Education of the obstetrician-gynecologist

EDUCATION DANIEL

OF THE

OBSTETRICIAN-GYNECOLOGIST+

GREEN MORTON, M.D., Los ANGELES,

CALIF.

l3 AXE a motley crew, you and I. Some of us are obstetricians, some are gynecologists, and some are both. A few of us are infertility experts almost exclusively, and a number of us are really female endocrinologists. Others of US emphasize the surgical aspects of our specialty while a few of us scarcely touch the knife. Some of us are cancer specialists and a few of us arc pathologists. We have arrived at our respective accomplishments by many and devious routes; we are the products of all manner of different training p’ograllls. Whether we should be a more homogeneous lot I am not prepared to WY, but because of our varied character there is little wonder that there is SO much confusion regarding the desirable training program for qualification as an obstetrician-gynecologist. There are many, both within our ranks and without, who believe that the combination of obstetrics and gynecology is illogical and impractical. They point out that if one is to be well qualified in gynecology one should have a considerable surgical background. Such a man should be prepared to deal with a large variety of bowel and urological conditions as well as with t,hc gamut, of genital lesions. On the other hand if one is to be a top-flight obstetrician he must have spent a good deal more than a year or two dealing with the many obstetrical complications. The critics of combined obstetrics and gynecology believe that adequate bilateral tra.ining, to the extent rncntioned, is well-nigh impossible. They also point out that from the practice point of view the unpredictability of obstetrics frequently interferes with surgical efficiency, particularly if an operating room schedule is to be met, as is usually the case. Those who believe that obstetrics and gynecology should remain wedded rttaintain that the problems of the reproductive function cannot be art~ificiall~ divi(led if the best of medical care is to be accorded our women. They feel that t,hose who are brought up exclusively in one of the disciplines oft,en fail to apprec.iate the implications of the other, a.nd thus do not see the [)ict,ure whole. Whichever point of view one has, there is no doubt whatever that. many ljroblems exist in providing an adequate education in both branches of the specialty in a reasonable length of time. Great problems are also posed by the dearth of facilities for adequate education in both fields, lmrticularly under one roof, for the large mml~er of men who seek to qualify t,hemselves as I)esl)it,e these perplesit,ies the majority of the ohs.1 et,rician-gynecologists. lea.clers in our specialty appear to favor a combined program of education. as

W

*Address of the quest Speaker, presented at the Twenty-third Annual Meeting of the Central Association of Obstetricians and Gynecologists, Columbus, Ohio, Oct. 6, 7, and 8, 1955. 043

A10I~7’0.s

944

Ini

i (11 , I\ atom. \L, 111;.

