- Email: [email protected]
Women: Our responsibility to them
TRANSACTIONS OF THE FIFTEENTH A N N U A l , MEETING OF THE AMERICAN GYNECOLOGICAL AND OBSTETRICAl. SOCIETY Women: Our responsibility to them Presidential address William J. Dignam, MI) Los Angeles, California
As have many of my predecessors in the office of President, I have reviewed some of the earlier presidential addresses. I was particularly impressed by the records of the m e e t i n g of 1886, 10 years after the f o u n d i n g of the American Gynecological Society--a m e e t i n g a t t e n d e d by 29 members. T h e welcoming address was presented by Dr. H.P.C. Wilson of Baltimore and the presidential address was given by Dr. T h a d d e u s A. Reamy of Cincinnati. By special a r r a n g e m e n t I have persuaded these two fine g e n t l e m e n to return to this m e e t i n g to repeat for us excerpts from their earlier presentations.
Dr. H.P.C. Wilson (Dr. Alan H. DeCherney) You have assembled here today from all parts of this great country to c o m p a r e the results of your studies and labors during the year past in that d e p a r t m e n t of medicine that relates to the diseases peculiar to women. As the honest h u s b a n d m a n prepares his soil, cultivates his crop, and gathers his harvest, so you are h e r e now to reap the fruit of a n o t h e r year's work and gather into the great storehouse of knowledge every grain of g o o d wheat while you reject the chaff and the tares. May it be a rich harvest feast to every one of you, in which the h u s b a n d m a n shall abundantly partake of the fruit of his labors! I stand h e r e in the n a m e of the resident Fellows, in the n a m e of the general profession, in the n a m e of the citizens of Baltimore, and in the n a m e of her women, to extend to you a hearty welcome. Were our hands half as large as our hearts, we fear we should kill you with kindness. We appreciate the h o n o r you have d o n e us by From the Center for Health Sciences, University of California, Los Angeles. Presented at the Fifteenth Annual Meeting of the American Gynecological and Obstetrical Society, AsheviUe, North Carolina, September 57, 199Z Reprint requests: William~ Dignam, MD, University of California, Los Angeles, 24-149 Centerfor Health Sciences, 10833 LeConte Ave., Los Angeles, CA 90024. Am J Obstet Gynecol 1997;176:736-40. Copyright © 1997 by Mosby-Year Book, Inc. 0002-9378/97 $5.00 + 0 6/6/80760
736
m e e t i n g in this city, and we beg you to r e m e m b e r that Baltimore is very ready--yea, a n x i o u s - t o welcome you within her borders whenever you may be inclined to come. T h e subject of your d e l i b e r a t i o n s - - " t h e diseases and accidents peculiar to w o m e n " - - i s one very near to the heart of every man, woman, and child. It is of greater importance than the affairs of state, than the o t h e r arts and sciences, than all things above or u n d e r the earth. "All that a m a n hath will he give for his life." All that is associated with the words wife, mother, daughter, sister, all that is contained in the words "Home, Sweet H o m e , " gather their sweetness from the influence of woman; and, when she is blighted with disease and suffering, h o m e is not h o m e - - y e a , earth has no joys. It is to you, sirs, and your brethren, that m a n k i n d turns with such longings when his fireside is invaded by the withering blast of sickness or t h r e a t e n e d by that fell destroyer, Death. It is on you alone he leans to save his h o m e from desolation and restore to health and happiness the c h a r m of the family circle. T h e magistrate, the merchant, the banker, the attorney, the minister are n o t in his thoughts. It is on the obstetrician, or gynecologist, that he rests all his hopes. I can speak, for I know, of the faithfulness with which the trust is e x e c u t e d and of the sacrifices that you continually endure. Let me, then, assure you of the great interest that this c o m m u n i t y takes in your deliberations. It is known that you live, toil, and die for the g o o d of woman, on whose t e n d e r care and sympathy all are so dependent: O, woman! in our hours of ease, Uncertain, coy, and hard to please, A n d variable as the shade By the light quivering aspen made, W h e n pain and anguish wring the bow, A ministering angel thou! T h a n k you, Dr. Wilson. Dr. Reamy, if you will now grace us with a repetition of some of your remarks
Volume 176, Number 4
Dignam 737
Am,l Obstet (;ynecol
presented on an earlier occasion, we shall be very grateful. Welcome to the podium.
