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Today and tomorrow
Transactions of the Eighty-fourth Annual Meeting of the American Association of Obstetricians and Gynecologists
Today and tomorrow Presidential address
ROBERT B. WILSON, M.D. Rochester, }vfinnesota
sive. It is important that we change for the better and not for the worse; it is also important to recognize that it is much easier to change for the worse than for the better. In education, WI:' deal for the most part with students; and, whether we consider medical schools, internships, or graduate programs, the participants are still students. It is now a fact of life that these men and women are active participants in the fonrmlation of curricula and that they readily and often enthusiastically give constructive criticism. There is little doubt that activity of this type is beneficial. However, one wonders about other changes in attitudes, changes that are illustrated by insistence that examinations are of little value and that grades. if given, should be used by the student for his personal evaluation of progress and not as determinants as to whether an individual should continue the study of medicine. Even more difficult to accept is the fonnation of unions or quasiorganizations with similar purposes for ensurance of "rights" or even actual confrontations with either teachers in classrooms or those in administrative controL At times, one speculates that these attitudes may have developed because today's student has been told so often of his superior intellect and ability and has concluded that such evaluations are indeed true. Perhaps it is redundant to remark that good minds and great abilities are not recent creations and
pRES 1 DENT I A L ADD RES S E S before our Association have, on many occasions, dealt with one or another aspect of medical education. I, too, wish to discuss this subject, my discussion being directed toward one aspect of medical education that, to the best of my knowledge, heretofore has not been discussed, namely, the leadership in our specialty of obstetrics and gynecology. After selecting this subject, I had not only second but also third and fourth thoughts about the v>isdom of discussing it. This is not because the subject should not be discussed but because I am somewhat apprehensive that my remarks might be misinterpreted.
Changes in education
We live in a changing world and, at times, one is inclined to believe that today's world is changing more than in many times in the past. Change in itself is not unique or disturbing; in fact, change is a normal aspect of all times. Changes are always proposed in the name of progress; the real issue is to detennine which changes are truly progresFrom the Department of Obstetrics and Gynecology, Mayo Clinic. Presented at the Eighty-fourth Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot Springs, Virginia, September 6-8, 1973. Reprint requests: Section of Publications, J;fayo Clinic, Rochester, Minnesota 55901.
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that preventive medicine, social responsibilities, and real concern for mankind are not new to the medical ethic. One cannot ignore the observation that attitudinal changes of students have occurred at a time when the attitudes and philosophies of those who educate have undergone tremendous changes. I do not know whether our problems are because of factors arising in the thought processes of students or because of changes in educational philosophy and general permissiveness or whether they result from many of the shortcomings that exist in our profession. A particularly galling example of such a shortcoming is a law deemed necessary, and passed, by the 1973 Minnesota State Legislature (Session Laws, 1973, Chapter 688) ; in part and paraphrased, this law states that every patient shall have the right to considerate and respectful care, shall be kept informed as to his medical status, shall know the name of his primary physician, and shall have every consideration of his privacy and individuality as it relates to his social, religious, and psychological well-being. What can a medical student possibly think as he learns that, on acceptance into medical school he is certain to receive a degree in medicine in 4 years? Recently, when discussing this essentially automatic graduation from medical school with the head of a department, I asked if it bothered him that individuals who did not deserve an M.D. degree were granted one. His answer was that it did indeed bother him, but the solution at his university was to ask the unqualified individuals if they would please not practice medicine! What sort of motivation will there be on learning that the only examination in which he or she has to succeed is one given not by his teachers, but by a National Board of Medical Examiners? What will his reaction be when he realizes that prominent medical school educators w~ite that if a student does not learn a subJect it is the fault of the professor rather than of the student? How will he react when he reads the following; The study of medicine is a lifelong commitment for the physician. This commitment, free of a
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formalized setting, is met only by the individual's initiative, self-discipline, and industry. Any motivation initiated by the pedantic stresses of tests, examinations, or the threat of failing is no longer valid. It is a function of personal integrity to be informed and capable of evaluating new ideas and advances. 1
It is evident that in this type of educational environment the only thing that is saving the medical profession is the fact that it still attracts extremely intelligent men and women who somehow become physicians, even with wide gaps in their knowledge, despite us. It would seem that medical schools, despite great efforts expended on using the services of educators in formal departments of education and numerous curriculumplanning committees, are quite consciously drifting toward the concept that individuals really are not going to learn much in medical school and that knowledge will ultimately be acquired in the residency years-and a residency, after all, is nothing more than a glorified preceptorship wherein the student is exposed to multiple rather than single preceptors. If this is so, one might ask why we have any medical schools at all. The place of our specialty in medicine today
These general remarks bring us to a consideration of our specialty and its place in the medical spectrum. We are all aware of the diminished appeal of our discipline, as shown by data presented last year at this meeting by Dr. Lawrence Hester. In 1970, 40 per cent of some 3,081 residency positions offered in obstetrics and gynecology were filled by individuals who had received their undergraduate education in foreign medical schools; 5 years previously, 27 per cent ( 682 of 2,526) were filled by foreign graduates. Currently, approximately 50 per cent of those examined for certification by the American Board of Obstetrics and Gynecology have received their education in foreign schools. The motivation for the foreign graduate to become an obstetrician and gynecologist must be considerable for, at the present time, there is no way for him
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to obtain full certification unless he applies for United States citizenship, is licensed, and has completed 2 years of unrestricted practice in the U nitcd States. One is at once both amazed and mystified as to tht:> reasons for this trend; and, as teachers, we should be chagrined by the fact that this trend evidently means that in our medical schools obstetrics and gynecology are taught in a manner devoid of real appeal. If this trend continues, not many years will elapse before a majority of specialists in obstetrics and gynecolog-y will have been trained in foreign countries. Many studies have been done in an attempt to unravel this problem. but I know of none that has directed its efforts toward an evaluation of the methods of teaching obstetrics and srynecology in foreign schools; or, to put it another way, why do graduates of foreign medical schools develop an interest in our specialty and why do so few, in proportion, develop the same interest when they graduate from our own schools? As an aside, if this trend continues, one might expect that in our specialty 60 to 70 per cent of obstetricians and gynecologists will have been trained in foreign medical schools. Thereafter, the American Civil Liberties Union might become involved and insist that the governing bodies of our specialty. such as our American Board, include 60 to 70 per cent of foreign graduates. Should such come to pass, those living in this country may find not only that vast segments of our economy are controlled and owned by those who live and produce in the Far East and the Middle East as well as in Europe but also that our segment of medicine is controlled by those who are foreign trained. These remarks about foreign graduates are not made in a derogatory manner~for, after all. most of us are only second- or third-generation Americans--but to bring into the open the observation that obstetrics and gynecology, as taught by those from beyond our borders, seemingly has more appeal and is more competitive with other specialties than our specialty as taught by us. Perhaps there are other reasons for this
;>daJch 1. !9H Am .