I sII~III S~~O\Vlater. TI~PI*P is IOSS VOII(.C~I*II;Is to \\-ll(Jthrr t11~ ~I*ZI~LI~~C~S(11’tli~ss~n I)t~)gtxrns later c*Ilc)ost~ 10 litnit their [Il’ilC’liC’C’S 10 ol~stetk~s. of’ III cyLlv+~tlog>.. 01’ to tlo both. The chnract~er of the rcGclc>nt training ~~r~~~tx~trs. whethrr stimulating :111ti rt>warding in clinical opportunity or 1101. has ati illlI)ortant boaring 111x)11f hct and resideli1.s and, iti ;~tltl i;ittracti\reness 01’ 0111' speciilItJ* t0 stu~lrflt s, interlis. tion. is of great interest to all ol’ us lb(‘(IiIllS? thv cluality of I’ntUrP olrstc~tric% zll1~1gynecologp in Anlrricn clcpencls lwrgc~l\u1~11t ihc~ir colltent. I should like to give you some oi’ the high lights of an in\;estigatiou ot resident, training programs it1 the lTjlit.ecl States which was carried out clnriux the last year by a subcommittee (of ;I ~ommitt~ec~ appointed by the ,4mrric;It1 Gynecological Society to inrtstigatc* t’wCt,ors in\-olvecl in the attraction oi talented mcln to the specialty of obstetrics-gynecology 1 consisting of Drs. (‘onrad C’ollins, Robert Kitnhrough. (‘II:1 t-l(as JIc~lirt~nan. William Mcnger+. William Dieckmann, ant1 m?;scll’. I f’cc~l 1lrat this information is ot’ inttArc4 ;I tI(I may bc of VillllC to all oi’ 11s l)w:llIsc~ it girc3 11s a t’t3tnc 0U rtfercllc*c~ nlltl IY~Hc‘c~ls T I~~oposc tltc~ to comrm’nt npo11 SOIIIC 01 prcseii t l.llori~lit and arrang:rmcnts. tlrc fcatnres discussed and to add my own views. 1\h~ Oi’ YOU ltR\.C’ rcwivc~cl ii copy of a. report on the infarmatmt obtained tluring 1ht. invcstigatiott trill others of you Iiavc not. The investigation was carried out by means of a (]uestionnnirc~. (~lrc~ri(~(i u-ere all 71 active fonr-year medical schools in the TTnitcd S,t,ates, am1 12 lnryt~ hospitals not directly affilia.tecl with mctlic~al schcmls. Replies wcbt.t* roc~c4vcti from 64 of the former and 34 of the latter. With regard to internships, t,he majority, in both university atrtl 11onuniversity hospitals favored a rotating internship, and indeed a fexv stilt(ls require an internship of this character. In a. ilozc9 or more instancrs othc~r internships wclre regarded as acceptable. such as internships in mc4ciltc. pathology, surgery, or straight obstetrics and gynecology. Jn 5 instnnrcs :I surgical internship was reported as required. Only 4 indicr,tecl that, they rvqnired il straight internship in obstetrics and gynecology. Nine indica,tr%(l that “ any good illternship” was acceptable. The breakdown into universit,y ;rntl non-univcrsitservices is shown in Table J. From this information I gathrrcd thilt thercb is no great concern over internships becanse the first )‘(‘;I I’ oI’ assistant residency is depended upon to acdcomplish t,he kind of n~imt;ltiOll and experienctl in the specialty which is ordinarily crpcctcd from an illttlrllship. Opinion iIl~l)enrctl to 1)~ a.bont. cclttully divicfcrl ;IS to whether tllcl ;rIlc,li t,ion of the straight internship in ohstc~tt,i,,s-fiync:c.c,Ir,~~ \votlItl I)ro\.cL ;I tjtit pj I)leltt, to th(x :Il)ility to attract residents in hospitals whrrc stra,ight itlt(~t*ltsIlil,,~ cxsistetl oil otlir~r services. ‘rART.1:

I.

~67’J~:1;65111,‘S ~-

7~.vI\-EKs,‘r\

Ilotatlng Straight Straight Any

ol)stetrics-~pne~~loa!surgery ~00~1

intfmwhip

Nl~h~I~S1~1:,:5,‘,‘\

-z-----z

Lm )

‘I’, WA

53 12 5

.I- > .5 .>

51 1; ;

ii

I,

!I

I

‘1’11~ Ic~tlgih of thr tarsidcnt ttxilliflg I)rcjgram \\‘ils IIIIY~(~ ~-t~;lI~s ot* 1,1()1*(,ill all 0F thcl university clinic3 responding, illId in dJ c’SctsJ?f -f of Ihe tlott-lt?liv(~t.sity hospitals (TabJc TI) . Whether t,his l-ennre e\~olvcd I)ccausc~ it basils c,)rlsidered most desirable or because of the requirements of the Americ!an Board of Obstetrics and Gynecology is not entirely clear. In 22 of the university and 7 of the non-university services, however, a fonr-year program was r,‘-

biilume

71

N~lntlm 5

EDUCATION

OI”

OHXTE’L’Rl~‘lhh’-~;YN~~~O~~OC;1S1

!I45

ported, and in 8 others fifth or sixth years were offered or required. 111 .L(j additional instances the rcsl)ondents iltdicated t,hat they desired or had plans l’or a four-year program to replace their present three-year course. Among the universities iherc were two outstanding csamplcs of separate depa~tmcnt,s, c)lYWing an integrated program in which the residelits are trained predominantly in obstet,rics or in gynecology, but l~rcsun~ably receive an sdequstc t txining in the related discipline as well (Johns llopkins and Harvard). Most. of those who have a program of more than four years indicated that the additional years were designed especially to give added opportunities to men who might wish to pursue an academic career. ln only 4 instances (all nonlinivcrsity) were programs devoted to obstetrics or gynecology alone reportecl. TABLE

Threevears Three ‘and one-half I’onr -fears Rlore t,han four T-ears I’ius special add”itions

II.

