Our Generation: Where have all the teachers gone?

Since moving to Phoenix, I've come to realize how much I enjoy teaching and sharing my passion for obstetrics and gynecology. My job at Phoenix Integrated Residency ties together my experiences with the Residency Review Committee, involvement with the American College of Obstetricians and Gynecologists, and my previous private practice of obstetrics and gynecology. Now I really understand how difficult it is for faculty physicians to do research and design lectures while also delivering and operating on patients. There is never enough time for everything.

Yet I am overjoyed with teaching because it is an opportunity to revisit why I chose ob/gyn and to reminisce about how it felt to have hope for the future, however misguided that may have been. I don't mind being on call and up all night teaching medical students and interns how to deliver babies. I find I'm constantly seeking new and more efficient ways to teach. With the new limitations on duty hours, it is a constant challenge to ensure that students have sufficient time and training to fulfill their ob/gyn educational objectives.

The threat of litigation also looms in the teaching environment, as do concerns about patient safety and the aforesaid limits on work hours. Some residency programs are leveraging technology-such as simulators for laparoscopic surgery, operative delivery, and postpartum hemorrhage-to fill in the gaps. But for many institutions, the cost of such devices is prohibitive. Constantly re-evaluating an educational program is imperative, since what may have worked 3 years ago may not today, particularly when it comes to the surgical experience.

As an educator, I have decided to implement ways to help familiarize my residents with oral presentation and prepare for examination. For me, that means giving them honest feedback on their style of presentation and knowledge base. Being examined in a format such as the oral board is becoming more rare, given the limited time for interactions between faculty and residents and scarce opportunities to give oral presentations and do walking rounds.

Are we, as a specialty, placing too much emphasis on service over education? Do we spend enough quality-rather than quantity-time with residents teaching, demonstrating, and evaluating their practice of obstetrics and gynecology? Are we so concerned about how we'll continue to subsidize our training programs that our trainees are being shortchanged? And if so, are we willing to admit that this is a national, rather than local, problem?

Teaching the next generation of ob/gyns is not limited to those of us who are in formal education settings. Community ob/gyns are the arms, hands, and fingers of our educational programs. You are the ones who demonstrate techniques and practices every day and evaluate our residents. Without community ob/gyns, many residents would not be able to practice delivering babies and performing surgery. Last year's CREOG survey showed that almost two thirds of residents had such mentors and a similar percentage got most of their professional advice from those role models. Let's be ever mindful of the fact that as we learned, we appreciated the teachers who cared and gave of themselves, and let this philosophy guide us in training our future ob/gyns.

"Our Generation" offers real-world solutions to problems faced by ob/gyns new to practice. Written by young readers for young readers, a specific problem and offers practical "street-smart" advice. Columnists Steven J. Fleischman, MD (sfleischman@snet.net
), Elizabeth Lapeyre, MD (lizlapeyre@yahoo.com
), Maria Manriquez Gilpin, MD (mmgilpin@yahoo.com
),and Editorial Board Advisor Nanette Santoro, MD (glicktoro@aol.com
), welcome your questions, comments, and ideas. Let them know how life is going in the trenches. Submission of a letter or e-mail constitutes permission for Contemporary OB/GYN, its licensees, and its assignees to use it in the journal's various print and electronic publications and in collections, revisions, and any other form of media.

New challenges for residency programs By Barbara Weiss

New rules, new pressures, new demographics. Academic physicians areas stressed out as their colleagues in private care these days.

If you've ever thought that you'd like to trade the daily grind of private practice for the cushy life of the ivory tower, think again. As Maria Gilpin points out, the new requirements that residents be limited to an 80-hour workweek have drastically altered the terrain, placing new strains on residency programs. Frank Ling, MD, past president of the Association of Professors of Gynecology and Obstetrics, current Vice President of the American Board of Obstetrics and Gynecology, and a Clinical Professor at Vanderbilt University, acknowledges that the new rules "have created challenges for the residents in getting the training they need, and challenges for the faculty in creating ways of packaging information more efficiently."

In addition to an 80-hour workweek, the rules now prohibit residents from staying in the hospital for more than 24 consecutive hours and mandate a 24-hour day off in a 7-day period. Programs that were short on manpower to begin with and depended on residents as the primary caregivers may now have to depend on nurse practitioners, nurse midwives, attendings, or even faculty to deliver care. "If the resident must leave the hospital, sometimes the faculty must keep on working," Ling says, noting that "there's no 80-hour restriction on the faculty." Institutions are experimenting with different types of scheduling, such as floating night shift, or with different arrangements for shifting manpower.

From an educational standpoint, residents are now challenged to absorb information in less time. "They may have to walk away from some educational opportunities," Ling explains. "If they don't, it jeopardizes the institution and the program." [The Accreditation Council for Graduate Medical Education is sending questionnaires to residents to see if the rules are being violated.] The use of organized didactic time is now at a premium, and the faculty must revamp educational time to make it more efficient. "Faculties are scrambling to make sure their efforts have maximum benefit," he continues. "We need to eliminate any wasted hour or any program that's not teaching the residents what they need."

Concerns remain, however, about the cutbacks in residents' clinical experience. A recent study at Case Western Reserve University of senior resident case experience before and after the enactment of work-hour restrictions showed significant decreases in experience in total abdominal hysterectomy, procedures for stress urinary incontinence, and hysteroscopy. Residents also had less experience in vaginal birth after cesarean section, primary cesarean section, and vacuum delivery.

As Gilpin explains, new simulative technology is an attractive option, but it remains prohibitively expensive. "Most of these programs are done by the military because they have the hardware, or else by industry," Ling notes. "But these are not things most teaching programs can easily afford."

Gilpin also notes the anxiety quotient of preparing for oral boards. In fact, there has been a renewed interest lately in alternative ways of assessing residents, especially when it comes to surgical skills. Recent studies have reported good results from "objective, structured" assessment of laparoscopic procedures on pigs; simulation of laparoscopic bench tasks with the use of a box, camera, and video display; or surgical procedures on "lifelike surgical models," and indeed these kinds of assessments may be important in the future. But don't expect to see the end of oral boards any time soon. Ling reports: "The Board is very comfortable that the current series of examinations [written and oral boards and some form of maintenance certification] is doing a good job of accomplishing what it needs. At the appropriate time in a physician's career, it shows they are capable of being a certified practitioner."

What the future holds In recent years, more emphasis has been placed on primary care-making the curriculum more crowded than ever-and that focus is not expected to diminish. The Residency Review Committee requires that all residents have continuity of care clinics and also a structured equivalent of 6 months of primary care (including geriatrics, etc.) But the way in which individual programs meet the primary-care expectations is still being evaluated, according to Ling.