Personal Perspectives
The Sky Is Not Falling, But It Is Severely Drooping for the Specialist Obstetrician–Gynecologist Louis Weinstein,
MD
I
n a fable written by J. G. Chandler in 1840 titled “The Remarkable Story of Chicken Little,” the protagonist Chicken Little becomes frightened by a leaf falling on her tail and starts the lament to all who will listen that “the sky is falling.”1 At times I have felt like Chicken Little by writing about the potential demise of the “general obstetrician–gynecologist.” In a Personal Perspective piece published in the June 2011 issue of Obstetrics & Gynecology titled, “Society for Women’s Health Oversight: Establishing Equality in the Profession of Obstetrics and Gynecology,” I discussed the negative effects of the increasing number of subspecialists in obstetrics and gynecology with a resulting decrease in the number and role of the general obstetrician–gynecologist (ob-gyn).2 I suggested that the plethora of subspecialties, including maternal– fetal medicine, reproductive endocrinology, gynecologic oncology, urogynecology, pelvic surgery, laborists, and family planning, were all negatively affecting the general ob-gyn. This results in fully trained physicians’ (whose education may be shortchanged during residency training by the presence of fellows) having the majority of their clinical practice relegated to performing uncomplicated vaginal deliveries, uncomplicated cesarean deliveries, abdominal hysterectomies (few have skills for the vaginal approach), and simple office practice. If this trend continues, it is likely that we shall not be able to continue to attract the best and brightest medical students into obstetrics and gynecology. The number of residents entering subspecialty training continues to rise, with more than 20% of all trainees currently choosing this route.3 It is my opinion
From the Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania. Corresponding author: Louis Weinstein, MD, P.O. Box 21829, Charleston, SC 29413; e-mail: [email protected]. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
VOL. 125, NO. 4, APRIL 2015
that, within the next 10–20 years, 50% or more of ob-gyn residents will choose some type of fellowship position. The reasons for this continuing increase in fellowship selection include higher remuneration, Generation X and Y physicians who desire less after-hours hospital call (lifestyle), the ability to have a defined schedule, the mastery of a narrow area of clinical practice removing uncertainty from many patient encounters, and the decrease in the variety of clinical care that the ob-gyn can offer. Residents who do not enter a fellowship will have the leftovers of a practice to choose from, with many seeking part-time work and others leaving the profession at a much younger age.4,5 This will result in a worsening shortage of practicing obstetricians and gynecologists, a phenomenon that the profession is already experiencing. In my 2011 editorial, I suggested that general obgyns be elevated to the level of the subspecialist and that a new society be formed to recognize their importance to the teaching mission of academic medicine and to the role of private practitioner.2 I am pleased that a new organization was formed in 2012 called the “Society of Academic Specialists in General Obstetrics and Gynecology” (www.sasgog.org) to foster the importance of the ob-gyn to the academic mission. I am concerned that the Society has not been forceful enough in elevating the role of the specialist (no longer should we use the term “generalist”) in obstetrics and gynecology to that of subspecialist. Also, I suggest that the Society remove “General” from their name, because this is an ill-defined term. Unfortunately, I have seen a negative change in the direction of the path that the profession of obstetrics and gynecology is taking. A recent editorial in an American College of Obstetricians and Gynecologists’ Clinical Review titled “We Know What We Are, but Know Not What We May Be” suggests that the fully trained ob-gyn should not be called a generalist but a “specialist in comprehensive obstetrics and gynecology (SCOG).”6
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
975
I completely agree with the term “specialist” for all obgyns, but no specific recommendations were made as to how to change the role of the specialist and elevate her or him to the appropriate level. These specialists are the mainstay of an academic department—they do the majority of the teaching and clinical care. Having them serve as role models for physicians-in-training further strengthens the quality of the private practitioner, who should return to the role of being the foundation for the practice of women’s health. Instead of continuing the lament that the “sky is falling,” I propose a set of suggestions to prop up the sky and eliminate its droop. 1. The term “generalist” should be removed totally from our profession, including all future publications; we are all specialists and should be recognized as such (to have subspecialists there must be specialists). This will start the process of elevating the image of the specialist to the residents, other faculty, and the administration. 2. The majority of faculty in an academic obstetric and gynecologic department should be specialists (currently less than 50%), not subspecialists, with the specialists providing the majority of women’s health care in both the inpatient and outpatient setting. 3. The proliferation of divisions within academic departments should cease, with each department having only two divisions—one for the specialists and another for the subspecialists. This would place both groups on equal footing for departmental resources as well as allow the chair to treat both groups equally. 4. The compensation and academic rank of the specialist should be on par with that of the subspecialist. This will be more easily accomplished by having only two divisions within each department. 5. The majority of teaching should be performed by the specialist, because she or he is the best role model for the residents. 6. The American College of Obstetricians and Gynecologists should mandate that an equal number of specialists and subspecialists be present on all educational task forces, Councils on Resident Education in Obstetrics and Gynecology, Personal Reviews of Learning in Obstetrics and Gynecology, and working committees. 7. The proliferation of fellowships should cease, with the American Board of Obstetrics and