Dr. Thaddeus A. Reamy (Dr, Norman Gant) It may be said that the time d u r i n g which o u r society has b e e n in existence is the a b d o m i n a l e p o c h of the surgical age in gynecology. It has seen a b d o m i n a l section so d e v e l o p e d a n d perfected that the b r i l l i a n t a c h i e v e m e n t s of skillful operators have far e x c e e d e d the most s a n g u i n e expectations of 10 years ago. This is n o t only true of all fields of a b d o m i n a l section b u t especially so of ovariotomy, the p i o n e e r o p e r a t i o n in this realm. We have already seen that surgical results are eminently satisfactory so far as relates to cystic disease of the ovary, which imperils life. But is the operation of removing the ovaries for supposed b e g i n n i n g "cystic degeneration," "cirrhosis," "catarrhal salpingitis," "chronic catarrh of the tubes," "stenosis," "congestion," "enlargement," always justifiable? I trow not. Have n o t the glowing reports of such cases, a n d the cures wrought, together with the facility of the operation, a n d its comparative i m m u n i t y from d a n g e r to life, led to the extirpation of m a n y a sinless ovary.? How often in our experience have we met cases with the constant pelvic pain a n d its various reflexes, with a t e n d e r ovary slightly displaced, or some tortuous body about the uterine f u n d u s that we t h o u g h t was the "congested, . . . hypertrophied," or dilated t u b e s - - i n short, having a clinical history a n d physical aspect incapable of differentiation from those cases-flom which we hear of ovaries being removed, a n d yet we have seen them cured by a patient recourse to diet, massage, electricity, vaginal irrigation, medication of the vaginal vault a n d cervix, rest of body a n d mind, postural treatment, etc. We have so often a d d u c e d these figures to d e m o n strate the wondrous progress of our art a n d offered them in expiation for what we considered the b l u n d e r s of our drugging, dosing, a n d bleeding forefathers. I greatly fear, however, that somebody will, one of these days, show the other side of the picture, that some ingenious statistical cynic will c o m p u t e the years of h u m a n life lost to the race by this destruction of ovaries, whose functional activity is yet unabated, a n d whose structure yet bears many possibilities for population. There have b e e n entirely too m u c h constructive pathologic reports written about the ovary. Much of them, I fear, have b e e n created to order, tojustify, the removal of functionally active ovaries after they have b e e n extirpated. We n e e d the fiat lux of a practical pathologic study sustained by the most extensive comparative investigation on healthy a n d u n h e a l t h y ovaries. A h u m a n a n d economic conservatism should keep our fingers off these organs until we know whether they are yet capable of discharging their function or whether they are physio-
logically dead or whether their possessor can be cured without their sacrifice. Again, many of the remarkable cures reported after this operation must be taken c u m grano salis, until such time has passed as will preclude the possibility of a relapse, or at least r e n d e r it improbable. Time will, I fear, m u c h change the aspect of some reported cures; this o p i n i o n is n o t wholly speculative. Let us, as a society a n d as individuals, do our duty toward w o m e n by proclaiming and practicing against this unsexing enthusiasm. Can we n o t take some steps toward the establishment of some hard a n d fast lines for the g o v e r n m e n t of this practice? G e n t l e m e n , thank you for your inspiring remarks. Present-day m e m b e r s clearly do share your p r o f o u n d admiration for the women whom we serve a n d are intrigued to note that 110 years ago, a n d soon after a b d o m i n a l surgery was proved safe, you were already directing attention to the possibility that unnecessary surgery was being p e r f o r m e d a n d calling for evidencebased medical practice in the form of the necessity for careful study of the structure a n d function of ovaries to d e t e r m i n e which should be removed and which could be preserved. Regrettably, few a m o n g us are able to express our feelings for our patients in such a magnificent style as have you, b u t the depth of our admiration and respect are no less great. These patients are so t e n d e r a n d have such a capacity for deep, deep, a n d unswerving emotions. It is our great privilege to share in their trials a n d tribulations, as well as their overwhelming joy, as for example, when a n o r m a l baby is born. In some ways our patients of today have many more stresses than did your patients in 1886. At that time they c o m m o n l y enjoyed the support a n d assistance of a family that was nearby, whereas today our patients may well be far from h o m e a n d pretty m u c h on their own, a n d faced with the care of a n e w b o r n baby who never seems to sleep, as their husbands spend long hours away from h o m e trying to accumulate resources for the family. The trust a n d confidence these women place in their physicians is heartwarming a n d inspiring. We in obstetrics and gynecologT are i n d e e d a privileged lot. The wonderful characteristics of w o m e n are perhaps best exemplified in our female colleagues. Not only are they bright a n d professionally skilled but they bring such insight to our activities. So deep are their emotions that on occasion I have n o t e d the shedding of a few tears when these sensitive individuals were apprised of the very poor prognosis for a particular patient. If perchance our own behavior has b e e n a bit calloused in nature, it brings us immediately back to the appropriate frame of mind. Fortunate i n d e e d is the practitioner who is asked to c a r e for o n e of our female colleagues. He or she is, of course,
738
Dignam
very flattered and privileged to receive the trust of one so well informed and yet still subject to the emotional changes occasioned by pregnancy or serious disease. How these wonderful women, young or old, are able to tolerate their situations and yet, as they do, continue to devote time and attention to their own patients has always been a source of great wonder for me. What do we owe to these wonderful individuals whom we are privileged to know and for whom we provide care? First, of course, we should be unstinting in our efforts to provide that care to the very best of our ability and to bring to the activity as much current knowledge as is humanly possible. Sometimes, however, these are not enough, and we are unsuccessful in our attempts. We have all experienced these very deep frustrations and have wished that our knowledge could grow more rapidly. We must therefore devote great effort to research concerning the diseases peculiar to women, to gain greater understanding of the pathophysiologic characteristics, greater accuracy in reaching diagnosis, and greater success in carrying out treatment. Thanks to the great generosity of some of our earlier members, and the depth of conviction of our present-day members, this