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What tangled webs we weave Presidential address
Americanlournalof
Obstetrics and Gynecology Founded in 1920 volume 149 number 1
MAY
1, 1984
Transactions of the Fiftieth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society
What tangled webs we weave Presidential address George A. Macer, M.D. Pasadena, California
Medicine has been and still is replete with controversy-much of it of our own making. Many of the concerns that I will raise may be nothing more than the bleating of an old professor emeritus. However, as William Hazlitt said over one hundred fifty years ago, "When a thing ceases to. be subject of controversy it ceases to be a subject of interest." Being president has also proved to be quite an educational experience. First, one reviews and reads the addresses of all past presidents. This is in the hope that one will not say the same old things that have been said before. There is also the hope that a seed might germinate, grow, and produce an idea for a presidential address. Our Society was formed by clinicians who joined together to talk about mutual problems and to discuss new modes and methods of management. The early addresses were related to the everyday practice of our specialty. In 1934, Lyle McNeile, in his presidential address, spoke on the intramuscular use of camphor in oil for suppressing lactation. Henry Shaw presented his fascial strip operation for suspending the vault of the prolapsed vagina. Reading on, one is soon able to categorize most of the addresses. As horizons expanded, as knowledge proliferated, and as departments changed from voluntary to full time, the presidential addresses seemed to reflect this. Many were concerned about the relationship of town and gown. Others concerned themselves with Presented at the Fiftieth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Vancouver, British Columbia, Canada, September 6-10, 1983. Reprint requests: Dr. George A. Macer, 185 South Euclid Ave., Pasadena, CA 91101.
where our profession had been, was then, and would be going. This was also true of medical education. Naturally, philosophically, addresses began to reflect on the changing face of the practice of obstetrics and gynecology, with each generation decrying or justifying the changes according to its own values and experIences. We are now in the throes of such a major change because of our technological advances. Medicine as you and I knew it will never be the same. Because of our technology, we have now been able to extend the limits of our capabilities. This extension had led to some legal and ethical considerations with which medicine did not have to contend previously. The physician and the patient are at the very center of this technological revolution. This raises concerns that involve not only the physician but also the patient. Take, for instance, fetal monitoring. Almost all major centers have monitoring facilities, and one of our foremost proponents and authorities in this field concludes, in one of his articles, that continuous monitoring is preferable to intermittent auscultation, even in low-risk women. This same physician supported the development of the midwife program, which has been claimed to be the "latest growth industry," according to Medical Economics, and this is because the so-called consumer has been resisting this new technology. Besides midwifery, the patient has been choosing alternate birthing techniques in the hospital and even in the home, and the father is now an important part of this scene-whether he likes it or not! Recently, I asked a long-time patient of mine, whose
2 Macer
daughter I had delivered many years ago and who was near term, who was going to deliver the baby. She said that, "as of now, we do not quite know whether it will be the obstetrician, a midwife, a paramedic girlfriend, or the father himself with the aid of their other children." Talk about confusion! This is happening in spite of the fact that our obstetrics technology has made us the best health care system in the world. With our increased knowledge of prenatal care, we can now designate the high-risk patient so as to monitor her closely during her gestation. The increased knowledge of the parameters that determine fetal maturity has led to the dramatic decrease in fetal morbidity and mortality. We are now salvaging a large percentage of the 750 gm infants. My concern, however, as well as that of many of our colleagues, is how soon, because of our increased improvements in technology, we will be trying to salvage a questionable 500 gm infant, and at what cost. Our technology has made us anxious to take on the challenge of saving this questionable infant. But who is going to advise us when to stop trying? Moreover, with our new techniques, we can more successfully reanastomose fallopian tubes that were once occluded either iatrogenically or by pelvic pathologic conditions, while in the operating room next door a healthy 18-week fetus is being aborted . Who will make these future decisions and what parameters will they use? Expert witnesses are standing ready on both sides of the fence . Let us not paint ourselves into a corner. One corner that we have squirmed out of is the fear on the part of both the patient and the physician of prescribing oral contraceptives-something that I have always said is the best thing to have happened to woman SInce man. In the early 1960s, our research centers deluged us with reports on the dangers of the oral contraceptive. They warned us of liver problems, gallbladder disease, thromboembolism, heart disease, hypertension, and even emotional disturbances and headaches. It was the practicing clinician who got all the headaches. All of the premature adverse publicity made us fearful of prescribing oral contraceptives, which most of us thought were the safest and most effective means of contraception. We knew that the use of them was no more harmful than pregnancy itself, and probably produced fewer complications. In our younger years, we saw patients in our county hospital who, after marriage, had no more than one or two menstrual periods-sometimes, none during their 20 years of reproductive life. Pregnancy did not seem to harm most of them. We did not see heart disease or strokes. We did see pregnancyinduced hypertension, and we called it toxemia. Certainly, there were gallbladder problems and obesity and headaches-but who would not have headaches
May 1,1984 Am. J. Obstet. Gynecol.
