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The golden years
American Journal of Obstetrics
and Gynecology Founded in 1920
volume 153
number 2
SEPTEMBER
15, 1985
TRANSAC TIONS OF THE FORTY-SE VENTH ANNUAL MEETING OF THE SOUTH ATLANTIC ASSOCIAT ION OF OBSTETRI CIANS AND GYNECOL OGISTS The golden years Presidential address William T. Mixson, M.D. Coral Gables, Florida
As I review my professional career, I become aware of the fact that I have had the opportunity and privilege of practicing during the golden years of medicine. Since I entered medical school in 1943, my professional career has spanned the last four decades, beginning during World War IL It was a time when physicians were regarded highly by their patients and with greater esteem by the public than any other professional group. It was a time when financial return was assured by an expanding, prosperous society and the emergence of extensive public and private insurance coverage. Bad debts on the books of a private physician went from 40% to 5%. It was a time of an explosion of scientific knowledge and technology which provided the physician with a much greater understanding of many pathologic processes, tools for diagnosis, and options for treatment. Before the 1930s, the physician was very much limited in what he could do to help patients. Considerable progress was made during the 1930s, but the proces~ of research and discovery accelerated markedly in the 1940s, probably because of the influence of the war. Let us look for a moment at some of the advances. The importance of prenatal care was recognized in the 1930s but became generally accepted in the 1940s when physicians offered full prenatal, delivery, and postpartum care for a single fee. Conditions which would affect the health of the mother and fetus were Presented at the Forty-seventh Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 27-30, 1985. Reprint requests: Dr. William T. Mixson, 250 Catalonia Ave., Suite 804, Coral Gables, FL 33134.
detected and treated, or a plan of management was developed to obtain the best result. Diabetes, renal and cardiac disease, hypertension and preeclampsia, poor nutrition and anemia, syphilis and tuberculosis were among those conditions which could , be altered. The advent of amniocentesis, fetal monitoring, ultrasound, and other biophysical and biochemical methods of fetal surveillance led to continued improvement in outcome. In addition, improved care for high-risk pregnancies, an increase in cesarean section deliveries in high-risk cases, and neonatal intensive care units contributed to a marked improvement in perinatal and infant mortality. ' Improved contraception and availability of abortion helped reduce the number of high-risk patients by decreasing the number of pregnancies for each woman, especially for the very young and older patients, and increasing the interval between pregnancies. Beginning in the 1960s, changes in the health care delivery system resulted in new or improved services to the poor. Comprehensive care was targeted to highrisk mothers and infants. Nonmedical factors, such as an improved standard of living, accompanied by improved nutrition and an increase in the level of education, contributed to the improved results. During this period came the understanding of Rh disease, treatment of which then rapidly evolved. Landsteiner and Weiner first discovered the Rh antigen on red blood cells in 1940, and Bevis, in 1956, showed the clinical significance of an increase in blood pigments in amniotic fluid. In 1960, Freda' used an injection of Rh antibody to the Rh-negative mother shortly after the 119
120 Mixson
delivery of an Rh-positive infant. Now, with extension to antepartum prophylaxis and abortion prophylaxis, the complete elimination of Rh isoimmunization due to pregnancy may be possible. In 1941, for the first time, a connection was made between rubella and an effect on the fetus when N. McAllister Gregg, of Sydney, Australia, reported on congenital cataracts subsequent to German measles in the mother. 2 Later studies revealed an incidence of fetal anomalies as high as 60% in infants whose mother had rubella in the first trimester. A chronic rubella syndrome was described that involved all stages of intrauterine life and on into postnatal life with disastrous sequelae. Spontaneous abortion, premature delivery, and fetal death due to rubella infection were increased significantly. Rubella vaccine first became available in 1970. In 1977, a national program was begun to encourage the vaccination of all children under the age of 15 years, and all susceptible postpubertal women. In spite of this, outbreaks of rubella in 1982 showed the potential for the continued occurrence of the rubella syndrome. In 1984, only 750 cases of rubella were reported, the lowest number ever. 3 The antibiotic era was ushered in during World War II. When penicillin became available in the mid-1940s, the treatment for lobar pneumonia was only 2500 units every 3 hours. In 1949, there was a report of typhoid fever being cured with the use of a dose of one million units, but no one could imagine giving such a large amount. Since then, the development of more drugs effective against a larger number of organisms has resulted in an enormous decrease in human suffering and a decrease in loss of life. Puerperal sepsis always had been a problem for the obstetrician. Understanding contagion and then applying principles of prevention resulted in an 80% drop in maternal mortality by the 1930s. Since the introduction of penicillin in 1944, serious morbidity has had a low incidence and death due to puerperal sepsis has become a rare occurrence.•· 5 In 1943, Papanicolaou and Traut6 published a 48page monograph entitled "Diagnosis of uterine cancer by the vaginal smear." 6 Ernest Ayer established acervical cytologic screening service in Miami, Florida, in 1952, thereby making that area one of the earliest to be exposed to mass screening. But cytology was not rapidly accepted and applied. It still was not an accepted procedure at Temple University when I completed training in 1953, and not until 1962 was cytology included in examinations by the American Board of Pathology. We now know that the incidence of invasive cancer drops dramatically in a population screened a second
September 15, 1985 Am J Obstet Gynecol
