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THE OBSTETRICIAN AND GYNECOLOGIST* JAMES A. MERRILL, M.D. Professor and Chairman, Department of Gynecology-Obstetrics University of Oklahoma College of Medicine Oklahoma City, Okla.
A LL of medicine is changing and the changes are rapid. Much of this is the result of increasing societal and individual health-care expectations. Health care has become increasingly family oriented. From many quarters we are being encouraged to emphasize the primary physician and primary health care. Traditional medicine has involved the diagnosis and treatment of disease; the services of the physician have been sought only after the patient developed complaints. This tradition now has changed and will change even further. Maintenance of health has become a national goal and essentially all health-care planning is being directed to that end. This is especially apparent in the care of women. Many health-care needs of women do not involve disease or illness, but involve an educational component consisting of information, support, and counsel concerning normal phenomena. Moreover, social and cultural attitudes are altering the roles of women; different women perceive the priorities of their health-care needs differently and, in some instances, differently from the established medical attitude. These changes require considerable education of physicians, and not the least part of this educational process must be directed toward changing the attitudes of physicians who treat women. This must occur in medical school curricula and educational programs for residents. Increasingly, the obstetrician-gynecologist is the physician to whom women turn for their ongoing health care and medical supervision, to identify health problems as they arise, and to make appropriate referral when indicated. This comes under the definition of primary care, and *Presented in a panel, Education to Provide Primary Medical Care, as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1122
MERRILL J. A. MERRILL
1122J.
A.
many people suggest that the obstetrician-gynecologist should be recognized as the primary physician of women. In a recent study by Burkons and Willson,* women who were seeing an obstetrician-gynecologist were asked a series of questions concerning their health care. Significantly, only 14% indicated that they saw another physician for periodic examinations. Eighty-six percent saw only their obstetrician-gynecologist on a regular basis. If we were to ask obstetricians and gynecologists if they consider themselves to be primary-care physicians, their answers might be different. Such a study is under way. It does seem clear from this and other observations, however, that obstetricians and gynecologists do function as primary physicians to a considerable extent. Further, there is little evidence of dissatisfaction on the part of physicians with this role. This may not be so in other specialties. Perhaps this is because the content of gynecological residencies encompasses activities which are much like those in actual practice. Preventive medicine has long been an essential part of obstetrics and gynecology (Ob-Gyn), as best exemplified by prenatal care. The periodic examination to screen for pelvic cancer was initiated by gynecologists. The contemporary concerns of obstetrician-gynecologists are no longer limited to the management of normal pregnancy, labor and delivery, and the therapy of benign and malignant pelvic disease. Indeed, contemporary concerns include some of the most pressing problems in our society, such as the quality of human reproduction and its effective control. More and more, the gynecologist is involved in counselling teen-agers concerning social as well as medical issues. Since many problems are presented to the gynecologist for which no organic cause is apparent, these physicians increasingly are evaluating emotional problems and offering help in the form of short-term psychotherapy. Thus, the attitudes of women and the behavior of obstetricians and gynecologists indicate that they have assumed or are assuming the role of primary-care physicians. What is being done to meet the demand for more primary health care? There evidently has been an increase in the number of practicing obstetricians and gynecologists. Each of the last five years has shown an increase in the number of specialists certified by the American Board; in 1970 it was 625, in 1974, 738. Although the number of residency programs in obstetrics and gynecology has declined slightly, the number of *Burkon, D. M. and Willson, J. R.: Is the obstetrician-gynecologist a specialist or primary care physician to women? Am. J. Obstet. Gynec. 121: 808, 1975.
Bull. N. Y. Acad. Med.
