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Scientific advances, societal trends, and the education andpractice of obstetrician-gynecologists
American Journal of Obstetrics
and Gynecology Founded in 1920
volume 162
number 5
MAY
1990
CLINICAL SECTION Clinical Opinion Scientific advances, societal trends, and the education and practice of obstetrician-gynecologists J.
Robert Willson, MD
Albuquerque, New Mexico Specialization in medicine in the United States began in Colonial America and expanded rapidly, spurred by increasing scientific information and advancing technology. By 1972, when the American Board of Obstetrics and Gynecology instituted subspecialty divisions, it had become impossible for the general obstetrician-gynecologist to remain competent in all areas of our specialty. Changes we can anticipate are a decreasing need for operations and hospital care coupled with increasing emphasis on primary health care for women. Most of our resident education programs have not yet reflected the need to begin to prepare obstetrician-gynecologists for a role that will be quite different from their present one. (AM J OBSTET GVNECOL 1990;162:1135-40.)
Key words: Obstetrician-gynecologist, education, specialization
Although specialization in medicine had already occurred in Great Britain and Europe, most physicians in Colonial America were general practitioners. In 1765 John Morgan, one of the founders of the School of Medicine in the College of Philadelphia, later the University of Pennsylvania, announced that he intended to limit himself to the practice of physic (internal medicine) and suggested that if medicine were divided into different branches" ... the knowledge of medicine will be then daily improved, and it may be practiced with greater accuracy and skill."l By 1886 specialization had advanced to a point at which William Brodie, the President ofthe American Medical Association, commented that interest in limiting practice was increasing because physicians had begun to realize that they could work less hard, earn more money, and do more good as specialists than as general practitioners. At this time surgery was expanding rapidly and a From the Department of Obstetrics and Gynecology, University of New Mexico School of Medicine. Reprint requests: J. Robert Willson, MD, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM 87131. 611117785
bitter rivalry developed between surgeons who did gynecologic operations and obstetricians. The surgeons wanted to relegate the role of obstetricians to that of midwives and in some instances were able to prevent their doing anything except normal deliveries. In 1920 Peterson criticized this attitude, strongly recommending combined departments! As a result of his efforts, and those of others influential in the specialty, departmental unification progressed. By 1959 only three schools, Harvard University, Johns Hopkins University, and the University of Oklahoma, still had divided departments. Harvard combined theirs in 1959, Johns Hopkins in 1960, and Oklahoma in 1961. Specialization in all fields of medicine was inevitable, but the expansion occurred in an informal manner. The establishment of the American Board of Obstetrics and Gynecology in 1930 and the Residency Review Committee later provided the structure needed to improve both education and practice in obstetricsgynecology. At that time graduates of well-designed residencies were able to provide a broad range of services, but their abilities were limited by the lack of general scientific information. The rapid expansion of both knowledge and tech-
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nology after World War II permitted us to understand many medical problems that had been mysteries before and to treat conditions for which previously there had been no relief. Because the general obstetriciangynecologist could no longer either become or remain competent in all the new phases of our specialty, the American Board of Obstetrics and Gynecology developed criteria for certification as subspecialists in gynecologic oncology, maternal-fetal medicine, and reprod uctive endocrinology and infertility in 1972. A principal reason for developing subspecialty programs was to improve teaching and patient care and expand research capabilities by providing medical school faculty members in the specialized areas. In 1987 MerrilP surveyed 113 departmental chairmen and 599 former fellows: 61 % of those in maternal-fetal medicine, 62% in reproductive endocrinology and infertility, and 59% in oncology were medical school faculty members. A survey by Zuspan and Sachs 4 confirmed the opinion that fellowships have aided in advancing obstetricsgynecology, but not everyone was in agreement. An important undesirable effect of subspecialization is that it tends to fragment departments. Sixty-nine percent of the respondents to the Zuspan-Sachs survey agreed that this is happening. Each subspecialty can develop into a small self-sufficient unit with more interest in maintaining its own existence than in the welfare of the department. This is a concern for not only individual departments of obstetrics-gynecology but also the future of our specialty. The demise of obstetricsgynecology as we know it could occur if perinatologists banded together with neonatologists and reproductive endocrinologists with medical endocrinologists to form research and practice teams and if gynecologic oncologists and gynecologic surgeons assume responsibility for major gynecologic surgery. There would no longer be a need for broad-based departments. Gynecologic surgery
Except for the occasional removal of ovarian tumors, the earliest gynecologic surgical procedures were those designed to repair chronic childbirth injuries. Improvements in surgical techniques, the ability to prevent and treat infections, advances in anesthesia and fluid therapy, and an increased understanding of the effects of surgery on physiologic functions now permit us to perform major abdominal and vaginal procedures with reasonable safety. With this came an expansion of surgery to a point at which we are criticized for extending our indications inappropriately. In 1970, 2.841 million obstetric-gynecologic operations were peformed in the United States. This represented 23% of all operations. By 1979 this had increased to 4.339 million, 26% of the total. The 1979 peak was followed by a decrease in both numbers and
May 1990 Am J Obstet Gynecol
