- Email: [email protected]
A blueprint for academic obstetrics and gynecology 1
Graduate Education A blueprint for academic obstetrics and gynecology Steven G. Gabbe, MD, Eberhard Mueller-Heubach, MD, Jack N. Blechner, MD, Warren H. Pearse, MD, Richard Depp, MD, and Robert K. Creasy, MD A consensus conference sponsored by the Council of University Chairs of Obstetrics and Gynecology in February 1997 formulated the organization’s response to the many external issues affecting academic medicine and obstetrics and gynecology including 1) a new practice model based on “wellness,” 2) reimbursement changes that have jeopardized traditional revenue sources, 3) an emphasis on quality assurance based on outcomes research and evidence-based medicine, 4) the concept of lifelong learning dictated by an expanding knowledge base and new technology, 5) insufficient resources for basic and clinical investigation in obstetrics and gynecology, 6) workforce statistics indicating stabilization in the number of subspecialists, 7) the increasing diversity of the United States population. Recommendations were developed that are intended to foster change and contribute to the design of academic programs. These include appropriate training for residents as providers of primary care, with an emphasis on continuity clinics, an interdisciplinary curriculum in women’s health for medical students; promotion of gender, racial, and ethnic diversity at all levels of medical education and academic leadership; creation of clinical trials research units; and the development of expanded opportunities for research in obstetrics and gynecology supported by the National Institutes of Health. (Obstet Gynecol 1998;92:1033–7. © 1998 by The American College of Obstetricians and Gynecologists.)
From the University of Washington School of Medicine, Seattle, Washington; Wake Forest University School of Medicine, WinstonSalem, North Carolina; University of Connecticut Health Center School of Medicine, Farmington, Connecticut; Jacobs Institute of Women’s Health, Washington, DC; Jefferson Medical College, Philadelphia, Pennsylvania; and University of Texas Medical School, Houston, Texas. The conference reported here was supported in part by educational grants from Ortho Pharmaceuticals, Raritan, New Jersey, and WyethAyerst Laboratories, Philadelphia, Pennsylvania. The authors thank Martha Snyder Taggart, MA, a health communications consultant, for her assistance with this project.
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These are difficult times for academic medicine in general, and for academic departments of obstetrics and gynecology in particular. Numerous pressures are causing the specialty to evolve and redefine itself. Given their long-term perspective, academic departments have an obligation to lead the process of change while they struggle to adapt. A proactive stance will help improve the effectiveness of training programs in obstetrics and gynecology and enhance the specialty’s influence on patient care and research in women’s health. In the spring of 1997, the Council of University Chairs of Obstetrics and Gynecology held a consensus conference. Representatives of leading organizations involved in patient care, education, and research were invited to participate (Table 1). The goals of the conference were to better understand issues facing the specialty and recommend changes that might contribute to future successes of academic departments. The proceedings of the conference, including presentations, discussion, and consensus recommendations, have been published separately and circulated to chairs, deans of medical schools, and specialty groups.1 The purpose of this article is to review the recommendations developed by participants at the conference.
Practice Recommendations By far the greatest number of recommendations developed during the Council of University Chairs of Obstetrics and Gynecology conference (Table 2) related to a consensus that as a specialty we must define ourselves as primary care physicians and augment our knowledge and skills in that area (Tables 2 through 4). In our view, this path is fundamental and unavoidable. The pressures driving the specialty in this direction are economic and philosophic. Although today’s marketdriven insistence on primary care is likely to recede, there are other important reasons for us to assert our leadership in primary health care for women. A major rethinking of organization and reimbursement of health care in this country has occurred under the rubric of “competition.” Although many training programs have felt the impact of managed care contracting, Medicare indirect graduate medical education payments have helped by subsidizing these educational responsibilities. Now there is erosion of that support for all but primary care disciplines.2,3 At the average academic medical center today, funding for education and research mostly depends upon the profitability of practice activities, which represent more than 50% of the average academic department’s budget.2 It is widely held that free access to patients depends on primary care designation for obstetrician-gynecologists. Some have argued for an alternative, suggesting that
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Table 1. Participating Organizations Organization
Abbreviation
American Board of Medical Specialists American Board of Obstetrics and Gynecology, Inc. American College of Obstetricians and Gynecologists American Gynecological and Obstetrical Society American Medical Association American Society of Reproductive Medicine Association of American Medical Colleges Association of Professors of Gynecology and Obstetrics Council of University Chairs of Obstetrics and Gynecology Council on Resident Education in Obstetrics and Gynecology National Institute of Child Health and Human Development Residency Review Committee for Obstetrics and Gynecology Society for Gynecologic Investigation
ABMS ABOG ACOG AGOS AMA ASRM AAMC APGO CUCOG CREOG NICHD RRC SGI
