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Rededication to the basics
American Journal of
Obstetrics and Gynecology Founded in 1920 volume 144
number 2
SEPTEMBER
15, 1982
Transactions of the Forty-fourth Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists
Rededication to the basics Presidential JOHN
H.
address
RIDLEY,
M.D.,
F.A.C.O.G.
Atlanta, Georgia
HAVE BEEN CALLED the “physicians of the primary care of women,” and we accept that designation gladly. The responsibility of accepting this title has grown during the past three decades and is continuing to grow enormously; this time frame has been chosen because the American Academy of Obstetrics and Gynecology was conceived in 195 1, and then became the American College of Obstetricians and Gynecologists in 1956. An explosion of educational efforts in all specialties has led to a torrent of information, spawned subspecialties, created some confusion and jealousies, and made it imperative that we pause and reflect on what this is doing to our one reason for existence, viz., optimumpatient care. In the year 1980, there were 1,100 approved continuing medical education seminars (CME seminars) in our specialty alone. Although most of these seminars were good, some were useless-no more than traveling medical shows. In our efforts to learn
WE
Presented at the Forty-fourth Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, New Orleans, Louisiana, January 3I-February 3, 1982. Reprint requests: John H. Rid&y, M.D., Northwest, Atlanta, Georgia 30309. 0002-9378/82/180123+04$00.40/0
0
1982
The
35 Collier
C. V. Mosby
Road,
Co.
everything about everything to which we are exposed, we are led to confusion and frustration that recalls to mind the little vignette of Paul Dukas, the “sorcerer’s apprentice,” in which the little fellow is inundated by the efforts of his good intentions, the results of which get out of control. We have drifted away from the basics of our profession. We have become distracted, if not enchanted, by the world of computers and transistors, and by exotic instrumentation. If this enhances the basic care of the patient, all is well and good. But does it always? Our specialty is becoming so large and demanding that we are approaching a point of diminishing returns for the practicing physician. A basic responsibility of a member of our specialty is to be a proficient gynecologic and obstetric surgeon. Proficiency will distinguish us from surgeons of other specialties who would encroach upon our basic responsibility. We must learn to be critically intolerant of mediocrity, and never admit that the general surgeon whose specialty has almost become abdominal surgery can perform female pelvic surgical procedures superior to those which we ourselves can do. We must claim firmly that we are better able than the general urologist to manage the urologic problems of the female pelvis. At the 1981 meeting of the Society of Pel123
124
Ridley
vie Surgeons in Chicago, a panel discussion was presented by selected members of the specialties of gynecology/obstetrics, general surgery, and urology. The main theme was overlapping responsibilities of the three specialties. Undeniably, each contributor had special qualifications by virtue of his interest and training, but one came away from the panel discussion with the distinct impression that the specialty of gynecology/obstetrics has the preponderant responsibility for the surgical care of the female patient. However, among the concessions and claims made by these diverse specialists, there was, indeed, agreement that training in basic general surgical technique is paramount. We gynecologic surgeons must learn enough to be at ease with the general surgical problems that may arise in the female pelvis. Our aim should not be to do elective general surgery but, as Brunschwig has said, and I heartily agree, to be able to quickly recognize and extricate ourselves from the emergencies that can always arise. In short, the gynecologic surgeon should be able to get out of the difficulty into which he has put himself. To go a step further, no surgeon in the course of a difficult procedure should ever hesitate, for a moment, to put pride aside and call upon the needed specialist. Furthermore, we should assume responsibility for management of the diseases of the female breast, as is the case in some institutions at the present time. The fact is that we are the primary physicians of the female genital tract, including the breast, and, therefore, more than members of any other specialty, we are the first to see breast diseases. All of this is by virtue of our basic training in the interrelationship of the anatomy, physiology, endocrinology, and pathology of the female genital tract. However, and to the surprise of no one, I reemphasize my interest in basic surgical training, and I think that this training has been neglected. I think that the young gynecologists/obstetricians who are starting out today are not so competently trained as those who started practice 25 years ago. Before anyone takes offense, let me assure you that I know that the intelligence, the dexterity, and the potential skills are unchanging, and that we older clinicians and academicians are to blame, in part, for the present shortcomings. Although changing factors have reduced the availability of the clinic patient, nonetheless, more patients are cared for surgically now than were previously because of third-party and government participation. However, because of our lack of communication, or lack of demonstration, we have not motivated enough potentially fine young surgeons. We have not effectively guided them through the formative years of basic training, at which time there must be encouragement
September 15, 1982 Am. J. Obstet. Gynecol.
