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A Proposal for the Dissolution of the Specialty of Obstetrics andFrom: Geffrey H. Klein, MD (gklein@bcm.tmc.edu)Sat Jun 28 14:43:29 1997
A Proposal for the Dissolution of the Specialty of Obstetrics and Gynecology Klein, GH Medical expense represents close to 13% of the gross national product. Despite significant advances in the insurance industry designed to control costs, medical care expenses still are rising faster than the general rate of inflation. The current state of medicine in the United States requires us to examine our spending and make appropriate cuts in health care expeditures. Those of us in OB-GYN have the unique opportunity to substantially reduce the cost of health care by voluntarily dissolving the specialty. Physicians solely in the practice of obstetrics and gynecology are a luxury that this nation simply can no longer afford. In reality, the public is done more harm than good by these doctors, as has been repeatedly demonstrated in the literature. (1,2) I call for an immediate study of the cost savings possible with the dissolution of the specialty of ob-gyn. If this figure is substantial enough, it justifies an insurance industry directed social change that can be phased in over five years (The transition period). Five years is required to slowly make the transition as painless as possible for those whose livelihoods are linked to the practice of ob-gyn. The only exception for this 5 year phase out would be the academic departments of ob-gyn at our medical schools. These programs should cease operation immediately thus cutting off the over-supply of new physicians being trained for positions which will no longer exist. Residents in these programs will have the option of reassignement to other residency programs or allied health schools. Those involved in the education of new ob-gyn physicians will be immediately reassigned to retraining programs in other academic departments. Reassignment of the current duties should be a simple task, as the ob-gyn physician currenly duplicates many of the services already provided by other medical professionals. A breakdown of the proposed changes follows: 1) Obstetrics: The prenatal care and delivery of low risk pregnant patients will be provided soley by certified nurse midwives. Should operative delivery be required, a general surgeon should be consulted. Eventually, however, the training programs in midwifery should be altered to train its students in these procedures. Postgraduate courses on the techniques can be offered to midwives out of training. Certification in these techniques will be required after the transition period for those wishing to remain on provider lists. 2) Maternal-Fetal Medicine: The duties of those in practice of maternal fetal medicine will be transferred to internists and internal medicine subspecialists. If a problem is identified by the primary care midwife during pregnancy, referral to the appropriate internist is suggested. We cannot eliminate maternal fetal medicine completely, as there are some procedures performed soley by those doctors. I propose the creation of a separate field named "gestational intervention" for those patients requiring PUBS, intrauterine transfusion, etc.. Hopefully advances in prevention and treatment of Rh isoimmunization will obviate the future need for gestational interventionalists. 3) Benign Gynecology: The duties of those performing routine operative gynecologic procedures (both open or laparoscopic) will be transferred immediately to general surgeons. General surgery residencies will be required to teach the basic techniques and those in practice of general surgery will be required to take a retraining course in order to remain on the provider lists. 4) Gynecologic Oncology: The practice of operative gynecologic oncology will require that oncology surgeons be retrained in the surgical management of the gynecologic malignancies and their oncologist counterparts will provide any necessary chemotherapy. Current oncology fellowships will be required to teach these techniques. 5) Office Gynecology: All of these responsibilities will be assumed by family practitioners and internists. Eventually, however, physician assistants and nurse practitioners will provide this service under the guidance of family physicians and internists. 6) Endocrinology: All duties assigned to medical endocrinologists. 7) Infertility: All services immediately removed from insurance reimbursement. Those needing this service will be required to pay in full. 8) Urologic gynecology: to the urologist.. Once the study is complete, the total yearly savings (TYS) should be calculated. During each of the 5 years of the transition period, the insurance industry will contribute to a Transition Fund the amount of the TYS. This fund will finance retaining programs for those interested in continuing the practice of medicine in other capacities and retirement vehicles (pension plans, IRAs, etc) for those wishing to cease the practice of medicine. It is your obligation as a health care practitioner to control health care costs, now is your opportunity to act. References: 1. Sisk, JE. "Improving the use of research-based evidence in policy making: effective care in pregnancy and childbirth in the United States." Milbank Quarterly 1993; 71:477-96. As cited in Ian Graham, *Episiotomy: Challenging Obstetric Interventions* (Blackwell, 1997), p. 143. 2. "Obstetrics has been rated as the least scientifically-based specialty in medicine". (Chalmers I. Evaluating the quality of new procedures. Arch Gynecol Obstet 1987; 241 (suppl):S101-S106.)
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