Though theoretical, the threat of aerosolized viral particles places health care providers at risk. Certain safety measures can be taken. View the full, peer-reviewed article, and more, in this month's edition of Contemporary OB/GYN.

July 2020 | Vol 65 No 07

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), has merged four existing clinical trials networks to create the COVID-19 Prevention Trials Network (CoVPN).

CoVPN was established as a result of President Trump’s Operation Warp Speed, which aims to deliver a safe vaccine for the virus by January 2021.

It is composed of four existing, NIAID-funded clinical trials networks: the HIV Vaccine Trials Network (HVTN); the HIV Prevention Trials Network (HPTN); the Infectious Diseases Clinical Research Consortium (IDCRC); and the AIDS Clinical Trials Group.

“Finding a safe and effective vaccine to prevent infection with SARS-CoV-2 is an urgent public health priority,” said NIAID Director Anthony S. Fauci, M.D. in a recent press release.

 efforts, these networks will continue to perform clinical trials for HIV vaccine and prevention, as well as other infectious diseases.

CoVPN is expected to conduct the first Phase 3 clinical trial this summer. It will use a harmonized vaccine protocol developed by the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) public-private partnership. It will involve testing the investigational mRNA-1273 vaccine, developed by NIAID scientists and their collaborators at the biotechnology company Moderna, Inc.

As the CoVPN studies become active, they will reflect on the network’s website under 

NIH launches clinical trials network to test COVID-19 vaccines and other prevention tools. News release. National Institutes of Health; July 8, 2020.

NIH Clinical Trial of investigational Vaccine for COVID-19 Begins. News release. National Institute of Allergy and Infectious Diseases; March 16, 2020.

Articles

This new network aims to enroll thousands of volunteers in trials testing investigational vaccines and monoclonal antibodies to fight COVID-19. 

NIH launches clinical trials network to test COVID-19 vaccines and prevention strategies

Journal of Obstetrics, Gynecology and Cancer Research

, the prospective observational study looked at 

 who had been diagnosed with breast cancer and who were experiencing climacteric symptoms. Results included improved quality of life. 

These patients had undergone surgery, radiation otherapy, and/or chemotherapy more than 1 year prior to the study, and were receiving tamoxifen or an AIaromatase inhibitor.

The sample included 57 women who completed a sociodemographic questionnaire, the Blatt-Kupperman Menopausal Index (KI) and the World Health Organization Quality of Life version-bref (WHOQOL-bref) scale.

The median age of patients was 54.4 5.9 years; 86% had ductal carcinoma, 98% had undergone surgery, 70% had received chemotherapy, and 96% had received radiation otherapy.

Patients were divided into two2 groups: 35 patients who used tamoxifen, and 22 patients who took AIaromatase inhibitors. 

Comparison of the KI and WHOQOL-bref scales showed improvement in scores at 6 months in patients who used AIaromatase inhibitors.

In both groups, KI scores declined significantly (

<0.011) over the study. The authors concluded that patients using AIaromatase inhibitors had higher quality-of-life scores than those on tamoxifen. 

 patients with breast cancer found that AIaromatase inhibitors to have a good toxicity profile, with lower rates of hot flashes, nausea, vaginal bleeding, vaginal discharge, endometrial cancer, and thromboembolic events.

Macruz CF, Lima SMRR, Postigo S, Martins MM, Lucarelli AP, de Oliveira VM. Quality of Life and Climacteric Symptoms in Postmenopausal Women Receiving Hormone Therapy for Breast Cancer [published online ahead of print, 2020 Mar 27]. 

. 2020;S1701-2163(20)30262-0. doi:10.1016/j.jogc.2020.02.124

New research shows that, in postmenopausal women undergoing hormone therapy for breast cancer, aromatase inhibitors (AIs) lead to a reduction in climacteric symptoms and significantly improved quality of life.  

Aromatase inhibitors for climacteric symptoms in women with breast cancer

Ben Schwartz is Associate Editor, Contemporary OB/GYN.

Vulvovaginal candidiasis (VVC) is relatively common, and research from 

 indicates a woman’s risk could be increased by certain personal behaviors as well as the composition of her vaginal microbiota. 

 is the most common etiology for VCC and this study looked at what factors are associated with its molecular detection. 