.f.
Obstt>t nynrcnl.
state of affairs. As the medic<1l student progresses. one of the most exciting of his experictHTS is to learn about conception and tlw growth and development of the fetus and then not only to learn about but also observe and participate in the ddivPrv of a baby. Furthermore, he is attracted to die rhallenges of gynPcologic surgPry, the mys· teries of gync·cologir endocrinology, and the excitement of the new and contimwlly drw~lopin,g science of neonatology. But then he learns that rnanv of our leaders, most of them professors in om schools, belie\ e that midwives should care for women \\ ho arc rxpected to han· nom1al deliwries ;1nd that all who have. or are expected to have. abnormalities should be rrferred to a regional centN. Or he learns that gynecologists are ''nothing but tired obstetricians" and hears all sorts of invidious comparisons between the sur,gical abilities of gynecologic surgeons as compared to those of ,general surgeons. If the student should be attracted to endocrinology. he soon learns that nearlv all of the endocrinologists of repute arrive as leading endocrinolog·ists via the field of internal medicine. Is it any wonder, tlwn. that the student is "turned off"? What is so particularly disheartening is that most of our leaders' statements state· ments to the effect that prenatal care is not all that important, that the midwife should perform the deliveries. and that there is nothing really exciting or challenging about what I will refer to as the everyday practiec of obstetrics and gynecology--~are either opinions that have no basis in fact or opinions that are based on data that are interpreted to suit the personal fancy of the person who is speaking or writing. Also giving cause for concern is the lack of appeal that chairmanship of a department seems to have and the dearth of acceptable individuals to fill positions available as chairmen of departments of obstetrics and gynecology. One can enumerate, without a pause for breath, 7 to 10 schools each of which is now seeking an individual for the chair of obstetrics and gynecology. Not so evident is the knowledge that a number of current chairmen are unhappy in their
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present positions and would be receptive to offers from other institutions. Perhaps this seeming lack of available candidates is really related to the possibility that individuals who would do an outstanding job as teachers of students and in the clinical training of those at the graduate level and who have a reasonable but not overwhelming interest in research are personae non gratae as far as deans and others in administrative control are concerned. I suspect, too, that many individuals with these talents simply refuse to subject themselves to the almost impossible demands to which presentday chairmen are subjected. One can only admire many of today's chairmen who, in some way, serve on curriculum committees, admissions committees, planning-for-thefuture committees, and finance committees and who also attend a multitude of staff and faculty meetings, assume innumerable and important national responsibilities, hold major offices in specialty societies, and search for funds via grants and capitation yet still find some time for teaching, participation in residency training, work in operating rooms, and research. It is apparent that my thesis is based on the belief that the future of our specialty depends not on the quality of our leaders (for. as I have said, they are for the most part exceptionally able, competent, and dedicated) but upon the direction in which those involved are led by them. I have come to this conclusion because, wherever I have looked, I have not found any organization with significant control of the important aspects of our specialty that is not controlled by the chairmen, for the most part, and full-time members of departments of our medical schools. All 18 Directors of our American Board of Obstetrics and Gynecology are academicians. Of the members of the Residency· Review Committee, 12 of 15 are professors. The Association of Professors of Gynecology and Obstetrics is, by structure, 100 per cent academic. In the American College of Obstetricians and Gynecologists, academicians are overwhelmingly influential. In a recent year ( 1972), 86 per cent of the Examiners for the Annual Board
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Examinations were primarily academicians. Most of the members of the American Gynecological Society and of this Association are either full-time medical school appointees or have an academic appointment with a school. It is of some interest that during the last 5 years the 30 newly elected members to the American Gynecological Society were academicians, and, in this Association, all 28 elected to membership were full-time members of medical school departments. Last year, in a letter to the President of the Association Foundation, Dr. Saul B. Gusberg2 wrote, in part, the following: Before I become confused by my responsibilitie.s at home, I wish to elaborate on my proposal to you concerning the consideration of Medals for Distinction to be given possibly annually by the Association Foundation. My thoughts about this arose from the fact that, like the weather as Mark Twain said, we talk a great deal about excellence in our discipline but we don't do much about it. This consideration also stems from my belief that, in the midst of all our whimpering about the poor recruitment to our discpline, the role models for young people have become either less attractive, less numerous or too remote. Of course, there are many facets to this problem, but I make this proposal as one small approach.