THE OBSTETRICIAN AND GYNECOLOGIST
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residents in training has increased. To be sure, this increase has been greater among foreign medical graduates than among American graduates. However, there is recent evidence of a reversal in that trend. The number of students entering residencies in Ob-Gyn is showing a slight but definite increase. At present approximately 6% of graduating seniors enter training programs in Ob-Gyn. What have we done and what can be done to insure that these physicians are properly educated for the tasks at hand? Burkons and Willson made several suggestions, including these: 1) To recruit into Ob-Gyn students with aptitude for primary care 2) To change the emphasis of education programs for residents 3) To change the methods of practice of the obstetrician-gynecologist to permit him to function more efficiently as a primary physician I cannot see much change in recruiting policies, but possibly there is some. Certainly there have been and continue to be changes in the emphasis of our residency-training programs. To a great extent Ob-Gyn residencies recognize the operational philosophy of actual practice and are so conducted. There is much emphasis on ambulatory care. Each new patient should have a complete history and physical examination. The Residency Review Committee for Obstetrics and Gynecology has singled this area out for special examination when reviewing a program. Not only must there be adequate experience for ambulatory care, but this must be well-supervised and the opportunity must be given for continuity of care. Rather than residents spending short periods of time in an outpatient clinic, it may be more appropriate for them to have continuous contact with and follow-up of their ambulatory patients. Residency programs are accomplishing this in a variety of ways. An increasing number of residency programs now function with a team system. Residents and faculty at various levels together provide outpatient and inpatient care for an identified population of patients. They remain as a team throughout the training period and thus have the opportunity to provide a continuum of care. In some programs this has replaced the block system, in which residents are rotated from one section of the department or hospital service to another. A continuum of care is further available through participation in community-centered clinics. To be sure, these opportunities are aimed primarily at prenatal care, family planning, and cancer screening; however, it is possible to maintain continuity and to learn about ongoing care and the community resources available for appropriate referral. Further, the resiVol. 52, No. 9, November 1976
1124
1124
J. A. MERRILL
J.
A.
MERRILL
dent learns the importance and methods of educating patients. Since a significant number of problems presented to the obstetrician-gynecologist involve emotional factors, a specific learning opportunity may be afforded in the area of psychiatry and psychosomatic medicine. Ideally, this is accomplished by a member of the faculty who is specially trained or someone from the department of psychiatry who fills this role. In this way, the resident may obtain continuing advice from his teacher in the management of long-term problems which have an emotional component but which are not of the magnitude which requires psychiatric referral. A similar sort of learning opportunity also may be provided through close liaison with departments of internal medicine. This has functioned best in the treatment of medical complications of pregnancy. However, the practice of working intimately with the internist in the management of obstetrical patients also provides the opportunity to learn more of the broad field of medicine to provide the expertness necessary to identify problems outside the discipline and to make appropriate referrals. In the Burkons and Willson study, 41% of the patients reported that their obstetrician-gynecologist either had treated them for nongynecologic conditions or had decided that no treatment was necessary. There must be frequent interchange in education and learning experience with Ob-Gyn and the content of other disciplines. A soon-to-be-distributed national guide to the content of residency programs in Ob-Gyn includes an entire section on primary health care. The American Board of Obstetrics and Gynecology has recognized the need for a change in the emphasis of residency-training programs and has recommended that the first year of graduate education include substantial experience in general medicine. What this change should encompass requires further definition, but it should not be limited to a mere rotation through departments of internal medicine. The education necessary to change the actual role and attitudes of practicing obstetrician-gynecologists will be somewhat more difficult. Important to this end is the training and utilization of a variety of paramedical health personnel and the changing attitudes of physicians toward encouraging the appropriate use of such individuals. The fact that a number of Ob-Gyn departments now are engaged in the education of paramedical health personnel is a good sign. Further, the fact that these personnel are being educated along with medical students and residents makes it likely that the graduating resident will know how to work effectively with these new health professionals. It seems clear that the utilization of a variety of
Bull. N. Y. Acad. Med.
THE OBSTETRICIAN AND GYNECOLOGIST
1125
health professionals will permit obstetrician-gynecologists to function more efficiently and to provide health surveillance and health screening for a greater number of women. Further, this should permit them to devote more time to those tasks which require specialized skill and education. This might increase the attractiveness of this discipline. Many of the duties performed by the obstetrician could be accomplished by someone with less education following a treatment plan and acting under his direct supervision. At the University of Oklahoma College of Medicine these individuals certainly have proved most valuable, and our residents are coming to understand their role in the total scheme of health-care delivery. Ob-Gyn must move to greater emphasis on group practice and a team approach using a variety of existing and new health professionals. One area of education in Ob-Gyn could have a negative impact upon the development of primary-care physicians: subspecialization. At present certificates are issued for special competence in three areas: oncology, maternal-fetal medicine, and reproductive endocrinology. To date less than 100 specialists have been so certified. If obstetrics and gynecology were to splinter into a number of special interest areas this could be counterproductive. Therefore, it seems essential that the number of training programs and trainees in these areas be strictly limited to the need. Further, such subspecialization must not be allowed to detract from the prestige of the primary specialty. The development of effective referral centers will do much to insure this. The orientation of the discipline of Ob-Gyn by its very nature includes the basic concepts of primary care. Educational programs tend to be designed to expose the resident to the type of practice that he may anticipate. With an increased emphasis upon comprehensive and continuing care it should be possible to improve the number and quality of
primary-care physicians.