time, and that invasive cancer is discovered at a progressively earlier stage as rescreening continues. Still, a large number of women in the United States has never been screened. All studies show a higher incidence of cervical cancer in women in the lower socioeconomic groups, and these are the ones who are least likely to avail themselves of screening. In 1981, Paul Underwood et al. 7 reported to The South Atlantic Association of Obstetricians and Gynecologists their experience with a Papmobile in South Carolina. This was an effort to provide cytologic screening of the cervix to everyone in South Carolina. Nine percent of the patients screened had had no previous Papanicolaou smear. The cost was $155 to find a significant abnormality, and $1700 to find a premalignant lesion, thus demonstrating that any program which can discover lesions at an early phase, when treatment is simple, safe, and inexpensive, is cost effective. By appropriate screening of all women and treatment of early lesions, invasive cancer of the cervix could be eliminated almost completely in the United States. Before 1956, the mortality rate in women with malignant trophoblastic disease was 90%. In 1956, Li et al. 8 reported that methotrexate, a folic acid antagonist, could cure metastatic trophoblastic disease. Now, with chemotherapy, cure is in the range of 90%, and women with this condition subsequently can bear normal children. The reversal of the prognosis for this disease was rapid and dramatic. The introduction of the radioimmunoassay technique revolutionized our ability to study many substances in the body, with precise measurement from a small specimen or minute concentrations. 9 This has been particularly valuable in reproductive endocrinology, and has led to the establishment of the role of prolactin in physiologic and pathologic processes, the discovery of hypothalamic hormones, and the concept of pulsatile release of gonadotropins. The development of oral contraceptives is a major advance which occurred during the last four decades. Russell Marker, in 1943, synthetically produced progesterone for the first time. From this beginning, progestational agents were developed which are effective orally. Margaret Sanger, Abraham Stone, Gregory Pincus, and John Rock were instrumental in instituting a study in Puerto Rico, in 1956, in which a progestational substance was used for contraception. Enovid was approved for contraception in 1960. 10• 11 Today, the use of oral contraceptives as a means of preventing pregnancy is safe, easy, highly effective, and relatively inexpensive. Progress continues as we better understand the factors related to complications, and adjustments are made to reduce dosage and alter formulations to decrease those complications.
Volume 153 Number 2
During my obstetrics-gynecology residency at Temple University, we had a separate gynecologic isolation ward that was almost always filled with patients who were seriously ill because of septic abortion. Abortion complications of hemorrhage and infection were the single most common cause of maternal mortality during my tenure as chairman of the Florida Medical Association Maternal Mortality Committee in the midl 960s.12 This problem has been largely eliminated since the Supreme Court's decision legalized abortion in 1973. Now, abortion can be performed under aseptic conditions by skilled personnel. Although I am opposed to abortion, I would not favor a change to make it illegal. Our responsibility is to reduce abortions to the lowest possible number by preventing unwanted pregnancies. This is a major challenge. The technology is available, with a wide range of acceptable methods of contraception, and safe and easy methods of sterilization. An expanded effort at education is necessary. We need to deal with the myths and exaggerations about the danger of oral contraceptives. Oral contraceptives have been more thoroughly studied and followed than almost anything else concerning humans. With appropriate follow-up and judgment based on our knowledge, using oral contraceptives is one of the safest things humans do. The level of serious complications is very low. The risk is far less than driving to the grocery store, and about the same as that of a pedestrian in her hometown. 13 Well, what do things look like today? Along with these great advances in science, there are many negatives. With our dependence on expanding technology has come a loss of humanism. Government has increasingly intruded on the scene. Cost containment and competitive forces have yielded up a new alphabet soup of HMOs, PPOs, ABCs, DRGs, which always threaten to interfere with needed medical judgment and treatment. On top of this is the growing crisis of professional liability. We have internal problems, such as a cesarean section rate of 30% to 35% in some areas, segments of the population receiving no care, some incompetent or indifferent physicians, inappropriate fees, and unnecessary surgical procedures. The respected position of the physician has deteriorated. The very technology that can produce so many benefits has caused problems. What some people call medical "gadgetry," such as fetal monitoring equipment, which should enhance medical care, often intrudes into the close personal relationship between the patient and the physician. Professional personnel become so absorbed in the mechanical milieu and what it is doing that the patient's emotional response may be ignored. At times, the patient is manag-ed as a disease, rather
The golden years
121
than as a person with a disease. Many now see us as rich doctors who do not care. Although technology offers great advantages, our tendency is to overuse it. Is fetal monitoring really necessary in every patient during labor? Is there justification for a $20,000 laser machine in the private physician's office when cryocautery or hot cautery will properly treat most conditions for which the laser is used? It is not surprising that we have been the target of some of the activity of the feminist movement. Because most obstetricians and gynecologists are men, we are described as "male chauvinists," with no understanding of or compassion for women. I have been an advocate of women for 40 years and so see myself as a "female chauvinist." Webster defines a chauvinist as one who has undue partiality for or attachment to a group. We have come to a time when there seems to be a breakdown in family unity and an increase in sexual promiscuity. There is an increase in lung cancer and obstructive pulmonary disease in women, due to smoking. This year, cancer of the lung will equal breast cancer as the major cancer killer in women. All of these problems concern us because our responsibility includes preventive health care and counseling both for individual patients and as a profession for our society. Professional liability is the number-one problem facing physicians today. The cost of insurance, of defensive medicine, lost productive practice time, and the emotional cost make it very expensive. The premium for one of my colleagues in Hialeah, in 1985, is $81,000, and this is the regular premium, not a