organization has been exceptionally active and successful in providing resources for the many young, very bright, and very industrious individuals who are rapidly becoming very productive research workers in our specialty. You have heard from some of them at this meeting and I am certain that you are as impressed with their accomplishments as am I. You will note that much of their work uses molecular biologic techniques. Clearly these techniques are permitting the very rapid accumulation of knowledge of the processes in which we are interested. The procedures involved require a major c o m m i t m e n t of resources. This is not to say that research using other techniques, such as those used in epidemiology, outcomes research, physiology of pregnancy, drug trials, improvements in surgical procedures, to name just a few, are not equally important. Because many of the fellows supported by this organization have chosen projects that involve molecular biologic techniques, I have chosen to focus my remarks on this area. The fellowships of the American Association of Obstetricians and Gynecologists Foundation have been exceptionally successful. Some of our most distinguished members have devoted much thought, time, and energy to organizing and supporting these fellowships. Dr. Lawrence Longo and now Dr. RobertJaffe have been equally effective in leading the Reproductive Scientist Development Program. Recently, Dr. Robert Creasy and now Dr. Sherman Elias have chaired the relevant committee in our organization. Dr. Creasy has surveyed the graduates and the results of his survey were published in the American Journal of Obstetrics and Gynecology, August 1996,
April ]997 AmJ Obstet Gynecol
volume 175, n u m b e r 2, pages 494 to 495. He has indicated that of the first 44 fellows who have completed fellowships in our program or in the Reproductive Scientist Development Program 91% are members of medical school faculties and 75% of them have succeeded in obtaining extramural research funding. This is very impressive in these days of marked restriction of funds available for research. Our fellows are a very impressive group of young, very highly motivated physicians. I had the privilege of attending their retreat last year and it was an exhilarating experience. They are completely dedicated to the pursuit of excellence in their professional careers. However, they did express some concern about the opportunities that would be available for them in academic departments after completing these arduous fellowships. Dr. Donald Dudley had organized that retreat and we agreed that he would survey the fellows to gain a more exact impression of the nature and depth of their concerns. You have heard from him earlier in this meeting and you will recall that they did express some concern about their chances of obtaining extramural funding in the future. They did express some anxiety concerning their future success at becoming certified by the American Board of Obstetrics and Gynecology. There was some expression of opinion that longer periods of fellowship would be necessary to properly prepare them to be successful research scientists. The desirability of continued support for a few years after the fellowships was noted. This would permit them to have a reduction in the time required for them to spend in other activities during their early years in academic departments and therefore be able to get their research programs started in a rigorous manner. The importance of appropriate mentors during the fellowship programs was stressed. Assistance with obtaining information about possible sources of research funding and with preparation of appropriate proposals were noted as important needs for the fellows. Both during the retreat and in the survey which followed it was clear that fellows are concerned about the opportunities available for them in academic departments. They expressed concern about the availability of positions, particularly about positions in departments where there is a clear understanding of the importance of research so that significant amounts of time for research and appropriate amounts of resources are made available for young faculty members. I therefore decided to survey all residency program directors listed in the 1995 to 1996 Graduate Medical Education Directory. I am very grateful to the directors who participated. Of tile 272 individuals solicited, 177 (or 65%) responded. This was not intended to be a statistically valid survey but rather a gathering of the opinions of those who responded. Because some of the respondents chose to not answer particular questions,
Dignam 739
Volume 176, Number 4 Am.J Obstet Gynecol
Table I. Locations of residency programs Principal teaching imspital for school of medicine Hospital closely affiliated with school of medicine Hospital not affiliated with school of medicine Research-oriented institution Non-research-oriented institution
Table IV. Protected time and laboratory space 78 75 24 83 87
Table II. Faculty breakdown Residents receiving instruction at these institutions Full-time faculty members involved Faculty members who have held National Institutes of Health or equivalent grants
3188 2776 325
Table III. Expected faculty appointments Faculty members to be appointed during next 5 years 427 No. who will be expected to perform laboratory 136 research
there are some small discrepancies in the numbers reported in some related categories. As noted in Table I, directors of programs located at principal teaching hospitals for medical schools numbered 78. Those located at hospitals closely affiliated with medical schools numbered 75 and those at hospitals not affiliated with medical schools were 24 in number. Eighty-three directors identified their programs as being located at research-oriented institutions and 87 at nonresearch-oriented institutions. A total of 3188 residents are receiving instruction at these institutions. The total number of full-time faculty members involved is 2776 and the number who have held National Institutes of Health or equivalent grants is 325 (Table II). The fellows are particularly interested in the number of faculty positions that may be available in the future. Respondents to this survey have indicated that during the next 5 years they have plans to appoint 427 faculty members. O f these, the number who will be expected to perform laboratory research is 136 (Table III). Protection of time for young faculty members to perform significant research is important. Most of these individuals devote many extra hours to research activities, but it is also important for them to have time during usual working hours when laboratory personnel are available tbr discussion. Sixty-six of the research-oriented institutions indicated that time could be so protected, and on average this amounted to approximately 25%. Forty-five of the institutions that are not research oriented indicated that time could be protected, and on average the amount indicated was approximately 20%. The amount of laboratory space equipped to perform molecular biology research is approximately 2700 square feet on average for the research-oriented institutions (Table IV).
