Unconventional obstetrics and gynecology

Unconventional Reflections

Obstetrics

and Gynecology

on the Growth and Development JOHN

R. G. GOSLING,M.D., Ann

an essay on the place of obstetrics P REPARE and gynecology in American surgical education? Gladly. Nothing easier! This process began with that very naive assumption and, if nothing else, has provided a considerable educational experience for the author. Any effort to speculate upon the place of obstetrics and gynecology as a surgical discipline must first examine the basic assumption that it is surgical. Historically, the man midwife was recruited from the ranks of the surgeons, just as the gynecologist in his own time evolved as a surgeon with a primary and professional interest in the female reproductive tract. However, any argument based upon history is confronted by the observation that the specialty has changed character as it has evolved. Admitting this to be so, we have reason to believe the basic personal attributes have not. The preliminary material presented by Helen H. Gee in the Association of American Medical Colleges’ study on psychologic traits related to career choice demonstrates a closer parallel between those who choose obstetrics and gynecology and those who choose surgery than for other specialty groups. Yet there are subtle and increasingly significant differences. Participation in the program of both the American College of Obstetrics and Gynecology and the American College of Surgeons is assumed to be a fit and proper attitude of any full fledged member of our specialty. On the other hand, one has the authoritative assertion that a straight medicine internship is fully as useful as a straight surgical or rotating service for the embryonic obstetrician-gynecologist. As a specialty group we are, in a number of instances, ambivalent about our identification. Perhaps it is the ambivalence that disturbs us.

Arbor,

of a Specialty

Michigan

Yet our dominant philosophy is surgical. We recruit, for good or ill, from the young men of surgical inclinations and most of us feel mortally off ended if our qualifications as competent surgeons are slighted in some degree. Are we, then, an awkward or an intermittently unwilling surgical subspecialty? Have we, in fact, clamped the umbilical cord, or are we still palpating pulsations and awaiting a suitable moment for decision? It would be easy to solicit a large majority dissent to any such assertion. “Absolutely not. We have departmental status in virtually every Medical School on this continent” or something similar. Reference might be made to the struggle with departments of medicine and surgery for a fair share of curriculum hours. Thirty years’ago H. J. Stander could point with pride to a departmental allocation of 605 hours for obstetrics and gynecology compared with 680 hours for medicine and 630 hours for general surgery. Since this represented an increase from 306 hours five years earlier, it represented progress, but does it in fact represent differentiation? Such arguments are administrative, not philosophic. On occasion one detects the same note of emotional argument that one associates with the newly emergent nations of the world. We have accomplished our independence and it has been a struggle. We like to believe that we have successfully extricated gynecology from the clutches of departments of surgery, and we have avoided the hazard of division of our specialty into medical and surgical aspects, at least for administrative purposes. We ought to feel a bit uncomfortable about an “independent and unified specialty” that is still forced to describe itself with a three word label, but this unique 4.4

American Journal of Surgery

Unconventional

Obstetrics

attribute, “ obstetrics and gynecology,” belongs to another area of argument. One would be reluctant to argue against the propriety of the independence, yet we must avoid the hazards of unreasoning assertions of independence at the cost of the valid development of our program. The men who laid down the guidelines for our autonomy were, in most instances, trained as general surgeons. That was approximately two generations ago. My own teachers received their training from these men and brought the specialty to its present well rounded state of integrity. Our surgical heritage has been in good hands and has been fundamental in our evolution, but surgery itself has changed considerably in the interval. From my own experience, it is increasingly difficult to maintain any really practical contact with our basic philosophic discipline. What should we expect? “The very proliferation of knowledge makes it inevitable that there be more specialization.” That argument has an uncomfortable and familiar ring. We can find it expressed by the Roman encyclopedists some two thousand years ago who maintained that the range of knowledge exceeded the abilities of one man. Nor does this reflect a total difference of culture or locale. To come closer to our own frame of “In modern times the constituent reference, branches of medical science are so expanded that they cannot be acquired by any physician in a lifetime and still less by a student in his pupilage. The same is true even of many individual branches. It is not therefore to be concluded that ‘a scheme of scientific instruction should embrace the whole science and no part should be omitted,’ nor that ‘a well digested plane of lecture embrace all that is to be known and taught.’ Medical science has at this day become so unwieldly and contains so much that is necessary, at least to beginners, that the attempt to explain to students the whole is likely to involve the result of their learning but little.” The words were presented by Dr. Jacob Begelow of the Harvard Medical School in 1850. Medicine has probably not deteriorated in the interval, yet the medical profession’s efforts at developing subspecialties may not be described as uniformly and completely successful. In our own specialty we should follow this road to subdivision with considerable caution. One might ask whether it is really necessary to follow it at all. Are we in obstetrics and gyneVol. 110, July