penalty. Many older physicians retire before they desire to or should. Accessibility of care may become a problem. In December, 1984, on the island of Molokai, Hawaii, all of the family physicians, who provided all of the obstetric care on the island, discontinued obstetric practice after they received notice of the premiums for their professional liability coverage. One example of the potentially devastating effect of the liability situation is related to vaccination programs-product liability. Because of the large number of suits, and adverse decisions against manufacturers of vaccine, all companies, except one, have withdrawn from the manufacture of DPT vaccine, and one company, rubella vaccine. To return to the days of whooping cough epidemics or a resurgence of rubella syndrome would be horrible in suffering and cost for our society. The potential for disturbed financial reimbursement is the second most serious problem of concern to the physician today. We have had unprecedented prosperity during these 40 golden years, almost as though we had had a blank check. Medical costs have gotten out
122 Mixson
of hand and it is time for retrenchment. Materialism has become dominant and too many candidates for medical school have been attracted to the profession because of the financial rewards, rather than the desire to serve. Some of us have forgotten why we are here ... and that is to serve women's health care in this country. This is not to say that we should sit idly by while external forces take total control of our future. Our best effort at coping with changes in the financial structure is through vigilance, education of physicians, and interaction with government and health planners through organized medicine. The American College of Obstetricians and Gynecologists is very active in this area, as are other specialty societies; but the one group that can have the greatest influence on the outcome is the American Medical Association, and it deserves the support of all physicians. One natural consequence of reviewing the last 40 "golden years" of medicine and the current state of affairs is to contemplate the future. I wish that I could say that I have the answer to the professional liability problem, but no one knows the final solution. What I do know, absolutely, is that it will be solved, and in such a way that physicians can give their full attention to the care of patients without being constantly distracted by the specter of a potential suit. The process will change in such a way that an injured patient will be fairly compensated, the cost will be spread over the society, and doctors will be able to concentrate on providing good care but still will be held to a high standard of care. As the reimbursement turmoil subsides, I believe that the physician will be fairly compensated and will enjoy a good standard of living, although not at the level of the recent past. With solution of the professional liability problem and resolution of the turmoil in regard to reimbursement, we will come to a time when our major concerns appropriately address the question of improving health care for women. If there has been an explosion of scientific knowlege and technology during the last 40 years, is there reason to expect this progress to stop? Immnology appears ready to burst out of the research laboratory and be applied in clinical practice. Understanding why the immune system does not reject the normal pregnancy will help us solve some of the cases of habitual abortion and premature labor, with a resultant decrease in pregnancy loss. Monoclonal antibodies as tumor markers show promise in the diagnosis and monitoring of cancer and in localizing tumors. Monoclonal antibodies also appear to have the potential of delivering chemotherapeutic agents to all cancer cells, and may be an important treatment modality.
September 15, 1985 Am J Obstet Gynecol
The study of chromosomal changes in cancer cells shows a consistent breakage site in certain kinds of cancer. Follow-up of this lead may be important in the future diagnosis of cancer. 14 Although we have improved survival rates in patients with cancer of the cervix and of the endometrium, and to some extent in patients with breast cancer, there has been very little change in the survival rate of patients with ovarian cancer. Seventy to seventy-five percent of ovarian cancer is first discovered when at Stage III or IV. If discovered early, while still at Stage I, grade 1, the cure rate is 92%. 15 These new techniques should enable us to make an early diagnosis. Although we cannot achieve immortality, since everyone must die of something, our specialty will make great progess in reducing mortality due to cancer. Molecular genetics may be the wave of the future. Some DNA abnormalities of specific gene sites related to specific conditions, such as growth hormone deficiency, or substances, such as prolactin, have been identified. The procedure is called a DNA or gene probe. This will permit prediction of certain diseases or traits from as early as the fetal stage of life, and allow better counseling and an intelligent response by parents. Subsequently, this may open new avenues of treatment. Good news for patients, although not the most exciting news for the operating doctor, is the potential for endocrine treatment of benign neoplasms, particularly leiomyoma. Medical treatment of other surgical conditions looms as a possibility. In China, methotrexate is being used for treatment of ectopic pregnancy and results in less tubal damage than does surgical intervention. Another medical therapy which appears to be promising is the use of folic acid in the prevention of neural tube defects. With the recognition that we are unable to totally eliminate unintended or unwanted pregnancy, there will be safe, inexpensive medications to accomplish abortion. Luteolytic agents are an example of one pathway to accomplish this early in pregnancy, even before the missed period. Advances continue in the development of prostaglandin therapy and estrogen/progesterone receptor blockers. For contraception, a synthetic version of luteinizing hormone releasing hormone, normally produced in the hypothalamus, is about 140 times more potent than the natural hormone. It may become a one-time-a-month antifertility drug for either women or men. 16· 17 Intrauterine surgery is in its infancy, but applications will broaden as techniques improve. At the present time, intrauterine shunts for hydrocephalus and bilateral hydronephrosis, and correction of spina bifida have had limited success, but indicate potential. We can expect rapid advancement in fetal monitoring technology that will be more accurate, noninvasive, and less disturbing emotionally to the patient.
