The scientific approach to categorizing mesh complications, as well as optimal methods to address them, have been complicated by the rapid proliferation and evolution of materials and techniques that have been used over the past 20 years in surgical treatment of pelvic floor disorders. 

In addition, terminology used to diagnose and categorize mesh complications, as well as the descriptions of surgical procedures to manage them, have been adopted inconsistently, further hampering development of a collective experience with a standardized lexicon. 

Finally, much of the high-quality data on management of mesh complications is based on materials that are rarely used or not commercially available today.

Women experiencing mesh complications need to be heard, and should have access to resources and providers who are most able to help. Many women require multiple procedures to address their mesh complications, and for some of these patients, relief is incomplete. 

We should strive to optimize the treatment at the initial diagnosis of a mesh-related complication.

: Using the best and most relevant evidence available, provide guidance for the FPMRS subspecialist caring for patients who may be experiencing mesh complications.

: Provide an algorithm outlining treatment choices for patients with mesh-related complications that can be used as a platform for shared decision-making in the treatment of these complications.

: Identify and prioritize gaps in evidence concerning specific mesh complications and their treatments.

: Identify provider and health facility characteristics that may optimize the outcomes of treatments for these complications

The treatment algorithm requires consistent and accurate terminology for treatment procedures, as follows:

: either no mesh is removed (e.g., dissecting and primarily closing vaginal epithelium), or a small edge of mesh is removed such that the structural integrity of the implant is left intact.

: a segment/component of the mesh is removed or transected, such that the structural integrity of the implant is altered.

 removal of segments or components of mesh beyond, or not in contact with, the vagina

the surgical goal is the removal of 100% of the implant; extirpation.

The treatment algorithm is presented, along with the level of evidence supporting each decision node. Recognizing that some patients will require more than one procedure, the recommendation is made that treatments are not repeated; if a given treatment is unsuccessful, consideration should be given to advancing to the next item on the algorithm.

Full text of “Management of Mesh-Related Complications for the FPMRS Specialist” can be found 

This was created in partnership with the American Urogynecologic Society (AUGS). AUGS was established in 1979 and represents more than 1,900 members, including practicing physicians, nurse practitioners, physical therapists, nurses and health care professionals, and researchers from many disciplines.

Articles

The American Urogynecologic Society (AUGS) released new information on managing mesh problems, which includes guidance, treatment algorithms and ways to optimize treatment outcomes for these complications.

AUGS Consensus Statement: Managing mesh problems

In the throes of COVID-19, with cases continuing to increase daily at my hospital, we are now further stressed with the brutal death of George Floyd, an African American whose death at the hands of law enforcement, while pleading that he could not breathe, is immortalized in a visceral video. 

His death and those of others has spurred nationwide protests against systemic racism that are colliding with attempts to mitigate the COVID-19 pandemic. With these crises on multiple fronts, we face increased tensions, anxiety, and stress.

COVID-19 has resulted in myriad changes and heightened anxieties, especially for patients of mine who are among the hardest hit. With schools no longer open, their children are home – as often are their spouses, as their jobs are lost and wages scarce. 

To add to this burden, we as a society are recognizing that we do not treat people equally, and just as the slogan “Black Lives Matter” says, we need to recognize that systemic racism and implicit bias are an issue and need to be addressed directly. 

Furthermore, COVID-19 disproportionately impacts people of color, another blow we must mitigate.

Nearly every professional society I belong to has launched campaigns and sent emails highlighting a zero tolerance policy of racism, for example:

“The American College of Obstetricians and Gynecologists (ACOG) is committed to eliminating disparities in women’s health and to confronting implicit and explicit bias and racism. This means recognizing and examining our own prejudice and bias and addressing the way in which health care systems perpetuate inequality.”

“The Society for Maternal-Fetal Medicine (SMFM) recognizes the impact of racism and is committed to working towards the elimination of the racism and health inequities that impact our members and the patients they serve.”

“The American Board of Obstetrics and Gynecology (ABOG) stands in solidarity with our health care community in opposition to the institutional racism, discrimination, and violence that has plagued the country for so long.”

As healers, Alpha Omega Alpha (AΩA) condemns racism and bias in all forms, including police brutality. Racism, discrimination, and social injustice are barriers in the care of patients and public health. 

AΩA stands with and cares for people of all races, ethnicities, and gender identities. In these times of crisis for our country and world, we must guide medicine to be unbiased, open, accepting, inclusive, and culturally aware in order to be worthy to serve the suffering.”