percentage of all operations. The decreased number of gynecologic operations was overshadowed by the increase in cesarean sections. 5 The most common major operations between 1979 and 1984 are listed in Table I. The only operative procedures that increased were those to correct infertility, undoubtedly because of the increased number of subspecialists trained in infertility surgery. In 1950 I recommended that we expand the use of hysterectomy and decrease radiation castration for the control of excessive perimenopausal bleeding." The discussants of the presentation decried this radical proposal, but only one was foresighted enough to suggest that we might someday be able to regulate bleeding by improved hormone therapy. As hysterectomy became safer the indications expanded to include sterilization, minimal uterine enlargement caused by leiomyomas, abdominopelvic pain, the pelvic congestion syndrome, and even hysterectomy in response to patients' wishes. A significant factor in reducing the number of operations was improved surveillance. Between 1964 and 1971 the annual number of hysterectomies in Saskatchewan increased by 72%, whereas the number of women over age IS years increased by only 7.6%. After a list of acceptable indications for the operation was compiled and applied, the number of hysterectomies in the hospitals studied decreased significantly between 1971 and 1975. 7 Another controlling factor is the expansion of prepaid health plans in which the emphasis is on avoiding surgery. We all know that many of the hysterectomies performed in this country could be avoided. The hysterectomy ratio in New England in 1982 was 540/100,000 population; this was compared with 220 for National Health Service patients in Great Britain and 118 in Norway. Similar differences occurred in rates for cholecystectomy and tonsillectomy, but the rates for appendectomy were similar in all areas." Unfortunately, physicians who are taught to operate and expect surgery to represent significant amounts of their practices will find reasons to do so. How have these changes influenced the practice of gynecologic surgery? According to a medical economics survey, obstetrician-gynecologists each performed ISO major operations per year in 1981; by 1986 this had fallen to 60, a decrease of 69%. There was little or no change in the other surgical specialties surveyed. 9 It seems likely that the need for surgery will continue to decrease. We will be able to control bleeding by improved hormonal therapy or by destroying or resecting the endometrium, and we can influence both bleeding and the growth of leiomyomas by gonadotropinreleasing hormone therapy. It will also be possible to prevent or control the growth of malignant lesions. Undoubtedly there will be improvements and innova-
Changing needs for resident education
Volume 162 Number 5
tions in the future that will make our present methods seem crude. The need for surgical sterilization can be eliminated as new, effective permanent and temporary methods to prevent pregnancy are developed. A drug, RU 486, which induces early abortion by blocking progesterone receptors, is already available to the rest of the world. If it, or more effective drugs, is approved for use in this country, the need for surgical abortion will be reduced significantly. Ours is not the only specialty that will have a decreasing need for operative therapy. Mandeli lO anticipates a similar fate for urologic surgery. These changes have already had a significant effect on resident education, and it will be even greater in the future. In many hospitals resident experience with major abdominal and vaginal operations is too limited to provide the base they need to become competent surgeons. This will probably not improve as nonoperative therapy is improved and insurance coverage is extended to include women who have traditionally been resident patients. Obstetrician-gynecologists will accept these women as private patients to expand their diminishing surgical practices. In addition, general surgeons certainly will not give up gynecologic operations and urologists are performing more and more operations for incontinence, vaginal as well as abdominal. This will be at the expense of experience for obstetricgynecologic residents. It is unlikely that residents who are graduated with inadequate basic experience in surgery and whose surgical practices are limited to one or fewer major operations per week can ever become specialist-consultant gynecologic surgeons. Obstetrics Obstetrics, which has been the most challenging segment of our specialty, is rapidly losing its glamour. The opportunity to deal with young, healthy women during the miracle of pregnancy and delivery is an experience not available in any other specialty. Neither is the opportunity to cope with unexpected and potentially lethal complications that challenge the expertise of even the most experienced and skillful practitioners. It is impossible to predict accurately the total number of births we can anticipate in the future. Women are having fewer babies and beginning childbearing at a later age. In 1965, 24% of married women aged 20 to 24 years and 13% of those aged 25 to 29 years were childless. By 1983 this had changed to 40% and 27%, respectively." One third of the women who had babies in 1988 were over 30 years of age. Moreover, in 1988, 54% of women over age 30 years planned on having a baby sometime in the future. Most middle- and upperclass women now plan on no more than two children, and many none. The provision of obstetric care may well become
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Table I. Gynecologic operations 1979
1981
1983
Operation
(n)
(n)
(n)
Cesarean section Hysterectomy Vaginal repair Infertility
601,000 638,000 175,000 27,000
704,000 673,000 175,000 50,000
809,000 673,000 150,000 58,000
more demanding. The pregnancies of healthy older mothers usually are uneventful, but the incidence of complicating chronic conditions, such as diabetes, hypertension, uterine leiomyomas, and others, is higher than in younger women. In addition, births to unmarried, low-income, and teenage women are expected to increase. Fifteen percent of those who were born in 1970 live in poverty; this increased to 21 % of those born in 1987. The combination of births to single mothers, teenagers, older women, and those living in poverty will increase the responsibilities of obstetricians. These patients need much more than "routine" obstetric care. A principal cause of disenchantment with obstetrics is the liability risk, the cost of liability insurance, and the emotional effect of being charged with malpractice when none was involved. This has led many obstetricians to curtail their obstetric practices, accepting only patients with minimal risk of developing complications. They refer women with risk factors and those whose pregnancies become abnormal to perinatologists. More and more are giving up obstetrics completely. In 1982, 83% of obstetrician-gynecologists performed vaginal deliveries; by 1988 this had decreased to 72%. The decrease was greatest in those under age 36 years (- 15.2%) and next in those between 46 and 55 years of age (- 13.8%).1> The trend toward giving up obstetrics at an early age is in contrast to what Randalp3 found in exploring the practice patterns of 9703 American Board of Obstetrics and Gynecology diplomates in 1974: 1393 over age 60 years were still practicing obstetrics; 57 of these were over 90 years of age. Only 15% ofthose who had retired before 1973 had left practice before age 65 years. It would be interesting to repeat this survey. It might give a clue as to what to expect in the future. Most hospitals have been reluctant to close obstetric services, but they may have to curtail the services they provide. Women will probably increase their demands for improved, acceptable, and low-cost care during normal pregnancies. This may reduce the need for expensive, high-technology hospital labor-delivery suites in favor of hospital-based or free-standing childbirth centers. Entire hospitals have already closed because of financial problems and more will in the future. Many of these will be in rural areas that have attracted obstetrician-gynecologists because most large urban areas are saturated with physicians.