The golden years 123
Volume 153 Number 2
Chorionic villous biopsy may replace amniocentesis in the next 5 to IO years. It can be performed earlier in the pregnancy than amniocentesis, and provides a larger sample of tissue for prompt analysis. With new methods of genetic analysis this may become standard procedure, with the potential of detecting a large number of abnormalities, many of which may be amenable to intrauterine therapy. One of the most exciting of emerging technologies is nuclear magnetic resonance imaging. This is an imaging technique that uses nuclear magnetic resonant signals attached to computer technology which will provide information about biologic processes in a noninvasive manner, and without destruction of tissue. With the use of it, we may be able to recognize the anatomically and metabolically compromised fetus before the onset of labor, which would be important medically, but particularly important in regard to the medicolegal question of so-called "birth trauma." It promises to be able to measure fetal pH, placental and fetal blood flow, deposition of fat, and abnormal concentrations of metabolites in the placenta, liver, brain, and other organs. Our ability to analyze fetal metabolism is of particular importance in diabetic, hypertensive, and toxemic patients. Nuclear magnetic resonance imaging may allow us to distinguish benign from malignant tumors. It may either pinpoint positive nodes or demonstrate the absence of positive nodes in patients with cancer, to better guide the gynecologic surgeon in deciding whether an extensive surgical procedure is needed. In other words, it may provide accurate staging and assessment of cancer without an operation, and allow more appropriate use of the gynecologist vis-a-vis the gynecologic oncologist. This technology will enable us to differentiate blood from pus, infection from tumor, and solid from cystic masses. With it we can determine the extent of pelvic infection and the rate of resolution. This technology may obviate the need for computerized tomographic scanners within the next 10 years. 18 At this time, the technology is in its infancy. The machine, which occupies a large room and is very ex-
pensive, now costs up to $2.5 million, but may be obsolete in a year because the technology is advancing so rapidly. However, the potential is fabulous. Finally, I am optimistic. If my son, who is in his third year in medical school, were to ask me about the future, I would say that the golden years lie ahead.
REFERENCES 1. Freda V. Hemolytic disease of the newborn. In: Danforth DN. Obstetrics and gynecology. 4th ed. Philadelphia: Harper and Rowe, 1972:423. 2. Gregg NM: Congenital cataract following German measles in mother. Trans Ophthalmol Soc Aust 1941:3:35. 3. Morbidity and Mortality Weekly Report. US Center for Disease Control, Atlanta, Georgia. 1984; 33: 3 7. 4. Charles D, Dinland M. Obstetric and perinatal infections. Philadelphia: Lea & Febiger, 1973. 5. Ledger W: Infection in the female patient. Philadelphia: Lea & Febiger, 1977. 6. Papanicolaou GN, Traut HF. Diagnosis of uterine cancer by the vaginal smear. New York: Commonwealth Fund, 1943. 7. Underwood P, Stramm SL, Riggs JM, Dumas BP. Papmobile: a four and one-half years experience. Unpublished. Presented before The South Atlantic Association of Obstetricians and Gynecologists, January, 1981. 8. Li MC, Hertz R, Spencer DB. Effect of methotrexate therapy upon choriocarcinoma and chorioadenoma. Proc Soc Exp Biol Med 1956;93:361-6. 9. LeMaire . W. Reproductive endocrinology: twenty-five years of progress. South Carib J Obstet Gynecol 1984;2:5. 10. Diczfalusy E. Gregory Pincus and steroidal contraception revisited. Acta Obstet Gynecol Scand 1982; 105(suppl): 7-15. 11. Goldzieher JW, Rudel HW. How the oral contraceptive came to be developed. JAMA 1974;230:421. 12. Mixson WT. Florida maternal mortality survey 1964-65. Monograph. 13. Urquhart J, Heilmann K. Risk watch-the odds of life. New York: Facts on File, 1984:49. 14. Sell S. Diagnostic uses of cancer markers. Female Patient 1984;9:33. 15. Sorbe B, Frankendal B, Veress B. The importance of histologic grading in the prognosis of epithelial ovarian cancer. Obstet Gynecol 1982;59:5. 16. National Institute of Child Health and Human Development. Research highlights and topics of interest. June, 1982. 17. Ziporyn T. LHRH: clinical applications growing. Medical News. JAMA 1985;253:4. 18. Mattison DR, Kay HH, Heinricks WL. The widening window of magnetic resonance imaging. Contemp Ob/Gyn 1984;24.
