De-stressing ob/gyn

Dr Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at DrLockwood@ubm.com.

The January 2017 issue of Contemporary OB/GYN provided a window into the minds of some of our colleagues by reporting the results of our second annual Labor Force survey. About 670 of our readers responded. Seventy-five percent were 50 years or older, 68% were in private practice, 56% were male, and 40% had been in practice for more than 30 years. Thus, there is a likely selection bias toward more senior, male ob/gyns on the “exit ramp” of their careers rather than younger, female physicians on the “entry ramp and passing lane” of their careers. Those caveats notwithstanding, the results are revealing and concordant with my conversations with colleagues.

Related: We're only human

Among the most disturbing findings was that slightly more than half of the respondents would not choose ob/gyn as a career if they could start over. Reasons they cited included a lack of work-life balance (an ironically millennial-sounding complaint), increasing payer and regulatory burdens, the chronic stress and costs of our intractable professional liability insurance crisis, maintenance-of-certification requirements, and a combination of rising overhead and stagnant reimbursements. Anxiety also accrued around uncertainty posed by the Affordable Care Act, now likely exacerbated by uncertainty over GOP repeal and reform eff orts. But the primary leit motif running through individual narratives was that the frantic pace imposed by seeing more and more patients in less and less time, coupled with time wasted on electronic health record (EHR) documentation and the burden of keeping up with accelerating increases in medical knowledge, was sucking the joy out of what should be the most joyful of professions.

Thankfully, these aren’t the good old days

If I had a dollar for every time I have heard an older colleague lament about how much easier medical practice was 30 years ago, I would be a wealthy man. The truth is we had a lot fewer tools and far less to know back then. When I was a third-year medical student in 1980, medical knowledge doubled about every 7 years. By 2020, it will double every 73 days.¹ This fact alone may explain the enormity of the challenge we face in preventing physician burnout. However, to better frame the problem, simply reflect on changes in our discipline since 1980. Back then in obstetrics we had no aneuploidy screening other than maternal age. Ultrasound was rudimentary, fetal surgery de minimis, and Rh isoimmunization difficult to treat and often fatal. Back then, premature labor was diagnosed based on contractions and cervical dilation, treated acutely with ethanol or ritodrine, and chronically with prolonged bed rest and oral tocolysis. However, our patients were younger, healthier, and thinner, and seldom required induction. In 1980, a national consensus conference was called to address the alarming rise in cesarean deliveries, which had tripled between 1968 and 1978, reaching an inconceivable 15.2% of live births.² In 1980, aides were people who helped out and AIDS the disease had yet to be described or HIV discovered. No American obstetrician had ever heard of Zika. A great obstetrician was one who could discern late decelerations from background noise on a fetal heart rate tracing, and was adept at forceps and total breech extractions.

As for gynecology, in 1980 there had been no successful US in vitro fertilization pregnancies, no Da Vinci robots, and no tension-free vaginal tapes. Premarin and Provera therapy for symptomatic menopausal patients was common. Laparoscopy was in its infancy. Ectopic pregnancies were diagnosed by culdocentesis, signs and/or symptoms and managed by laparotomy. Breast cancers were treated with radical mastectomies. A great gynecologist was adept at colposcopy, cone biopsies, vaginal and abdominal hysterectomies, Marshall-Marchetti-Krantz procedures, and reading pathology slides. Then, subspecialists were relatively rare and knew a little more about a little less. And folks were often paid what they charged.

NEXT: Learning from the past

Today, obstetricians must be familiar with the nuances of cell-free fetal DNA testing using massive parallel sequencing, know common microdeletions, and appreciate the advantages of chromosomal microarrays. The average ob/gyn’s ultrasound skills are vastly superior to those of 1980 maternal-fetal-medicine specialists, and modern machines have unimaginably improved resolution. Surgery for select fetuses with neural tube defects improves outcomes, and isoimmunization is both rare and easily treated. Premature labor is diagnosed with fetal fibronectin and/or sonographic cervical length determinations, tocolysis is limited to 48 hours, and prematurity potentially prevented with prophylactic progestins. However, our national cesarean delivery rate exceeds 30%, a reflection of an older, obese population with more comorbidities and indications for induction. Also linked to the cesarean epidemic is the decline in operative vaginal and breech deliveries, to the extent that many young ob/gyns will annually perform more cesarean hysterectomies for placenta accreta than forceps deliveries. HIV is a chronic disease and maternal-to-fetal transmission a rarity. Today, keeping up with the obstetrical literature takes herculean stamina, though Contemporary OB/GYN does help!