of talent and ambition, as well as scrutiny to detect the development of bad habits in surgical judgment and technique. The impressionable years are the time when the incompetent, the inept, the disinterested, indifferent, and poorly motivated trainee should be weeded out, and the aspiring resident be helped to choose the avenue which he will dedicatedly follow. Some have little interest in the surgical aspects of our specialty, and that fact should be recognized as soon as possible so that the period of training can be devoted to a subspecialty in which the trainee is better skilled and motivated. I will address my thoughts to that broad and important subject later. More specifically, however, we have neglected our obligation as physicians to teach, to teach! The busy clinician may default by virtue of “being too busy,” or because of indifference, laziness, or ineptness. The academician may default by aloofness, condescension, “being too busy,” disinterest, or ineptness. The responsibility of teaching gynecologic surgery should not be left to the parade of residents, by which practice we see an inbreeding of bad habits and techniques, which become established by lack of supervision and demonstration on the part of the more experienced staff. Granted, we may not all be interested in the surgical aspects and responsibilities of our specialty, but, overall, there is a reservoir of skill that needs to be recognized and used for training. The specialty of gynecology/obstetrics has always been classified as one of the surgical specialties. I was privileged to have been taught gynecologic surgery by clinicians and academicians who were dedicated and superbly qualified, and to them I am deeply grateful. I have also assisted men whose technique and judgment I abhorred. But it is axiomatic to say that we learn how to do things and we also learn how not to do things. Actually, the gynecologic trainee spends much less time in the operating room than does the general surgical trainee, in the average programs. The academician has a most important responsibility in the training of the fledgling surgeon. As is sometimes the case, the academician may not be surgically oriented or talented or, in fact, may even be a very poor surgical technician with little interest in surgical skills, one who never goes into the surgical theater. Nevertheless, he should be able to direct into teaching those on his staff, either full-time or voluntary, who have surgical skills. During the past 35 years, as an active participant in teaching gynecologic surgery, both as a clinician and, for a while, as an academician, I have noticed changes in the attitudes of the academician. A barrier to communication, or even a wall of jealousy, seems to have developed on the part of the academician and the clinician. There was a time
Volume Number
144 2
when the demonstrable skill of the clinician was sought and appreciated. Possibly, he was given an academic clinical title which, though it cost the department nothing, served to express appreciation for his efforts. Many times, these efforts were made at the sacrifice of his own valuable time, and he may have been expected to tolerate without complaint interminable delays in the operating room or on the wards, where he was, in an appreciable manner, held responsible for the preoperative evaluation, as well as the decision for and conduct of the operation. Also, he was to follow closely the postoperative care and evaluation. This willingness to share the teaching load is undiminished and should be exploited to the fullest, because, in my opinion, the finest basic surgical skills are in the hands of the busy clinician. Again, I say that the tyro learns how to perform operations, and how not to, by observing many surgeons at work. I have winced at our not positively asserting ourselves fully into the field of pelvic surgery, wherein the gynecologic surgeon has the greatest potential and responsibility. The general surgeon will do his share of pelvic surgical procedures, not always wisely; and the urologist will argue that the gynecologist is invading his province of pelvic urologic procedures in the female. I reject this argument. More recently, the urologist has grown more protective, if not agitated, as he realizes that we are using, very competently, more and more of the simple diagnostic techniques of cystourethroscopy and urodynamics. For years, the urologist has had only a passing interest in female urologic care. For example, on one occasion many years ago, Dr. Wyland Ledbetter, of Baltimore and Boston, told me at a conference that he had never seen a female urologic complaint that could not be cured with an adequate urethral dilation. He was kidding, of course, but he made known his basic philosophy, nevertheless. This overlapping in the field of responsibility dates back, as an example, to the respective services of gynecology under the direction of Howard A. Kelly and of urology under Hugh Hampton Young, at the Johns Hopkins Hospital. More recently, we have competently and rightfully broadened our interest in and reasserted our legitimate claim to female urologic care with studies in urodynamics and with sharpened surgical skills. We are more capable of managing these urologic problems because we can competently approach the difficulty by either the vaginal or abdominal route. The urologist and general surgeon rarely use the vaginal approach for the correction of anything, and thereby frequently leave the conditions poorly and incompletely treated. This point emphasizes the importance of training competent vaginal surgeons, because they excel where others are ill at ease