and Gynecology Founded in 1920
volume 153
number 2
SEPTEMBER
15, 1985
TRANSAC TIONS OF THE FORTY-SE VENTH ANNUAL MEETING OF THE SOUTH ATLANTIC ASSOCIAT ION OF OBSTETRI CIANS AND GYNECOL OGISTS The golden years Presidential address William T. Mixson, M.D. Coral Gables, Florida
As I review my professional career, I become aware of the fact that I have had the opportunity and privilege of practicing during the golden years of medicine. Since I entered medical school in 1943, my professional career has spanned the last four decades, beginning during World War IL It was a time when physicians were regarded highly by their patients and with greater esteem by the public than any other professional group. It was a time when financial return was assured by an expanding, prosperous society and the emergence of extensive public and private insurance coverage. Bad debts on the books of a private physician went from 40% to 5%. It was a time of an explosion of scientific knowledge and technology which provided the physician with a much greater understanding of many pathologic processes, tools for diagnosis, and options for treatment. Before the 1930s, the physician was very much limited in what he could do to help patients. Considerable progress was made during the 1930s, but the proces~ of research and discovery accelerated markedly in the 1940s, probably because of the influence of the war. Let us look for a moment at some of the advances. The importance of prenatal care was recognized in the 1930s but became generally accepted in the 1940s when physicians offered full prenatal, delivery, and postpartum care for a single fee. Conditions which would affect the health of the mother and fetus were Presented at the Forty-seventh Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 27-30, 1985. Reprint requests: Dr. William T. Mixson, 250 Catalonia Ave., Suite 804, Coral Gables, FL 33134.
detected and treated, or a plan of management was developed to obtain the best result. Diabetes, renal and cardiac disease, hypertension and preeclampsia, poor nutrition and anemia, syphilis and tuberculosis were among those conditions which could , be altered. The advent of amniocentesis, fetal monitoring, ultrasound, and other biophysical and biochemical methods of fetal surveillance led to continued improvement in outcome. In addition, improved care for high-risk pregnancies, an increase in cesarean section deliveries in high-risk cases, and neonatal intensive care units contributed to a marked improvement in perinatal and infant mortality. ' Improved contraception and availability of abortion helped reduce the number of high-risk patients by decreasing the number of pregnancies for each woman, especially for the very young and older patients, and increasing the interval between pregnancies. Beginning in the 1960s, changes in the health care delivery system resulted in new or improved services to the poor. Comprehensive care was targeted to highrisk mothers and infants. Nonmedical factors, such as an improved standard of living, accompanied by improved nutrition and an increase in the level of education, contributed to the improved results. During this period came the understanding of Rh disease, treatment of which then rapidly evolved. Landsteiner and Weiner first discovered the Rh antigen on red blood cells in 1940, and Bevis, in 1956, showed the clinical significance of an increase in blood pigments in amniotic fluid. In 1960, Freda' used an injection of Rh antibody to the Rh-negative mother shortly after the 119
120 Mixson
delivery of an Rh-positive infant. Now, with extension to antepartum prophylaxis and abortion prophylaxis, the complete elimination of Rh isoimmunization due to pregnancy may be possible. In 1941, for the first time, a connection was made between rubella and an effect on the fetus when N. McAllister Gregg, of Sydney, Australia, reported on congenital cataracts subsequent to German measles in the mother. 2 Later studies revealed an incidence of fetal anomalies as high as 60% in infants whose mother had rubella in the first trimester. A chronic rubella syndrome was described that involved all stages of intrauterine life and on into postnatal life with disastrous sequelae. Spontaneous abortion, premature delivery, and fetal death due to rubella infection were increased significantly. Rubella vaccine first became available in 1970. In 1977, a national program was begun to encourage the vaccination of all children under the age of 15 years, and all susceptible postpubertal women. In spite of this, outbreaks of rubella in 1982 showed the potential for the continued occurrence of the rubella syndrome. In 1984, only 750 cases of rubella were reported, the lowest number ever. 3 The antibiotic era was ushered in during World War II. When penicillin became available in the mid-1940s, the treatment for lobar pneumonia was only 2500 units every 3 hours. In 1949, there was a report of typhoid fever being cured with the use of a dose of one million units, but no one could imagine giving such a large amount. Since then, the development of more drugs effective against a larger number of organisms has resulted in an enormous decrease in human suffering and a decrease in loss of life. Puerperal sepsis always had been a problem for the obstetrician. Understanding contagion and then applying principles of prevention resulted in an 80% drop in maternal mortality by the 1930s. Since the introduction of penicillin in 1944, serious morbidity has had a low incidence and death due to puerperal sepsis has become a rare occurrence.•· 5 In 1943, Papanicolaou and Traut6 published a 48page monograph entitled "Diagnosis of uterine cancer by the vaginal smear." 6 Ernest Ayer established acervical cytologic screening service in Miami, Florida, in 1952, thereby making that area one of the earliest to be exposed to mass screening. But cytology was not rapidly accepted and applied. It still was not an accepted procedure at Temple University when I completed training in 1953, and not until 1962 was cytology included in examinations by the American Board of Pathology. We now know that the incidence of invasive cancer drops dramatically in a population screened a second
September 15, 1985 Am J Obstet Gynecol
