- Email: [email protected]
Patterns of recruitment to the specialty of obstetrics and gynaecology
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 156–178 *Corresponding
author. Tel.: +44 7414151355
E-mail address: [email protected] (S. Rao). 1
Darlington Memorial Hospital, Darlington, United Kingdom. 2 The James Cook University Hospital, Middlesbrough, United Kingdom. Received 6 December 2015
http://dx.doi.org/10.1016/j.ejogrb.2015.12.025
Patterns of recruitment to the specialty of obstetrics and gynaecology Dear Editors, We have performed a 15 year retrospective observational study of data obtained from General Medical Council primary medical registration and specialist O&G registration databases from 1998 to 2012. Our study has shown that the total number of doctors who first registered during this time period was 74,658. Male and female graduates were 32,128 (43%) and 42,530 (57%) respectively. There were 1047 (1.4%) new entries to the O&G specialist register comprising 466 (45%) males and 581 (55%) females (Table 1). The proportion of new entries to the O&G specialist register out of the total number of doctors who first registered during this time period include 1.45% for males and 1.37% for females, the number of female first registrations was fairly steady overtime; however the percentage of female O&G registrations increased particularly from 2007. Large recruiters to this specialty were Belfast, Edinburgh and Glasgow, whereas less recruitment was seen from Southampton, Newcastle and Birmingham. The large O&G recruiters were 3–4 times more successful than the smaller recruiters. The high proportion of male recruitment as compared to females was observed from Liverpool (2.2% males and 1.5% females), and Birmingham (1.3% and 0.6% respectively).
175
The greatest proportion of female O&G entries compared to males was observed from Cambridge graduates, where females and males were 2.2% and 0.9%, Glasgow; 2.2% and 1.3% and Aberdeen; 1.5% and 0.7%. Even though more female candidates are joining medical schools at undergraduate level this does not explain the whole increase in female O&G registrations. Heiligers [1] observed in his study in the Netherlands that female graduates tend to choose less surgery related specialties and more General Practice/non-surgery-related specialties as compared to men. It has been recognized in previous studies that male graduates are opting against the career in O&G [2,3]. The differences between male and female recruitment may be related to certain external factors such as their career guidance, undergraduate experience, influence of role models or mentorship, gender discrimination, work-life imbalance or job satisfaction, long hours of mental and physical work, patient preference of female doctors, stress and litigation in this speciality [2–5]. Some, but not all, of these factors may affect male doctors disproportionally. Our results are similar to the Turner et al. [3] were significantly higher than average number of graduates from Belfast, Aberdeen, Dundee, Edinburgh and Liverpool joined the specialty. Less recruitment was seen from Southampton, Birmingham and Wales. The strengths of our study include a large data set and reliable, complete data on registrations. The limitation of the study is that the data set covers 15 years and the length of specialist training is 9 years after graduation. Therefore many O&G specialists graduated outside of the period of study and many medical graduates were not included in the data on specialist registration. To examine a data set to evaluate the time between graduation and specialization would be difficult and would only give an evaluation of the previous decade. The universities that recruit a large proportion of their graduates should be studied to find out why they are so successful. Over the past decades more females have graduated from Medical school [1] resulting in a change of the makeup of the graduate profession. However the graduate gender imbalance does not explain the O&G gender imbalance and the operative factors for this should be studied.
