Introduction
These are interesting and challenging times for practicing obstetricians and gynecologists around the world and somewhat -- perhaps I should be stronger and say outright -- difficult times. In the United States, for example, the medical liability crisis is so serious that it has forced many obstetricians to simply close down shop and stop delivering babies. As a result, The American College of Obstetricians and Gynecologists (ACOG) has aggressively put pressure on the US government to enact tort reform through 2 campaigns, the "Red Alert" and the equally dramatically titled public education initiative, "Who Will Deliver My Baby?" (see also our Medscape report from this past annual meeting of ACOG on medico-legal issues). Last summer, gynecologists and reproductive endocrinologists around the world were rocked to the core with the sudden announcement of the findings of the Women's Health Initiative on menopausal hormone therapy, and many -- angry and confused themselves -- were confronted with very angry and confused patients. This past week, federal legislation passed in the United States will make it difficult, and possibly a crime, for Ob/Gyns to perform second-trimester abortions. Indeed, even the case that led to the legalization of abortion in the United States 30 years ago was challenged this past week (unsuccessfully) by Norma McCorvey, aka "Ms Roe" herself. This year we also witnessed the conviction of James Kopp for the 1998 slaying of Dr. Barnett Slepian, an Ob/Gyn who worked in an abortion clinic in Buffalo. Dr. Slepian had been targeted by anti-abortion protesters for over a decade and received more than 200 death threats. Apparently, he was 1 of only 4 doctors in Buffalo who performed abortions and the only provider who accepted Medicaid patients.
Just the other day we read the news of a British woman who gave birth to a son after undergoing in vitro fertilization (IVF) and embryo screening in the United States to ensure the baby was genetically matched to help cure an older brother with a rare form of anemia. She had had the treatment in the United States because she had been refused permission for it in Britain on ethical grounds. Earlier in 2002, another controversial birth occurred: a deaf lesbian couple in the United States realized their wish of having a deaf child by selecting as a sperm donor a deaf friend with 5 generations of deafness in his family Also, with IVF come issues surrounding the fate of excess embryos. And, there was the first successful human cloning, or so we are told!
Generally, women well beyond what has been considered the usual age range of childbearing are increasingly having children. A recent article in Fertility and Sterility states: "In the United States alone, the 2001 rates for births to women aged 35-39, 40-44, and 45-49 years rose 30, 47, and 190% compared with 1990. Specifically, there were about 5000 births to women > or = 45 years."[1] Not only are older women wanting to bear children and so involving Ob/Gyns in complex aspects of reproductive endocrinology, genetics, and counseling, but the population of women as a whole is growing older, and Ob/Gyns are more than ever dealing with core primary care issues associated with aging -- symptoms associated with menopause, osteoporosis, urinary incontinence, breast cancer, cardiovascular disease, cognitive decline, mood disorders, and weight management. (Depression and weight management in females of all ages have been a growing concern for Ob/Gyns generally.)
Ob/Gyns are also providing care for an increasing number of women with HIV/AIDS. In the United States alone, 27% of newly diagnosed HIV infections in 2000 occurred in women. Although ACOG has recently endorsed the use of assisted reproduction technology in HIV-infected patients,[2] a number of studies suggest that physicians are reluctant to do universal prenatal HIV screening. Yet, with advances in antiretroviral pharmacology enabling longer survival, Ob/Gyns are now seeing the perinatally infected daughters of women with HIV/AIDS live to grow old enough and be physically healthy enough to become sexually active and pregnant.
Obstetricians are also confronted with controversial consumer demands -- elective cesarean delivery, for example. That this is still a highly charged issue is highlighted by its center-stage focus at the past 2 annual ACOG meetings. As Dr. Cole writes in his coverage of the 2002 session, a discussion that was supposed to last 15 minutes "was extended to an hour because of the emotions expressed by the audience on this subject." In 2003, the topic was discussed in a more formal pro and con debate between 2 (as it happens male) specialists, a urogynecologist and a maternal-fetal medicine specialist (see also Medscape Medical News). In a sad twist on the issue -- just before the invasion of Iraq, maternity wards of hospitals such as Elwiyah Hospital were inundated with pregnant women -- some who were well short of what would be considered normally due -- demanding cesarean delivery of their babies before the outbreak of war.
