Over the course of 38 years of practice it has become painfully obvious to me that the 'raison-de-tet" for most of the sub specialities in Obstetrics and Gynecology has grown out of the advances in both disciplines.The explosion of knowledge and the technological advances that has occurred in the last 35 years has been breathtaking.(we did not have a pregnancy test other than a serum P4 nor did we have any form of sonography other than a "B-scan when I trained at Baylor Medical College in Houston in 1972, Laparoscopy had just been reintroduced from Europe after an earlier" failure to launch" due to complications) I feel that as Technology advances that the basic Residency in OBGYN will disappear and post graduate training will morph into a 2 year basic course of study followed by a residency in a sub speciality.Standards of care have now made my training , which i feel was excellent ,require me to refer many patients that I used to take care of without a thought of inadequacy. I have diligently adopted all the new technologies as they were developed (Novasure ,LAVH, Adiana ,Pelvic resection by laparoscopic techniques etc) by post graduate CME courses. Yet I feel that as sub specialists are able to confine their attention to a single set of skills, they naturally offer my patients an advantage for better care and I refer a lot of them that I would normally done myself.Which leads me to the conclusion that at least Obstetrics will have to be separated from Gynecology in the future ; and very likely the practice of" general Gynecology" will become a series of subspecialty disciplines.Do I like this development ? No; because I feel there is a need for a general practitioner for women's health care that follows them over the course of their lifetimes.Unfortunately , in the reimbursement climate in which we find ourselves a Physician so inclined will find it hard to make a living.
To further compound the problem ( here I am beginning to get a little "curmudgeonly")The quality of training that I have seen coming out of residencies in the last 10 years has been very inadequate.Residents finish programs after doing maybe 5 vaginal Hysterectomies by themselves , the correct use of forceps and the knowledge of the function of the various types has gone the way of the cranio-clast and the osteotome.Young physicians now prefer a Cesarian section, or worse, a vacuum extractor . (which is probably in the patients best interest given their training, but sad).Perhaps the other "reason -de -tet" for sub-specialoization is that residents are so poorly trained in their residencies that they must learn some skill set by sub-specialising. Therefore; I am not sure that this trend is not in the best interest of quality patient care. It just remains to be seen who will be the "LMD" who refers them?
Edited on: 2012-04-06 09:44:39 by: David Carpenter, M. D .
David I feel your pain...even if I may be a tad younger.
This past fall I heard a very high ranking ACOG official say that there has been a transition afoot among the fellowship. In the past fellows wanted the ACOG Practice Bulletins to be vague to allow for individual variations in care practices while today the fellowship wants the Practice Bulletins to be very specific - to be 'cookbook.' In many ways this transition is appealing. Protocols in theory ensure that the best evidenced care is delivered for a given clinical problem. There is, however, a metaphysical problem - you'll have to excuse me but I tend to be right brained. In order to develop a care protocol there has to be some agreement over what is the goal of diagnosis and treatment. Imagine a woman presenting with a broken arm. A clinician can usually assume that in presenting with the broken arm the goal of care is the mend this arm to restore function. So far so good for broken arms but what about less tangible problems? Imagine another woman presenting with pelvic pain. Insofar as that problem likely overlaps with a variety of clinical, cultural, and lifestyle issues what is the goal of treatment? Should it be resolution of pain but ignore her joblessness? Should it be to treat her depression but ignore her loveless marriage? Lives are messy and so are the outcomes modern healthcare tries to create to quantify them. Sometimes protocols just don't work but there is comfort for the clinician to live within these protocols because outside of them are those messy life issues that we all know are over our heads.
Malcolm Gladwell gave a talk celebrating the genius of Howard Moskowitz and his contribution to spaghetti sauce (you can view the talk by Googling "Gladwell spaghetti sauce." Its a marvelously entertaining talk highlighting that the food industry has learned over the years that by embracing diversity of tastes there is more net happiness among consumers. So we have chunky and extra garlic and spicy among many other varieties of spaghetti sauce. If modern medicine were to approach the question of what spaghetti sauce is best we'd likely drum up a randomized trial and after some sort of regression learn that some, likely bizarre combination of garlic, pepper, and tomato paste makes the 'best' sauce. We' likely then create a protocol to make sure each time we make spaghetti sauce we make it the 'right' way. Yet if diversity is so celebrated among consumers for spaghetti sauce isn't it reasonable to believe that such is true of medical treatments? If 1 in 3 women have a pelvic floor problem (a grossly misleading statistic that is often promoted for less than entirely wholesome reasons) then should it be expected that all women will want the same treatment? Of course not. Among the problems you have identified is the equally troubling problem that specialized training undermines the legitimacy of doing less than the 'evidenced' treatment. Response shift is a feared problem when studying a given medical problem. If a patient in the course of her care for a given medical problem comes to lower her treatment expectations then the ultimate evaluation of any treatment is overestimated. Yet is response shift not a part of every human life? Is it not reasonable to expect that with age it might take me a bit longer to empty my bladder in the morning? Health is a ill-defined concept and embracing a diversity of definitions seems as logical for human existence as spaghetti sauce. There is, however, another metaphysical problem.
