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The future of gynecologic oncology: Are we headed for super-specialization?
Gynecologic Oncology 122 (2011) 3–4
Contents lists available at ScienceDirect
Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y g y n o
Letter from Houston
The future of gynecologic oncology: Are we headed for super-specialization?
My father was a “general practitioner” in the truest sense. After medical school education and postgraduate training in the Northeast, he relocated to rural Illinois in the middle of the Great Depression to begin his solo practice. Except for a 4-year interruption for service in the Army Air Corps in the European Theater during World War II, he worked tirelessly, with few vacations, until his retirement at age 78. His office hours were 8 am–5 pm and 7–8 pm, Monday through Saturday, and 10 am–noon on Sundays. His typical week consisted of a few obstetrical deliveries, 3–5 early morning surgeries, and up to 100 office visits per day. I had settled on a career in medicine at an early age, subconsciously influenced by my father's strong desire and his dream that I would one day join him in practice. However, based on my observations over the years, particularly after starting medical school, I wanted nothing to do with his world. I secretly scoffed at his lack of sophistication, his failure to “keep up” with the latest medical advances (although he was an avid reader of medical literature), and the fundamental truth that he knew a little about a lot but was an expert on nothing. In retrospect, I'm also certain that my early experiences had much to do with my strong bent toward academic medicine. Of course, part of this elitist attitude was related to my naïve idealism. These childhood impressions combined with a 4-year stint at a medical school that emphasized specialty care crystallized my strong motivation to be not just a “specialist” but rather a “subspecialist.” From the time I settled on obstetrics and gynecology during my senior year, it was clear that I would enter one of the subspecialties. Ultimately, during my residency, gynecologic oncology emerged as my choice. It had great appeal to me because of its combination of surgery, medicine, and science, and because of its core value of longitudinal rather than episodic care. And it is the integration of these components that is responsible for my sustained enthusiasm to the present. However, I have recently focused on the fact that medicine is rapidly being transformed, and our subspecialty along with it. This phenomenon is occurring for several reasons, not the least of which is the explosion of technological and scientific advances. What will the discipline of gynecologic oncology look like in the future? Will it become “super-specialized?” In the 19th century, the principal driving forces underpinning the emergence of medical specialization were advances in medical research and education. By the end of that century, it had become obvious that one could not possibly master all of medical science; specialization was inevitable. As George Weisz, a professor of history of medicine at McGill University, has written, “…it was not the rapid expansion of knowledge so much as a new collective desire to expand medical knowledge that initially prompted doctors to specialize; only specialization, it was believed, allowed for the rigorous empirical 0090-8258/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.ygyno.2011.04.017
observation of many cases that had become necessary in academic medicine.” [1] Interestingly, medical specialization emerged initially in Paris in the early nineteenth century, whereas the London medical community lagged far behind its French counterpart. As Weisz goes on to state, “Specialization permitted mastery of the existing medical literature in a specific domain and, more important, allowed physicians to see the large number of cases of the same type that were now deemed necessary for rigorous clinical research and serious medical training.” This transformation was also greatly facilitated by the French style of administration and organization and extensive network of municipal specialty hospitals. Opposition to specialization did occur related to turf battles, a more holistic view of medical science, or a sincere concern about fragmentation of care. By the end of the 19th century, however, medical specialization was flourishing in Paris and was beginning to take hold in the United States and other European countries. The specialties of obstetrics and gynecology developed in parallel worlds during most of the 19th century. In 1912, J. Whitridge Williams, the famous Johns Hopkins professor and author of Williams Obstetrics, conducted a questionnaire study of the teaching of obstetrics and gynecology in American medical schools [2]. He found that, in 24 of the 42 schools responding, only eight had truly unified departments. By 1934, only 60% of America's medical schools had integrated departments of obstetrics and gynecology [3]. A decade