Charles J. Lockwood, MD, MHCM

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’s founding Editor-in-Chief, Dr. John Queenan, to join its Editorial Board. It was an unexpected honor and just a bit intimidating given that the Board was a veritable “who’s who” of ob/gyn greats.  I quickly realized that the twin pillars of the magazine’s success were John’s inspirational leadership and the quality, sagacity, and editorial independence of that board. For 25 years, Dr. Queenan had been a master at picking the 

 board members who, in turn, identified key topics, emerging trends and outstanding authors. John led their deliberations, added his own prescient ideas and, of course, crafted truly memorable editorials.

The next year, I was stunned when John asked me to become 

’s second Editor-in-Chief. I have enjoyed my time in this post immensely. Fortunately, I strictly followed John’s “recipe” by assembling a great board, a number of whom have been with me since the start, including Drs. Joe Leigh Simpson, Paula Adams Hillard, and Sharon Phelan. I was blessed to be able to add other leaders in the field including my old friends Joshua Copel from Yale, one of the true greats in obstetrical ultrasound, and Sarah Kilpatrick, Chair of Obstetrics and Gynecology at Cedars-Sinai in Los Angeles and an expert in medical complications of pregnancy. Newer friends joined including Drs. John Delancey, a pioneer and leader in urogynecology; Ilana Cass, a brilliant gynecologic oncologist and now Chair of the Department  of Obstetrics & Gynecology at Dartmouth; Chris Pettker, a leader in the patient safety movement from Yale; and Steve Ory, a master clinician and reproductive endocrinologist from Florida International University in Miami. I was also lucky enough to recruit Dr. Jon Einarsson, an international authority in minimally invasive gynecological surgery from Harvard, as Deputy Editor. What great success the magazine has enjoyed over the past two decades is largely due to these wonderful folks as well as their predecessors, including giants like Drs. Leon Speroff and Ed Wallach. 

Perhaps the most daunting task over the past two decades has been coming up with ideas for editorials. Some concepts were obvious, like telling the story of 9/11 from the perspective of my patients at NYU and Bellevue Hospital. Others were inspired by the recurrent professional liability crisis, onerous new government regulations, political threats to women’s reproductive health, rapidly changing healthcare financing, physician burnout, and the challenges of residency training. However, most reflected bread and butter clinical topics including the safety of vaginal breech deliveries and trials of labor after prior cesareans, the causes of maternal mortality and preterm birth, the appropriate use of antenatal corticosteroids, misoprostol and low molecular weight heparin, and screening for thrombophilias, genetic disorders, Group B 

 and gestational diabetes. Gyn topics included postmenopausal hormone therapy, new contraceptives, screening for cervical cancer, and the need to encourage human papillomavirus vaccination. While I have not shied away from controversial topics, I have also tried to tell stories from the perspective of busy clinicians. 

Click here to read some of Dr. Lockwood's editorials

And I have been honored to receive a number of national publishing awards for these editorials, including three prestigious Jesse H. Neal Awards from the American Society of Business Publication Editors, as well as two Gold Awards for Editorials and an Award in the Editorial/Editor’s Letter category from the American Society of Healthcare Publication Editors. My approach to writing has been simple: find a topic I was interested in or passionate about, critically review all relevant literature, and then sit down and write. I do hope my editorials have helped shape ob/gyn practice in positive ways. I have certainly enjoyed hearing from readers, who have not been shy about providing feedback in person, by phone, by e-mails, through formal letters to the editor, and more recently, via social media.  

It is hard to imagine it’s been 20 years. I have truly enjoyed every minute. But this seems like a propitious time to pass the Editor-in-Chief “baton” to someone from the next generation of ob/gyn leaders who can provide a different perspective and their own passion. Over the next few months, the magazine will select a new leader and I am sure they can maintain 

’s extraordinary success over the past 45 years if they also follow John Queenan’s tried and true formula. 

In closing, I want to thank our dedicated, brilliant, and very witty past and present editorial board members. I am also incredibly grateful to my terrific managing editors, including Judy Orvos, Paul Cerrato, Susan Olmstead, and Linda Wetzel, whose professionalism and sage counsel have been invaluable. Finally, I want to thank our wonderful readers, who were my inspiration.

Articles

After 20 years as editor-in-chief, Dr. Lockwood announces that he has stepped down and reflects on his time with the magazine.

A fond farewell

If you find yourself on a mountain or at a lake this summer with those rarest of modern gifts-peace, solitude, and the chance for a few days of uninterrupted reading-I recommend Tom Friedman’s 

 It is vintage Friedman with the meticulously researched reportage expected from a three-time Pulitzer Prize winner. The book addresses three of the weightiest subjects of our time: the simultaneous acceleration of information technology, economic globalization, and climate change. While these three challenges ought to matter to every human on the planet, they have special resonance for ob/gyns because globally their impacts fall disproportionately on women and because women hold a key to the planet’s ability to overcome their collective threat.
	 