LRKGTH

OFRESILIENCY PHOGRM

~SIW

1

There was a considerable dift’erence of opinion as to whelher the strnc2tul.c. CICthe program should he a parallel or a pyramidal one (Table 1II). The Inajority favored the parallel system. The pyramidal program is criticized by many. especially residents, who like to feel that if they are acceptc~d at all 1heir rntirca training will I)e guaranteed, at least to the extent of ~L3o;rrdIF cluirements. While this m;ry prove no difficulty where large services are avail;rl)lc. it poses great problems in the smaller centers. C’ert,ninly a servicaewhic*h has been watered down sinil)ly lo satisfy on paper a Eonrd requirement is 11111 atI a~lcc~uatr solution.

,dn effort was made to obtain information regarding the desirability and/or essentiality of (1) cert,ain special features (such as rounds, clinical pathological conferences, seminars, journal clubs, radiological rounds, tumor conferences, etc.) and (2) exposure to related disciplines (such as pathology, surgery, psychia.try, enclocrinology. clinical laboratory services, etc.). These portions of the questionnaire were not answered in sufficient detail to permit a \-pry revealing analysis though it seemsto your essayist that such considerations are of the greatest moment. The information obtained is presented in ‘I’al)les IV and V. Most services reported a period of time on pathology (83) :IU~ a weekly pathology conference (75). A number of those who do not ha.ve such features expressed the wish that they did have. Rounds by a senior I)erson, daily, or several times a week are conducted at most institutions (82), :rud most of them (74) hold special conferences of one sort or another, like journal club, tumor board, basic, science lectures, etc., but there was no very i’requent or consistent pattern revealed by the reports. Vith regard to research: In 9 university clinics a period of time on research is required of all residents. or a thesis is required. In many others opportunities are offered or encouraged. Some seem to feel that more research shollld be demanded, and others that research has no part in a resident’s 1raining. Statements regarding the character of research opportunities were

In almost all ol’ the university, and in many 011t,he other hospit~als. SOIII~~ teaching is carried out by the residents--ot’ nurses, students, or interns- -~IIJI wards, in operating and delivery rooms, in ronferences, or as lectures. One of the most pertinent questions regardin g resident training programs would seem to be the amount of clinical material available for study ant1 operative experience. However. IIO consistent picture was found, and it- may well be that one cannot compress the value of :I program of this type into mere figures even though we all realize that a resident must have a “~MSOIIable ’ ’ amount of practical esl)erience. Table VI contains t,he information rtsgarding beds (only 56 university clinics reportjet t,he csact, number of beds ). One university clinic has as many as 210 and one as Pew as 135beds. Only a felt, I+cpol*ted less than 50 or more than 100 clinic beds. -

________---_ NON-TJNIVERSITY

--;---.-( 56 )

UNIVERSJTY

I

, “0 1

0 hstetrics.--Clinic Private Total

Gyrk~colo.qy.--Clinic Private

31.6

Total All

(fXi<$

:

18.3

18.4+ 50 clinic

beds

+

81.6 ~___-~~~

Since the actual number ol’ rclat,ion to the nnmbcr of residents was made to develop a formula into consideration and he of some Con from 55 university hospitals WR.Savailable for this calculation

(O.X$$,

33.6+ 52 - ~~. ...__..~

--.--.-.

-.

-.

-

-i-

42.
_._.

beds available may hr of importance only in and the length of their training, an ad.tcmpt which would take all t,hrer of t,he variables value

RS n measwr

and 26 non-university (Table VJT).

of

ilde(luaey.

affilia.ted

Informit-

inst,itntions

EDUCATION

01’

ORSTETRICIAN-GYNECOLOGIST

!Ui

The resultant figures varied markedly and inconsistently all over the cdountry. The highest was 310 and the lowest was 112. Often gynecological beds were indicated as varying in number. Often it was mentioned that beds in affiliated hospitals were a.vailable for some functions. Variability in number of residents and years of training was also indicated occasionally. The figures used were the minimums mentioned. Obviously no conclusions can bc drawn. These figures are meaningless at this time but may bc of value in the future since all three variables must be considered in an evaluation of’ this type. TABLE -

Average Median

VII.