Vol. 52, No. 9, November 1976
THE OBSTETRICIAN AND GYNECOLOGIST* JAMES A. MERRILL, M.D. Professor and Chairman, Department of Gynecology-Obstetrics University of Oklahoma College of Medicine Oklahoma City, Okla.
A LL of medicine is changing and the changes are rapid. Much of this is the result of increasing societal and individual health-care expectations. Health care has become increasingly family oriented. From many quarters we are being encouraged to emphasize the primary physician and primary health care. Traditional medicine has involved the diagnosis and treatment of disease; the services of the physician have been sought only after the patient developed complaints. This tradition now has changed and will change even further. Maintenance of health has become a national goal and essentially all health-care planning is being directed to that end. This is especially apparent in the care of women. Many health-care needs of women do not involve disease or illness, but involve an educational component consisting of information, support, and counsel concerning normal phenomena. Moreover, social and cultural attitudes are altering the roles of women; different women perceive the priorities of their health-care needs differently and, in some instances, differently from the established medical attitude. These changes require considerable education of physicians, and not the least part of this educational process must be directed toward changing the attitudes of physicians who treat women. This must occur in medical school curricula and educational programs for residents. Increasingly, the obstetrician-gynecologist is the physician to whom women turn for their ongoing health care and medical supervision, to identify health problems as they arise, and to make appropriate referral when indicated. This comes under the definition of primary care, and *Presented in a panel, Education to Provide Primary Medical Care, as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1122
MERRILL J. A. MERRILL
1122J.
A.
many people suggest that the obstetrician-gynecologist should be recognized as the primary physician of women. In a recent study by Burkons and Willson,* women who were seeing an obstetrician-gynecologist were asked a series of questions concerning their health care. Significantly, only 14% indicated that they saw another physician for periodic examinations. Eighty-six percent saw only their obstetrician-gynecologist on a regular basis. If we were to ask obstetricians and gynecologists if they consider themselves to be primary-care physicians, their answers might be different. Such a study is under way. It does seem clear from this and other observations, however, that obstetricians and gynecologists do function as primary physicians to a considerable extent. Further, there is little evidence of dissatisfaction on the part of physicians with this role. This may not be so in other specialties. Perhaps this is because the content of gynecological residencies encompasses activities which are much like those in actual practice. Preventive medicine has long been an essential part of obstetrics and gynecology (Ob-Gyn), as best exemplified by prenatal care. The periodic examination to screen for pelvic cancer was initiated by gynecologists. The contemporary concerns of obstetrician-gynecologists are no longer limited to the management of normal pregnancy, labor and delivery, and the therapy of benign and malignant pelvic disease. Indeed, contemporary concerns include some of the most pressing problems in our society, such as the quality of human reproduction and its effective control. More and more, the gynecologist is involved in counselling teen-agers concerning social as well as medical issues. Since many problems are presented to the gynecologist for which no organic cause is apparent, these physicians increasingly are evaluating emotional problems and offering help in the form of short-term psychotherapy. Thus, the attitudes of women and the behavior of obstetricians and gynecologists indicate that they have assumed or are assuming the role of primary-care physicians. What is being done to meet the demand for more primary health care? There evidently has been an increase in the number of practicing obstetricians and gynecologists. Each of the last five years has shown an increase in the number of specialists certified by the American Board; in 1970 it was 625, in 1974, 738. Although the number of residency programs in obstetrics and gynecology has declined slightly, the number of *Burkon, D. M. and Willson, J. R.: Is the obstetrician-gynecologist a specialist or primary care physician to women? Am. J. Obstet. Gynec. 121: 808, 1975.
Bull. N. Y. Acad. Med.