it is not critical to seek primary care designation as long as there are guarantees of direct access to patients provided by state legislative mandates and through other channels. During our conference, the assertion was made that clinicians would not receive guarantees of direct access if they were not already accepted as primary care providers.4 Current practice data substantiate our recommendation that the typical generalist qualifies as a primary care provider. More than 90% of those in our specialty have chosen the generalist route of practice,5 and greater than half of practicing obstetrician-gynecologists spend 50% or more of their time providing primary and preventive care.6 Obstetrician-gynecologists provide more general medical examinations to women aged 15 years and older than do family practitioners and internists combined.7 It is generally acknowledged that a large portion of the care provided to pregnant women is primary
Table 2. Recommendations to Improve Practice 1. Obstetrician-gynecologists should be appropriately trained as providers of primary care for women. 2. US medical schools should play a role in planning and delivering health care to their surrounding communities, working in collaboration with residents, providers, payers, local government, community organizations, and other groups. 3. Measures of quality appropriate to women’s health care should be developed as a basis for evaluation. 4. Accurate estimates of future training and workforce requirements should be established. 5. Academic medical centers should place proper value on the contribution of clinical faculty members. 6. An advisory body should be created to monitor and assist academic departments’ adjustment to Health Care Financing Administration rules and program changes.
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Table 3. Recommendations to Improve Education and Training 1. Training in primary care should be a requisite for obstetriciangynecologists. 2. Other specialties should place more emphasis on women’s health as a central aspect of primary care education. 3. A 4-year, interdisciplinary curriculum in women’s health should be implemented for undergraduate medical education. 4. Academic departments should consider designation as departments of “Obstetrics, Gynecology, and Women’s Health.” 5. The 4th year of medical school should provide a broad-based education in support of primary care training. 6. Continuity clinics should be expanded and improved as an integral part of primary care training. 7. Academic programs should highlight their expertise in aspects of primary care education and training and make it available to other specialties. 8. Postgraduate curricula on practical aspects of primary care for women should be developed for obstetrician-gynecologists. 9. Primary care questions should be included in recertification examinations. 10. Voluntary continuous recertification should be encouraged and established. 11. Schools of medicine and departments of obstetrics and gynecology should dedicate a certain portion of institutional funds to promote excellence in teaching. 12. Excellence in teaching should be rewarded through the promotion and tenure process. 13. The Residency Review Committee for Obstetrics and Gynecology should simplify and streamline its data collection requirements. 14. Gender, racial, and ethnic diversity should be promoted at all levels of medical education and academic leadership.
care, but the primary care services the obstetriciangynecologist performs for the nonpregnant patient go largely unrecognized.8 We recommended that there be continuous collection and monitoring of workforce data to assess choices in training and practice. Current workforce projections suggest that both the training of and need for subspecialists have stabilized;9,10 however, wide-scale adoptions of primary care practice among obstetriciangynecologists and the increased life expectancy of women could increase the demand for specialty and subspecialty care.4,11 Council of University Chairs of Obstetrics and Gynecology conferees also considered ways in which additional training and expertise in primary care might be encouraged among practicing clinicians. This material can be taught in postgraduate courses. For obstetriciangynecologists enrolling as primary care providers in some managed care organizations, mandatory review courses might be routine. We have recommended that primary care questions be included on recertification examinations and, for practitioners who are exempt from this requirement, that a program of voluntary continuous recertification be established.
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Table 4. Recommendations to Improve Research 1. Academic departments should appoint individuals to serve in research leadership roles (ie, vice chairs or division directors for research). 2. A consultative service should be established to assist academic chairs in the development of research programs at their own institutions. 3. Individuals planning academic careers are encouraged to pursue training in fundamental and clinical epidemiologic research. 4. Academic departments should establish collaborative, highquality and cost-effective clinical trials units and should collaborate with industry to develop drugs and technologies to benefit the health of women. 5. Alternative clinical training pathways for physician scientists should be explored to reduce the time spent in clinical training. 6. Fellowship programs should be extended to 3 years and require 18 months of research. 7. Protected time is essential for research success; therefore academic departments with research missions should support a limited number of physician scientists, understanding that their reimbursement is lower than that provided for clinical activity. 8. The intramural research program in obstetrics and gynecology should be strengthened within the National Institutes of Health. 9. Our faculty members should be encouraged to serve on National Institutes of Health committees.