with so many children running around. Now, after two decades of experience with the oral contraceptive, report after report is telling us about the benefit of this maligned pill. It now protects breasts from benign and possibly even malignant disease, and militates against malignant disease of the genital tract, such as uterine, as well as ovarian. It even decreases the incidence of pelvic inflammatory disease. The Centers for Disease Control tell us that it is protection against ectopic pregnancy . Another surprising finding is the palliative effect on rheumatoid arthritis. Because of this it is estimated that approximately 50,000 hospitalizations a year are averted. What a turnaround! What happened to all the deaths that were predicted? It certainly is easier to recommend and prescirbe oral contraceptives today. I wish that the drug information pamphlets would now be changed so that this corner would be much more comfortable. In passing, I must mention our schizophrenia in prescribing estrogen . The same pattern of fear, concern, and then rational logic in the use of it evolved. My prediction for the future is that more estrogen will be used and for an extended number of years. I ts benefits far outweigh any of its disadvantages . Recent reports are beginning to show this trend . Our probingtechnology, supported by our clinicians, will confirm this. Similarly, not much intelligence was needed to realize that sex reversal operations were not the answer for some sadly disturbed individuals. Johns Hopkins determined that "sexual reassignment surgery" is valueless and terminated its program, whereas other institutions are beginning to offer this type of operation. Such inconsistencies raise questions about our scientific credibility. Technology is now invading our social conscience, as well as the fabric of our society (such as it is)., I am referring to in vitro fertilization, surrogate mothers, frozen sperm banks, and sex determination. Even these pale in significance beside the questions that arise in regard to the performance of in utero fetal operations. I wish I had the forty years of hindsight necessary to try to comment on these concerns, but all this I leave to the next generation. My great concern is whether the next generation's background will be humanistic enough, moral enough, and family-oriented enough to formulate the guidelines of a physician and not those of a technician . We are going to need thoughtful reporting as we invade these questionable domains, so that we do not again paint ourselves into a corner. The control will fall on the shoulders of those in charge of research centers. I am weaving this web of concern for one reason only. A number of studies have indicated that approximately 85% of the health care in this country is given by the private practitioner, and only 15% is done in health care institutions and teaching centers. As you
Volume 149 Number I
can see, we have problems in our specialty that are unique in their involvement of the physician, the patient, and the patient's family. This 85% is in the front-line trenches, dealing on a daily basis with these unique situations. None is better qualified to do this than the obstetrician-gynecologist, whose ability to see the big picture is based on his background. Most obstetrician-gynecologists are remarkably capable, highly motivated physicians who possess the capacity to perform large amounts of work very efficiently. Just as important, their diligent pursuit of continuing education is a little short of phenomenal. We have observed their conscientious attendance year after year. In 1978, the University of Southern CaliforniaMendenhall study revealed that 78% of obstetricians and gynecologists practiced primary care. The American College of Obstetricians and Gynecologists has beseeched us to be the primary care physician of the woman. Most clinicians have accepted this designation. However, because there were some who did not agree with this concept, the American College, in 1979, assigned a task force, chaired by our friend and colleague, Dr. Keith Russell, to delineate the scope and function of the obstetrician and gynecologist. The task force's definition was received and accepted by the executive board in 1980, as follows. "Obstetrics and gynecology is a specialty in the profession of medicine devoted to the health care of women. As such, this specialty encompasses the medical and surgical management of disorders of the female reproductive systems as well as the psychological, social, and preventive aspects of such care. Thus obstetrician-gynecologists are specialists who provide health care for women, with particular reference to the female reproductive systems. In addition to applying knowledge and skill to a particular organ system, they are involved in the care of the whole patient. The female patient frequently considers the obstetrician-gynecologist her principal physician for advice and referral as well as for treatment in his or her field of special competence." As Dr. Roy Parker stated, in his Cosgrove address, "This is a long and complicated answer to a simple questionwho are we?" I believe that most practicing clinicians would agree with this definition. However, just this year, opposing viewpoints were presented in two separate presidential addresses. One speaker was a clinician and president of a large regional society who advocated a rededication to basics in order to make better primary care physicians. The other speaker was an academician and president of the newly formed coalition of the American Gynecological Society and the American Association of Obstetricians and Gynecologists (now called the American Gynecological and Obstetrical Society), who stated that, "The