The objective of the study was to better understand epidemiologic factors associated with molecular 

detection and to evaluate how the vaginal microbiota and relative abundance of individual bacterial taxa differ between women with and without 

For the cross-sectional study, vaginal swabs were self-collected by 394 non-pregnant, reproductive-age women. The participants submitted two swabs; one was used to characterize the composition and structure of the vaginal microbiota and the other was used the prepare a smear for Nugent Gram stain scoring.

 using polymerase chain reaction targeting 

 ITS1/2 region. Vaginal microbiota was characterized using 16S rRNA gene amplification sequencing of the V3 to V4 hypervariable regions and then clustered into community state types (CSTs).

Five primary CSTs were identified in this study; four dominated by 

Lactobacillus species (L. iners, L. crispatus, L. gasseri, L. jensenii)

, plus one lacking significant numbers of 

and characterized by higher proportions of strict and facultative anaerobic bacteria (termed CST IV). 

The authors used multiple logistic regression to identify risk factors associated with 

 in 21%of vaginal samples (83 of 394). Women in whom 

 was detected were more likely to report use of tampons, engage in receptive oral sex, and use of over-the-counter (OTC) antifungals to self-treat for vaginal infections before seeing a doctor for examination.

Neither self-reported diagnosis of VVC nor bacterial vaginosis in the prior 60 days were associated with 

Furthermore, detection was not associated with vaginal pH, re-porting any type of vaginal symptom in the past 60 days, age, history of pregnancy, use of hormonal contraception in the past 60 days, number of recent sexual partners, or other forms of sexual activity in the past 60 days.

-dominated CST had increased, but not statistically significant, oddsof 

 CST IV after cofactor adjustment of receptive oral sex and a history of self-treatment with OTC antifungals (adjusted odds ratio, 2.05%; 95% CI 0.97-4.37, n=323). 

However, using the same model, antifungal use and receptive oral sex were significantly associated with 

detection, with a dose-response trend for increasing frequency of oral sex and escalating odds of 

When assessing individual bacteria to determine if there were taxa that were most likely to be associated with 

Lactobacillus coleohominis, Prevotella oris

 being in higher relative abundance in women in whom 

The authors believe their findings indicate that 

-dominated vaginal microbiota may be associated with increased 

 detection. They also point to receptive oral sex as a risk factor for 

Moura APC, Ribeiro HSAA, Bernardo WM, et al. Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: Systematic review and meta-analysis. PLOS One. 2019;14(4):e0214842.

Candida albicans is the most common etiology for VCC and this study looked at what factors are associated with its molecular detection. 

Risk factors for candidiasis

Judith M. Orvos, ELS, is a a BELS-certified medical writer and editor and an editorial consultant for Contemporary OB/GYN.

While urging caution in interpretation of their results, the authors say the findings could be particularly important for management of nulliparas.

Findings from the study—which was stopped early because of a signifi cantly higher rate of peri-natal mortality in the expectant management group—were pub-lished in BMJ. 

SWEPIS (SWEdish Post-term Induction Study) was a multicenter, open-label, random-ized superiority trial conducted at 14 hospitals in Sweden from 2016 to 2018.

Of the 2760 women enrolled, all of whom had low-risk, uncomplicated pregnancies, 1381 were randomized to induction at 41 weeks and 1379 to ex-pectant management with induction at 42 weeks. In many centers in the UK and Scandinavia, induction is com-mon no later than 42 weeks. 

Recent studies have shown a significantly increased risk of perinatal mortality and morbidity at 41 weeks, and of stillbirth beginning at 39 weeks.

The primary outcome of SWEPIS was a composite of perinatal out-come including one or more of still-birth, neonatal mortality, Apgar < 7 at 5 minutes, pH < 7.00 or metabolic aci-dosis in the umbilical artery, hypoxic ischemic encephalopathy, intracranial hemorrhage, convulsions, meconium aspiration syndrome, mechanical ventilation within 72 hours, or obstetric brachial injury. 

The secondary outcome was perinatal mortality. The primary analysis was intent to treat.

In the induction group, there were fewer admissions to a [NICU], lower incidence of neonatal jaundice...and fewer infants with macrosomia.