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Ambulatory care
Obstetrician-gynecologists were among the first to initiate programs in preventive health care. Prenatal care was introduced in Boston during the last decade of the nineteenth century, primarily to detect preeclampsia during early stages. The annual gynecologic examination was proposed by MacFarlane et al. 14 in 1940 in an attempt to detect what was then considered to be early cervical cancer. We have the information and technology that permit us to diagnose and treat many disorders of reproductive function in our offices, and we perform an increasing number of operative procedures without admitting patients to a hospital. Although we have become reasonably adept at dealing with physical disorders, we are lacking in our ability to identify psychosocial problems and help our patients cope with them. Despite expanding opportunities to diagnose and treat interesting disorders in ambulatory patients, many residents consider the clinic only as a place where they find patients to fill the surgical schedule. This obviously is important, but surgery represents a small part of our responsibilities, and it will decrease progressively during the years ahead. Justification for changes in resident education
The services we now provide are important, but we can do more. As the ratio of obstetrician-gynecologists to women continues to change, we must do more if we expect to retain our patients. Pediatricians care for their patients long after they have passed through childhood. Primary-care internists and family practitioners provide many of the services we do and undoubtedly will continue to do so. What special skills can we offer our patients? The obvious one is our knowledge of reproductive physiology and disorders of the reproductive system. In addition, there is no reason to think that we cannot assume more responsibility for primary care than we now do. In 1971 Burkons and 115 reported on a survey designed to determine whether Michigan obstetriciangynecologists practiced as limited specialists or as primary-care physicians to women. Although 54% of 1008 patients of obstetrician-gynecologists stated that they had family physicians, only 14% saw those physicians regularly. They relied on their obstetriciangynecologists for general periodic examinations. Seventy-eight percent of women without a family physician and 55% of those with family physicians had consulted their obstetrician-gynecologists concerning nongynecologic problems; 14% did so regularly. On the basis of this, and confirmatory information obtained from 520 American College of Obstetricians and Gynecologists Fellows concerning their practice patterns, we proposed a curriculum that would permit
May 1990 Am J Obstet Gynecol
residents to develop the skills necessary for not only specialized practices but also those that would enhance their ability to practice as primary physicians. 16 The educational experiences included internal medicine, hypertension and renal disease, reproductive and medical endocrinology, psychiatry, and a weekly session during which each resident could provide general care for his or her own patients. The psychiatric portion should be directed toward improving skills in interviewing, communication, and recognizing and dealing with psychosocial problems, rather than traditional psychiatry. An increasing responsibility is to enhance our ability to deal with changing social behavior and nontraditional patients; for example, single women who are heads of families, working and professional women, unmarried women who request artificial insemination, lesbians, physically handicapped women with sexual problems, sexually active young teenagers, drug and alcohol use, ordinary sexually transmitted diseases, acquired immune deficiency syndrome and a host of others. The top nonscholastic problems in public schools today are drug and alcohol abuse, pregnancy, suicide, rape, robbery, and physical assault. During the 1940s problems were talking in class, chewing gum, making noise, running in the halls, getting out of turn in line, wearing inappropriate clothing, and not putting paper in waste baskets. The expanding population of older women will challenge our ability not only to provide gynecologic care but also to help them solve psychosocial and medical problems. To accomplish this we must become more familiar with the physiology, psychology, and problems of aging, spend more time with each patient, be more aware of their special needs, and become familiar with the agencies to which they can be referred for help. Preventive obstetrics-gynecology
We have been so involved in treating well-established disorders of reproductive organs that we have devoted too little thought to truly preventive obstetricsgynecology. The combination of increasing numbers of obstetrician-gynecologists and a decrease in the number of women for whom each will provide traditional services offers an unusual opportunity to expand our efforts in disease prevention. Grimes 17 has described levels of preventive care ranging from prevention of the basic disease as a primary effort to prevention of disability and death as a last resort. Areas in which prevention can be most effective are in contraception to prevent three million unplanned pregnancies each year, prevention of sexually transmitted diseases, prevention of cervical and uterine cancer, prevention of deaths from breast cancer, prevention of disability and death in our patients and their offspring as a result of
Volume 162 Number 5
drugs and alcohol, prevention of osteoporosis and cardiovascular diseases in aging women, prevention of lung cancer, and many others. Grimes states, "In the years ahead, social gynecology may emerge as a discipline of equal stature as surgical gynecology in the United States."17 Number of obstetrician-gynecologists The guesses as to the need for obstetriciangynecologists may be as accurate as the guesses of demographers concerning birth rates and numbers of deliveries. The Graduate Medical Education National Advisory Committee Report" concluded that there would soon be a surplus, whereas from the figures the American Colllege of Obstetricians and Gynecologists indicated that there would not. Schwartz et al. 19 are equally certain that there will not be an excess of physicians by the turn of the century, but they did not consider needs for individual specialties. Mulhausen and McGeeo estimate that there will be a need for 10.7 obstetrician-gynecologists/100,000 population in health maintenance organizations. This is in contrast to 9.9 obstetrician-gynecologistsIlOOO,OOO population in the Graduate Medical Education National Advisory Committee Report. My contention has been that we already have more obstetrician-gynecologists than we need to provide traditional services and the disparity can only increase unless we either limit residency programs or change our approach to resident education. Although we may need fewer gynecologic surgeons, there certainly will be an expanding need for a different sort of health care for women than what we now provide. Factors that have not been considered adequately in establishing needs are the increasing number of women in our specialty and the life-styles anticipated by both men and women. Most residents expect to work fewer hours a week in practice than did their predecessors. Many women expect to combine a career as mother with that of obstetrician-gynecologist and undoubtedly will curtail practice to devote more time to their families. Members of practice groups and those employed by health maintenance organizations will certainly reduce their working hours. Many residents expect to retire at what has been considered an early age. If these changes do occur, if we expand our efforts in ambulatory and primary care, and if medical student interest in obstetrics-gynecology wanes, there may well be a shortage. Between 1981 and 1986 there was a 15% reduction in applicants to medical schools, but a slight increase in applicants occurred in 1989. So far there has been little change in the 6% to 7% of graduates who choose to become obstetrician-gynecologists, but this may not continue. In 1983,5.4% of men and 11.9% of women