What tangled webs we weave
3
government worried over the lack of care in some American communities by funding primary care physician training." He further stated that many in the field of obstetrics and gynecology then tried to prove that we are primary care people. We did not have to prove this premise, because we had already assumed that role. It was his next statement that convinced me to speak of this concern in my present address. He stated, and I quote, "The idea was ill-conceived, inappropriate and detrimental. We are not primary care physicians in the way family practitioners are." Should the president of our foremost specialty society produce more confusion at a time when many of us think that our residents are not being prepared to take on the duties of today's private practitioner? I can readily understand that anyone working in a teaching care institution will immediately say, "No, I am not a primary care physician nor do I want to be, for it is so convenient for me to refer next door or to the next floor without cost or trouble to the patient." (It also gets the problem out of his arena.) The author then goes on to say, and, again, I quote, "Patients feel separated from their physicians by the complexity of today's practice. They get computerized bills and statements from the medical service as they do from the bank, the insurance company, the garage mechanic, and the grocer. It is impersonal. The woman's hospital bill is a chilly account of only half-understood treatments in a process that she remembers as involving the very personal invasions of her body. If something goes wrong, she perceives the system as being at fault, and often turns to a lawsuit for compensation." In saying all this, he makes a very good case for why we need to be primary care physicians. In this day of sophisticated diagnostic and therapeutic technology, the patient needs someone to turn to for guidance and counseling. Logically, it is her obstetrician and gynecologist who has cared for her during her "growing-up" years, advised her about contraception, may have done an abortion (or two) for her, later delivered her children, and during these years counseled her through many a marital problem. We may not have elected to become primary care physicians but have by necessity been pushed into the role. It is the patient herself who molds the character of our practice. Because of this pressure from the patient, we must be trained and ready to accommodate her. Sadly, however, most training programs as they are now structured are not preparing our residents for the job. Today, medical students must choose their direction or track in the junior year-whether it be medicine, surgery, pediatrics, or obstetrics and gynecology. In their senior year, they will be taking electives related to their anticipated specialty. How can junior
4 Macer
May 1,1984
Am.
students possibly know their interests and capabilities before being exposed to them. Many of us recall the number of times that we changed our specialty, even in our intern year. For some unknown reason, we seem to be shortening the period of training at a time in which our horizons have expanded. We have done away with the rotating internship. It is now called postgraduate level one, with emphasis on the chosen specialty. With today's adequate stipend, there certainly is no urgency to cut short this important period of training. I am tempted to relate to my own period of training. I can safely say, and I trust that my colleagues present today will agree with me, that one who finished the required 2-year rotating internship emerged as a competent family practitioner. Less than 50% of us pursued further training. Our residency at that time was for 3Y2 years. Having completed this training, we left the program well prepared to be primary care physicians of women. Included in our residency were 3 months of female urology, 3 months of surgical pathology, and 6 months of general surgery. We were trained by dedicated and superbly qualified clinicians, persons who came out in the middle of the night to teach clinical obstetrics. They did not teach us to diagnose dystocia by calling it failure to dilate or failure of descent of failure to progress. They made a diagnosis of why the patient "did not dilate," "did not engage," or "did not make progress." They did not need a Friedman curve to know whether labor was normal or abnormal. They were also competent gynecologic surgeons, having been taught the basics of surgery by generations of competent surgeons. The residents who completed such programs readily accepted the role of primary care physicians. To better prepare our residents, the senior year in school should not be devoted to clerks hips related to their specialty. They should be exposed to a broad range of basic medical practice, possibly similar to an
