Ultrasonography in the diagnosis of gynecologic disorders.

Ultrasonographic examination is being used with progressively greater frequency as an aid in diagnosis of gynecologic disorders but too often without consideration of whether information other than that obtained from clinical examination is needed and whether ultrasonography can supply it. The size, number, and position of pelvic masses and, in some instances, the type of tumor can be identified, but it is not often necessary when operation is clearly indicated. Ultrasonographic screening for diseases of the reproductive organs has been proposed, but its use for this purpose is limited and it is not cost-effective. It should be used as an adjunct to clinical diagnosis, not as a primary diagnostic procedure.

Scientific advances, societal trends, and the education and practice of obstetrician-gynecologists.

Specialization in medicine in the United States began in Colonial America and expanded rapidly, spurred by increasing scientific information and advancing technology. By 1972, when the American Board of Obstetrics and Gynecology instituted subspecialty divisions, it had become impossible for the general obstetrician-gynecologist to remain competent in all areas of our specialty. Changes we can anticipate are a decreasing need for operations and hospital care coupled with increasing emphasis on primary health care for women. Most of our resident education programs have not yet reflected the need to begin to prepare obstetrician-gynecologists for a role that will be quite different from their present one.

Educating the obstetrician-gynecologist for the future.

Among the many factors that have altered the practice of obstetrics-gynecology are the following: the numbers of obstetrician-gynecologists, the increasing percentage of women entering the specialty, the expansion of ambulatory services with a simultaneous reduction in hospital admissions, a decrease in gynecologic surgical procedures, a stabilized number of total births with an anticipated increase in those to socially deprived and unmarried women, an increasing number of elderly women, general social and behavioral changes, and increasing outside control of practice. A proposal is presented for improving the education of residents and obstetrician-gynecologists in practice.

The conquest of cesarean section-related infections: a progress report.

More than a century ago, Robert P. Harris demonstrated convincingly that death from infection after cesarean section could be reduced significantly by operating early, rather than after several days of labor, by using aseptic surgical technique, and by closing the uterine incision. For the most part, his advice was ignored and the mortality rate remained high, except in hospitals with well-organized and well-controlled obstetric services. Although the incidence of total infections has been decreased by the use of prophylactic antibiotics, too many serious infections and maternal deaths still occur. These can be reduced by proper management of labor, by recognizing the need for cesarean section early, by using alternative methods for delivery when appropriate, by meticulous surgical technique, and by selective use of prophylactic antibiotics. These changes are not likely to occur unless care of obstetric patients is assumed by experienced obstetricians who are prepared to recognize and correct abnormal labor early and to perform instrumental extraction and vaginal breech deliveries rather than cesarean section in carefully selected patients.

Effect of repeated hyperbaric exposures on the menstrual cycle: preliminary study.

Two healthy female volunteers were subjected to hyperbaric air pressure of 5 ATA comparable to 130 feet of sea water (fsw) for 20 min 7 or 8 times during their menstrual cycles (experimental cycles). During the experimental cycles hormone assays for follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, and testosterone were performed before and after each dive on alternate days between the 5th and 11th cycle days (follicular phase), daily during the time ovulation was expected to occur, and on alternate days during the luteal phase; these were compared with the same assays throughout control cycles, during which the subjects were not pressurized. Periodic pressurization produced no significant changes in hormone patterns; ovulation was not inhibited and menstrual periods were unchanged.

Hyperbaric exposure during pregnancy in sheep: staged and rapid decompression.

Hyperbaric exposure during pregnancy in sheep: staged and rapid decompression. Undersea Biomed Res 1983; 10(1): 11-15. --Twelve sheep with dated pregnancies were exposed for 20 min to hyperbaric pressure comparable to 165 feet of sea water weekly between the 49th and 133rd days of pregnancy. Six were decompressed in stages and six directly without decompression stops. Those that were decompressed gradually delivered normally at or near term. One lamb was abnormal, but the relationship to pressurization is unclear. Three of those decompressed rapidly aborted dead fetuses, and two others delivered mature, but affected, lambs. Under the conditions of this study staged decompression after repeated hyperbaric exposures protected the fetuses from the destructive effects of rapid decompression. Hyperbaric pressure did not alter gross anatomic development.