time, and that invasive cancer is discovered at a progressively earlier stage as rescreening continues. Still, a large number of women in the United States has never been screened. All studies show a higher incidence of cervical cancer in women in the lower socioeconomic groups, and these are the ones who are least likely to avail themselves of screening. In 1981, Paul Underwood et al. 7 reported to The South Atlantic Association of Obstetricians and Gynecologists their experience with a Papmobile in South Carolina. This was an effort to provide cytologic screening of the cervix to everyone in South Carolina. Nine percent of the patients screened had had no previous Papanicolaou smear. The cost was $155 to find a significant abnormality, and $1700 to find a premalignant lesion, thus demonstrating that any program which can discover lesions at an early phase, when treatment is simple, safe, and inexpensive, is cost effective. By appropriate screening of all women and treatment of early lesions, invasive cancer of the cervix could be eliminated almost completely in the United States. Before 1956, the mortality rate in women with malignant trophoblastic disease was 90%. In 1956, Li et al. 8 reported that methotrexate, a folic acid antagonist, could cure metastatic trophoblastic disease. Now, with chemotherapy, cure is in the range of 90%, and women with this condition subsequently can bear normal children. The reversal of the prognosis for this disease was rapid and dramatic. The introduction of the radioimmunoassay technique revolutionized our ability to study many substances in the body, with precise measurement from a small specimen or minute concentrations. 9 This has been particularly valuable in reproductive endocrinology, and has led to the establishment of the role of prolactin in physiologic and pathologic processes, the discovery of hypothalamic hormones, and the concept of pulsatile release of gonadotropins. The development of oral contraceptives is a major advance which occurred during the last four decades. Russell Marker, in 1943, synthetically produced progesterone for the first time. From this beginning, progestational agents were developed which are effective orally. Margaret Sanger, Abraham Stone, Gregory Pincus, and John Rock were instrumental in instituting a study in Puerto Rico, in 1956, in which a progestational substance was used for contraception. Enovid was approved for contraception in 1960. 10• 11 Today, the use of oral contraceptives as a means of preventing pregnancy is safe, easy, highly effective, and relatively inexpensive. Progress continues as we better understand the factors related to complications, and adjustments are made to reduce dosage and alter formulations to decrease those complications.
Volume 153 Number 2
During my obstetrics-gynecology residency at Temple University, we had a separate gynecologic isolation ward that was almost always filled with patients who were seriously ill because of septic abortion. Abortion complications of hemorrhage and infection were the single most common cause of maternal mortality during my tenure as chairman of the Florida Medical Association Maternal Mortality Committee in the midl 960s.12 This problem has been largely eliminated since the Supreme Court's decision legalized abortion in 1973. Now, abortion can be performed under aseptic conditions by skilled personnel. Although I am opposed to abortion, I would not favor a change to make it illegal. Our responsibility is to reduce abortions to the lowest possible number by preventing unwanted pregnancies. This is a major challenge. The technology is available, with a wide range of acceptable methods of contraception, and safe and easy methods of sterilization. An expanded effort at education is necessary. We need to deal with the myths and exaggerations about the danger of oral contraceptives. Oral contraceptives have been more thoroughly studied and followed than almost anything else concerning humans. With appropriate follow-up and judgment based on our knowledge, using oral contraceptives is one of the safest things humans do. The level of serious complications is very low. The risk is far less than driving to the grocery store, and about the same as that of a pedestrian in her hometown. 13 Well, what do things look like today? Along with these great advances in science, there are many negatives. With our dependence on expanding technology has come a loss of humanism. Government has increasingly intruded on the scene. Cost containment and competitive forces have yielded up a new alphabet soup of HMOs, PPOs, ABCs, DRGs, which always threaten to interfere with needed medical judgment and treatment. On top of this is the growing crisis of professional liability. We have internal problems, such as a cesarean section rate of 30% to 35% in some areas, segments of the population receiving no care, some incompetent or indifferent physicians, inappropriate fees, and unnecessary surgical procedures. The respected position of the physician has deteriorated. The very technology that can produce so many benefits has caused problems. What some people call medical "gadgetry," such as fetal monitoring equipment, which should enhance medical care, often intrudes into the close personal relationship between the patient and the physician. Professional personnel become so absorbed in the mechanical milieu and what it is doing that the patient's emotional response may be ignored. At times, the patient is manag-ed as a disease, rather
The golden years
121
than as a person with a disease. Many now see us as rich doctors who do not care. Although technology offers great advantages, our tendency is to overuse it. Is fetal monitoring really necessary in every patient during labor? Is there justification for a $20,000 laser machine in the private physician's office when cryocautery or hot cautery will properly treat most conditions for which the laser is used? It is not surprising that we have been the target of some of the activity of the feminist movement. Because most obstetricians and gynecologists are men, we are described as "male chauvinists," with no understanding of or compassion for women. I have been an advocate of women for 40 years and so see myself as a "female chauvinist." Webster defines a chauvinist as one who has undue partiality for or attachment to a group. We have come to a time when there seems to be a breakdown in family unity and an increase in sexual promiscuity. There is an increase in lung cancer and obstructive pulmonary disease in women, due to smoking. This year, cancer of the lung will equal breast cancer as the major cancer killer in women. All of these problems concern us because our responsibility includes preventive health care and counseling both for individual patients and as a profession for our society. Professional liability is the number-one problem facing physicians today. The cost of insurance, of defensive medicine, lost productive practice time, and the emotional cost make it very expensive. The premium for one of my colleagues in Hialeah, in 1985, is $81,000, and this is the regular premium, not a penalty. Many older physicians retire