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For academia: A bill of particulars
American Journal of
Obstetrics and Gynecology volume 137
number 6
Jvi
Y
15, 19HO
CLINICAL OPINION
This section reports opinion on the handling of clinical situations, i.e., the clinical diagnosis and management of certain disease entities. Papers should range from eight to twenty typed pages, including illustrations. tables, and figures which clarify the author's management. References are limited to sixteen citations. Mail to Frederick P. Zuspan, M.D., Editor.
For academia: A bill of particulars RICHARD L. MILLER, M.D., F.A.C.O.G. Waterloo, Iowa
THE WORD" ACADEMIA" is not to be found in every dictionary. Its usage here is meant to include full-time faculty members of the departments of obstetrics and gynecology of our teaching institutions. Despite the usual postgraduate course polls, there remains the suggestion that this group is not always tu~ed into the educational needs of us "out there." It is also they who plan our meetings. run our professional societies, sit upon elevated dais and lecture to us, and who wield the considerable power of the microphone. For the most part they also write and edit our journals and carry on endless public monologues in the lay popular media as well. This bill of particulars touches upon only a few points which these people might ponder. There are many more. Finally, these points are set down here in no prioritv sequence. Ultrasound
This technology, especially the new real-time scanner, is of fantastic benefit for us all, but many of us legitiReprint requests: Dr. Richard L. Miller, 330 South St., Waterloo. Iowa 50701. 0002·9378/B0/140635+03$00.30/0
©
1980 The C. V. Mosby Co.
mately dread the possibility that somewhere down the line we shall face something akin w the diethylstilbestrol and x-ray problems we now know exist. Exposing cell cultures or sheep fetuses to ultrasound waves is not quite the same as exposing humans in utero in the early weeks of intrauterine life to these same waves. We really do not know if this modality is safe, and responsible long-range data ought to be ongoing right now.
Breech There is no doubt that many breech deliveries of the past ought better to have been accomplished abdominally, but it is another thing altogether to imply that all breech presentations should be delivered bv cesarean section. A breech presentation should be treated as any other high-risk situation: X-ray pelvimetry as well as a determination of position especially as it pertains to the fetal head is indicated. Internal fetal monitoring during labor is important, and good anesthetic procedures as well as skill and experience on the part of the obstetrician are other essentials to good management. Many of us have delivered hundreds of breeches and have 635
636
Miller
juh 1·•. \111. J
not left in our wake maimed or retarded citizens. It is also possible that all the problems do not occur in the birth room but may be related to intrauterine factors; The fetal calvaria may not do well when in close approximation to the area of fundal dominance, and there are other speculations one might entertain. There is not, to my knowledge, a good prospective study of carefully monitored breech labors and such a study should be done forthwith before we are all forced to deliver by cesarean section for reasons of malpractice. Infection
Today our maternity units, once so clean, are adrift in a vast primordial bacterial soup. The germs have now gone underground and whereas a short time ago anaerobes were of little concern to us they now constitute a formidable problem. Could some of this be due in part to Academia's dubious recommendation that it was no longer necessary to separate postpartum patients from postoperative gynecologic patients, particularly as applied to postoperative vaginal surgery patients? Bacteria have something in common with rats-they are very adaptive in their survival techniques. The germs are adapting faster than we can invent effective microbials to contain them and there may well come a day when they become useless. It is a sad state of affairs when we are advised to use prophylactic antibiotics in situations where careful surgical expertise should suffice. If the original quasi-Semmelweissian concept of postpartum care is now considered passe, if adequate cleansing and perhaps even shaving of the perineum so traumatic and unnatural, if meticulous surgical technique so time consuming, then we have learned very little and the problem will continue.
Resident training The percentage of medical students opting for our specialty remains fixed at about 7, perhaps not always the brightest in the class but still very bright indeed. Somewhere along the line, however, Academia have inHuenced these young people to become somewhat too dependent on electronic gadgetry, endless esoteric laboratory tests, and antibiotics. Perhaps it might be a good idea to incorporate into each department a fulltime seasoned clinician-he could leaven all this pure science with common sense both as it applies to patient care and as it applies to the insurance carriers' or patients' purses. Residents still should be able to auscultate, palpate, evaluate, and even think on occasion, and they ought not be taught to resort to the scalpel so quickly in minimal stress situations.
1!1~1>
()h..,rct ( r\ !H'< ()I.