Changing needs for resident education
1139
medical school seniors applied for residency training in obstetrics-gynecology. By 1987 this had decreased to 4.3% of men (-20%) and 10.2% of women (-14%).21 Positions in good residency programs fill regularly, but residents are no longer willing to accept what they consider to be unusual demands on their time and unacceptable stresses. They are much more mobile than they were in the past, resigning to accept positions in programs that conform more to their life-styles or on the insistence of their spouses. Some abandon obstetrics-gynecology completely. Too often they find that they have sacrificed quality of education for an easier short-term existence. In a specialty as broad as ours we should be able to create programs that will fill the needs of anyone who is interested in the medical and psychosocial problems of women. Defining obstetrics-gynecology In 1888 Van de Warker22 objected to the definition of gynecology as "the doctrine of the nature and diseases of women" as being too restricted. He thought the field was too broad to be a specialty" ... since ethics, dialectics, casuistry and sociology contribute to the solution of mental, moral, social and physical problems in a field where priest and logician claim an equal right with the medical man.":!2 More recently committees from the American College of Obstetricians and Gynecologists and other organizations struggled for months to produce a satisfactory definition of an obstetrician-gynecologist. The final definition describes the traditional practitioner and provides for individual variation. Ryan's definition is a functional one: " ... the specialty has been defined, is being defined, and will be defined in the future by the innumerable interactions between patients and their obstetriciangynecologists. Each interaction represents a definition by the patient of those services she desires ... and a definition by the physician of the services he or she is willing to provide."23 Proposal for change We have a problem. It has been generated by a progressing expansion of knowledge and technology, both of which will continue. We have been forced to fragment the specialty of obstetrics-gynecology because it is no longer possible for a single individual to become and remain competent in all its branches. If we admit this we can only conclude that our resident educational programs will soon be outmoded because we are still preparing house officers to practice as did their predecessors. I am not the first to recognize the problem. In 1968 Morton stated, "The time has arrived whell we, as educators, should recognize these changes (advances in knowledge, increased specialization) more fully than we
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have. We must recognize that there is not time, opportunity or desire for the creation of the 'compleat obstetrician-gynecologist' during the course of a standard acceptable residency. "24 It would be inappropriate to abandon traditional house officer education precipitately, because the advances that will alter our responsibilities will develop slowly. However, we can make changes that will not compromise resident's ability to provide traditional services while we are expanding their capabilities in areas that will become progressively more important. We have two basic choices. One is to reduce the number of residencies drastically, retaining only those needed to educate obstetrician-gynecologists as we now do and provide an appropriate number of subspecialists. This would be unacceptable because it ignores the unfilled health care needs of women. More appropriate models would provide basic training for careers in health care for women. These individuals would be prepared to provide diagnostic, therapeutic, counseling, and preventive services that are not now readily available, provide care during pregnancy and labor, and perform cesarean sections and undemanding gynecologic operations. This is exactly what many obstetriciangynecologists now do. An appropriate number would be selected for advanced training in obstetricsgynecology and the subspecialties. The justification for such a change is expressed in a letter from a graduate of our program: "I have been a primary physician, an educator, a lawyer and a secretary. As an obstetrician I am expected to deliver perfect babies every time, and with a low cesarean section rate, even though 16% of our primigravidas have babies weighing more than 4000 gm. I am to be a gynecologist who solves all problems without surgery. My patients will obtain second, and even third, opinions before having a cone biopsy. They will demand removal of submucous fibroids by resectoscope, ask for yttriumaluminum-garnet laser obliteration, or undergo longterm gonadotropin-releasing hormone agonist therapy rather than have a hysterectomy. Of course, I am also a psychiatrist."
REFERENCES 1. Morgan J. A discourse upon the institution of medical schools in America. Philadelphia: W Bradford, 1765. 2. Peterson R. The future of obstetrics and gynecology as a specialty. ]AMA 1920;74:1361-4.
May 1990 Am J Obstet Gynecol
3. Merrill ]A. (Sub)specialization in obstetrics and gynecology: results of a survey by ABOG. AM] OBSTET GYNECOL 1987;156:550-7. 4. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. AM ] OBSTET GYNECOL 1988; 158:747-53. 5. Rutkow 1. Obstetric and gynecologic operations in the United States, 1979 to 1984. Obstet Gynecol 1986;67: 755-9. 6. Willson ]R, Daly MJ. Changing indications for hysterectomy in the climacteric woman. AM] OBSTET GYNECOL 1950;60: 1088-100. 7. Dyck F], Murphy FA, Murphy ]K, et al. Effect of surveillance on the number of hysterectomies in the Province of Saskatchewan. N Engl] Med 1977;296:1326-8. 8. McPherson K, Wennberg]E, Hovind OB, et al. Small area variations in the use of common surgical procedures: an international comparison of New England, England and Norway. N Engl] Med 1982;307:1310-4. 9. Owens A. How much better are surgeons doing? Med Econ 1988:208-27. 10. Mandell HN. Wither urology. Postgrad Med 1989;85: 31-4. 11. United States Bureau of the Census. Statistical abstract of the United States, 1985. Washington, DC: United States Bureau of the Census, 1985. 12. American Medical Association. Access to normal obstetric care: a disturbing trend. SMS reports 3 (1). Chicago: American Medical Association, 1989. 13. Randall CL.The current practices of board-certified obstetricians and gynecologists in the United States. AM] OBSTET GYNECOL 1974; 119: 156-64. 14. MacFarlane C, Fetterman FS, Sturgis MC. An experiment in cancer control: preliminary report on periodic pelvic examination on 1000 well women. AM] OBSTET GYNECOL 1940;39:983-8. 15. Burkons D, Willson ]R. Is the obstetrician-gynecologist a specialist or a primary physician. AM] OBSTET GYNECOL 1975;121:808-12. 16. Willson]R, Burkons D. Obstetrician-gynecologists are primary physicians: education for a new role. AM] OBSTET GYNECOL 1976;126:744-54. 17. Grimes DA. Declining surgical caseload of the obstetrician-gynecologist. Obstet Gynecol 1986;67: 760-2. 18. Summary report of the Graduate Medical Education Advisory Committee to the Secretary, Department of Health and Human Services. Washington DC: Health Resources Administration, 1980; publication (HRA) 81-656. 19. Schwartz WB, Sloan FA, Mendelson DN. Why there will be little or no physician surplus between now and the year 2000. N Engl] Med 1988;318:892-7. 20. Mulhausen R, McGee J. Physician need: an alternative projection from a study of large prepaid group practices. ]AMA 1989;261:1930-4. 21. Babbott D, Baldwin DC, Killian CD, et al. Trends in evolution of specialty choice: comparison of U.S. medical school graduates in 1983 and 1987. ]AMA 1989;261: 2367-71. 22. Van De Warker E. How gynecology is taught. ]AMA 1888;11:167. 23. Ryan GM Jr. Your place or mine. Obstet Gynecol 1982;60:725-8. 24. Morton DG. The changing aspects of specialization. AM ] OBSTET GYNECOL 1968; 102:619-23.
and Gynecology Founded in 1920
volume 162
number 5
MAY
1990
CLINICAL SECTION Clinical Opinion Scientific advances, societal trends, and the education and practice of obstetrician-gynecologists J.