later, this figure had risen to 73%. Amazingly, the unification of the departments of obstetrics and gynecology at Johns Hopkins did not occur until 1960. Since its incorporation in 1930, the American Board of Obstetrics and Gynecology (ABOG) had strongly promoted the integration of obstetrics and gynecology into a single discipline in American training programs. And for the last half of the 20th century, with a couple of exceptions, residency training in obstetrics and gynecology has been relatively stable. In response to the health care reform initiative of the Clinton administration in the early 1990s, primary care was integrated into residency training [4]. In 1994, in his presidential address to the American Gynecological and Obstetrical Society, Dr. Charles Hammond introduced the concept of tracking for residents after three years of a core curriculum, and this was subsequently adopted by ABOG and the Residency Review Committee (RRC) [5]. However, for a variety of reasons, this well-meaning change has been utilized infrequently. Currently, there is a growing concern about the quality of residency training programs, particularly as it relates to surgical training. The Liaison Committee for Obstetrics and Gynecology (LCOG) met at a retreat in Chantilly, VA, in 2002. Two subsequent retreats, convened by ABOG, RRC, the American College of Obstetricians and Gynecologists (ACOG), and the Council on Resident
4
Letter from Houston
Education in Obstetrics and Gynecology (CREOG) were held in Chantilly in 2008 and 2009 [6]. Although these retreats addressed a number of very important issues regarding residency training, the report seems to contain more questions than answers. And, reading between the lines, it appears that there is a resistance to doing what is really needed—a radical re-engineering of the fundamental structure of both residency training and fellowship training. The Chantilly report does include a brief section of the role of subspecialty training. Currently, there are three approved subspecialties, with a fourth—female pelvic medicine and reconstructive surgery—very close to approval. Yet other subspecialties may be in the offing, including family planning, pediatric/adolescent gynecology, breast diseases, and minimally invasive surgery. In considering general obstetrics and gynecology along with all of the potential approved or non-approved subspecialties, it appears to be time to develop much more flexible tracking systems. Logistically, however, this will be an extraordinary challenge—both in terms of the structure of postgraduate training and in the board certification process. My dream of the ideal gynecologic oncologist may well be obsolescent. In his 1982 Janeway Lecture before the American Radium Society, Dr. Felix Rutledge wisely recognized that a gynecologic oncologist should be not only a skilled surgeon but also trained in the principles of radiotherapy and the expert use of systemic therapies [7]. He knew that the gynecologic oncologist is in the best position to make decisions regarding the integration and sequencing of all modalities of treatment for women with gynecologic malignancies. However, the training, skills, and knowledge base required of a gynecologic oncologist are rapidly expanding. Added to the original areas of radical pelvic surgery, chemotherapy, radiation therapy, and pathology have been radical upper abdominal surgery, minimally invasive and robotic surgery, translational medicine and research, palliative medicine (already a cross-disciplinary subspecialty), health services research, and comparative effectiveness research. Is it reasonable to expect that a well-trained gynecologic oncologist should be able to master all or even most of these fields? I fear not. Of course, long ago, gynecologic oncologists at some of the most prestigious institutions narrowed their scope of practice to surgery. According to the Society of Gynecologic Oncologists' 2010 State of the Subspecialty Survey, only 79% of respondents reported routinely administering chemotherapy in their practice [8]. However, I suspect that as the physician shortage mounts and as there are more pressures to perform surgery—both open and minimally invasive—in some sectors this percentage will further decline over time. Similarly, I predict that an increasing number of gynecologic oncologists will focus primarily on one of the following: surgery alone, systemic therapy and clinical trials, hospice and palliative care, research (laboratory-based translational research, health services research, etc.), or other niches. In essence, the same phenomena that led to medical specialization in the 19th century and subspecialization in the 20th century, will culminate in even more fragmentation and “super-
