Dr. Goldstein is Professor of OB/GYN, Co-Director Bone Density Medical Unit, New York University Langone Medical Center, New York, NY.

Steven R. Goldstein, MD, CCD NCMP, FACOG, FRCOG(H)

Problems in the specialty go beyond malpractice worries

I am an ob/gyn in private practice in Hartford, Conneticut. I read Dr. Copel's May 2012 editorial ("Are we sending the wrong message to future ob/gyns?") with some interest, and have considered his remarks. the number of malpractice cases . led in Connecticut has remained remarkably stable over the last 20-plus years, so the notion of an imagined "malpractice crisis" is correct.  

Dr. Copel hits another bull's eye with his assertion that ob/gyns complain openly, and we make no e. ort to conceal our frustrations. But I am persuaded that there are several "elephants in the room" that go to the heart of why our profession is viewed unfavorably by physicians in training. 

If one considers time a commodity, this career uses considerably more time than many other specialties. It is a beautiful profession, as Dr. Copel suggests. But some of the most beautiful moments happen in the middle of the night, after many hours spent in labor and delivery. The image of several obstetricians waiting together in labor and delivery at 3 am for their respective patients to deliver is all too familiar. the residents and medical students are acutely aware that the attending physicians are routinely working hours that far exceed those permitted for physicians in training. While our literature has infrequently reported on the inevitable cognitive degradation that must accompany sleep deprivation, no one disputes that sleep deprivation impairs cognitive and physical performance. the plaintiff's attorneys have no problem convincing juries that sleep-deprived physicians are more prone to make mistakes while on the job. 

Many other specialties have established hospitalist models that allow those physicians facing a full day in the office or the operating room to get an adequate amount of sleep the night before. In our specialty, we have lagged behind in establishing hospitalist/laborist models. How many obstetricians have performed a cesarean section while chugging along on 24-plus hours of little or no sleep? the residents and medical students are very aware of what we are doing. the medical students are also aware that patients typically do not realize how long their docs have been without sleep. Medical students are well able to appreciate that the clinical time demands of our profession far exceed those of many other specialties. 

What the future holds with respect to the rollout of the Affordable Care Act, the Supreme Court's decision on the individual mandate, and the formation of Accountable Care Organizations (ACOs) is unclear. But one thing is obvious to everyone: the field of women's care is facing uncertainty. Politicians have shaken the foundations of our  field with their recent discourse on access to birth control, and health insurers have been steadily pushing back on routine testing.  

Articles

Letters discuss the myriad of issues affecting the practice of specialties. Joshua A. Copel responds.

Letters to the Editor

Why perform any procedure that can cause intrauterine scarring?

Dr. Steven Goldstein originally was against global endometrial ablations (GEA) because he found that post-ablation intrauterine scarring made it "virtually impossible" to evaluate patients who returned with abnormal uterine bleeding ("It takes a big man to admit he's wrong," April 2012). 

He changed his mind after 10 satisfied post-ablation patients were referred to him by Cooper Surgical. Five had a radiofrequency ablation and 5, a cryoablation. On sonohysterogram (SIS), he found after cryoablation the endometrial cavities were extremely small and shortened but easily evaluated compared with radiofrequency ablation. 

Turnbull, et al did an MRI study following endometrial resection/ablation and found that over 90% of patients had persistent or regenerating endometrium in the upper fundal or cornual area, 18% had cornual hematometra, and 54% had evidence of significant retrograde bleeding.

  If the MRI is done during the menstrual phase of the cycle, cornual hematometra, hematosalpinx, and/or significant retrograde bleeding also can be demonstrated. 

We also agree that patient selection is critical. Global endometrial ablations should not be done in high-risk patients for subsequent endometrial cancer. Unfortunately, this is not fail-safe because 50% of patients who eventually develop endometrial cancer have no risk factors. 

An important question is: In treating intractable uterine bleeding, why perform any procedure that can potentially cause intrauterine scarring and contracture when a levonorgestrel-releasing intrauterine system (LNG IUS) or partial endometrial ablation can successfully treat menorrhagia without causing any intrauterine scarring? 

All of the above is thoroughly discussed and documented in a recent review article titled, "Long-Term Complications of Minimally Invasive Endometrial Ablation Devices."

				
			SUTTER INSTITUTE FOR MEDICAL RESEARCH 
			 SACRAMENTO, CA 

				
			CLINICAL PROFESSOR, UNIVERSITY OF CALIFORNIA DAVIS, SCHOOL OF MEDICINE 

Turnbull LW, Jumaa A, Bowsley SJ, Dhawan S, Horsman A, Killick SR. Magnetic resonance imaging of the uterus after endometrial resection. 

McCausland AM, McCausland VM. Long-term complications of minimally invasive endometrial ablation devices.

Letters discuss global endometrial ablations, intrauterine scarring, and disagreements over cancer biomarkers. Steven R. Goldstein and Andrew John Li respond.