- Email: [email protected]
Enriching research culture in residency
Letters 1271
Volume 181, Number 5, Part I Am] Obstet Gynecol
Enriching research culture in residency To the Editors: I read with great interest the article by Bissonnette et al (Bissonnette JM, Gabbe SG, Hammond CB, MacDonald PC, Polan ML, RobertsJM. Restructuring residency training in obstetrics and gynecology. Am J Obstet GynecoI1999;180:516-8). The vast majority of the residency programs in North America are rigidly structured to graduate the typical obstetrics and gynecology generalists with little if any flexibility to accommodate individual resident interest. It is very hard for a resident to deviate from those fixed goals and objectives. There is lots of pressure to spend any extra time in the operating suite or emergency department or at rounds to see patients as opposed to the research laboratory. Typically, more than average interest in basic research is automatically interpreted as lack of interest in clinical and surgical work. It is quite all right to chat about an interesting patient or a difficult surgery but not to discuss a challenging experiment or a preliminary discovery. The "antiresearch" culture in the clinical wards is prevalent and deep, and a lot of "restructuring" is needed in both the morphologic and psychologic components of residency. The result of this attitude is missed opportunities to advance knowledge in obstetrics and gynecology. We still know very little of the mechanisms of preterm labor, endometriosis, adhesions, and preeclampsia. We cannot diagnose ovarian cancer early enough because we know nothing of its premalignant stages. We treat all the many different causes of infertility simply by hyperstimulating the whole pathway. We "gonadotropin-releasing hormone" this and laser that and "antiprostaglandin" everything. Unless we understand more about why and how things happen, we cannot design intelligent, effective, and safe therapeutics, and we will continue to use whatever the pharmaceutical industry· throws our way in terms of pills, patches, and needles. Ayman Al-Hendy, MD, PhD Seniar Resident, Depart'flllmt of Obstetrics and Gynecology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada S7N OW8
6/8/102146
Response declined
Anatomy related to rectocele To the Editors: In the recent paper on anatomy related to rectocele (DeLancey JOL. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. AmJ Obstet Gynecol 1999;180:815-22), fascial sheets are described that attach the posterior lateral vaginal wall to the pelvic diaphragm. During total vaginectomy for gender dysphoria in 9 nulliparous patients, I have consistently encountered these structures. Five of these patients had concomitant hysterectomy, and at the time the described fascial sheets seemed to be a caudal continuation of the
uterosacral ligaments. I would appreciate any thoughts or data DeLancey might have regarding this. Mitchel S. Hoffman, MD Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Rorida College of Medicine, Suite 529, Harbour Side Medical Tower, Davis Islands, 4 Columbia Dr, Tampa, FL 33606
6/8/102143
Reply To the Editors: All of the connective tissue, which unites the genital tract to the pelvic sidewall, is continuous. In that sense the supportive tissues of levell, level 2, and level 3 are all part of the same body of tissue. Hoffman's observations support this fact and are additional confirmation about the anatomy described in our article. The uterosacral ligaments and the endopelvic fascia that attaches to the mid and distal vagina are in somewhat different portions of the vagina and therefore have different actions. Further research into the exact interrelationship between the uterosacral ligaments and the vaginal supports may help shed light on this. John O.L. DeLancey, MD Professar and Director, Division of Gynecology, Depart'flllmt of Obstetrics and Gynecology, University of Michigan Medical Center, 1500 E Medical Center Dr, L4100 WO'flllm S Hospita~ Ann Arbor, M1 481090276
6/8/102142
Brachial plexus palsy: An in utero injury? To the Editors: In their review of retrospective literature supporting the hypothesis that brachial plexus injuries occur naturally, Gherman et al (Gherman RB, Ouzounian JG, Goodwin TM. Brachial plexus palsy: An in utero injury? Am J Obstet Gynecol 1999;180:1303-7) conclude " .. .in utero forces may underlie a significant portion of these injuries." This is a curious conclusion from a bioengineering perspective because the authors never discuss intrauterine pressures or forces, despite considerable literature on the subject. For example, at 100 mm Hg, a contracting uterus slowly applies about 19 lb of compressive force to the fetus} The force needed to induce a temporary brachial plexus stretch injury is roughly 22 lb of traction, applied rapidly.2 Because most obstetric brachial plexus injuries are related to stretch, rather than compression, neuropathies, it is unlikely that intrauterine forces underlie nearly as many, or as severe, injuries as the authors intimate. Whereas a computer or laboratory model could answer that question in a more precise way, a more compelling issue is whether some brachial plexus injuries can be mitigated or altogether prevented.
