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OBSTETRICS AND GYNECOLOGY
ONE WOMAN—TWO SPECIALTIES
Prior to 1930, these two areas of medicine were separate and unequal. Obstetrics was considered a subspecialty of internal medicine and surgery departments claimed authority over gynecology. At that time, however, obstetricians were thriving on new developments in reproductive physiology and endocrinology, and many gynecology patients did not require surgery for their diagnoses (like sexually transmitted diseases). For this reason, the newly formed joint specialty of obstetrics and gynecology was born.
After completing their clerkship, medical students often comment how participating in their first hysterectomy, and then quickly running to assist in the miracle of childbirth, feels like an exhilarating adrenaline rush. The mind of every obstetrician is organized into three time frames: prenatal, intrapartum, and postpartum. The management of pregnancy, labor, and puerperium (the time period directly following childbirth) all fall within the realm of obstetrics. Obstetricians have the privilege of taking care of not one, but two patients—the mother and fetus. But the diagnosis of pregnancy is sometimes not as simple as a urine or blood test. Obstetricians must monitor the physiologic changes of the mother and her fetus during each stage of pregnancy. With an understanding of the symbiosis of pregnancy, they can better manage and determine its viability.
✓ Likes working with his or her hands.
✓ Can deal with tense situations involving sensitive subject matter.
✓ Likes to see immediate results from his or her efforts.
✓ Has the ability to make fast, confident decisions.
✓ Enjoys taking care of and advocating for women.
Although the outpatient component of obstetrics may seem like excessive watching and waiting, the transition from monitoring to action can occur faster than you might imagine. If the pregnancy is not viable, the physician must provide immediate medical or surgical care. In times of urgent crises, such as a preterm patient with uncontrolled hypertension or multiple gestations, obstetricians must react quickly and decisively. Because there are many ways in which a pregnancy can become complicated, each patient could possibly present a new challenge.
Gynecology focuses on the overall health of the female and her reproductive organ systems, and in particular, the diagnosis and treatment of female-specific diseases. Ambulatory gynecology incorporates ultrasound and colposcopy (a visual method to detect abnormal cervical cell); surgical gynecology involves pelvic surgery by either the vaginal or abdominal route. Gynecologists do more than just conduct Pap smears, prescribe oral contraceptives, perform hysterectomies, and dilatation and curettages (D&C). They also treat sexually transmitted diseases, manage pain disorders, urinary and sexual dysfunction, infertility, menopausal symptoms, and discuss psychosocial issues, such as domestic violence. Remember—women look to their gynecologists for assurance, guidance, and understanding of how to care for their bodies. These physicians assume great responsibility in helping women of all ages find pride in themselves and their bodies.
Obstetrics–gynecology is a hands-on specialty full of many surprises. There is never a dull moment. You must be able to keep your cool while dealing with many varied situations simultaneously. To excel in this specialty, medical students will touch many gravid abdomens, perform unlimited vaginal examinations, and get their hands dirty (after all, any type of bodily fluid is game). During the third stage of labor, obstetricians may find themselves covered in blood, vomit, urine, and even fecal matter. Like their colleagues in emergency medicine, OBGYNs are ready for anything when it comes to women’s health. Whether the case involves an infant failing to deliver head first, a placenta separating from the uterus, or woman hemorrhaging from uterine tumors or cervical cancer, OBGYNs have to think fast and react quickly and competently in life-threatening situations.
Many medical students enter obstetrics–gynecology because they are attracted by its integration of both surgery and medicine within the context of women’s health. For example, a serious antepartum obstetric complication, such as gestational diabetes or preeclampsia, requires careful thought for its diagnosis and management. In other situations, such as nonreassuring fetal heart tones or complete placenta previa, surgical methods are necessary to bring both the patient and the fetus to a successful outcome. Although OBGYNs perform many specialized procedures, such as hysterectomies, pelvic reconstructions, and exploratory laparotomies, the hands-on aspect of the specialty is not necessarily confined to the operating room.
