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Ten Goals for The American College of Obstetricians and Gynecologists for the First Decade of the Next Millennium

From the Department of Obstetrics and Gynecology, University of Kentucky, Lexington, Kentucky.

Address reprint requests to: Frank C. Miller, MD, Department of Obstetrics and Gynecology, University of Kentucky, 800 Rose Street, Lexington, KY 40536-0293, E-mail: fmillI{at}pop.uky.edu

Standing on the threshold of a new millennium, it is tempting to review the many dramatic improvements in women’s health care that have occurred over the past 100 years. Remarkably, in this century, infant mortality has decreased 90% and maternal mortality 99%.¹ It is noteworthy that this dramatic reduction in mortality from childbirth and the introduction of safe methods of reproduction control have contributed to bringing women of this country to their current place of influence and prominence in the national work- and policy-making force. Obstetrician-gynecologists played a central role in this remarkable achievement.

However, I agree with Thomas Jefferson who said, "I like the dreams of the future better than the history of the past." I also will not attempt to predict the future, because prediction is, at best, an unpredictable business. This is especially true when it relates to politics and social change. In 1967, the noted Harvard sociologist David Riesman predicted wrongly that by the end of the century, "if anything remains more or less unchanged, it will be the role of women."²

Rather than indulge in this unproductive process, I prefer to dream! I want to share with you my vision—goals that I believe can guide us into the 21st century. As we make this journey, we must resolve to preserve our core values and renew our commitment to ACOG’s mission to improve women’s health through education, advocacy, practice, and research.

Keith Russell, in his 1972 presidential address, was the first to articulate a set of goals for the College. He stated that organizations such as ours must set definable goals, and he proposed "Ten Goals in Ten Years."³

ACOG and our colleagues in other obstetrics and gynecology specialty organizations have made extensive efforts in strategic planning, dealing specifically with the future of our specialty as the leader in women’s health care. The College commissioned a National Workforce Analysis of Obstetricians and Gynecologists, conducted by the Health Sciences Administration of the Uniformed Services University of Health Sciences, to help determine population and demographic trends that will influence the number of obstetrician-gynecologists and the locations of their practices in the foreseeable future.⁴

ACOG also commissioned the Gallup Organization to conduct a poll of Fellows to assess the needs of the College and to measure members’ evaluation of ACOG as a professional organization. In August of 1998, ACOG hosted a retreat of Fellows and representatives of leading women’s health–related organizations nationwide to plan for "Meeting Women’s Health Needs in the 21st Century." The Council of University Chairs—Obstetrics and Gynecology (CUCOG) held a consensus conference in February 1997 to formulate obstetrician-gynecologists’ responses to the many external issues affecting academic and nonacademic practices.⁵ The Association of Professors of Gynecology and Obstetrics (APGO) held an interdisciplinary invitational conference to foster coordinated educational programs in women’s health at the medical school level.⁶ The Society of Gynecologic Investigation (SGI) and the American Gynecological and Obstetrical Society (AGOS) are working to develop consensus among obstetrics and gynecology specialty organizations on research scholarships. Their goal is to increase the number of investigators who will pursue an academic research career in our specialty by clarifying and coordinating the application process, consolidating when necessary, and increasing the duration and amount of research scholarship funding.

These organizations and others in our specialty are currently addressing other pressing issues that affect our patients and our ability to practice medicine. Using data from these strategic planning efforts as a background, I present, for your consideration, ten goals for the first 10 years of the next millennium.

	Goal 1: Define Clearly the Scope of the Practice of Obstetricians and Gynecologists

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
Our specialty must come together and do this, because if we do not, others less qualified will. Obstetrics and gynecology is a specialty limited to the care of women. However, it is the diversity of the care we provide that is one of its major appeals. When our patients need gynecologic surgery, we perform it and continue to provide care for them, not only through the postoperative period, but often throughout their lives. For many of us, it is this ability to perform surgery, deliver babies, and provide continuum of care that defines who we are. Socrates said, "the beginning of wisdom is the definition of terms." As the practice of medicine changes and we recognize that no one physician or medical specialty can provide all the care for everyone, it is imperative that we define clearly the depth and breadth of our specialty, rather than accept how others define it for us. Until we do, we cannot be recognized fully as the true leaders of women’s health care.