Education Recommendations Medical practice is emphasizing wellness and prevention rather than treatment of disease, and ambulatory care rather than hospitalization (Table 3). This philosophical shift demands structural changes in curricula and methods for training physicians. It underscores the need for primary care education and training. Another ramification is the shift from patient to populationbased care, emphasizing the unique health care needs of entire communities managed over time. Obstetrics and gynecology has always had a strong preventive focus, which should be emphasized in the curriculum in women’s health for medical students and house officers. We endorsed a 4-year, interdisciplinary, undergraduate-level curriculum in women’s health12 and have recommended that the 4th year of medical school provide broad-based instruction in primary care topics, rather than subspecialty electives which are often used as auditions for residency training. At the residency program level, obstetrics and gynecology has unique expertise to offer other primary care disciplines, as they do to us. Our specialty should receive credit and recognition for the wide range of primary and preventive services that it traditionally provides, including health screening, risk assessment, immunization, family planning, and breast selfexamination instruction.8 We have recommended that this expertise be shared with other specialties in interdisciplinary training programs. Continuity clinics, a relatively new concept in train-
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ing, are viewed as one of the most valuable educational opportunities for our residents and a mechanism for shifting training programs from their current hospital and surgical bases to ambulatory care settings. They, too, can incorporate an interdisciplinary focus. Concern has been expressed that residency programs cannot expend time and resources on education in primary care and still provide adequate opportunities for surgical training.11 We debated, but deferred, the issue of whether residency programs should be lengthened or include separate tracks for physicians pursuing subspecialty training versus generalist preparation. (This issue was also addressed under the Research Recommendations, where we propose alternative clinical training pathways for obstetrician-gynecologists pursuing research careers.) Conferees endorsed the current primary care special requirements put forth by the Residency Review Committee, the American Board of Obstetrics and Gynecology, Inc., the Association of Professors of Gynecology and Obstetrics, and the Council on Resident Education in Obstetrics and Gynecology. It was acknowledged that those requirements resulted from compromise13 and represent a minimum level of preparation. Our consensus recommendations are directed toward improving the quality of primary care education without extending its length. Proposed mechanisms for such improvement include using the 4th year of medical school for a broad-based introduction to primary care topics, strengthening continuity clinics, and emphasizing interdisciplinary approaches to training, when we serve as both instructor and pupil in carefully designed specialty rotations and clinic settings. Lifelong learning may not seem to be the concern of undergraduate and graduate medical education, until we realize that learning habits begin within our institutions and training programs. The concept of lifelong learning places greater importance on the quality of teaching and associated educational activities, including curriculum development and course design. Faculty must foster the process of knowledge acquisition, helping students and residents engage in a variety of tasks apart from memorization, including self-assessment and problem solving. All this calls for superior teachers who are also skilled in course development and curriculum design. In light of funding cutbacks for graduate medical education and growing clinical demands on faculty, chairs of academic departments and deans must invest in quality teaching, with dedicated funds for that purpose. Teaching should be assigned a higher value in the tenure review process. One mechanism for evaluating such competence is the teaching portfolio.14
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Research Recommendations A series of problems has prevented the establishment of active research programs (Table 4) within many academic departments. It includes lack of interest in and leadership for research, retrenchment in research funding directed to departments of obstetrics and gynecology, and a corresponding disinterest or inability among many academic departments to pursue and excel at research. The lack of federal funding directed toward research in obstetrics and gynecology is particularly striking.15 Little progress is being made in preventing and treating conditions that contribute greatly to morbidity and comorbidity among women and their resulting health care costs. Examples include preterm labor, sexually transmitted diseases, infertility, and unintended pregnancy. Increased support from the National Institutes of Health (NIH) for these and other related topics should be an aim for the future. We have recommended that the intramural research program in obstetrics and gynecology be strengthened. There are too few physicianscientists trained in obstetrics and gynecology at NIH. Council of University Chairs of Obstetrics and Gynecology will submit a list of obstetrician-gynecologists candidates for NIH committees, including study sections devoted to the review of grants in patient-oriented research. Within recent years, there have been attempts by Congress to reverse long-standing inequities in women’s health research and to direct funding into areas such as heart disease and cancer in women and other preventive health topics. These initiatives have already yielded valuable knowledge. Ironically, a relatively small portion of funding from the huge Women’s Health