Today, obstetricians must be familiar with the nuances of cell-free fetal DNA testing using massive parallel sequencing, know common microdeletions, and appreciate the advantages of chromosomal microarrays. The average ob/gyn’s ultrasound skills are vastly superior to those of 1980 maternal-fetal-medicine specialists, and modern machines have unimaginably improved resolution. Surgery for select fetuses with neural tube defects improves outcomes, and isoimmunization is both rare and easily treated. Premature labor is diagnosed with fetal fibronectin and/or sonographic cervical length determinations, tocolysis is limited to 48 hours, and prematurity potentially prevented with prophylactic progestins. However, our national cesarean delivery rate exceeds 30%, a reflection of an older, obese population with more comorbidities and indications for induction. Also linked to the cesarean epidemic is the decline in operative vaginal and breech deliveries, to the extent that many young ob/gyns will annually perform more cesarean hysterectomies for placenta accreta than forceps deliveries. HIV is a chronic disease and maternal-to-fetal transmission a rarity. Today, keeping up with the obstetrical literature takes herculean stamina, though Contemporary OB/GYN does help!
Today’s gynecologists must be well-versed on all forms of minimally invasive surgery with or without a robot. Ectopics are diagnosed far earlier using sensitive human chorionic gonadotropin assays, and high-resolution transvaginal ultrasound and medical treatment are now used in more than a third of cases.3 We must keep up with frequent changes in cervical cancer screening protocols. Publication of the Women’s Health Initiative (WHI) study results, linking hormone replacement therapy to increased cardiovascular disease when used in older women and also to breast cancers from the progestin component, has clearly had some public health benefit, but has also greatly complicated treatment of menopausal symptoms and osteoporosis.4 Breast cancer screening now has legal, not just professional liability ramifications, and breast-conserving surgical therapy is the norm. Across the discipline, subspecialists with deep knowledge of narrow fields have created as much competition with generalists as collaboration. And all of us must also be familiar with expanding lists of new drugs.5 In short, everyday ob/gyn practice has evolved dramatically over the past 4 decades. But with this progress the burden of keeping up with new discoveries, medications, devices, and surgical techniques is testing our limits. In addition, the profusion of much-needed, but voluminous, randomized trials, systematic reviews, and meta-analyses is causing constant evolution of evidenced-based practices and further straining our ability to keep pace with evolving practice demands.
But maybe the good old days weren’t so bad after all?
Perhaps the most frustrating aspect of our contemporary practice environment has been the steady flood of regulations over the past 4 decades. The 1980s saw charge-based provider fee-for-service payments evolve to hospital diagnosis-related group payments and practitioner current procedural terminology (CPT) code-based payments. These efforts to limit Medicare and Medicaid spending failed and the mid-1990s witnessed the chaotic introduction of managed care with gatekeepers and discounted fee-for-service payments. And over the past 2 decades both Republican and Democratic administrations have pushed through a cacophony of federal regulations designed to protect patients’ confidentiality, increase access to healthcare, reduce fraud and abuse, and restrain costs. Then there was all the time we spent completing the ICD-10 conversion. Many of us have also participated in other CMS experiments such as bundled payments and accountable care organizations. Of course, all these programs are likely to be further jumbled by the new presidential administration, which is likely to head in an entirely different direction with a focus on consumer-driven health plans wherein patients pay more for medical services—pitting patients against their doctors without third-party insurance buffers. Then there are mounting state regulations and increasing legislation affecting medical practice. Finally, our hospitals are mandating clinical pathways, patient safety bundles, team training, structured handoffs, and operating room checklists. Individually, each item in this long list may have some merit, but collectively they add a gargantuan layer of complexity and stress to our professional lives.
They don’t train them like they used to!
A second leit motif of the survey responses is that new residency graduates are less clinically skilled than they once were. There is some evidence to support this assertion. In a survey of practice readiness distributed to all fellowship directors in the 4 ob/gyn subspecialties, directors said that only 46% of first-year fellows were capable of independently performing an abdominal hysterectomy, only 34% a basic hysteroscopy, and a frightening 20% a vaginal hysterectomy.6 In a similar survey, half of gynecological oncologists reported that incoming fellows could not independently perform a hysterectomy.7 In a 2007 study, 60% of fourth-year ob/gyn residents reported performing fewer than 20 forceps deliveries during their residency.8 A number of factors may be responsible for these grim statistics. First, residents are exposed to fewer hysterectomies; in the US between 2002 and 2010, there was a 36.4% decrease in hysterectomies. 9 Implementation of the 80-hour work week regulations and competition with subspecialty fellows may also reduce available surgeries. Finally, the sheer breadth and depth of medical knowledge that must be crammed into 4 years of training may be crowding out core clinical experiences. Today, residents must learn pretty much everything we did in the 1980s plus the vast amount of knowledge cited above that we absorbed over the past 35 years! In other words, residents and young ob/gyns need to know far more than we did in the good old days.