Rededication
to basics
125
and only occasional operators. In other words, we can fit our skills to a given case rather than fit the case to a limited skill. One must perform a surgical procedure to become competent. No amount of nonparticipatory teaching can supplant the valuableness of actual surgical participation; one mustfeel the operation. Vaginal surgery, unlike abdominal surgery, does not lend itself to shared surgical responsibility. However, the senior gynecologic surgeon, with constant participating supervision, can allow his protege to perform in the various phases of the vaginal procedure, whether it be the colporrhaphy or the actual removal of the uterus itself. This type of teaching with shared responsibility is done even more easily in gynecologic abdominal cases. One such case well taught and supervised is worth a thousand videotaped and slide-projected procedures. However, the patient should fully understand the situation so that “ghost surgery” does not become an issue. The competent gynecologic surgeon, particularly in vaginal work, thus sets himself apart from any other type of surgeon, and our realization of this fact encourages us not only to teach competency but also to continuously strive toward superiority. It is distressing to see a young surgeon, the product of an otherwise extraordinarily good residency training, start his posttraining surgical career timidly, indecisively, and unsure of himself. It is on record that approximately 20% of the candidates for certification by the American Board of Obstetrics and Gynecology in 1980 had not performed a vaginal hysterectomy during the 2 years subsequent to the completion of their residency. Despite great potential skill, the young surgeon has not been allowed to develop confidence, so that he frequently continues to display poor surgical judgment that can be bred into surgical training services. We older men must watch for this, and the younger man must constantly realize that no one is ever too old to learn. Undaunted pride is a dangerous thing. And now, I present a final thought on a matter that has become of increasing importance with the passage of time. As Sir William Osler once said, “It is of use from time to time to take stock, so to speak, of our knowledge of a particular disease (or condition), to see exactly where we stand in regard to it; to inquire to what conclusions the accumulated facts seem to point and to ascertain in what direction we may look for fruitful investigation in the future.” It is necessary to take stock of the legendary relationship between obstetrics and gynecology, and the exponential growth of the entire specialty in the past 10 years; this is particularly true in the responsibilities and practice of obstetrics but also in the practice of gynecology. We are
126
Ridley
coming to realize that one cannot learn and competently practice in all of the basic areas and also in the developed subspecialties simultaneously. It is a truism that one cannot be an expert in everything because of the danger of becoming inexpert in all of one’s efforts. However, the demand on the gynecologist/obstetrician in practice today is that he be an expert in his chosen field. Anything short of this begs of mediocrity in the care of the patient and invites the possibility of a malpractice judgment by the increasingly litigious society. Our specialty is already beginning to be fragmented by subspecialties in oncology, endocrinology, neonatology, reproductive medicine, endoscopy, female urology, emergency medical care, human sexuality, maternal and fetal medicine, genetics, etc. These are our responsibilities, but they lead us away from the basics of our specialty, which are gynecologic surgery and basic obstetrics. The day will come again, sooner than later, when we will see the separation of gynecology and obstetrics. This will not be a step backward, but a step toward the future. Some of the finest obstetricians may have inferior gynecologic surgical skills, whereas the talented gynecologist may be inept in managing complicated obstetric cases with all of their prenatal and neonatal demands. There must be a way for us to allow the trainee to choose that field in which he has the skill, the aptitude, and the motivation that are required to be superior. It is my opinion that the residency training of the gynecologist/obstetrician must be redefined. The trainee, after a second year of postgraduate training, must decide on the area in which he wishes to concentrate. In these first 2 years, there should be a “core” training period during which not only basic gynecology/obstetrics is emphasized, but also selected basic specialties, such as general surgery, internal medicine, and urology; pathology is to be emphasized throughout the residency training. There would have to be reciprocity of training between the various services. This would not invite the general surgeon or urologist to practice gynecology/obstetrics, or those of our specialty to practice
September Am. J. Obstet.