Initiative project has been directed toward obstetrics and gynecology. A strategic planning group that includes Council of University Chairs of Obstetrics and Gynecology has been convened under the auspices of the Liaison Committee for Obstetrics and Gynecology to discuss these issues with leaders at the NIH. Several other recommendations are directed toward building research competency in our academic departments. A noticeable lack of such activity was criticized by an expert panel appointed by the Institute of Medicine earlier this decade.16 Therefore, Council of University Chairs of Obstetrics and Gynecology has been charged with assisting departments and program chairs with this task. One component of this effort is to build strong leadership for research undertaken at the department level. Too often, researchers and physicianscientists are spread throughout subspecialty divisions and lack cohesiveness, thus failing to coordinate their research agendas. As a solution to this problem, we
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propose the appointment of a vice chair or division director for research. Research depends on well-trained investigators. The recommendation that subspecialty fellowships be extended to 3 years, with an 18-month research requirement, is aimed at attracting only the most highly motivated physician-scientists into our programs and allowing them enough time to develop their skills. Protecting the time of investigators and providing stability of support were also addressed. We proposed that alternative pathways with reduced but adequate clinical training be established for these physician-scientists and that dedicated department support be directed to faculty whose primary function is research, albeit with the understanding that such time is reimbursed at a lower rate than for clinical activity. Today’s emphasis on quality assurance and evidencebased medicine, as measured by clinical outcomes, makes it particularly important that we encourage obstetrician-gynecologists to pursue training in clinical and epidemiologic research areas, including outcomesbased research.17 As a corollary to this, quality indicators specific to women’s health must be developed and implemented in practice settings (noted under our Practice recommendations). Establishing a clinical database is among the first steps prescribed for departments who are interested in developing an active research program.9 Council of University Chairs of Obstetrics and Gynecology plans specific actions to publicize available sources of training support for clinical investigators, and to coordinate, through NIH and private sources, the establishment of research career development awards in clinical epidemiology and health services research. Our academic departments are encouraged to establish clinical trial units, collaborating with industry in evaluating new drugs and technologies for women’s health care.
Conclusion As we cope with significant and rapid changes in the reimbursement system, academic departments of obstetrics and gynecology have opportunities to create a unified women’s health curriculum for undergraduate students, to share our traditional preventive and primary care expertise in residency programs, to provide continuity of care for women, to instill concepts of lifelong learning in our graduates, and to develop our basic and clinical research programs. Furthering these goals, an action plan has been developed to implement many items contained within our recommendations. During the past 20 years, a series of conferences has been convened by leaders in our specialty, and lists of recommendations considered important have been gen-
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erated. Many of these proposals have not been acted upon. Is there reason to believe that recommendations generated by the Council of University Chairs of Obstetrics and Gynecology Consensus Conference will lead to change? We believe there is. First, as described in the introduction, there is general agreement that our present environment requires change if we are to survive. Second, the members of the Council, all of whom are chairs of academic departments, are in unique positions to lead this process. In fact, since the Consensus Conference, the Council, serving in an advisory role with other important organizations in our specialty, has participated in the development of new NIH-funded research opportunities for young investigators. The recommendations present here indicate a consensus, and not unanimity, among the conference participants. Our blueprint is, therefore, an advisory plan. A future follow-up conference is being planned and will provide an opportunity to gather more perspectives, including those of insurers, hospitals, foundations, government, consumers, and the larger scientific community.
References 1. Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. 2. Jonas HS. National data comparing academic departments of obstetrics and gynecology. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. 3. Merkatz IR. Coping with the decline in federal funding for graduate medical education: The New York State plan. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. 4. Dunn LJ. Is it important for obstetrician-gynecologists to be designated as primary care providers? Views and misperceptions among practitioners. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. 5. Gant NF. Subspecialty training in OB/GYN: A surplus that is real or imagined? In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. 6. Horton JA, Cruess DF, Pearse WH. Primary and preventive care services provided by obstetrician-gynecologists. Obstet Gynecol 1993;82:723– 6. 7. National Center for Health Statistics (NCHS). National ambulatory medical care survey: 1991 summary. Vital Health Stat 1994;13:1– 110. 8. Zinberg S. The obstetrician-gynecologist as primary care physician. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by
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9.