In addition to stating their support and the importance of these issues, these professional societies are committing to action. 

SMFM is educating their members and collaborating with other groups to promote policies to improve access to care and advocating for research. 

AΩA, a medical honor society, has a new award for excellence in inclusion, diversity, and equity in medical education and patient care.

Both COVID-19 and racism have far-reaching impacts politically and medically. It is imperative that we as providers highlight these impacts, recognizing the serious consequences that may follow. 

A household survey by the Centers for Disease Control and Prevention that was intended to monitor anxiety and depression in the setting of COVID-19 – an important metric given the social distancing and isolation – takes on new meaning now.

 Anxiety and depression have tripled in the last year, with US rates for anxiety around 8% in 2019 and over 30% in 2020 (Figure 1). 

Importantly, the rates of anxiety vary notably across racial groups, and those of mixed race have the highest rates with the ongoing demonstrations and protests. During the pandemic, women are reporting more anxiety than are men. 

In addition, people of reproductive age have the highest rates of anxiety (Figure 2). As the initial collision of crises passes, it will be vitally important to understand the impact going forward.

Critically, as the movement to raise awareness of social injustice and racism escalates, the rates of cases of COVID-19 continue to increase – the directionality of the interrelationship is unclear.

Unfortunately, they are not mutually exclusive, and the critical need to raise awareness clashes with the social isolation needed to quell the spread of COVID-19. Neither is more important, neither is less.

As I round on my antepartum patients, I have a new routine speech. It is hard to live in the world today, much less to be pregnant. Being hospitalized without visitors, juggling the media and messages of racism with the need for social distancing, does not easily allow for a healthy mental or physical state. 

I listen, try to understand, and offer the services of psychiatry and psychology to provide some attempt at mental balance, although far from normalcy. 

We discuss that this is situational, not specific to my patients, and they may benefit from external support. In truth, 

American College of Obstetricians and Gynecologists. Our commitment to changing the culture of medicine and eliminating racial disparities in women's health outcomes. Available at 

https://www.acog.org/about/our-commitment-to-changing-the-culture-of-medicine-and-eliminating-racial-disparities-in-womens-health-outcomes Accessed June 15

Society for Maternal-Fetal Medicine. SMFM issues a statement to its membership on racism as a publichealth crisis. Available at 

https://s3.amazonaws.com/cdn.smfm.org/media/2391/Racism_Statement.pdf

American Board of Obstetrics and Gynecology. ABOG statement on racism. Available at 

https://www.abog.org/about-abog/news-announcements/2020/06/03/abog-statement-on-racism

Alpha Omega Alpha Honor Medical Society. Statement on inclusion, diversity, equity, and service in the profession of medicine. Available at 

https://www.alphaomegaalpha.org/#gsc.tab=0

Centers for Disease Control and Prevention. National Center for Health Statistics. Household Pulse Survey. Available at 

https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

As a pandemic and protests converge, there is a need to recognize long-term effects.

A Collision of Crises

According to the Centers for Disease Control and Prevention (CDC), racial and ethnic minority communities have been disproportionately affected by the virus. In health care, it is impossible to treat patients without acknowledging these disparities.

, Editor-in-Chief Catherine Y. Spong, MD, addresses implicit bias and makes the connection with COVID-19 in “

As we prepare for a potential second wave of illness in the fall, our new website will continue to reflect the ever-evolving landscape. It launched on June 12, and streamlines our industry-leading content for a more concise, reader-friendly user experience. 

We are eager to hear your feedback. As we continue to evolve with each generation, we hope to continue to provide practicing ob/gyns with the exceptional clinical, peerreviewed content they look for. 

We would also like to announce the launch of our new podcast, Pap Talk, a weekly medical podcast that features in-depth interviews, treatment advice, commentary from industry experts and more. 

 page to learn more, and don’t forget to subscribe on Apple Podcasts, Spotify, or wherever you listen. And, as always, let us know your thoughts by contacting Senior Editor Angie DeRosa at aderosa@mjhlifesciences.com.

The COVID-19 pandemic has been at the top of everyone's mind for the past several months. More recently, social justice has taken the spotlight.

Chairman's Letter: Website overhaul, podcast & more

A 21-year-old G2P1001 was admitted on July 28 at 38 weeks, 4 days’ gestation for labor induction for a suspected large for gestational age (LGA) baby. The patient’s original estimated date of deliver was August 22. 