Robert Willson, MD
Albuquerque, New Mexico Specialization in medicine in the United States began in Colonial America and expanded rapidly, spurred by increasing scientific information and advancing technology. By 1972, when the American Board of Obstetrics and Gynecology instituted subspecialty divisions, it had become impossible for the general obstetrician-gynecologist to remain competent in all areas of our specialty. Changes we can anticipate are a decreasing need for operations and hospital care coupled with increasing emphasis on primary health care for women. Most of our resident education programs have not yet reflected the need to begin to prepare obstetrician-gynecologists for a role that will be quite different from their present one. (AM J OBSTET GVNECOL 1990;162:1135-40.)
Key words: Obstetrician-gynecologist, education, specialization
Although specialization in medicine had already occurred in Great Britain and Europe, most physicians in Colonial America were general practitioners. In 1765 John Morgan, one of the founders of the School of Medicine in the College of Philadelphia, later the University of Pennsylvania, announced that he intended to limit himself to the practice of physic (internal medicine) and suggested that if medicine were divided into different branches" ... the knowledge of medicine will be then daily improved, and it may be practiced with greater accuracy and skill."l By 1886 specialization had advanced to a point at which William Brodie, the President ofthe American Medical Association, commented that interest in limiting practice was increasing because physicians had begun to realize that they could work less hard, earn more money, and do more good as specialists than as general practitioners. At this time surgery was expanding rapidly and a From the Department of Obstetrics and Gynecology, University of New Mexico School of Medicine. Reprint requests: J. Robert Willson, MD, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM 87131. 611117785
bitter rivalry developed between surgeons who did gynecologic operations and obstetricians. The surgeons wanted to relegate the role of obstetricians to that of midwives and in some instances were able to prevent their doing anything except normal deliveries. In 1920 Peterson criticized this attitude, strongly recommending combined departments! As a result of his efforts, and those of others influential in the specialty, departmental unification progressed. By 1959 only three schools, Harvard University, Johns Hopkins University, and the University of Oklahoma, still had divided departments. Harvard combined theirs in 1959, Johns Hopkins in 1960, and Oklahoma in 1961. Specialization in all fields of medicine was inevitable, but the expansion occurred in an informal manner. The establishment of the American Board of Obstetrics and Gynecology in 1930 and the Residency Review Committee later provided the structure needed to improve both education and practice in obstetricsgynecology. At that time graduates of well-designed residencies were able to provide a broad range of services, but their abilities were limited by the lack of general scientific information. The rapid expansion of both knowledge and tech-
1135
1136 Willson
nology after World War II permitted us to understand many medical problems that had been mysteries before and to treat conditions for which previously there had been no relief. Because the general obstetriciangynecologist could no longer either become or remain competent in all the new phases of our specialty, the American Board of Obstetrics and Gynecology developed criteria for certification as subspecialists in gynecologic oncology, maternal-fetal medicine, and reprod uctive endocrinology and infertility in 1972. A principal reason for developing subspecialty programs was to improve teaching and patient care and expand research capabilities by providing medical school faculty members in the specialized areas. In 1987 MerrilP surveyed 113 departmental chairmen and 599 former fellows: 61 % of those in maternal-fetal medicine, 62% in reproductive endocrinology and infertility, and 59% in oncology were medical school faculty members. A survey by Zuspan and Sachs 4 confirmed the opinion that fellowships have aided in advancing obstetricsgynecology, but not everyone was in agreement. An important undesirable effect of subspecialization is that it tends to fragment departments. Sixty-nine percent of the respondents to the Zuspan-Sachs survey agreed that this is happening. Each subspecialty can develop into a small self-sufficient unit with more interest in maintaining its own existence than in the welfare of the department. This is a concern for not only individual departments of obstetrics-gynecology but also the future of our specialty. The demise of obstetricsgynecology as we know it could occur if perinatologists banded together with neonatologists and reproductive endocrinologists with medical endocrinologists to form research and practice teams and if gynecologic oncologists and gynecologic surgeons assume responsibility for major gynecologic surgery. There would no longer be a need for broad-based departments. Gynecologic surgery
Except for the occasional removal of ovarian tumors, the earliest gynecologic surgical procedures were those designed to repair chronic childbirth injuries. Improvements in surgical techniques, the ability to prevent and treat infections, advances in anesthesia and fluid therapy, and an increased understanding of the effects of surgery on physiologic functions now permit us to perform major abdominal and vaginal procedures with reasonable safety. With this came an expansion of surgery to a point at which we are criticized for extending our indications inappropriately. In 1970, 2.841 million obstetric-gynecologic operations were peformed in the United States. This represented 23% of all operations. By 1979 this had increased to 4.339 million, 26% of the total. The 1979 peak was followed by a decrease in both numbers and
May 1990 Am J Obstet Gynecol
percentage of all operations. The decreased number of gynecologic operations was overshadowed by the increase in cesarean sections. 5 The most common major operations between 1979 and 1984 are listed in Table I. The only operative procedures that increased were those to correct infertility, undoubtedly because of the increased number of subspecialists trained in infertility surgery. In 1950 I recommended that we expand the use of hysterectomy and decrease radiation castration for the control of excessive perimenopausal bleeding." The discussants of the presentation decried this radical proposal, but only one was foresighted enough to suggest that we might someday be able to regulate bleeding by improved hormone therapy. As hysterectomy became safer the indications expanded to include sterilization, minimal uterine enlargement caused by leiomyomas, abdominopelvic pain, the pelvic congestion syndrome, and even hysterectomy in response to patients' wishes. A significant factor in reducing the number of operations was improved surveillance. Between 1964 and 1971 the annual number of hysterectomies in Saskatchewan increased by 72%, whereas the number of women over age IS years increased by only 7.6%. After a list of acceptable indications for the operation was compiled and applied, the number of hysterectomies in the hospitals studied decreased significantly between 1971 and 1975. 