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OB/GYN Editorial november 2003
Moving Toward the Future
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Recently, there have been several editorials in the obstetrical
and gynecological literature concerning the future of academic
medicine and the specialty of obstetrics and gynecology (OB/GYN).
At this time, I have serious concerns about academic medicine as
do most individuals in the traditional medical centers. With decreasing
reimbursements and more reliance on generated clinical dollars,
many medical schools are having a difficult time maintaining faculty
and continuing their research missions. Unfortunately, this will
probably be rectified in a crisis in the next several years. That
is not the intent of this editorial, but to discuss where I see
the specialty going and some of the more positive things that I
have observed.
Many of the editorials have talked about the increasing number
of women—and all agree this has been a very positive impact—in
OB/GYN, and the lack of men (and their reluctance) to enter the
field. This seems to have been the case several years ago; however,
over the past couple of years, more and more men have inquired
about how OB/GYN would accept them into the specialty. Last year,
one of my colleagues attended an LCME meeting where a great deal
of discussion was initiated by the women participants about the
absence of males entering OB/GYN. Fortunately, within our own medical
school, we are seeing more and more men taking the perceived risk
of entering the specialty. They are drawn to what many practitioners
have found positive about OB/GYN, and that is the role of the physician
in childbirth and the focus on women’s health. To this end,
we have multiple excellent candidates coming through our program
who are looking beyond the obvious possibility of gender discrimination
and dedicating their lives to women’s health care. Fortunately,
I think this is a very important trend and that we, as a community,
will be the first to lead out of superficial gender wars and look
more toward the compassion and the abilities of the individual.
I have felt this way over many years; however, it is comforting
to me that the pendulum is swinging in the direction of a more
gender-neutral approach to our specialty.
I have been thinking a lot about where the future of our specialty
will be going. One of my colleagues (a non-OB/GYN) recently attended
a conference that was concerned primarily about the economics of
health care (ie, how to make more money and where the money is
going to be made in the health care arena). He rapidly told me
that the focus of the meeting was toward urogynecology and the
overall issue of urinary continence among the elderly. After reflecting
on this a fair amount of time, I think that there is probably a
certain amount of wisdom in his enthusiasm. Urogynecology is moving
forward with better and better diagnostics and with the creation
of fellowships, the importance of the American Urogynecologic Society,
and an interest in these problems. As new surgical procedures are
being added daily that are less invasive and have a high degree
of success, there is a higher satisfaction for our patients. Many
of these procedures can be performed on an outpatient basis, which
limits the amount of anesthesia and medical complications that
are inherent. Unfortunately, like most technical skills, there
is a learning curve, and there are many problems attaining the
necessary knowledge and skills to perform these procedures on a
regular basis.
The one area that I see the greatest growth in is going to be diagnostic
imaging. I have informed many of my radiological colleagues in
the past that the reason OB/GYN got into imaging is because nobody
was there to help us. With time, women’s imaging is rapidly
becoming a subspecialty area of interest among radiologists, who
have discovered that a different skill set is helpful. With better
and better resolution, and a better understanding of the physiology
of the female reproductive tract, imaging is becoming more and
more important for the diagnosis, prognosis, and planning of care.
With the new generation of digital mammography comes the possibility
of computer-generated neural networks to enhance diagnostic outcomes,
which allows improved, less invasive, and better yielding biopsies.
This, coupled with the sterotactic biopsy techniques already available
as well as dedicated breast centers, make access easier, allowing
for “one-stop shopping” for patients. Hopefully, in
my lifetime, the ability to predict breast cancer at earlier stages
and to diagnose it and initiate therapy will help decrease this
scourge on women.
Invasive radiology is more and more invading the area of general
gynecology, especially with the elimination of fibroids through
embolization. As these procedures become sophisticated, the necessity
of surgery will probably lessen. Also, as more biological and pharmacological
agents are introduced that will regulate the growth of these tumors,
the necessity of gynecological surgery will decrease.
The genetics of various cancers is slowly but surely starting
to be elucidated. Newer tests including DNA screening of stools
and newer diagnostic techniques are in the future. The problem
with privacy, HIPPA, and insurance is something that will need
to be further defined, probably by legislation. I do not think
that the insurance companies will happily go along with individuals
who may be “high risks” despite never developing the “target” disease
state. This probably will have to be forced from above as an individual
rights issue rather than as an economic decision.
Overall, I think the specialty of OB/GYN will be changing in the
next 5 to 10 years and fulfill the prophecy related to me 20 years
ago that gynecology will become a medical specialty. Obstetrics
has certainly gone the other direction!!! I don’t necessarily
disagree with that, but think practitioners will have to be aware
that the surgical approach to all diseases in gynecology is slowly
coming to an end.
Thomas E. Nolan, MD, MBA
Editor-in-Chief
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