Applying to subspecialty fellowship: clarifying the confusion and conflicts!

Of graduating obstetrics and gynecology residents, 40% apply for fellowship training and this percentage is likely to increase. The fellowship interview process creates a substantial financial burden on candidates as well as significant challenges in scheduling the multiple interviews for residents, residency programs, and fellowship programs. Coverage with relatively short lead time is needed for some resident rotations, multiple residents may request time off during overlapping time periods, and applicants may not be able to interview based on conflicting interview dates or the inability to find coverage from other residents for their clinical responsibilities. To address these issues, we propose that each subspecialty fellowship within obstetrics and gynecology be allocated a specified and limited time period to schedule their interviews with minimal overlap between subspecialties. Furthermore, programs in close geographic areas should attempt to coordinate their interview dates. This will allow residents to plan their residency rotation schedules far in advance to minimize the impact on rotations that are less amenable to time away from their associated clinical duties, and decrease the numbers of residents needing time off for interviews during any one time period. In addition, a series of formal discussions should take place between subspecialties related to these issues as well as within subspecialties to facilitate coordination.

How resident unprofessional behavior is identified and managed: a program director survey.

OBJECTIVE: To determine how unprofessional behavior by residents is identified/ managed within residency programs, and under what conditions concerns are communicated to potential employers. STUDY DESIGN: A web-based survey was emailed to 241 directors of US obstetrics and gynecology residency programs. RESULTS: 141 program directors (PDs) responded (58%). 84% of PDs indicated that problems with professionalism most commonly come to their attention through personal communication. Methods of addressing the problem included expression of expectation of improvement (95%), psychological counseling (68%), placing resident on probation (59%), and dismissal (30%). The majority of PDs felt remediation was not completely successful. All PDs are willing to communicate professionalism concerns to potential employers, but 42% provide this information only if asked. CONCLUSION: Resident unprofessional behavior is a common problem for program directors, and remediation is challenging. PDs are willing to express concerns to potential employers, but a significant percentage indicate concerns only if asked.

Physician reentry: a concept whose time has come.

Three retrainees were accepted into an innovative program designed to refresh skills to return physicians to the obstetrics and gynecology workforce after a voluntary leave of absence. The program was constructed in such a way that it did not affect existing training opportunities for medical students and residents. A protocol for application and acceptance was developed that incorporated an admissions committee and a fellowship director. The need for such retraining programs and considerations in structuring, including candidate selection, faculty involvement and support, needs assessment and curriculum development, and a protocol for administration are presented. It is hoped that other training programs with experienced educators and a surplus of clinical cases will use our model to establish their own physician reentry programs, returning these valuable members of the physician workforce to practice.

Effect of Balint training on resident professionalism.

OBJECTIVE: The study was designed to assess the impact of 6 months of Balint training on self- and faculty-assessed measures of professionalism in obstetrics and gynecology residents. STUDY DESIGN: Pre- and post-Balint training resident self-assessment and pre- and post-training faculty assessment using standard professionalism instruments were used to compare the resident Balint group to the group that did not participate. Participating residents also completed a qualitative assessment of the experience. RESULTS: Residents who participated were enthusiastic regarding the value of Balint in promoting self-reflection and gaining insight into self- and patient-care issues, both key components of professionalism. There were no significant differences in self or faculty assessment of professionalism between residents who participated in Balint and those who did not. CONCLUSION: Six months of Balint training was successful in providing resident education in professionalism, measured by resident self-report. No differences were detected on 2 measures of professionalism between the training and control groups.

What's "normal": female genital mutilation, psychology, and body image.

Despite international efforts to halt the practice of female genital mutilation (FGM), the number of African girls and women undergoing the procedure is not declining as rapidly as international observers had hoped when the World Health Organization began focusing attention on the practice in the 1960s. This article focuses on the psychological effects of FGM through the example of a patient who had undergone the procedure in childhood and now felt that her closed appearance was "normal" and that to be opened would be "abnormal." Western advocates must educate themselves about the various cultural forces that lead to FGM in order to help women who have undergone the procedure heal psychologically, thereby breaking the pattern of abuse from generation to generation.

