An Open Letter to the American College of Surgeons: Residency Training in Gynecology Is Dangerously Deficient.
I’ve been accused of having an “axe to grind” against OB/GYNs.
I’ve been accused of stereotyping and of being offensive to a whole group of doctors.
I’ve been told to mind my own business and focus on my own specialty.
But why am I fully qualified to comment to you?
Because I do, as a matter of fact, have an “axe to grind”. And this axe is sharply directed at a group of surgeons I know harm women at a far higher rate than is acceptable because they are inadequately trained.
And, yes, my wife died from a negligent complication at the hands of reckless gynecologists, when they chose to mince up a tumor inside her belly as a negligent routine of theirs using a “power morcellator”.
So, I assure you, that I am more than qualified to comment to you and expect a correct response from you — not only as a colleague but as a patient-advocate.
To be clear, I know some very competent OB/GYNs — and I have some good friends who are Gynecologists. So, my critique is not about this group of doctors’ moral character or beneficent intent. It’s about the undeniable fact that their residency training programs are dangerously deficient and do not produce technically safe surgeons.
OB/GYNs, on the whole, are bad surgeons. Not because they deliberately choose to be so — rather, they are so by virtue of the extremely limited time they spend training as abdominal surgeons, as you well know.
Most OB/GYNs eventually settle into a practice pattern and are well protected from litigation by virtue of our laws and the legal defenses provided them by their professional societies, like ACOG and AAGL.
But, irrespective of legal defensibility, the deficient surgical training of gynecologists is a clear and present danger to the health of the women who trust these well-decorated surgeons.
Let me dissect what I mean — for the benefit of the public.
To become an OB/GYN, after graduating from medical school, a doctor is required to complete a 4 year residency program in Obstetrics and Gynecology. Most OB/GYNs end up either practicing Obstetrics or Gynecology. Some practice both. And some go on to do subspecialty fellowships in areas like Infertility Medicine, Minimally Invasive Gynecology, GYN-Oncology or High-risk Materno-Fetal Medicine, prematurely, before being anywhere near being technically proficient and safe abdominal surgeons. Worse yet, a vast number do no fellowship training at all before starting to operate on women independently.
As background for non-physicians, Obstetrics focuses on the safe delivery of babies — whereas, Gynecology focuses on the surgical treatment of the female pelvic and reproductive organs. These are distinct, but overlapping areas in women’s health. Whereas Obstetrics is less surgically and technically demanding, Gynecology IS real abdominal surgery requiring technical skill and finesse.
To the layman, it might sound like OB/GYNs spend plenty of time in medical school and residency training. But, in actuality, their residency structure affords very little time to become well-rounded and proficient clinicians — much less safe surgeons.
The first year of an OB/Gyn residency, like in other residencies, is called internship. During this year the resident physician is getting his/her feet wet and really just getting used to running around the hospital on administrative errands. There is some exposure to gynecology, a few medical rotations, but nothing very substantive from an operative standpoint. What’s astonishing is that OB/GYN interns, unlike any other surgical specialty, spend virtually no time cross-training with general surgeons or other surgical subspecialties — though there are a few very rare residency programs that spend a few internship weeks on general surgery rotations, but these are the excpetions.
The meat of the OB/GYN residency program is the three years following internship. These are split up, nearly evenly, between rotations in Obstetrics, Gynecology and outpatient OB/GYN Electives.
In the end, when an OB/GYN decides to become an independent and board-certified gynecologist after residency, he/she has basically received about 1–1.5 years of surgical training in Gynecology. This is radically deficient and dangerous by any standard — other than the GYNs’ own.
Let me clarify this point as a basis for comparison with other surgical specialties.
All other surgical disciplines complete at least one year cross-training in general surgical disciplines — and this is critical to becoming a well rounded surgeon who grasps the gravity of patients’ illnesses and learns to be technically well-rounded by observing other specialists at work.
General surgeons spend 5 years in residency training.
Colorectal surgeons do 5 years of general surgery followed by one year of fellowship.
Orthopedic surgeons do about one year of general surgery followed by 4 years of Orthopedics.
Urologists do about one year of general surgery followed by 4 years of urology.
Surgical oncologists do 5 years of general surgery followed by 2 years of surgical oncology.
Vascular surgeons do 3–5 years of general surgery followed by 2–3 years of vascular fellowship.