10.
11.
12.
13.
14.
15.
16.
17.
the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. Goldenberg R. Strategies for building clinical research capacity in OB/GYN departments. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOGG, 1997. Jacoby I. An obstetrics and gynecology physician workforce study. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. Entman SS. Should obstetrician-gynecologists become primary care providers? A dissenting view. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. Magrane DM, McIntyre-Selman K. Women’s health care issues for medical students: an education proposal. Womens Health Issues 1996;6:183–91. Fishburne JI. Redesigning residency requirements in obstetrics and gynecology to reflect a primary care emphasis. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. Chescheir N. Documenting your career: The curriculum vitae and teaching portfolio. In: Young WW, ed. Career development in academic medicine: Your journey to success. Washington, DC: Association of Professors of Gynecology and Obstetrics 1996. Mueller-Heubach E. The future of research in obstetrics and gynecology: Priorities and issues to consider. In: Gabbe S, MuellerHeubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997. National Academy of Sciences, Institute of Medicine. Strengthening research in academic OB/GYN departments. Washington, DC: National Academy Press, 1992. Grimes D. A research agenda emphasizing clinical outcomes in OB/GYN. In: Gabbe S, Mueller-Heubach E, eds. Blueprint for academic obstetrics and gynecology. A consensus conference convened by the Council of University Chairs of Obstetrics and Gynecology (CUCOG). Washington, DC: CUCOG, 1997.
Address reprint requests to:
Steven G. Gabbe, MD Department of Obstetrics and Gynecology University of Washington School of Medicine BB617 Health Sciences Building, Box 356460 Seattle, WA 98195-6460 E-mail: [email protected]
Received March 19, 1998. Received in revised form May 28, 1998. Accepted June 19, 1998. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
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From the University of Washington School of Medicine, Seattle, Washington; Wake Forest University School of Medicine, WinstonSalem, North Carolina; University of Connecticut Health Center School of Medicine, Farmington, Connecticut; Jacobs Institute of Women’s Health, Washington, DC; Jefferson Medical College, Philadelphia, Pennsylvania; and University of Texas Medical School, Houston, Texas. The conference reported here was supported in part by educational grants from Ortho Pharmaceuticals, Raritan, New Jersey, and WyethAyerst Laboratories, Philadelphia, Pennsylvania. The authors thank Martha Snyder Taggart, MA, a health communications consultant, for her assistance with this project.
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These are difficult times for academic medicine in general, and for academic departments of obstetrics and gynecology in particular. Numerous pressures are causing the specialty to evolve and redefine itself. Given their long-term perspective, academic departments have an obligation to lead the process of change while they struggle to adapt. A proactive stance will help improve the effectiveness of training programs in obstetrics and gynecology and enhance the specialty’s influence on patient care and research in women’s health. In the spring of 1997, the Council of University Chairs of Obstetrics and Gynecology held a consensus conference. Representatives of leading organizations involved in patient care, education, and research were invited to participate (Table 1). The goals of the conference were to better understand issues facing the specialty and recommend changes that might contribute to future successes of academic departments. The proceedings of the conference, including presentations, discussion, and consensus recommendations, have been published separately and circulated to chairs, deans of medical schools, and specialty groups.1 The purpose of this article is to review the recommendations developed by participants at the conference.