One notes that Dr. Gusberg refers to "role models." Each of us will need to define the tern1 "role models." As far as I am concerned, in the context of this letter, a "role model" is a teacher. It would be of interest to have a profile in depth of our leaders in order to know not only their areas of interest and their degree of competence but also what they really think and want, what they foresee for the future of our specialty as it relates to the practice of medicine, what they consider must, and not should, be taught to medical students, and, most important, what they really believe the primary responsibi~ity of the chairman of a department should be. One would think that the primary responsibility would be the teaching of the fundamentals of obstetrics and gynecology to students. One would think this because it must be the primary duty of members of
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a medical school faculty to inculcate, during a 4 year period, a body of students with basic knowledge that will result in the development of an individual who is well on his way toward becoming an accomplished physician. Or do our professors, in their own scheme of things, place student teaching in a secondary role? Within the past year, a professor made this remark to me, "Medical school would be a great place if it just weren't for students." The remark was probably made in jest but I could not be certain. Do many of our leaders hold such beliefs? Do they believe that residency training programs are all or most important? Do they believe that the number of grants they obtain, the magnitude of their surgical procedures, the number of their laboratories, the number of committees on which they serve, the number of national offices they hold, or the number of their faculty who are completely or almost completely research oriented should be at the top of their lists of priorities? It is apparent to the interested observer that certain teachers have few problems in attracting superior residents. These are the teachers who are personally involved in actual undergraduate teaching, who encourage consultation with students, who do not believe it beneath their dignity to participate in prenatal care or appear in a delivery room at night or to work in an operating room, and who cause their students to know at a social level that they are important people. In schools where these laudable conditions exist, research has a lesser role, the faculties are well rounded and composed of individuals with expertise in most areas of obstetrics and gynecology, and the chairmen are talented physicians who practice clinical obstetrics and gynecology. With respect to those who currently head departments, some reasonably accurate data stem from a review of the current chairmen in 94 medical schools in the United States, not including provisional schools. The average age of the department chairman is 50 years; the average age when appointed chairman is 42; and the time from certification to appointment, 7 years. In these 94
March I, 1974 Am. ,1. Obstet. Gynecol.
medical schools, 38 chairmen were first appointed within 5 years of certification, and the length of time in their current appointments was l!"ss than 5 years for 39; .'i to 10 years, for 23; and more than 10, for 22. Ther!" W!"re 10 schools that had either acting chairmen or chairmen who had not been certified by our American Board. Such data have little significance, but a study conducted by a disinterested objective individual or individuals, all infonnation being confidential, could well give significant information and provide insight as to the future of our specialty. After all, studies have been made of all other involved groups. Why should not a profile be obtained of those who control our future? Equally important would be the development of a profile depicting the qualifications desired by deans for chairmen and forthright statements from them as to the place of obstetrics and gynecology in the over-all academic picture. If such studies were done, it might be that insurmountable conflicts between administrators and teachers would be found. Much more likely would be the discovery that the desires of both groups would not be far apart, the probability thereafter lmng the development of firm plans for selection of chairmen and for the teaching of obstetrics and gynecology. If studies such as these were ever to be done, I believe they should be initiated, supported, and reported on by professors themselves--perhaps by the Association of Professors of Gynecolo~>y and Obstetrics or by another organization with like membership. It would be most n'vealing if the academicians would ask thernselvPs who they are, what they are, what thPy stand for, what they believe, what they want for our specialty, and just what their personal role should be in the teaching of medical students, in training at the graduate level, and in research. With answers to questions like these, obtained without identification of the individuals concerned, I believe most of the problems concerning the appeal of our specialty could be resolved. Before I finish the portion of this address that deals with the problems of today, I wish to say that I am not as pessimistic
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about matters as my remarks might imply. At present, in this country, we have an active, important, needed, and respected group of obstetricians and gynecologists, more than 19,000 strong. These were educated and trained, for the most part, by a previous generation of professors. The question is whether in the future there will be a similar number of equally active, dedicated, needed, competent, and respected obstetricians and gynecologists. Future developments
To consider what will occur tomorrow is always a tenuous process. This is particularly true today in all fields of medicine. In this regard, a recent symposium3 on graduate education is of interest. This symposium, which was published in the March, 1973, Bulletin of the American College of Surgeons, was presented by Dr. John C. Nunemaker, Executive Director, American Board of Medical Specialties; Dr. William D. Holden, the Oliver H. Payne Professor of Surgery, Western Reserve University; Dr. Thomas K. Kinney, Director of Medical and Allied Health Education, Duke U niversity Medical Center; Dr. Keith Reemtsma, professor of surgery and chairman of the Department of the College of Physicians and Surgeons, Columbia University; and Dr. Robert A. Chase, professor of plastic surgery, Stanford University, and Chairman of the American College of Surgeons Committee on Graduate Education. Graduate education was defined therein as those formal years of internship and residency that follow receipt of the M.D. degree. Although this symposium dealt with today's standards for accreditation and licensure, it is of interest to note the policy-making organizations involved and some of their current opinions and plans. These organizations include the American Board of Medical Specialties (ABMS); the Council on Medical Education of the American Medical Association (AMA) with a number of its subdivisions; the Association of American Medical Colleges ( AAMC) which, in the past few years, has been reorganized by the creation of three separate councils, namely, the
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Council of Deans, a Council of Teaching Hospitals, and a Council of Academic Societies; the Council of Medical Specialty Societies (CMSS); and the American Hospital Association (AHA) . Also involved are a Liaison Committee on Graduate Medical Education, which has representatives from each of the five aforementioned national bodies, and a Liaison Committee on Medical (medical school) Education. Finally, there is a Coordinating Council on Medical Education, which is to function as an intermediary between the official accrediting agencies (the Boards), the liaison committees, and the policy-making organization, the AMA, the AAMC, ABMS, AHA, and CMSS. Dr. Kinney, in his portion of this symposium on graduate education, related that a consortium of the five policy-making organizations has been formed to ". . . begin deliberations and establish policies for future accreditation of graduate programs." 3 While out of context, some quotations from Dr. Kinney's,., remarks shed light on what may be expected in the future. ... there are certain prerequisites which almost certainly will be required of institutions wishing to qualify as an academic medical center that is capable of being accredited for graduate medical education programs. Most often, they will consist of university or closely affiliated hospitals directly influenced or controlled by a medical school, although accreditation should also be granted to large institutions that are equipped to mount at least four or more major graduate programs without a university or medical school affiliation. The ultimate responsibility for each institution's graduate medical program should rest in a board of trustees representative of the community, probably that of the university or the medical school. These trustees should be . . . responsible also for the appointment of the administrator, who will have administrative authority over the graduate medical programs. . . . his prerogatives should equal those of the dean of an undergraduate medical school and each program director should be administratively responsible to him.
