Perspectives on a changing field

Dr. Frederic D. Frigoletto Jr attended medical school in another time. He completed his residency training in another era. And he started his first practice in a different world. After 40+ years of practice, Dr. Frigoletto is the Associate Chief of the Department of Obstetrics and Gynecology at Massachusetts General Hospital, one of the most highly esteemed medical, research, and academic institutions in our country. In the October 2015 Green Journal, Dr. Frigoletto offers his reflections on a changing environment over the past nearly five decades.

In the 1960s, OBGYN residents were nearly all male and nearly all left to their own devices in caring for patients. 10% of medical students were male. They lived in the hospitals, working day and night without any restrictions. Chief Residents generally fulfilled the role of the Attending doctor. Physicians did not monitor fetal heart rate throughout labor or do high-tech, high-resolution ultrasounds on admission. They jotted quick notes about their patients' hospital course on paper, administered verbal orders to the nurses, and never sat in on lectures about billing codes, malpractice, or quality metrics. They only did c-sections for 5% of women. They performed a small handful of gynecologic surgeries and with great frequency. Laparoscopy did not exist. Neither did sub specialization: reproductive endocrinology & infertiliy, maternal-fetal medicine, gynecologic oncology, or uro-gynecology.

Fast-forward to 2015. Women attend medical school in equal numbers as men, and 80% of OBGYN residents are female. Following the 1984 Libby Zion case in New York City, training programs instituted the 80 Hour Rule, limiting residents to "just" 80 hours per week on average in the hospital. In my first year of residency training, each of my decisions was reviewed first by my Chief Resident and then by my Attending. Even in the dead of the night, I had two staff physicians at my disposal, to monitor my decisions and ensure patient safety. My attention was constantly divided between two screens, the bright blue electronic fetal heart rate monitoring system and the blank white of unwritten notes in our electronic health record. I created hundreds of templates to fulfill billing, regulatory, and quality metric requirements. I attended not only countless lectures on malpractice and quality metrics, but I completed an entire month-long mandatory class at Harvard about health care policy. About 33% of women in our nation give birth via c-section. 25% of the infants I delivered in my training greeted the world by cesarean delivery. I cannot count the number of different surgical procedures I witnessed, the new devices, the technology. If learning laparoscopy was a new educational burden on residents, now we learn open surgery, laparoscopic surgery, and robotic surgery! To compound the problem of surgical experience, fewer women require surgical interventions for common gynecologic problems such as fibroids. Half of my co-residents entered a sub-speciality field.

Dr. Frigoletto's insightful article reviews the history of these changes. The reasons and ways we arrived at the 2015 version of medicine- introduction of subspecialties in 1969, invention of electronic fetal monitoring in the 1960s, introduction of recertification programs in 1977, Roe v. Wade in 1973, work hour restrictions in the 1980s, HMOs in the 1990s, and the Affordable Care Act in 2010. Unfortunately, surveys show an increasing rate of physician dissatisfaction. Obstetrics and Gynecology suffers from one of the highest rates of physician burnout of all specialties. Increasing bureaucratic requirements burden physicians with "meaningless work without proof of significant benefit," and physicians have failed to enter the ranks of administrators in large numbers. Dr. Frigoletto sums up his interesting summary of the course of history that has resulted in our current medical system with a hopeful note. He encourages physicians to take solice in the knowledge that medicine is a worthy calling that serves needs beyond the practitioner, but those of the patient, community, and population. My conclusion? I am sending my OBGYN a thank you note so she knows how much at least one of her patients appreciates her!