Practice Recommendations By far the greatest number of recommendations developed during the Council of University Chairs of Obstetrics and Gynecology conference (Table 2) related to a consensus that as a specialty we must define ourselves as primary care physicians and augment our knowledge and skills in that area (Tables 2 through 4). In our view, this path is fundamental and unavoidable. The pressures driving the specialty in this direction are economic and philosophic. Although today’s marketdriven insistence on primary care is likely to recede, there are other important reasons for us to assert our leadership in primary health care for women. A major rethinking of organization and reimbursement of health care in this country has occurred under the rubric of “competition.” Although many training programs have felt the impact of managed care contracting, Medicare indirect graduate medical education payments have helped by subsidizing these educational responsibilities. Now there is erosion of that support for all but primary care disciplines.2,3 At the average academic medical center today, funding for education and research mostly depends upon the profitability of practice activities, which represent more than 50% of the average academic department’s budget.2 It is widely held that free access to patients depends on primary care designation for obstetrician-gynecologists. Some have argued for an alternative, suggesting that
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Table 1. Participating Organizations Organization
Abbreviation
American Board of Medical Specialists American Board of Obstetrics and Gynecology, Inc. American College of Obstetricians and Gynecologists American Gynecological and Obstetrical Society American Medical Association American Society of Reproductive Medicine Association of American Medical Colleges Association of Professors of Gynecology and Obstetrics Council of University Chairs of Obstetrics and Gynecology Council on Resident Education in Obstetrics and Gynecology National Institute of Child Health and Human Development Residency Review Committee for Obstetrics and Gynecology Society for Gynecologic Investigation
ABMS ABOG ACOG AGOS AMA ASRM AAMC APGO CUCOG CREOG NICHD RRC SGI
it is not critical to seek primary care designation as long as there are guarantees of direct access to patients provided by state legislative mandates and through other channels. During our conference, the assertion was made that clinicians would not receive guarantees of direct access if they were not already accepted as primary care providers.4 Current practice data substantiate our recommendation that the typical generalist qualifies as a primary care provider. More than 90% of those in our specialty have chosen the generalist route of practice,5 and greater than half of practicing obstetrician-gynecologists spend 50% or more of their time providing primary and preventive care.6 Obstetrician-gynecologists provide more general medical examinations to women aged 15 years and older than do family practitioners and internists combined.7 It is generally acknowledged that a large portion of the care provided to pregnant women is primary
Table 2. Recommendations to Improve Practice 1. Obstetrician-gynecologists should be appropriately trained as providers of primary care for women. 2. US medical schools should play a role in planning and delivering health care to their surrounding communities, working in collaboration with residents, providers, payers, local government, community organizations, and other groups. 3. Measures of quality appropriate to women’s health care should be developed as a basis for evaluation. 4. Accurate estimates of future training and workforce requirements should be established. 5. Academic medical centers should place proper value on the contribution of clinical faculty members. 6. An advisory body should be created to monitor and assist academic departments’ adjustment to Health Care Financing Administration rules and program changes.
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Table 3. Recommendations to Improve Education and Training 1. Training in primary care should be a requisite for obstetriciangynecologists. 2. Other specialties should place more emphasis on women’s health as a central aspect of primary care education. 3. A 4-year, interdisciplinary curriculum in women’s health should be implemented for undergraduate medical education. 4. Academic departments should consider designation as departments of “Obstetrics, Gynecology, and Women’s Health.” 5. The 4th year of medical school should provide a broad-based education in support of primary care training. 6. Continuity clinics should be expanded and improved as an integral part of primary care training. 7. Academic programs should highlight their expertise in aspects of primary care education and training and make it available to other specialties. 8. Postgraduate curricula on practical aspects of primary care for women should be developed for obstetrician-gynecologists. 9. Primary care questions should be included in recertification examinations. 10. Voluntary continuous recertification should be encouraged and established. 11. Schools of medicine and departments of obstetrics and gynecology should dedicate a certain portion of institutional funds to promote excellence in teaching. 12. Excellence in teaching should be rewarded through the promotion and tenure process. 13. The Residency Review Committee for Obstetrics and Gynecology should simplify and streamline its data collection requirements. 14. Gender, racial, and ethnic diversity should be promoted at all levels of medical education and academic leadership.
care, but the primary care services the obstetriciangynecologist performs for the nonpregnant patient go largely unrecognized.8 We recommended that there be continuous collection and monitoring of workforce data to assess choices in training and practice. Current workforce projections suggest that both the training of and need for subspecialists have stabilized;9,10 however, wide-scale adoptions of primary care practice among obstetriciangynecologists and the increased life expectancy of women could increase the demand for specialty and subspecialty care.4,11 Council of University Chairs of Obstetrics and Gynecology conferees also considered ways in which additional training and expertise in primary care might be encouraged among practicing clinicians. This material can be taught in postgraduate courses. For obstetriciangynecologists enrolling as primary care providers in some managed care organizations, mandatory review courses might be routine. We have recommended that primary care questions be included on recertification examinations and, for practitioners who are exempt from this requirement, that a program of voluntary continuous recertification be established.
