Obstetricians know the statistics—1 out of every 10 babies is born premature; preeclampsia affects 1 in 25 pregnant people; the United States has the highest rate of maternal mortality in the developed world. Yet, physicians and scientists still do not fully understand the biology of normal pregnancy, let alone what causes these complications. Obstetrics and gynecology-trained physician-scientists are uniquely positioned to fill critical knowledge gaps by addressing clinically-relevant problems through fundamental research and interpreting insights from basic and translational studies in the clinical context. Within our specialty, however, physician-scientists are relatively uncommon. Inadequate guidance, lack of support and community, and structural barriers deter fellows and early stage faculty from pursuing the physician-scientist track. One approach to help cultivate the next generation of physician-scientists in obstetrics and gynecology is to demystify the process and address the common barriers that contribute to the attrition of early stage investigators. Here, we review major challenges and propose potential pathways forward in the areas of mentorship, obtaining protected research time and resources, and ensuring diversity, equity, and inclusion, from our perspective as early stage investigators in maternal-fetal medicine. We discuss the roles of early stage investigators and leaders at the institutional and national level in the collective effort to retain and grow our physician-scientist workforce. We aim to provide a framework for early stage investigators initiating their research careers and a starting point for discussion with academic stakeholders. We cannot afford to lose the valuable contributions of talented individuals due to modifiable factors or forfeit our voices as advocates for the issues that impact pregnant populations.
Introduction
Adverse pregnancy-related outcomes are rising in the United States. One in 10 infants is born preterm. Hypertensive disorders of pregnancy are diagnosed in about 9% of birthing people, which amounts to >300,000 affected pregnancies per year. Disturbingly, the US maternal mortality rate is not improving, and exceeds that of the most developed countries. , These concerning trends in reproductive health outcomes affect individuals across all communities and sociodemographic backgrounds, but disproportionately impact Black and Indigenous people, who are 2 to 3 times more likely to die from pregnancy-related causes than White individuals. Despite the urgent need to address these longstanding issues, we have failed to materially improve reproductive health outcomes owing largely to: (1) gaps in our understanding of normal pregnancy biology and disease mechanisms, and (2) underinvestment in women’s health research. Failure to prioritize basic and translational research in obstetrics jeopardizes our ability to develop effective preventive, diagnostic, and therapeutic strategies for pregnancy complications and to reverse the trends in adverse outcomes.
Physician-scientists trained in obstetrics and gynecology are positioned to understand and address unmet needs in women’s health and reproductive biology. Those who pursue subspecialty training have an opportunity to focus on building their research interests and career beginning in the fellowship years. Subspecialty training coupled with scientific rigor, knowledge of biology, and advanced methods provides the foundation for the clinical translation of bench discoveries. Researchers with advanced training in population health and epidemiology are also needed. Yet, the pathway to recruit and support obstetrics and gynecology-trained physician-scientists remains ill-defined and poorly supported.
The total number of early stage investigators in obstetrics and gynecology is unclear. However, available data suggest a relative dearth of scientists in the field. National Institutes of Health (NIH) data, for example, show that departments of obstetrics and gynecology receive far fewer career development awards than all of the other major specialties ( Figure 1 , A). Furthermore, the number of obstetrics and gynecology K08 and K23 awardees has remained modest and largely unchanged over the past decade ( Figure 1 , B).
While fast-tracked physician-scientist training programs are well-established in internal medicine and pediatrics, similar tracks do not exist in obstetrics and gynecology. This may be 1 reason why so few US MD-PhD graduates pursue postgraduate training in obstetrics and gynecology compared with other major specialties ( Figure 1 , C). , The fraction of MD-PhD fellows in obstetrics and gynecology subspecialties is also relatively small. In 2019, for instance, 6% of maternal-fetal medicine (MFM) fellows were MD-PhDs compared with 14% of hematology-oncology fellows. These surrogate estimates are limited in that they do not include the other funding mechanisms for early stage investigators, and MD-PhD data do not capture all the physician-scientists nor do all MD-PhDs pursue a research career. Still, these data reveal a need to prioritize the development of early stage investigators within obstetrics and gynecology departments, which receive <1% of NIH funding overall. There has indeed been a renewed call to support the “endangered physician-scientist” at the national level, and efforts in our field to expand the perinatal biology physician-scientist workforce. Nevertheless, more work is needed to recruit and retain the next generation of researchers.
Here, we describe the challenges facing early stage investigators from our perspective as MFM physician-scientists. We identify the following major areas for early stage investigators and obstetrics and gynecology leaders to consider and address when investing in a research career: mentorship; protected research time and resources; and diversity, equity, and inclusion (DEI) ( Figure 2 ). Our objectives are to voice the perspectives of early stage investigators and to optimize the academic environment to enable their success, given that the future of our field depends on a robust physician-scientist workforce.
We anticipate that many of the themes presented herein will resonate broadly but acknowledge that this commentary cannot fully address the experiences and specific issues germane to other subspecialties, in particular the heavily surgical subspecialties (gynecologic oncology, female pelvic medicine and reconstructive surgery, and minimally-invasive gynecologic surgery) which have their own unique set of concerns. Although we focus on the needs of lab-based researchers here, supporting early stage investigators on the clinical research track is an equally important goal, and much of the discussion will apply to them as well.
For obstetrics and gynecology fellows and junior faculty interested in a research-focused career, figuring out how to get started is the first hurdle. Early stage investigators rely on support and guidance from others, but are ultimately responsible for navigating their own careers. In Table 1 , we provide a reference for early stage investigators—the checklist we wish we had. Ideas for how department leaders, institutions, professional organizations, and the NIH can support early stage investigators are presented in Table 2 .
| Fellowship and Transition to Faculty |
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| Early faculty (years 1–2) |
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| Stakeholders | Mentorship | Protected time and resources | DEI |
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| Department leaders and institutions |
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| Professional organizations |
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| NIH |
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