976
Weinstein
The Sky Is Not Falling
Gynecology capping the number of fellows-intraining at a projected level that meets a reasonable need for both education and practice. 8. The time spent by residents on subspecialty rotations should be substantially decreased and replaced by more time spent with specialist clinicians, mastering the art of teaching and learning leadership skills. These are radical suggestions, but the current path our profession is on must be altered for the role of the specialist to remain relevant. Since my previous 2011 editorial on this topic, the number of fellows has increased, the number of specialists within faculty has decreased with a larger decrease in those with mastery of the total profession, residents continue to have subspecialists as their role models, and the compensation of the specialist compared with that of the subspecialist is not commensurate with their critical role in training future practitioners. The sky is not falling, but the droop continues to worsen and eventually will crush all of us if changes are not made. We have a great profession; the only one that is active throughout the total life experience of a woman ranging from birth to death. What other health care provider is responsible for 125 years of life (50 for the mother who delivers at 25, and 75 for the child)? The time is now to place the supports that will strengthen the sky so that Chicken Little can eliminate her lament and I can finish my career satisfied that our great, exciting, noble profession will continue to thrive and grow. The SPECIALIST is the foundation of our profession. REFERENCES 1. Chandler JG. Remarkable story of Chicken Little. Boston (MA): Degen, Estes & Co.; 1840. 2. Weinstein L. Society for women’s health oversight: establishing equality in the profession of obstetrics and gynecology. Obstet Gynecol 2011;117:1392–93. 3. Rayburn WF, Gant NF, Gilstrap LC, Elwell LC, Williams SB. Pursuit of accredited subspecialties by graduating residents in obstetrics and gynecology. Obstet Gynecol 2012;120:619–25. 4. Rayburn WF. The obstetrician-gynecologist workforce in the United States: facts, figures, and implications 2011. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011. 5. Horan CM, Weinstein L. Faculty satisfaction and retention in obstetrics and gynecology. Rayburn WF, Schulkin J, editors. Changing landscape of academic women’s health care in the United States. New York (NY): Springer Publishing; 2011. 6. Gaba ND, Swaim LS, Lawrence HC. We know what we are, but we know not what we may be. ACOG Clin Rev 2014;19:6.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Sky Is Not Falling, But It Is Severely Drooping for the Specialist Obstetrician–Gynecologist Louis Weinstein,
MD
I
n a fable written by J. G. Chandler in 1840 titled “The Remarkable Story of Chicken Little,” the protagonist Chicken Little becomes frightened by a leaf falling on her tail and starts the lament to all who will listen that “the sky is falling.”1 At times I have felt like Chicken Little by writing about the potential demise of the “general obstetrician–gynecologist.” In a Personal Perspective piece published in the June 2011 issue of Obstetrics & Gynecology titled, “Society for Women’s Health Oversight: Establishing Equality in the Profession of Obstetrics and Gynecology,” I discussed the negative effects of the increasing number of subspecialists in obstetrics and gynecology with a resulting decrease in the number and role of the general obstetrician–gynecologist (ob-gyn).2 I suggested that the plethora of subspecialties, including maternal– fetal medicine, reproductive endocrinology, gynecologic oncology, urogynecology, pelvic surgery, laborists, and family planning, were all negatively affecting the general ob-gyn. This results in fully trained physicians’ (whose education may be shortchanged during residency training by the presence of fellows) having the majority of their clinical practice relegated to performing uncomplicated vaginal deliveries, uncomplicated cesarean deliveries, abdominal hysterectomies (few have skills for the vaginal approach), and simple office practice. If this trend continues, it is likely that we shall not be able to continue to attract the best and brightest medical students into obstetrics and gynecology. The number of residents entering subspecialty training continues to rise, with more than 20% of all trainees currently choosing this route.3 It is my opinion
From the Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania. Corresponding author: Louis Weinstein, MD, P.O. Box 21829, Charleston, SC 29413; e-mail: [email protected]. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
VOL. 125, NO. 4, APRIL 2015
that, within the next 10–20 years, 50% or more of ob-gyn residents will choose some type of fellowship position. The reasons for this continuing increase in fellowship selection include higher remuneration, Generation X and Y physicians who desire less after-hours hospital call (lifestyle), the ability to have a defined schedule, the mastery of a narrow area of clinical practice removing uncertainty from many patient encounters, and the decrease in the variety of clinical care that the ob-gyn can offer. Residents who do not enter a fellowship will have the leftovers of a practice to choose from, with many seeking part-time work and others leaving the profession at a much younger age.4,5 This will result in a worsening shortage of practicing obstetricians and gynecologists, a phenomenon that the profession is already experiencing. In my 2011 editorial, I suggested that general obgyns be elevated to the level of the subspecialist and that