E. Albert Reece, MD, PhD, MBA, the dean of the University of Maryland School of Medicine, Baltimore, and medical editor of Ob.Gyn. News, has spoken often in the newspaper’s pages about how the fetus has become a visible and intimate patient – one who, “like the mother, can be interrogated, monitored, and sometimes treated before birth.”
Physician-scientists have been instrumental in lifting the cloud of mystery that surrounded the fetus and fetal outcomes. Yet today, in a trend that Dr. Reece and his colleagues call deeply concerning, the number of physician-scientists is declining. “We’re missing out on a workforce that is dedicated to exploring the biologic basis of disease – knowledge that enables the development of targeted therapeutic interventions,” he said in an interview.
Notable Yale physician-scientist alumni have been honored over the years as part of the YOGS meetings, including John C. Hobbins, MD, a former division head of maternal-fetal medicine and a pioneer of ultrasound imaging in the field of obstetrics and gynecology; Roberto Romero, MD, DMedSci, chief of the Perinatology Research Branch at the National Institute of Child Health and Human Development, and editor-in-chief of the American Journal of Obstetrics and Gynecology; and Charles J. Lockwood, MD, dean of the University of South Florida’s Morsani College of Medicine, Tampa, and a former chair of Yale’s ob.gyn. department.
As this year’s honoree, Dr. Reece spoke about the importance of inspiring a new generation of physician-scientists not only within colleges and universities, but also by reaching out to younger students to spark interest in science and research. He recalled being a postdoctoral fellow in perinatology at Yale in the 1980s and being inspired by Dr. Hobbins, whom he credits as his mentor, as well as Dr. Romero, who was finishing his fellowship at Yale while Dr. Reece was beginning his fellowship.
Yale’s department of ob.gyn. and its division of maternal-fetal medicine have had a long history of “firsts” and seminal contributions, including the first ultrasound-guided fetal blood sampling and transfusions in the United States, invention of the fetal heart monitor, the first karyotype in amniotic fluid, the development of postcoital contraception and of methods for early detection of ectopic pregnancies, the discovery of endometrial stem cells and the role that endocrine-disrupting chemicals play in the developmental programming of the uterus, and discovery of the role of cytokines in premature labor and fetal injury.
According to current department chair, Hugh S. Taylor, MD, the 1980s and 1990s were a particularly “exciting time.” Under the tutelage of Dr. Hobbins, who directed both obstetrics and maternal-fetal medicine, obstetrical ultrasound was fast advancing, for instance, and fetoscopy was drawing patients and other physician-scientists from around the world.
“It was an unbelievable time – a magnetic period when many of the things we now take for granted were first being introduced,” said Dr. Reece, who went on after his fellowship to serve as an instructor in ob.gyn. (1982-4), assistant professor (1984-7), and then associate professor (1987-91) at Yale. “It was like going to the symphony and getting to choose the best seat in the house to see the rehearsals all the way through the concert.”
After leaving the Yale faculty and prior to joining the University of Maryland School of Medicine, Dr. Reece served as the chair of obstetrics and gynecology at Temple University School of Medicine, Philadelphia, and then vice chancellor and dean of the University of Arkansas College of Medicine, Little Rock. “Dr. Reece is an incredible bulldog,” said Dr. Hobbins, speaking of the honor given to Dr. Reece at the YOGS meeting. “We could see this right at the beginning at Yale. He latches into something and won’t let it go. He has a work ethic that’s remarkable ... He’s always thinking, ‘How can this be done better?’ ”
Dr. Hobbins, who went on after Yale to a tenure at the University of Colorado at Denver, Aurora, told Ob.Gyn. News that what he remembers “more than anything else, is that we would sit down in a room and just kind of spitball – just brainstorm.”
It is this intellectual curiosity and scientific drive that seems increasingly at risk of being lost, Dr. Hobbins said. “There’s not the same impetus to do a fellowship or to become a physician-scientist or pursue an MD-PhD,” he said. “There just doesn’t seem to be the same oomph to get into the nuts and bolts of how things work, to explore and understand the science. Yes, it has to do with funding. But there’s more to it: We have to somehow stimulate more fire in the belly.”
Dr. Lockwood, who served his fellowship in maternal-fetal medicine at Yale under the guidance of Dr. Hobbins, Dr. Reece, and other faculty, and who later chaired the Yale department of ob.gyn. for 9 years, said that research-rich environments that are “full of inquiry” drive better clinical care.
“The same rigor [gets] applied to the clinical enterprise. Where evidence-based medicine is applicable, it’s done ... and where there are gaps in knowledge, there’s a real spirit of research and inquiry to try to improve care,” Dr. Lockwood said in an interview. “All the great stuff in our health care system is really a direct correlate with the fact that we’ve had this extraordinary research enterprise for so long – most of it funded by the National Institutes of Health, either directly or indirectly.”