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The academic medical center should have a faculty that exercises the same responsibility for graduate medical education as the faculty of the medical school has for undergraduate education. . . . The most significant change, and the one that will cause the most controversy, will be this assignment of responsibility for graduate training of residents to the entire faculty of the academic medical center. (Today,) each service sets its own standards, organizes its own program, and determines its own criteria of achievement. There is very little or no input from other disciplines. Indeed, the very idea that a physiologist or pediatrician might have the right to criticize or suggest changes in a surgical training program was unthinkable until very recently. The involvement of the entire medical school faculty would enrich the quality of graduate medical education by forcing individual faculty members to think of graduate medical education in the broad terms of an educational institution, and not in the narrow terms of a single specialty.
The implications of these remarks, should these ideas come to pass, are almost too much to contemplate. If my interpretation of these remarks is correct, it means that all medical education will be controlled by the faculties of medical schools and that the place of obstetrics and gynecology, as for all specialties, in the future will depend almost solely on the abilities of the chairmen of departments. I venture to predict that our specialty will have few problems if our chairmen are personally involved in teaching and, by example. have shown themselves to be superior clinicians and physicians whose energies arc not dissipated in being demographers, urban planners, economists, or social scientists or who are not exclusively or almost exclusively involved in research aetivitics and if in some way they divorce themselves from certain of the responsibilities that currently have been given medical schools. namely, the curing of many social needs, the correction of nutritional deficits in the general population, the solving of transportation problems, and the development of programs for the underprivi-
March!, 1974 Am. J. Obstet. Gynecol.
leged. This is not to be construed as meaning that there should be no interest in the social problems that exist in our communities, there should be no involvement in political and environmental problems, or research activities should not be important. It should be construed as meaning that the primary goal of education in our profession is the development of knowledge for the prevention of disease and for the relief of disability and prevention of death in specific human beings. The question as to the place of the academician in educational activities and in the practice of medicine has long been disputed, and the dispute is no closer to resolution today than it has been in the past. Dr. Raymond D. Pruitt, Director of Education for the Mayo Foundation and Dean of the Mayo Medical School, recently observed that conflicts in this area have existed at least since the time of William Osler and Abraham Flexner. Dr. Pruitt 5 wrote: Flexner argued that "practical importance is not a sufficient title to academic recognition," and while he urged that "universities maintain contact with the actual world," he proposed that they ''continue to be irresponsible with respect to practical affairs." The professor of medicine is a trainer of men who "has not the slightest obligation to look after as many sick people as he can." In 1911, Osler, in his letter to President Remsen of Johns Hopkins University, responded thus, "Cabined, cribbed, confined within the four walls of a hospital, practicing the fugitive and cloistered virtues of a clinical monk, how shall he [the clinical professor], forsooth, train men for a ntce the dust and heat of which he knows nothing and-this is a possibility-cares less."
As I come to the final portions of this address, I wish to make some remarks based on observations made on what has happened at my home institution since I arrived there in 1936. These observations hopefully will emphasize the point that, in the triad of education, research, and practice. it is practice that is far and away the most important. In 1936, we were staffed hv 165
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permanent staff members and 160 residents. Today, this number of permanent staff and residents has increased by some 360 per cent. During this time, more than 2,100,000 individuals have sought medical care at the ~ayo Clinic. While caring for these patients, 1 of every 50 specialists now practicing in this country was trained. Despite these clinical and teaching activities, the research efforts have been considerable, important, and rewarding, and a not inconsiderable number of our permanent staff have devoted all of their time to research. The question that requires an answer is this: Why has this number of people come to us and why do so many young people seek us for graduate training? Is it because of individual status, fame, or renown? Is it because of individual status, fame ' or renown? Is it because of the contributions to fundamental medical knowledge made by those whose sphere of activity is in research, or do they come because they expect to and do receive quality care by experienced physicians? I believe that the answer lies in the fact that we have always put the patient and his welfare first. At our most recent general staff meeting, the President 6 of our staff in his address remarked: A few years ago, a nationally prominent physician in the endocrine field from a very famous hospital in Boston was a visiting professor in our division. After making rounds and attending clinics for several days, he stated that he finally realized what made us so successful and so attractive to the patient. He was truly surprised that not only did we put the patient and his welfare first, but we actually acted as if it was a privilege to serve the patient. He stated that at his institution, the feeling was that the patient
REFERENCES
l. Chez, R. A., and Hutchinson, D. L.: Obstet.
Gynecol. 33: 127, 1969. 2. Gusberg, S. B.: Personal communication. 3. ~~~:f.osium: Bull. Am. Col!. Surg. 58: 12, 4. ~~~~-ey, T.D.: Bull. Am. Coli. Surg. 58: 18,
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should feel privileged to be there and that patient care, especially outpatient care, simply did not come first.
Delivery of patient care, defined as you wish, is what medicine is all about; it is also what must not be forgotten if our efforts in making our particular segment of medicine one that is well taught and. well practiced are to be successful. Today's statements that much of our work is not intellectually stimulating, that obstetricians should only attend high-risk patients, that we should not see patients who, at times, have other than gynecologic complaints, and that much of our work can and should be done by nurses and assistants miss the point. What real physicians do is to take care of people. All research, all education, all committee activities-if they have pertinence to our profession-ultimately must lead to quality care of people. People, not their complaints or needs or diseases, are intellectually stimulating. There is no disease, there is no operation, there is no problem-no matter how unusual or exotic-that does not become boring if faced repetitively. Therefore, let us realize that what we do is not work not play, not service, but something intang~ ible that only those who are true physicians understand and that this intangible something involves the care of people and making certain that those who follow are better than we are. Should our leaders accept this view and proceed to teach along these lines and pattern their daily lives about the concept that they are primarily physicians, I believe our specialty will have a bright future and will maintain its proper place in the field of medicine.
5. Pruitt, R. D.: Mayo Clin. Proc. 48: 287, 1973. 6. Salassa, R. M.: President's address, Read at the Annual Meeting of the Voting Staff of M~yo Clinic, November, 1972, Rochester, Mmnesota.