specialization” in the 21st. Based primarily on what is optimal for the patient, I persist in my belief that no practitioner has a better perspective on the integration of all available diagnostic and therapeutic modalities than a gynecologic oncologist who practices the depth and breadth of the subspecialty as it is currently constituted. However, just as a radical change is required in the organization and structure of residency training, the same is true of fellowship training and beyond. How all of this will evolve I cannot predict. But just as our parent discipline—obstetrics and gynecology—is changing and fragmenting, I anticipate that gynecologic oncology will also metamorphose in terms of fragmentation of care and core competencies— initially in the academic centers and then more broadly. Regrettably, however, there will be unintended consequences. Postscript: As I was in the final stages of preparation of this manuscript, an article, “Specialization, Subspecialization, and Subsubspecialization in Internal Medicine,” appeared in the New England Journal of Medicine [9]. While this article focuses principally on the growing number of subspecialties within internal medicine and the implications for board certification and society, it definitely follows a similar theme and is worthy of the reader's attention. References [1] Weisz G. The emergence of medical specialization in the nineteenth century. Bull Hist Med 2003 Fall;77(3):536–75. [2] Williams JW. Medical education and midwife problem in the United States. JAMA 1912;58:1–7. [3] Speert H. Obstetrics and gynecology in America: a history. Baltimore: Waverly Press, Inc; 1980. [4] Hale RW. The obstetrician and gynecologist: primary care physician or specialist? Am J Obstet Gynecol 1995 Apr;172(4 Pt 1):1181–3. [5] Hammond CB. Future directions for academic obstetrics and gynecology—“… through a glass, darkly…”. Am J Obstet Gynecol 1995 Apr;172(4 Pt 1):1073–9. [6] Future directions in resident education. August 2008 and July 2009 Westfields Conference Center, Chantilly, Virginia, Summary of Conclusions. Washington DC: The American College of Obstetricians and Gynecologists; 2010. [7] Rutledge F. Gynecologic oncology—1982–2002: 1982 Janeway Lecture, American Radium Society. Am J Clin Oncol 1982 Oct;5(5):471–81. [8] State of the subspecialty. Gynecologic Oncology 2010. Chicago: Society of Gynecologic Oncologists; 2010. [9] Cassel CK, Reuben DB. Specialization, subspecialization, and subsubspecialization in internal medicine. N Engl J Med 2011 Mar 24;364(12):1169–73.
David M. Gershenson Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA Corresponding author at: Department of Gynecologic Oncology & Reproductive Medicine, Unit 1362, The University of Texas M. D. Anderson Cancer Center, P.O. Box 301439, Houston, TX 77230-1439, USA. Fax: +1 713 745 3510. E-mail address: [email protected].
Contents lists available at ScienceDirect
Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y g y n o
Letter from Houston
The future of gynecologic oncology: Are we headed for super-specialization?
My father was a “general practitioner” in the truest sense. After medical school education and postgraduate training in the Northeast, he relocated to rural Illinois in the middle of the Great Depression to begin his solo practice. Except for a 4-year interruption for service in the Army Air Corps in the European Theater during World War II, he worked tirelessly, with few vacations, until his retirement at age 78. His office hours were 8 am–5 pm and 7–8 pm, Monday through Saturday, and 10 am–noon on Sundays. His typical week consisted of a few obstetrical deliveries, 3–5 early morning surgeries, and up to 100 office visits per day. I had settled on a career in medicine at an early age, subconsciously influenced by my father's strong desire and his dream that I would one day join him in practice. However, based on my observations over the years, particularly after starting medical school, I wanted nothing to do with his world. I secretly scoffed at his lack of sophistication, his failure to “keep up” with the latest medical advances (although he was an avid reader of medical literature), and the fundamental truth that he knew a little about a lot but was an expert on nothing. In retrospect, I'm also certain that my early experiences had much to do with my strong bent toward academic medicine. Of course, part of this elitist attitude was related to my naïve idealism. These childhood impressions combined with a 4-year stint at a medical school that emphasized specialty care crystallized my strong motivation to be not just a “specialist” but rather a “subspecialist.” From the time I settled on obstetrics and gynecology during my senior year, it was clear that I would enter one of the subspecialties. Ultimately, during my residency, gynecologic oncology emerged as my choice. It had great appeal to me because of its combination of surgery, medicine, and science, and because of its core value of longitudinal rather than episodic care. And it is the integration of these components that is responsible for my sustained enthusiasm to the present. However, I have recently focused on the fact that medicine is rapidly being transformed, and our subspecialty along with it. This phenomenon is occurring for several reasons, not