CORRELATION:

BEDS,

UNIVERSITY 48.5 42

RESIDENTS, 1

TENURE.

NON-UNIVERSITY 55 ‘) 50--

FORMULA: /

Hn Y

7

ALL 50.i

Only a few hospitals require of their resident,s a specific number of operat,ire or other procedures, or experience in the management of a selected list of complications. Most of the respondents replied that their residents managed 01 operated upon “all or almost all of the clinic patients.” A few referred to ‘ ‘the gamut” of obstetrical and gynecological procedures. Many remarked tha,t the residents had ample operative opportunity. Suggestions for improvement,s in programs were extremely varied. Those rnent,ioned most o-ften were : Increase program i.0 4 years More research More pathology Exposure to surgery Exposure to urology

I6 Id II 13 7

mentioned were “more patients, ” ’ ‘full-time teachers, ’ ’ “more money, ’ ’ “office gynecology,” more “basic science.” Deplored were “the draft,” “early marriage, ” “lack of space,” etc. The results of this questionnaire study leave us far from satisfied. There appear to be certain reasonably common features, however, which characterize the programs of training in obstetrics and gynecology today in our university hospitals and in a considerable number of other large hospitals. The most common features are: a previous rotating internship; usually a three- hut fairly often a four-year residency, arranged in parallel fashion; a combinetl obstetrical-gynecological service ; six months of mixed general and gynecological pathology and a weekly clinical-pathological conference ; frequent (usually daily) rounds by a senior staff member; and less frequent special features such as journal clubs, special basic science lectures, radiological conferences, resealsell opportunit,irs; some teaching duties ; ahoat 50 ck. ) ; indifferent. clinic obstetrical and 31 clinic gynecological beds; infrequent and inadequate This opportunities in related fields such as surgery, urology, and psychiatry. type of program represents the best of the picture; this is what is offered in our university clinics and a sizable sample of the larger non-university hospitals. We are all aware, however, of the very great number of men who arca receiving their training on smaller and often less well-organized services all over the country, frequently, of necessity repeating a one-year residency three times in order to meet American Board requirements. We are also well aware’ of the large num,ber of men who receive a portion of their specialty education through the medium of t,he preceptorship, often an unsatisfactory method

Also

EDUCATION

OF OHSTETRICTAN-GYNECOLOGIHT

!L4!)

anatomical and physiological facts and the principal abnormal conditions, :lllcl We can hope to stimulate to reveal the most important sources of information. and inspire but we cannot espect to equip our medical students with enough of the detailed knowledge of obstetrics and gynecology to l)ermit them to prac ticc, the specialty without further training. \\‘ith regard to internship I believe that the trend revealed in our study is reasonable and sound, Cz., a rotating (or mixed) internship is prefera I)lt~. hut, prohabl~ any good internship should be acceptable. As a mnt,ter of fact, I cloubt if the straight internship in obstetrics and gynecology is quite as inPossibly there will fle iltl(YflElte Rs it appeat5 to l)e regarded at this time. problems in attracting a fair share of superior int,rrlls to go into obstetrics ant1 gynecology in those institutions in which straight internshil)s in medicine, surg~~ry, pc~cliatrics, etc., exist, but none in obstet,rics and gynecology. WhatCJW is formally labelled “internship, ” it would appear that the first pear of iI residency program should and tloes ilet as an internship in obstetrics antI gyrlrccllogy. I believe that this is apl)ropriate since it is manifest,ly impossible to provide very much obstetrical and gynecological experience in a totaling illtclrnship--and none at all in straight internships in other fields. 1,ike most others I feel that education in obstetrics and/or gynecology is best, pro~iclcd through the medium nl’ n combined serl-ice, though it is cvideni that this entails numerous tlifficult prohlcms in the pro+ion of experience in closely relatetl fields like surgery and urology. The pt*oblem is one not onI> 0P facilities but also of time. Tf it were agreed, and I believe that it shoultl Iw, that esljosure to a selected esperience in surgery, urology, psychiatry, c~ntlocrinology, pathology, and czlinic*al laborat,ory is desirable in the edueat,iorr (II’ the oMetrician-gynecologist, then it seems obyions that the length of i hc t railiing p7*ogram must be extended to a minimum 0 f four years. Possibly e\rell tnorc time would be desirable. Vhilc most programs arc currently three-yrar ones, many seem to feel the need of more time. iVtoreov(9’, I believe that the Ilrrcc-year program rather than a longer one hns come about, largely through force of circumstances rather t,hnn deliberate planning. The determining c4rrunAances have been the resident’s economic plight, the unavailability of cisperience in related fields (or lack of planning for it), an insufficiency of slkitable teaching material, and the requirements of the American Board of (~l)stctrics and Gynecology, which are largely a distillatt> of minimal desirable t.t,rlairement,s, al&able programs, and economics. ISesicles exposure t,o three years of clinical obstetrics and clinical gyne~logy in equal proportions in positions of gradually increasing responsibility, ;Idditional experience in the disciplines enumerated above would seem to mc: t,o be a necessity if our aim is t,o be for the optimum. Pathology, both general and special, has been appreciated in the past and should continue to be in the future. There is a peculiarly intimate association between clinical gynecology and its basic pathology. To study gynecological pathology is to gain a concept of gynecological conditions which cannot be ga.incd in any ot.hcr way. Many services include six months of pathology and a weekly clinical-pathological conference. This seems satisfactory to me’.