J. Obstet. Gynecol.
intern year. Then, after graduation, they should have a rotating internship, with emphasis on general medicine, pediatrics, dermatology, psychiatry, and other basic services, with minimal emphasis on their future specialty. They then should enter the specialty program with enough time to prepare to become competent obstetricians and gynecologists. This philosophy must be accepted and embraced by both teachers and clinicians, remembering that 85% of health care is delivered by private practitioners. Sad to say, these clinicians are not involved in decision-making committees, research or otherwise. They are not adequately represented on the American Board of Obstetrics and Gynecology, nor are they, except rarely, involved in designing the curriculum in the medical school or at the postgraduate level. Perhaps because of this, we see dramatically divergent positions in our profession and by our leaders. Instead of dividing ourselves, we should complement each other. More than ever before, there must be more and better communication between those who produce the research and write the reports and those who put the results into practice. We need the basic research that only the university can give, but we cannot live by research alone. Without clinical practice and clinical application, the discoveries made will never be of value to our patients. Research needs to be leavened by the input of the clinician in order to make the project relevant. Teachers and researchers must realize that the reason that we have the finest medical care in the world is not only the brilliant developments but also the effective application by the clinician. Do not let superspecialization, and what Allan Barnes called fractionation of our specialty, cause us to lose sight of the big picture. Let us bring our talents together to produce the type of physician our society truly needs .
Obstetrics and Gynecology Founded in 1920 volume 149 number 1
MAY
1, 1984
Transactions of the Fiftieth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society
What tangled webs we weave Presidential address George A. Macer, M.D. Pasadena, California
Medicine has been and still is replete with controversy-much of it of our own making. Many of the concerns that I will raise may be nothing more than the bleating of an old professor emeritus. However, as William Hazlitt said over one hundred fifty years ago, "When a thing ceases to. be subject of controversy it ceases to be a subject of interest." Being president has also proved to be quite an educational experience. First, one reviews and reads the addresses of all past presidents. This is in the hope that one will not say the same old things that have been said before. There is also the hope that a seed might germinate, grow, and produce an idea for a presidential address. Our Society was formed by clinicians who joined together to talk about mutual problems and to discuss new modes and methods of management. The early addresses were related to the everyday practice of our specialty. In 1934, Lyle McNeile, in his presidential address, spoke on the intramuscular use of camphor in oil for suppressing lactation. Henry Shaw presented his fascial strip operation for suspending the vault of the prolapsed vagina. Reading on, one is soon able to categorize most of the addresses. As horizons expanded, as knowledge proliferated, and as departments changed from voluntary to full time, the presidential addresses seemed to reflect this. Many were concerned about the relationship of town and gown. Others concerned themselves with Presented at the Fiftieth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Vancouver, British Columbia, Canada, September 6-10, 1983. Reprint requests: Dr. George A. Macer, 185 South Euclid Ave., Pasadena, CA 91101.