the least of which is the explosion of technological and scientific advances. What will the discipline of gynecologic oncology look like in the future? Will it become “super-specialized?” In the 19th century, the principal driving forces underpinning the emergence of medical specialization were advances in medical research and education. By the end of that century, it had become obvious that one could not possibly master all of medical science; specialization was inevitable. As George Weisz, a professor of history of medicine at McGill University, has written, “…it was not the rapid expansion of knowledge so much as a new collective desire to expand medical knowledge that initially prompted doctors to specialize; only specialization, it was believed, allowed for the rigorous empirical 0090-8258/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.ygyno.2011.04.017
observation of many cases that had become necessary in academic medicine.” [1] Interestingly, medical specialization emerged initially in Paris in the early nineteenth century, whereas the London medical community lagged far behind its French counterpart. As Weisz goes on to state, “Specialization permitted mastery of the existing medical literature in a specific domain and, more important, allowed physicians to see the large number of cases of the same type that were now deemed necessary for rigorous clinical research and serious medical training.” This transformation was also greatly facilitated by the French style of administration and organization and extensive network of municipal specialty hospitals. Opposition to specialization did occur related to turf battles, a more holistic view of medical science, or a sincere concern about fragmentation of care. By the end of the 19th century, however, medical specialization was flourishing in Paris and was beginning to take hold in the United States and other European countries. The specialties of obstetrics and gynecology developed in parallel worlds during most of the 19th century. In 1912, J. Whitridge Williams, the famous Johns Hopkins professor and author of Williams Obstetrics, conducted a questionnaire study of the teaching of obstetrics and gynecology in American medical schools [2]. He found that, in 24 of the 42 schools responding, only eight had truly unified departments. By 1934, only 60% of America's medical schools had integrated departments of obstetrics and gynecology [3]. A decade later, this figure had risen to 73%. Amazingly, the unification of the departments of obstetrics and gynecology at Johns Hopkins did not occur until 1960. Since its incorporation in 1930, the American Board of Obstetrics and Gynecology (ABOG) had strongly promoted the integration of obstetrics and gynecology into a single discipline in American training programs. And for the last half of the 20th century, with a couple of exceptions, residency training in obstetrics and gynecology has been relatively stable. In response to the health care reform initiative of the Clinton administration in the early 1990s, primary care was integrated into residency training [4]. In 1994, in his presidential address to the American Gynecological and Obstetrical Society, Dr. Charles Hammond introduced the concept of tracking for residents after three years of a core curriculum, and this was subsequently adopted by ABOG and the Residency Review Committee (RRC) [5]. However, for a variety of reasons, this well-meaning change has been utilized infrequently. Currently, there is a growing concern about the quality of residency training programs, particularly as it relates to surgical training. The Liaison Committee for Obstetrics and Gynecology (LCOG) met at a retreat in Chantilly, VA, in 2002. Two subsequent retreats, convened by ABOG, RRC, the American College of Obstetricians and Gynecologists (ACOG), and the Council on Resident
4
Letter from Houston
Education in Obstetrics and Gynecology (CREOG) were held in Chantilly in 2008 and 2009 [6]. Although these retreats addressed a number of very important issues regarding residency training, the report seems to contain more questions than answers. And, reading between the lines, it appears that there is a resistance to doing what is really needed—a radical re-engineering of the fundamental structure of both residency training and fellowship training. The Chantilly report does include a brief section of the role of subspecialty training. Currently, there are three approved subspecialties, with a fourth—female pelvic medicine and reconstructive surgery—very close to approval. Yet other subspecialties may be in the offing, including family planning, pediatric/adolescent gynecology, breast diseases, and minimally invasive surgery. In considering general obstetrics and gynecology along with all of the potential approved or non-approved subspecialties, it appears to be time to develop much more flexible tracking systems. Logistically, however, this will be an extraordinary challenge—both in terms of the structure of postgraduate training and in the