Today and tomorrow Presidential address
ROBERT B. WILSON, M.D. Rochester, }vfinnesota
sive. It is important that we change for the better and not for the worse; it is also important to recognize that it is much easier to change for the worse than for the better. In education, WI:' deal for the most part with students; and, whether we consider medical schools, internships, or graduate programs, the participants are still students. It is now a fact of life that these men and women are active participants in the fonrmlation of curricula and that they readily and often enthusiastically give constructive criticism. There is little doubt that activity of this type is beneficial. However, one wonders about other changes in attitudes, changes that are illustrated by insistence that examinations are of little value and that grades. if given, should be used by the student for his personal evaluation of progress and not as determinants as to whether an individual should continue the study of medicine. Even more difficult to accept is the fonnation of unions or quasiorganizations with similar purposes for ensurance of "rights" or even actual confrontations with either teachers in classrooms or those in administrative controL At times, one speculates that these attitudes may have developed because today's student has been told so often of his superior intellect and ability and has concluded that such evaluations are indeed true. Perhaps it is redundant to remark that good minds and great abilities are not recent creations and
pRES 1 DENT I A L ADD RES S E S before our Association have, on many occasions, dealt with one or another aspect of medical education. I, too, wish to discuss this subject, my discussion being directed toward one aspect of medical education that, to the best of my knowledge, heretofore has not been discussed, namely, the leadership in our specialty of obstetrics and gynecology. After selecting this subject, I had not only second but also third and fourth thoughts about the v>isdom of discussing it. This is not because the subject should not be discussed but because I am somewhat apprehensive that my remarks might be misinterpreted.
Changes in education
We live in a changing world and, at times, one is inclined to believe that today's world is changing more than in many times in the past. Change in itself is not unique or disturbing; in fact, change is a normal aspect of all times. Changes are always proposed in the name of progress; the real issue is to detennine which changes are truly progresFrom the Department of Obstetrics and Gynecology, Mayo Clinic. Presented at the Eighty-fourth Annual Meeting of the American Association of Obstetricians and Gynecologists, Hot Springs, Virginia, September 6-8, 1973. Reprint requests: Section of Publications, J;fayo Clinic, Rochester, Minnesota 55901.
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that preventive medicine, social responsibilities, and real concern for mankind are not new to the medical ethic. One cannot ignore the observation that attitudinal changes of students have occurred at a time when the attitudes and philosophies of those who educate have undergone tremendous changes. I do not know whether our problems are because of factors arising in the thought processes of students or because of changes in educational philosophy and general permissiveness or whether they result from many of the shortcomings that exist in our profession. A particularly galling example of such a shortcoming is a law deemed necessary, and passed, by the 1973 Minnesota State Legislature (Session Laws, 1973, Chapter 688) ; in part and paraphrased, this law states that every patient shall have the right to considerate and respectful care, shall be kept informed as to his medical status, shall know the name of his primary physician, and shall have every consideration of his privacy and individuality as it relates to his social, religious, and psychological well-being. What can a medical student possibly think as he learns that, on acceptance into medical school he is certain to receive a degree in medicine in 4 years? Recently, when discussing this essentially automatic graduation from medical school with the head of a department, I asked if it bothered him that individuals who did not deserve an M.D. degree were granted one. His answer was that it did indeed bother him, but the solution at his university was to ask the unqualified individuals if they would please not practice medicine! What sort of motivation will there be on learning that the only examination in which he or she has to succeed is one given not by his teachers, but by a National Board of Medical Examiners? What will his reaction be when he realizes that prominent medical school educators w~ite that if a student does not learn a subJect it is the fault of the professor rather than of the student? How will he react when he reads the following; The study of medicine is a lifelong commitment for the physician. This commitment, free of a
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formalized setting, is met only by the individual's initiative, self-discipline, and industry. Any motivation initiated by the pedantic stresses of tests, examinations, or the threat of failing is no longer valid. It is a function of personal integrity to be informed and capable of evaluating new ideas and advances. 1
It is evident that in this type of educational environment the only thing that is saving the medical profession is the fact that it still attracts extremely intelligent men and women who somehow become physicians, even with wide gaps in their knowledge, despite us. It would seem that medical schools, despite great efforts expended on using the services of educators in formal departments of education and numerous curriculumplanning committees, are quite consciously drifting toward the concept that individuals really are not going to learn much in medical school and that knowledge will ultimately be acquired in the residency years-and a residency, after all, is nothing more than a glorified preceptorship wherein the student is exposed to multiple rather than single preceptors. If this is so, one might ask why we have any medical schools at all. The place of our specialty in medicine today
These general remarks bring us to a consideration of our specialty and its place in the medical spectrum. We are all aware of the diminished appeal of our discipline, as shown by data presented last year at this meeting by Dr. Lawrence Hester. In 1970, 40 per cent of some 3,081 residency positions offered in obstetrics and gynecology were filled by individuals who had received their undergraduate education in foreign medical schools; 5 years previously, 27 per cent ( 682 of 2,526) were filled by foreign graduates. Currently, approximately 50 per cent of those examined for certification by the American Board of Obstetrics and Gynecology have received their education in foreign schools. The motivation for the foreign graduate to become an obstetrician and gynecologist must be considerable for, at the present time, there is no way for him
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to obtain full certification unless he applies for United States citizenship, is licensed, and has completed 2 years of unrestricted practice in the U nitcd States. One is at once both amazed and mystified as to tht:> reasons for this trend; and, as teachers, we should be chagrined by the fact that this trend evidently means that in our medical schools obstetrics and gynecology are taught in a manner devoid of real appeal. If this trend continues, not many years will elapse before a majority of specialists in obstetrics and gynecolog-y will have been trained in foreign countries. Many studies have been done in an attempt to unravel this problem. but I know of none that has directed its efforts toward an evaluation of the methods of teaching obstetrics and srynecology in foreign schools; or, to put it another way, why do graduates of foreign medical schools develop an interest in our specialty and why do so few, in proportion, develop the same interest when they graduate from our own schools? As an aside, if this trend continues, one might expect that in our specialty 60 to 70 per cent of obstetricians and gynecologists will have been trained in foreign medical schools. Thereafter, the American Civil Liberties Union might become involved and insist that the governing bodies of our specialty. such as our American Board, include 60 to 70 per cent of foreign graduates. Should such come to pass, those living in this country may find not only that vast segments of our economy are controlled and owned by those who live and produce in the Far East and the Middle East as well as in Europe but also that our segment of medicine is controlled by those who are foreign trained. These remarks about foreign graduates are not made in a derogatory manner~for, after all. most of us are only second- or third-generation Americans--but to bring into the open the observation that obstetrics and gynecology, as taught by those from beyond our borders, seemingly has more appeal and is more competitive with other specialties than our specialty as taught by us. Perhaps there are other reasons for this
;>daJch 1. !9H Am .
