careers. Both had pursued M.D.-Ph.D. programs in medical school and had obtained their Ph.D. degrees in one of the foremost molecular endocrinology laboratories in the country. The first of these individuals, who completed his training 3 years ago, went through the conventional residency training program. He performed extremely well and, for several reasons, entered private practice at the conclusion of his training. His mentor in the laboratory in which he obtained his doctorate said that he was one of the most promising graduate students he had ever trained. While he is performing in an excellent fashion in clinical practice, there is a high likelihood that he also would have had a brilliant career in academic obstetrics and gynecology. The second individual, with a similar background, is the first to be pursuing the modified program which I described previously. On completion of his fellowship training, he will enter a faculty position in which, I predict, he will have a very productive career. Although there is no assurance that the first individual would have elected an academic career were he to have enrolled in the alternative pathway, it is my view that this would have enhanced the chances of his doing so. Since there is a great need for exciting, well-trained clinician-investigators in academic departments of obstetrics and gynecology throughout the country, and since traditional training programs do not appear to be meeting this need, this alternative track seems worthy of trial in selected institutions. With regard to fellowship training, it appears that
ing the remainder of the individual's training period; (4), and perhaps most important, the individual would have continued stimulus to pursue an investigative academic career. The disadvantages to such a program include the following: (1) difficulties in scheduling rotations that would integrate these individuals with residents pur-
779
780
Jaffe
greater flexibility also might be beneficial if individuals are to be prepared for productive, academic research careers. Many of the current obstetric-gynecologic leaders in reproductive research pursued training programs that would be proscribed by current guidelines of the subspecialty boards. Thus, while many spent 1 or 2 years in a laboratory either abroad or in a basic science department in the United States, these are not components of "approved" programs of the current subspecialty disciplines. Furthermore, extensive clinical requirements, for example, the need for reproductive endocrinologists to train in tubal microsurgery and in vitro fertilization, and the large amounts of time in clinical pursuits mandated in fetal and maternal medicine and oncology mitigate against obtaining the requisite training to pursue an independent, productive, and competitive research-oriented career-and the discipline sorely needs this facet of the specialty better represented. Although I was not personally involved, the activity of this Society of which I have been most supportive and proud has been the creation ofthe Kennedy-Dannreuther fellowships. They furnish tangible evidence of the Society's commitment to training investigators in the reproductive sciences. To maximize these opportunities, the greatest possible program flexibility needs to be encouraged and facilitated.
Experience with flexibility in an academic residency program Charles H. Hendricks, M.D. Chapel Hill, North Carolina
During my tenure as Director of the Residency Program in Obstetrics and Gynecology at the University of North Carolina at Chapel Hill, from 1968 through 1980, seven principles served as guidelines. All of these principles are important, but the first two were absolutely critical in our residency management during those years: 1. The residency exists primarily to serve the developmental needs of the resident and not the service needs of the hospital where he is being trained. From the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: Charles H. Hendricks, M.D., Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 214 MacNider Building 202H, Chapel Hill, NC 27514.
April, 1986 Am J Obstet Gynecol
2. Education is not neatly confined within the white picket fence of any institution nor tidily contained within a classical school year. The University should be thought of as a universal idea rather than as an institution. The strategy of utilizing the University should allow for rearranging the boundaries of time and geography where such adaptations can aid in the development of a single individual's career. 3. A residency should be considered to be a vital, demanding, prolonged postgraduate academic experience. Treating a residency training program as a trade school program demeans both the resident and the residency. 4. Ideally, residency experiences should be designed to help the person reach toward his highest aspirations for his own development. It is unrealistic to design a residency program to produce only academicians or only practitioners. Having high aspirations for a fulltime academic career is no more worthy than having high aspirations for a successful career in private practice. S. The individualization of resident care is just as important as the individualization of patient care. 6. Both the resident and the residency benefit by having some input by the resident, in the design of his own learning program. 7. It is manifestly impossible for the resident to "learn" obstetrics and gynecology during a 4-year period. Rather than "learning" the field, the resident should be learning intellectual inquiry and disciplined study methods that will qualify him as a life-long student in his chosen field. Only in this way can he hope to avoid boredom, obsolescence, and professional decay.