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Table 4. Recommendations to Improve Research 1. Academic departments should appoint individuals to serve in research leadership roles (ie, vice chairs or division directors for research). 2. A consultative service should be established to assist academic chairs in the development of research programs at their own institutions. 3. Individuals planning academic careers are encouraged to pursue training in fundamental and clinical epidemiologic research. 4. Academic departments should establish collaborative, highquality and cost-effective clinical trials units and should collaborate with industry to develop drugs and technologies to benefit the health of women. 5. Alternative clinical training pathways for physician scientists should be explored to reduce the time spent in clinical training. 6. Fellowship programs should be extended to 3 years and require 18 months of research. 7. Protected time is essential for research success; therefore academic departments with research missions should support a limited number of physician scientists, understanding that their reimbursement is lower than that provided for clinical activity. 8. The intramural research program in obstetrics and gynecology should be strengthened within the National Institutes of Health. 9. Our faculty members should be encouraged to serve on National Institutes of Health committees.
Education Recommendations Medical practice is emphasizing wellness and prevention rather than treatment of disease, and ambulatory care rather than hospitalization (Table 3). This philosophical shift demands structural changes in curricula and methods for training physicians. It underscores the need for primary care education and training. Another ramification is the shift from patient to populationbased care, emphasizing the unique health care needs of entire communities managed over time. Obstetrics and gynecology has always had a strong preventive focus, which should be emphasized in the curriculum in women’s health for medical students and house officers. We endorsed a 4-year, interdisciplinary, undergraduate-level curriculum in women’s health12 and have recommended that the 4th year of medical school provide broad-based instruction in primary care topics, rather than subspecialty electives which are often used as auditions for residency training. At the residency program level, obstetrics and gynecology has unique expertise to offer other primary care disciplines, as they do to us. Our specialty should receive credit and recognition for the wide range of primary and preventive services that it traditionally provides, including health screening, risk assessment, immunization, family planning, and breast selfexamination instruction.8 We have recommended that this expertise be shared with other specialties in interdisciplinary training programs. Continuity clinics, a relatively new concept in train-
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ing, are viewed as one of the most valuable educational opportunities for our residents and a mechanism for shifting training programs from their current hospital and surgical bases to ambulatory care settings. They, too, can incorporate an interdisciplinary focus. Concern has been expressed that residency programs cannot expend time and resources on education in primary care and still provide adequate opportunities for surgical training.11 We debated, but deferred, the issue of whether residency programs should be lengthened or include separate tracks for physicians pursuing subspecialty training versus generalist preparation. (This issue was also addressed under the Research Recommendations, where we propose alternative clinical training pathways for obstetrician-gynecologists pursuing research careers.) Conferees endorsed the current primary care special requirements put forth by the Residency Review Committee, the American Board of Obstetrics and Gynecology, Inc., the Association of Professors of Gynecology and Obstetrics, and the Council on Resident Education in Obstetrics and Gynecology. It was acknowledged that those requirements resulted from compromise13 and represent a minimum level of preparation. Our consensus recommendations are directed toward improving the quality of primary care education without extending its length. Proposed mechanisms for such improvement include using the 4th year of medical school for a broad-based introduction to primary care topics, strengthening continuity clinics, and emphasizing interdisciplinary approaches to training, when we serve as both instructor and pupil in carefully designed specialty rotations and clinic settings. Lifelong learning may not seem to be the concern of undergraduate and graduate medical education, until we realize that learning habits begin within our institutions and training programs. The concept of lifelong learning places greater importance on the quality of teaching and associated educational activities, including curriculum development and course design. Faculty must foster the process of knowledge acquisition, helping students and residents engage in a variety of tasks apart from memorization, including self-assessment and problem solving. All this calls for superior teachers who are also skilled in course development and curriculum design. In light of funding cutbacks for graduate medical education and growing clinical demands on faculty, chairs of academic departments and deans must invest in quality teaching, with dedicated funds for that purpose. Teaching should be assigned a higher value in the tenure review process. One mechanism for evaluating such competence is the teaching portfolio.14
