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ORIGINAL RESEARCH |
Presidential Address presented at the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists, San Francisco, California, May 20–24, 2000.
Address reprint requests to: W. Benson Harer, Jr, MD Riverside County Regional Medical Center Department of Obstetrics and Gynecology 26520 Catcus Avenue Moreno Valley, CA 92555 E-mail: pkharer{at}att.net
Anniversaries and birthdays are important because they provide opportunities to reflect on where we are, where we have been, and where we are going. Hopefully, these assessments provide cause for celebration as well as an opportunity to learn from the past and shape the future.
We celebrate first the induction of our new Fellows. Joining the ACOG is a milestone in your careers, culminating many years of preparation. You may justly take pride in adding the letters FACOG after your names. Indeed, because we live in an era of change when patients often lack continuity of care, the sight of those letters should be seen as a reassuring mark of excellence. Today, when third parties often intrude into the doctor-patient relationship and many physicians have significant economic concerns, patients must have confidence in their doctors. Let me assure you that if you put their interests first and take good care of them, they, in return, will take good care of you. This has been true in every culture throughout history.
In 2000, ACOG celebrated its 50th anniversary. It grew from the vision of a handful of our founders into an organization over 40,000 strong—the largest and arguably the most influential organization in the world in women’s health. This, too, is cause for celebration. We can justly applaud our accomplishments, but we cannot rest on them.
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Women’s Health in the Past |
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From earliest civilization until the onset of the 20th century, medical practice was essentially based on gross observation, pragmatism, and a bewildering assortment of therapies that reflected magical, religious, or whimsical theories of disease. This resulted in some appalling statistics. Until the 20th century, if a woman became pregnant the odds were about 1 in 100 that she would die. Almost half of all live-born term infants died by age 5 years. Women who survived childhood into their childbearing years had an average life expectancy of 40 years or so. However, those who survived to menopause lived beyond the life span of the average male, who otherwise outlived a woman by about 5 years. Effective contraception was virtually nonexistent, which may have been just as well because the average woman had to bear seven or eight infants just to maintain a stable population.1,2
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Medicine and Women’s Health in the Present |
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We are presently experiencing another revolution based on molecular biology and analysis of the human genome. New and different interventions will proliferate. Many of the surgical skills we worked so hard to perfect will be displaced by them. No doubt we will always have trauma, and as life expectancy increases, the need for reconstructive surgery will increase, but minimal intervention procedures also will increase, so historians may well look back at the 20th century as the golden age of major surgery. The pace of change is so rapid that the half-life of medical knowledge might be only 5 years, so we must all commit to a life of continuing education.
The new opportunities for intervention open vistas that challenge the imagination. Already we have technical capabilities but not the philosophical and ethical foundations to guide their applications. Developing ethics to guide us may be our most difficult challenge.
The delivery of health care is changing from a cottage industry through failed factory-modeled production into a future that may be shaped as much by politics and economics as by science. The demand for meaningful outcome data will grow. This will lead to increased accountability of practitioners, which will prompt increased regulation. The unconscionable operation of for-profit managed care organizations will be sharply restricted, perhaps with regulation of both health care payers and providers through the equivalent of a Public Utilities Commission. Somehow, a system must evolve to care for the nation’s 44 million uninsured people.4
When I became a Fellow of ACOG I was practically a clone. It was easy to describe a Fellow—he was male, white, born and educated in the United States, and a generalist in obstetrics and gynecology. A glance around reveals that that description hardly applies today; in fact there is no typical Fellow. We are rapidly moving to a female majority. Racial and national diversity has expanded but at slower and uneven rates. Today about 15% of our Fellows are either foreign-born or at least partially educated abroad. Our diversity enriches us, but also raises challenges for representation.
