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.

Articles

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

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.

 After transitioning to OTC status, adult use of oral levonorgestrel EC increased from 4% of women in 2002 (prior to OTC conversion) to 11% of women by 2010, amounting to a total of 5.8 million women who had ever used this product.

Since the day-to-day intricacies of women's lives vary tremendously, we need a multitude of ways that they can access their preferred contraceptive method. Some women may still prefer in-office visits, but our experience with the OTC transition of oral levonorgestrel EC showed that women need the option to buy contraceptive methods directly off the shelf.

As an intermediate step toward OTC status, some states have given pharmacists the ability to provide hormonal contraception directly to people without a prescription from a provider. Through this behind-the-counter model, the pharmacist performs a risk assessment and sometimes a blood pressure measurement prior to dispensing combined hormonal contraception (CHC) (COC), transdermal patch, monthly vaginal ring). 

The most recent tally shows that 13 states along with Washington, D.C., allow pharmacists to directly dispense some types of hormonal contraception.

 Nuances of behind-the-counter provision vary. Only nine of these states (along with Washington, D.C.,) allow the pharmacist to give the method directly to the patient without any prescriber involvement.

Four states actually require a collaborative practice agreement between pharmacists and providers, creating another possible barrier.

Though a step in the right direction, behind-the-counter hormonal contraception still has its limitations. Pharmacist reimbursement for their patient assessment and counseling has also been a logistical obstacle and potential disincentive.

These visit costs can get passed down to patients. In addition, we know that women experience pharmacist objection to dispensation of reproductive health products such as EC and this is will likely occur with other contraceptive products.

A variety of health care organizations and private companies have tried to address theseaccess barriers and created systems of online contraceptive consultation with mail-order products. Women undergo standard health screening, with variation in other requirements like recent blood pressure measurement. 

Sites also often charge women a separate consultation fee and vary in insurance acceptance. Importantly, women may find it difficult to obtain a clear estimate of insurance coverage. Some sites offer a clear low-cost cash option so women can gauge this option as a back-up if their insurance coverage is limited.

Online hormonal contraceptive access is a convenient option for many women, but there is still a large cohort for whom this is not an option. Access to online hormonal contraception changes depending on which state a woman orders her method from since legal restrictions vary widely. 

States with restricted online contraceptive access are typically those with restrictive laws regarding in-person contraceptive provision or insurance coverage, so online access cannot totally overcome geographic disparities.

Though most women have Internet access to visit these websites, translating the online encounters into actual in-hand contraception can pose additional challenges. Requiring an electronic method of payment may be a barrier to some people. Women and adolescents can have challenges obtaining electronic methods such as credit cards for a wide range of reasons. 

Privacy is still a risk with obtaining online contraception, whether through the electronic record of the transaction or the risk of a package being opened or intercepted at home. Those facing reproductive coercion or domestic violence are particularly at risk and lose the opportunity to have their method in hand right away so they can take necessary precautions. 

The need for a stable mailing address also poses a barrier to those with housing instability. In the COVID-19 pandemic, widespread shipping delays can lead to gaps in contraception and thus pregnancy risk. Only OTC availability can give women rapid access to hormonal contraception that they can control immediately from time of acquisition.

Even before the COVID-19 pandemic abruptly exacerbated contraceptive access barriers, the American College of Obstetricians and Gynecologists (ACOG) published a committee opinion in support of OTC hormonal contraception 8 years ago.

 In the realm of oral contraceptive access, the OTC movement has been long in existence, with a broadly inclusive, multidisciplinary OC OTC working group founded over 15 years ago.

Professional organizations providing their support include ACOG, the American Academy of Pediatrics, American College of Nurse-Midwives, American Nurses Association, Association of Physician Assistants in Obstetrics & Gynecology, and Society of Adolescent Health and Medicine.

A wide range of reproductive health advocacy groups and justice organizations serve as partners in addition to university-based researchers and experts in the field.

 The American Academy of Family Physicians has maintained a clear position statement in favor of OTC hormonal contraception and makes the important distinction that insurance should provide coverage for these medications regardless of prescription or OTC status.