To borrow from the food industry again, it is well known that consumers like choice but not too much choice. Fifty kinds of bread at the grocery store is as annoying as having just one. So if health definitions celebrate diversity but only to a point, who gets to winnow the field? Increasingly this task falls on organized medicine in collaboration with health payers (to include Uncle Sam) and again the aggregate gets to tell the individual what health means. This is not a new tension. It is a tension between utilitarianism and duty (John Stuart Mill vs. Kant). I'm not going to resolve this tension here but in asking the question, "Why FPMRS?" this tension is lurking. New ACOG fellows want 'rules.' Utilitarians want rules. Rules are comfortable because 'right' and 'wrong' are not intrinsically defined but lie at the endnode of a cost-benefit decision tree. For modern healthcare the final arbiter of right and wrong is too often the balance sheet. Utilitarians like the balance sheet but Kant would not. Subspecialties abound because they feed on physician insecurity about doing the right thing (and in many cases this insecurity is justified) yet many times the subspecialty care outcomes are only marginally improved (and some times worsened) over generalists. Doing more of the same thing must improve outcomes right? Maybe. The times that it does and does not sometimes isn't heralded by the clinicians degree of training but in their professional ethics.
I could not agree more with your simile which describes the current situation within our discipline.Unfortunately the problem is . in fact, a metaphysical one ,and Kant vs. Mills is all to appropriate a way to see the problem at its root.This approach of course is being born out in almost every Scientific field as well as in Education . Every newly minted governmental "expert" is desperate to add some "metric " to the analysis. The answer to our dismal education system is to "quantify' the product ; ie. test the students to see how much they have learned. Well it sounds good , but what has happened is that so much is riding on the results that teachers have given up their gifts and graces that called them to a life's work that is woefully underpaid and little appreciated and now spend their time "teaching the test". Test scores have fallen and teacher moral as well as student moral have declined .This intrusion by politicians into a field they know so little about was facilitated by a few "intellectuals" who were sure that they possessed the inside knowledge to understand and evaluate the education of children. Sadly , like Spaghetti sauce, the outcome has worsened the problems. And instead of questioning the real need to reduce the process to a metric, the political hacks and the "intellectuals " are now arguing over who is to blame for the results of all the testing which show a decline in scholastic ability! Is not the definition of insanity to keep doing the same thing and to keep getting the same bad result?Who can stand before these armchair 'experts"and say stop the maddness and try what has worked in Asia ; a return to rote learning for the first 6 grades.
In our field ,sometimes I feel that ACOG is our worst enemy.The leadership seems determined to continue to knit ropes with which to hang its Fellows.The AMA long ago abandoned representing the interests of Physicians and now occupies the false role of arbitrator between American Medicine and the Government.( and what is worse , they continually ramp up the cost of doing business by implementing new ICD10 codes and New CPT codes which require an ongoing investment in the educational products that they sell !) Instead both groups have become partners in the manufacture of a foul tasting spaghetti sauce. The shift toward sub-specialization may , in fact, be more a response to the dangers posed by our own societies rather than my postulation that it resulted from the explosion of knowledge!
The idea that applying a metric will help to improve the outcome sounds so appealing. But like you point, out metaphysical problems are extremely resistant to being reduced to numerical analysis . If one adds in the real danger that" pseudo- experts" will be called upon to provide the metrics then the process is doomed from the start. Mark Twain once said that " there are people who are very good at what they do and do it well, the rest choose to teach"
I am sometimes glad that I am on this side of the journey.However; I do have an optimistic view that the tide will turn and this country will return to what has worked for so many years , and improvement will take the form, as you say, of providing a few varieties of spaghetti sauce all of them tasty instead of a single inedible variety.
Edited on: 2012-04-07 09:04:12 by: David Carpenter, M. D .
Sorry to not respond sooner. I'm not exactly sure there is much to say. I am disappointed other folks have not joined this thread to add their impressions of this topic. The appeal of metrics is to be found 'right' so long as you stay within the lines. Good and bad are discernable by obeisance to the rules. Judgment is not valued if it falls outside of a metric. I read an interesting article yesterday regarding the misrepresentation 'choice' has caused in healthcare. In truth there is very little autonomous choice in health care (do patient's choose to have the testing and assessments that distill down to a choice between treatment "A" and "B"?). The notion that respecting persons distills down to respecting choice is naive. The most damaging problem of misrepresenting choice in the ethics of care delivery is that it can leave clinician believing they have no moral responsibility toward the patient EXCEPT to present a 'choice.' That is of course not true. Clinicians do have a moral responsibility to do good toward their patients although this can quickly become more complicated insofar as how do you define 'good' in a multicultural/lifestyles context?
I've wandered far from the question of 'why FPMRS?' I would love to hear what a younger person with and without fellowship training thinks about the need for FPMRS?