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The changing tides in obstetrics and gynecology

2001; Elsevier BV; Volume: 184; Issue: 5 Linguagem: Inglês

10.1067/mob.2001.113850

1097-6868

Paul B. Underwood,

Health and Medical Research Impacts

During the 41 years that I have been associated with academic obstetrics and gynecology, I have observed, participated in, and lived through many changes in our discipline. Today, I plan to reflect on my interpretation of these cyclic changes in 10-year intervals and close with challenges for the upcoming 10 years. I chose the title “Changing Tides in Obstetrics and Gynecology” because I live on tidal water and watch 4½ to 7 feet of water come in and go out behind my home twice each day. Tidal changes are the result of a gravitational pull primarily by the moon, which is 360 times closer to Earth than the sun. The angle between the moon and Earth affects the height and fall of each tide and every 27.3 days the moon and sun revolve around a common point, which results in unusually high and low tides. In addition, northeastern storms, and especially hurricanes, have profound effects on tides. As I reflect over my own career, I recall daily ups and downs, cyclic changes, and, yes, several storms and even a few hurricanes. I only wish I understood what external force produced these changes in our specialty as well as we understand changes in tides. When I entered the Medical University of South Carolina in 1955, tuition was $400, we were told the bottom 10% of the class would fail out, and it did. Students sat in alphabetic order in numbered seats. If you could walk, you attended class, because if that seat was vacant, the professor asked that seat a question and took notes when no one answered. During the third and fourth years of medical school, you were expected to know everything about your patients and their disease processes. Everyone knew the professor was in charge and students dared not be unprepared. If you did not meet these standards, you were verbally abused and frequently asked to leave rounds or conference. Students also drew all blood samples, started all intravenous infusions, and actually performed the routine laboratory analyses themselves. In the year 2000, can you even in your wildest imagination predict the outcome of a professor or department who returned to these teaching methods? The tides have changed. Upon graduation, everyone was required to serve a 1-year internship after which you could either enter private practice or choose a specialty. There was no “matching program.” I chose to enter an obstetrics and gynecology residency at the Medical University of South Carolina, where I had been told I had a position; I did not apply anywhere else. When I entered the training program, it was for 3 years, but it almost immediately increased to 4 years. The bright spot in that increase was that I had in-house call every third night rather than every other night. Today, the residency review committee mandates that a resident can only work every third night and must have 1 day in 7 totally off. The tides have changed. My salary was $197 per month. My wife taught English in a local high school for another $200. We lived in a very nice apartment at $72 per month, including utilities, and shrimp cost only 39 cents per pound. The tides have changed. The chief resident was in charge of all residents and no junior resident ever crossed him. You went where you were told and carried out your assignment well because the word harassment was not in the English vocabulary. The department consisted of two full-time faculty members and multiple clinical faculty who were obstetricians and gynecologists in private practice. There was no town-gown problem because the in-town physicians were very much involved in all department activities. All resident-performed procedures required verbal approval and outcomes were closely monitored but there was no direct supervision of midforceps delivery, cesarean sections, or gynecologic surgery. One could always call for help when in trouble. Despite this resident freedom, the chief resident knew the phrase “fear of God” well at preoperative and morbidity and mortality conferences. The clinical services were limited to obstetrics, gynecology, and cancer. The full-time faculty were self-trained specialists, but everyone was a generalist by today’s criteria. We had 4 antibiotics available—sulfa, penicillin, streptomycin, and chloramphenicol. There was no intensive care unit or neonatal intensive care unit. Most of the bedside care, especially at night, was delivered by student nurses. Can you believe that we practiced obstetrics and gynecology without a laparoscope, ultrasound, computed tomography scan, or magnetic resonance imaging and that we used a rabbit for pregnancy tests? The breadth of our specialty was narrow and a resident could be well trained in all areas of our discipline. The tides have changed. Hospital administration consisted of only a chief financial officer and one financial officer. Hospital costs were low and state support was high. Malpractice was $200 per year. Money was not an issue! The tides have changed. Then came the 1970s, which I label the beginning of the switch of power. The subspecialists entered our discipline. Full-time faculty began to increase in academic departments and technology exploded. A power shift began. The chief resident lost power and the fellow entered the picture. The subspecialists, although still serving the role as