Several aspects of primary care and emergency medicine are also very important in this specialty. Despite subspecialty development, the vast majority of physicians who train in this field consider themselves generalists, meaning that they assume the role of obstetrician, gynecologist, primary care doctor for women, or all three. “In this specialty, you can really do a lot for your patients,” remarked one gynecologist in private practice. In a single day, you may be delivering a baby, treating a sexually transmitted disease with an antibiotic, evaluating unusual vaginal bleeding in the emergency room, or counseling a woman on the psychological effects of menopause. However, the most difficult situations may be the mental anguish of telling a woman that she has ovarian cancer or a mother that there is no cardiac motion at her 32-week prenatal care visit. Thankfully, more than 90% of the cases are success stories. In all cases, the OBGYN listens to the patient and empathizes with health issues that are unique to women.
IS IT PRIMARY OR SPECIALTY CARE?
Obstetrics–gynecology is unique in being highly specialized—in the medical and surgical treatment of female health problems—while still categorized as primary care. The majority of reproductive-age women in this country consider their OBGYN as their primary care provider. In a recent survey of obstetrics–gynecology residents, 87% believed that obstetrics–gynecology was primary care, while 85% intended to establish a balanced practice drawing on all of the skills they learned in residency,1 with special focus on health maintenance, screening, and disease prevention.
The first encounter with an OBGYN can mean the difference between a lifetime patient and an unsatisfied client. As a primary care physician, you use compassion, understanding, and patience to forge close interpersonal relationships. For example, during pregnancy, obstetricians promote a healthy lifestyle and continuously remind the mother of the best ways to care for both herself and her unborn child. They provide screening services related to blood-pressure assessment, Papanicolaou smear, breast examination and review of the breast self-examination, and referral for mammography or other specialized services. They spend time discussing work-related health risks, smoking, seat-belt use, safe sex and sexually transmitted disease prevention, and genetic screening for family planning.
Continuity of care is extremely important in obstetrics–gynecology. Following delivery, the obstetrician holds a responsibility to the mother for at least 6 weeks. The physician must continue to evaluate not only her anatomy, but also her psychological well-being. Most patients of gynecologists are either initially transferred from their obstetric clinic or referred from nurse practitioners or internists. They usually remain with their gynecologist throughout the course of their lives. Thus, patient relationships may be as short as one delivery or continue through the lifetime of several generations.
OBSTETRICS–GYNECOLOGY IN THE OPERATING ROOM
The art and science of surgery forms the core of this specialty. Without it, obstetrics and gynecology would probably remain under the jurisdiction of internal medicine. Because of the thrilling rush of the operating-room experience, some OBGYNs like the surgical aspect of their specialty the best. Caesarean delivery has become the most common hospital-based operative procedure in the United States and now accounts for about 23.5% of all live births, and with the advent of primary cesarean by request, the numbers increased but now there is a movement to encourage more safe vaginal deliveries.2 Gynecologists also use their surgical skills to carry out many types of operations, such as an exploratory laparotomy for a ruptured ectopic, hysterectomy, and pelvic reconstructive surgery. One academic physician stated, “in most cases, my surgical efforts cure problems, usually with good outcomes.” She reiterates that many students are attracted to this specialty because of the immediate ability to fix problems using surgery.
Medical students should disregard condescending comments made by other surgical subspecialists. The manual dexterity required for obstetric or gynecologic surgery may not approach that of, for example, neurosurgery or otolaryngology. However, the notion that gynecologists are not true surgeons is a myth. Despite the reduction in operating-room time due to new primary care educational requirements, graduating residents in this specialty are still well-trained, competent surgeons of the abdomen and pelvis whether by vaginal, laparoscopic, or an open technique. And if you desire further training in any field, OBGYNs can take the initiative of completing a 1- to 3-year fellowship in pelvic surgery.