.f.
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state of affairs. As the medic<1l student progresses. one of the most exciting of his experictHTS is to learn about conception and tlw growth and development of the fetus and then not only to learn about but also observe and participate in the ddivPrv of a baby. Furthermore, he is attracted to die rhallenges of gynPcologic surgPry, the mys· teries of gync·cologir endocrinology, and the excitement of the new and contimwlly drw~lopin,g science of neonatology. But then he learns that rnanv of our leaders, most of them professors in om schools, belie\ e that midwives should care for women \\ ho arc rxpected to han· nom1al deliwries ;1nd that all who have. or are expected to have. abnormalities should be rrferred to a regional centN. Or he learns that gynecologists are ''nothing but tired obstetricians" and hears all sorts of invidious comparisons between the sur,gical abilities of gynecologic surgeons as compared to those of ,general surgeons. If the student should be attracted to endocrinology. he soon learns that nearlv all of the endocrinologists of repute arrive as leading endocrinolog·ists via the field of internal medicine. Is it any wonder, tlwn. that the student is "turned off"? What is so particularly disheartening is that most of our leaders' statements state· ments to the effect that prenatal care is not all that important, that the midwife should perform the deliveries. and that there is nothing really exciting or challenging about what I will refer to as the everyday practiec of obstetrics and gynecology--~are either opinions that have no basis in fact or opinions that are based on data that are interpreted to suit the personal fancy of the person who is speaking or writing. Also giving cause for concern is the lack of appeal that chairmanship of a department seems to have and the dearth of acceptable individuals to fill positions available as chairmen of departments of obstetrics and gynecology. One can enumerate, without a pause for breath, 7 to 10 schools each of which is now seeking an individual for the chair of obstetrics and gynecology. Not so evident is the knowledge that a number of current chairmen are unhappy in their
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present positions and would be receptive to offers from other institutions. Perhaps this seeming lack of available candidates is really related to the possibility that individuals who would do an outstanding job as teachers of students and in the clinical training of those at the graduate level and who have a reasonable but not overwhelming interest in research are personae non gratae as far as deans and others in administrative control are concerned. I suspect, too, that many individuals with these talents simply refuse to subject themselves to the almost impossible demands to which presentday chairmen are subjected. One can only admire many of today's chairmen who, in some way, serve on curriculum committees, admissions committees, planning-for-thefuture committees, and finance committees and who also attend a multitude of staff and faculty meetings, assume innumerable and important national responsibilities, hold major offices in specialty societies, and search for funds via grants and capitation yet still find some time for teaching, participation in residency training, work in operating rooms, and research. It is apparent that my thesis is based on the belief that the future of our specialty depends not on the quality of our leaders (for. as I have said, they are for the most part exceptionally able, competent, and dedicated) but upon the direction in which those involved are led by them. I have come to this conclusion because, wherever I have looked, I have not found any organization with significant control of the important aspects of our specialty that is not controlled by the chairmen, for the most part, and full-time members of departments of our medical schools. All 18 Directors of our American Board of Obstetrics and Gynecology are academicians. Of the members of the Residency· Review Committee, 12 of 15 are professors. The Association of Professors of Gynecology and Obstetrics is, by structure, 100 per cent academic. In the American College of Obstetricians and Gynecologists, academicians are overwhelmingly influential. In a recent year ( 1972), 86 per cent of the Examiners for the Annual Board
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Examinations were primarily academicians. Most of the members of the American Gynecological Society and of this Association are either full-time medical school appointees or have an academic appointment with a school. It is of some interest that during the last 5 years the 30 newly elected members to the American Gynecological Society were academicians, and, in this Association, all 28 elected to membership were full-time members of medical school departments. Last year, in a letter to the President of the Association Foundation, Dr. Saul B. Gusberg2 wrote, in part, the following: Before I become confused by my responsibilitie.s at home, I wish to elaborate on my proposal to you concerning the consideration of Medals for Distinction to be given possibly annually by the Association Foundation. My thoughts about this arose from the fact that, like the weather as Mark Twain said, we talk a great deal about excellence in our discipline but we don't do much about it. This consideration also stems from my belief that, in the midst of all our whimpering about the poor recruitment to our discpline, the role models for young people have become either less attractive, less numerous or too remote. Of course, there are many facets to this problem, but I make this proposal as one small approach.