Journals
Academia must cut back on their output before we literally drown in paper. There should he a ban on publishing preliminary reports and fiH· the most part large, well-controlled, double-blind prospective studies are the only ones which should reach the press. Academia, who are all too hot to publish fot· one reason or another, should communicate by telephone or mailogram in private rather than in the journals when they are merely hinting at things or giving their impressions.
Recertification
It will soon be a matter of survival and most of us are resigned to it, but it is nonetheless a very bitter pill. Consumers probably first thought of it as a good idea but it \vas fostered by Academia, although they love to make a point out of differentiating themselves. fn'>m the American Board. 1t is a bitter pill because we all know that no written examination can ever hope to truly evaluate the skills of an experienced, innovative clinician. Many of the examination questions are too absurd and impractical to discuss and the very considerable stresses of the recertification process upon us are incalculable. The pill
The extraordinary zeal with which investigators have researched the pill has no precedent in medkine. They have found very little good in it and have brayed at the top of their lungs vis-a-vis the media about all the possible problems in a manner some of us find quite offensive. Young women are fleeing the pill in large numbers and this portends ill for the future. Who wishes to return to the enormous numbers of unwanted pregnancies of the past with all the problems associated with then1? Many of us use the pill as our front-line contraceptive and have for years, and I am still looking for my first significant pill problem. The anti-pill flak should be turned down a bit because the alternative to a near-perfect, effective contraceptive· is usually pregnancy, which is not free from risk as we all know perfectly well, and this ought to be factored into
the equation much more so than it presently is. Cancer
There is terrible confusion here-too many incomplete short-term studies. Cancer is much too serious a disease to treat with anything but the best within us and the treatment phase of it simply cannot all be done by oncologists in oncology centers, desirable as this goal may he. With all the tragic material around us one
For academia
Volume J:l7 :\umber 11
would think that bv now \W would have effective protocols for most of the gynecologic malignancies, but we are far from it. There is confusion in the literature on almost every therapeutic point and the confusion has spread to our patients through the insidious implications of the public press. Granted the exact cause of cancer is unknown, but it is poor policy indeed, for example, to tell the public that uterine cancer is caused bv estrogens. These "estrogen cancers"-peculiar because apparently they neither invade nor metastasize. Why in Norway has there been a doubling of the incidence of uterine cancer in a country where estrogens have never been used to any extent in treatment of the menopause and where Premarin has never been introduced: There are obviouslv many factors at work. Academia should clean up its cancer act in our medical literature but almost of more importance in the public media as well.
Postgraduate education Academia has done a very superior job here and we are grateful to them. In spite of their efforts, however, a few points ought to be made: the expense-why are the meetings all held in such expensive places? When last in San Francisco I spent $92.00 per day for a modest hotel room and when I inspected the $70.00 rooms I found them to be closets. Why not arrange ratesreasonable rates-like the other large groups do? The temptation to escalate the fees should be resisted. At a nearby university with an active postgraduate education program they are dealing with fees of over a million dollars yearly and this is not only big business but a big temptation as well. In fact, it would be interesting to see what happens to these large sums-1 mean who gets how much? Some of us are rather amused by the age of om teachers at these meetings. When a full professor aged ::Fi speaks at length and always very eruditely about problems with breech or placenta previa, etc., it might best be described as pathetically amusing since his experience must be minuscule-all we ask is
637
that he keep himself in perspective ..Manv ul us prefer to be taught practical things we can use ;md merelv kPpt abreast of the e.<,oteric technology. Some ()f us might even like to be instructed as to how ex
Anachronisms Academia ought to lead the wav in restructuring some ancient misconceptions. The 40-week gestation myth should be the first to go and all pregnancies ought to be dated from conception. The douche long ago should have become obsolete but it is still being taught to the residents-it is akin to treating conjunctivitis with Murine. Prolapse of the umbilical cord should be seen f(>r what it is-a sign of profound hypotension within the umbilical arterie~ associated with a shock state in the fetus due to whatever, not just due to the fetal position in utero. A normal rord with normal arterial pressures will not and cannot prolapse irrespective of the fetal position. Anchoring the round ligaments to the vaginal cuff for "suppOJ·t" is another hoary surgical procedure that is totally unnecessary but still being taught. Estrogen shots- I have no syringe in my office for shots of any kind, etc. etc. In conclusion, Academia,
Obstetrics and Gynecology volume 137
number 6
Jvi
Y
15, 19HO
CLINICAL OPINION
This section reports opinion on the handling of clinical situations, i.e., the clinical diagnosis and management of certain disease entities. Papers should range from eight to twenty typed pages, including illustrations. tables, and figures which clarify the author's management. References are limited to sixteen citations. Mail to Frederick P. Zuspan, M.D., Editor.