	While these three forces seem suddenly upon us, climate change reflects centuries of industrialization. On the other hand, the explosion in computing power and economic globalization have emerged over decades. In fact, most of the critical components of the latter two forces date back to one year – 2007.

 That year the iPhone and Android operating system were introduced, AT&T invested in a massive expansion in software-enabled networks setting the stage for logarithmic increases in wireless traffic, and IBM’s Watson was created giving birth to the dawn of artificial intelligence (AI). Also, in 2007, Kindle was rolled out by Amazon, and Airbnb was conceived. Twitter, LinkedIn and Facebook all started around that year using software developed by a company called Hadoop that generated software algorithms allowing hundreds of thousands of computers to function as one. In biotech, 2007 saw leveraging of this raw computational power to begin to dramatically reduce the cost and unimaginably increase the speed of DNA sequencing. Interestingly, that was also the year that experimental proof of CRISPR was reported.

 Thus, “infotech” and “biotech” are inextricably linked. All these changes accelerated economic globalization disrupting traditional markets in goods and services (including healthcare), labor and capital. 


	Moore’s law states that the speed and capacity of computing doubles every 2 years in parallel to the number of transistors that can be placed on a microchip. To illustrate this geometric expansion, Friedman notes that compared to its first-generation microchip, Intel’s sixth-generation chip has 3,000 times the performance and 90,000 times the energy efficiency at 60,000 times lower cost. The acceleration in information technology has also been made possible by startling advances in collectively developed open-source software (e.g., GitHub) and development of seamlessly interactive application programming interfaces (APIs). These APIs are the programming commands that allow you to save and send files, connect various web applications, buy stuff on-line, make apps, and permit individual computers to be networked – basically they make the Web the Web. Moreover, investments in ultra-fast transmission fiberoptic cabling coupled with introduction of 

 (CDMA) software to exponentially increase wireless capacity have allowed unprecedented and previously unimaginable levels of connectivity. 

The “cloud,” a vast network of computers spread across the globe, now stores, accesses, and shares data and permits software and services to run directly off the Internet, further amplifying acceleration of information technologies. Simultaneously, there have been dramatic improvements in computer sensors from cameras to detectors of motion, water pressure, energy consumption, engine performance, traffic congestion, temperature, global positioning, etc., all of which can broadcast their data, leading to the “Internet of things” and permitting both preventive and prescriptive maintenance (i.e., letting you know when a device will fail). In health care the Internet of things will generate 1 million GB of personal health information for each patient in her lifetime, which is equivalent to about 300 million books.

All these advances have vastly amplified the flow of data while reducing the complexity and cost of accessing it and accelerating the potential power of AI. One consequence for physicians is that a primary care doctor would need 630 hours per month just to keep up with the explosion of new literature.

 However, this accelerated flow of information affects all professions, contributing to the pervasive burnout being experienced across society.


	Friedman’s second great acceleration is globalization of the economy. Access to abundant and nearly free flows of information has led to many disruptive business innovations from Amazon, Lyft and Uber to Airbnb, all of which have displaced workers and whole industries across the planet. I recently received a harangue from a taxi driver in Nashville about the evils of Uber and what it had done to his income. While I sympathized with his plight, I realized he might as well be howling at the moon. Self-service whether it’s to create legal contracts, complete tax returns, book hotel and airline flights, or conduct real estate transactions has disrupted all those industries. Your iPhone is quickly replacing credit cards, and blockchain-derived currencies like Bitcoin may soon replace cash. Physicians will not be immune from this revolution. Wait till telehealth and facilitated self-service Internet-based medicine drive the provision of health care to the lowest bidder and soon we may be howling at the moon as well.

Access to abundant and free information also allows innovative start-ups to blossom from anywhere in the world where someone has sufficient training, a computer, and access to the Internet.

 Friedman notes that Massive Open Online Courses (MOOCs) are allowing poor students in rural India take some of the most advanced IT courses offered by top US colleges. Even manufacturers now crowdsource across the globe to optimize designs for new products. All this is fueling acceleration of the globalized economy. And restricting immigration will not limit the spread of innovative business disruption delivered via a new app developed by a creator in Turkey or Turkmenistan. Friedman points out that in 2014, $30 trillion in goods, services, and capital-equal to nearly 40% of the planet’s gross domestic product-crossed national borders, a 6-fold increase from 1990. And that does not begin to measure the impact of the free flow of information around the world. Tariffs may raise costs but are unlikely to stop that flow! 