One notes that Dr. Gusberg refers to "role models." Each of us will need to define the tern1 "role models." As far as I am concerned, in the context of this letter, a "role model" is a teacher. It would be of interest to have a profile in depth of our leaders in order to know not only their areas of interest and their degree of competence but also what they really think and want, what they foresee for the future of our specialty as it relates to the practice of medicine, what they consider must, and not should, be taught to medical students, and, most important, what they really believe the primary responsibi~ity of the chairman of a department should be. One would think that the primary responsibility would be the teaching of the fundamentals of obstetrics and gynecology to students. One would think this because it must be the primary duty of members of
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a medical school faculty to inculcate, during a 4 year period, a body of students with basic knowledge that will result in the development of an individual who is well on his way toward becoming an accomplished physician. Or do our professors, in their own scheme of things, place student teaching in a secondary role? Within the past year, a professor made this remark to me, "Medical school would be a great place if it just weren't for students." The remark was probably made in jest but I could not be certain. Do many of our leaders hold such beliefs? Do they believe that residency training programs are all or most important? Do they believe that the number of grants they obtain, the magnitude of their surgical procedures, the number of their laboratories, the number of committees on which they serve, the number of national offices they hold, or the number of their faculty who are completely or almost completely research oriented should be at the top of their lists of priorities? It is apparent to the interested observer that certain teachers have few problems in attracting superior residents. These are the teachers who are personally involved in actual undergraduate teaching, who encourage consultation with students, who do not believe it beneath their dignity to participate in prenatal care or appear in a delivery room at night or to work in an operating room, and who cause their students to know at a social level that they are important people. In schools where these laudable conditions exist, research has a lesser role, the faculties are well rounded and composed of individuals with expertise in most areas of obstetrics and gynecology, and the chairmen are talented physicians who practice clinical obstetrics and gynecology. With respect to those who currently head departments, some reasonably accurate data stem from a review of the current chairmen in 94 medical schools in the United States, not including provisional schools. The average age of the department chairman is 50 years; the average age when appointed chairman is 42; and the time from certification to appointment, 7 years. In these 94
March I, 1974 Am. ,1. Obstet. Gynecol.
medical schools, 38 chairmen were first appointed within 5 years of certification, and the length of time in their current appointments was l!"ss than 5 years for 39; .'i to 10 years, for 23; and more than 10, for 22. Ther!" W!"re 10 schools that had either acting chairmen or chairmen who had not been certified by our American Board. Such data have little significance, but a study conducted by a disinterested objective individual or individuals, all infonnation being confidential, could well give significant information and provide insight as to the future of our specialty. After all, studies have been made of all other involved groups. Why should not a profile be obtained of those who control our future? Equally important would be the development of a profile depicting the qualifications desired by deans for chairmen and forthright statements from them as to the place of obstetrics and gynecology in the over-all academic picture. If such studies were done, it might be that insurmountable conflicts between administrators and teachers would be found. Much more likely would be the discovery that the desires of both groups would not be far apart, the probability thereafter lmng the development of firm plans for selection of chairmen and for the teaching of obstetrics and gynecology. If studies such as these were ever to be done, I believe they should be initiated, supported, and reported on by professors themselves--perhaps by the Association of Professors of Gynecolo~>y and Obstetrics or by another organization with like membership. It would be most n'vealing if the academicians would ask thernselvPs who they are, what they are, what thPy stand for, what they believe, what they want for our specialty, and just what their personal role should be in the teaching of medical students, in training at the graduate level, and in research. With answers to questions like these, obtained without identification of the individuals concerned, I believe most of the problems concerning the appeal of our specialty could be resolved. Before I finish the portion of this address that deals with the problems of today, I wish to say that I am not as pessimistic
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about matters as my remarks might imply. At present, in this country, we have an active, important, needed, and respected group of obstetricians and gynecologists, more than 19,000 strong. These were educated and trained, for the most part, by a previous generation of professors. The question is whether in the future there will be a similar number of equally active, dedicated, needed, competent, and respected obstetricians and gynecologists. Future developments
To consider what will occur tomorrow is always a tenuous process. This is particularly true today in all fields of medicine. In this regard, a recent symposium3 on graduate education is of interest. This symposium, which was published in the March, 1973, Bulletin of the American College of Surgeons, was presented by Dr. John C. Nunemaker, Executive Director, American Board of Medical Specialties; Dr. William D. Holden, the Oliver H. Payne Professor of Surgery, Western Reserve University; Dr. Thomas K. Kinney, Director of Medical and Allied Health Education, Duke U niversity Medical Center; Dr. Keith Reemtsma, professor of surgery and chairman of the Department of the College of Physicians and Surgeons, Columbia University; and Dr. Robert A. Chase, professor of plastic surgery, Stanford University, and Chairman of the American College of Surgeons Committee on Graduate Education. Graduate education was defined therein as those formal years of internship and residency that follow receipt of the M.D. degree. Although this symposium dealt with today's standards for accreditation and licensure, it is of interest to note the policy-making organizations involved and some of their current opinions and plans. These organizations include the American Board of Medical Specialties (ABMS); the Council on Medical Education of the American Medical Association (AMA) with a number of its subdivisions; the Association of American Medical Colleges ( AAMC) which, in the past few years, has been reorganized by the creation of three separate councils, namely, the
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Council of Deans, a Council of Teaching Hospitals, and a Council of Academic Societies; the Council of Medical Specialty Societies (CMSS); and the American Hospital Association (AHA) . Also involved are a Liaison Committee on Graduate Medical Education, which has representatives from each of the five aforementioned national bodies, and a Liaison Committee on Medical (medical school) Education. Finally, there is a Coordinating Council on Medical Education, which is to function as an intermediary between the official accrediting agencies (the Boards), the liaison committees, and the policy-making organization, the AMA, the AAMC, ABMS, AHA, and CMSS. Dr. Kinney, in his portion of this symposium on graduate education, related that a consortium of the five policy-making organizations has been formed to ". . . begin deliberations and establish policies for future accreditation of graduate programs." 3 While out of context, some quotations from Dr. Kinney's,., remarks shed light on what may be expected in the future. ... there are certain prerequisites which almost certainly will be required of institutions wishing to qualify as an academic medical center that is capable of being accredited for graduate medical education programs. Most often, they will consist of university or closely affiliated hospitals directly influenced or controlled by a medical school, although accreditation should also be granted to large institutions that are equipped to mount at least four or more major graduate programs without a university or medical school affiliation. The ultimate responsibility for each institution's graduate medical program should rest in a board of trustees representative of the community, probably that of the university or the medical school. These trustees should be . . . responsible also for the appointment of the administrator, who will have administrative authority over the graduate medical programs. . . . his prerogatives should equal those of the dean of an undergraduate medical school and each program director should be administratively responsible to him.