7 Another controlling factor is the expansion of prepaid health plans in which the emphasis is on avoiding surgery. We all know that many of the hysterectomies performed in this country could be avoided. The hysterectomy ratio in New England in 1982 was 540/100,000 population; this was compared with 220 for National Health Service patients in Great Britain and 118 in Norway. Similar differences occurred in rates for cholecystectomy and tonsillectomy, but the rates for appendectomy were similar in all areas." Unfortunately, physicians who are taught to operate and expect surgery to represent significant amounts of their practices will find reasons to do so. How have these changes influenced the practice of gynecologic surgery? According to a medical economics survey, obstetrician-gynecologists each performed ISO major operations per year in 1981; by 1986 this had fallen to 60, a decrease of 69%. There was little or no change in the other surgical specialties surveyed. 9 It seems likely that the need for surgery will continue to decrease. We will be able to control bleeding by improved hormonal therapy or by destroying or resecting the endometrium, and we can influence both bleeding and the growth of leiomyomas by gonadotropinreleasing hormone therapy. It will also be possible to prevent or control the growth of malignant lesions. Undoubtedly there will be improvements and innova-
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tions in the future that will make our present methods seem crude. The need for surgical sterilization can be eliminated as new, effective permanent and temporary methods to prevent pregnancy are developed. A drug, RU 486, which induces early abortion by blocking progesterone receptors, is already available to the rest of the world. If it, or more effective drugs, is approved for use in this country, the need for surgical abortion will be reduced significantly. Ours is not the only specialty that will have a decreasing need for operative therapy. Mandeli lO anticipates a similar fate for urologic surgery. These changes have already had a significant effect on resident education, and it will be even greater in the future. In many hospitals resident experience with major abdominal and vaginal operations is too limited to provide the base they need to become competent surgeons. This will probably not improve as nonoperative therapy is improved and insurance coverage is extended to include women who have traditionally been resident patients. Obstetrician-gynecologists will accept these women as private patients to expand their diminishing surgical practices. In addition, general surgeons certainly will not give up gynecologic operations and urologists are performing more and more operations for incontinence, vaginal as well as abdominal. This will be at the expense of experience for obstetricgynecologic residents. It is unlikely that residents who are graduated with inadequate basic experience in surgery and whose surgical practices are limited to one or fewer major operations per week can ever become specialist-consultant gynecologic surgeons. Obstetrics Obstetrics, which has been the most challenging segment of our specialty, is rapidly losing its glamour. The opportunity to deal with young, healthy women during the miracle of pregnancy and delivery is an experience not available in any other specialty. Neither is the opportunity to cope with unexpected and potentially lethal complications that challenge the expertise of even the most experienced and skillful practitioners. It is impossible to predict accurately the total number of births we can anticipate in the future. Women are having fewer babies and beginning childbearing at a later age. In 1965, 24% of married women aged 20 to 24 years and 13% of those aged 25 to 29 years were childless. By 1983 this had changed to 40% and 27%, respectively." One third of the women who had babies in 1988 were over 30 years of age. Moreover, in 1988, 54% of women over age 30 years planned on having a baby sometime in the future. Most middle- and upperclass women now plan on no more than two children, and many none. The provision of obstetric care may well become
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Table I. Gynecologic operations 1979
1981
1983
Operation
(n)
(n)
(n)
Cesarean section Hysterectomy Vaginal repair Infertility
601,000 638,000 175,000 27,000
704,000 673,000 175,000 50,000
809,000 673,000 150,000 58,000
more demanding. The pregnancies of healthy older mothers usually are uneventful, but the incidence of complicating chronic conditions, such as diabetes, hypertension, uterine leiomyomas, and others, is higher than in younger women. In addition, births to unmarried, low-income, and teenage women are expected to increase. Fifteen percent of those who were born in 1970 live in poverty; this increased to 21 % of those born in 1987. The combination of births to single mothers, teenagers, older women, and those living in poverty will increase the responsibilities of obstetricians. These patients need much more than "routine" obstetric care. A principal cause of disenchantment with obstetrics is the liability risk, the cost of liability insurance, and the emotional effect of being charged with malpractice when none was involved. This has led many obstetricians to curtail their obstetric practices, accepting only patients with minimal risk of developing complications. They refer women with risk factors and those whose pregnancies become abnormal to perinatologists. More and more are giving up obstetrics completely. In 1982, 83% of obstetrician-gynecologists performed vaginal deliveries; by 1988 this had decreased to 72%. The decrease was greatest in those under age 36 years (- 15.2%) and next in those between 46 and 55 years of age (- 13.8%).1> The trend toward giving up obstetrics at an early age is in contrast to what Randalp3 found in exploring the practice patterns of 9703 American Board of Obstetrics and Gynecology diplomates in 1974: 1393 over age 60 years were still practicing obstetrics; 57 of these were over 90 years of age. Only 15% ofthose who had retired before 1973 had left practice before age 65 years. It would be interesting to repeat this survey. It might give a clue as to what to expect in the future. Most hospitals have been reluctant to close obstetric services, but they may have to curtail the services they provide. Women will probably increase their demands for improved, acceptable, and low-cost care during normal pregnancies. This may reduce the need for expensive, high-technology hospital labor-delivery suites in favor of hospital-based or free-standing childbirth centers. Entire hospitals have already closed because of financial problems and more will in the future. Many of these will be in rural areas that have attracted obstetrician-gynecologists because most large urban areas are saturated with physicians.