Table 1 The numbers of male and female graduates and the number of male/female O&G specialist registrants (expressed as a percentage of male and female graduates) for each UK university. University Southampton Newcastle upon Tyne Birmingham Wales Sheffield Leeds Aberdeen Nottingham Oxford Dundee Leicester Manchester Bristol Cambridge London Liverpool Glasgow Edinburgh Belfast Total
Male graduates n
Female graduates n
Total
Male O&G n (%)
Female O&G n (%)
Total
1154 1364 1671 1180 1283 1210 1160 1421 891 955 1161 2554 1013 1002 8726 1421 1400 1347 1215
1601 2239 2370 1716 1901 1843 1403 2071 1009 1228 1546 3189 1607 979 10,068 2126 2120 1978 1530
2755 3603 4041 2896 3184 3053 2563 3492 1900 2183 2707 5743 2620 1981 18,794 3547 3520 3325 2751
0.78 0.88 1.26 1.10 0.62 0.99 0.69 0.99 1.01 1.36 1.38 1.33 1.38 0.90 1.99 2.18 1.29 1.86 2.14
0.50 0.89 0.63 0.76 1.10 1.14 1.50 1.26 1.29 1.14 1.23 1.44 1.43 2.15 1.52 1.55 2.17 1.87 2.02
0.62% 0.89% 0.89% 0.90 0.91% 1.08% 1.13% 1.15% 1.16% 1.24% 1.29% 1.39% 1.41% 1.51% 1.74% 1.80% 1.82% 1.86% 2.07%
32,128
42,530
74,658
1.45
1.37
1.40%
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 156–178
176
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ejogrb.2016.01. 002. References [1] Heiligers PJM. Gender differences in medical students’ motives and career choice. BMC Med Educ 2012;12:82. http://dx.doi.org/10.1186/1472-6920-12-82. [2] Ogbonmwan D, Ogbonmwan S. Recruitment and retention in obstetrics and gynaecology in the UK. BJHM 2010;71:103–5. [3] Turner G, LambertTW, Goldacre MJ, Barlow D. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical schools. BJOG 2006;113:350–6. [4] Royal College of Obstetrics Gynaecology. A career in obstetrics and gynaecology: recruitment and retention in the specialty. London: RCOG Press; 2006. [5] Morrison J. Influences before and during medical school on career choices. Med Educ 2004;38:230–1.
Sophia Umber Rushd* University Hospital Crosshouse, Kilmarnock Road, Kilmarnock KA2 0BE, UK Victoria Allgar Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK Stephen Lindow Head of Division of Obstetrics, Sidra Medical and Research Center, Doha, Qatar *Corresponding author. Tel.: +44 7889207609 E-mail address: sofi[email protected] (S.U. Rushd).
Received 26 December 2015 http://dx.doi.org/10.1016/j.ejogrb.2016.01.002
Engorged myometrial vein sign in uterine torsion Dear Editors, We found engorged myometrial veins in a case of surgically proven uterine torsion. We hope this sign may help in the preoperative diagnosis of uterine torsion. A 38-year-old female presented with complaint of mass abdomen. Clinical examination suggested a large abdominopelvic mass; differential diagnosis was ovarian mass/fibroid uterus. Ultrasound (USG) examination showed a huge subserous fibroid extending from pelvis to epigastrium and to both flanks. There was suggestion of a pedicle from right side of uterus extending to fibroid; USG differential diagnosis was subserous/broad ligament fibroid. There was unexplained engorgement of myometrial veins; patient had no abdominal pain. Peroperatively uterus was seen rotated 1808 to left side, so that anatomical left lateral wall of uterus was on right side of abdomen and vice versa. A 4 kg pseudo-broad ligament fibroid (that is a subserous fibroid insinuating between folds of broad ligament) was seen with pedicle on right side of abdomen (attached to anatomical left lateral wall of uterus). Surface of uterus appeared congested; later cut sections showed prominent spaces consistent with venous origin within myometrium.