For academia: A bill of particulars RICHARD L. MILLER, M.D., F.A.C.O.G. Waterloo, Iowa
THE WORD" ACADEMIA" is not to be found in every dictionary. Its usage here is meant to include full-time faculty members of the departments of obstetrics and gynecology of our teaching institutions. Despite the usual postgraduate course polls, there remains the suggestion that this group is not always tu~ed into the educational needs of us "out there." It is also they who plan our meetings. run our professional societies, sit upon elevated dais and lecture to us, and who wield the considerable power of the microphone. For the most part they also write and edit our journals and carry on endless public monologues in the lay popular media as well. This bill of particulars touches upon only a few points which these people might ponder. There are many more. Finally, these points are set down here in no prioritv sequence. Ultrasound
This technology, especially the new real-time scanner, is of fantastic benefit for us all, but many of us legitiReprint requests: Dr. Richard L. Miller, 330 South St., Waterloo. Iowa 50701. 0002·9378/B0/140635+03$00.30/0
©
1980 The C. V. Mosby Co.
mately dread the possibility that somewhere down the line we shall face something akin w the diethylstilbestrol and x-ray problems we now know exist. Exposing cell cultures or sheep fetuses to ultrasound waves is not quite the same as exposing humans in utero in the early weeks of intrauterine life to these same waves. We really do not know if this modality is safe, and responsible long-range data ought to be ongoing right now.
Breech There is no doubt that many breech deliveries of the past ought better to have been accomplished abdominally, but it is another thing altogether to imply that all breech presentations should be delivered bv cesarean section. A breech presentation should be treated as any other high-risk situation: X-ray pelvimetry as well as a determination of position especially as it pertains to the fetal head is indicated. Internal fetal monitoring during labor is important, and good anesthetic procedures as well as skill and experience on the part of the obstetrician are other essentials to good management. Many of us have delivered hundreds of breeches and have 635
636
Miller
juh 1·•. \111. J
not left in our wake maimed or retarded citizens. It is also possible that all the problems do not occur in the birth room but may be related to intrauterine factors; The fetal calvaria may not do well when in close approximation to the area of fundal dominance, and there are other speculations one might entertain. There is not, to my knowledge, a good prospective study of carefully monitored breech labors and such a study should be done forthwith before we are all forced to deliver by cesarean section for reasons of malpractice. Infection
Today our maternity units, once so clean, are adrift in a vast primordial bacterial soup. The germs have now gone underground and whereas a short time ago anaerobes were of little concern to us they now constitute a formidable problem. Could some of this be due in part to Academia's dubious recommendation that it was no longer necessary to separate postpartum patients from postoperative gynecologic patients, particularly as applied to postoperative vaginal surgery patients? Bacteria have something in common with rats-they are very adaptive in their survival techniques. The germs are adapting faster than we can invent effective microbials to contain them and there may well come a day when they become useless. It is a sad state of affairs when we are advised to use prophylactic antibiotics in situations where careful surgical expertise should suffice. If the original quasi-Semmelweissian concept of postpartum care is now considered passe, if adequate cleansing and perhaps even shaving of the perineum so traumatic and unnatural, if meticulous surgical technique so time consuming, then we have learned very little and the problem will continue.
Resident training The percentage of medical students opting for our specialty remains fixed at about 7, perhaps not always the brightest in the class but still very bright indeed. Somewhere along the line, however, Academia have inHuenced these young people to become somewhat too dependent on electronic gadgetry, endless esoteric laboratory tests, and antibiotics. Perhaps it might be a good idea to incorporate into each department a fulltime seasoned clinician-he could leaven all this pure science with common sense both as it applies to patient care and as it applies to the insurance carriers' or patients' purses. Residents still should be able to auscultate, palpate, evaluate, and even think on occasion, and they ought not be taught to resort to the scalpel so quickly in minimal stress situations.
1!1~1>
()h..,rct ( r\ !H'< ()I.