a new society be formed to recognize their importance to the teaching mission of academic medicine and to the role of private practitioner.2 I am pleased that a new organization was formed in 2012 called the “Society of Academic Specialists in General Obstetrics and Gynecology” (www.sasgog.org) to foster the importance of the ob-gyn to the academic mission. I am concerned that the Society has not been forceful enough in elevating the role of the specialist (no longer should we use the term “generalist”) in obstetrics and gynecology to that of subspecialist. Also, I suggest that the Society remove “General” from their name, because this is an ill-defined term. Unfortunately, I have seen a negative change in the direction of the path that the profession of obstetrics and gynecology is taking. A recent editorial in an American College of Obstetricians and Gynecologists’ Clinical Review titled “We Know What We Are, but Know Not What We May Be” suggests that the fully trained ob-gyn should not be called a generalist but a “specialist in comprehensive obstetrics and gynecology (SCOG).”6
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
975
I completely agree with the term “specialist” for all obgyns, but no specific recommendations were made as to how to change the role of the specialist and elevate her or him to the appropriate level. These specialists are the mainstay of an academic department—they do the majority of the teaching and clinical care. Having them serve as role models for physicians-in-training further strengthens the quality of the private practitioner, who should return to the role of being the foundation for the practice of women’s health. Instead of continuing the lament that the “sky is falling,” I propose a set of suggestions to prop up the sky and eliminate its droop. 1. The term “generalist” should be removed totally from our profession, including all future publications; we are all specialists and should be recognized as such (to have subspecialists there must be specialists). This will start the process of elevating the image of the specialist to the residents, other faculty, and the administration. 2. The majority of faculty in an academic obstetric and gynecologic department should be specialists (currently less than 50%), not subspecialists, with the specialists providing the majority of women’s health care in both the inpatient and outpatient setting. 3. The proliferation of divisions within academic departments should cease, with each department having only two divisions—one for the specialists and another for the subspecialists. This would place both groups on equal footing for departmental resources as well as allow the chair to treat both groups equally. 4. The compensation and academic rank of the specialist should be on par with that of the subspecialist. This will be more easily accomplished by having only two divisions within each department. 5. The majority of teaching should be performed by the specialist, because she or he is the best role model for the residents. 6. The American College of Obstetricians and Gynecologists should mandate that an equal number of specialists and subspecialists be present on all educational task forces, Councils on Resident Education in Obstetrics and Gynecology, Personal Reviews of Learning in Obstetrics and Gynecology, and working committees. 7. The proliferation of fellowships should cease, with the American Board of Obstetrics and
976
Weinstein
The Sky Is Not Falling
Gynecology capping the number of fellows-intraining at a projected level that meets a reasonable need for both education and practice. 8. The time spent by residents on subspecialty rotations should be substantially decreased and replaced by more time spent with specialist clinicians, mastering the art of teaching and learning leadership skills. These are radical suggestions, but the current path our profession is on must be altered for the role of the specialist to remain relevant. Since my previous 2011 editorial on this topic, the number of fellows has increased, the number of specialists within faculty has decreased with a larger decrease in those with mastery of the total profession, residents continue to have subspecialists as their role models, and the compensation of the specialist compared with that of the subspecialist is not commensurate with their critical role in training future practitioners. The sky is not falling, but the droop continues to worsen and eventually will crush all of us if changes are not made. We have a great profession; the only one that is active throughout the total life experience of a woman ranging from birth to death. What other health care provider is responsible for 125 years of life (50 for the mother who delivers at 25, and 75 for the child)? The time is now to place the supports that will strengthen the sky so that Chicken Little can eliminate her lament and I can finish my career satisfied that our great, exciting, noble profession will continue to thrive and grow. The SPECIALIST is the foundation of our profession. REFERENCES 1. Chandler JG. Remarkable story of Chicken Little. Boston (MA): Degen, Estes & Co.; 1840. 2. Weinstein L. Society for women’s health oversight: establishing equality in the profession of obstetrics and gynecology. Obstet Gynecol 2011;117:1392–93. 3. Rayburn WF, Gant NF, Gilstrap LC, Elwell LC, Williams SB. Pursuit of accredited subspecialties by graduating residents in obstetrics and gynecology. Obstet Gynecol 2012;120:619–25. 4. Rayburn WF. The obstetrician-gynecologist workforce in the United States: facts, figures, and implications 2011. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011. 5. Horan CM, Weinstein L. Faculty satisfaction and retention in obstetrics and gynecology. Rayburn WF, Schulkin J, editors. Changing landscape of academic women’s health care in the United States. New York (NY): Springer Publishing; 2011. 6. Gaba ND, Swaim LS, Lawrence HC. We know what we are, but we know not what we may be. ACOG Clin Rev 2014;19:6.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