1965

and

Gynecology

45

cology, for all the administrative and philosophic obfuscation, simply the senior and most well established subspecialty of all? If so, of what? Surgery is the simple answer. Here lies our greatest community of attitude and experience. Yet clearly this does not meet all the criteria, for much of the future lies in areas which have fully as much to do with medicine. Endocrinology and hematology are increasingly important to us. Examine the character of our publications for an example in support of this assertion. Out of these contrasting observations we can build the best argument for our integrity as a specialty, but one can also recognize problems. The people who select the field of obstetrics and gynecology are primarily “surgical types.” True, the one distinguishing and determining factor may well be an interest in the birth process itself, but this might be challenged as a base for the total development of the specialty. As a professional discipline we express some distress that we are not attracting the caliber of persons comparable to those entering the surgical and medical specialties. Yet we have done little about it except to discuss stepping up the advertising campaign. Perhaps it is time to admit that there might be more than one reasonable road leading to the specialty of obstetrics and gynecology, and that our specialized knowledge can reasonably be built upon differing foundations. In the process we might broaden our appeal considerably. We should find no occasion within this specialty for a division into “thinkers” and “doers,” yet both attributes have their value if we encourage them to find a place. The basic question to which we must address ourselves is based on the assumption that we are in fact a distinct professional discipline. The assumption may be argued, but there are those of us who ardently believe it to be so. If it is so, then predictably we shall be subject to the same experience already confronted in medicine and surgery, as they have responded to the rapid growth and knowledge and skill in their major disciplines. If the analogy holds, we shall be subject to continuing internal pressure to subdivide and to subspecialize. Having just achieved a fusion within the memory of living man, we now contemplate some type of fission. If we are in fact a valid discipline within medicine, it would be possible to evolve in our own pattern, hopefully a rational one. How shall it be accomplished? Gynecologic endocrinology

Gosling and pelvic malignancies represent legitimate specific areas of interest. They also can represent separate medical and surgical gynecology and gynecologists. Yet if we maintain the unity of experience which constitutes the present scope of our specialty, how can we possibly train any man adequately within the period of a three or four year residency? One tempting possibility for a practical program of training within such a time limit would be just that, practicality. The argument may begin from the defensible position “let’s equip the man to provide the type of service commonly required in the community.” Yet if one carries this forward, one of the paths leads to a full circle. “Obstetrical competence is the unique aspect of this experience so why not train the man to do good obstetrics and leave the less common procedures to the surgeons within the community.” At this point a full century vanishes in a puff of smoke. The path of prophecy presents a thorny enough prospect that I will not presume to enter it. It does not require the gift of prophecy to see that the specialty of obstetrics and gynecology, willingly or not, must evolve further during the years ahead. To question the prospect of evolution seems foolish. Such folly would be exceeded only by the unrealistic assumption that any one voice or small number of voices could materially influence the direction of that evolution. Yet the evolution can be influenced by the conduct of the entire specialty, and influenced favorably. Basically this requires a willingness to experiment with programs, evaluate, and exchange experience in as objective a fashion as possible. Without this we leave our future to capricious chance. Certain assertions seem justifiable. First, the unique character of our specialty has the reproductive process at its core, not the process of birth itself, appealing though that may be, but the process of reproduction. Subordinate to this are surgical skills, in the broad sense, including not only our basic gynecologic operative technics but the entire range of obstetric manipulation. Of equal importance are the basic concepts of physiology and endocrinology which are, in fact, medical disciplines. Ranking with these are the basic psychologic and psychiatric abilities and understandings which often make the difference between success and failure. Temper-

amentally, each person finds one or another of these aspects more appealing, more available as he enters this specialty. “For his own good” he is given a premeasured dose of the three in a planned three or four year experience. Is this program really essential? Are we basically too defensive about our special characteristics? What would be the result of a two year program of obstetrics and gynecology given to men of promise who have already com$leted an internship and two years of residency training in either medicine or surgery? Not that there is anything magic about two years, but then there is nothing magic about Bowdlerized medicine and surgery in our existing programs either. We have separated ourselves further than need be from the sources of the basic concepts we espouse. Subspecialties in both disciplines, in their best form, require a basic two year experience. Both come closer to full scope of medicine than do we. Granted that the individual person must choose, but does the specialty have to make an either/or or a neither type of judgment? Isolation may be too high a price to pay for autonomy; for that matter it may not be a requirement at all. There is clearly a price. We would have to share our prized clinical material with the surgeon and the internist. We would have to admit that surgeons can perform hysterectomies and that internists can treat vaginitis or control diabetes in the pregnant patient, but these reflect an existing state of affairs and a substantial change is unlikely. One could go from here through a whole range of possible programs. The rules of the game are broad and any number can play. These personal observations should be taken less as a serious proposal of a specific method than as an earnest plea for examination of our direction and long range objectives. I can only hope that my concern for the prospect of more and more fragmentation and separation is shared by some of my colleagues, and that in the years to come we may examine the possible merit in drawing more toward our parent disciplines for their basic values on the assumption that these are’shared by all of us. That we have something of a unique appeal to offer, beyond such basic competence, should be both a source of continuing satisfaction and a justification for our hard won autonomy.

American

Journal

of Surgery