15, 1982 Gynecol.
general surgery or urology, but would enable all of the trainees to have a better understanding of the various basic surgical problems of female pelvic pathology. Selection could then be made either by the trainee himself or by the head of the services. It may be that the young trainee has found that he has insufficient interest and skill in gynecologic surgery, or his tutors may determine that he is better suited to pursue a predominantly obstetric course, with the alliance and emphasis into that spreading field of care of both the mother and infant. Specialization too early leads to rigidity and immature judgment and promotes factionalism, but this is unlikely to occur after 2 years of “core training.” The following years are better directed into either gynecology or obstetrics, with no disenfranchisement of one from the other. A period spent in an animal laboratory for the perfecting of basic surgical skills is invaluable and is encouraged. Extending the training period from 4 to 5 years will probably become routine. At the present time, this extra year of preparation is accomplished by fellowships and the voluntary selection by the trainee of various subjects within his area of expertise and interest. There will forever be competition for the gynecologist/obstetrician from other specialties; in other words, there is the gray zone of overlap which can and does occur between many specialties in the practice of medicine. We can establish superiority in our given field by competently training ourselves and our successors in basic gynecologic/obstetric principles and practices. In our teaching, we must also extend our efforts to the coworkers in our specialty. We have a primary and most important obligation to teach, and assist in teaching, the fundamentals of gynecology/obstetrics to our nursing staff and paramedical personnel. Without their support, we cannot expect the best care for the patient. I close with a question: Are you satisfied that you have done your share of basic teaching during the past year?
Obstetrics and Gynecology Founded in 1920 volume 144
number 2
SEPTEMBER
15, 1982
Transactions of the Forty-fourth Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists
Rededication to the basics Presidential JOHN
H.
address
RIDLEY,
M.D.,
F.A.C.O.G.
Atlanta, Georgia
HAVE BEEN CALLED the “physicians of the primary care of women,” and we accept that designation gladly. The responsibility of accepting this title has grown during the past three decades and is continuing to grow enormously; this time frame has been chosen because the American Academy of Obstetrics and Gynecology was conceived in 195 1, and then became the American College of Obstetricians and Gynecologists in 1956. An explosion of educational efforts in all specialties has led to a torrent of information, spawned subspecialties, created some confusion and jealousies, and made it imperative that we pause and reflect on what this is doing to our one reason for existence, viz., optimumpatient care. In the year 1980, there were 1,100 approved continuing medical education seminars (CME seminars) in our specialty alone. Although most of these seminars were good, some were useless-no more than traveling medical shows. In our efforts to learn
WE
Presented at the Forty-fourth Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, New Orleans, Louisiana, January 3I-February 3, 1982. Reprint requests: John H. Rid&y, M.D., Northwest, Atlanta, Georgia 30309. 0002-9378/82/180123+04$00.40/0
0
1982
The
35 Collier
C. V. Mosby
Road,
Co.