where our profession had been, was then, and would be going. This was also true of medical education. Naturally, philosophically, addresses began to reflect on the changing face of the practice of obstetrics and gynecology, with each generation decrying or justifying the changes according to its own values and experIences. We are now in the throes of such a major change because of our technological advances. Medicine as you and I knew it will never be the same. Because of our technology, we have now been able to extend the limits of our capabilities. This extension had led to some legal and ethical considerations with which medicine did not have to contend previously. The physician and the patient are at the very center of this technological revolution. This raises concerns that involve not only the physician but also the patient. Take, for instance, fetal monitoring. Almost all major centers have monitoring facilities, and one of our foremost proponents and authorities in this field concludes, in one of his articles, that continuous monitoring is preferable to intermittent auscultation, even in low-risk women. This same physician supported the development of the midwife program, which has been claimed to be the "latest growth industry," according to Medical Economics, and this is because the so-called consumer has been resisting this new technology. Besides midwifery, the patient has been choosing alternate birthing techniques in the hospital and even in the home, and the father is now an important part of this scene-whether he likes it or not! Recently, I asked a long-time patient of mine, whose
2 Macer
daughter I had delivered many years ago and who was near term, who was going to deliver the baby. She said that, "as of now, we do not quite know whether it will be the obstetrician, a midwife, a paramedic girlfriend, or the father himself with the aid of their other children." Talk about confusion! This is happening in spite of the fact that our obstetrics technology has made us the best health care system in the world. With our increased knowledge of prenatal care, we can now designate the high-risk patient so as to monitor her closely during her gestation. The increased knowledge of the parameters that determine fetal maturity has led to the dramatic decrease in fetal morbidity and mortality. We are now salvaging a large percentage of the 750 gm infants. My concern, however, as well as that of many of our colleagues, is how soon, because of our increased improvements in technology, we will be trying to salvage a questionable 500 gm infant, and at what cost. Our technology has made us anxious to take on the challenge of saving this questionable infant. But who is going to advise us when to stop trying? Moreover, with our new techniques, we can more successfully reanastomose fallopian tubes that were once occluded either iatrogenically or by pelvic pathologic conditions, while in the operating room next door a healthy 18-week fetus is being aborted . Who will make these future decisions and what parameters will they use? Expert witnesses are standing ready on both sides of the fence . Let us not paint ourselves into a corner. One corner that we have squirmed out of is the fear on the part of both the patient and the physician of prescribing oral contraceptives-something that I have always said is the best thing to have happened to woman SInce man. In the early 1960s, our research centers deluged us with reports on the dangers of the oral contraceptive. They warned us of liver problems, gallbladder disease, thromboembolism, heart disease, hypertension, and even emotional disturbances and headaches. It was the practicing clinician who got all the headaches. All of the premature adverse publicity made us fearful of prescribing oral contraceptives, which most of us thought were the safest and most effective means of contraception. We knew that the use of them was no more harmful than pregnancy itself, and probably produced fewer complications. In our younger years, we saw patients in our county hospital who, after marriage, had no more than one or two menstrual periods-sometimes, none during their 20 years of reproductive life. Pregnancy did not seem to harm most of them. We did not see heart disease or strokes. We did see pregnancyinduced hypertension, and we called it toxemia. Certainly, there were gallbladder problems and obesity and headaches-but who would not have headaches
May 1,1984 Am. J. Obstet. Gynecol.