An ultrasound at 19 weeks, 6 days adjusted her date of delivery to August 7. The patient had a normal antepartum course, with normal antenatal screening, and normal glucose screening at 28 weeks’ gestation.

Two years earlier, the patient had given birth to an 8 lb, 10 oz male at term via an uncomplicated vaginal delivery with a three-degree extension.

During the current pregnancy, she was admitted at 33 weeks 0 days for possible preterm labor. Visual exam revealed a friable cervix, with 

. The patient was observed for approximately 21 hours, during which she received a dose of subcutaneous terbutaline, which led to diminished contractions, without significant cervical change. 

She was given a course of steroids and discharged on clindamycin and metronidazole.

On admission for labor induction on July 28, the patient’s diagnosis was advanced cervical dilatation and LGA. The admission history and physical documented a vertex presentation, with a cervix 3-cm dilated, 50% effaced, and a -2 station. The woman’s pelvis was described as “adequate.” 

Documentation did not include an estimated fetal weight (EFW). Induction proceeded with intravaginal prostaglandins, inserted at 7:30 am, with regular contractions beginning approximately 40 minutes thereafter. Fetal heart tones (FHTs) revealed a Type 1 pattern, with a baseline fetal heart rate (FHR) in the 140s. Augmentation of the patient’s labor with oxytocin was begun, at 2 mU/min.

Approximately 4 ½ hours later, at 12:05 p.m., the physician examined the patient. At that time, with oxytocin at 10 mU/min, her contractions were every 1 to 2 minutes, 60- to 70-mmHg in strength, with a continued Type 1 pattern. Her cervix was 4-cm dilated, 50% effaced, at a -2-3 station, with an occiput posterior position. Amniotomy revealed a small amount of clear fluid, and an internal FHR electrode was placed. 

An epidural was placed shortly thereafter. At 1:55 pm, with oxytocin at 12 mU/min, the patient’s cervix was 7- to 8-cm dilated, 90% effaced, at a 0+1 station. FHTs were in the 140s and, despite minimal variability, no decelerations were observed. At 3:45 pm, examination revealed a cervix with an anterior lip. 

No mention was made of the fetal station. The patient began pushing at 4:45 pm. FHTs were stable. The physician remained in the room while the patient pushed. Severe variable decelerations to the 60s started at 5 pm and the head was delivered at 5:10 pm and spontaneously rotated from right occiput posterior to occiput anterior position. The body did not immediately deliver. 

A McRoberts maneuver was used for 2 minutes and various maneuvers were performed to resolve a 6-minute shoulder dystocia. Fundal pressure was applied to assist with delivery of the body, which was accomplished at 5:18 pm. An 11 lb, 12 oz (5335 g) male was delivered with Apgar scores of 1, 6, and 8, at 1, 5, and 10 minutes, respectively. The arterial cord gases were pH = 7.19; pO2 = 23; pCO2 = 60; base excess = -7.0.

Also described was an appropriate repair of a three-degree extension.

Subsequently, placental pathology revealed focal, mild, chronic non-specific chorionitis.

The newborn examination revealed bruising of the baby’s ears, face, chest, and right underarm. The right underarm bruising was consistent with traction to the armpit. There was no movement of the left arm. 

 while the pediatrician could not rule out a dislocation of the right shoulder. The left shoulder would have been the anterior shoulder at time of delivery. The baby had a low blood sugar at 37 and required an infusion of dextrox 10% in water.

The baby was transferred to an academic medical center. The admission physical revealed no movement of the left upper or lower arm. Radiologic studies revealed no dislocation of the left or right shoulder. 

revealed avulsion of the nerve roots on the left at C8 to T1, with mild displacement of the cord to the right. There was a possible subarachnoid hemorrhage. A cranial ultrasound was normal. Computed tomography of the head revealed no evidence of intracranial hemorrhage or displacement of the midline sutures. There was swelling on the right side of the face with minor asymmetry of the coronal suture.

A neurology consult confirmed Erb’s palsy, with a significant avulsion injury and complete left brachial plexus palsy. The neurologist opined that other roots may be torn more distally. There was probable right Horner’s syndrome, right torticollis, and a hoarse voice suggestive of laryngeal paresis.

Despite intensive physical therapy, there was no recovery of the function of the left upper extremity over 5 months, associated with mild ptosis of the left eyelid and ipsilateral pupil, consistent with Bernard-Homer Syndrome. 