As part an effort to better understand what Ob/Gyns might need from Medscape Ob/Gyn & Women's Health to help them provide the best possible healthcare for women, I thought it might be informative to consider the Ob/Gyn as a study subject. To that end, I combed our content and MEDLINE for studies published between 2001 and 2003 that highlight obstetricians and/or gynecologists and the fields obstetrics and gynecology. At first I just collected the abstracts, but before long I could organize them without too much artifice into fairly distinct topics and subtopics. You can view the components of this series at the following links:
The Practicing Ob/Gyn:
Seen as a whole, the abstract collection provides a picture of the world of obstetrics and gynecology. I would like to highlight just some of what I found. Perhaps the following note that I received from a reader earlier this year serves as an interesting starting point:
There is no doubt in my mind that if I had known that medicine, or in this case OBGYN, was going to end up the way it has, I would have never studied medicine, nor would I have chosen OBGYN as my specialty. After years of educational suffering, financial debt, and long and arduous hours of residency training and actual practice, I have advised many students to think of another career and forget about medicine...
How can anyone expect young people to choose medicine as a lifelong career if managed care is going to control the way medicine is practiced? Malpractice is sky high; doctors have to beg managed care organizations (HMOs) for what is their due; the hours are long and family life is nonexistent. No surprise that the number of well-qualified students are not applying to medical school.
Our reader's note brings up professional issues that seem to be felt and experienced by many physicians practicing obstetrics and/or gynecology, according to studies published in the past 2 years. A recent study of US physicians practicing in the late 1990s found that as a career, obstetrics and gynecology was significantly more dissatisfying than family medicine (OR, 1.6).[3] A study of incomes between 1987 and 1998 for generalists, general interns, general surgeons, pediatricians, and Ob/Gyns showed that only the Ob/Gyns experienced a net loss of annual income.[4] It should be noted that the study did not find that physicians were working longer hours than in previous years. The dissatisfaction is not unique to American physicians. A study of a group of family physicians in Canada revealed that 45% were planning to leave maternity care within 5 years.[5] Among the reasons cited were conflict between maternity care and personal life. Another Canadian study found that as a first choice for career, fewer medical students are choosing obstetrics and gynecology -- one of the fields of general surgery deemed in the study as a "poor lifestyle specialty."[6] Medical students in the United Kingdom are also rejecting obstetrics and gynecology as their first choice for a career for reasons relating to quality of life; 75% of the graduates of 1999 who rejected obstetrics and gynecology did so because they believed they would have poor career prospects.[7]
Balancing career and personal life is difficult for any medical professional, but medicine can be especially challenging for women physicians trying to raise families. It also seems that the days of gender discrimination with respect to salaries and promotions to leadership positions are not history. Yet, by 2010, it is estimated that 30% of US physicians will be women. Therefore, it will be important to look at studies of women physicians, which I will do in more depth for the July-August issue of the column. For now, I will focus briefly on women physicians, primarily Ob/Gyns. A recent comparison[8] of women physicians in Australia, Canada, the United Kingdom, and the United States showed that already:
Women now make up nearly half of all medical students in all 4 countries and 20% to 30% of all practicing physicians. Most are concentrated in primary care specialties and obstetrics/gynecology and are underrepresented in surgical training programs. Women physicians practice largely in urban settings and work 7 to 11 fewer hours per week than men do, for lower pay. Twenty percent to 50% of women primary care physicians are in part-time practice.
Further, consider this paragraph from a study on the effect of gender in obstetrics and gynecology[9]:
Data from the American Medical Association socioeconomic survey and from a survey of ACOG Fellows indicate that, as a group, female physicians in the specialty are approximately 85% as productive as male physicians in the specialty. ACOG data for physician net income validate the productivity calculations (P < .03). The increasing numbers of female physicians in the specialty will lead to a decreasing aggregate productivity. At the same time, the increasing numbers of women of all ages in the United States will lead to a decline in the available obstetrician-gynecologist work force beginning in the year 2010.
I think it is hard to gauge what an increase in percentage of practicing female Ob/Gyns portends. Perhaps a decreasing aggregate productivity, but also perhaps a more satisfied group of physicians and ultimately better overall healthcare for women. A recent study[10] of adult patients' encounters with primary care physicians (internists, family physicians, and obstetrician/gynecologists) showed that "female physicians were more likely to see female patients, had longer visit durations, and were more likely to perform female prevention procedures and make some follow-up arrangements and referrals." This research group also found that "male physicians devoted more time to technical practice behaviors and discussions of substance abuse" and further that "patients of female physicians were more satisfied than were those of male physicians, even after adjusting for patient characteristics, visit length, and physician practice style behaviors."[10] Other studies also reveal positive aspects of the female physician-patient relationship, but it should be noted that when it comes to obstetrics and gynecology, a number of studies suggest that women seem less concerned with a physician's gender and more concerned with his or her experience, interpersonal and communication style, and technical expertise.