Uterine torsion is rotation of uterus on its long axis for >458 (reported range 60–7208 [1]). Though common in veterinary [2] obstetrics (common complication of labour in cow, fairly common in goat & sheep, rare in horse, dog and pig), uterine torsion is relatively rare in humans. Less than 300 cases of uterine torsion have been reported after the first reports in late 19th century (torsion of human nongravid uterus reported in post-mortem examination in 1863; torsion of uterus reported in living woman in 1876). But many cases are likely under-reported due the nonspecific clinical features and difficult pre-operative diagnosis. Dextrorotation is seen in two thirds of cases and levorotation in one third [1]. Torsion occurs in 2 situations: (a) nongravid uterus, usually associated with fibroid and (b) gravid uterus. Torsion of gravid uterus, though rare in humans, has been described in all age groups of reproductive period, in all parity groups and at all stages of pregnancy [1]. Torsion of nongravid uterus, though rare, is a potentially fatal acute abdominal condition. Normally, position of uterus is maintained with help of broad ligament, round ligaments and uterosacral ligaments. But when large and heavy fibroids rotate, they exert traction on uterus and cause uterus also to rotate. The pseudo-broad ligament location of fibroid in our case must have aided torsion. Here, torsion was asymptomatic, patient presenting with only mass per abdomen due to fibroid. About 11% of torsion in pregnancy has been reported to be asymptomatic [1]. Gas in uterine cavity on plain radiographs [2] and Computed Tomography (CT) scan [2] has been described in uterine torsion. Reported USG findings include change in position of fibroids and placenta [3] compared to previous scan and abnormal position of ovarian vessels across uterus on Doppler. CT examination [4] may show whorled appearance of cervix (suggestive of torsion), areas of hyperdensity and lack of contrast enhancement in causative pelvic mass (haemorrhagic infarction). MRI features [5] include X-shaped configuration of upper vagina (normal vagina is H-shaped on MRI; torsion leads to X-shape). Venous engorgement has been noted per-operatively [3] in uterine torsion; to the best of our knowledge, this is the first ultrasound report of venous engorgement. Preoperative diagnosis of uterine torsion is highly desirable to avoid undue delay in surgery so as to reduce mortality and morbidity; but clinical features are often nonspecific. Ultrasound being relatively widely available, this ‘engorged myometrial vein’ sign may help early diagnosis. Acknowledgements Dr Rajith Mukundan (literature search), Dr Sheela (Pathology), Dr Suma Job, Dr Ashwin, Dr Sandhya, Dr Nandini, Ms Hanna (Government Medical College Kottayam). References [1] Jensen JG. Uterine torsion in pregnancy. Acta Obstet Gynecol Scand 1992;71(4):260–5. [2] Davies JH. Case report: torsion of a nongravid nonmyomatous uterus. Clin Radiol 1998;53:780–2. [3] Kremer JAM, van Dongen PWJ. Torsion of the pregnant uterus with a change in placental localization on ultrasound; a case report. Eur J Obstet Gynecol Reprod Biol 1989;31:273–5. [4] Luk SY, Leung JLY, Cheung ML, So S, Fung SH, Cheng SCS. Torsion of a nongravid myomatous uterus: radiological features and literature review. Hong Kong Med J 2010;16(4):304–6. [5] Nicholson WK, Coulson CC, McCoy MC, Semelka RC. Pelvic magnetic resonance imaging in the evaluation of uterine torsion. Obstet Gynecol 1995;85(5): 888–90.
author. Tel.: +44 7414151355
E-mail address: [email protected] (S. Rao). 1
Darlington Memorial Hospital, Darlington, United Kingdom. 2 The James Cook University Hospital, Middlesbrough, United Kingdom. Received 6 December 2015
http://dx.doi.org/10.1016/j.ejogrb.2015.12.025
Patterns of recruitment to the specialty of obstetrics and gynaecology Dear Editors, We have performed a 15 year retrospective observational study of data obtained from General Medical Council primary medical registration and specialist O&G registration databases from 1998 to 2012. Our study has shown that the total number of doctors who first registered during this time period was 74,658. Male and female graduates were 32,128 (43%) and 42,530 (57%) respectively. There were 1047 (1.4%) new entries to the O&G specialist register comprising 466 (45%) males and 581 (55%) females (Table 1). The proportion of new entries to the O&G specialist register out of the total number of doctors who first registered during this time period include 1.45% for males and 1.37% for females, the number of female first registrations was fairly steady overtime; however the percentage of female O&G registrations increased particularly from 2007. Large recruiters to this specialty were Belfast, Edinburgh and Glasgow, whereas less recruitment was seen from Southampton, Newcastle and Birmingham. The large O&G recruiters were 3–4 times more successful than the smaller recruiters. The high proportion of male recruitment as compared to females was observed from Liverpool (2.2% males and 1.5% females), and Birmingham (1.3% and 0.6% respectively).