Protected time for junior f~tculty members at research-oriented institutions Protected time for junior faculty members at non-researchoriented institutions Average amount of laboratory space equipped to perform molecular biology research in research-oriented institutions
Approximately 25% Approximately 20% 2700 square feet
Table V. Departments selected for educating fellows Baylor Duke Harvard University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Pennsylvania University of Pittsburgh University of Texas, Southwestern University of Washington Yale
It appears then that in the institutions from which responses were received in this survey 136 faculty members who are expected to perform laboratory research will be appointed during the next 5 years and will be provided with some protected time to pursue this research. In the opinion of those 70 program directors who responded to this question, we should be educating from 0 to 120 fellows annually in this country for laboratory research careers. Several program directors suggested that we should be educating 100 fellows annually and several more suggested a number of 50, so the overall average of 32 is skewed upward. The median is 20. Respondents were asked to give an opinion about the number of departments of obstetrics and gynecology that have the capability to properly educate these fellows. Of the 55 program directors who responded to this question, the average number suggested was approximately 20. Departments that were most often identified as being in this category are indicated in Table V. Program directors in those departments most commonly r eco m m en d ed that 20 fellows be educated annually. Respondents were asked to indicate the two scientific developments in medicine during the past 50 years that have had the greatest impact on the care of obstetric and gynecologic patients. Those most commonly mentioned are listed in Table VI. It is clear that many of these accomplishments were made by individuals outside the specialty of obstetrics and gynecology. We are grateful for their contributions and have been quick to apply their findings when appropriate. However, we need to apply our own energies to the solution of problems peculiar to our patients.
740
April 1997 AmJ Obslet Gynecol
Dignam
Table VI. Developments with most impact on obstetrics and gynecology
Ultrasonography Antibiotics Endoscopy Molecular biology-genetics Contraceptives Fetal monitoring In vitro fertilization Papanicolaou smear Blood banking RhoGAM
I have emphasized research with molecular biologic techniques because delineation of molecular phenomena is rapidly advancing our understanding of a variety of medical problems in the fields of infectious disease, malignancy, degenerative diseases, genetic abnormalities, and behavioral abnormalities, to name just a few. Given proper resources, these findings are rapidly accumulated and quickly applied to the solution of medical problems. I believe that we must be devoting a major portion of our resources to studies with these techniques. Research of this nature requires a major commitment of resources. Federal governmental agencies have been very supportive, but there is mounting concern about the amount of funding that will be available in the future. The more private funds that we can accumulate, the more certain we shall be of our continuing ability to support the many bright young investigators who are so highly motivated to perform this important work. To generate a sut~cient amount of current income, a significant amount of capital is required. Some of the earlier members of this society have been exceptionally generous and present-day members have been very supportive.
Current and past fellows feel strongly about the need and almost without exception have contributed to the effort. The American Board of Obstetrics and Gynecology and the Burroughs Wellcome Fund have been very supportive. At the current time, seven fellows are enrolled in programs supported by the American Association of Obstetricians and Gynecologists Foundation and eight fellows are enrolled in the Reproductive Scientist Development Program. Because each of these fellows is enrolled in a program that is of at least 2 years' duration, we are not, in these two programs, producing more than seven or eight fellows per year. The survey that I have reported suggests that we should be educating several times that n u m b e r and that there will be good opportunities for them in academic medicine after their fellowships. Earlier in this meeting Dr. Jaffe has expressed his feelings about the importance .of research fellowships and support of young faculty members. Clearly, I share his depth of conviction, if not his eloquence. I see a clear need to develop an endowment of sutficient size to be able to support these programs on a continuing basis, rather than depending on the year by year support of generous individuals and organizations. The American Association of Obstetricians and Gynecologists is well poised, under the able leadership of Dr. Charles Hammond, to have a significant impact, but I believe that this is a project for our entire specialty and I believe that all of the organizations engaged in the organization and support of fellowships should be involved. I recommend that a meeting of the leaders of all of these organizations be convened to organize a well-considered approach by our entire specialty. It is thus that we can meet some of our obligations to those wonderful women who are our beloved patients.
Bound v o l u m e s available to subscribers Bound volumes of the Alnerican Journal of Obstetrics and Gynecology are available to subscribers (only) for the 1997 issues from the publisher, at a cost of $105.50 for domestic, $137.50 for Canada, and $128.50 for international for Vol. 176 (]anualy-June) and Vol. 177 (July-December). Shipping charges are included. Each b o u n d volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800)453-4351 or (314)453-4351. Subscriptions must be in force to qualify. B o u n d volumes are not available in place o f a regular Journal subscription.
