GYNECOLOGIC ONCOLOGY 62, 7–9 (1996)
ARTICLE NO. 0182
DISTINGUISHED PROFESSOR SERIES
A Gynecologic Oncologist Looks at Obstetrics
and Gynecology of Today and Tomorrow
JAMES H. NELSON, JR., M.D.
Department of Obstetrics and Gynecology, Harvard Medical School, Stamford Hospital, Stamford, Connecticut 06904
Received April 10, 1996
As I look back on my life in medicine, I find my develop-
ment to be a result of frequent encounters with inspirational
figures, coupled with an unusual capacity for hard work and
a modest IQ. I seem to have benefited from almost every
quirky turn along the way. These factors were added to a
desire to be a physician for as long as I can remember.
Looking at obstetrics and gynecology as it exists today,
I am concerned about its direction and therefore its future.
I feel qualified to comment in this way, based on my experi-
ence over a 40-year career as a resident, teacher of medical
students and residents without interruption, and departmental
chairman for 20 of those 40 years. In addition, I served as one
of the original five members of the Division of Gynecologic
Oncology of the American Board of Obstetrics and Gynecol-
ogy. Dr. John L. Lewis, Jr. was the chairman of the original
division and Drs. Felix Rutledge, J. George Moore, and
George Lewis and I completed the roster. This was perhaps
the most important undertaking of my career and lasted for
10 years. It helped usher in formal subspecialty Advanced
Certification in Obstetrics and Gynecology. The Society of
Gynecologic Oncologists was founded in 1969. I was one
of the 34 founding members and beginning in 1970 every
annual meeting was the scene of angry debates concerning
subspecialization. As might be expected the five members
of the Oncology Division of the American Board of Obstet-
rics and Gynecology were targets of these debates and sub-
jected to severe criticism. I recount this experience only to
preface my remarks and present part of my credentials for
making these remarks.
The timing of subspecialty training in obstetrics and gyne-
cology could not have been better, in my view. I became a
departmental chairman in 1970 for the first time, and this
provided me with an excellent perspective. It was my genera-
tion that opened the way for women to obtain residency
training in our field of obstetrics and gynecology. In the 20
years before I became Chairman of Obstetrics and Gynecol-
ogy at SUNY Downstate Medical Center in Brooklyn, only
one woman had completed residency training there and be-
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fore I became the Director of Gynecologic Oncology in
1964, only one woman had completed a 1-year oncology
fellowship in gynecologic oncology. By 1970 I had trained
two women in 2-year fellowships. By 1974 half of the 24
residents in the program were women. In 1965 I changed
the oncology fellowship at Downstate to 2 years; it was the
first of its kind in the country. Acceptance of women into
residency training was occurring all over the country and
without celebration. This change, coupled with the advent
of subspecialization, transformed obstetrics and gynecology
from a residency which attracted an average of 6% of medi-
cal school graduates to one attracting 17% and improved the
quality of residents. Why? First, some women are naturally
attracted to the health problems peculiar to women. Second,
the subspecialties attracted people of both sexes because
they had the whole spectrum from which to choose. Many
medical students are excited about pregnancy and its prob-
lems and childbirth. Many quickly become interested in in-
fertility or in reproductive endocrinology. Gynecologic On-
cology attracts a completely different group. This group
tends to be more surgically oriented and more interested in
critical care.
Another change appeared on the scene at roughly the same
time as subspecialization and that was the revolution in med-
ical technology. Fetal monitoring, ultrasonography, and lap-
aroscopy all appeared on the scene in the 1960s and com-
pletely changed our field and its various subspecialties. It
led me to address the Ob/Gyn Department in Brooklyn, with
its 10 major affiliated hospitals, at the first grand rounds of
my chairmanship by giving an hour-long disclaimer. I simply
said that I was a gynecologic oncologist and could not fill
the role Dr. Louis M. Hellman, my predecessor, had as the
professor who was an expert across the entire field. I was
not an expert in obstetrics, nor did I want to be and the same
applied to reproductive endocrinology. The past two decades
have seen a solidification and maturation of obstetrics and
gynecology and its subspecialties.
Today, the leaders in obstetrics and gynecology have my
Copyright q 1996 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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8 JAMES H. NELSON, JR.
sympathy, but I feel they need to hear the concerns many of
us training and counseling residents have about their actions.
Managed care has caused a great upheaval as we all know
and I’m sure none of us can be dogmatic about how it can
be dealt with. However, I think we must keep several goals
clearly in mind. First, our field has as one of its primary
goals and responsibilities the health care of women, but more
specifically the health care problems peculiar to women.
Second, as educators we must teach and train physicians to
fulfill goal number one. Third, we must promote research
efforts which will move us forward in achieving these goals.
In today’s world we must do these things as economically
as is feasible, but not at the expense of quality care. I suggest
strongly that it is that simple. It is not reactionary as some
may read it to be. If we keep those goals clearly in mind,
then we are less likely to lose our way, as we try to cope
with managed care.
I am distressed, as I think a significant number of others
in obstetrics and gynecology are, about the current directions
being taken by the Residency Review Committee and also
supported by some in ACOG. Most of these changes seem
to be as a result of reactions to managed care and the changes
being wrought in medicine by managed care. The latest re-
port which was finally stated from the podium of the recent
CREOG and Residency Review Committee deliberations
formalized a deemphasis of pathology and gynecologic on-
cology. Meanwhile, an almost frantic effort is being pursued
to make primary care doctors out of obstetricians and gyne-
cologists. Primary care in obstetrics and gynecology should
be defined as health care problems peculiar to women. Obste-
tricians and gynecologists did not enter the speciality to
treat ENT diseases, pulmonary diseases, and cardiac diseases
except as they relate to pregnancy and to other diseases
peculiar to women. Obstetrics and gynecology rapidly be-
came one of the premium specialties for medical students
immediately upon developing subspecialties. We have not
had difficulty in filling our residency programs with top-
notch people since subspecialties were formalized and recog-
nized. In 1995 in the state of Connecticut a law was passed
and enacted into law giving women direct access to their
obstetrician and gynecologist. This is the sane way to ap-
proach this problem. Women cannot be cut off from their
obstetrician and gynecologist for the prevention and treat-
ment of women’s diseases in Connecticut. New York State
has the same type of law.
