Obstetrics and gynaecologyBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7138.2 (Published 11 April 1998) Cite this as: BMJ 1998;316:S2-7138
…are rewarding and popular specialties. But oversupply of specialists may have an impact on todayõs senior house officers argues Andrew Pickersgill
- Andrew Pickersgill, chairman,
The medical profession and general public seem fascinated as to how anyone could possibly want to pursue this occupation: “So why did you choose this profession?” I should reply by asking why does every doctor not wish to follow this interesting and most satisfying pathway. I have lost count of the number of times I have been asked the question and then listened to the joke about decorating the hall through my letter box.
What other specialty allows you to care for two human beings simultaneously, especially during what is, usually, a joyous life event? Obstetrics deals mainly with young, fit, and healthy women, who normally leave our care with happy memories, a screaming bundle, and perhaps a small scar. They do not return worse in the winter months, for us to palliate but never cure. Most need minimal medical input antenatally, with about a third requiring assisted delivery.
The physicians among us manage diverse disorders from AIDS to Wilsonõs disease. We are public health servants, screening for conditions like diabetes. We are teachers, advising on the advantages of breast feeding and the harmful effects of smoking. A working knowledge and cooperation with geneticists is essential in the diagnosis of chromosomal abnormalities. Some obstetricians work as “pre-neonatologists,” treating babies in utero weeks before delivery. Radiological interests develop from using ultrasound scanning to identify an abnormal or compromised fetus, to diagnose early pregnancy problems and gynaecological disorders, both benign and malignant. There is an element of emergency medicine, not knowing what is going to present next. When complications occur in pregnancy they can develop quickly and soon become fatal, requiring clear thinking and fast action, the skills of an intensivist. Finally, for almost 20% of women, we wield the knife, performing one of the oldest operations in the world.
Benign gynaecological conditions (such as fibroids and endometriosis) are common, affecting about 30% of women in Britain. A thorough knowledge of endocrinology is necessary when treating them. They may not be life threatening but are associated with substantial morbidity, perhaps reflecting the fact that hysterectomy is the commonest operation performed. Gynaecologists play a central role in preventive medicine, both medically (such as hormone replacement therapy) and surgically (colposcopy has reduced deaths from cervical cancer).
We also help to prevent pregnancy, requiring an extensive knowledge of contraception, but are not forced to perform terminations. Conversely, we help couples achieve pregnancies when nature has failed. Techniques like preplantation diagnosis, and intracytoplasmic sperm injection are pioneering breakthroughs at the forefront of medical science. Gynaecological oncology is one of the most rewarding oncological disciplines: gynaecological tumours (except ovarian) generally present early, hence treatment is curative for most women. Gynaecological urology improves the lives of the 20% of women who suffer with incontinence. Furthermore, outpatient procedures are developing, and minimal access surgery is making inpatient stay shorter. Community gynaecology is an expanding field, encompassing contraception, colposcopy, and the climacteric among other things.
The training scheme
All entrants into specialist registrar training programmes are appointed at competitive interview. They must have completed a minimum of two years as a senior house officer and at least one in the specialty. In addition, they require the first part of the membership of the Royal College of Obstetricians and Gynaecologists (RCOG). This is a multiple choice examination concentrating on basic sciences (such as anatomy, embryology, medical statistics, and physiology).
The length of specialist registrar training is five years. Years 1-3 are general training, while in years 4 and 5 trainees can undertake six month modules in areas of special interest or compete nationally for a three year subspecialty programme. It is advisable to take the second part of the membership before entering year 4, although failing the exam does not preclude progress through the grade. Before sitting the examination, a dissertation based on a clinical case or an audit has to be accepted. The examination is clinically based, incorporating a written paper, a structured oral section, and long cases. At present there are no plans for an exit examination.
Throughout training, biannual assessments are performed, and trainees complete a log book based on clinical competency. At some point during training an elective year is necessary. It can be in a different specialty (such as urology) or in research, either in Britain or abroad. Further periods of “time out” can also be arranged.
Research, audit, and teaching
Audit and research training remain essential ingredients in the production of a consultant.(1) A research qualification may be perceived as helpful in becoming a good consultant,(1) but research advances the body of knowledge and secures the existence of people who are capable of critically following the course of medicine to enhance all aspects of medical practice in the future.(2) Research is encouraged, especially in the later years of training, when one day a week is free for developing special interests. Publication of articles in peer reviewed journals remains essential for appointment as consultant. Although increasingly limited, there are still opportunities to pursue an academic career and to obtain higher degrees.