As have many of my predecessors in the office of President, I have reviewed some of the earlier presidential addresses. I was particularly impressed by the records of the m e e t i n g of 1886, 10 years after the f o u n d i n g of the American Gynecological Society--a m e e t i n g a t t e n d e d by 29 members. T h e welcoming address was presented by Dr. H.P.C. Wilson of Baltimore and the presidential address was given by Dr. T h a d d e u s A. Reamy of Cincinnati. By special a r r a n g e m e n t I have persuaded these two fine g e n t l e m e n to return to this m e e t i n g to repeat for us excerpts from their earlier presentations.
Dr. H.P.C. Wilson (Dr. Alan H. DeCherney) You have assembled here today from all parts of this great country to c o m p a r e the results of your studies and labors during the year past in that d e p a r t m e n t of medicine that relates to the diseases peculiar to women. As the honest h u s b a n d m a n prepares his soil, cultivates his crop, and gathers his harvest, so you are h e r e now to reap the fruit of a n o t h e r year's work and gather into the great storehouse of knowledge every grain of g o o d wheat while you reject the chaff and the tares. May it be a rich harvest feast to every one of you, in which the h u s b a n d m a n shall abundantly partake of the fruit of his labors! I stand h e r e in the n a m e of the resident Fellows, in the n a m e of the general profession, in the n a m e of the citizens of Baltimore, and in the n a m e of her women, to extend to you a hearty welcome. Were our hands half as large as our hearts, we fear we should kill you with kindness. We appreciate the h o n o r you have d o n e us by From the Center for Health Sciences, University of California, Los Angeles. Presented at the Fifteenth Annual Meeting of the American Gynecological and Obstetrical Society, AsheviUe, North Carolina, September 57, 199Z Reprint requests: William~ Dignam, MD, University of California, Los Angeles, 24-149 Centerfor Health Sciences, 10833 LeConte Ave., Los Angeles, CA 90024. Am J Obstet Gynecol 1997;176:736-40. Copyright © 1997 by Mosby-Year Book, Inc. 0002-9378/97 $5.00 + 0 6/6/80760
736
m e e t i n g in this city, and we beg you to r e m e m b e r that Baltimore is very ready--yea, a n x i o u s - t o welcome you within her borders whenever you may be inclined to come. T h e subject of your d e l i b e r a t i o n s - - " t h e diseases and accidents peculiar to w o m e n " - - i s one very near to the heart of every man, woman, and child. It is of greater importance than the affairs of state, than the o t h e r arts and sciences, than all things above or u n d e r the earth. "All that a m a n hath will he give for his life." All that is associated with the words wife, mother, daughter, sister, all that is contained in the words "Home, Sweet H o m e , " gather their sweetness from the influence of woman; and, when she is blighted with disease and suffering, h o m e is not h o m e - - y e a , earth has no joys. It is to you, sirs, and your brethren, that m a n k i n d turns with such longings when his fireside is invaded by the withering blast of sickness or t h r e a t e n e d by that fell destroyer, Death. It is on you alone he leans to save his h o m e from desolation and restore to health and happiness the c h a r m of the family circle. T h e magistrate, the merchant, the banker, the attorney, the minister are n o t in his thoughts. It is on the obstetrician, or gynecologist, that he rests all his hopes. I can speak, for I know, of the faithfulness with which the trust is e x e c u t e d and of the sacrifices that you continually endure. Let me, then, assure you of the great interest that this c o m m u n i t y takes in your deliberations. It is known that you live, toil, and die for the g o o d of woman, on whose t e n d e r care and sympathy all are so dependent: O, woman! in our hours of ease, Uncertain, coy, and hard to please, A n d variable as the shade By the light quivering aspen made, W h e n pain and anguish wring the bow, A ministering angel thou! T h a n k you, Dr. Wilson. Dr. Reamy, if you will now grace us with a repetition of some of your remarks
Volume 176, Number 4
Dignam 737
Am,l Obstet (;ynecol
presented on an earlier occasion, we shall be very grateful. Welcome to the podium.