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The academic medical center should have a faculty that exercises the same responsibility for graduate medical education as the faculty of the medical school has for undergraduate education. . . . The most significant change, and the one that will cause the most controversy, will be this assignment of responsibility for graduate training of residents to the entire faculty of the academic medical center. (Today,) each service sets its own standards, organizes its own program, and determines its own criteria of achievement. There is very little or no input from other disciplines. Indeed, the very idea that a physiologist or pediatrician might have the right to criticize or suggest changes in a surgical training program was unthinkable until very recently. The involvement of the entire medical school faculty would enrich the quality of graduate medical education by forcing individual faculty members to think of graduate medical education in the broad terms of an educational institution, and not in the narrow terms of a single specialty.
The implications of these remarks, should these ideas come to pass, are almost too much to contemplate. If my interpretation of these remarks is correct, it means that all medical education will be controlled by the faculties of medical schools and that the place of obstetrics and gynecology, as for all specialties, in the future will depend almost solely on the abilities of the chairmen of departments. I venture to predict that our specialty will have few problems if our chairmen are personally involved in teaching and, by example. have shown themselves to be superior clinicians and physicians whose energies arc not dissipated in being demographers, urban planners, economists, or social scientists or who are not exclusively or almost exclusively involved in research aetivitics and if in some way they divorce themselves from certain of the responsibilities that currently have been given medical schools. namely, the curing of many social needs, the correction of nutritional deficits in the general population, the solving of transportation problems, and the development of programs for the underprivi-
March!, 1974 Am. J. Obstet. Gynecol.
leged. This is not to be construed as meaning that there should be no interest in the social problems that exist in our communities, there should be no involvement in political and environmental problems, or research activities should not be important. It should be construed as meaning that the primary goal of education in our profession is the development of knowledge for the prevention of disease and for the relief of disability and prevention of death in specific human beings. The question as to the place of the academician in educational activities and in the practice of medicine has long been disputed, and the dispute is no closer to resolution today than it has been in the past. Dr. Raymond D. Pruitt, Director of Education for the Mayo Foundation and Dean of the Mayo Medical School, recently observed that conflicts in this area have existed at least since the time of William Osler and Abraham Flexner. Dr. Pruitt 5 wrote: Flexner argued that "practical importance is not a sufficient title to academic recognition," and while he urged that "universities maintain contact with the actual world," he proposed that they ''continue to be irresponsible with respect to practical affairs." The professor of medicine is a trainer of men who "has not the slightest obligation to look after as many sick people as he can." In 1911, Osler, in his letter to President Remsen of Johns Hopkins University, responded thus, "Cabined, cribbed, confined within the four walls of a hospital, practicing the fugitive and cloistered virtues of a clinical monk, how shall he [the clinical professor], forsooth, train men for a ntce the dust and heat of which he knows nothing and-this is a possibility-cares less."
As I come to the final portions of this address, I wish to make some remarks based on observations made on what has happened at my home institution since I arrived there in 1936. These observations hopefully will emphasize the point that, in the triad of education, research, and practice. it is practice that is far and away the most important. In 1936, we were staffed hv 165
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permanent staff members and 160 residents. Today, this number of permanent staff and residents has increased by some 360 per cent. During this time, more than 2,100,000 individuals have sought medical care at the ~ayo Clinic. While caring for these patients, 1 of every 50 specialists now practicing in this country was trained. Despite these clinical and teaching activities, the research efforts have been considerable, important, and rewarding, and a not inconsiderable number of our permanent staff have devoted all of their time to research. The question that requires an answer is this: Why has this number of people come to us and why do so many young people seek us for graduate training? Is it because of individual status, fame, or renown? Is it because of individual status, fame ' or renown? Is it because of the contributions to fundamental medical knowledge made by those whose sphere of activity is in research, or do they come because they expect to and do receive quality care by experienced physicians? I believe that the answer lies in the fact that we have always put the patient and his welfare first. At our most recent general staff meeting, the President 6 of our staff in his address remarked: A few years ago, a nationally prominent physician in the endocrine field from a very famous hospital in Boston was a visiting professor in our division. After making rounds and attending clinics for several days, he stated that he finally realized what made us so successful and so attractive to the patient. He was truly surprised that not only did we put the patient and his welfare first, but we actually acted as if it was a privilege to serve the patient. He stated that at his institution, the feeling was that the patient
REFERENCES
l. Chez, R. A., and Hutchinson, D. L.: Obstet.
Gynecol. 33: 127, 1969. 2. Gusberg, S. B.: Personal communication. 3. ~~~:f.osium: Bull. Am. Col!. Surg. 58: 12, 4. ~~~~-ey, T.D.: Bull. Am. Coli. Surg. 58: 18,
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should feel privileged to be there and that patient care, especially outpatient care, simply did not come first.
Delivery of patient care, defined as you wish, is what medicine is all about; it is also what must not be forgotten if our efforts in making our particular segment of medicine one that is well taught and. well practiced are to be successful. Today's statements that much of our work is not intellectually stimulating, that obstetricians should only attend high-risk patients, that we should not see patients who, at times, have other than gynecologic complaints, and that much of our work can and should be done by nurses and assistants miss the point. What real physicians do is to take care of people. All research, all education, all committee activities-if they have pertinence to our profession-ultimately must lead to quality care of people. People, not their complaints or needs or diseases, are intellectually stimulating. There is no disease, there is no operation, there is no problem-no matter how unusual or exotic-that does not become boring if faced repetitively. Therefore, let us realize that what we do is not work not play, not service, but something intang~ ible that only those who are true physicians understand and that this intangible something involves the care of people and making certain that those who follow are better than we are. Should our leaders accept this view and proceed to teach along these lines and pattern their daily lives about the concept that they are primarily physicians, I believe our specialty will have a bright future and will maintain its proper place in the field of medicine.
5. Pruitt, R. D.: Mayo Clin. Proc. 48: 287, 1973. 6. Salassa, R. M.: President's address, Read at the Annual Meeting of the Voting Staff of M~yo Clinic, November, 1972, Rochester, Mmnesota.