The University of Maryland requires all its medical students to take a course in research and critical thinking and to complete a research project. It also runs programs for young students such as a “mini medical school” for underprivileged children who live in nearby neighborhoods. “If you get them excited about science early, and you keep the research continuum going, we believe you’ll have a better chance of recruiting committed physician-scientists into the field,” Dr. Reece said.
The infection has “become an important issue because 10%-20% of women who receive an epidural develop a fever and many of these babies have to have a septic workup and antibiotic treatment,” he said in an e-mail after the meeting. ”Our data indicate that antibiotic administration is not indicated in 40% of cases and the antibiotics currently used do not cover frequent organisms causing infection.”
Dr. Hobbins, who has been using sophisticated imaging techniques to assess subtle changes in fetuses with growth restriction, spoke about the potential value of cardiac size as an indicator of cardiac dysfunction. In utero cardiac dysfunction “sets the tone” for later cardiovascular and neurologic function, he told Ob.Gyn. News. “We think that you can use cardiac size in small babies as a screening tool to tell you whether you need to delve a little further into cardiac function ... Let’s get away from old protocols and rethink other things that are going on in the [small] fetus. Let’s cast a wider net.”
Dr. Lockwood has long been investigating the prevention of recurrent pregnancy loss and preterm delivery, and at the meeting he presented March of Dimes–funded research aimed at identifying mechanisms for dysfunction of the progesterone receptor in premature birth.
Dr. Reece spoke about his research on diabetes in pregnancy and birth defects, and how years of research on diabetes-induced birth defects has shown that maternal hyperglycemia is a teratogen that can trigger a series of developmental fetal defects. “We now have enough information such that we truly have a biomolecular map regarding the precise steps and cascading events which lead to the induction of diabetes-induced birth defects,” said Dr. Reece, who holds a PhD in biochemistry and directs a multimillion-dollar NIH-funded research laboratory at the University of Maryland.
This research began when Dr. Reece asked a question during his fellowship at Yale. “I was struck by the number of birth defects I saw in women with diabetes. I asked Jerry Mahoney, one of the geneticists: Do we know the cause of this? Why is this happening?” he recalled in the interview. “Dr. Mahoney took me to his office, opened his file cabinet and showed me some papers of an [in-vitro rat embryo model], where the rats were made diabetic and the serum seemed to have a way of inducing these birth defects in the embryo. That intrigued me immensely and I thought: I can do this!”
Dr. Reece got his feet wet in an embryology laboratory. As he moved on after his fellowship to join the faculty at Yale, he began directing his own research team – the Diabetes-in-Pregnancy Study Unit.
Dr. Romero said this was the start of “many important contributions to optimize the care of pregnant women with diabetes.” Dr. Reece, he said, has been “able to dissect the role of oxidative stress, program cell death, and lipid metabolism in the genesis of congenital anomalies” in babies of mothers with diabetes.
In other talks at the YOGS meeting, Yale alumnus Ray Bahado-Singh, MD, of Oakwood University, Rochester, Mich., addressed the epigenetics of cardiac dysfunction and the “new frontier” of using epigenetic markers to assess fetal cardiac function. Frank A. Chervenak, MD, of Cornell University, New York, rounded out the meeting by addressing the issue of professionalism and putting the patient first, as well as the professional virtues of self-sacrifice, compassion, and integrity – themes that Dr. Reece frequently cites as integral to both practice and research in ob.gyn.
Clinical care and “the research we’re all doing to assess fetal health both directly and indirectly has to be sitting on a platform of moral, ethical, and solid principles,” said Dr. Reece, who authored a special feature for Ob.Gyn. News – “,” on the recent history of obstetrics.
Mary Jane Minkin, MD, a Yale alumna of many levels (medical school through residency) and a longtime Yale faculty member and private-practice ob.gyn. in New Haven, Conn., noted that the YOGS meeting was attended by the 94-year-old Virginia Stuermer, MD, who joined Yale’s ob.gyn. department in 1954 and who is “celebrated within the department” for defying legal barriers to provide patients with contraception and services. “She wanted to come see Dr. Reece,” said Dr. Minkin, who has served as director of YOGS since its inception.
Dr. Stuermer was running the Planned Parenthood clinic in New Haven the day in 1961 when then-department chair Charles Lee Buxton, MD, and Connecticut Planned Parenthood League executive director Estelle Griswold were arrested and jailed. “Everyone knows about the Supreme Court decision, Griswold v. Connecticut , that legalized contraception in the U.S.,” said Dr. Minkin. “But most don’t realize that the doctor who was actually fitting the diaphragms that day was Dr. Stuermer.”
The YOGS reunion preceded a symposium held early in June commemorating the 100-year anniversary of women at Yale Medical School.