Knough

surgery t,o IJC~ familiar wit.h ~~llet*itI surgical principles :III~I t.0 INS capable of dealing with trowel complications shottld certainly t)to acvltrirwi during the course of’ training. The gynecdologist.shottld know how to t.lvv~gJtixc~ ;III~ rutmap, both n~rtlic:ally ;ltlcl surgidly, itlt estinal obst ru(~tic~u. xastI*ic* clilatwtion. an(l i~(l~tt:tttlic~ iletts: hr should IJtl ;~l)lv to t*c!s(v:t, bowel ;~nd ~~~~I~I’oI~I~I cwlostorlJ~.

P’Pu. srrvivrs

havca IJWIL ;II)I(~ III itlvlltclp

iItlc(l~litt(~

t t.;iitritlg

1-1’ this

t,?l)r a.nci I (10 trot, krlow holy the tlefiG~lc*~~ sh~~ttl~lhe remetliecl. I I’ it wt’r( possihlc~,ac*ti\,tJ part,icipatiort 011 it slIr#iC*;ll sprvit*ta (]urillg which 0l)pcjrtiiiiitics of the sort. mtJntioneci were offered woultl hrh the hcst. This has ll()? l~SlIaII>~ been possible. howevcl-, and in m>- opinion is not like]!- to he in t htl 1’1t1.1tt’f’ I Jog s~~rger~’ might t’nrnish a reasonahl(~ stlhstitute t’or the technic>;11 sslJc~(~ts. f )thcrwist> the c*onrrl)t, oII ill1 services. of h;lvinp f hc residents I’ollO\r. t tl~*otl~l~ in t tic rsaminatiori anct c&a rfx of indiridua I patients. incdluding those rt~l’~~r*Wcl 10 other servic*rs ( t’.g.. stlrg(ir~’ j and pr.oc~c~tllilY3 I tlc‘l7* 1)iirtic*ipa tcb in I rtb;rtnipnt might. provid(l iin il tlswf~r. Hsposnre to c.ertain urologic*al procedllres and cxa minat,ions would t)(j tlight) advantageous. This too has received short shrift in the past in most institutions. I beli,vt> that thcadesired end could b(l ac~c*ornplisht?d reasonabl>, easily by Jll(?lllS of schrdnled attendance at c*)*stoscopic~linic~s, arId possibly by gyn(4ogic+a 1 and urological resident,s sharing in thfa w Iv’ and treatment of th(> ov(~rlappin? c*onditions, like tistula, incontinence. etc.. In 1he ease of psychiatry and clinic*aI laboratory it srcnls that irl hot Ir iI]st.ancaest hc ~sposurc would ha,ve to 1~5arc*omplished l)y dealing with the I)itI’wit,h c~losec~ollahorat io11 titular problems as t,hey occurred in gj-necological caases! hetwccn the responsible resident and the> appropriatcl expert c*onsult~arll. Tll(~ importance ol’ acquiring some familiarity with th(l recognition and nlanapt>ltrellt .I ISO. of psychiatric WJ~n~JO~l~ntS of gyntvdogica~ diseases ncwls no jltstificatiotl. I think it clnitc evident that. 111) to thv present, snc*h prol~l~~ms hav(b Iu)t rcvvi\d tht attention they destrvc. It is my heliel’ that thollght and planning SIIOU]~I tw direct,ed toward remtdping this dcfic*ienry in every ohsttlt ricdal and ~yrtccolopic*w I resident program, With regarti to clinicdal laboratory, I have iI1 Itkind such prohlenls iis tiuitf and electrolytcb balance. the techniques and significance of hormorrt~ tlctcrrGzCons, tho bacteriology of the female genital t,ra,c*l.,etc. 111addition to ;I c*oll;~ho~~ five effort, relat,etl t,o individual patients it. would Sam or lectllres 011 pertinent snhj&s of the sari, rtlrnt~iotld tireuess OFthe resident’s educat,ion.