everything about everything to which we are exposed, we are led to confusion and frustration that recalls to mind the little vignette of Paul Dukas, the “sorcerer’s apprentice,” in which the little fellow is inundated by the efforts of his good intentions, the results of which get out of control. We have drifted away from the basics of our profession. We have become distracted, if not enchanted, by the world of computers and transistors, and by exotic instrumentation. If this enhances the basic care of the patient, all is well and good. But does it always? Our specialty is becoming so large and demanding that we are approaching a point of diminishing returns for the practicing physician. A basic responsibility of a member of our specialty is to be a proficient gynecologic and obstetric surgeon. Proficiency will distinguish us from surgeons of other specialties who would encroach upon our basic responsibility. We must learn to be critically intolerant of mediocrity, and never admit that the general surgeon whose specialty has almost become abdominal surgery can perform female pelvic surgical procedures superior to those which we ourselves can do. We must claim firmly that we are better able than the general urologist to manage the urologic problems of the female pelvis. At the 1981 meeting of the Society of Pel123
124
Ridley
vie Surgeons in Chicago, a panel discussion was presented by selected members of the specialties of gynecology/obstetrics, general surgery, and urology. The main theme was overlapping responsibilities of the three specialties. Undeniably, each contributor had special qualifications by virtue of his interest and training, but one came away from the panel discussion with the distinct impression that the specialty of gynecology/obstetrics has the preponderant responsibility for the surgical care of the female patient. However, among the concessions and claims made by these diverse specialists, there was, indeed, agreement that training in basic general surgical technique is paramount. We gynecologic surgeons must learn enough to be at ease with the general surgical problems that may arise in the female pelvis. Our aim should not be to do elective general surgery but, as Brunschwig has said, and I heartily agree, to be able to quickly recognize and extricate ourselves from the emergencies that can always arise. In short, the gynecologic surgeon should be able to get out of the difficulty into which he has put himself. To go a step further, no surgeon in the course of a difficult procedure should ever hesitate, for a moment, to put pride aside and call upon the needed specialist. Furthermore, we should assume responsibility for management of the diseases of the female breast, as is the case in some institutions at the present time. The fact is that we are the primary physicians of the female genital tract, including the breast, and, therefore, more than members of any other specialty, we are the first to see breast diseases. All of this is by virtue of our basic training in the interrelationship of the anatomy, physiology, endocrinology, and pathology of the female genital tract. However, and to the surprise of no one, I reemphasize my interest in basic surgical training, and I think that this training has been neglected. I think that the young gynecologists/obstetricians who are starting out today are not so competently trained as those who started practice 25 years ago. Before anyone takes offense, let me assure you that I know that the intelligence, the dexterity, and the potential skills are unchanging, and that we older clinicians and academicians are to blame, in part, for the present shortcomings. Although changing factors have reduced the availability of the clinic patient, nonetheless, more patients are cared for surgically now than were previously because of third-party and government participation. However, because of our lack of communication, or lack of demonstration, we have not motivated enough potentially fine young surgeons. We have not effectively guided them through the formative years of basic training, at which time there must be encouragement
September 15, 1982 Am. J. Obstet. Gynecol.
of talent and ambition, as well as scrutiny to detect the development of bad habits in surgical judgment and technique. The impressionable years are the time when the incompetent, the inept, the disinterested, indifferent, and poorly motivated trainee should be weeded out, and the aspiring resident be helped to choose the avenue which he will dedicatedly follow. Some have little interest in the surgical aspects of our specialty, and that fact should be recognized as soon as possible so that the period of training can be devoted to a subspecialty in which the trainee is better skilled and motivated. I will address my thoughts to that broad and important subject later. More specifically, however, we have neglected our obligation as physicians to teach, to teach! The busy clinician may default by virtue of “being too busy,” or because of indifference, laziness, or ineptness. The academician may default by aloofness, condescension, “being too busy,” disinterest, or ineptness. The responsibility of teaching gynecologic surgery should not be left to the parade of residents, by which practice we see an inbreeding of bad habits and techniques, which become established by lack of supervision and demonstration on the part of the more experienced staff. Granted, we may not all be interested in the surgical aspects and responsibilities of our specialty, but, overall, there is a reservoir of skill that needs to be recognized and used for training. The