a generalist in the department, began to become involved in their areas of expertise. The role of the clinical faculty, so valuable in the 1960s, began to fade. Supervision of patient care and clinical activities by faculty grew rapidly. Physicians were paid fee for service, hospitals were paid cost of care by Medicare, and malpractice was less than $500. Both department and hospital were financially fat. A northeastern storm tide. The 1980s became the explosive growth period for academic obstetrics and gynecology. The number of residency training programs decreased; however, the number of residents per established program grew rapidly. The full-time faculty in academic departments, especially subspecialists, mushroomed. Prior to the 1980s, women in obstetrics and gynecology were almost rare and women medical students represented fewer than 10% of classes. Changing lifestyles in families rapidly brought women into the workplace. Medicine became a popular profession for career women; however, initially these women were primarily attracted to pediatrics and anesthesia. In the late 1980s, rather suddenly, women became interested in their own health care with obstetrics and gynecology becoming the popular residency for women. The number of male applicants remained constant but, with the massive influx of highly qualified women, the specialty became extremely competitive, with some programs receiving more than 500 applications for 5 or 6 positions. The quality of our house officers skyrocketed. Almost all faculty were full-time equivalents and clinical faculty were being replaced by the subspecialists. These young subspecialists in general were workaholics, upgrading resident teaching and clinical care and generating large revenues for the department. Although faculty salaries had markedly increased, subspecialists began demanding larger salaries and many left academic medicine for private practice. Even though malpractice costs increased from less than $500 per year to more than $50,000 per year over a 3- to 4-year period, departments and hospitals were financially doing extremely well. Fee for service was still in vogue and, therefore, departmental revenues markedly increased and reserve accounts became sizable. The quality and supervision of health care delivered were superb and technology was finding its place. It was truly the greatest decade for our discipline. A hurricane surge tide. I have labeled the 1990s as the financial downfall of the departments; this was probably predictable because simultaneous informational, technical, and financial explosions frequently produce chaos. Despite this, two enormous assets occurred—the influence of women on our specialty and the enormous growth in breadth of obstetrics and gynecology. I will first discuss these positives. Women became interested in obstetrics and gynecology in the 1980s but their impact for change occurred in the 1990s. Women entering medicine were highly intellectual achievers who had the desire for self-esteem. They had to be because their role in daily life was much tougher. Women had to balance and integrate a professional career with a marriage and with the joy and frustrations of raising children. The obvious question under these lifestyles was, Why did we have the traditional boot camp mentality of working very long hours and frequent nights? The answers were obvious and changes occurred that resulted in a more livable quality of life for residents. A very high tide. Our consumer—the patient—and the marketplace were seeking women obstetricians and gynecologists possibly because of the fact that they had more insight and experience in menstrual cramps, premenstrual syndrome, mood swings, pregnancy, labor, and sexual discord, which provided easier communication and understanding of the patients’ problems. Seventy-two percent of the 1999 first-year residents in obstetrics and gynecology were women. The accomplishments and academic productivity of these women have been unbelievable. I have been known to say, “We need to lower our standards to recruit a male resident.” Women have markedly upgraded the image of our specialty and appear to have influenced male obstetricians and gynecologists to dedicate more of themselves to their own families and outside interests. I congratulate our women colleagues for their many accomplishments. During the 1990s, the breadth of our specialty exploded. The definition of primary care expanded to the entire woman. Gynecologic oncologists became accepted for their surgical skills and techniques. The ability to genetically evaluate an intrauterine fetus expanded beyond belief. Reproductive enhancement became routine despite its precision techniques. Diagnostic laparoscopy expanded to operative laparoscopy. The understanding of the physiologic changes that occur in the critically ill patient and the ability to reverse these changes became a requirement for obstetricians with severely ill pregnant women and for oncologists with radical surgery and chemotherapy patients. The obstetrician essentially cannot practice obstetrics without obstetric ultrasound skills. The techniques of urodynamic testing and cystoscopy, as well as the understanding of the treatment of urinary incontinence, also expanded the scope of resident training. Finally, midlife health enters the picture. A woman’s life expectancy in the United States is 78.6 years; therefore over one third of her life is spent in the postmenopausal years. This represents 45 million to 50 million women in the United