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Research Recommendations A series of problems has prevented the establishment of active research programs (Table 4) within many academic departments. It includes lack of interest in and leadership for research, retrenchment in research funding directed to departments of obstetrics and gynecology, and a corresponding disinterest or inability among many academic departments to pursue and excel at research. The lack of federal funding directed toward research in obstetrics and gynecology is particularly striking.15 Little progress is being made in preventing and treating conditions that contribute greatly to morbidity and comorbidity among women and their resulting health care costs. Examples include preterm labor, sexually transmitted diseases, infertility, and unintended pregnancy. Increased support from the National Institutes of Health (NIH) for these and other related topics should be an aim for the future. We have recommended that the intramural research program in obstetrics and gynecology be strengthened. There are too few physicianscientists trained in obstetrics and gynecology at NIH. Council of University Chairs of Obstetrics and Gynecology will submit a list of obstetrician-gynecologists candidates for NIH committees, including study sections devoted to the review of grants in patient-oriented research. Within recent years, there have been attempts by Congress to reverse long-standing inequities in women’s health research and to direct funding into areas such as heart disease and cancer in women and other preventive health topics. These initiatives have already yielded valuable knowledge. Ironically, a relatively small portion of funding from the huge Women’s Health Initiative project has been directed toward obstetrics and gynecology. A strategic planning group that includes Council of University Chairs of Obstetrics and Gynecology has been convened under the auspices of the Liaison Committee for Obstetrics and Gynecology to discuss these issues with leaders at the NIH. Several other recommendations are directed toward building research competency in our academic departments. A noticeable lack of such activity was criticized by an expert panel appointed by the Institute of Medicine earlier this decade.16 Therefore, Council of University Chairs of Obstetrics and Gynecology has been charged with assisting departments and program chairs with this task. One component of this effort is to build strong leadership for research undertaken at the department level. Too often, researchers and physicianscientists are spread throughout subspecialty divisions and lack cohesiveness, thus failing to coordinate their research agendas. As a solution to this problem, we
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propose the appointment of a vice chair or division director for research. Research depends on well-trained investigators. The recommendation that subspecialty fellowships be extended to 3 years, with an 18-month research requirement, is aimed at attracting only the most highly motivated physician-scientists into our programs and allowing them enough time to develop their skills. Protecting the time of investigators and providing stability of support were also addressed. We proposed that alternative pathways with reduced but adequate clinical training be established for these physician-scientists and that dedicated department support be directed to faculty whose primary function is research, albeit with the understanding that such time is reimbursed at a lower rate than for clinical activity. Today’s emphasis on quality assurance and evidencebased medicine, as measured by clinical outcomes, makes it particularly important that we encourage obstetrician-gynecologists to pursue training in clinical and epidemiologic research areas, including outcomesbased research.17 As a corollary to this, quality indicators specific to women’s health must be developed and implemented in practice settings (noted under our Practice recommendations). Establishing a clinical database is among the first steps prescribed for departments who are interested in developing an active research program.9 Council of University Chairs of Obstetrics and Gynecology plans specific actions to publicize available sources of training support for clinical investigators, and to coordinate, through NIH and private sources, the establishment of research career development awards in clinical epidemiology and health services research. Our academic departments are encouraged to establish clinical trial units, collaborating with industry in evaluating new drugs and technologies for women’s health care.
Conclusion As we cope with significant and rapid changes in the reimbursement system, academic departments of obstetrics and gynecology have opportunities to create a unified women’s health curriculum for undergraduate students, to share our traditional preventive and primary care expertise in residency programs, to provide continuity of care for women, to instill concepts of lifelong learning in our graduates, and to develop our basic and clinical research programs. Furthering these goals, an action plan has been developed to implement many items contained within our recommendations. During the past 20 years, a series of conferences has been convened by leaders in our specialty, and lists of recommendations considered important have been gen-
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erated. Many of these proposals have not been acted upon. Is there reason to believe that recommendations generated by the Council of University Chairs of Obstetrics and Gynecology Consensus Conference will lead to change? We believe there is. First, as described in the introduction, there is general agreement that our present environment requires change if we are to survive. Second, the members of the Council, all of whom are chairs of academic departments, are in unique positions to lead this process. In fact, since the Consensus Conference, the Council, serving in an advisory role with other important organizations in our specialty, has participated in the development of new NIH-funded research opportunities for young investigators. The recommendations present here indicate a consensus, and not unanimity, among the conference participants. Our blueprint is, therefore, an advisory plan. A future follow-up conference is being planned and will provide an opportunity to gather more perspectives, including those of insurers, hospitals, foundations, government, consumers, and the larger scientific community.
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Address reprint requests to:
Steven G. Gabbe, MD Department of Obstetrics and Gynecology University of Washington School of Medicine BB617 Health Sciences Building, Box 356460 Seattle, WA 98195-6460 E-mail: [email protected]
Received March 19, 1998. Received in revised form May 28, 1998. Accepted June 19, 1998. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
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