Mandatory parental notification: the importance of confidential health care for adolescents.

Studies have shown that lack of confidentiality is a barrier to adolescents use of needed health care services. Professional medical organizations support confidential care for adolescents as a matter of individual and public health. Confidentiality is governed by both state and federal law, and physicians must be aware of both. Physicians must facilitate communication between teens and parents while guaranteeing confidential care to their adolescent patients.

The impact of perceived gender bias on obstetrics and gynecology skills acquisition by third-year medical students.

PURPOSE: To investigate the perceptions of third-year medical students about how their acquisition of skills during their obstetrics and gynecology clerkship may be affected by their gender. METHOD: From January 1999 to December 2001, all third-year students at one school completing their obstetrics and gynecology rotation were given an anonymous questionnaire addressing whether gender had a positive, negative, or neutral effect on their learning experience. Students were also asked to enumerate procedures they had performed (e.g., deliveries and speculum examinations) and to rate their ability to counsel women on several clinical problems. To further investigate the perceptions of gender discrimination, a focus group of 12 fourth-year students was held. RESULTS: A total of 263 questionnaires (95%) were returned. Of the respondents, 78% of the men felt their gender adversely affected their experience, and 67% of women felt gender had a positive affect. All but five of the remaining students were in the neutral group. Those students who reported a positive gender effect performed significantly more speculum examinations (15.5 versus 12.3), labor coaching (8.7 versus 6.2), and independent deliveries (3.4 versus 2.7) than did the negative gender-effect group. The positive gender-effect group felt more confident of counseling skills. The neutral group did not differ from the negative group. The overall numerical differences among groups were small, and all groups, on average, performed adequate numbers of skills to meet clerkship objectives. CONCLUSIONS: There is a strong perception among medical students that gender influences experience on their obstetrics and gynecology clerkship, but the differences are actually small. Possible reasons for such strong feelings are addressed and related to the history of sexism in reproductive health care and to the ethics of patients' preferences.

Ethics surrounding the impoverished patient.

A case is presented in which an uninsured woman sought care at a medical clinic and then an emergency room, where she was ultimately diagnosed with early cervical cancer. Although cervical cancer at this stage carries an excellent prognosis, the patient was unable to pay for the diagnostic testing, surgery, and additional treatment that she needed and was therefore told that she would be treated in an emergency situation only. The ethics of providing care in a health care system that makes no provision for care of the indigent is discussed, with consideration of obligations of individual physicians as well as of institutions to care for the sick. A single-payer system is advocated as a solution to the problem of providing care to the under- and uninsured.

Moral diversity among physicians and conscientious refusal of care in the provision of abortion services.

Physicians are independent moral agents whose values, like those of nonphysicians, are shaped by personal experience, religious beliefs, family, and lifetime mentors. Most individuals are free to exercise their moral values in the ways that they see fit within the boundaries of legality. Physicians' moral values take on special significance, however, when considering services patients may request but that contradict that physician's moral beliefs, such as termination of pregnancy. In this article I analyze the competing obligations to self and to patient that a conscientiously objecting physician must consider when his or her personal morality affects his or her relationship with the patient. Despite each physician's freedom to choose his or her mode of practice and which services to provide, a physician with a moral viewpoint that would prevent even counseling on certain options should consider practicing in an area of medicine in which the patient's right to full disclosure of options and informed consent is not compromised by the physician's personal moral stance.

Ethical considerations of applications of preimplantation genetic diagnosis in the United States.