with so many children running around. Now, after two decades of experience with the oral contraceptive, report after report is telling us about the benefit of this maligned pill. It now protects breasts from benign and possibly even malignant disease, and militates against malignant disease of the genital tract, such as uterine, as well as ovarian. It even decreases the incidence of pelvic inflammatory disease. The Centers for Disease Control tell us that it is protection against ectopic pregnancy . Another surprising finding is the palliative effect on rheumatoid arthritis. Because of this it is estimated that approximately 50,000 hospitalizations a year are averted. What a turnaround! What happened to all the deaths that were predicted? It certainly is easier to recommend and prescirbe oral contraceptives today. I wish that the drug information pamphlets would now be changed so that this corner would be much more comfortable. In passing, I must mention our schizophrenia in prescribing estrogen . The same pattern of fear, concern, and then rational logic in the use of it evolved. My prediction for the future is that more estrogen will be used and for an extended number of years. I ts benefits far outweigh any of its disadvantages . Recent reports are beginning to show this trend . Our probingtechnology, supported by our clinicians, will confirm this. Similarly, not much intelligence was needed to realize that sex reversal operations were not the answer for some sadly disturbed individuals. Johns Hopkins determined that "sexual reassignment surgery" is valueless and terminated its program, whereas other institutions are beginning to offer this type of operation. Such inconsistencies raise questions about our scientific credibility. Technology is now invading our social conscience, as well as the fabric of our society (such as it is)., I am referring to in vitro fertilization, surrogate mothers, frozen sperm banks, and sex determination. Even these pale in significance beside the questions that arise in regard to the performance of in utero fetal operations. I wish I had the forty years of hindsight necessary to try to comment on these concerns, but all this I leave to the next generation. My great concern is whether the next generation's background will be humanistic enough, moral enough, and family-oriented enough to formulate the guidelines of a physician and not those of a technician . We are going to need thoughtful reporting as we invade these questionable domains, so that we do not again paint ourselves into a corner. The control will fall on the shoulders of those in charge of research centers. I am weaving this web of concern for one reason only. A number of studies have indicated that approximately 85% of the health care in this country is given by the private practitioner, and only 15% is done in health care institutions and teaching centers. As you
Volume 149 Number I
can see, we have problems in our specialty that are unique in their involvement of the physician, the patient, and the patient's family. This 85% is in the front-line trenches, dealing on a daily basis with these unique situations. None is better qualified to do this than the obstetrician-gynecologist, whose ability to see the big picture is based on his background. Most obstetrician-gynecologists are remarkably capable, highly motivated physicians who possess the capacity to perform large amounts of work very efficiently. Just as important, their diligent pursuit of continuing education is a little short of phenomenal. We have observed their conscientious attendance year after year. In 1978, the University of Southern CaliforniaMendenhall study revealed that 78% of obstetricians and gynecologists practiced primary care. The American College of Obstetricians and Gynecologists has beseeched us to be the primary care physician of the woman. Most clinicians have accepted this designation. However, because there were some who did not agree with this concept, the American College, in 1979, assigned a task force, chaired by our friend and colleague, Dr. Keith Russell, to delineate the scope and function of the obstetrician and gynecologist. The task force's definition was received and accepted by the executive board in 1980, as follows. "Obstetrics and gynecology is a specialty in the profession of medicine devoted to the health care of women. As such, this specialty encompasses the medical and surgical management of disorders of the female reproductive systems as well as the psychological, social, and preventive aspects of such care. Thus obstetrician-gynecologists are specialists who provide health care for women, with particular reference to the female reproductive systems. In addition to applying knowledge and skill to a particular organ system, they are involved in the care of the whole patient. The female patient frequently considers the obstetrician-gynecologist her principal physician for advice and referral as well as for treatment in his or her field of special competence." As Dr. Roy Parker stated, in his Cosgrove address, "This is a long and complicated answer to a simple questionwho are we?" I believe that most practicing clinicians would agree with this definition. However, just this year, opposing viewpoints were presented in two separate presidential addresses. One speaker was a clinician and president of a large regional society who advocated a rededication to basics in order to make better primary care physicians. The other speaker was an academician and president of the newly formed coalition of the American Gynecological Society and the American Association of Obstetricians and Gynecologists (now called the American Gynecological and Obstetrical Society), who stated that, "The
What tangled webs we weave
3