	Freidman’s third great acceleration is climate change. The atmosphere now has 400 parts per million (ppm) of carbon dioxide, which is 50 ppm above the limit needed to prevent catastrophic global warming. Biodiversity is diminishing as deforestation has reduced the earth’s original forests to 62% while most climate scientists believe we cannot afford to dip below 75%. Pesticides and fertilizers are creating toxic algae blooms while ocean acidification is destroying our coral reefs and native fish populations. Desertification is a major threat to sub-Saharan Africa and drought is leading to crop failure in Central America. Climate change is also harming global health by driving alterations in vector ecology including expansion of pathogens such as malaria and Lyme disease, and arboviruses such as chikungunya, dengue, Zika, and West Nile. Additional adverse health effects accrue related reductions in drinking water quality, air pollution, and heat-related illnesses. 

Friedman also notes, ironically, that improved global health measures have reduced infant mortality, fueling population increases in impoverished lands already unable to fully feed, educate or employ their current populations. Overpopulation leads to over-farming, deforestation, and a growing scarcity of fresh water, which in turn worsen climate change. For example, Niger’s population in 1950 was 2.5 million, in 2016 it was 19 million, and by 2050 it is predicted to be 72 million, while the planet will have 9.7 billion inhabitants. 

Why adapting to change is so difficult for humans


	Since 2007, the pace of change in information technologies, economic globalization and climate change have all accelerated beyond Homo Sapiens’ ability to adjust their educational structures, economies, energy consumption, government regulations, and social safety nets to accommodate to them. Friedman argues that while technology platforms turn over every 5 to 7 years, it takes 10 to 15 years for humans to adapt to these new technologies. And this maladaptation is far greater in under-resourced countries that are also the most adversely impacted by climate change, leading to further impoverishment, famines, and mass migrations of primarily young men northward into Europe and North America.

 Thus, in these under-resourced areas it is women who are left behind on failing farms, often with no education and with elderly relatives and many young mouths to feed. Increasingly, though, women and children are contributing to the refugee crisis, exacerbating the adverse public health consequences of associated violence, accidents, inadequate nutrition, and lack of medical care. 


	So how do Americans and the citizens of industrialized nations cope with the disruptive impact of information technologies and a globalized economy? For example, how do ob/gyns and other physicians adjust to an era when medical knowledge doubles every 73 days such that between the start of medical school and the end of residency training, students will experienced three doublings of medical knowledge?7 The strategy is the same for physicians and plumbers. To remain viable in this new workplace, everyone must embrace lifelong learning by transforming AI into IA – which includes intelligent assistance and intelligent assistants.  

Friedman suggests that intelligent assistance is a way for government, employers, and, I would add, universities and academic health centers to provide powerful online learning tools to facilitate lifelong learning. New companies are already filling this niche (e.g., Udacity, edX, Coursera, Khan Academy) and LinkedIn has assembled a large repertoire of mini-courses to assist lifelong learning. Universities are offering MOOCs while medical schools and hospitals are expanding their professional development programs and simulation centers. For our part, 

 monitors current women’s health reports and pushes out summaries in our weekly e-newsletter while assembling various resource centers containing curated reviews. 

Intelligent assistants consist of the AI interface between humans and the tools they need to complete a job. (Think of a Da Vinci robot blocking you from ligating a ureter). In medicine, intelligent assistants could also consist of an electronic health record with AI-stoked decision support providing just-in-time and point-of-care access to relevant data needed to precisely choose the correct diagnostic test or prescribe the optimal personalized medication. It could also include AI-empowered search engines that not only search what you query but know what you don’t know and should be searching.

 Of course, when search engines decide what you should know, should do and should think, we will have even bigger problems! 

But what about the vast majority of the globe’s population who do not live in industrialized nations or worse, reside in failed states like Syria where chaos holds sway? It has been estimated that 4.5 billion people are either urban or rural poor. As noted, these parts of the globe are most affected by climate change and overpopulation, which is promoting collapse of their agriculture. They also have substandard educational systems, limited web access, and inchoate manufacturing sectors. This leaves millions of disaffected young men (and some young women) prone to join drug gangs, guerrilla groups or jihadists. While addressing climate change should be the planet’s top priority, Friedman suggests that in the short run we should focus on three simple remedies. The first is planting trees across sub-Saharan Africa to slow desertification (“the Great Green Wall”). The second is providing chickens to desperately poor families because chickens require minimal resources to maintain and can serve as both a source of protein-rich nutrition and modest income. But perhaps the best hope for these countries to escape the effects of the three “accelerations” is increased access to high-quality education for women. This will enhance economic development and help break the cycle of violence generated by disaffected young men who fall prey to irrational ideologies. Education should also help increase access to and use of contraception so desperately needed to break the cycle of poverty in under-resourced nations. 