Despite long-standing interest in OTC hormonal contraception, we are greatly limited in our ability to conduct research due to FDA restriction of these medications as prescription-only.

As a result, we draw upon a growing body of literature from international contexts to supplement our domestic survey research. It is important to note that the United States is in the minority when it comes to restricting hormonal contraception to prescription-only status, with one global assessment revealing that only 45 of 147 countries have this limitation.

On a population level, the majority of the world’s population resides in countries with OTC access.

 Although OTC access is a common approach to hormonal contraception, there are important safety considerations as with all medications.

Switching a prescription-only hormonal contraceptive to OTC would require initial action from drug manufacturers. The company would need to submit a new drug application to the FDA that includes a risk assessment of the medication when accessed OTC and a risk-benefit assessment for consumers. 

Medication label and package inserts will be particularly important with OTC hormonal contraceptives as they would include self-screening instructions along with typical dosing and adverse effect information. Drug manufacturers and the FDA would need to ensure this information is comprehendible based on consumer reading levels and that it translates to correct contraceptive use.

Hormonal contraceptives are safe for the vast majority of women and adolescents. In a switch from provider-guided assessments, OTC provision will require individuals to self-screen for their own eligibility for both progestin-only and combined estrogen/progestin methods.

Venous thromboembolism (VTE) risk is a common safety concern with hormonal contraceptives. Fortunately, progestin-only methods, which include the progestin-only pill and subcutaneous depot-medroxyprogesterone acetate injection, carry no or minimal risk of VTE and do not require any in-person evaluation prior to initiation.

Estrogen-containing methods, which include COC, monthly vaginal ring, and transdermal patch, do carry a comparatively increased VTE risk in certain populations.

 However, the marginal increase in VTE risk among COC users is significantly lower than pregnancy or the postpartum time period.

OTC hormonal contraceptives would contain a checklist that potential purchasers could use to screen for medical conditions that would caution against self-use of these medications, particularly those that contain estrogen (Figure 2). 

Overall, studies have demonstrated that women tend to overestimate the risk of hormonal contraception and are more likely to restrict their own use more than what a medical provider would recommend. In one study, 6.9% of women reported contraindications to combined hormonal contraception while only 2.4% actually had a real contraindication on chart review.

Women in one study in the United Kingdom were so accurate in their self-assessment that none of the over 300 women included would have taken hormonal contraception contrary to medical guidelines.

Women could also be provided with guidance to determine whether they can be reasonably certain they are not currently pregnant.

 Some women may fall outside of these criteria and it is possible that they could start hormonal contraception with a clinically unrecognized pregnancy. 

Since these methods can alter women’s bleeding patterns and their overall suspicion for pregnancy, women who are not completely certain they aren’t currently pregnant could quick start their method and take a home pregnancy test in 2 weeks.

Additional guidance for backup contraception could be provided. Fortunately, if a woman does take hormonal contraception while pregnant, the exogenous hormones should not harm a developing pregnancy in the event she desires pregnancy continuation.

Contraceptive visits are often a time to review other aspects of a woman’s health. The Centers for Disease Control and Prevention’s 2016 

U.S. Selected Practice Recommendations for Contraceptive Use

 (SPR) advises against withholding contraception for breast exams, pelvic exams, sexually transmitted infection testing, or cervical cancer screening.

Though the SPR does recommend blood pressure measurement prior to starting estrogen-containing methods, women could use assessment from a recent health care visit or perform a self-measurement at a pharmacy or at home.

Decreased cost could be an additional benefit of OTC hormonal contraception since women would avoid office visit fees. The Affordable Care Act (2010) provided a federal contraceptive coverage guarantee that required private health plans to cover all 18 methods of FDA-approved contraception without co-pay or deductible.

General insurance coverage was also extended to dependents under the age of 26, spanning a large number of adolescent and adult contraceptive users.

Some states expanded contraceptive coverage, with 20 states and Washington, D.C., requiring insurers to cover dispensation of an extended supply of contraception at one time.

Given recent attempts by the current federal administration to weaken the contraceptive coverage guarantee, women may face cost concerns about whether their method is obtained with a prescription, from a pharmacist, or OTC. 