No perinatal deaths occurred in the group induced at 41 weeks but six occurred in the expectant management group (5 stillbirths, 1 early neonatal death; P = 0.03). No differences were seen between the groups in the composite primary perinatal outcome (2.4% [33/1381] induction group; 2.2% [31/1379] expectant management; RR 1.06, 95% CI 0.6 to 1.73; P = 0.90). 

The proportion of cesarean deliveries, instrumental vaginal deliveries, or major maternal morbidities also did not differ between the groups.

The authors also found that in the induction group, there were fewer admissions to a neonatal intensive care unit, lower incidence of neonatal jaundice requiring therapy, and fewer infants with macrosomia. 

The rate of cesarean delivery did not differ significantly between the two groups. Of note, the researchers said, all perinatal deaths occurred in the nulliparous women. 

“If this finding can be replicated in fu-ture studies,” they indicated, “it could mean that nulliparous women may require particular attention, and interventions such as labor induction might be even more important in this group.” 

The number needed to treat with induction of labor at 41 weeks to prevent one perinatal death was 230, which the authors said was lower than previous estimates.

A nationwide study by Swedish researchers suggests that inducing labor at no later than 41 weeks could be one of the few interventions that reduce stillbirths. 

Inducing labor to reduce stillbirths

 found that more than 95% of the prescriptions were for short-acting opioids (SAOs) only, while 4.1% were for both SAOs and extended-release/long-acting opioids (LAOs).

Only 0.6% of women filled a prescription for LAOs alone.

“Endometriosis is a debilitating disease that can cause significant pelvic pain,” said principal investigator Sawsan As-Sanie, MD, MPH, co-chief of gynecology and director of minimally invasive gynecologic surgery at the University of Michigan in Ann Arbor. 

“However, currently available treatments are not consistently effective for all women, and some may resort to opioids to manage their pain, despite the fact that opioids are not recommended for the treatment of endometriosis pain or any other chronic non-malignant pain condition. Long-term opioid use can be associated with significant harm.”

The investigators, who sought to better understand the scope of opioid prescribing patterns in women with endometriosis, performed a retrospective cohort analysis of data from the Truven MarketScan Commercial database for the period January 2011 to December 2016.

Women who filled an opioid prescription within 12 months of their first endometriosis diagnosis were compared to women who did not fill an opioid prescription during the study period.

The dataset comprised 58,472 women with endometriosis, of whom 61.7% filled an opioid prescription within the first year. While only 10% of women did not have any surgery in the first year after the first listed endometriosis diagnosis, the prevalence of patients who received an opioid prescription remained high, even after excluding opioids prescribed in the perioperative period (defined as anytime between 14 days before or 30 days after surgery). 

After excluding prescriptions in the perioperative period, 49% of women with endometriosis filled at least one opioid prescription.

Compared to endometriosis patients who did not fill an opioid prescription, endometriosis patients who filled an opioid prescription had significantly higher baseline comorbidities (especially gynecological and chronic pain comorbidities), endometriosis-related medication use, mental health disorders and substance abuse.

“I expected that this would be common after surgery, but was especially surprised that these patterns persisted, even after excluding opioid prescribing outside of the surgical period.” 

Patients who filled both LAO and SAO prescriptions had the highest total days' supply of opioids, proportion of days covered by prescriptions and morphine equivalent daily dose.

Baseline opioid abuse, opioid dependence, and opioid overdose were also significantly higher in the SAO and LAO-SAO groups compared to the non-opioid group: SAO: 0.3%, 2.2%, 0.2% respectively; LAO-SAO: 2.5%, 15.8%, 2.4% respectively; non-opioid: 0.2%, 1.2%, 0.1% respectively (

These patients also had the highest proportions of opioid switching and dose augmentation.

“While I do not recommend the use of opioids for the management of chronic pain in my practice, I was surprised by how commonly opioids are prescribed in women with endometriosis,” Dr. As-Sanie told 

Dr. As-Sanie said an important next step in understanding and optimizing endometriosis care is further research into when opioids are prescribed relative to the diagnosis and treatment timeline, and the reasons surrounding the use of opioids in relation to other recommended treatments, such as combined hormonal contraceptives, gonadotrophin-releasing hormone agonists (GnRHa), progestins, and surgical excision.

