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From: Geffrey H. Klein, MD[SMTP:gklein@bcm.tmc.edu]
Sent: Saturday, June 28, 1997 12:44 PM
To: Multiple recipients of list
Subject: A Proposal for the Dissolution of the Specialty of Obstetrics and
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.)
--
______________
:)
Geffrey H. Klein, MD
listowner: OB-GYN-L
Advisory Board Chairman, OBGYN.net < http://www.obgyn.net >
Co-moderator: sci.med.obgyn
gklein@bcm.tmc.edu gklein@icsi.net
http://members.aol.com/gklein01/geff.html
6800 W. Loop South #520
Bellaire, Texas 77401
(713) 664 8900
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