For policymakers, transitioning hormonal contraception to OTC status should not free it from insurance coverage. The place that a woman accesses her method should not be linked to the amount an insurance company will cover for the same medication.

As we navigate the global COVID-19 pandemic and anticipate our new normal, we need to ensure access to contraception. Reproductive planning is complex at baseline and a person’s interest in becoming pregnant may alter depending on their own personal experience during this time. From financial to medical concerns and everything in between, risk-benefit calculations regarding pregnancy will change.

Now is the time for drug companies to pursue OTC status for hormonal contraception. We need to empower people like my patient in their execution of their reproductive goals. With all the uncertainty in the world, access to hormonal contraception should be ensured.

Grossman D, Grindlay K, Li R, et al. Interest in over-the-counter access to oral contraceptives among women in the United States. Contraception. 2013; 88:544-52.

Grindlay K, Grossman D. Interest in over-the-counter access to a progestin-only pill among women in the United States. Women’s Health Issues. 2018; 28(2): 144-51.

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Pfizer. Depo-SubQ Provera 104 (medroxyprogesterone acetate) injectable suspension, for subcutaneous use [package insert]; 2019. U.S. Food and Drug Administration website 

https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021583s031lbl.pdf

Grindlay K, Grossman D. Prescription birth control access among U.S. women at risk of unintended pregnancy. J Womens Health (Larchmt). 2016; 25: 249-54.

Approval of emergency contraception. 30 Achievements in Women’s Health in 30 Years (1984-2014). Updated 2019. Office on Women’s Health. US Dept of Health & Human Services. Accessed 4/25/20 at 

https://www.womenshealth.gov/30-achievements/19

Free The Pill. What’s the law in your state? Cambridge (MA): Ibis Reproductive Health; 2020. Accessed 4/25/20 at: 

Pharmacist Prescribing: Hormonal Contraceptives. National Alliance of State Pharmacy Associations; 2019. Accessed 4/25/20 at: 

https://naspa.us/resource/contraceptives/

Landau S, Besinque K, Chung F, et al. Pharmacist interest in and attitudes toward direct pharmacy access to hormonal contraception in the United States. J Am Pharm Assoc. 2009 ;49(1):43–50.

Richman AR, Daley EM, Baldwin J, et al. The role of pharmacists and emergency contraception: are pharmacists’ perceptions of emergency contraception predictive of their dispensing practices? Contraception. 2012; 86(4): 370–5.

American College of Obstetricians and Gynecologists. Over-the-Counter Access to Hormonal Contraception. ACOG Committee Opinion No. 788. Obstet Gynecol. 2019; 134 (4): e96-105.

OCs OTC Working Group. Cambridge (MA): Ibis Reproductive Health; 2020/ Accessed 4/24/20 at: 

American Academy of Family Physicians. Over-the-Counter Oral Contraceptives. 2014, Reaffirmed 2019. Accessed 4/21/20 at: 

https://www.aafp.org/about/policies/all/otc-oral-contraceptives.html

Grindlay K, Burns B, Grossman D. Prescription requirements and over-the-counter access to oral contraceptives: a global review. Contraception 2013;88(1):91–96.

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HRA Pharma. A study of oral contraception under simulated OTC conditions (OPTION). ClinicalTrials.gov identifier: NCT03559010. Bethesda (MD): National Library of Medicine. Accessed 4/21/20 at: 

https://www.clinicaltrials.gov/ct2/show/NCT03559010

U.S. Food and Drug Administration. FDA Drug Safety Communication: updated information about the risks of blood clots in women taking birth control pills containing drospirenone. Silver Spring (MD): FDA; 2012. Accessed 4/21/20 at: 

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-updated-information-about-risk-blood-clots-women-taking-birth-control

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

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

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.

Bridging the generational gap in the physician workforce.

Vol 65 No 07

Shoulder dystocia: The unpredictable nightmare

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

Introducing Dr. Millennial

AUGS Consensus Statement: Managing mesh problems

Discussing patients' sexual concerns

Smoke evacuation in the age of COVID-19

A Collision of Crises

Chairman's Letter: Website overhaul, podcast & more