Dr. As-Sanie receives royalties from UpToDate, and is a consultant to AbbVie, Myovant Sciences, Bayer, and Merck.

As-Sanie S, Soliman AM, Evans K, et al. Short-acting and long-acting opioids utilization among women diagnosed with endometriosis in the United States: a population-based claims study. 

. Published online June 9, 2020. doi:10.1016/j.jmig.2020.05.029

Nearly two-thirds of women newly diagnosed with endometriosis filled an opioid prescription within the first year, according to a US population-based claims study. 

Opioid use in women with endometriosis

A significant positive association exists between hormone replacement therapy (HRT) and mammographic density (MD), according to a systematic literature review in the journal 

The review concluded that the highest increase in MD is among current users of HRT, particularly those taking continuous estrogen plus progestin (CEP).

“HRT has been used as an effective treatment for alleviating the climacteric symptoms of menopause, such as hot flushes, sleeping disturbance, depressive mood, and muscle and joint pain for many years,” said senior author Shadi Azam, PhD, a breast cancer epidemiologist at Karolinska Institute in Stockholm, Sweden.

 that various papers and reviews have evaluated the effect of different HRT regimes, state of exposure and risk of breast cancer. 

“However, ours is the first systematic review to assess the impact of HRT regimens on MD, which is an important risk factor for breast cancer,” she said.

Articles published between 2002 and 2019 from PubMed, Embase and Ovid were reviewed. Among the 22 studies that met the inclusion criteria, six studies showed that using estrogen plus progestin (E + P) HRT was associated with higher MD than estrogen alone.

Four studies reported that CEP was connected to higher MD than sequential estrogen plus progestin (SEP) or estrogen alone, but two studies showed that SEP caused slightly higher MD than CEP or estrogen alone.

“The review showed that MD significantly increases in women who have ever used HRT, compared to never users, with the highest increase in MD among current HRT users,” Dr. Azam said. “CPP users also have the highest increase in MD, followed by SEP users and estrogen alone users.”

Dr. Azam is not surprised by any of the findings. “Epidemiological evidence is rather consistent, suggesting that there is a positive association between HRT and MD,” she said.

However, it is unclear why HRT causes increasing MD, although one established hypothesis is based on the breast cell proliferation theory. 

In menstruating women, it has been observed that breast epithelial cell proliferation is increased due to high levels of estrogen and progestin.

Study findings can be helpful in primary prevention of breast cancer and secondary prevention of false-negative diagnosis of small tumors, according to Dr. Azam.

“From the primary prevention perspective, our results indicate that HRT should be minimized at the lowest doses needed for as short of time as possible,” she said, “And from the secondary prevention perspective, women who currently use HRT and for whom an increase in MD is detected by mammography screening may require additional screening procedures, shorter screening intervals and the use of advanced imaging techniques such as magnetic resonance imaging/ultrasound for detecting small tumors.”

Dr. Azam emphasized that MD is one of the strongest risk factors for breast cancer. 

“At a given age and body mass index (BMI), women with very dense breasts (more than 75% dense) have a four- to six-times greater risk of breast cancer compared with women with less dense tissue (occupying less than 5% of the breast),” she said.

To prevent breast cancer, “HRT should be given with caution and consideration.” Dr. Azam said.

Dr. Azam reports no relevant financial disclosures.

Azam S, Jacobsen KK, Aro AR, et al. Hormone replacement therapy and mammographic density: a systematic literature review. 

. 2020;183(2):555-759. doi:10.1007/s10549-020-05744-w

Link between hormone replacement therapy and mammographic density

According to the American College of Obstetricians and Gynecologists (ACOG), there are several benefits of using the stem cells in cord blood to treat disease

Stem cells from cord blood can be given to more people than those from bone marrow. The stems cells in cord blood are less likely to be rejected than those in bone marrow.

It is easier to collect cord blood than bone marrow, as bone marrow collection poses risks and can be painful for the donor.

Unlike bone marrow stem cells, cord blood can be used to strengthen immune systems during cancer treatments.

ACOG also notes, however, that cord blood does not contain as many stem cells as bone marrow. “Units from several donors can be combined to increase the number of stem cells if a transplant is needed for an adult.”