Journals
Academia must cut back on their output before we literally drown in paper. There should he a ban on publishing preliminary reports and fiH· the most part large, well-controlled, double-blind prospective studies are the only ones which should reach the press. Academia, who are all too hot to publish fot· one reason or another, should communicate by telephone or mailogram in private rather than in the journals when they are merely hinting at things or giving their impressions.
Recertification
It will soon be a matter of survival and most of us are resigned to it, but it is nonetheless a very bitter pill. Consumers probably first thought of it as a good idea but it \vas fostered by Academia, although they love to make a point out of differentiating themselves. fn'>m the American Board. 1t is a bitter pill because we all know that no written examination can ever hope to truly evaluate the skills of an experienced, innovative clinician. Many of the examination questions are too absurd and impractical to discuss and the very considerable stresses of the recertification process upon us are incalculable. The pill
The extraordinary zeal with which investigators have researched the pill has no precedent in medkine. They have found very little good in it and have brayed at the top of their lungs vis-a-vis the media about all the possible problems in a manner some of us find quite offensive. Young women are fleeing the pill in large numbers and this portends ill for the future. Who wishes to return to the enormous numbers of unwanted pregnancies of the past with all the problems associated with then1? Many of us use the pill as our front-line contraceptive and have for years, and I am still looking for my first significant pill problem. The anti-pill flak should be turned down a bit because the alternative to a near-perfect, effective contraceptive· is usually pregnancy, which is not free from risk as we all know perfectly well, and this ought to be factored into
the equation much more so than it presently is. Cancer
There is terrible confusion here-too many incomplete short-term studies. Cancer is much too serious a disease to treat with anything but the best within us and the treatment phase of it simply cannot all be done by oncologists in oncology centers, desirable as this goal may he. With all the tragic material around us one
For academia
Volume J:l7 :\umber 11
would think that bv now \W would have effective protocols for most of the gynecologic malignancies, but we are far from it. There is confusion in the literature on almost every therapeutic point and the confusion has spread to our patients through the insidious implications of the public press. Granted the exact cause of cancer is unknown, but it is poor policy indeed, for example, to tell the public that uterine cancer is caused bv estrogens. These "estrogen cancers"-peculiar because apparently they neither invade nor metastasize. Why in Norway has there been a doubling of the incidence of uterine cancer in a country where estrogens have never been used to any extent in treatment of the menopause and where Premarin has never been introduced: There are obviouslv many factors at work. Academia should clean up its cancer act in our medical literature but almost of more importance in the public media as well.
Postgraduate education Academia has done a very superior job here and we are grateful to them. In spite of their efforts, however, a few points ought to be made: the expense-why are the meetings all held in such expensive places? When last in San Francisco I spent $92.00 per day for a modest hotel room and when I inspected the $70.00 rooms I found them to be closets. Why not arrange ratesreasonable rates-like the other large groups do? The temptation to escalate the fees should be resisted. At a nearby university with an active postgraduate education program they are dealing with fees of over a million dollars yearly and this is not only big business but a big temptation as well. In fact, it would be interesting to see what happens to these large sums-1 mean who gets how much? Some of us are rather amused by the age of om teachers at these meetings. When a full professor aged ::Fi speaks at length and always very eruditely about problems with breech or placenta previa, etc., it might best be described as pathetically amusing since his experience must be minuscule-all we ask is
637
that he keep himself in perspective ..Manv ul us prefer to be taught practical things we can use ;md merelv kPpt abreast of the e.<,oteric technology. Some ()f us might even like to be instructed as to how ex
Anachronisms Academia ought to lead the wav in restructuring some ancient misconceptions. The 40-week gestation myth should be the first to go and all pregnancies ought to be dated from conception. The douche long ago should have become obsolete but it is still being taught to the residents-it is akin to treating conjunctivitis with Murine. Prolapse of the umbilical cord should be seen f(>r what it is-a sign of profound hypotension within the umbilical arterie~ associated with a shock state in the fetus due to whatever, not just due to the fetal position in utero. A normal rord with normal arterial pressures will not and cannot prolapse irrespective of the fetal position. Anchoring the round ligaments to the vaginal cuff for "suppOJ·t" is another hoary surgical procedure that is totally unnecessary but still being taught. Estrogen shots- I have no syringe in my office for shots of any kind, etc. etc. In conclusion, Academia,