Dr. Thaddeus A. Reamy (Dr, Norman Gant) It may be said that the time d u r i n g which o u r society has b e e n in existence is the a b d o m i n a l e p o c h of the surgical age in gynecology. It has seen a b d o m i n a l section so d e v e l o p e d a n d perfected that the b r i l l i a n t a c h i e v e m e n t s of skillful operators have far e x c e e d e d the most s a n g u i n e expectations of 10 years ago. This is n o t only true of all fields of a b d o m i n a l section b u t especially so of ovariotomy, the p i o n e e r o p e r a t i o n in this realm. We have already seen that surgical results are eminently satisfactory so far as relates to cystic disease of the ovary, which imperils life. But is the operation of removing the ovaries for supposed b e g i n n i n g "cystic degeneration," "cirrhosis," "catarrhal salpingitis," "chronic catarrh of the tubes," "stenosis," "congestion," "enlargement," always justifiable? I trow not. Have n o t the glowing reports of such cases, a n d the cures wrought, together with the facility of the operation, a n d its comparative i m m u n i t y from d a n g e r to life, led to the extirpation of m a n y a sinless ovary.? How often in our experience have we met cases with the constant pelvic pain a n d its various reflexes, with a t e n d e r ovary slightly displaced, or some tortuous body about the uterine f u n d u s that we t h o u g h t was the "congested, . . . hypertrophied," or dilated t u b e s - - i n short, having a clinical history a n d physical aspect incapable of differentiation from those cases-flom which we hear of ovaries being removed, a n d yet we have seen them cured by a patient recourse to diet, massage, electricity, vaginal irrigation, medication of the vaginal vault a n d cervix, rest of body a n d mind, postural treatment, etc. We have so often a d d u c e d these figures to d e m o n strate the wondrous progress of our art a n d offered them in expiation for what we considered the b l u n d e r s of our drugging, dosing, a n d bleeding forefathers. I greatly fear, however, that somebody will, one of these days, show the other side of the picture, that some ingenious statistical cynic will c o m p u t e the years of h u m a n life lost to the race by this destruction of ovaries, whose functional activity is yet unabated, a n d whose structure yet bears many possibilities for population. There have b e e n entirely too m u c h constructive pathologic reports written about the ovary. Much of them, I fear, have b e e n created to order, tojustify, the removal of functionally active ovaries after they have b e e n extirpated. We n e e d the fiat lux of a practical pathologic study sustained by the most extensive comparative investigation on healthy a n d u n h e a l t h y ovaries. A h u m a n a n d economic conservatism should keep our fingers off these organs until we know whether they are yet capable of discharging their function or whether they are physio-
logically dead or whether their possessor can be cured without their sacrifice. Again, many of the remarkable cures reported after this operation must be taken c u m grano salis, until such time has passed as will preclude the possibility of a relapse, or at least r e n d e r it improbable. Time will, I fear, m u c h change the aspect of some reported cures; this o p i n i o n is n o t wholly speculative. Let us, as a society a n d as individuals, do our duty toward w o m e n by proclaiming and practicing against this unsexing enthusiasm. Can we n o t take some steps toward the establishment of some hard a n d fast lines for the g o v e r n m e n t of this practice? G e n t l e m e n , thank you for your inspiring remarks. Present-day m e m b e r s clearly do share your p r o f o u n d admiration for the women whom we serve a n d are intrigued to note that 110 years ago, a n d soon after a b d o m i n a l surgery was proved safe, you were already directing attention to the possibility that unnecessary surgery was being p e r f o r m e d a n d calling for evidencebased medical practice in the form of the necessity for careful study of the structure a n d function of ovaries to d e t e r m i n e which should be removed and which could be preserved. Regrettably, few a m o n g us are able to express our feelings for our patients in such a magnificent style as have you, b u t the depth of our admiration and respect are no less great. These patients are so t e n d e r a n d have such a capacity for deep, deep, a n d unswerving emotions. It is our great privilege to share in their trials a n d tribulations, as well as their overwhelming joy, as for example, when a n o r m a l baby is born. In some ways our patients of today have many more stresses than did your patients in 1886. At that time they c o m m o n l y enjoyed the support a n d assistance of a family that was nearby, whereas today our patients may well be far from h o m e a n d pretty m u c h on their own, a n d faced with the care of a n e w b o r n baby who never seems to sleep, as their husbands spend long hours away from h o m e trying to accumulate resources for the family. The trust a n d confidence these women place in their physicians is heartwarming a n d inspiring. We in obstetrics and gynecologT are i n d e e d a privileged lot. The wonderful characteristics of w o m e n are perhaps best exemplified in our female colleagues. Not only are they bright a n d professionally skilled but they bring such insight to our activities. So deep are their emotions that on occasion I have n o t e d the shedding of a few tears when these sensitive individuals were apprised of the very poor prognosis for a particular patient. If perchance our own behavior has b e e n a bit calloused in nature, it brings us immediately back to the appropriate frame of mind. Fortunate i n d e e d is the practitioner who is asked to c a r e for o n e of our female colleagues. He or she is, of course,
738
Dignam
very flattered and privileged to receive the trust of one so well informed and yet still subject to the emotional changes occasioned by pregnancy or serious disease. How these wonderful women, young or old, are able to tolerate their situations and yet, as they do, continue to devote time and attention to their own patients has always been a source of great wonder for me. What do we owe to these wonderful individuals whom we are privileged to know and for whom we provide care? First, of course, we should be unstinting in our efforts to provide that care to the very best of our ability and to bring to the activity as much current knowledge as is humanly possible. Sometimes, however, these are not enough, and we are unsuccessful in our attempts. We have all experienced these very deep frustrations and have wished that our knowledge could grow more rapidly. We must therefore devote great effort to research concerning the diseases peculiar to women, to gain greater understanding of the pathophysiologic characteristics, greater accuracy in reaching diagnosis, and greater success in carrying out treatment. Thanks to the great generosity of some of our earlier members, and the depth of conviction of our present-day members, this