Strategies The residents were selected through the usual selection mechanisms except for those who joined the program at an irregular time. We made provision for accepting as early starters, and therefore early finishers, those individuals who had completed their medical school requirements for the M.D. degree sooner than their fellows had done. During 12 of the years under study here, the resident applicants were encouraged to have some input into their own curriculum, designed to advance their personal goals. Their elective programs were determined partly by their requests and partly by suggestions offered by the faculty. There was no requirement that any resident would have to perform any research. We did take care, however, to provide opportunities for research, which we enthusiastically aided and abetted. If one applies seriously and logically all of the precepts listed above, it is perfectly apparent that there
and to recommend action steps that might be appropriate for the Society; (2) that a morning session during each annual meeting be devoted to discussion of a specific topic that concerns academic departments; (3) that the members of the Committee on Graduate Education and of the Program Committee cooperate in selecting the issue to be considered and in developing the program; and (4) that knowledgeable individuals, not necessarily Fellows of the American Gynecological and Obstetrical Society, be invited to prepare position papers to be presented and discussed during the session and that the papers and discussions be considered for publication with the scientific papers. We also recommended that the first such session be developed for the 1985 meeting and that the subject be "Flexibility in obstetric-gynecologic residencies: why is it necessary?" Obviously, the Council approved the suggestion. Finally, I should like to thank the members of both Committees who worked so diligently and effectively in gathering information on the issues and for their assistance in preparing the final reports. I also thank Drs. Jaffe and Hendricks for agreeing to prepare and present the papers today and to Drs. Merrill and Pitkin for their responses. They obviously share the concerns of the committee members.
The need for flexibility in preparing clinician-scientists for academic careers Robert B. Jaffe, M.D. San Francisco, California
Academic obstetrics and gynecology is not realizing its potential. With reproductive sciences at the cutting edge of contemporary biology, and with increased numbers of outstanding, highly motivated and well-educated physicians choosing careers in obstetrics and gynecology, the discipline is not attracting a commensurate increase in the numbers of these highly qualified individuals into the academic research component of the specialty. The reasons for this are many and varied. They include: (1) lack of sufficient, appropriate role models during house officer training; (2) a negative perception of the com-
From the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: Robert B. Jaffe, M.D., Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94143.
April,1986 Am J Obstet Gynecol
petitive and political aspects of academic medicine; (3) the discrepancy in income between academic medicine and private practice; (4) inadequate exposure to, and hence inadequate appreciation of, the intellectual excitement of academic investigative pursuits; and (5) inflexibility in the training programs in obstetrics and gynecology in most academic centers. It is these latter two interrelated factors that will be the focus of much of this discussion. Although the majority of comments will be directed toward residency training, the discussion will be extended briefly to a consideration of the need for flexibility in fellowship training as well. In many of the constituent disciplines of reproductive medicine and biology, reproductive science is, or should be, at the forefront. For example, in the field of endocrinology, over half of the articles in the two leading American endocrinologic journals deal with some facet of reproductive endocrinology. In the field of oncology, in which studies concerning normal and abnormal cell and tissue growth, oncogenes, and other aspects of cell biology have captured the imagination of fundamental biologists, gynecologic oncology has the opportunity to make meaningful strides. To a great degree, this potential has not as yet been realized. There are no academic obstetrician-gynecologists currently in the National Academy of Sciences, only three in the Institute of Medicine, and just two in the Association of American Physicians, and tellingly, none are members of the American Society for Clinical Investigation, the "Young Turks," who are under 45. In part because of (1) the excitement of contemporary reproductive biology, (2) a concern with important social issues, and (3) the attraction of being involved with both medical and surgical aspects of a discipline, as well as for a variety of other reasons, obstetrics and gynecology programs are attracting some of the brightest and best graduates of leading medical schools. Many of these individuals have had extensive research experience before beginning their house officer training. Yet relatively few pursue meaningful, academic investigative careers following their training. Of individuals who started Board-approved subspecialty fellowships that could have been completed before 1984, approximately 60% have full-time academic appointments. However, the number competing successfully for National Institutes of Health grants is very low compared to other academic disciplines. For example, in fiscal years 1983 and 1984, approximately 10% of National Institute of Child Health and Human Development extramural funding went to Departments of Obstetrics and Gynecology. Approximately half of the awardees held M.D. or M.D. and Ph.D. degrees. Thus about 5% of the awards of the National Institute of Child Health and Human Development and only 6% of its funds went to obstetrician-gynecologists. Of the total National