Recommended: Concerns about future of ob/gyn as a specialty

Today’s gynecologists must be well-versed on all forms of minimally invasive surgery with or without a robot. Ectopics are diagnosed far earlier using sensitive human chorionic gonadotropin assays, and high-resolution transvaginal ultrasound and medical treatment are now used in more than a third of cases.³ We must keep up with frequent changes in cervical cancer screening protocols. Publication of the Women’s Health Initiative (WHI) study results, linking hormone replacement therapy to increased cardiovascular disease when used in older women and also to breast cancers from the progestin component, has clearly had some public health benefit, but has also greatly complicated treatment of menopausal symptoms and osteoporosis.⁴ Breast cancer screening now has legal, not just professional liability ramifications, and breast-conserving surgical therapy is the norm. Across the discipline, subspecialists with deep knowledge of narrow fields have created as much competition with generalists as collaboration. And all of us must also be familiar with expanding lists of new drugs.⁵ In short, everyday ob/gyn practice has evolved dramatically over the past 4 decades. But with this progress the burden of keeping up with new discoveries, medications, devices, and surgical techniques is testing our limits. In addition, the profusion of much-needed, but voluminous, randomized trials, systematic reviews, and meta-analyses is causing constant evolution of evidenced-based practices and further straining our ability to keep pace with evolving practice demands.

But maybe the good old days weren’t so bad after all?

Perhaps the most frustrating aspect of our contemporary practice environment has been the steady flood of regulations over the past 4 decades. The 1980s saw charge-based provider fee-for-service payments evolve to hospital diagnosis-related group payments and practitioner current procedural terminology (CPT) code-based payments. These efforts to limit Medicare and Medicaid spending failed and the mid-1990s witnessed the chaotic introduction of managed care with gatekeepers and discounted fee-for-service payments. And over the past 2 decades both Republican and Democratic administrations have pushed through a cacophony of federal regulations designed to protect patients’ confidentiality, increase access to healthcare, reduce fraud and abuse, and restrain costs. Then there was all the time we spent completing the ICD-10 conversion. Many of us have also participated in other CMS experiments such as bundled payments and accountable care organizations. Of course, all these programs are likely to be further jumbled by the new presidential administration, which is likely to head in an entirely different direction with a focus on consumer-driven health plans wherein patients pay more for medical services-pitting patients against their doctors without third-party insurance buffers. Then there are mounting state regulations and increasing legislation affecting medical practice. Finally, our hospitals are mandating clinical pathways, patient safety bundles, team training, structured handoffs, and operating room checklists. Individually, each item in this long list may have some merit, but collectively they add a gargantuan layer of complexity and stress to our professional lives.

They don’t train them like they used to!

A second leit motif of the survey responses is that new residency graduates are less clinically skilled than they once were. There is some evidence to support this assertion. In a survey of practice readiness distributed to all fellowship directors in the 4 ob/gyn subspecialties, directors said that only 46% of first-year fellows were capable of independently performing an abdominal hysterectomy, only 34% a basic hysteroscopy, and a frightening 20% a vaginal hysterectomy.⁶ In a similar survey, half of gynecological oncologists reported that incoming fellows could not independently perform a hysterectomy.⁷ In a 2007 study, 60% of fourth-year ob/gyn residents reported performing fewer than 20 forceps deliveries during their residency.⁸ A number of factors may be responsible for these grim statistics. First, residents are exposed to fewer hysterectomies; in the US between 2002 and 2010, there was a 36.4% decrease in hysterectomies. 9 Implementation of the 80-hour work week regulations and competition with subspecialty fellows may also reduce available surgeries. Finally, the sheer breadth and depth of medical knowledge that must be crammed into 4 years of training may be crowding out core clinical experiences. Today, residents must learn pretty much everything we did in the 1980s plus the vast amount of knowledge cited above that we absorbed over the past 35 years! In other words, residents and young ob/gyns need to know far more than we did in the good old days.