thal. ii series of sc~rtiiIt:ir’s ~ortld atltl to thr, r,ft’cv*

Since so n~wny gynecological conditiolIs are intimately tied 111) wit Ii aberrations of’ ductless gland function, a t,horough appreciation of entlocritlological physiology should he in the possession of every graduating ohstetCc:tl could IN, and gynecological resident. 1 believe that sufficient opportunity presented by having all resident,s spend a reasonable i)eriod of t,imr in an outpatient clinic devot,ed to such problems, possibly irl conjunction with 111~ infertility clinic. If possible an endocrinologist should he in a.ttendance as well 3s a.gynecologist,

The matt.t!r of research opportunities is certainly a controversial OIL& 111 111y opinion a period of time on research should be included in the trainills period, if not for all, then for those who show aptitude for or who CxlJr(w illt,errst in all academic career. I. do not know where it should come, but suslwct that it would be best near t.hc end. i.e., after three years, or perhaps t’veti after five years. Hut, even before this tinit! every resident should IJt! I*ecluiret1 to participate in SUIIIC vliniwl resrarch investigation became it wuul(~ give him some familiarity with the lit,erat,urc 01’th(l specialty, it would te;tcll him how t.o marshal1 facts and write thcnl up, and it, would give him the CSI)crience of presenting them to the staff. Ot’her special features which are currently inclutlrtl in many residelit 16ning progrxms, which 1 regard as a “must” arc: (1) a weekly staft conferencc or grand rounds, (2) daily or almost daily ward rounds with a seniot St.af?fmember, (3) a weekly seminar 011 sprc+ial subjects (e.g., radiological problems, both therapeutic and diagnostic, the Bh problem, virus diseasesin pregnancy, toxemia, etc.), (4) a journ; club, and (5) ;L weekly chart review. None of these require discussion, but a,11.l believe are essential. TWO final problems of different nat.ure invite some comment. The first has to do with the amount of clinic*al material available per resident. At the present time there is marked variation in this respect as was pointed out (%rlier. Whether a minimum should be established I do not know. As a ma.tter of fact there are evils associated with too many paCents as well as wit,11 too few. The most common problem at the present, however, is the diminishing number of clinic patients. More and more ha,ve acquired private patient status by virt,ue of hospitalization and medical care insurance. While this is good socially, it has diminished residents’ opportunities in all of the surgical specialties part,icularly. I believe that the problem can be solved but it will require some revision of thinking and policy. First of all, it is quit.e possible to conduct a great deal of valuable resident education with private patients as subject,s; a great deal has been carried out in t,he past, and more is possible in the future, with the sympathet,ic cooperation of private practitioners and a better understanding by patients of the resident’s role in their care. This resolves itself into a selling job-we have to sell the idea of teamwork. .Mally pat,ients misunderstand, and when they do I think it well worth t,hc t,ime ancl #t’ort. to stol) and explain. I see no reason why residents should noi; 1~. guidtatl through many procrtlures carried out 011 private l)a.tients. Naturally t II(~ ljatient’s doctor remains the responsible member of the t,e:trn. I’tlrhaps thtasts lltell in training should be regarded and called “my assistants” rather thau This would at least exemplify the type of relationship and “the residents.” the place of the resident’s responsibility that we must try to sell. Second, a change in the attitude of organized medicine a.nd o-f insurance companies toward the treatment of patients with some t,ypes of insurance by residents would be of great help in amplifying opportunities. Should it not be possible for residents to treat patients with hospitalization insurance only, or thosta with small medical care provisions? Funds could be collected toward a house