The baby was referred to a pediatric neurosurgeon at another academic institution and underwent left brachial plexus exploration and external and internal neurolysis approximately 11 months after birth. Nerve grafting was not performed, as intraoperative electrical stimulation of the musculocutaneous nerve produced some visible and palpable contractions of the biceps brachii, and stimulation of the accessory nerve produced a similar response of the left deltoid muscle. 

Six weeks after surgery, the child was able to partially extend the elbow and flex his fingers. 

, there was no flexion at the elbow or extension of the fingers. Neurosurgery follow-up 4 months later (5 months postoperatively) identified no further recovery. The child continues with physical therapy.

Following discovery, the defense elected to proceed with trial, as the case was deemed highly defensible.

At trial, the plaintiff’s experts noted that induction of labor for a LGA baby is not recommended by the American College of Obstetricians and Gynecologists (ACOG). Lack of an estimated fetal weight, either clinically or with ultrasound, was a breach of the standard of care. Had the physician estimated the weight as at least 5000 g, 

a primary cesarean delivery should have been pursued

Even with an estimated fetal weight > 4500 g, the risk of shoulder dystocia is up to 50%. The baby suffered permanent irreversible injuries that will require long-term physical and occupational therapy. The child will never have a normal life.

The defense experts testified that shoulder dystocia cannot be accurately predicted or prevented. None of the risk factors for macrosomia were present in this case, including preexisting diabetes and gestational diabetes, maternal obesity, excessive gestational weight gain, or abnormal antepartum glucose screening. 

The patient’s first baby weighed 8 lb, 10 oz or 3934 g and was delivered vaginal without difficulty. There was no clinical evidence of macrosomia, noting that the fundal height at 38 weeks was 39 cm.

Although an estimated fetal weight was not documented, the obstetrician deemed that the mother’s pelvis was adequate, evidence that there was consideration of the estimated fetal weight. 

Clinical and ultrasound estimates of fetal weight are poor indicators of actual fetal weight. Ultrasound is, at best, accurate to within 10% in estimating weight, and worse with larger babies.

Induction of labor is controversial. Earlier studies show an increased cesarean rate without a significant reduction in shoulder dystocia. Recent studies show induction of labor results in a four times reduction in the rate of shoulder dystocia. 

 even a primary cesarean delivery does not eliminate the risk of birth trauma and neonatal brachial plexus injury associated with macrosomia.

Further, most macrosomic babies do not experience shoulder dystocia. Finally, brachial plexus injuries can occur as a result of intrauterine positioning, not just a result of a shoulder dystocia.

The patient rapidly entered active labor following induction. She did not experience a prolonged labor, a prolonged second stage, nor was operative delivery required. Once the shoulder dystocia was encountered, all maneuvers were appropriate. The shoulder dystocia lasted 6 minutes, which is not an extended time. 

The umbilical cord gases were normal, evidence that the baby did not suffer any hypoxic compromise. The clinician’s contemporaneous documentation was excellent.

During rebuttal, the plaintiff’s experts again criticized the care, particularly the lack of documentation of an estimated fetal weight. If the estimated fetal weight had been less than 5000 g, attempting a vaginal delivery could have been justified. 

However, had the estimated fetal weight been 5000 g or greater, according to ACOG, a primary cesarean delivery should have been performed. The baby weighed 5335 g and thus, a cesarean delivery should have been performed. 

Further, in managing the shoulder dystocia, the documentation states, “the slightest amount of downward traction” was applied. Avulsion of the nerves does not occur without the application of excessive, improperly directed force. Avulsion injuries are not a result of intrauterine positioning. 

The baby has permanent injuries with paralysis of the left arm and distortion of his face, which will result in lack of social acceptance in the future. 

Defense experts testified that ACOG only states that a scheduled cesarean delivery may be beneficial and does not mandate that it be performed. The ACOG recommendations are based on expert opinion, not randomized trials. 

During the reparative surgery, there was evidence of some nerve conduction, thus the current disabilities may still respond to therapy in the future.

After 6 hours of deliberation, the jury found for the plaintiff, awarding $3.5 million.

This case was defensible, except for two major issues

: the lack of a pre-induction estimated fetal weight and the resulting nerve avulsion. The lack of an estimated fetal weight is not uncommon in shoulder dystocia cases resulting in litigation. Even though inaccurate, a clinical or ultrasound-based estimated fetal weight should be included in the initial assessment of all patients, whether for induction or in labor. Documentation of an estimated fetal weight, even if inaccurate, renders cases more defensible. 

