Dr Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at [email protected].
The January 2017 issue of Contemporary OB/GYN provided a window into the minds of some of our colleagues by reporting the results of our second annual Labor Force survey. About 670 of our readers responded. Seventy-five percent were 50 years or older, 68% were in private practice, 56% were male, and 40% had been in practice for more than 30 years. Thus, there is a likely selection bias toward more senior, male ob/gyns on the “exit ramp” of their careers rather than younger, female physicians on the “entry ramp and passing lane” of their careers. Those caveats notwithstanding, the results are revealing and concordant with my conversations with colleagues.
Among the most disturbing findings was that slightly more than half of the respondents would not choose ob/gyn as a career if they could start over. Reasons they cited included a lack of work-life balance (an ironically millennial-sounding complaint), increasing payer and regulatory burdens, the chronic stress and costs of our intractable professional liability insurance crisis, maintenance-of-certification requirements, and a combination of rising overhead and stagnant reimbursements. Anxiety also accrued around uncertainty posed by the Affordable Care Act, now likely exacerbated by uncertainty over GOP repeal and reform eff orts. But the primary leit motif running through individual narratives was that the frantic pace imposed by seeing more and more patients in less and less time, coupled with time wasted on electronic health record (EHR) documentation and the burden of keeping up with accelerating increases in medical knowledge, was sucking the joy out of what should be the most joyful of professions.
Thankfully, these aren’t the good old days
If I had a dollar for every time I have heard an older colleague lament about how much easier medical practice was 30 years ago, I would be a wealthy man. The truth is we had a lot fewer tools and far less to know back then. When I was a third-year medical student in 1980, medical knowledge doubled about every 7 years. By 2020, it will double every 73 days.1 This fact alone may explain the enormity of the challenge we face in preventing physician burnout. However, to better frame the problem, simply reflect on changes in our discipline since 1980. Back then in obstetrics we had no aneuploidy screening other than maternal age. Ultrasound was rudimentary, fetal surgery de minimis, and Rh isoimmunization difficult to treat and often fatal. Back then, premature labor was diagnosed based on contractions and cervical dilation, treated acutely with ethanol or ritodrine, and chronically with prolonged bed rest and oral tocolysis. However, our patients were younger, healthier, and thinner, and seldom required induction. In 1980, a national consensus conference was called to address the alarming rise in cesarean deliveries, which had tripled between 1968 and 1978, reaching an inconceivable 15.2% of live births.2 In 1980, aides were people who helped out and AIDS the disease had yet to be described or HIV discovered. No American obstetrician had ever heard of Zika. A great obstetrician was one who could discern late decelerations from background noise on a fetal heart rate tracing, and was adept at forceps and total breech extractions.
As for gynecology, in 1980 there had been no successful US in vitro fertilization pregnancies, no Da Vinci robots, and no tension-free vaginal tapes. Premarin and Provera therapy for symptomatic menopausal patients was common. Laparoscopy was in its infancy. Ectopic pregnancies were diagnosed by culdocentesis, signs and/or symptoms and managed by laparotomy. Breast cancers were treated with radical mastectomies. A great gynecologist was adept at colposcopy, cone biopsies, vaginal and abdominal hysterectomies, Marshall-Marchetti-Krantz procedures, and reading pathology slides. Then, subspecialists were relatively rare and knew a little more about a little less. And folks were often paid what they charged.