	Goal 2: Restructure Our Residency Training Programs to Ensure That Our Residents Continue to Acquire the Knowledge and Skills Necessary to Become the Type of Women’s Health Care Physicians We Aspire to Be

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We find ourselves increasingly in the classic position of supporting resident training to achieve outcome A, while hoping for outcome B. We state that obstetricians and gynecologists are the primary health care providers that many women rely on for comprehensive medical care. Yet critics point out that the amount of time available in a 4-year residency program and the current structure of programs are inadequate to prepare our charges to do so. Others are concerned that additional primary care training in our programs detracts from the training we give our gynecologic surgeons, offering them too few cases and too little experience to be competitive in the surgical arena. Only 3 years ago, medical politics was such that many of the women for whom we had been the principal physicians for years were at risk of being denied access to our services. In response, the Residency Review Committee (RRC), after extensive discussion and compromise, added the requirement of 6 months of primary/ambulatory care for residency training in obstetrics and gynecology. It is becoming increasingly clear that additional remodeling of our residency training programs will be necessary. I am confident that ACOG, in concert with the Residency Review Committee, the Board, and other specialty societies, will make the necessary adjustments to ensure the quality of training for obstetrician and gynecology residents.

	Goal 3: Reassert Our Role as Leading Advocates for Access, Equity, and Excellence in Women’s Health Care

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
Today in the United States, it is truly the best and worst of times. Our nation is enjoying the longest sustained economic boom in history, yet many of our patients cannot afford adequate health care. More than 43 million citizens—primarily women and children—have no health insurance at all.⁷

For a nation to be great, it must have compassion, especially for those who are often most vulnerable. It is our responsibility to advocate universal access to health care for women for their immediate welfare and for the long-term benefits to society. Still, this is not enough. Too often, women who are insured are denied the care they need. Last year, we witnessed a supreme example of gender discrimination with the instant reimbursement of sildenafil citrate (Viagra; Pfizer Inc., New York, NY) by many of the same health insurance plans that have denied women oral contraception coverage for the last 30 years. In some states, women are being discriminated against by pharmacies and pharmacists who refuse to honor physicians’ prescriptions for oral contraceptives and for the "morning-after pill." This is taken to absurd lengths by some pharmacists who refuse to fill a prescription for oral contraceptives if they think that it might be used as a postcoital contraceptive. This is wrong, and it needs to change. Women and their physicians must be allowed the rights of choice in contraceptive decisions.

	Goal 4: Be Active in Our Communities to Effect Change on the Influences That Harm Our Patients’ Health

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Every community we live in and practice in is unique, and so are our patients and their health problems. Some of the most serious threats to women seem to be outside the traditional realm of medicine.⁸ These might be behavioral, such as substance abuse; societal, especially violence against women, including the elderly; or socioeconomic, with all of the side effects of poverty. We see the consequences of these influences in our offices every day in the form of obesity or poor nutrition, chronic pelvic pain, or positive tests for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) and AIDS. A large segment of our patients, reproductive-age females, is the group with the most alarming increase in HIV and AIDS. We spend more resources treating these problems than helping prevent them. It is a vicious cycle that must be stopped.

We all can remember when people were shocked when they heard the statistic that there were 1 million teenage pregnancies every year, at least half of them unintended. It is very worrisome that today it no longer shocks us. We, the physicians of these young women, must take a leadership role. We must become more active in our communities. Prevention of unintended pregnancy is clearly cost-effective. We owe our teenagers honest sex education. Ignorance and fear are to be deplored and fought by education, involvement, and compassion. Sex education belongs in the home and in the school and in the media and every other place where we can reach young people. Contraception must be made available to teens who are sexually active, especially to adolescent girls for the prevention of unintended pregnancies as well as deadly STDs. Every young woman has a choice of abstinence or sexual activity with contraception. Easily accessible and affordable contraceptive services allow teenage women to maintain control of their reproductive lives and to retain more control in other aspects of their lives. These are our sisters and our daughters, and they deserve better. They need our help.

It is time for us—as ACOG and as obstetrician-gynecologists—to become more prominent in the abortion debate. Above all the rhetoric, high-pitched debate, and innuendo, we must recognize, as Harry Jonas stated in his ACOG presidential address, "that reasonable people can never find unanimity on the question of whether abortion should be legal, lightly, or tightly controlled, or abolished; however, it makes no sense, and is bad public policy to decry abortion on one hand, and attack family planning programs that help prevent unwanted pregnancies on the other."⁹ If we are truly committed to preventing abortions, then we must speak out in our communities to promote comprehensive sex education and family planning programs. The decision to terminate a pregnancy, and there are multiple reasons and circumstances why an abortion might be deemed necessary, is a personal one to be made by women, according to their consciences and the law. We also must denounce violence against our colleagues and fight for more legal protection for patients and other health care providers who are supporting women’s legal rights to choose.

