Maintaining excellence in obstetrics and gynecology
A call to action from leaders in the field.
Faced with dramatic changes in the practice and financing of medicine during the past 2 decades, clinicians, educators, and researchers have struggled to adapt. Obstetrics and gynecology has seen an increased emphasis on subspecialization, without equal emphasis on enhancing women’s care. The workforce also has changed, with the rise of shift work. Ob/gyn trainees must master—and educators must respond to—a rapidly expanding scope of knowledge. This will require redesign of our resident/fellowship education programs.
Research in our specialty is suffering from insufficient funding and emphasis on funding large randomized trials rather than smaller translational studies, which are the seeds of innovation. Compounding the problem, faculty are increasingly being asked to generate more clinical income.
The US healthcare system faces many serious challenges requiring solutions that combine political, economic, and societal input. The recent presidential election adds a further layer of uncertainty.
Here we challenge our specialty to address its own shortcomings in clinical practice, education, and research. This call to action grew out of presentations at the 2015 annual meeting of the Yale Obstetrics and Gynecological Society (YOGS), a group whose members include current and past medical school deans, departmental chairs, division chiefs, past presidents of our major professional societies, and members of the National Academy of Medicine.
Contemporary US obstetrics and gynecology is awash in paradox. Preterm neonates are surviving at ever-earlier gestational ages1,2 and preterm birth (PTB) rates have modestly declined during the past decade but they still exceed those of other western nations.3
US maternal mortality rates are low by historical standards but higher than in other developed countries,4 and rose from 7.2/100,000 live births in 1987 to 17.8/100,000 in 2011.5 Cardiovascular disease and cardiomyopathy together account for a quarter of all maternal deaths, likely reflecting survival of infants with congenital heart disease to adulthood, an aging pregnant population with more comorbidities, and inconsistent access to preconception care.
Recent public health triumphs such as a decrease in teen pregnancies to an all-time low of 26.5 per 1000 women3, declining elective terminations of pregnancy6, and expanded access to reversible contraception7 are threatened by political pressure to limit or roll back access to contraception.8
In the last decade, hysterectomy rates have decreased by 40%9 and the cesarean delivery rate has risen to 32%.10 The latter has resulted in increased rates of placenta accreta11,12 and cesarean scar pregnancies13— trends that could exacerbate maternal morbidity and mortality and do increase healthcare costs.
These examples reflect both achievements and challenges in our field. The latter are particularly sobering given that our specialty’s very identify rests on safeguarding women’s general and reproductive health.
The specialty has wrestled for decades with the balance between its essential function as a primary care discipline (an ob/gyn may be the only physician a woman 20–50 years of age will see regularly), and a growing emphasis on the need for subspecialty expertise (gynecologic oncology, maternal-fetal medicine, reproductive endocrinology and infertility, urogynecology, and family planning). Currently, about 1 in 3 ob/gyns are practicing as subspecialists but, especially in large urban training programs, the status of the career path of the specialist (alternatively defined as the generalist) in the field has been downplayed.
Several trends have conspired to fuel this development. First, in our fee-for-service paradigm, the bigger financial rewards associated with activities generated by subspecialists lure many young ob/gyns into those careers. Secondly, in academic training centers where federal grant funding and state support have been stagnant for years, departments have increasingly depended upon clinical earnings to survive; ergo, the financial necessity of hiring disproportionately more subspecialists who influence the direction of residents into subspecialties. However, specialists are essential to women’s healthcare as they serve as primary care providers for many women in their reproductive years. They also provide subspecialty-type care for women who live far from tertiary care hospitals, where subspecialists are concentrated.
Moreover, without the specialist, who would provide basic ob/gyn care for these women? Family practitioners are increasingly eschewing obstetrics. Nurse practitioners, physician assistants, or certified nurse-midwives can provide some such care, but need well-trained general ob/gyns to handle pregnancy complications, gynecologic consultations, and surgery. The generalist can also provide preventive care to prevent obesity and metabolic syndrome, assist in family planning, and manage menopause, especially in a team-based care method.
In rural, exurban, and many suburban areas, absence of a seasoned specialist skilled in labor management and operative delivery may increase cesarean delivery rates. The importance of the annual well-woman visit—a catalyst for preventive medicine—and the management of psychosocial issues could also be compromised.