As many ob/gyns know, cord blood must be stored carefully. According to the Food and Drug Administration, “cord blood stored for personal use, for first- or second-degree relatives, and that also meets other criteria in FDA’s regulations, does not require the agency’s approval before use. Private cord banks must still comply with other FDA requirements.”

“Not every cord blood unit will meet requirements for public banking, adds Safa Karandish, M.T., an FDA consumer safety officer. If that happens, some of this donated cord blood may be used for non-clinical research.”

Cord Blood Banking. American College of Obstetrics and Gynecology. Accessed July 6, 2020. 

https://www.acog.org/patient-resources/faqs/pregnancy/cord-blood-banking#advantages

Cord Blood: What You Need to Know. Food and Drug Administration. Accessed July 6, 2020. 

https://www.fda.gov/consumers/consumer-updates/cord-blood-what-you-need-know?deliveryName=USCDC_277-DM31597

For Cord Blood Awareness Month, here are some updated usages and FDA regulations for practitioners using cord blood.

Cord Blood Awareness: Quick facts

Obstetrics and Gynecology has undergone notable change in the last few decades: advancement in subspecialties, greater diversity in practitioners, liability, robotics, and much more. The healthcare industry overall is experiencing an historic transformation that is impacting many facets of medicine. 

Patients’ expectations, communication, access to health information, and desire for transparency and accessibility are just a few of the many aspects that are different today than they were a short time ago.

In the midst of the proliferation of the Internet and related technologies, the Millennial generation emerged in the workforce, and according to the U.S. Bureau of Labor Statistics, Millennials will comprise 75% of employees by 2030. 

Generational awareness and proactive adaptations are paramount to enhance relationships among providers and patients and to maximize the attributes of each respective workplace age group.

Generations are defined as cohorts of people born in a span of roughly 15 to 20 years that are influenced and often characterized by the social, economic, and political events that occur during their formative years. 

These experiences help to shape a common system of beliefs, attitudes, and values held prominently within each group. Generations are often named by pop culture and the media, however, the United States Census Bureau defined one generation, the Baby Boomers.


The current healthcare workforce is composed of members of the Silent Generation (born 1928-1945), Baby Boomers (1946-1964), Generation X (1965-1980), and Millennials (1981-1996). 

Members of Generation Z (1997-2012) are just beginning to enter medical school and careers in healthcare (Figure 1). 

Although each generation has stereotyped descriptors, it is important to acknowledge that individual members may not always demonstrate these characteristics or self-identify with their own generation, depending on unique cultural conditions and life experiences.

Figure 2 summarizes the characteristics, experiences, innovations, and workplace attitudes for each generation. Members of the Silent Generation were children of crisis; their formative years occurred during the Great Depression and World War II, and thus birth rates were the lowest of any generation. 

The Silent Generation came of age in an era of great scarcity and austerity and are known to be hard-working rule-followers who value stability and avoid rocking the boat. 

Early in their careers, members were thought to be happy to have a secure job, even if it was not the most desirable, and loyally kept their noses to the grindstone. For many, this loyalty holds fast today.

Baby Boomers were born during social and political upheaval but were also raised during a period of economic prosperity. They are characterized as competitive and ambitious, and are high-achieving, goal-oriented employees. 

Striving towards and realizing the American Dream was a priority for many. Baby Boomers live to work, and many continue to work beyond the typical retirement age due to the joy they find in their occupations.

Resourceful and self-sufficient, Generation X’ers were dubbed “latchkey kids”; both parents often worked outside the home, so members of this generation looked after themselves and their younger siblings. 

Many saw their mother and father divorce and were raised in single-parent households. Having witnessed the workaholic approaches of their Silent Generation or Baby Boomer predecessors, Generation X’ers have a mantra of “work to live” and value a more flexible work environment.

Millennials are the first generation to have been immersed in digital technology early in life; many had computers in their classrooms and were natural adopters of electronic modes of communication. 

Their parents tended to be protective and very involved; “helicopter” and “snowplow” parents are widely used descriptors. Millennials are the most educated of any generation; nearly 40% of millennials have a bachelor’s degree or higher, compared with 15% of the Silent Generation.

Members of this cohort are marrying later, starting families later, and are the most racially and ethnically diverse generation in the history of the workforce. 