specialty of gynecology/obstetrics has always been classified as one of the surgical specialties. I was privileged to have been taught gynecologic surgery by clinicians and academicians who were dedicated and superbly qualified, and to them I am deeply grateful. I have also assisted men whose technique and judgment I abhorred. But it is axiomatic to say that we learn how to do things and we also learn how not to do things. Actually, the gynecologic trainee spends much less time in the operating room than does the general surgical trainee, in the average programs. The academician has a most important responsibility in the training of the fledgling surgeon. As is sometimes the case, the academician may not be surgically oriented or talented or, in fact, may even be a very poor surgical technician with little interest in surgical skills, one who never goes into the surgical theater. Nevertheless, he should be able to direct into teaching those on his staff, either full-time or voluntary, who have surgical skills. During the past 35 years, as an active participant in teaching gynecologic surgery, both as a clinician and, for a while, as an academician, I have noticed changes in the attitudes of the academician. A barrier to communication, or even a wall of jealousy, seems to have developed on the part of the academician and the clinician. There was a time
Volume Number
144 2
when the demonstrable skill of the clinician was sought and appreciated. Possibly, he was given an academic clinical title which, though it cost the department nothing, served to express appreciation for his efforts. Many times, these efforts were made at the sacrifice of his own valuable time, and he may have been expected to tolerate without complaint interminable delays in the operating room or on the wards, where he was, in an appreciable manner, held responsible for the preoperative evaluation, as well as the decision for and conduct of the operation. Also, he was to follow closely the postoperative care and evaluation. This willingness to share the teaching load is undiminished and should be exploited to the fullest, because, in my opinion, the finest basic surgical skills are in the hands of the busy clinician. Again, I say that the tyro learns how to perform operations, and how not to, by observing many surgeons at work. I have winced at our not positively asserting ourselves fully into the field of pelvic surgery, wherein the gynecologic surgeon has the greatest potential and responsibility. The general surgeon will do his share of pelvic surgical procedures, not always wisely; and the urologist will argue that the gynecologist is invading his province of pelvic urologic procedures in the female. I reject this argument. More recently, the urologist has grown more protective, if not agitated, as he realizes that we are using, very competently, more and more of the simple diagnostic techniques of cystourethroscopy and urodynamics. For years, the urologist has had only a passing interest in female urologic care. For example, on one occasion many years ago, Dr. Wyland Ledbetter, of Baltimore and Boston, told me at a conference that he had never seen a female urologic complaint that could not be cured with an adequate urethral dilation. He was kidding, of course, but he made known his basic philosophy, nevertheless. This overlapping in the field of responsibility dates back, as an example, to the respective services of gynecology under the direction of Howard A. Kelly and of urology under Hugh Hampton Young, at the Johns Hopkins Hospital. More recently, we have competently and rightfully broadened our interest in and reasserted our legitimate claim to female urologic care with studies in urodynamics and with sharpened surgical skills. We are more capable of managing these urologic problems because we can competently approach the difficulty by either the vaginal or abdominal route. The urologist and general surgeon rarely use the vaginal approach for the correction of anything, and thereby frequently leave the conditions poorly and incompletely treated. This point emphasizes the importance of training competent vaginal surgeons, because they excel where others are ill at ease
Rededication
to basics
125
and only occasional operators. In other words, we can fit our skills to a given case rather than fit the case to a limited skill. One must perform a surgical procedure to become competent. No amount of nonparticipatory teaching can supplant the valuableness of actual surgical participation; one mustfeel the operation. Vaginal surgery, unlike abdominal surgery, does not lend itself to shared surgical responsibility. However, the senior gynecologic surgeon, with constant participating supervision, can allow his protege to perform in the various phases of the vaginal procedure, whether it be the colporrhaphy or the actual removal of the uterus itself. This type of teaching with shared responsibility is done even more easily in gynecologic abdominal cases. One such case well taught and supervised is worth a thousand videotaped and slide-projected procedures. However, the patient should fully understand the situation so that “ghost surgery” does not become an issue. The competent gynecologic surgeon, particularly in vaginal work, thus sets himself apart from any other type of surgeon, and our realization of this fact encourages us not only to teach competency but also to continuously strive toward superiority. It is distressing to see a young surgeon, the product of an otherwise extraordinarily good residency training, start his posttraining surgical career timidly, indecisively, and unsure of