Volume 154 Number 4
Flexibility in academic obstetric-gynecologic residencies
Institutes of Health extramural budget, only 0.8% went to obstetrician-gynecologists. Although various forms of scholarship are essential, it seems clear that there needs to be greater emphasis on productive research as an integral part of a greater number of academic departments of obstetrics and gynecology. Several barriers exist for the pursuit of such research training. They include lack of significant exposure to contemporary research for the 4 years of residency training in many programs; a lack of first-hand experience in research by many of the leaders in obstetrics and gynecology; the presence of role models during residency training who spend most of their time in the clinical practice of obstetrics and gynecology; the additional time that would be required to satisfy subspecialty board requirements; and, for the individual with a strong research background, the 4-year period during which it is extremely difficult to keep current in and excited by contemporary investigative biology. For these reasons we proposed several years ago an alternate residency training program for selected individuals who were contemplating academic careers and who had significant previous research experience. This program, in which at least two individuals would have to be contemporaneously enrolled for logistic purposes, would intertwine clinical training and research during a 6-year period. It would involve primarily clinical residency training during the first 2 to 3 years following medical school. Thereafter, a year would be spent in the laboratory and, in the case of reproductive endocrinology, in gaining expertise in the clinical aspects of endocrinology and infertility. After this the individual would complete his or her clinical and research training in a manner sufficient to qualify both for the general boards in obstetrics and gynecology and, for those areas in which subspecialty boards are offered, in those subspecialty areas as well. Although there is a limited number of centers in which such a program could be established now, this number can and should be expanded if the model is successful. In my view the advantages of such a program are several: (1) the individual could stay in closer contact with the scientific aspects of the discipline without having to wait 4 years to renew that contact; (2) he or she would be guaranteed funding in advance for the fellowship experience as well as the residency; (3) research projects could be begun which could be continued dur-
suing traditional 4-year training programs; (2) loss of some continuity in clinical training and experience; (3) decrease in the development of the camaraderie that occurs as an individual goes through training with the same group of individuals; and (4), unless these are additional positions rather than just substitute positions, antagonism and jealousies by other house officers. Although these disadvantages are real, in my view the advantages markedly outweigh the disadvantages. However, the parent American Board of Obstetrics and Gynecology has not seen fit to give approval to such a program other than on a case-by-case basis. This is not feasible, since an applicant needs to know in advance, before making a decision about the location of his or her training program, that such an option would be available. In addition, program directors have to make decisions in advance so that they can plan appropriately for their training programs. It would seem that just as programs are approved for specialty and subspecialty training, selected programs also could be approved for this alternative form of training. Two examples might be illustrative. Our house officer training program has had two individuals in it, both of whom had similar backgrounds and both of whom showed excellent promise for academic careers. Both had pursued M.D.-Ph.D. programs in medical school and had obtained their Ph.D. degrees in one of the foremost molecular endocrinology laboratories in the country. The first of these individuals, who completed his training 3 years ago, went through the conventional residency training program. He performed extremely well and, for several reasons, entered private practice at the conclusion of his training. His mentor in the laboratory in which he obtained his doctorate said that he was one of the most promising graduate students he had ever trained. While he is performing in an excellent fashion in clinical practice, there is a high likelihood that he also would have had a brilliant career in academic obstetrics and gynecology. The second individual, with a similar background, is the first to be pursuing the modified program which I described previously. On completion of his fellowship training, he will enter a faculty position in which, I predict, he will have a very productive career. Although there is no assurance that the first individual would have elected an academic career were he to have enrolled in the alternative pathway, it is my view that this would have enhanced the chances of his doing so. Since there is a great need for exciting, well-trained clinician-investigators in academic departments of obstetrics and gynecology throughout the country, and since traditional training programs do not appear to be meeting this need, this alternative track seems worthy of trial in selected institutions. With regard to fellowship training, it appears that