LIFESTYLE CONSIDERATIONS AND PRACTICE OPTIONS
A medical student who had completed his required clerkship in obstetrics–gynecology commented that the attending physicians “seem like very energetic and outgoing people.” Self-confidence and a positive personality are necessary to deal with the stressful events and tense situations you face daily. There is little room for indecisiveness, meekness, or timidity within this specialty. Because gynecologic surgeries start quite early in the morning and deliveries or ruptured ectopic pregnancies can occur during the middle of the night, you must be able to function at all times of day or night. Even when tired or agitated, obstetrics–gynecology physicians have to be sensitive to the emotional and psychosocial needs of their patients. Your common sense and experience are calming and reassuring for an expectant mother about to deliver her first child, a preoperative gynecologic patient, and a woman struggling with the loss of a pregnancy.
The OBGYN’s typical day often consists of a mix of surgery, hospital rounds, clinic, and administrative duties. Due to the erratic lifestyle, many medical students strike this specialty from their list of choices. Every practicing OBGYN experiences long hours and irregular schedules. Whether at the office or while enjoying the evening at home, your plans may be altered by obstetrical patients in labor. However, there is some variability depending on your choice of practice. In private practice, the hours of patient care depend on the number of group members, location, and patient load. After finishing residency, some doctors choose to practice only gynecology. After all, the delivery of uncomplicated pregnancies also falls under the domain of family practitioners and nurse midwives. In the academic setting, OBGYNs who are full-time faculty members spend less time in surgery and in clinic. More time is devoted to teaching and mentoring residents, conducting research, and administrative tasks.
Gynecology |
$261,285 |
Obstetrics |
$311,853 |
Obstetrics–gynecology |
$333,231 |
Reproductive endocrinology and infertility |
$384,659 |
Gynecologic oncology |
$481,823 |
Source: American Medical Group Association.
The introduction of the hospitalist, which allows OBGYNs to work 12- to 24-hour shifts, has brought both an element of job satisfaction and contentment due to improved work–life balance. It is estimated that 40% to 75% of OBGYNs experience some form of professional burnout (e.g., losing control, conflicting demands on time, or diminishing sense of worth). Although work–life balance can be difficult to maintain most OBGYNs are extremely fulfilled by their careers. Their high level of career satisfaction and desire to practice is comparable to that of other women physicians, particularly those in surgery.3 If given the opportunity, the majority would not change their career decision. To honor maternity/paternity leave and family obligations, most hospitals and group practices create contracts with defined schedules including part-time hours, minimal on-call nights, and less operating time. Despite such flexibility, a recent study found that female OBGYNs, compared to other women physicians, worked significantly more clinical hours and call nights; they slept even less when on call.4 Consequently, domestic responsibilities, such as cooking and housework, and quality time with their children are greatly minimized.4 According to a recent survey, nearly 67% of both male and female OBGYNs were unhappy with their sex lives, making them the least satisfied among all specialists surveyed.5 However, the trend of “work first” is changing, and more physicians are taking time to be with their families.
DIVERSITY IN THE WORKPLACE
The number of ACOG Fellows in practice in 2017 was 35,586, including 31,163 Fellows and 4235 Junior Fellows in active practice.
More and more female physicians are becoming OBGYNs. According to the American Medical Association, the percentage of women in this specialty increased from just 7.2% in 1970 to 26.9% in 1994.6 In current training programs, nearly 82% of the residents who match are women.7 By 2010, many predicted that the number of female physicians would far exceed that of men practicing obstetrics–gynecology.8 However, as of 2017, 58% of practicing OBGYNs are female. The gender factor continues to greatly influence its scope of practice and research.
In 2016, OBGYNs were reported in to have the highest proportion of underrepresented minorities (18.4% in 2014, combined), especially African Americans (11.1%) and Hispanics (6.7%). Underrepresented minority OBGYNs are more likely than white or Asian OBGYNs to practice in federally funded underserved areas or in areas where poverty levels are high. American Indians, Alaska Natives, and Pacific Islanders comprise the OBGYN group with the highest proportion practicing in rural areas.