States alone, and this number is growing yearly. These women are extremely active; in fact, they are the backbone of our society. They are demanding top-of-the-line health care, especially preventive care. This new specialty falls squarely on our shoulders. We must train our house officers to meet these demands or some other specialty will; others have actually already begun to do so—a tide that must be recognized. We must overcome the destructive financial impact that the 1990s had on all physicians and especially on academic departments. Medicaid increased its payment for obstetric care and delivery. Pregnant Medicaid patients suddenly left the academic clinic and sought physicians in private practice; this resulted in a 30% to 40% decrease in the number of deliveries in most teaching hospitals. This has caused an enormous loss of revenue. I am sad to admit that we in academic departments brought this on ourselves by taking these women for granted and not offering personalized care earlier. Recognizing our mistakes and inadequacies, most academic departments have now instituted continuity clinics, provided attendings in ambulatory clinics and delivery rooms, and improved personal attention; this has resulted in a partial recovery of these losses. At the same time, managed health care entered the picture. We provided poor leadership for the spiraling health costs that opened the door for industry and business to demand cost controls. Physicians were poorly trained in business principles and were pushovers to businessmen who used phrases such as, “You will lose patients to other physicians,” as fear techniques to lower reimbursement. Unfortunately, today’s physicians have signed contracts for reimbursements that are below our cost. Then came Medicare and its revised rules and regulations. Until now, physicians could obtain a pertinent history, examine the involved areas, make a diagnosis, treat the patient, and charge or not charge our fee for that service. We could even vary our charges when we knew of financial hardships. These guidelines for charges were frequently subjective but they worked. Today, big government has entered the picture. We must count the number of systems reviewed, the number of organs examined, and place a number on how difficult it was to reach our decision of management to arrive at a code number. To further insult our independence and freedom of expression, we must charge everyone a fee that corresponds to this code number regardless of their financial ability or hardship. What has happened to common sense? Is common sense dead or is government too big? We must again live by conviction and not by numbers. We must have rules, regulations, and laws to live under; however, should these laws be so precise and specific? Many say that uniformity ensures fairness; however, requirements that leave no room for common sense are never fair. Does anyone believe we have slipped into a system of health care where patients and physicians are beginning to accept the new era like a person on a mind-numbing drug who no longer realizes what is missing? I for one do not believe this. A dangerous tide. The horrible 1990s are behind us. What awaits us in the 2000s? Today, almost every academic department of obstetrics and gynecology in the United States is financially in the red or has radically cut costs, including faculty salaries, to keep barely afloat. Basic research and teaching are not money producers; therefore, with dicta in academic centers that each faculty member’s salary must be based on monies that he or she brings into the department, a natural self-protective trend among faculty is to do more clinical medicine and less bench research and teaching. Some chairs have chosen to hire highly dedicated money earners to support the researchers and teachers. The obvious problem with this plan is that the money earners rapidly become hostile over supporting other faculty who in their eyes are not working as hard and demand salary increases by threatening to leave. They frequently open practices in the local area, taking a large volume of patients and referral patterns with them; this results in another financial slap in the face. An alternate and more acceptable method is to use core institutional or state monies, which in the past have been distributed on the basis of rank and longevity, to be paid on the basis of amount of teaching and research delivered. A productive tide change. How was it possible for academic departments that were financially healthy 10 years ago to find themselves in financial terms as “intensive care unit patients” today? We must blame our academic centers, our leaders, and even ourselves. We failed to respond to the spiraling health care costs. Business saw an open door and entered. Out of fear we have swallowed their threats hook, line, and sinker. Our leaders were weak and gullible and supported their threats. Physicians panicked and signed contracts under which we cannot survive. Mark Twain said it well, “You cannot depend on your eyes when your imagination is out of focus.” It is time for the tides to wash away managed health care organizations. When a physician works very hard all day in the office to provide health care to a larger volume of patients with less personnel assistance but with more documentation and forms to complete, yet still cannot earn enough money to meet office expenses, there is a problem. Patients have become unhappy because they receive less time with their physician and less tender