More than any other generation, Millennials are in search of a work-life integration that grants both personal and professional fulfillment.

From house calls to smartphones, communication among members of the healthcare team and with patients has varied widely over the last several decades. While members of the earlier generations may recall a time when house calls were not unheard of, the evolution of clinical productivity standards now demands that physicians from all generations embrace email and increasingly text messaging. 

Even the telephone is quickly becoming obsolete as practitioners seek to both deliver and consume communication asynchronously, sending and receiving when time allows. 

Millennials who came of age during the smart machine revolution, which began around the turn of the 21st century and is ongoing, strongly prefer and are hastening the adoption of more modern communication regimes. 

Millennials often expect this type of communication to be the norm, and it is not uncommon for them, when joining a practice, to start a group text thread among partners that they use freely at all hours of the day and night.

Just as the lines of communication are being redrawn, perhaps more uncomfortable for some, the traditional clinical chains of command are being blurred by eager and confident members of later generations. 

Years ago, it would have been improper for a medical student to address an attending by their first name, but some new attendings actually prefer and invite trainees to dismiss formalities. This type of disregard for hierarchy sends ripple effects throughout academic departments and practices that are tolerated differently based on organizational philosophy and cultural acceptance of change. 

A side effect of the gradual dissolution of hierarchy may be an exaggeration of ambiguity in how trainees and colleagues of different generations perceive workplace mistreatment by both peers and superiors.

Team-based approaches to learning and problem solving have been hardwired into newer generations. While most can easily conjure images from childhood of a favorite teacher at the chalkboard espousing wisdom to the masses, Millennials experienced the beginning phases of an ongoing reformation of classroom teaching that more heavily emphasizes problem-based learning in peer groups. 

Recognizing that collaboration in the healthcare workplace is natural and necessary, many medical schools have trended in this direction, as well. 

This evolution of teaching and learning has broad implications for how generations of physicians relate and work together. Millennials, for example, may have learned to frequently seek out the opinions of various care-team members while earlier generations might have been trained to make decisions based more on their own understanding and experience.

What is work and what is life? There are thousands of articles on work-life “balance,” “fit,” “blend,” and “integration.” 

The ratios of time and energy spent on personal and professional endeavors may vary not only by generation but also depending on stage of life. The values of any one member of a generation may change as the milestone events of life unfold. 

What remains constant, however, are the positive professional and personal benefits of sustained maintenance of self-care. 

Many are familiar with pre-flight instructions that advise passengers to don their own oxygen masks before assisting others; if providers aren’t mentally and physically healthy themselves, how can anyone expect them to care for their patients effectively?

Just as generation and stage of life are important determinants of values, gender cannot be overlooked. Today, more than half of ob/gyns are women, and over 80% of medical students who match into the specialty are female.

Compare these numbers to 1970 when 93% of ob/gyns were men. And in 1970, many male physicians were not also responsible for caregiving and domestic duties. Women in medicine are almost twice as likely as men to have partners who are employed full-time (86% of females versus 45% of males). 

Females in medicine with partners and children reported spending an average of 8.5 hours more on parenting and domestic tasks than their male counterparts each week.

Physicians feel they are being asked to do more with less. There never seem to be enough hours in the day to complete work responsibilities, let alone adequate time for family and pleasure. 

And while it may be easy for some to dismiss these sentiments as an insufficient work ethic in younger generations, one must carefully consider the disruptive transformation of modern healthcare delivery that is significantly influencing the dynamics of work-life integration. 

Volumes could be devoted to an exploration of how this topic impacts other vital industries just as acutely as medicine, but take for example the mass exodus of teachers from the K-12 education arena. Only in recent history have regulations led to a demand for student recordkeeping so burdensome that the careers of many educators are extinguished prematurely. 

The original meaning many teachers sought from a profession once regarded as a cornerstone of our society is being increasingly eroded, and this is a refrain that sounds all too familiar to many physicians today.

Whether symptoms of burnout have actually increased dramatically, or there is now more attention called to exhaustion, or both, job flexibility that allows for some work-life integration is highly valued, especially by younger generations. This begs the question: Is it possible to achieve work-life balance as a physician? 