Lack of such documentation, as in this case, is a major obstacle to successful defense. Avulsion of the nerve roots on the left at C8 to T1 was an additional impediment to successful defense. Plaintiff attorneys who frequently litigate shoulder dystocia cases often pursue only cases with nerve avulsion, as the forces required to cause avulsion have been shown to exceed the forces associated with the typical maneuvers used to manage shoulder dystocia. 

Further, avulsion injuries rarely recover spontaneously and require early surgical intervention, which if not successful, result in permanent disabilities. 

, the presence of the child in the courtroom throughout the trial was a constant visual reminder of his life-long disabilities.

This case involves induction of labor for a suspected large for gestational
age (LGA) baby in a mother with a normal antepartum course.

Shoulder dystocia: The unpredictable nightmare

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.

Introducing Dr. Millennial

Though her face was covered with a mask, her frustration was clear. As a 38-year-old woman who had recently moved to the United States with her husband for an exciting job opportunity, she has been taking combined oral contraceptives (COCs) reliably for the past 20 years with no pregnancies. 

In Brazil, she would simply walk into her neighborhood store and buy a pack of COCs along with her shampoo. She had known for her whole life that she didn’t want children and remained highly motivated to avoid pregnancy, especially now that she is in America and had a chance to further her career beyond what she could achieve in Brazil.

I met her amid a global pandemic, as she had been granted an urgent appointment to our otherwise closed outpatient clinic due to an early undesired pregnancy. The last physician she saw would only provide her with 1 month of COCs to carry her over until she could be seen for an annual exam. 

This single pill pack ended as the COVID-19 pandemic reached our state and the stay-at-home order was initiated. She was unable to get a refill from the initial prescribing physician and, though she tried to be careful, ultimately conceived.

The current COVID-19 pandemic has amplified the existing unnecessary barriers to contraception, much to the detriment of women. My patient wasn’t alone in her interest in over-the counter (OTC) contraception. 

A survey nearly 10 years ago in the United States demonstrated that two-thirds of women were in favor of the concept and one-third would utilize it themselves.

A recent survey of over 2,000 women and 500 adolescents in the United States revealed that nearly 40% and 30% of each group would be interested in OTC progestin-only pill (POP) access.

Now is the time to give women like my patient access to hormonal contraception over the counter.

In the United States, there are an estimated 43 million women at risk of unintended pregnancy.3 Prescription-based contraceptive methods are actively used by nearly one-third of contracepting women, and four of five sexually experienced women have used an oral contraceptive (OC) pill at some point in their lifetime.

Although physicians are typically most familiar prescribing OCs, the transdermal patch, and the monthly vaginal ring, there is also a self-administered subcutaneous form (104 mg) of depot-medroxyprogesterone acetate (DMPA) that can be directly prescribed to women.5 

With the subcutaneous formulation, women can self-inject their DMPA via a small 3/8-inch needle without requiring an in-person visit for the standard 150mg intramuscular injection (Figure 1).

Barriers to accessing hormonal contraception

Unfortunately, women experienced a multitude of barriers to prescription-based contraception long before the COVID-19 pandemic. One large survey of US women currently on prescription methods including OCs, the transdermal patch, and monthly vaginal ring, revealed that one-third of them had experienced access barriers while initiating or continuing their chosen method.

Of the women who reported barriers, the vast majority (62%) were related to the physical need to see a provider in an office to obtain a prescription. Other factors such as cost (25%), pharmacy access (7%), and non-specified barriers (6%) were significantly less common.

Our specialty has successfully overcome the limitations of prescription status on access to reproductive health services, specifically in the context of oral levonorgestrel emergency contraception. Although initially prescription-only when approved by the US Food and Drug Administration in 1998, oral levonorgestrel emergency contraception (EC) was given OTC status in 2006 for women age 18 and above.

In 2013, the age restriction was removed so anyone with reproductive potential could access this form of EC.

“This wouldn’t have happened if I was still in Brazil!” exclaimed my patient.

Vol 65 No 07

AUGS Consensus Statement: Managing mesh problems

A Collision of Crises

Chairman's Letter: Website overhaul, podcast & more

Shoulder dystocia: The unpredictable nightmare

Introducing Dr. Millennial

Now is the time for over-the-counter hormonal contraception

Discussing patients' sexual concerns

Smoke evacuation in the age of COVID-19