before they desire to or should. Accessibility of care may become a problem. In December, 1984, on the island of Molokai, Hawaii, all of the family physicians, who provided all of the obstetric care on the island, discontinued obstetric practice after they received notice of the premiums for their professional liability coverage. One example of the potentially devastating effect of the liability situation is related to vaccination programs-product liability. Because of the large number of suits, and adverse decisions against manufacturers of vaccine, all companies, except one, have withdrawn from the manufacture of DPT vaccine, and one company, rubella vaccine. To return to the days of whooping cough epidemics or a resurgence of rubella syndrome would be horrible in suffering and cost for our society. The potential for disturbed financial reimbursement is the second most serious problem of concern to the physician today. We have had unprecedented prosperity during these 40 golden years, almost as though we had had a blank check. Medical costs have gotten out
122 Mixson
of hand and it is time for retrenchment. Materialism has become dominant and too many candidates for medical school have been attracted to the profession because of the financial rewards, rather than the desire to serve. Some of us have forgotten why we are here ... and that is to serve women's health care in this country. This is not to say that we should sit idly by while external forces take total control of our future. Our best effort at coping with changes in the financial structure is through vigilance, education of physicians, and interaction with government and health planners through organized medicine. The American College of Obstetricians and Gynecologists is very active in this area, as are other specialty societies; but the one group that can have the greatest influence on the outcome is the American Medical Association, and it deserves the support of all physicians. One natural consequence of reviewing the last 40 "golden years" of medicine and the current state of affairs is to contemplate the future. I wish that I could say that I have the answer to the professional liability problem, but no one knows the final solution. What I do know, absolutely, is that it will be solved, and in such a way that physicians can give their full attention to the care of patients without being constantly distracted by the specter of a potential suit. The process will change in such a way that an injured patient will be fairly compensated, the cost will be spread over the society, and doctors will be able to concentrate on providing good care but still will be held to a high standard of care. As the reimbursement turmoil subsides, I believe that the physician will be fairly compensated and will enjoy a good standard of living, although not at the level of the recent past. With solution of the professional liability problem and resolution of the turmoil in regard to reimbursement, we will come to a time when our major concerns appropriately address the question of improving health care for women. If there has been an explosion of scientific knowlege and technology during the last 40 years, is there reason to expect this progress to stop? Immnology appears ready to burst out of the research laboratory and be applied in clinical practice. Understanding why the immune system does not reject the normal pregnancy will help us solve some of the cases of habitual abortion and premature labor, with a resultant decrease in pregnancy loss. Monoclonal antibodies as tumor markers show promise in the diagnosis and monitoring of cancer and in localizing tumors. Monoclonal antibodies also appear to have the potential of delivering chemotherapeutic agents to all cancer cells, and may be an important treatment modality.
September 15, 1985 Am J Obstet Gynecol
The study of chromosomal changes in cancer cells shows a consistent breakage site in certain kinds of cancer. Follow-up of this lead may be important in the future diagnosis of cancer. 14 Although we have improved survival rates in patients with cancer of the cervix and of the endometrium, and to some extent in patients with breast cancer, there has been very little change in the survival rate of patients with ovarian cancer. Seventy to seventy-five percent of ovarian cancer is first discovered when at Stage III or IV. If discovered early, while still at Stage I, grade 1, the cure rate is 92%. 15 These new techniques should enable us to make an early diagnosis. Although we cannot achieve immortality, since everyone must die of something, our specialty will make great progess in reducing mortality due to cancer. Molecular genetics may be the wave of the future. Some DNA abnormalities of specific gene sites related to specific conditions, such as growth hormone deficiency, or substances, such as prolactin, have been identified. The procedure is called a DNA or gene probe. This will permit prediction of certain diseases or traits from as early as the fetal stage of life, and allow better counseling and an intelligent response by parents. Subsequently, this may open new avenues of treatment. Good news for patients, although not the most exciting news for the operating doctor, is the potential for endocrine treatment of benign neoplasms, particularly leiomyoma. Medical treatment of other surgical conditions looms as a possibility. In China, methotrexate is being used for treatment of ectopic pregnancy and results in less tubal damage than does surgical intervention. Another medical therapy which appears to be promising is the use of folic acid in the prevention of neural tube defects. With the recognition that we are unable to totally eliminate unintended or unwanted pregnancy, there will be safe, inexpensive medications to accomplish abortion. Luteolytic agents are an example of one pathway to accomplish this early in pregnancy, even before the missed period. Advances continue in the development of prostaglandin therapy and estrogen/progesterone receptor blockers. For contraception, a synthetic version of luteinizing hormone releasing hormone, normally produced in the hypothalamus, is about 140 times more potent than the natural hormone. It may become a one-time-a-month antifertility drug for either women or men. 16· 17 Intrauterine surgery is in its infancy, but applications will broaden as techniques improve. At the present time, intrauterine shunts for hydrocephalus and bilateral hydronephrosis, and correction of spina bifida have had limited success, but indicate potential. We can expect rapid advancement in fetal monitoring technology that will be more accurate, noninvasive, and less disturbing emotionally to the patient.