175
The greatest proportion of female O&G entries compared to males was observed from Cambridge graduates, where females and males were 2.2% and 0.9%, Glasgow; 2.2% and 1.3% and Aberdeen; 1.5% and 0.7%. Even though more female candidates are joining medical schools at undergraduate level this does not explain the whole increase in female O&G registrations. Heiligers [1] observed in his study in the Netherlands that female graduates tend to choose less surgery related specialties and more General Practice/non-surgery-related specialties as compared to men. It has been recognized in previous studies that male graduates are opting against the career in O&G [2,3]. The differences between male and female recruitment may be related to certain external factors such as their career guidance, undergraduate experience, influence of role models or mentorship, gender discrimination, work-life imbalance or job satisfaction, long hours of mental and physical work, patient preference of female doctors, stress and litigation in this speciality [2–5]. Some, but not all, of these factors may affect male doctors disproportionally. Our results are similar to the Turner et al. [3] were significantly higher than average number of graduates from Belfast, Aberdeen, Dundee, Edinburgh and Liverpool joined the specialty. Less recruitment was seen from Southampton, Birmingham and Wales. The strengths of our study include a large data set and reliable, complete data on registrations. The limitation of the study is that the data set covers 15 years and the length of specialist training is 9 years after graduation. Therefore many O&G specialists graduated outside of the period of study and many medical graduates were not included in the data on specialist registration. To examine a data set to evaluate the time between graduation and specialization would be difficult and would only give an evaluation of the previous decade. The universities that recruit a large proportion of their graduates should be studied to find out why they are so successful. Over the past decades more females have graduated from Medical school [1] resulting in a change of the makeup of the graduate profession. However the graduate gender imbalance does not explain the O&G gender imbalance and the operative factors for this should be studied.
Table 1 The numbers of male and female graduates and the number of male/female O&G specialist registrants (expressed as a percentage of male and female graduates) for each UK university. University Southampton Newcastle upon Tyne Birmingham Wales Sheffield Leeds Aberdeen Nottingham Oxford Dundee Leicester Manchester Bristol Cambridge London Liverpool Glasgow Edinburgh Belfast Total
Male graduates n
Female graduates n
Total
Male O&G n (%)
Female O&G n (%)
Total
1154 1364 1671 1180 1283 1210 1160 1421 891 955 1161 2554 1013 1002 8726 1421 1400 1347 1215
1601 2239 2370 1716 1901 1843 1403 2071 1009 1228 1546 3189 1607 979 10,068 2126 2120 1978 1530
2755 3603 4041 2896 3184 3053 2563 3492 1900 2183 2707 5743 2620 1981 18,794 3547 3520 3325 2751
0.78 0.88 1.26 1.10 0.62 0.99 0.69 0.99 1.01 1.36 1.38 1.33 1.38 0.90 1.99 2.18 1.29 1.86 2.14
0.50 0.89 0.63 0.76 1.10 1.14 1.50 1.26 1.29 1.14 1.23 1.44 1.43 2.15 1.52 1.55 2.17 1.87 2.02
0.62% 0.89% 0.89% 0.90 0.91% 1.08% 1.13% 1.15% 1.16% 1.24% 1.29% 1.39% 1.41% 1.51% 1.74% 1.80% 1.82% 1.86% 2.07%
32,128
42,530
74,658
1.45
1.37
1.40%
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 156–178
176
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ejogrb.2016.01. 002. References [1] Heiligers PJM. Gender differences in medical students’ motives and career choice. BMC Med Educ 2012;12:82. http://dx.doi.org/10.1186/1472-6920-12-82. [2] Ogbonmwan D, Ogbonmwan S. Recruitment and retention in obstetrics and gynaecology in the UK. BJHM 2010;71:103–5. [3] Turner G, LambertTW, Goldacre MJ, Barlow D. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical schools. BJOG 2006;113:350–6. [4] Royal College of Obstetrics Gynaecology. A career in obstetrics and gynaecology: recruitment and retention in the specialty. London: RCOG Press; 2006. [5] Morrison J. Influences before and during medical school on career choices. Med Educ 2004;38:230–1.
Sophia Umber Rushd* University Hospital Crosshouse, Kilmarnock Road, Kilmarnock KA2 0BE, UK Victoria Allgar Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK Stephen Lindow Head of Division of Obstetrics, Sidra Medical and Research Center, Doha, Qatar *Corresponding author. Tel.: +44 7889207609 E-mail address: sofi[email protected] (S.U. Rushd).