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Ambulatory care
Obstetrician-gynecologists were among the first to initiate programs in preventive health care. Prenatal care was introduced in Boston during the last decade of the nineteenth century, primarily to detect preeclampsia during early stages. The annual gynecologic examination was proposed by MacFarlane et al. 14 in 1940 in an attempt to detect what was then considered to be early cervical cancer. We have the information and technology that permit us to diagnose and treat many disorders of reproductive function in our offices, and we perform an increasing number of operative procedures without admitting patients to a hospital. Although we have become reasonably adept at dealing with physical disorders, we are lacking in our ability to identify psychosocial problems and help our patients cope with them. Despite expanding opportunities to diagnose and treat interesting disorders in ambulatory patients, many residents consider the clinic only as a place where they find patients to fill the surgical schedule. This obviously is important, but surgery represents a small part of our responsibilities, and it will decrease progressively during the years ahead. Justification for changes in resident education
The services we now provide are important, but we can do more. As the ratio of obstetrician-gynecologists to women continues to change, we must do more if we expect to retain our patients. Pediatricians care for their patients long after they have passed through childhood. Primary-care internists and family practitioners provide many of the services we do and undoubtedly will continue to do so. What special skills can we offer our patients? The obvious one is our knowledge of reproductive physiology and disorders of the reproductive system. In addition, there is no reason to think that we cannot assume more responsibility for primary care than we now do. In 1971 Burkons and 115 reported on a survey designed to determine whether Michigan obstetriciangynecologists practiced as limited specialists or as primary-care physicians to women. Although 54% of 1008 patients of obstetrician-gynecologists stated that they had family physicians, only 14% saw those physicians regularly. They relied on their obstetriciangynecologists for general periodic examinations. Seventy-eight percent of women without a family physician and 55% of those with family physicians had consulted their obstetrician-gynecologists concerning nongynecologic problems; 14% did so regularly. On the basis of this, and confirmatory information obtained from 520 American College of Obstetricians and Gynecologists Fellows concerning their practice patterns, we proposed a curriculum that would permit
May 1990 Am J Obstet Gynecol
residents to develop the skills necessary for not only specialized practices but also those that would enhance their ability to practice as primary physicians. 16 The educational experiences included internal medicine, hypertension and renal disease, reproductive and medical endocrinology, psychiatry, and a weekly session during which each resident could provide general care for his or her own patients. The psychiatric portion should be directed toward improving skills in interviewing, communication, and recognizing and dealing with psychosocial problems, rather than traditional psychiatry. An increasing responsibility is to enhance our ability to deal with changing social behavior and nontraditional patients; for example, single women who are heads of families, working and professional women, unmarried women who request artificial insemination, lesbians, physically handicapped women with sexual problems, sexually active young teenagers, drug and alcohol use, ordinary sexually transmitted diseases, acquired immune deficiency syndrome and a host of others. The top nonscholastic problems in public schools today are drug and alcohol abuse, pregnancy, suicide, rape, robbery, and physical assault. During the 1940s problems were talking in class, chewing gum, making noise, running in the halls, getting out of turn in line, wearing inappropriate clothing, and not putting paper in waste baskets. The expanding population of older women will challenge our ability not only to provide gynecologic care but also to help them solve psychosocial and medical problems. To accomplish this we must become more familiar with the physiology, psychology, and problems of aging, spend more time with each patient, be more aware of their special needs, and become familiar with the agencies to which they can be referred for help. Preventive obstetrics-gynecology
We have been so involved in treating well-established disorders of reproductive organs that we have devoted too little thought to truly preventive obstetricsgynecology. The combination of increasing numbers of obstetrician-gynecologists and a decrease in the number of women for whom each will provide traditional services offers an unusual opportunity to expand our efforts in disease prevention. Grimes 17 has described levels of preventive care ranging from prevention of the basic disease as a primary effort to prevention of disability and death as a last resort. Areas in which prevention can be most effective are in contraception to prevent three million unplanned pregnancies each year, prevention of sexually transmitted diseases, prevention of cervical and uterine cancer, prevention of deaths from breast cancer, prevention of disability and death in our patients and their offspring as a result of
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drugs and alcohol, prevention of osteoporosis and cardiovascular diseases in aging women, prevention of lung cancer, and many others. Grimes states, "In the years ahead, social gynecology may emerge as a discipline of equal stature as surgical gynecology in the United States."17 Number of obstetrician-gynecologists The guesses as to the need for obstetriciangynecologists may be as accurate as the guesses of demographers concerning birth rates and numbers of deliveries. The Graduate Medical Education National Advisory Committee Report" concluded that there would soon be a surplus, whereas from the figures the American Colllege of Obstetricians and Gynecologists indicated that there would not. Schwartz et al. 19 are equally certain that there will not be an excess of physicians by the turn of the century, but they did not consider needs for individual specialties. Mulhausen and McGeeo estimate that there will be a need for 10.7 obstetrician-gynecologists/100,000 population in health maintenance organizations. This is in contrast to 9.9 obstetrician-gynecologistsIlOOO,OOO population in the Graduate Medical Education National Advisory Committee Report. My contention has been that we already have more obstetrician-gynecologists than we need to provide traditional services and the disparity can only increase unless we either limit residency programs or change our approach to resident education. Although we may need fewer gynecologic surgeons, there certainly will be an expanding need for a different sort of health care for women than what we now provide. Factors that have not been considered adequately in establishing needs are the increasing number of women in our specialty and the life-styles anticipated by both men and women. Most residents expect to work fewer hours a week in practice than did their predecessors. Many women expect to combine a career as mother with that of obstetrician-gynecologist and undoubtedly will curtail practice to devote more time to their families. Members of practice groups and those employed by health maintenance organizations will certainly reduce their working hours. Many residents expect to retire at what has been considered an early age. If these changes do occur, if we expand our efforts in ambulatory and primary care, and if medical student interest in obstetrics-gynecology wanes, there may well be a shortage. Between 1981 and 1986 there was a 15% reduction in applicants to medical schools, but a slight increase in applicants occurred in 1989. So far there has been little change in the 6% to 7% of graduates who choose to become obstetrician-gynecologists, but this may not continue. In 1983,5.4% of men and 11.9% of women