Preimplantation genetic diagnosis (PGD) was developed to offer diagnosis of genetic disorders prior to initiation of a pregnancy, whereas previously such disorders would be diagnosed at amniocentesis or chorionic villus sampling after a pregnancy had already been undertaken. Such application of this technology is not controversial. But PGD has been used to not only diagnose genetic disorders but also to select for certain other characteristics, and this use of the technique is much more controversial. A case is presented in which PGD was used not only to select against a genetic disorder, but to select for a certain HLA type which matched an affected sibling. The new child's cord blood was transplanted into his affected sister, who subsequently was found to be free of disease. The ethics of "having a child to save a child" are explored, and possible other uses of PGD that lead to eugenic outcomes are considered. The lack of regulation of this technology in the US is contrasted with existing legislation in other countries, and the need for national and international consensus regarding appropriate uses of PGD is emphasized.

Gestational surrogacy for a human immunodeficiency virus seropositive sperm donor: what are the ethics?

Clinics that provide assisted reproductive technology (ART) are guided by general guidelines set forth by the American Society for Reproductive Medicine and its Ethics Committee and are free to set their own policies within those guidelines. This article presents a case in which a university clinic was presented with a novel request. A same-sex male couple, both positive for the human immunodeficiency virus (HIV), asked to use one of the couple's sperm to establish a pregnancy in an unrelated gestational surrogate through in vitro fertilization, intracytoplasmic sperm injection, and embryo transfer. The couple's argument in favor of such a plan was that no documented case of HIV seroconversion had so far occurred in recipients of gametes from HIV-positive donors. Since gestational surrogates routinely accept the risks inherent in pregnancy and childbearing, an informed surrogate should be allowed to accept the risks of such an arrangement. They further argued that if no clinic were willing to provide such services, data regarding seroconversion would never be obtained. The university ethics committee examined the fertility clinic's policies and found the clinic's refusal to provide such services to be completely consistent with its policy that allows providing services to HIV-discordant couples, same-sex couples, and gestational surrogates, but that always acts to protect the surrogate from exposure to infectious risk.

Patient choice of provider gender.

As the proportion of women physicians in the United States increases, patients have increased access to physicians of either sex, and some patients express a clear preference for female providers. This is especially true in obstetrics/gynecology, where patients may have a variety of reasons for requesting female physicians. This column presents a case in which the patient not only expressed a preference for a female physician, but also, in fact, refused care from any male obstetrician/gynecologist. Possible responses to such a request are examined, with consideration of the competing priorities involved.

Ethical issues in gynecology: adolescent confidentiality, provider conscience and abortion, and patient choice of provider gender.

All medical specialists struggle with problems that cannot be solved with medical knowledge alone. The field of gynecology is not unique in medicine for the presence of ethical dilemmas, but the nature of the dilemmas are unique. Gynecologists commonly confront complex ethical questions in their practices that can be answered only through thoughtful consideration of the values, interests, rights, goals, and obligations of those involved. In this paper, three ethical issues that commonly arise in the practice of gynecology are presented: adolescent confidentiality regarding reproductive health services, physician conscience and provision of abortion services, and the question of accommodating patient choice of provider gender. Each topic is introduced with a case vignette followed by an analysis of the issues involved and recommendations for resolution.

Ethical considerations of complementary and alternative medical therapies in conventional medical settings.

Increasing use of complementary and alternative medical (CAM) therapies by patients, health care providers, and institutions has made it imperative that physicians consider their ethical obligations when recommending, tolerating, or proscribing these therapies. The authors present a risk-benefit framework that can be applied to determine the appropriateness of using CAM therapies in various clinical scenarios. The major relevant issues are the severity and acuteness of illness; the curability of the illness by conventional forms of treatment; the degree of invasiveness, associated toxicities, and side effects of the conventional treatment; the availability and quality of evidence of utility and safety of the desired CAM treatment; the level of understanding of risks and benefits of the CAM treatment combined with the patient's knowing and voluntary acceptance of those risks; and the patient's persistence of intention to use CAM therapies. Even in the absence of scientific evidence for CAM therapies, by considering these relevant issues, providers can formulate a plan that is clinically sound, ethically appropriate, and targeted to the unique circumstances of individual patients. Physicians are encouraged to remain engaged in problem-solving with their patients and to attempt to elucidate and clarify the patient's core values and beliefs when counseling about CAM therapies.