NEXT: Preventing burn out

Preventing burn out

All of us, young and old, face the same frenetic pace of patient care and keeping up with new medical knowledge. We all face loss of autonomy from mounting administrative and regulatory burdens, as well as time and financial pressures, the chronic stress of professional liability, and uncertainty about future federal healthcare policies. And at some point we need to ask when these stressors will exceed our ability to adapt, accommodate, and avoid burnout. Burnout occurs when there is a pervasive sense of emotional exhaustion, depersonalization, and lack of accomplishment.^10,11 Other manifestations of physician distress include substance abuse, depression, disillusionment, and divorce. Burnout has been linked to an increase in suicidal ideation among medical students.¹² A Medscape Lifestyle Report survey reported that in 2015, 46% of US physicians on the front lines of patient care reported burnout, compared with 40% just 2 years earlier.¹³ These numbers are consistent with other studies.¹⁴ In the “happiness at work” metric, ob/gyns scored in the middle of specialties between happy dermatologists and unhappy internists; however, 10% of ob/gyns reported having the highest severity scores for burnout.¹³ As with the medical profession in general, female ob/gyns reported a higher prevalence of burnout (55%) than males (42%). Perhaps most concerning, higher rates of burnout were reported in younger physicians, with 53% of ob/gyns ≤ 35 years reporting this symptom. This finding suggests that our survey may not be so biased after all.

Short-term solutions

Attempting to implement strategies for reducing physician burnout is difficult. Exercise and good nutrition are tough when you are working 80 hours a week. Taking enough vacation time is also difficult if you are facing declining reimbursements and increased overhead. A rich spiritual life helps, but religion isn’t a pill you can take.

Long-term solutions

It is time for our professional organizations to re-examine ob/gyn residency training. Should we track all rising fourth-year residents through either a 2-year subspecialty fellowship or 2 more years of primary care and general ob/gyn surgical training? Similarly, it is past time for a rigorous, empirical, specialty-specific reassessment of the 80-hour resident work week. We should also work through our professional societies and their political action committees to eliminate ineffective, nonevidenced-based and excessive federal and state regulations. Start with EHR Meaningful Use regulations. The government should conduct a definitive study of the public health impact of the widespread introduction of EHRs. If there is no benefit, their use should be curtailed or they should be redesigned to reduce documentation burdens. If there is evidence of benefit, government and commercial payers should reimburse the costs of their use (eg, the 2–3 hours a day busy clinicians waste typing and clicking) or pay the costs of scribes. Finally, in light of the convergence of a Republican Congress, Executive Branch, and Supreme Court, let’s implement true professional liability insurance reform.

Next: How is the profession changing?

Take-home message

A confluence of factors has conspired to exert unique stress on ob/gyns. The situation has been exacerbated by an outdated graduate medical education system and partisan political chaos to create a toxic stew that promotes physician burnout and distress. Individuals can take steps to restore their enthusiasm, engagement, and energy for our great profession, but substantial reforms of physician training, a new work-flow model, and reform of our regulatory and payment systems are also needed.

References

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2. Gleicher N. Cesarean section rates in the United States. The short-term failure of the National Consensus Development Conference in 1980. JAMA. 1984;252(23):3273-6.

3. Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol. 2010;115(3):495-502.

4. Ghazal S, Pal L. Perspective on hormone therapy 10 years after the WHI. Maturitas. 2013;76(3):208-12. Review.

5. http://www.centerwatch.com/drug-information/fda-approvals/ (accessed 1/16/17)

6. Guntupalli SR, Doo DW, Guy M, et al. Preparedness of Obstetrics and Gynecology Residents for Fellowship Training. Obstet Gynecol. 2015;126(3):559-568.

7. Doo DW, Powell M, Novetsky A, Sheeder J, Guntupalli SR. Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology. Gynecol Oncol Rep. 2015;12:55-60.

8. Powell J, Gilo N, Foote M, Gil K, Lavin JP. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol. 2007;27(6):343-6

9. Wright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol. 2013;122(2 Pt 1):233-41.

10. Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol. 2012;30(11):1235-41. Review.

11. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003 ;114(6):513-9.

12. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-41.

13. http://www.medscape.com/viewarticle/838437 (accessed 1/16/17)

14. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-85