Received 26 December 2015 http://dx.doi.org/10.1016/j.ejogrb.2016.01.002
Engorged myometrial vein sign in uterine torsion Dear Editors, We found engorged myometrial veins in a case of surgically proven uterine torsion. We hope this sign may help in the preoperative diagnosis of uterine torsion. A 38-year-old female presented with complaint of mass abdomen. Clinical examination suggested a large abdominopelvic mass; differential diagnosis was ovarian mass/fibroid uterus. Ultrasound (USG) examination showed a huge subserous fibroid extending from pelvis to epigastrium and to both flanks. There was suggestion of a pedicle from right side of uterus extending to fibroid; USG differential diagnosis was subserous/broad ligament fibroid. There was unexplained engorgement of myometrial veins; patient had no abdominal pain. Peroperatively uterus was seen rotated 1808 to left side, so that anatomical left lateral wall of uterus was on right side of abdomen and vice versa. A 4 kg pseudo-broad ligament fibroid (that is a subserous fibroid insinuating between folds of broad ligament) was seen with pedicle on right side of abdomen (attached to anatomical left lateral wall of uterus). Surface of uterus appeared congested; later cut sections showed prominent spaces consistent with venous origin within myometrium.
Uterine torsion is rotation of uterus on its long axis for >458 (reported range 60–7208 [1]). Though common in veterinary [2] obstetrics (common complication of labour in cow, fairly common in goat & sheep, rare in horse, dog and pig), uterine torsion is relatively rare in humans. Less than 300 cases of uterine torsion have been reported after the first reports in late 19th century (torsion of human nongravid uterus reported in post-mortem examination in 1863; torsion of uterus reported in living woman in 1876). But many cases are likely under-reported due the nonspecific clinical features and difficult pre-operative diagnosis. Dextrorotation is seen in two thirds of cases and levorotation in one third [1]. Torsion occurs in 2 situations: (a) nongravid uterus, usually associated with fibroid and (b) gravid uterus. Torsion of gravid uterus, though rare in humans, has been described in all age groups of reproductive period, in all parity groups and at all stages of pregnancy [1]. Torsion of nongravid uterus, though rare, is a potentially fatal acute abdominal condition. Normally, position of uterus is maintained with help of broad ligament, round ligaments and uterosacral ligaments. But when large and heavy fibroids rotate, they exert traction on uterus and cause uterus also to rotate. The pseudo-broad ligament location of fibroid in our case must have aided torsion. Here, torsion was asymptomatic, patient presenting with only mass per abdomen due to fibroid. About 11% of torsion in pregnancy has been reported to be asymptomatic [1]. Gas in uterine cavity on plain radiographs [2] and Computed Tomography (CT) scan [2] has been described in uterine torsion. Reported USG findings include change in position of fibroids and placenta [3] compared to previous scan and abnormal position of ovarian vessels across uterus on Doppler. CT examination [4] may show whorled appearance of cervix (suggestive of torsion), areas of hyperdensity and lack of contrast enhancement in causative pelvic mass (haemorrhagic infarction). MRI features [5] include X-shaped configuration of upper vagina (normal vagina is H-shaped on MRI; torsion leads to X-shape). Venous engorgement has been noted per-operatively [3] in uterine torsion; to the best of our knowledge, this is the first ultrasound report of venous engorgement. Preoperative diagnosis of uterine torsion is highly desirable to avoid undue delay in surgery so as to reduce mortality and morbidity; but clinical features are often nonspecific. Ultrasound being relatively widely available, this ‘engorged myometrial vein’ sign may help early diagnosis. Acknowledgements Dr Rajith Mukundan (literature search), Dr Sheela (Pathology), Dr Suma Job, Dr Ashwin, Dr Sandhya, Dr Nandini, Ms Hanna (Government Medical College Kottayam). References [1] Jensen JG. Uterine torsion in pregnancy. Acta Obstet Gynecol Scand 1992;71(4):260–5. [2] Davies JH. Case report: torsion of a nongravid nonmyomatous uterus. Clin Radiol 1998;53:780–2. [3] Kremer JAM, van Dongen PWJ. Torsion of the pregnant uterus with a change in placental localization on ultrasound; a case report. Eur J Obstet Gynecol Reprod Biol 1989;31:273–5. [4] Luk SY, Leung JLY, Cheung ML, So S, Fung SH, Cheng SCS. Torsion of a nongravid myomatous uterus: radiological features and literature review. Hong Kong Med J 2010;16(4):304–6. [5] Nicholson WK, Coulson CC, McCoy MC, Semelka RC. Pelvic magnetic resonance imaging in the evaluation of uterine torsion. Obstet Gynecol 1995;85(5): 888–90.