Understandably, there will be less of a balance and more of a blend as an ob/gyn, but creative solutions are imperative to ensure the feasibility of fulfilling both home and work responsibilities, within reason. 

Further, these adaptations play a critical role in preventing exacerbation of the upcoming physician shortage by doctors who don’t maximize their career potential and instead retire early, decrease to part-time or less, or even change careers.

One would assume that shifting careers from a physician to a different profession was previously unlikely, but Millennials and likely future generations perceive their careers to be less defining of their identities. As mentioned, professional 

 personal fulfillment are highly regarded by Millennials. 

As such, opportunities to develop hobbies, devote time to family and friends, and volunteer in the local community and beyond will need to be recognized and supported by employers to ensure satisfaction and stability in the workforce.

A generational divide may seem inevitable; however, gaps can be narrowed with effort.

Employers and organizations that provide support in the way of formalized mentoring programs will facilitate the dissemination of wisdom to newer generations and encourage goal setting. Clinical skills, productivity pearls, and expertise amassed through decades of practice are invaluable resources for junior partners. 

Beyond these attributes, mentors may guide mentees by facilitating network connections and providing advice on promotion and career pathway optimization. Mentors serve as sounding boards during professionally challenging times or when difficult situations arise.

Reverse mentoring can occur in the same partnership; in this scenario the junior physician mentors the senior physician in unique skillsets they possess, especially adaptation to technology, which is second nature to Generation X and certainly to Millennials. 

Reverse mentorship can offer mentees advice on electronic health record efficiency, template sharing, app utilization, website and social media presence, and more.

Formal mentorships are excellent resources for physicians in every career stage. These relationships can be created in departments and practices, or through utilization of the American College of Obstetricians and Gynecologists Mentor Program, especially when local connections are more limited. 

As mentors and mentees begin to exchange viewpoints and develop relationships, generational understanding is naturally achieved, reinforced, and enriched.

Opportunities forflexibility in scheduling can be employee-friendly and also patient-friendly. Consider offering evening or weekend office hours a few times per month, which are highly desirable to Millennial patients. 

Members of younger generations may gladly exchange morning hours for evening hours on occasion, as this may afford the opportunity to be involved in school activities for their children or errand-running that is otherwise not possible with a traditional physician schedule.

Similarly, setting up a practice to offer and receive reimbursement for e-visits or video visits is another convenient way to efficiently deliver healthcare. This can allow for occasional windows of time to work outside of the traditional office setting or even from home. 

Though Obstetrics and Gynecology may be more limited than specialties such as Psychiatry in the visit types that can be offered electronically, opportunities do exist and will become more commonplace as generational demand increases.

Laborist and gynecologic hospitalist models have increased patient safetyand can provide unique appeals of acute, inpatient medicine and defined shifts.

Though these models lack the benefit of patient continuity, both junior and senior physicians, as well as many practices, find this to be an attractive alternative to relinquishing obstetric services earlier in a career than desired and can also increase productivity in the office.

Encourage input from all generations when crafting new policies and procedures and in solving problems. Harnessing the creativity of the group is likely to yield different perspectives and invoke innovation. When meeting together, all generations will appreciate a clear agenda with defined and respected start and end times. 

Consider whether an email or text thread would be just as effective and more efficient than face-to-face contact. Leaders should strive to acknowledge the attributes and perspectives of each generation to achieve harmony and optimize productivity.

As we strive to enhance our relationships with our colleagues and patients, it would benefit us all to consider the values, characteristics, and experiences of every generation. 

With some effort, generational gaps can be narrowed and ob/gyns of all ages will thrive at home and at work and continue to deliver high-quality care to our patients.

Bialik K, Fry R. Millennial life: How young adulthood today compares with prior generations. https://www.pewsocialtrends.org/essay/millennial-life-how-young-adulthood-today-compares-with-prior-generations/. Pew Research Center. February 14, 2019.

Rayburn W. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implication. Washington, DC: ACOG; 2017.

Jolly S, Griffith K, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. 

Association of American Medical Colleges.New findings confirm predictions on physician shortage. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage. August 23, 2019.

ACOG Committee Opinion 459. The Obstetric and Gynecologic Hospitalist. Committee Opinion No. 459. American College of Obstetricians and Gynecologists. 

Bridging the generational gap in the physician workforce.