Within the specialty there is a long tradition of audit, which sets the standards of clinical practice. Confidential inquiries into maternal deaths were started in 1953; they were the first of their kind in the world and are often referred to as the “gold standard.” RCOG has its own audit unit, which collects data nationally. Audit also occurs locally, with monthly perinatal meetings and regular data collection to calculate assisted delivery rates. RCOG pioneered continuing medical education five years ago. Teaching and education are part of the training scheme, and weekly postgraduate meetings are held in 78% of hospitals.(3) About 10% of the new modular log book for specialist registrar training is dedicated to the development of management, audit, and teaching skills, and trainees are encouraged to develop interests in medical education and medical management towards the end of their training, helping to enhance the consultant body of the future.
So whereõs the catch?
Like all training programmes this is a simplistic view. In reality, because of competition at the senior house officer level, with over 100 applicants for each specialist registrar vacancy, it takes over two years as a senior house officer, and many applicants have their membership or other qualifications before becoming a specialist registrar.
In May 1996 (latest figures) 1,286 consultants (217 female) and 861 specialist registrars were in post in the United Kingdom. The overall number of female consultants remains substantially lower than in the training grades (45% of British trainees), but over the past five years 40% of new consultant appointees have been women. Part time training is actively supported to further increase this number. There were over 1,800 senior house officers (more than half women), including 739 general practitioner trainees. The specialty prides itself in training overseas doctors (over 800), who make an invaluable contribution to the service.
In 1993 obstetrics and gynaecology attracted 4.9% of medical undergraduates,(4) and this has recently increased to 6.9%.5 The rising interest in the specialty is encouraging but is not without problems. RCOG based its calculations of numbers of specialist registrars on an expansion rate for consultants of 5%, but over the past few years the rate has been diminishing: in 1996 it was calculated to be 3.3%. With less expansion and fewer retirements, we are now faced with the overproduction of fully qualified doctors within our specialty, which has implications for current senior house officers. This problem will be further compounded by the loss of 220 specialist registrar jobs over the next three years, as directed by the Medical Workforce Standing Advisory Committee of the Department of Health.
There are many reasons to expand the profession. RCOG recommends one consultant per 500 deliveries, but in England and Wales the average number is one per 599.(2) As a result of the confidential inquiries into maternal deaths6 and stillbirths and deaths in infancy,(7) it is accepted that, in order to improve patient care and reduce “unnecessary” deaths, greater input from consultants in labour wards is required, which can happen only by increasing the numbers of consultants.
There are also pressures (litigation), to increase the number of consultant sessions on delivery suites. Obstetrics is the most litigious of all specialties. Defence fees for private obstetrics currently stand at a maximum of £10,895 (almost twice that for gynaecology, £5600), hence few consultants practise private obstetrics. Overall, 1% of babies are born with an abnormality, and parents may be devastated to learn that their baby is not perfect. This is not always our fault, but when things go wrong parents want someone to blame and often it is the obstetrician.
Finally, many babies are born nocturnally and some need help. Consequently, trainee obstetricians are among the busiest of doctors outside normal working hours. Despite the intensity of work, our trainees do not like working shifts, preferring to undertake more traditional on call rotas.1
The life of a consultant
The average age of appointment is 38 and retirement is 63.3 Currently, 84% of British trainees intend to become consultants, a quarter wish to become subspecialists, and only 4% aspire to academia.1 Most consultants currently practise obstetrics and gynaecology.
Although there seems to be an increasing belief that it will become two specialties, 75% of trainees wish them to remain as one,(1) a sentiment echoed by Kenneth Calman, recently highlighting “the important role of the generalist in clinical practice.”
The daytime demands on consultants are high, both from their patients and from junior doctors. Typically, each week a consultant will run at least one antenatal and gynaecology clinic, two theatre lists, one special interest session, attend one postgraduate meeting, teach and assess his or her juniors, read one complaint, and have one management meeting.
Consultants will also be on call at least one night a week. Attitudes towards being resident on call are hardening, with almost a third of our trainees stating that they would never be prepared to be resident as a consultant.(1)
There are opportunities for private practice, especially in gynaecology. These vary throughout the country, as do the potential earnings. Sadly, medicolegal reports are common and also generate extra income. Medical management, politics, and academia provide opportunities to obtain merit awards that are similar to those in most other specialties.
Obstetrics and gynaecology is not only an essential part of the training of most general practitioners, it is also one of the most rewarding hospital specialties.
I thank Keith Anderson for factual information.