Changing needs for resident education
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medical school seniors applied for residency training in obstetrics-gynecology. By 1987 this had decreased to 4.3% of men (-20%) and 10.2% of women (-14%).21 Positions in good residency programs fill regularly, but residents are no longer willing to accept what they consider to be unusual demands on their time and unacceptable stresses. They are much more mobile than they were in the past, resigning to accept positions in programs that conform more to their life-styles or on the insistence of their spouses. Some abandon obstetrics-gynecology completely. Too often they find that they have sacrificed quality of education for an easier short-term existence. In a specialty as broad as ours we should be able to create programs that will fill the needs of anyone who is interested in the medical and psychosocial problems of women. Defining obstetrics-gynecology In 1888 Van de Warker22 objected to the definition of gynecology as "the doctrine of the nature and diseases of women" as being too restricted. He thought the field was too broad to be a specialty" ... since ethics, dialectics, casuistry and sociology contribute to the solution of mental, moral, social and physical problems in a field where priest and logician claim an equal right with the medical man.":!2 More recently committees from the American College of Obstetricians and Gynecologists and other organizations struggled for months to produce a satisfactory definition of an obstetrician-gynecologist. The final definition describes the traditional practitioner and provides for individual variation. Ryan's definition is a functional one: " ... the specialty has been defined, is being defined, and will be defined in the future by the innumerable interactions between patients and their obstetriciangynecologists. Each interaction represents a definition by the patient of those services she desires ... and a definition by the physician of the services he or she is willing to provide."23 Proposal for change We have a problem. It has been generated by a progressing expansion of knowledge and technology, both of which will continue. We have been forced to fragment the specialty of obstetrics-gynecology because it is no longer possible for a single individual to become and remain competent in all its branches. If we admit this we can only conclude that our resident educational programs will soon be outmoded because we are still preparing house officers to practice as did their predecessors. I am not the first to recognize the problem. In 1968 Morton stated, "The time has arrived whell we, as educators, should recognize these changes (advances in knowledge, increased specialization) more fully than we
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have. We must recognize that there is not time, opportunity or desire for the creation of the 'compleat obstetrician-gynecologist' during the course of a standard acceptable residency. "24 It would be inappropriate to abandon traditional house officer education precipitately, because the advances that will alter our responsibilities will develop slowly. However, we can make changes that will not compromise resident's ability to provide traditional services while we are expanding their capabilities in areas that will become progressively more important. We have two basic choices. One is to reduce the number of residencies drastically, retaining only those needed to educate obstetrician-gynecologists as we now do and provide an appropriate number of subspecialists. This would be unacceptable because it ignores the unfilled health care needs of women. More appropriate models would provide basic training for careers in health care for women. These individuals would be prepared to provide diagnostic, therapeutic, counseling, and preventive services that are not now readily available, provide care during pregnancy and labor, and perform cesarean sections and undemanding gynecologic operations. This is exactly what many obstetriciangynecologists now do. An appropriate number would be selected for advanced training in obstetricsgynecology and the subspecialties. The justification for such a change is expressed in a letter from a graduate of our program: "I have been a primary physician, an educator, a lawyer and a secretary. As an obstetrician I am expected to deliver perfect babies every time, and with a low cesarean section rate, even though 16% of our primigravidas have babies weighing more than 4000 gm. I am to be a gynecologist who solves all problems without surgery. My patients will obtain second, and even third, opinions before having a cone biopsy. They will demand removal of submucous fibroids by resectoscope, ask for yttriumaluminum-garnet laser obliteration, or undergo longterm gonadotropin-releasing hormone agonist therapy rather than have a hysterectomy. Of course, I am also a psychiatrist."
REFERENCES 1. Morgan J. A discourse upon the institution of medical schools in America. Philadelphia: W Bradford, 1765. 2. Peterson R. The future of obstetrics and gynecology as a specialty. ]AMA 1920;74:1361-4.
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3. Merrill ]A. (Sub)specialization in obstetrics and gynecology: results of a survey by ABOG. AM] OBSTET GYNECOL 1987;156:550-7. 4. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. AM ] OBSTET GYNECOL 1988; 158:747-53. 5. Rutkow 1. Obstetric and gynecologic operations in the United States, 1979 to 1984. Obstet Gynecol 1986;67: 755-9. 6. Willson ]R, Daly MJ. Changing indications for hysterectomy in the climacteric woman. AM] OBSTET GYNECOL 1950;60: 1088-100. 7. Dyck F], Murphy FA, Murphy ]K, et al. Effect of surveillance on the number of hysterectomies in the Province of Saskatchewan. N Engl] Med 1977;296:1326-8. 8. McPherson K, Wennberg]E, Hovind OB, et al. Small area variations in the use of common surgical procedures: an international comparison of New England, England and Norway. N Engl] Med 1982;307:1310-4. 9. Owens A. How much better are surgeons doing? Med Econ 1988:208-27. 10. Mandell HN. Wither urology. Postgrad Med 1989;85: 31-4. 11. United States Bureau of the Census. Statistical abstract of the United States, 1985. Washington, DC: United States Bureau of the Census, 1985. 12. American Medical Association. Access to normal obstetric care: a disturbing trend. SMS reports 3 (1). Chicago: American Medical Association, 1989. 13. Randall CL.The current practices of board-certified obstetricians and gynecologists in the United States. AM] OBSTET GYNECOL 1974; 119: 156-64. 14. MacFarlane C, Fetterman FS, Sturgis MC. An experiment in cancer control: preliminary report on periodic pelvic examination on 1000 well women. AM] OBSTET GYNECOL 1940;39:983-8. 15. Burkons D, Willson ]R. Is the obstetrician-gynecologist a specialist or a primary physician. AM] OBSTET GYNECOL 1975;121:808-12. 16. Willson]R, Burkons D. Obstetrician-gynecologists are primary physicians: education for a new role. AM] OBSTET GYNECOL 1976;126:744-54. 17. Grimes DA. Declining surgical caseload of the obstetrician-gynecologist. Obstet Gynecol 1986;67: 760-2. 18. Summary report of the Graduate Medical Education Advisory Committee to the Secretary, Department of Health and Human Services. Washington DC: Health Resources Administration, 1980; publication (HRA) 81-656. 19. Schwartz WB, Sloan FA, Mendelson DN. Why there will be little or no physician surplus between now and the year 2000. N Engl] Med 1988;318:892-7. 20. Mulhausen R, McGee J. Physician need: an alternative projection from a study of large prepaid group practices. ]AMA 1989;261:1930-4. 21. Babbott D, Baldwin DC, Killian CD, et al. Trends in evolution of specialty choice: comparison of U.S. medical school graduates in 1983 and 1987. ]AMA 1989;261: 2367-71. 22. Van De Warker E. How gynecology is taught. ]AMA 1888;11:167. 23. Ryan GM Jr. Your place or mine. Obstet Gynecol 1982;60:725-8. 24. Morton DG. The changing aspects of specialization. AM ] OBSTET GYNECOL 1968; 102:619-23.