organization has been exceptionally active and successful in providing resources for the many young, very bright, and very industrious individuals who are rapidly becoming very productive research workers in our specialty. You have heard from some of them at this meeting and I am certain that you are as impressed with their accomplishments as am I. You will note that much of their work uses molecular biologic techniques. Clearly these techniques are permitting the very rapid accumulation of knowledge of the processes in which we are interested. The procedures involved require a major c o m m i t m e n t of resources. This is not to say that research using other techniques, such as those used in epidemiology, outcomes research, physiology of pregnancy, drug trials, improvements in surgical procedures, to name just a few, are not equally important. Because many of the fellows supported by this organization have chosen projects that involve molecular biologic techniques, I have chosen to focus my remarks on this area. The fellowships of the American Association of Obstetricians and Gynecologists Foundation have been exceptionally successful. Some of our most distinguished members have devoted much thought, time, and energy to organizing and supporting these fellowships. Dr. Lawrence Longo and now Dr. RobertJaffe have been equally effective in leading the Reproductive Scientist Development Program. Recently, Dr. Robert Creasy and now Dr. Sherman Elias have chaired the relevant committee in our organization. Dr. Creasy has surveyed the graduates and the results of his survey were published in the American Journal of Obstetrics and Gynecology, August 1996,
April ]997 AmJ Obstet Gynecol
volume 175, n u m b e r 2, pages 494 to 495. He has indicated that of the first 44 fellows who have completed fellowships in our program or in the Reproductive Scientist Development Program 91% are members of medical school faculties and 75% of them have succeeded in obtaining extramural research funding. This is very impressive in these days of marked restriction of funds available for research. Our fellows are a very impressive group of young, very highly motivated physicians. I had the privilege of attending their retreat last year and it was an exhilarating experience. They are completely dedicated to the pursuit of excellence in their professional careers. However, they did express some concern about the opportunities that would be available for them in academic departments after completing these arduous fellowships. Dr. Donald Dudley had organized that retreat and we agreed that he would survey the fellows to gain a more exact impression of the nature and depth of their concerns. You have heard from him earlier in this meeting and you will recall that they did express some concern about their chances of obtaining extramural funding in the future. They did express some anxiety concerning their future success at becoming certified by the American Board of Obstetrics and Gynecology. There was some expression of opinion that longer periods of fellowship would be necessary to properly prepare them to be successful research scientists. The desirability of continued support for a few years after the fellowships was noted. This would permit them to have a reduction in the time required for them to spend in other activities during their early years in academic departments and therefore be able to get their research programs started in a rigorous manner. The importance of appropriate mentors during the fellowship programs was stressed. Assistance with obtaining information about possible sources of research funding and with preparation of appropriate proposals were noted as important needs for the fellows. Both during the retreat and in the survey which followed it was clear that fellows are concerned about the opportunities available for them in academic departments. They expressed concern about the availability of positions, particularly about positions in departments where there is a clear understanding of the importance of research so that significant amounts of time for research and appropriate amounts of resources are made available for young faculty members. I therefore decided to survey all residency program directors listed in the 1995 to 1996 Graduate Medical Education Directory. I am very grateful to the directors who participated. Of tile 272 individuals solicited, 177 (or 65%) responded. This was not intended to be a statistically valid survey but rather a gathering of the opinions of those who responded. Because some of the respondents chose to not answer particular questions,
Dignam 739
Volume 176, Number 4 Am.J Obstet Gynecol
Table I. Locations of residency programs Principal teaching imspital for school of medicine Hospital closely affiliated with school of medicine Hospital not affiliated with school of medicine Research-oriented institution Non-research-oriented institution
Table IV. Protected time and laboratory space 78 75 24 83 87
Table II. Faculty breakdown Residents receiving instruction at these institutions Full-time faculty members involved Faculty members who have held National Institutes of Health or equivalent grants
3188 2776 325
Table III. Expected faculty appointments Faculty members to be appointed during next 5 years 427 No. who will be expected to perform laboratory 136 research
there are some small discrepancies in the numbers reported in some related categories. As noted in Table I, directors of programs located at principal teaching hospitals for medical schools numbered 78. Those located at hospitals closely affiliated with medical schools numbered 75 and those at hospitals not affiliated with medical schools were 24 in number. Eighty-three directors identified their programs as being located at research-oriented institutions and 87 at nonresearch-oriented institutions. A total of 3188 residents are receiving instruction at these institutions. The total number of full-time faculty members involved is 2776 and the number who have held National Institutes of Health or equivalent grants is 325 (Table II). The fellows are particularly interested in the number of faculty positions that may be available in the future. Respondents to this survey have indicated that during the next 5 years they have plans to appoint 427 faculty members. O f these, the number who will be expected to perform laboratory research is 136 (Table III). Protection of time for young faculty members to perform significant research is important. Most of these individuals devote many extra hours to research activities, but it is also important for them to have time during usual working hours when laboratory personnel are available tbr discussion. Sixty-six of the research-oriented institutions indicated that time could be so protected, and on average this amounted to approximately 25%. Forty-five of the institutions that are not research oriented indicated that time could be protected, and on average the amount indicated was approximately 20%. The amount of laboratory space equipped to perform molecular biology research is approximately 2700 square feet on average for the research-oriented institutions (Table IV).