government worried over the lack of care in some American communities by funding primary care physician training." He further stated that many in the field of obstetrics and gynecology then tried to prove that we are primary care people. We did not have to prove this premise, because we had already assumed that role. It was his next statement that convinced me to speak of this concern in my present address. He stated, and I quote, "The idea was ill-conceived, inappropriate and detrimental. We are not primary care physicians in the way family practitioners are." Should the president of our foremost specialty society produce more confusion at a time when many of us think that our residents are not being prepared to take on the duties of today's private practitioner? I can readily understand that anyone working in a teaching care institution will immediately say, "No, I am not a primary care physician nor do I want to be, for it is so convenient for me to refer next door or to the next floor without cost or trouble to the patient." (It also gets the problem out of his arena.) The author then goes on to say, and, again, I quote, "Patients feel separated from their physicians by the complexity of today's practice. They get computerized bills and statements from the medical service as they do from the bank, the insurance company, the garage mechanic, and the grocer. It is impersonal. The woman's hospital bill is a chilly account of only half-understood treatments in a process that she remembers as involving the very personal invasions of her body. If something goes wrong, she perceives the system as being at fault, and often turns to a lawsuit for compensation." In saying all this, he makes a very good case for why we need to be primary care physicians. In this day of sophisticated diagnostic and therapeutic technology, the patient needs someone to turn to for guidance and counseling. Logically, it is her obstetrician and gynecologist who has cared for her during her "growing-up" years, advised her about contraception, may have done an abortion (or two) for her, later delivered her children, and during these years counseled her through many a marital problem. We may not have elected to become primary care physicians but have by necessity been pushed into the role. It is the patient herself who molds the character of our practice. Because of this pressure from the patient, we must be trained and ready to accommodate her. Sadly, however, most training programs as they are now structured are not preparing our residents for the job. Today, medical students must choose their direction or track in the junior year-whether it be medicine, surgery, pediatrics, or obstetrics and gynecology. In their senior year, they will be taking electives related to their anticipated specialty. How can junior
4 Macer
May 1,1984
Am.
students possibly know their interests and capabilities before being exposed to them. Many of us recall the number of times that we changed our specialty, even in our intern year. For some unknown reason, we seem to be shortening the period of training at a time in which our horizons have expanded. We have done away with the rotating internship. It is now called postgraduate level one, with emphasis on the chosen specialty. With today's adequate stipend, there certainly is no urgency to cut short this important period of training. I am tempted to relate to my own period of training. I can safely say, and I trust that my colleagues present today will agree with me, that one who finished the required 2-year rotating internship emerged as a competent family practitioner. Less than 50% of us pursued further training. Our residency at that time was for 3Y2 years. Having completed this training, we left the program well prepared to be primary care physicians of women. Included in our residency were 3 months of female urology, 3 months of surgical pathology, and 6 months of general surgery. We were trained by dedicated and superbly qualified clinicians, persons who came out in the middle of the night to teach clinical obstetrics. They did not teach us to diagnose dystocia by calling it failure to dilate or failure of descent of failure to progress. They made a diagnosis of why the patient "did not dilate," "did not engage," or "did not make progress." They did not need a Friedman curve to know whether labor was normal or abnormal. They were also competent gynecologic surgeons, having been taught the basics of surgery by generations of competent surgeons. The residents who completed such programs readily accepted the role of primary care physicians. To better prepare our residents, the senior year in school should not be devoted to clerks hips related to their specialty. They should be exposed to a broad range of basic medical practice, possibly similar to an
J. Obstet. Gynecol.
intern year. Then, after graduation, they should have a rotating internship, with emphasis on general medicine, pediatrics, dermatology, psychiatry, and other basic services, with minimal emphasis on their future specialty. They then should enter the specialty program with enough time to prepare to become competent obstetricians and gynecologists. This philosophy must be accepted and embraced by both teachers and clinicians, remembering that 85% of health care is delivered by private practitioners. Sad to say, these clinicians are not involved in decision-making committees, research or otherwise. They are not adequately represented on the American Board of Obstetrics and Gynecology, nor are they, except rarely, involved in designing the curriculum in the medical school or at the postgraduate level. Perhaps because of this, we see dramatically divergent positions in our profession and by our leaders. Instead of dividing ourselves, we should complement each other. More than ever before, there must be more and better communication between those who produce the research and write the reports and those who put the results into practice. We need the basic research that only the university can give, but we cannot live by research alone. Without clinical practice and clinical application, the discoveries made will never be of value to our patients. Research needs to be leavened by the input of the clinician in order to make the project relevant. Teachers and researchers must realize that the reason that we have the finest medical care in the world is not only the brilliant developments but also the effective application by the clinician. Do not let superspecialization, and what Allan Barnes called fractionation of our specialty, cause us to lose sight of the big picture. Let us bring our talents together to produce the type of physician our society truly needs .