board certification process. My dream of the ideal gynecologic oncologist may well be obsolescent. In his 1982 Janeway Lecture before the American Radium Society, Dr. Felix Rutledge wisely recognized that a gynecologic oncologist should be not only a skilled surgeon but also trained in the principles of radiotherapy and the expert use of systemic therapies [7]. He knew that the gynecologic oncologist is in the best position to make decisions regarding the integration and sequencing of all modalities of treatment for women with gynecologic malignancies. However, the training, skills, and knowledge base required of a gynecologic oncologist are rapidly expanding. Added to the original areas of radical pelvic surgery, chemotherapy, radiation therapy, and pathology have been radical upper abdominal surgery, minimally invasive and robotic surgery, translational medicine and research, palliative medicine (already a cross-disciplinary subspecialty), health services research, and comparative effectiveness research. Is it reasonable to expect that a well-trained gynecologic oncologist should be able to master all or even most of these fields? I fear not. Of course, long ago, gynecologic oncologists at some of the most prestigious institutions narrowed their scope of practice to surgery. According to the Society of Gynecologic Oncologists' 2010 State of the Subspecialty Survey, only 79% of respondents reported routinely administering chemotherapy in their practice [8]. However, I suspect that as the physician shortage mounts and as there are more pressures to perform surgery—both open and minimally invasive—in some sectors this percentage will further decline over time. Similarly, I predict that an increasing number of gynecologic oncologists will focus primarily on one of the following: surgery alone, systemic therapy and clinical trials, hospice and palliative care, research (laboratory-based translational research, health services research, etc.), or other niches. In essence, the same phenomena that led to medical specialization in the 19th century and subspecialization in the 20th century, will culminate in even more fragmentation and “super-
specialization” in the 21st. Based primarily on what is optimal for the patient, I persist in my belief that no practitioner has a better perspective on the integration of all available diagnostic and therapeutic modalities than a gynecologic oncologist who practices the depth and breadth of the subspecialty as it is currently constituted. However, just as a radical change is required in the organization and structure of residency training, the same is true of fellowship training and beyond. How all of this will evolve I cannot predict. But just as our parent discipline—obstetrics and gynecology—is changing and fragmenting, I anticipate that gynecologic oncology will also metamorphose in terms of fragmentation of care and core competencies— initially in the academic centers and then more broadly. Regrettably, however, there will be unintended consequences. Postscript: As I was in the final stages of preparation of this manuscript, an article, “Specialization, Subspecialization, and Subsubspecialization in Internal Medicine,” appeared in the New England Journal of Medicine [9]. While this article focuses principally on the growing number of subspecialties within internal medicine and the implications for board certification and society, it definitely follows a similar theme and is worthy of the reader's attention. References [1] Weisz G. The emergence of medical specialization in the nineteenth century. Bull Hist Med 2003 Fall;77(3):536–75. [2] Williams JW. Medical education and midwife problem in the United States. JAMA 1912;58:1–7. [3] Speert H. Obstetrics and gynecology in America: a history. Baltimore: Waverly Press, Inc; 1980. [4] Hale RW. The obstetrician and gynecologist: primary care physician or specialist? Am J Obstet Gynecol 1995 Apr;172(4 Pt 1):1181–3. [5] Hammond CB. Future directions for academic obstetrics and gynecology—“… through a glass, darkly…”. Am J Obstet Gynecol 1995 Apr;172(4 Pt 1):1073–9. [6] Future directions in resident education. August 2008 and July 2009 Westfields Conference Center, Chantilly, Virginia, Summary of Conclusions. Washington DC: The American College of Obstetricians and Gynecologists; 2010. [7] Rutledge F. Gynecologic oncology—1982–2002: 1982 Janeway Lecture, American Radium Society. Am J Clin Oncol 1982 Oct;5(5):471–81. [8] State of the subspecialty. Gynecologic Oncology 2010. Chicago: Society of Gynecologic Oncologists; 2010. [9] Cassel CK, Reuben DB. Specialization, subspecialization, and subsubspecialization in internal medicine. N Engl J Med 2011 Mar 24;364(12):1169–73.
David M. Gershenson Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA Corresponding author at: Department of Gynecologic Oncology & Reproductive Medicine, Unit 1362, The University of Texas M. D. Anderson Cancer Center, P.O. Box 301439, Houston, TX 77230-1439, USA. Fax: +1 713 745 3510. E-mail address: [email protected].