Protected time for junior f~tculty members at research-oriented institutions Protected time for junior faculty members at non-researchoriented institutions Average amount of laboratory space equipped to perform molecular biology research in research-oriented institutions
Approximately 25% Approximately 20% 2700 square feet
Table V. Departments selected for educating fellows Baylor Duke Harvard University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Pennsylvania University of Pittsburgh University of Texas, Southwestern University of Washington Yale
It appears then that in the institutions from which responses were received in this survey 136 faculty members who are expected to perform laboratory research will be appointed during the next 5 years and will be provided with some protected time to pursue this research. In the opinion of those 70 program directors who responded to this question, we should be educating from 0 to 120 fellows annually in this country for laboratory research careers. Several program directors suggested that we should be educating 100 fellows annually and several more suggested a number of 50, so the overall average of 32 is skewed upward. The median is 20. Respondents were asked to give an opinion about the number of departments of obstetrics and gynecology that have the capability to properly educate these fellows. Of the 55 program directors who responded to this question, the average number suggested was approximately 20. Departments that were most often identified as being in this category are indicated in Table V. Program directors in those departments most commonly r eco m m en d ed that 20 fellows be educated annually. Respondents were asked to indicate the two scientific developments in medicine during the past 50 years that have had the greatest impact on the care of obstetric and gynecologic patients. Those most commonly mentioned are listed in Table VI. It is clear that many of these accomplishments were made by individuals outside the specialty of obstetrics and gynecology. We are grateful for their contributions and have been quick to apply their findings when appropriate. However, we need to apply our own energies to the solution of problems peculiar to our patients.
740
April 1997 AmJ Obslet Gynecol
Dignam
Table VI. Developments with most impact on obstetrics and gynecology
Ultrasonography Antibiotics Endoscopy Molecular biology-genetics Contraceptives Fetal monitoring In vitro fertilization Papanicolaou smear Blood banking RhoGAM
I have emphasized research with molecular biologic techniques because delineation of molecular phenomena is rapidly advancing our understanding of a variety of medical problems in the fields of infectious disease, malignancy, degenerative diseases, genetic abnormalities, and behavioral abnormalities, to name just a few. Given proper resources, these findings are rapidly accumulated and quickly applied to the solution of medical problems. I believe that we must be devoting a major portion of our resources to studies with these techniques. Research of this nature requires a major commitment of resources. Federal governmental agencies have been very supportive, but there is mounting concern about the amount of funding that will be available in the future. The more private funds that we can accumulate, the more certain we shall be of our continuing ability to support the many bright young investigators who are so highly motivated to perform this important work. To generate a sut~cient amount of current income, a significant amount of capital is required. Some of the earlier members of this society have been exceptionally generous and present-day members have been very supportive.
Current and past fellows feel strongly about the need and almost without exception have contributed to the effort. The American Board of Obstetrics and Gynecology and the Burroughs Wellcome Fund have been very supportive. At the current time, seven fellows are enrolled in programs supported by the American Association of Obstetricians and Gynecologists Foundation and eight fellows are enrolled in the Reproductive Scientist Development Program. Because each of these fellows is enrolled in a program that is of at least 2 years' duration, we are not, in these two programs, producing more than seven or eight fellows per year. The survey that I have reported suggests that we should be educating several times that n u m b e r and that there will be good opportunities for them in academic medicine after their fellowships. Earlier in this meeting Dr. Jaffe has expressed his feelings about the importance .of research fellowships and support of young faculty members. Clearly, I share his depth of conviction, if not his eloquence. I see a clear need to develop an endowment of sutficient size to be able to support these programs on a continuing basis, rather than depending on the year by year support of generous individuals and organizations. The American Association of Obstetricians and Gynecologists is well poised, under the able leadership of Dr. Charles Hammond, to have a significant impact, but I believe that this is a project for our entire specialty and I believe that all of the organizations engaged in the organization and support of fellowships should be involved. I recommend that a meeting of the leaders of all of these organizations be convened to organize a well-considered approach by our entire specialty. It is thus that we can meet some of our obligations to those wonderful women who are our beloved patients.
Bound v o l u m e s available to subscribers Bound volumes of the Alnerican Journal of Obstetrics and Gynecology are available to subscribers (only) for the 1997 issues from the publisher, at a cost of $105.50 for domestic, $137.50 for Canada, and $128.50 for international for Vol. 176 (]anualy-June) and Vol. 177 (July-December). Shipping charges are included. Each b o u n d volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800)453-4351 or (314)453-4351. Subscriptions must be in force to qualify. B o u n d volumes are not available in place o f a regular Journal subscription.