Cardiothoracic surgeons do 4–5 years of general surgery followed by 3–5 years of cardiothoracic training.
Neurosurgeons do about one year of general surgery followed by 4 years of neurosurgery.
ENTs do about one year of general surgery followed by 4 years of ENT training.
These are verifiable facts!
Well, very literally, these surgeons who are responsible for operating deep inside women’s abdominal and pelvic cavities do NO cross training with general surgeons. NONE!
OB/Gyn residents spend ONLY 1–1.5 years of training even in gynecology itself. And that happens in a cloistered silo, away from cross-disciplinary training with other surgeons. THEY DO NO CROSS-TRAINING WITH GENERAL SURGEONS — and this is a disastrous training scheme for any surgeon but especially for those charged with the care of women.
I will attest with 100% certainty that if a surgeon in any of the listed disciplines gets only 1–1.5 year of training before becoming an independent operator, they will be VERY unsafe operators. And, I know, that most surgeons and surgical program directors know exactly what I mean.
Despite the fact that the vast majority of my surgical colleagues are standing on professional decorum on this problem in gynecology, we all know that what I write here is a dangerous fact and a public health hazard.
OB/GYN residents, even at very high caliber institutions, are being inadequately trained to become safe abdominal surgeons. They spend insufficient time operating in the abdomen and they are cloistered with teachers whose own training was limited to “Gynecology”.
But who bears the cost of this insufficient training? Without a question, it is unsuspecting and trusting women across the United States who bear the brunt of complications.
I know, as a surgeon, that my wife’s complication and death, were a result of this specialty’s reckless training and thinking — and of her gynecologists’ negligence, because they actually knew of the specific complication to which she fell and ignored the possibility.
So, yes, I do have a very serious grievance that is driving me to write you — and which has harmed patients on a systemic level. So, the American College of Surgeons will only ignore my writing at risk to its own stature and integrity as a professional society of surgical leaders.
You might ask, “well, what do you suggest”?
First, I suggest that leaders of the American College of Surgeons get real and stop acting politically on this issue. Admit that residency training in Gynecology is dangerously deficient. Do so, because real lives are being compromised every day by an imminently fixable problem in GYN training. So being polite and standing on decorum to not offend our colleagues in Gynecology will have a quantifiable cost in lives harmed.
I suggest separating Obstetrics from Gynecology as sub-specialties. Having OB/GYN residents do at least 2 years of general surgery training before committing to either track.
But, fundamentally, a Gynecologist should get at least as much residency training operating in the abdomen as a plastic surgeon does (i.e., 2–5 years). And,as you know, plastic surgeons rarely delve into the belly with a knife as deeply as GYNs do. Here’s the structure of a typical minimum requirement for a plastic surgeon in accelerated “integrated” residency programs — they spend close to 2 years doing full time training with general surgeons.
Let me be clear, I am not writing this article to vent. It certainly has a cost to me professionally, as a surgeon, because I am hanging out my profession’s dirty laundry for all to see. Perhaps, some of you judge me as being emotional or grieving the loss of my wife too heavily to be objective. But, you are not correct in such conclusions.
To be clear, I am grieving the loss of Dr. Amy J. Reed. But, I have 100% clarity on what I write here, as I know you do, silently. It is simple to hide behind the walls of decorum and establishment in justifying your silence, lack of political willpower and courage to drive real change. I understand this.
But, here I write, for my wife and for all the other women in harm’s way at the hands of inadequately trained, but glib, gynecologists who assume themselves to be well-trained surgeons.
My sincere hope is that leaders in American medicine and surgery, and specifically in the American College of Surgeons, will look at the problem I am airing here and move efficiently to change OB/GYN training to become cross-disciplinary and safely adequate.
With this article, I am also informing the American public of a serious and undeniable hazard in women’s health — posed by the very surgeons charged with healing women. A hazard that the American College of Surgeons has the ethical (and, perhaps, legal) duty to eliminate.
Let us see who, amongst you, has the courage to call for the needed change in Gynecology training — lest, you too, wish to wait for outsiders and the courts to decide for you, as the GYNs did in the case of “power morcellators”.
This Letter was directly delivered to the leadership of the American College of Surgeons on 10/1/17 — on behalf of women across the United States and The American Patient Defense Union.