loving care from personnel. Physicians are unhappy because they cannot make a living even though they are working harder. As a result, the personal touch is gone. Today, the physician-patient relationship is in shambles. Being lean can lead to being mean. An eroding tide. Who is happy? The business world. Approximately $1.3 trillion is spent by the health care industry or $4000 per person in the United States per year. This is an ample supply of money but approximately one half is removed by entrepreneurs and other medically related industries and never reaches direct health care delivery. Medicine has permitted the business world to dictate to the physicians whom they can treat, which doctor is authorized to treat, when and where the treatment might take place, and if treatment is even permitted. All this for the business world’s personal financial gain at the expense of the patient and the physician. We have been puppets in their hands. This middle man health care sponge must be eliminated. Physicians must strive for quality health care and patients must demand it. We as physicians must reestablish trust in the physician-patient relationship and we must deliver the highest quality of care. The common sense answer is to calculate the precise costs of health care delivery to patients at various visit levels, add a 10% to 15% profit margin, and refuse to sign any contract below that margin. That is precisely what business does routinely. Without question, in today’s managed health care environment, companies would drop you and patient volume would temporarily fall. However, I believe that if you truly provide an “ideal patient encounter,” patients will demand you and thus force companies to renegotiate on your terms. We must be reminded that managed health care companies must contract physicians to provide their product—health care. Maybe I am naive, but I believe that in the future the quality of care and close patient-physician relationships will win over cheap, “wham-bam-thank-you-ma’am” care. We must not act in fear but with conviction. Leonardo da Vinci said, “Obstacles cannot crush me. Every obstacle yields to stern resolve.” This tide must change. Although finances are the number one issue in most academic departments, our specialty has other crises to solve, such as providing surgical training of our residents, providing primary care training, tracking pathways in resident education, and determining how academic centers will survive in the future. Surgical training of obstetrics and gynecology residents has always been number one on my list of resident education requirements. We are the only surgical subspecialty that does not require extra training in general surgery. Many general gynecologists are as good a surgeon as any general surgeon; however, in most community hospitals the weakest surgeon is the gynecologist. Many gynecologists consult a general surgeon to free pelvic adhesions so that they can do a hysterectomy or they consult a urologist to dissect out a ureter stuck to an ovarian cyst or a broad ligament fibroid. If an obstetrician-gynecologist is to perform pelvic surgery, it is obvious that he or she must be adequately trained to do so and should not have to call for help for basic fundamental surgical encounters. One of the most difficult gynecologic surgical challenges in our specialty is total pelvic reconstruction (total uterine or vaginal prolapse). In my opinion, the best surgically trained physician in our discipline is the oncologist. Why isn’t the best-trained surgeon in gynecology the primary surgeon for the most difficult procedure? The answer is simple. Our fellowship programs will not permit the gynecologic oncologist to train in pelvic reconstructive surgery. It would appear to me that such training would contribute far more to our specialty than the 1-year basic research requirement that is rarely used later. This tide needs studying. My second problem for the 2000s is the 5-month period out of a 48-month residency that is allotted to primary care medicine. I must be honest that when this issue first arose I supported it 100%, but in retrospect I feel that it was a mistake. James Baldwin said, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” I believe that we have faced it and that it’s time to change it. In my opinion, it is no different for us to claim that we are trained in primary care medicine than for the family medicine physician to claim to be trained in obstetrics. Those 5 months could certainly be used to improve surgical training. I believe we need a tide change. The third issue we must solve in this decade is tracking in resident education. The breadth of our specialty has grown beyond what anyone could imagine in the last 40 years. When I was a resident, I believe my brain had the capacity to absorb the knowledge available in obstetrics and gynecology. Today, I don’t think anyone has the brain capacity to learn enough to truly qualify as a consultant in all the breadth of our specialty. If I am correct in this assumption, then we as educators must choose pathways or tracks so that individual residents can become specialty consultants and receive only basic training in other areas. In my opinion, training individual residents in the pathway of their interest should provide superior obstetricians, gynecologists, office practitioners, sonographers, and endoscopy surgeons; furthermore, if residents plan to enter one of the subspecialties, such training should allow them to do so earlier. Each of us who