THE OBSTETRICIAN AND GYNECOLOGIST
1123
residents in training has increased. To be sure, this increase has been greater among foreign medical graduates than among American graduates. However, there is recent evidence of a reversal in that trend. The number of students entering residencies in Ob-Gyn is showing a slight but definite increase. At present approximately 6% of graduating seniors enter training programs in Ob-Gyn. What have we done and what can be done to insure that these physicians are properly educated for the tasks at hand? Burkons and Willson made several suggestions, including these: 1) To recruit into Ob-Gyn students with aptitude for primary care 2) To change the emphasis of education programs for residents 3) To change the methods of practice of the obstetrician-gynecologist to permit him to function more efficiently as a primary physician I cannot see much change in recruiting policies, but possibly there is some. Certainly there have been and continue to be changes in the emphasis of our residency-training programs. To a great extent Ob-Gyn residencies recognize the operational philosophy of actual practice and are so conducted. There is much emphasis on ambulatory care. Each new patient should have a complete history and physical examination. The Residency Review Committee for Obstetrics and Gynecology has singled this area out for special examination when reviewing a program. Not only must there be adequate experience for ambulatory care, but this must be well-supervised and the opportunity must be given for continuity of care. Rather than residents spending short periods of time in an outpatient clinic, it may be more appropriate for them to have continuous contact with and follow-up of their ambulatory patients. Residency programs are accomplishing this in a variety of ways. An increasing number of residency programs now function with a team system. Residents and faculty at various levels together provide outpatient and inpatient care for an identified population of patients. They remain as a team throughout the training period and thus have the opportunity to provide a continuum of care. In some programs this has replaced the block system, in which residents are rotated from one section of the department or hospital service to another. A continuum of care is further available through participation in community-centered clinics. To be sure, these opportunities are aimed primarily at prenatal care, family planning, and cancer screening; however, it is possible to maintain continuity and to learn about ongoing care and the community resources available for appropriate referral. Further, the resiVol. 52, No. 9, November 1976
1124
1124
J. A. MERRILL
J.
A.
MERRILL
dent learns the importance and methods of educating patients. Since a significant number of problems presented to the obstetrician-gynecologist involve emotional factors, a specific learning opportunity may be afforded in the area of psychiatry and psychosomatic medicine. Ideally, this is accomplished by a member of the faculty who is specially trained or someone from the department of psychiatry who fills this role. In this way, the resident may obtain continuing advice from his teacher in the management of long-term problems which have an emotional component but which are not of the magnitude which requires psychiatric referral. A similar sort of learning opportunity also may be provided through close liaison with departments of internal medicine. This has functioned best in the treatment of medical complications of pregnancy. However, the practice of working intimately with the internist in the management of obstetrical patients also provides the opportunity to learn more of the broad field of medicine to provide the expertness necessary to identify problems outside the discipline and to make appropriate referrals. In the Burkons and Willson study, 41% of the patients reported that their obstetrician-gynecologist either had treated them for nongynecologic conditions or had decided that no treatment was necessary. There must be frequent interchange in education and learning experience with Ob-Gyn and the content of other disciplines. A soon-to-be-distributed national guide to the content of residency programs in Ob-Gyn includes an entire section on primary health care. The American Board of Obstetrics and Gynecology has recognized the need for a change in the emphasis of residency-training programs and has recommended that the first year of graduate education include substantial experience in general medicine. What this change should encompass requires further definition, but it should not be limited to a mere rotation through departments of internal medicine. The education necessary to change the actual role and attitudes of practicing obstetrician-gynecologists will be somewhat more difficult. Important to this end is the training and utilization of a variety of paramedical health personnel and the changing attitudes of physicians toward encouraging the appropriate use of such individuals. The fact that a number of Ob-Gyn departments now are engaged in the education of paramedical health personnel is a good sign. Further, the fact that these personnel are being educated along with medical students and residents makes it likely that the graduating resident will know how to work effectively with these new health professionals. It seems clear that the utilization of a variety of
Bull. N. Y. Acad. Med.
THE OBSTETRICIAN AND GYNECOLOGIST
1125
health professionals will permit obstetrician-gynecologists to function more efficiently and to provide health surveillance and health screening for a greater number of women. Further, this should permit them to devote more time to those tasks which require specialized skill and education. This might increase the attractiveness of this discipline. Many of the duties performed by the obstetrician could be accomplished by someone with less education following a treatment plan and acting under his direct supervision. At the University of Oklahoma College of Medicine these individuals certainly have proved most valuable, and our residents are coming to understand their role in the total scheme of health-care delivery. Ob-Gyn must move to greater emphasis on group practice and a team approach using a variety of existing and new health professionals. One area of education in Ob-Gyn could have a negative impact upon the development of primary-care physicians: subspecialization. At present certificates are issued for special competence in three areas: oncology, maternal-fetal medicine, and reproductive endocrinology. To date less than 100 specialists have been so certified. If obstetrics and gynecology were to splinter into a number of special interest areas this could be counterproductive. Therefore, it seems essential that the number of training programs and trainees in these areas be strictly limited to the need. Further, such subspecialization must not be allowed to detract from the prestige of the primary specialty. The development of effective referral centers will do much to insure this. The orientation of the discipline of Ob-Gyn by its very nature includes the basic concepts of primary care. Educational programs tend to be designed to expose the resident to the type of practice that he may anticipate. With an increased emphasis upon comprehensive and continuing care it should be possible to improve the number and quality of
primary-care physicians.
Vol. 52, No. 9, November 1976