Multiple hyperbaric exposures during pregnancy in sheep.

Eleven sheep were subjected to hyperbaric comparable to 165 feet of sea water 31 times between the one hundred twelfth and one hundred thirty-seventh days of pregnancy. During 13 dives the maternal and fetal circulations were monitored for bubble formation during decompression. Bubbles were detected by external doppler probes in eight of 12 ewes, but in none of the fetuses. Nine ewes were delivered of normal lambs at term. In one, twin fetuses died during an abnormal labor. The pregnancy of another was terminated by cesarean section after decompression to look for bubbles in the fetal circulation.

Obstetrician-gynecologists are primary physicians to women.

Our studies of the practice patterns of Michigan obstetrician-gynecologists indicate that they serve in a dual capacity: that of primary physicians to women and that of specialist obstetrician-gynecologists. They provide a considerable amount of general medical care for their own patients in the former role, and traditional specialist services for their own patients and for those referred by other physicians in the latter. The objectives and educational content of most house officer training programs do not reflect these changes. Training is directed almost exclusively toward preparing residents for specialty practice and often does not offer them basic experience and permit them to develop basic skills in other disciplines, notably internal medicine nad psychiatry, which they will need to practice as parimary physicians to women. An educational program designed to prepare residents more broadly for what they will actually be doing in practice without compromising their training as specialists is described.

PIP: 2 studies conducted in Michigan indicate obstetrician-gynecologists (OBs) function as primary physicians to women. 44 percent of a sample of 1008 patients had no physician other than their OB while 86 percent see only their OB for periodic medical examination. Data from 420 active practitioners showed 87-93 percent (depending upon year of graduation from medical school) treated cancer of the ovary, an equally large number cancer of endometrium with decreasing numbers treating other gynecologic conditions, down to 16 percent of those graduating before 1939 treating genetic problems. (41 percent of those graduating 1959-1969.) The larger percentages of younger doctors treating a wider variety of specialized problems, such as complicated infertility and end ocrine problems, reflects the wider exposure to these matters in recent education. However, almost all the doctors asked said training had not prepared them to handle sexual and marital counseling while 60 percent said they had not enough training in infertility and 30-40 percent wished they had more training in urology. A broader residency program is detailed to give students more experience in primary care. It is also suggested that community hospital programs do not do as good a job of preparing obstetrician-gynecologists. Marginal programs should be closed and training concentrated and broadened to meet the needs of contemporary practice. Discussion by others follows.

Obstetrician-gynecologists are primary physicians to women. I. Practice patterns of Michigan obstetrician-gynecologists.

Michigan obstetrician-gynecologists were asked to complete questionnaires designed to determine what kinds of medical services they provide their patients. The questionnaires completed by 369 doctors, who had graduated from medical school between 1930 and 1964 and who are in active practice, form the basis of this report. More than 50% treat common non-obstetric-gynecologic disorders in their own patients and smaller numbers treat more serious medical conditions. This study confirms a previous one, derived from information obtained from patients, that obstetricians-gynecologists serve as primary physicians to women, not exclusively as specialist-consultants.

Is the obstetrician-gynecologist a specialist or primary physician to women?

In an attempt to answer the question, "Is the practicing obstetrician-gynecologist a specialist or a primary physician to women?" 1,008 patients of 51 Michigan obstetrician-gynecologists were asked a series of questions concerning their health care. Forty-four per cent have no primary-care physician and 86 per cent see only their obstetrician-gynecologists for regular periodic examinations. Forty-one per cent reported that their obstetrician-gynecologists either had treated them for nongynecologic conditions or had decided that no treatment was necessary. The training and practice of obstetrician-gynecologists must be altered in view of the role they are assuming--that of primary physician to women.