participates in the education of residents would agree that at the end of the first year you recognize their strengths and their weaknesses. These strengths could be cultivated and fertilized during the second year so that they could begin a tracking course during the third year. Entering a subspecialty a year earlier would permit the oncologist fellow time on surgical subspecialties, the maternal-fetal medicine fellow time on general medicine, the endocrine fellow time on either medical endocrinology or endoscopy surgery, or both, and the urogynecologist time on urology and general surgery. These would all be giant steps forward for the subspecialist. We must train super bench researchers and super clinicians for our specialty to excel. Our experience demonstrates that 2 years of clinical training and 1 year in the laboratory have failed to reach this goal. The tide must change! Training programs should concentrate on excelling in either clinical training or research. Replacing that 1 year of laboratory training with multidepartmental clinical exposure could produce that “superclinician.” The now-available 3- to 5-year research training programs could similarly produce that “superresearcher.” It is time for our subspecialty programs to reevaluate the potential for these tidal changes. My last challenge is to salvage academic medicine. It is unbelievable that one of the United States’ strongest enterprises—one that through medical education and research over the past century has contributed so much toward curing diseases, decreasing suffering, and expanding human life—is in jeopardy. It is true that the cost of medical care rose too fast in the 1980s, but also consider the billions and probably trillions of dollars that were saved, along with the corresponding improvement in quality of life, because of the following: the development of vaccines that prevented polio, smallpox, and even influenza; the development of antibiotics that cured infectious diseases, improved maternal and infant care, and improved surgical techniques; and the recent discoveries in the human genome—discoveries that have unlimited possibilities. Regardless of these benefits to society, academic institutions and leaders have permitted business to step in and dictate health care policy. The goal of business in a capitalist society is very different from the goal of health care. In medicine, we educate future leaders and encourage them to go to other institutions as leaders. We perform research and immediately distribute our discoveries worldwide. Such actions would be suicide for any business. Business sells health care in a marketplace that has no interest in paying for teaching and research. A very low tide. The fatal blow to the academic medical centers came from the federal government when, in an attempt to balance its own budget, it passed the Balanced Budget Act of 1997. This reduced billions of dollars available to hospitals over a 6-year period. To enhance the problem, the number of unfunded indigent patients is growing rapidly; the number is currently approaching 50 million. Approximately half of these patients receive their medical care in academic centers and this number is rising yearly, which places additional financial burdens on the academic centers. As a result, we are returning to the old two-class medical care system. We believe in unequal wealth—should we also believe in unequal health care? What is the solution? First, we must remove business organizations from their present status as dictators for the delivery of health care. Today, physicians can prescribe narcotics and make life-saving diagnoses, but we must request that an insurance clerk grant or deny us approval to carry out our designed treatment. Can you believe that we, as highly intelligent, obsessive-compulsive physicians, have let this happen? I believe that society realizes that the goals of business and the goals of health care delivery are different and that it is beginning to demand the necessary reversal. Second, we must convince our policy makers and politicians that academic medical centers are truly in jeopardy and that we are not just “crying wolf.” Evidence is plentiful because the majority of academic medical center budgets are in the red despite massive layoffs, downsizing, and even mergers. Once they are convinced of our perils and recognize the long-term social and humanitarian benefits that we provide this country through teaching, training health care providers, and advancements from research, they must alter the Balanced Budget Act and establish means for direct funding to academic centers to ensure their viability. In my opinion, the most difficult problem to solve in our national health care system is covering the cost of health care for the medically indigent. Having recently watched the Republican and Democratic conventions, I have heard both presidential candidates promise to solve this problem. I do not know the answer but recognize that limited and two-tier health care systems are bad choices that are on the horizon. I believe we are ready for a new beginning. The future is in our hands. We can let it control us or we can control it with change. This country cannot let one of its greatest enterprises, one that is envied around the world, fail. As Thomas Paine said, “These are the times that try men’s souls.” Just as tides are cyclic, I believe that medicine will reestablish its art and regain the trust of the patient. I look forward with pride to being a part of its recovery.