	Goal 5: Substantially Increase Government Funding for Research in Obstetrics and Gynecology

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Government spending for research is at an all-time high, with a commitment for continued increases. In 1997, of a 5.25 billion dollar extramural research budget, obstetrics and gynecology received only 68 million dollars from the National Institutes of Health (NIH).¹⁰ This represents about 1.5% of the total NIH extramural research budget, although women comprise more than half the population.

Pediatrics received more than 281 million dollars in 1997, more than four times the funding awarded to our field. Internal medicine received more than 1.4 billion dollars in research funding from the NIH, and that imbalance is growing every year. Obtaining the money to do research is only half the challenge. We must identify, nurture, and promote young investigators who will devote their careers to research in women’s health, and then guide and support them. This is a long-term commitment. It will take several years before we see the payoff, but as readily evidenced in other specialties, in time, the rewards will be great.

	Goal 6: Promote and Develop a Computer-Literate Membership

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The computer is a very powerful tool that is transforming communication, much like the introduction of the telephone in the early part of this century. Medicine has been slow to adopt these advances in information technology that already have transformed other industries. Several attempts to introduce an electronic medical record have faltered, and a large measure of this failure is due to resistance by physicians and other health care providers to adopt this new technology. It is encouraging to note that the March of Dimes Birth Defects Foundation has joined with ACOG to develop a computerized perinatal record that is progressing under the direction of Past President Fred Frigoletto. Over the next few years, computers will play an increasingly important role in our lives and our practices. It will be critical that we take advantage of this technology and incorporate it into our practices. But, the computer is only a tool and as such will never take the place of the personal touch of the physician in the healing process.

ACOG should also move quickly to develop an encyclopedia of women’s health to be made available to our Fellows and patients on the Internet and in print. This service would provide a peer-reviewed reference upon which our patients and we can rely, and it would enhance ACOG’s reputation as the premier authority in women’s health care.

	Goal 7: Lead Successfully the Effort to Reduce Medicolegal Risks for Obstetrician-Gynecologists

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
Obstetrician-gynecologists are in the highest risk category for malpractice suits. Not long ago, we showed effectively that the majority of brain-damaged infants are not a result of labor or other intrapartum events, and we were able to establish strict criteria for relating injury to the birthing process.^11,12 Using this experience as a model, we should prioritize the most frequent and costly events that lead to malpractice suits and compile systematically the evidence to identify accurately where the liability risks lie. This scientifically developed evidence can then be used to defend against unwarranted claims and challenge false testimony by expert witnesses and others. A clearer understanding of the reasons for liability risks should influence practice behavior, improve overall health care, and hopefully decrease malpractice cost.

	Goal 8: Maintain Professional Values in the Face of the Corporate Transformation of Medicine

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
The rise of health maintenance organizations and managed care was prompted in part by the need to curb health care costs. Unfortunately, it now appears that rather than save money, it has simply shifted the payments from the physicians and hospitals to the health maintenance organization managers and their investors. Managed care has eliminated the financial margins that physicians and hospitals once used to cover the cost of care for the uninsured, teaching the next generation of physicians, and research.¹³ Most physicians are still in shock over the loss of control of their practices and the erosion of the doctor-patient relationship, which is sacred. All physicians take an oath that binds each of us to the ethical cannons of patient responsibility. We are expected to place the needs of our patients above our own. This creates a conflict with the business culture in which the major motive is profit. President Calvin Coolidge said, "The chief business of the American People is business," but the practice of medicine is not business in the classic sense. That does not mean that we cannot learn from business about the financial aspects of medicine, ie, cost containment, and efficiencies in management, but we must maintain our professional independence and focus. The practice of medicine must be run by physicians if it is to continue its high level of quality and patient satisfaction. This will require us to develop a better understanding of the influences and policies that drive the current system, then actively and constructively address these problems through collaborative efforts in organized medicine and by direct involvement with industry, government, and civic leaders.