Other issues warrant concern. A study published in 2001[11] showed that over the past 20 years, the number of physician-scientists has not kept pace with the overall growth of the medical research community. The decline in interest in research was attributed to both male and female students, but matriculating and graduating women were significantly less likely than men to indicate strong intent of pursuing a career in research. The conclusion of the study is powerful:
Three worrisome trends in the research career intentions and participation of the nation's medical students (a decade-long decline for both men and women, a large and persistent gender gap, and a negative effect of the medical school experience for women) presage a further decline in the physician-scientist pipeline unless they are reversed promptly and decisively.
Now a study published in May 2003[12] reveals that Ob/Gyns in the ACOG districts in the United States are submitting fewer papers to the Green Journal, and the authors urge us to "focus on conditions in medical schools." One study[13] has considered the effects of perceptions and mentorship on pursuing a career in academic medicine in obstetrics and gynecology:
First-year women residents were more inclined to pursue careers in academic medicine than were first-year men ( P = .042), but their interest declined during residency. Women residents (43%) --especially minorities -- felt that men were mentored and recruited more for faculty positions, while men (38%) felt that women were mentored and recruited more. Fellows' reports of recruitment did not differ by gender. Most white residents did not perceive racial or ethnic bias in mentoring or recruiting, while most non-white residents did. Almost one third of non-white women residents felt that supervisors were more likely to condescend to women and minority individuals.
Today's Ob/Gyns are not supposed to be just surgeons and specialists but "women's healthcare physicians," as branded in the ACOG logo. Yet, fewer than 50% of medical schools in the United States currently offer a women's health curriculum. And recent studies show that Ob/Gyns clearly need both principal training and continuing education in aspects of primary care specifically for women, notably management of depression and mood disorders. Studies highlighted in the abstract collection on continuing education needs of Ob/Gyns also suggest that Ob/Gyns require programs that address ethical and cultural issues that affect delivery of healthcare to women; programs that delve into aspects of human sexuality more boldly and how to address female sexual complaints; programs that focus on the symptoms of diseases that are specific to female sex and gender, and perhaps somewhat surprisingly, programs that encourage physicians to more aggressively and comprehensively screen for sexually transmitted infections, sexual abuse, and intimate partner violence.
The impetus for gathering this collection of abstracts was to try to learn more about the climate of Ob/Gyn practice today and what it might be like tomorrow. But I would like to hear from you.
What are the most pressing issues you face as an Ob/Gyn today?
What are your concerns about the future of your practice? Do you anticipate any profound changes?
What are the most satisfying aspects of your practice, and what are the most frustrating?
Are you seeing any particular trends in your practice?
Are you providing a service now that you might not have previously considered something in the realm of your practice?
Are you collaborating with other generalist physicians to provide complete general and reproductive/postreproductive healthcare for patients, or are you providing comprehensive women's healthcare in your practice?
What advice might you have for future Ob/Gyns?
What do you need in terms of continuing education, whether or not it is for CME credit?
What does Medscape Ob/Gyn & Women's Health provide that keeps you coming back? Where have we failed?
What do you think we might provide that we don't currently or sufficiently that would be truly useful to your practice?
And future Ob/Gyns, what insight might you offer for those in practice and what insight might you have for us?
Of course, not all of women's physicians are Ob/Gyns, and I would like to hear from any physician (eg, family practitioner, internist) or clinician (eg, nurse practitioner or certified nurse midwife) whose practice entails caring for female patients. Please consider sending me an email that addresses any/all of these questions. It would be useful but not necessary to include your gender, your specialty or subspecialty focus, where you practice, and how long you have been practicing. In addition, I would like to feature some of your notes in a future column. So if you would like to share your experiences and views with your colleagues, please indicate that in the email. If you would like to take part in an online discussion with colleagues about Ob/Gyn practice today, why not begin a discussion forum.
Please send email to womenshealtheditor@webmd.net. My goal is to have Medscape Ob/Gyn & Women's Health be as relevant and important as possible to those involved in women's healthcare. Your input is vital. I hope to hear from you soon.
Medscape Ob/Gyn. 2003;8(2) © 2003 Medscape
Cite this: May/June 2003: The Ob/Gyn as Study Subject - Medscape - Jul 02, 2003.
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