DR. FUNAI is Associate Professor and Co-Chief, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, and Chief of Obstetrics, Yale-New Haven Hospital, New Haven, Conn.

Edmund F. Funai, MD

But physicians, too, are seeking government regulation to curb the excesses of managed-care companies and trial lawyers. Managed care has become an impenetrable colossus with arcane rules, while rising liability premiums have driven many obstetricians out of practice. Our specialty has not succeeded in collectively negotiating better payments from managed care or convincing the government to mandate standards for simplified credentialing and billing. We've had only spotty success with state and federal tort reform. 

So where is the silver lining in ob/gyn that I promised? It's the flip side of the perception of medicine as an industry. The negative connotation can become a positive when we use powerful tools from industry to improve patient safety in the health-care setting. We've all heard about the Patient Safety Movement and seen quotes from various Institute of Medicine reports that focus on the negative aspects. But how many of us have had the opportunity, for example, to take a class in communicating with nurses? It's time to get out of the "silos" we were assigned during training and explore how tools from the aviation and manufacturing worlds can help our patients. 

 has previously reported about a concept called Crew Resource Management (CRM) (see "Lessons from the cockpit: How team training can reduce errors on L&D [2006;Jan(51):34-45].) The idea was developed in 1979, in response to a NASA study of the contribution of human error to air crashes. It teaches techniques that empower all members of the team to point out safety concerns. On the tarmac, anyone from a baggage handler on up can stop a plane from taking off. Several organizations offer a formal CRM program developed for medicine, with specific obstetrics-related content.  

Hospitals have also taken a page from the manufacturing world in the form of performance management programs. One approach is to use Six Sigma: a methodology developed by Motorola that focuses on controlling a process to the point of ± six sigma (standard deviations) from the mean, or less than 3.4 defects per million opportunities. When a "broken" process is identified, the repair process follows a "DMAIC" approach: Design, Measure, Analyze, Improve, Control. CRM and Six Sigma are both predicated on the notion that individuals rarely fail on their own; it's usually the system that breaks down. 

At some point during your career, you've probably been asked why you chose medicine. The answer, for most us, is some variation on helping people. It's easy to lose sight of that goal with all the pressure on our specialty today. Like it or not, medicine has evolved since we entered training. On the bright side, change has meant development of novel tools that may actually lead us to better patient care. 

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Anyone who's been practicing ob/gyn for more than 20 years knows that our profession has changed tremendously, and largely to our great frustration.

Edmund F. Funai, MD

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