himself. It is on record that approximately 20% of the candidates for certification by the American Board of Obstetrics and Gynecology in 1980 had not performed a vaginal hysterectomy during the 2 years subsequent to the completion of their residency. Despite great potential skill, the young surgeon has not been allowed to develop confidence, so that he frequently continues to display poor surgical judgment that can be bred into surgical training services. We older men must watch for this, and the younger man must constantly realize that no one is ever too old to learn. Undaunted pride is a dangerous thing. And now, I present a final thought on a matter that has become of increasing importance with the passage of time. As Sir William Osler once said, “It is of use from time to time to take stock, so to speak, of our knowledge of a particular disease (or condition), to see exactly where we stand in regard to it; to inquire to what conclusions the accumulated facts seem to point and to ascertain in what direction we may look for fruitful investigation in the future.” It is necessary to take stock of the legendary relationship between obstetrics and gynecology, and the exponential growth of the entire specialty in the past 10 years; this is particularly true in the responsibilities and practice of obstetrics but also in the practice of gynecology. We are
126
Ridley
coming to realize that one cannot learn and competently practice in all of the basic areas and also in the developed subspecialties simultaneously. It is a truism that one cannot be an expert in everything because of the danger of becoming inexpert in all of one’s efforts. However, the demand on the gynecologist/obstetrician in practice today is that he be an expert in his chosen field. Anything short of this begs of mediocrity in the care of the patient and invites the possibility of a malpractice judgment by the increasingly litigious society. Our specialty is already beginning to be fragmented by subspecialties in oncology, endocrinology, neonatology, reproductive medicine, endoscopy, female urology, emergency medical care, human sexuality, maternal and fetal medicine, genetics, etc. These are our responsibilities, but they lead us away from the basics of our specialty, which are gynecologic surgery and basic obstetrics. The day will come again, sooner than later, when we will see the separation of gynecology and obstetrics. This will not be a step backward, but a step toward the future. Some of the finest obstetricians may have inferior gynecologic surgical skills, whereas the talented gynecologist may be inept in managing complicated obstetric cases with all of their prenatal and neonatal demands. There must be a way for us to allow the trainee to choose that field in which he has the skill, the aptitude, and the motivation that are required to be superior. It is my opinion that the residency training of the gynecologist/obstetrician must be redefined. The trainee, after a second year of postgraduate training, must decide on the area in which he wishes to concentrate. In these first 2 years, there should be a “core” training period during which not only basic gynecology/obstetrics is emphasized, but also selected basic specialties, such as general surgery, internal medicine, and urology; pathology is to be emphasized throughout the residency training. There would have to be reciprocity of training between the various services. This would not invite the general surgeon or urologist to practice gynecology/obstetrics, or those of our specialty to practice
September Am. J. Obstet.
15, 1982 Gynecol.
general surgery or urology, but would enable all of the trainees to have a better understanding of the various basic surgical problems of female pelvic pathology. Selection could then be made either by the trainee himself or by the head of the services. It may be that the young trainee has found that he has insufficient interest and skill in gynecologic surgery, or his tutors may determine that he is better suited to pursue a predominantly obstetric course, with the alliance and emphasis into that spreading field of care of both the mother and infant. Specialization too early leads to rigidity and immature judgment and promotes factionalism, but this is unlikely to occur after 2 years of “core training.” The following years are better directed into either gynecology or obstetrics, with no disenfranchisement of one from the other. A period spent in an animal laboratory for the perfecting of basic surgical skills is invaluable and is encouraged. Extending the training period from 4 to 5 years will probably become routine. At the present time, this extra year of preparation is accomplished by fellowships and the voluntary selection by the trainee of various subjects within his area of expertise and interest. There will forever be competition for the gynecologist/obstetrician from other specialties; in other words, there is the gray zone of overlap which can and does occur between many specialties in the practice of medicine. We can establish superiority in our given field by competently training ourselves and our successors in basic gynecologic/obstetric principles and practices. In our teaching, we must also extend our efforts to the coworkers in our specialty. We have a primary and most important obligation to teach, and assist in teaching, the fundamentals of gynecology/obstetrics to our nursing staff and paramedical personnel. Without their support, we cannot expect the best care for the patient. I close with a question: Are you satisfied that you have done your share of basic teaching during the past year?