Gender mix in obstetrics–gynecology has undergone a significant role reversal. Not only do male OBGYNs feel at times that they are losing ground, but some recruiters from private practice groups have begun discriminating against male physicians. Assuming that women prefer a female OBGYN, these practices aggressively seek female residents. They want to balance their male-dominated staff with female OBGYNs, creating a dramatically changed workforce. As a result, many qualified male doctors struggle to secure their preferred career. In fact, one study found that 26% of graduating male residents reported difficulty in finding a job, compared to 17% of female residents.9
Should these facts discourage male medical students from considering a career in obstetrics and gynecology? Certainly not—men still have the ability to do well in this field. The idea that female patients feel more comfortable with a female OBGYN is somewhat misleading. In a survey of obstetric patients during their postpartum hospital stay, the majority (58%) had no preference for the gender of their obstetrician; 34% preferred female physicians and 7% indicated a desire for a male doctor.10 Rather than specifying gender, the attributes most satisfied patients said they wanted in an OBGYN were excellent interpersonal skills, an empathic communication style, the ability to make a connection, and a high level of technical expertise. Men who cultivate traditionally female skills, particularly empathy and good communication, can thrive as OBGYNs.
DEALING WITH MALPRACTICE CONCERNS
When asked about any negative aspects of their specialty, most OBGYNs were quick to cite the critical and increasingly costly issue of medical malpractice. The current medicolegal climate of our society, with its get-rich quick incentives, makes obstetrics–gynecology a high-risk specialty. In fact, most medical students considering this specialty are especially concerned about the daily potential litigation. Many things can go wrong during the delivery of an infant. Because manifestations of incidents, such as neonatal brain damage, may not appear until the child is much older, the threat of liability is always present (until the patient reaches 18 years of age). In light of this ever-present malpractice concerns, OBGYNs must be passionate about their careers and committed to outstanding safe patient care. In many instances, the threat of litigation encourages the development and training of better physicians.
If you look at all the statistics and numbers, OBGYNs have the highest incidence of lawsuits throughout their careers. Since the 1950s, the number of malpractice claims filed against OBGYNs has increased nearly 15% every year.11 Approximately two-thirds of these physicians have been sued for alleged medical malpractice; they now have one of the highest (and continuing to skyrocket) malpractice insurance premiums in the nation.11 Some insurance companies are not only raising premiums, but are also refusing to provide liability coverage. In spite of all the negative statistics, there are still glimpses of hope. More than half of all claims were dismissed, settled without payment, or won by the physician.11
The rising malpractice claims are severely jeopardizing access to high-quality, affordable health care for women and their newborns. Due to unaffordable liability insurance premiums (or even the inability to obtain insurance) many physicians have curtailed their services. Physicians are forced to reduce the number of deliveries they perform, cut back on high-risk patients, and even stop some surgical services. This loss of access to prenatal and delivery care particularly affects women in rural and inner-city communities, which are typically underserved. As a result, many obstetricians are banning together in various states to pass tort reform bills that cap the restitutions patients can gain. In California, physicians lobbied to enact a series of reforms that curbed soaring liability premiums, stopped physicians from leaving the state, and prevented the decrease in availability of care. The 50-year challenge of malpractice will continue to be an important issue for future OBGYNs.
SHARING THE SPOTLIGHT: NURSE MIDWIVES
Due to rising insurance premiums and the overall threat of liability, fewer family physicians are including obstetrical care in their private practices. Many medical students wonder about the role of family practitioners and midwives as providers of pregnancy-related care. A midwife (meaning with a woman) provides prenatal care, attends childbirth, manages her clinic patients during labor and delivery, and supervises the general care of women and babies directly after birth. As advanced-degree registered nurses, nurse midwives have completed an accredited midwifery program and passed the certification examination. Family practitioners are medical doctors who are trained in comprehensive general obstetrics. Although they provide care to women during normal pregnancies and deliveries, they consult an obstetrician if complications develop. All midwives are required by the American Congress of Obstetrics and Gynecology (ACOG) to have a physician with hospital privileges as part of the maternity team. Nurse midwives, however, attend only about 9% of vaginal births in the United States.12
Whether in private practice or affiliated with an independent birthing center, both obstetricians and midwives seek to fulfill the common goal of providing excellent health care for women. As such, their professional relationship should always remain collegial and cooperative. It is one in which the obstetrician—the expert consultant—steps in whenever his or her services are necessary.