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Volume 153 Number 2
Chorionic villous biopsy may replace amniocentesis in the next 5 to IO years. It can be performed earlier in the pregnancy than amniocentesis, and provides a larger sample of tissue for prompt analysis. With new methods of genetic analysis this may become standard procedure, with the potential of detecting a large number of abnormalities, many of which may be amenable to intrauterine therapy. One of the most exciting of emerging technologies is nuclear magnetic resonance imaging. This is an imaging technique that uses nuclear magnetic resonant signals attached to computer technology which will provide information about biologic processes in a noninvasive manner, and without destruction of tissue. With the use of it, we may be able to recognize the anatomically and metabolically compromised fetus before the onset of labor, which would be important medically, but particularly important in regard to the medicolegal question of so-called "birth trauma." It promises to be able to measure fetal pH, placental and fetal blood flow, deposition of fat, and abnormal concentrations of metabolites in the placenta, liver, brain, and other organs. Our ability to analyze fetal metabolism is of particular importance in diabetic, hypertensive, and toxemic patients. Nuclear magnetic resonance imaging may allow us to distinguish benign from malignant tumors. It may either pinpoint positive nodes or demonstrate the absence of positive nodes in patients with cancer, to better guide the gynecologic surgeon in deciding whether an extensive surgical procedure is needed. In other words, it may provide accurate staging and assessment of cancer without an operation, and allow more appropriate use of the gynecologist vis-a-vis the gynecologic oncologist. This technology will enable us to differentiate blood from pus, infection from tumor, and solid from cystic masses. With it we can determine the extent of pelvic infection and the rate of resolution. This technology may obviate the need for computerized tomographic scanners within the next 10 years. 18 At this time, the technology is in its infancy. The machine, which occupies a large room and is very ex-
pensive, now costs up to $2.5 million, but may be obsolete in a year because the technology is advancing so rapidly. However, the potential is fabulous. Finally, I am optimistic. If my son, who is in his third year in medical school, were to ask me about the future, I would say that the golden years lie ahead.
REFERENCES 1. Freda V. Hemolytic disease of the newborn. In: Danforth DN. Obstetrics and gynecology. 4th ed. Philadelphia: Harper and Rowe, 1972:423. 2. Gregg NM: Congenital cataract following German measles in mother. Trans Ophthalmol Soc Aust 1941:3:35. 3. Morbidity and Mortality Weekly Report. US Center for Disease Control, Atlanta, Georgia. 1984; 33: 3 7. 4. Charles D, Dinland M. Obstetric and perinatal infections. Philadelphia: Lea & Febiger, 1973. 5. Ledger W: Infection in the female patient. Philadelphia: Lea & Febiger, 1977. 6. Papanicolaou GN, Traut HF. Diagnosis of uterine cancer by the vaginal smear. New York: Commonwealth Fund, 1943. 7. Underwood P, Stramm SL, Riggs JM, Dumas BP. Papmobile: a four and one-half years experience. Unpublished. Presented before The South Atlantic Association of Obstetricians and Gynecologists, January, 1981. 8. Li MC, Hertz R, Spencer DB. Effect of methotrexate therapy upon choriocarcinoma and chorioadenoma. Proc Soc Exp Biol Med 1956;93:361-6. 9. LeMaire . W. Reproductive endocrinology: twenty-five years of progress. South Carib J Obstet Gynecol 1984;2:5. 10. Diczfalusy E. Gregory Pincus and steroidal contraception revisited. Acta Obstet Gynecol Scand 1982; 105(suppl): 7-15. 11. Goldzieher JW, Rudel HW. How the oral contraceptive came to be developed. JAMA 1974;230:421. 12. Mixson WT. Florida maternal mortality survey 1964-65. Monograph. 13. Urquhart J, Heilmann K. Risk watch-the odds of life. New York: Facts on File, 1984:49. 14. Sell S. Diagnostic uses of cancer markers. Female Patient 1984;9:33. 15. Sorbe B, Frankendal B, Veress B. The importance of histologic grading in the prognosis of epithelial ovarian cancer. Obstet Gynecol 1982;59:5. 16. National Institute of Child Health and Human Development. Research highlights and topics of interest. June, 1982. 17. Ziporyn T. LHRH: clinical applications growing. Medical News. JAMA 1985;253:4. 18. Mattison DR, Kay HH, Heinricks WL. The widening window of magnetic resonance imaging. Contemp Ob/Gyn 1984;24.