Some predict that with elimination of barriers to gender equality, our specialty will become exclusively female. I do not believe it would serve the best interests of our specialty, or of women in general, if that happened. Remember, we have a long and enduring tradition of undervaluing work done by women as well as undervaluing work done for women. The Health Care Finance Administration and the managed care organizations of our nation have worked in concert to sustain this inequity. The College has done much to correct such disparities, but the struggle to achieve parity must continue.5
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The College of the Future |
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Our diversity challenges the College to engender leadership that reflects all of our members and their special concerns. If we fail to do so, we will end up with declining membership and, in turn, restricted leadership. Such an unfortunate course would severely impair our effectiveness in promoting women’s health. We must be willing to accept some organizational asymmetry in order to recognize our diverse elements with their different requirements for support, learning, and growth. In short, we must provide governance that assures that all of our Fellows feel represented. Then, I believe, we should create a hospitable environment for midlevel practitioners and less specially trained physicians to work under the guidance of ACOG. If we are to sustain our leadership, we must somehow accommodate all women’s health care workers. If the College is simply the last bastion of the obstetric-gynecologic generalist dealing strictly with reproductive health, then today we are celebrating the organization’s apex of achievement in both membership and influence, but if ACOG is the dynamic champion of education for lifelong women’s health, an exciting new era is dawning.
The attitudes and expectations of the past no longer ensure individual or institutional stability. We must not become prisoners of our history. We must be willing to modify or abandon systems and structures that no longer work and experiment to creatively adapt to our changing environment. We must further explore and redefine the scope of obstetrics and gynecology as the women’s health care specialty. We must expand our vision beyond reproduction to embrace conditions disproportionately affecting the quality of life for women, such as osteoporosis, hypothyroidism, and depression. In addition, I suggest we explore the geographic boundaries of the College just as we explore its intellectual boundaries. Few Fellows realize that today we include six sovereign nations within our ten districts. "American" does not refer simply to the United States, because we already incorporate almost all of North America.
As our Fellowship has evolved, so has the population we serve. America has always been a melting pot of nations and cultures, but it is becoming even more so. Sensitivity and respect for those differences are essential for high-quality care. Our elderly population is also increasing rapidly, especially women. Our challenge is now to move beyond prolonging life to preserving health and quality of life. Teen pregnancy and single-parent families have become commonplace, often to the socioeconomic disadvantage of those women and their children. Women comprise the majority of the disadvantaged and the elderly. They must be provided adequate care.
The dramatic reductions in maternal and neonatal mortality rates in the 20th century show what can be done. Sadly, when we look beyond the developed nations it is shocking to see that third-world nations have statistics matching those of centuries past. The challenge is to share the benefits of modern care with them. We cannot solve the problems of the world, but small efforts often produce disproportionately large benefits in such populations. As the world’s richest, largest, and most influential organization devoted to women’s health, we should seek other opportunities to affect problems such as female genital mutilation, restrictions of contraception, fertility control, and many other legal, cultural, and economic barriers to care.
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Elements of Change |
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As molecular biology expands our options for prevention and treatment, many political, social, and economic forces simultaneously are reshaping the delivery of health care. The transfer of information over the Internet and the advent of telemedicine are accelerating the pace. The ACOG website can now instantly disseminate our information worldwide and Medem.com will soon expand our service to patients. We can applaud these innovations that help the College lead change.
As powerful forces remodel the environment of women’s health care and the practice of obstetrics and gynecology, the College cannot simply wait to see what happens and then hope to adapt in time. We must participate at every level to provide leadership and guide the change to assure our capability to fulfill our mission. To do so the College must adapt itself to the demographic changes in our Fellowship as well as the demographic changes in the population we serve. The changes in health care in the next 10 years could exceed those of the past 100, which exceeded those of all history.
To quote the wise words of Thomas Jefferson carved on the wall of his monument in Washington, "As new discoveries are made, new truths discovered and manners and opinions change with the change of circumstances, institutions must advance also to keep pace with the times."
Today let us celebrate the induction of our new Fellows and 50 years of ACOG achievement. Tomorrow, rather than enter a period of complacency and decline, let us learn from history, adapt, and confront the challenges to help shape the new era. It will not be easy, but it will be interesting, and I urge all of our Fellows to take an active role.
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Footnotes |
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Received July 12, 2000. Received in revised form August 16, 2000. Accepted August 31, 2000.
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References |
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2. Harer WB Jr. Health in pharaonic Egypt. In: Davies WV, Walker R, eds. Biological anthropology and the study of ancient Egypt. London: British Museum Press, 1993:19–23.
3. De Kruif P. Microbe Hunters. New York: Harcourt Brace, 1926.
4. Census Bureau Report, March 1998–99 current population surveys; Employee Benefit Research Institute (uninsured trends). Washington, DC: US Government Printing Office, 1999.
5. Harer W. A guest editorial: Gender bias? Or is it really less work to care for women? Obstet Gynecol Surv 1996;51:507–8.[Medline]
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