FELLOWSHIPS AND SUBSPECIALTY TRAINING
After completing residency in obstetrics–gynecology, one may decide to specialize. Each of the following approved fellowships requires an additional 3 years of training. To earn board certification, graduating fellows must pass the American Board of Obstetrics and Gynecology (ABOG) subspecialty examination.
Maternal–Fetal Medicine
Patients with high-risk pregnancies, who have serious coexisting medical or surgical disease that could prevent delivery of a viable term infant or affect the survival of the mother, fall under the expertise of specialists in maternal–fetal medicine (MFM). These specialists serve as consultants to general obstetricians for referrals involving pregnancies complicated by major disease or for diagnostic or therapeutic procedures.
Although MFM physicians may focus on consultations and sonography, they are specially trained in a variety of intricate procedures. Diagnostically, they perform genetic amniocentesis, fetal blood sampling, obstetrical ultrasound, chorionic villus sampling, and cordocentesis. Therapeutically, they are experts at high-risk deliveries, medically indicated abortions, laparoscopy, fetal gene therapy, fetal reduction, and life-threatening emergencies.
Gynecologic Oncology
In 2013, 91,000 women were diagnosed with a gynecologic cancer. Roughly 15% of all cancers found in women involve tumors of the reproductive tract. This area of specialization focuses on the medical and surgical care of women with malignancies arising in the reproductive system: ovarian, uterine, cervical, vulvar, and vaginal cancer. These specialists receive extensive training in the biology and pathology of gynecologic cancer, particularly its diagnosis, treatment, and complications of oncologic care.
• Number of positions available: 1288
• 1202 US seniors and 552 independent applicants ranked at least one obstetrics–gynecology program
• 100% of all positions were filled in the initial Match
• The successful applicants: 81.4% US seniors, 8.2% foreign-trained physicians, and 9.5% osteopathic graduates
• Mean USMLE Step I score: 229
• Unmatched rate for US seniors applying only to obstetrics–gynecology: 8.1%
Source: National Resident Matching Program.
Gynecologic oncologists comprise an elite group of surgeons who bring hope to thousands of affected women. They are skilled pelvic surgeons who use the latest techniques in radical surgery, chemotherapy, and radiation treatment. They manage the urinary and bowel complications resulting from cancer treatment, as well as pain, palliative care, and psychosocial issues. Gynecologic oncologists are supported by a multidisciplinary team of medical oncologists, radiation oncologists, and gynecologic pathologists who collaborate to provide optimal care. Gynecologic oncologists practice in a variety of clinical settings—academic medical centers, regional hospitals, and specialized cancer centers.
REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY
The endocrine system, which is responsible for releasing hormones that modulate the development of the ovum, is one of the most intricate and complex regulatory systems. For the specialist in reproductive endocrinology and infertility (REI), establishing a pregnancy for couples diagnosed with infertility is extremely rewarding. Their practice also extends to the treatment of hormonal and reproductive disorders affecting women, children, men, and mature women. Reproductive endocrinologists gain special competence in advanced microsurgical procedures, such as reversal of tubal ligation, treatment with fertility drugs, and methods of assisted reproduction (in vitro fertilization and insemination). With vast knowledge and expertise on the physiology of reproduction, REI specialists medically and surgically treat a variety of complex hormonal disorders, such as infertility, endometriosis, recurrent pregnancy loss, menopause, and ovulatory dysfunction.