	We live in the age of acceleration. Advances in information technology occur at a pace exceeding the human mind’s ability to adapt. This, in turn, is fueling acceleration of economic globalization and both trends are disrupting traditional employment models. Economic privation and climate change are also accelerating mass refugee migrations from under-resourced countries and failed states to Europe and North America fueling a toxic cycle of extremism, violence, and nativism. But humans created all three of these accelerations and if we embrace empiricism, rationality, and evidenced-based policies while eschewing baseless ideologies, mysticism, and fear, we have the power to mitigate their adverse impacts. In addition to addressing climate change by thoughtfully but expeditiously transitioning to renewable energy sources and promoting “reforestation”, we need to address accelerating technological complexity and economic globalization by embracing lifelong learning achieved through converting AI to IA. We must also pursue a global commitment to educating all the world’s women and providing universal access to contraception. 

We have the power to mitigate the adverse impact of rapid advancement in information technology.

Coping in the age of acceleration

Almost 25% of women with breast cancer have a family history of the disease, and women with an affected first-degree relative have a 1.75-fold higher risk of developing cancer.

That risk increases to 2.5-fold with two or more affected first-degree relatives. Multiple genes have been identified that are associated with breast cancer. While 

 have received much attention as they are linked to 20% to 25% of hereditary breast cancers and 5% to 10% of all breast cancers, 6 genetic testing has expanded to include 28 genes. The above table

presents the National Comprehensive Cancer Network (

) guidelines for genetic testing. Genetic counselors can be a good referral source, should there be a need for genetic testing. If no genetic counselor is available in your area, then referral to a breast surgeon is appropriate to discuss family history as well as a patient’s lifetime risk of breast cancer and need for genetic testing.

			For more information on breast health: 

Almost 25% of women with breast cancer have a family history of the disease and, those who do have a higher risk of developing cancer.

NCCN guidelines for genetic testing 

USPSTF and ASCCP recommend cytology screening every 3 years from ages 21 to 29

From ages 30 to 64, screening can be cytologic every 3 years or cytology with high-risk HPV testing every 5 years (co-testing) 

Pap testing can be discontinued at age 65 for those who have had previous negative smears

The same Pap smear screening guidelines should be followed in women who had the HPV vaccine

Women under 21 may need testing for STIs but that does not include a Pap smear or HPV testing

Key points for today’s ‘well-woman’ exam: A guide for ob/gyns

CDC recommends HIV testing all patients aged 13 to 64 

Testing should be performed annually on high-risk patients

High-risk populations include injection-drug users and their sex partners, individuals who exchange sex for money or drugs, sex partners of HIV-infected individuals, and heterosexuals if they or their sex partners have had ≥ 1 sex partner since their most recent HIV test

Annual testing for chlamydia and gonorrhea is recommended in sexually active women < 25, and those older who have a new partner, multiple partners or a partner with a STD

Type-specific HSV testing should be considered in patients who present for STI evaluation 

Hepatitis C testing should be done on women born between 1945 and 1965 and patients who are at high risk, including individuals on immunosuppressive therapy or hemodialysis or who are HIV-positive

ACS recommends screening average-risk patients at age 45 

Options include colonoscopy every 10 years, computed tomographic colonography or sigmoidoscopy every 5 years, take-home high-sensitivity guaiac-based FOBT or FIT annually, and multitargeted stool-DNA testing every 3 years 

A positive result on a non-colonoscopy test should trigger colonoscopy 

USPSTF recommends mammography every 2 years for women > 50

USPSTF does not recommend biannual screening for women aged 40 to 49 but ACP does

For high-risk women, ACS recommends annual screening with mammography and MRI beginning at age 30 

ACP recommends mammography every 2 years in patients with life expectancy ≥ 10 years

After age 75, according to ACP, the decision to continue screening should be based on a patient’s health status

ACP recommends limiting use of MRI to patients at high risk or to determine disease extent after diagnosis

The AHA-approved cut-off for diagnosis of hypertension is now 130/80 mg/Hg

The risk calculator (cvriskcalculator.com) should be used instead of LDL levels to determine whether use of statins is warranted

To determine need for statins in patients with a 10-year risk of 5% to 20%, coronary artery calcium scoring is recommended by the Society for Cardiovascular Computed Tomography

Screening for diabetes should be done after pregnancy and in patients who have hypertension, hyperlipidemia or obesity (aged 40-70)

For patients aged ≥ 45, a baseline fasting blood sugar and repeat screening at least every 3 years thereafter are recommended

Annual screening is recommended for patients who are overweight or have risk factors for diabetes

BMD should be performed in women > 65 with no risk factors for osteoporosis

Follow-up testing should be done every 2 to 5 years, depending on risk

 should be used to evaluate 10-year risk of fracture 

As more patients turn to ob/gyns for wellness exams, physicians need to stay up-to-date on current recommendations.

Author | Charles J. Lockwood, MD, MHCM

Articles

A fond farewell

Coping in the age of acceleration

NCCN guidelines for genetic testing

The 'well-woman' screening guidelines