In my department we have tried valiantly and succeeded
up to this point to cope with the constantly changing require-
ments of obstetrical and gynecological training in this coun-
try. We have reached the breaking point of our capabilities.
The leaders must step back, take a recess on change, and
regroup.
Managed care is one thing but the needs of women in this
country are another. It is the latter to which the Residency
Review Committee and CREOG must address themselves.
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Not only must they address it but once the decision is made
the American college must spearhead the fight on the legisla-
tive front. We do not care what is good for the CEO of U.S.
healthcare or any other profit-making organization providing
health care insurance or coverage for women. Our only con-
cern must be to continue to provide the best health care for
women possible and to alter the elements of the health care
provided, based on what will improve health care for women
in this country.
I began this sermon from the standpoint of resident educa-
tion. Resident education is the second most important thing
we do as educators. The most important is the care of pa-
tients. It is my firm belief that a major overhaul of residency
training and subspecialty training in obstetrics and gynecol-
ogy is badly needed. We must start from ground zero and
be prepared to make major changes in how we do this. I
would start first by discarding obstetrics and gynecology as
the title of our speciality. I don’t pretend to have the perfect
title but I would strongly urge that it be something in the
nature of ‘‘women’s medicine and surgery’’ or some all-
encompassing title that makes it very clear that we deal with
women’s health problems and by that we are referring to
the problems that are peculiar to women. Second, I believe
we should restructure residency training. Too much empha-
sis is placed on obstetrics in terms of the time used out of
the residency training period. Third, I believe we should have
a basic time period for grounding a resident in obstetrics
and in gynecology. This could be 2 years of training in the
beginning following which residents begin pursuing what-
ever part of obstetrics and gynecology they wish to practice.
If they wish to be generalists in obstetrics and gynecology
then they can complete a 4-year training period in a fashion
similar to what is done today. If obstetrics is not their interest
then it escapes me as to why they should be required to
spend any more time in obstetrics after the first 2 basic years.
If they came into obstetrics and gynecology because their
primary interest was in reproductive endocrinology, then
why should they not be allowed to pursue that part of the
speciality after those first 2 years? Gynecologic oncology
could be treated the same way except that most oncology
training directors, I suspect, would wish the people applying
for subspecialty training in gynecologic oncology have more
surgical exposure before they reach gynecologic oncology
training as a full-time pursuit. The same may apply to urogy-
necology. Looking more closely at gynecologic oncology
training for an individual who wishes to pursue it as their
speciality, this should be decided by a group of leaders in
the field of gynecologic oncology. Those members on the
Division of Gynecologic Oncology of the board plus the
Directors of the American Board of Obstetrics and Gynecol-
ogy are in the best position to do this. I would not presume
to define office gynecology training nor the other numerous
areas which the Residency Review Committee and CREOG
seem to be pursuing. Readers of this may say it smacks too
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 OBSTETRICS AND GYNECOLOGY OF TODAY AND TOMORROW
much of surgery or of medicine. I will not argue that point,
but I will say it is a far better plan than we now have
where every person who enters obstetrics and gynecology
is shoehorned into the same 4-year program, even though
as many as half of those people do not want to do general
obstetrics and gynecology. That is the only thing they are
prepared to do after the 4 years of training. We will not
attract the bright young people out of medical school unless
we maintain well-organized quality training programs in the
subspecialties. The 1996 Resident Match indicates that over
50% of all graduates are looking for primary care. Those
are not the people we should be recruiting. Gynecologic
oncology now requires a 3-year fellowship and I am in favor
of that. This too is going to price us out of the market,
however, from a time standpoint unless the initial 4 years
of general training is altered. You cannot lock people up
and imprison them in training for a major part of their prime
adult years and leave them with debts of hundreds of thou-
sands of dollars when they finish.
The last of these thoughts concerns the future of surgery
in our specialty. Down through the years a number of authors
have expressed concerns about the quality of surgeons
trained by obstetrical and gynecological residencies. It is
apparent to those who are recognized as expert surgeons in
our field that we are currently headed for a real crisis in
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9
surgical training. In a number of programs surgical teachers
are either in short supply or don’t exist. On three occasions
friends have called me to find someone to teach residents
how to do abdominal and vaginal hysterectomies. Equally
important is the fact that case loads are decreasing and will
continue to do so. We cannot ignore this problem much
longer. The usual situation will show that the number of
residents in a residency has been increased to cover obstet-
rics. This increase dilutes the number of surgical cases per
resident. One obvious solution is to reduce the number of
residents as dictated by the surgical load available for each
resident. The obstetrical coverage can be supplemented by
nurse midwives or nurse specialists trained for this purpose.
Another possible solution is to make gynecologic oncolo-
gists responsible for all surgical training. If the problem is
not addressed soon we may very well find more and more
gynecologic surgery being done by general surgeons once
again. Already in some institutions urogynecology is being
done by urologists.
Training as it is presently being planned is unacceptable
to a great many of us and I am writing and devoting my
pages as a ‘‘distinguished professor’’ to make a plea for a
new era of planning. I understand there are unusual pressures
as well as unpredictable forces at work on us today. My
days as an unyielding critic are past. Now I offer some
thoughts and possible solutions.
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