ing the remainder of the individual's training period; (4), and perhaps most important, the individual would have continued stimulus to pursue an investigative academic career. The disadvantages to such a program include the following: (1) difficulties in scheduling rotations that would integrate these individuals with residents pur-
779
780
Jaffe
greater flexibility also might be beneficial if individuals are to be prepared for productive, academic research careers. Many of the current obstetric-gynecologic leaders in reproductive research pursued training programs that would be proscribed by current guidelines of the subspecialty boards. Thus, while many spent 1 or 2 years in a laboratory either abroad or in a basic science department in the United States, these are not components of "approved" programs of the current subspecialty disciplines. Furthermore, extensive clinical requirements, for example, the need for reproductive endocrinologists to train in tubal microsurgery and in vitro fertilization, and the large amounts of time in clinical pursuits mandated in fetal and maternal medicine and oncology mitigate against obtaining the requisite training to pursue an independent, productive, and competitive research-oriented career-and the discipline sorely needs this facet of the specialty better represented. Although I was not personally involved, the activity of this Society of which I have been most supportive and proud has been the creation ofthe Kennedy-Dannreuther fellowships. They furnish tangible evidence of the Society's commitment to training investigators in the reproductive sciences. To maximize these opportunities, the greatest possible program flexibility needs to be encouraged and facilitated.
Experience with flexibility in an academic residency program Charles H. Hendricks, M.D. Chapel Hill, North Carolina
During my tenure as Director of the Residency Program in Obstetrics and Gynecology at the University of North Carolina at Chapel Hill, from 1968 through 1980, seven principles served as guidelines. All of these principles are important, but the first two were absolutely critical in our residency management during those years: 1. The residency exists primarily to serve the developmental needs of the resident and not the service needs of the hospital where he is being trained. From the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine. Presented at the Fourth Annual Meeting of the American Gynecological and Obstetrical Society, Hot Springs, Virginia, September 4-7, 1985. Reprint requests: Charles H. Hendricks, M.D., Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 214 MacNider Building 202H, Chapel Hill, NC 27514.
April, 1986 Am J Obstet Gynecol
2. Education is not neatly confined within the white picket fence of any institution nor tidily contained within a classical school year. The University should be thought of as a universal idea rather than as an institution. The strategy of utilizing the University should allow for rearranging the boundaries of time and geography where such adaptations can aid in the development of a single individual's career. 3. A residency should be considered to be a vital, demanding, prolonged postgraduate academic experience. Treating a residency training program as a trade school program demeans both the resident and the residency. 4. Ideally, residency experiences should be designed to help the person reach toward his highest aspirations for his own development. It is unrealistic to design a residency program to produce only academicians or only practitioners. Having high aspirations for a fulltime academic career is no more worthy than having high aspirations for a successful career in private practice. S. The individualization of resident care is just as important as the individualization of patient care. 6. Both the resident and the residency benefit by having some input by the resident, in the design of his own learning program. 7. It is manifestly impossible for the resident to "learn" obstetrics and gynecology during a 4-year period. Rather than "learning" the field, the resident should be learning intellectual inquiry and disciplined study methods that will qualify him as a life-long student in his chosen field. Only in this way can he hope to avoid boredom, obsolescence, and professional decay.
Strategies The residents were selected through the usual selection mechanisms except for those who joined the program at an irregular time. We made provision for accepting as early starters, and therefore early finishers, those individuals who had completed their medical school requirements for the M.D. degree sooner than their fellows had done. During 12 of the years under study here, the resident applicants were encouraged to have some input into their own curriculum, designed to advance their personal goals. Their elective programs were determined partly by their requests and partly by suggestions offered by the faculty. There was no requirement that any resident would have to perform any research. We did take care, however, to provide opportunities for research, which we enthusiastically aided and abetted. If one applies seriously and logically all of the precepts listed above, it is perfectly apparent that there