	Goal 9: Establish a National Program to Assess Safety, Cost, and Effectiveness of New Technology Before It Is Introduced Into the Practice of Obstetrics and Gynecology

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
New technology is exciting. It holds the promise of safer, faster, and more accurate diagnosis or therapy. We see and use many of these advances in our practices today. Who can remember the practice of obstetrics without real-time ultrasound, treatment of infertility without in vitro fertilization, or gynecologic surgery without the laparoscope? We can also list other rapidly accepted and widely used technology that hasn’t proven useful. I believe that we can afford the new technology that we need if we approach evaluation and introduction thoughtfully and carefully. We should establish a system to investigate safety, cost, and relative effectiveness of new technology before it is introduced into practice. This evaluation process should include practicing physicians, academics, the government, and industry, if it is to be successful.

	Goal 10: Develop a Program of Continuous Quality Assessment for ACOG and Create More Opportunities for Fellows to Become Actively Involved in the College

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
ACOG reflects us—our goals and values. We expect ACOG to do the right thing on issues that we care about. When I reviewed the results of the Gallup poll of ACOG Fellows, I was impressed to find high praise for most of ACOG’s activities and services. We are fortunate to have a national society that is so highly regarded for its excellence in education for Fellows and patients and serves as a resource and advocate for women’s health in federal and state governments. I see ACOG as the model professional organization for the 21st century.

ACOG’s structure should be one that offers equal opportunities to anyone who wants to participate. This will require a review of the existing committee structure and appointment of task forces to replace many committees. These task forces will be short-lived and have very specific goals. They will involve more Fellows for shorter times to address specific problems.

We should reexamine the nomination and election process for all officers, national, district, and section, to attract more and diverse candidates, and we should revamp the Annual Clinical Meeting to increase attendance and make it more valuable and meaningful to the membership.

When I look out at those of you who are newly inducted, I see our future. It is up to each of you to get involved and let your voices be heard. When I see my colleagues and friends whom I’ve had the good fortune to grow up with, I see the wisdom that accumulates from generations of healing and caring for patients. It is up to each of you to share that wisdom and to help steer our passage into the new millennium.

We are living in extraordinary times. There has been more change in this century than in any other since the dawn of mankind, but we must hold steady to the course, steadfast in our commitments to our profession. The remarkable achievements of modern medicine give promise that even more miraculous advances—some unimaginable even today—are still to come. I look to the new millennium with excitement, hope, and wonder.

	Footnotes

 
Presidential Address presented at Annual Clinical Meeting of the American College of Obstetricians and Gynecologists, Philadelphia, Pennsylvania, May 19, 1999.

PII S0029-7844(99)00580-3

Received July 23, 1999. Received in revised form September 10, 1999. Accepted September 23, 1999.

	References

Top Goal 1: Define Clearly... Goal 2: Restructure Our... Goal 3: Reassert Our... Goal 4: Be Active... Goal 5: Substantially Increase... Goal 6: Promote and... Goal 7: Lead Successfully... Goal 8: Maintain Professional... Goal 9: Establish a... Goal 10: Develop a... References

 
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2. The next hundred years: Looking forward, looking back: A centennial issue. The New York Times Magazine.Sept. 29, 1996/Sec. 6.

3. Russell KP. The ACOG ten goals in ten years. Obstet Gynecol 1973;42:637–43.[Free Full Text]

4. Jacoby I, Meyer GS, Haffner W, Cheng EY, Potter AL, Pearse WH. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol 1998;92:450–6.[Abstract]

5. Gabbe SG, Mueller–Heubach E, Blechner JN, Pearse WH, Depp R, Creasy RK. A blueprint for academic obstetrics and gynecology. Obstet Gynecol 1998;92:1033–7.[Abstract]

6. Magrane DM. Women’s health education for medical students: An interdisciplinary response. Womens Health Issues 1997;7:248–52.[Medline]

7. America’s uninsured—The stark reality: The uninsured and their access to health care. Keynotes on health care. A publication of the Council of Teaching Hospitals and Health Care Systems—Winter 1999.

8. Sullivan LW. Healthy people 2000. N Engl J Med 1990;323:1065–7.[Medline]

9. Jonas HS. A time for reason. Obstet Gynecol 1987;69:141–5.[Free Full Text]

10. Korn D. Data on NIH funding to medical school departments years 1984–1997: AAMC: Council of Academic Societies Memorandum on "Data on NIH funding to medical school departments"; Aug. 3, 1998.

11. The Australian and New Zealand Perinatal Societies. The origins of cerebral palsy—A consensus statement. Med J Aust 1995;162: 85–90.[Medline]

12. MacLennan AH. A template for defining a causal relationship between acute intrapartum events and cerebral palsy. An international consensus statement. University of Adelaide: North Adelaide, South Africa. In press.

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