Residency in obstetrics–gynecology requires 4 years of postgraduate training. There are currently 241 accredited programs. Unlike other surgical subspecialties, a PGY-1 internship in general surgery is not required. Instead, residents immediately begin surgical training in obstetrics–gynecology. Upon graduation, residents are required to prove competency in all surgical and obstetric procedures. The typical monthly rotations include routine and high-risk obstetrics clinics and wards, general office and surgical gynecology, reproductive endocrinology and infertility, gynecologic oncology, urogynecology, primary care, and neonatal intensive care unit. Due to the increasing emphasis on primary care within this specialty, most residency programs now require at least 6 months of outpatient rotations. About 10% of residents continue their training in fellowships.
FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY
As women age, a history of multiple deliveries and other forms of strain may cause the musculature supporting the pelvic contents to slowly weaken. This can lead to disorders such as urinary incontinence or a prolapsed bladder, uterus, or vagina. To correct pelvic floor dysfunction, women should seek out specialists in female pelvic medicine and reconstructive surgery. Also known as urogynecology, this advanced surgical subspecialty remains on the cutting edge of medicine. It integrates the fields of urology and obstetrics–gynecology in the operating room. To diagnose pelvic prolapse and female voiding dysfunction, these physicians have special expertise in clinical evaluation of genitourinary diseases, cystoscopy, and analysis of urodynamic testing. Because this is a surgical fellowship, specialists in pelvic medicine perform many reconstructive operations to correct pelvic floor dysfunction. Many urogynecologists are also experts in management of pelvic pain using both medical and surgical modalities to treat sometimes complex pelvic pain. Fecal incontinence can also be managed surgically by urogynecologists and with the advent of transgender medicine and gender confirmation surgery, urogynecologists have found an additional population of patients for whom to care. Urogynecologists are experts in vaginal and laparoscopic surgery, including robotic surgery. They help to improve the quality of life for women with these disorders.
WHY CONSIDER A CAREER IN OBSTETRICS–GYNECOLOGY?
Despite its seemingly specialized nature, the field of obstetrics–gynecology provides much diversity and variety. Medical students should disregard the narrow views of colleagues who may dismiss these specialists as “Pap smear providers by day and baby delivery service by night.” The breadth of issues includes acute and chronic medical conditions, health maintenance, genetics, operative gynecology, pregnancy and delivery, adolescent and postmenopausal gynecology, infertility, endocrinology, urogynecology, and oncology.
Because of the diverse age of patients, your scope of practice can range from broad (primary ambulatory care) to very focused (concentration in an area of specialization). With so many paths available within this one specialty, there is no limit to what you may be able to offer to obstetrics–gynecology. After all, a single obstetrician or gynecologist cannot provide for all of the needs of a woman. The positive interactions between generalists and subspecialists allow for the highest quality of care for women of all ages.
Although our society expects great things from modern medicine to improve the quality of life, “nowhere are these expectations higher than in the practice of obstetrics and the desire and expectation of having a healthy child.”13 To achieve these goals, OBGYNs must demonstrate superior compassion, intelligence, and the ability to pay close attention to detail. Despite the rigorous lifestyle and the pressure of handling the high-risk responsibility, there are lots of rewards. Future OBGYNs will be part of a group of caring, competent, and conscientious doctors who strive for the best patient care for women. Although not every day is filled with success stories, most OBGYNs go home each day with the satisfaction of having changed someone’s life.
ABOUT THE CONTRIBUTOR
Dr. Kelly Oberia Elmore completed her residency in obstetrics–gynecology at the Naval Medical Center in San Diego. A lieutenant commander in the US Navy, she grew up in southern California and Chicago, graduated from Xavier University, and attended medical school at the University of Chicago. She practices both obstetrics and gynecology in the military with a focus on women’s sexual health. Dr. Elmore enjoys writing poetry and short stories. She acknowledges her family as her main source of inspiration and support. She can be reached by e-mail at drkelly@koemedicalconsulting.com.
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