Volume 181, Number 5, Part I Am] Obstet Gynecol
Enriching research culture in residency To the Editors: I read with great interest the article by Bissonnette et al (Bissonnette JM, Gabbe SG, Hammond CB, MacDonald PC, Polan ML, RobertsJM. Restructuring residency training in obstetrics and gynecology. Am J Obstet GynecoI1999;180:516-8). The vast majority of the residency programs in North America are rigidly structured to graduate the typical obstetrics and gynecology generalists with little if any flexibility to accommodate individual resident interest. It is very hard for a resident to deviate from those fixed goals and objectives. There is lots of pressure to spend any extra time in the operating suite or emergency department or at rounds to see patients as opposed to the research laboratory. Typically, more than average interest in basic research is automatically interpreted as lack of interest in clinical and surgical work. It is quite all right to chat about an interesting patient or a difficult surgery but not to discuss a challenging experiment or a preliminary discovery. The "antiresearch" culture in the clinical wards is prevalent and deep, and a lot of "restructuring" is needed in both the morphologic and psychologic components of residency. The result of this attitude is missed opportunities to advance knowledge in obstetrics and gynecology. We still know very little of the mechanisms of preterm labor, endometriosis, adhesions, and preeclampsia. We cannot diagnose ovarian cancer early enough because we know nothing of its premalignant stages. We treat all the many different causes of infertility simply by hyperstimulating the whole pathway. We "gonadotropin-releasing hormone" this and laser that and "antiprostaglandin" everything. Unless we understand more about why and how things happen, we cannot design intelligent, effective, and safe therapeutics, and we will continue to use whatever the pharmaceutical industry· throws our way in terms of pills, patches, and needles. Ayman Al-Hendy, MD, PhD Seniar Resident, Depart'flllmt of Obstetrics and Gynecology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada S7N OW8
6/8/102146
Response declined
Anatomy related to rectocele To the Editors: In the recent paper on anatomy related to rectocele (DeLancey JOL. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. AmJ Obstet Gynecol 1999;180:815-22), fascial sheets are described that attach the posterior lateral vaginal wall to the pelvic diaphragm. During total vaginectomy for gender dysphoria in 9 nulliparous patients, I have consistently encountered these structures. Five of these patients had concomitant hysterectomy, and at the time the described fascial sheets seemed to be a caudal continuation of the
uterosacral ligaments. I would appreciate any thoughts or data DeLancey might have regarding this. Mitchel S. Hoffman, MD Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Rorida College of Medicine, Suite 529, Harbour Side Medical Tower, Davis Islands, 4 Columbia Dr, Tampa, FL 33606
6/8/102143
Reply To the Editors: All of the connective tissue, which unites the genital tract to the pelvic sidewall, is continuous. In that sense the supportive tissues of levell, level 2, and level 3 are all part of the same body of tissue. Hoffman's observations support this fact and are additional confirmation about the anatomy described in our article. The uterosacral ligaments and the endopelvic fascia that attaches to the mid and distal vagina are in somewhat different portions of the vagina and therefore have different actions. Further research into the exact interrelationship between the uterosacral ligaments and the vaginal supports may help shed light on this. John O.L. DeLancey, MD Professar and Director, Division of Gynecology, Depart'flllmt of Obstetrics and Gynecology, University of Michigan Medical Center, 1500 E Medical Center Dr, L4100 WO'flllm S Hospita~ Ann Arbor, M1 481090276
6/8/102142
Brachial plexus palsy: An in utero injury? To the Editors: In their review of retrospective literature supporting the hypothesis that brachial plexus injuries occur naturally, Gherman et al (Gherman RB, Ouzounian JG, Goodwin TM. Brachial plexus palsy: An in utero injury? Am J Obstet Gynecol 1999;180:1303-7) conclude " .. .in utero forces may underlie a significant portion of these injuries." This is a curious conclusion from a bioengineering perspective because the authors never discuss intrauterine pressures or forces, despite considerable literature on the subject. For example, at 100 mm Hg, a contracting uterus slowly applies about 19 lb of compressive force to the fetus} The force needed to induce a temporary brachial plexus stretch injury is roughly 22 lb of traction, applied rapidly.2 Because most obstetric brachial plexus injuries are related to stretch, rather than compression, neuropathies, it is unlikely that intrauterine forces underlie nearly as many, or as severe, injuries as the authors intimate. Whereas a computer or laboratory model could answer that question in a more precise way, a more compelling issue is whether some brachial plexus injuries can be mitigated or altogether prevented.