Is separating obstetrics from gynaecology the way forward? A UK perspective

Abstract A recent editorial in this Journal argued that increasing surgical complexity coupled with more limited training calls for separating obstetrics from gynaecology. The speciality suffers manpower challenges and high attrition rates. There is an apparent gulf in approach between researchers focussing on the views of UK graduates or trainees and workforce planners who address the problem through overseas recruitment. Whilst available literature provides scant, if any, indication as to how to address current challenges, it is important that advocates for women’s health assess and mitigate potential drawbacks when exploring the way forward.


Background
A recent editorial published in this Journal questioned whether obstetrics and gynaecology should continue to be viewed as a single speciality (Ewies 2023).It is not possible to determine the exact time when gynaecology came to be associated with obstetrics.In his textbook, 'Obstetrics: the science and the art', where Meigs (1849) argued for Obstetricity to be distinguished as a science, he recognised that it is difficult to discover a perfect classification of the items of knowledge that compose the sum of the then emerging speciality.The major focus of this landmark textbook is within the domain of obstetrics and midwifery, but it also contained chapters on the ovaries, menstruation, and amenorrhoea, which form the core of today's gynaecology.The use of the coordination conjunction between obstetrics and gynaecology may indicate that these are somehow separate disciplines, yet they are linked because they address women's reproductive system and function and their aberrations.Jeffcoate (1971, p.1), a Past President of the RCOG opined that obstetrics is one aspect of gynaecology from which it cannot be separated.The dividing line between medical specialties evolves over time, based -amongst others -on custom and local service provision.For instance, breast disease which at one time was considered part of gynaecology is now a separate branch of surgery and despite the clear overlap in study and practice, in the UK, family planning is represented by a distinct Faculty within the Royal College of Obstetricians and Gynaecologists (Wilkinson and Halfnight 2013).

Breadth of training
The debate about what doctors need to learn as under-or post-graduates will also continue but much of this will remain rooted in opinion and conjecture.It is recognised that providing training is costly but it is not possible to quantify the value of acquiring skills beyond what is directly applicable to the task at hand.Arguably, trainees in urogynaecology or gynaecological oncology could spend more or all their formative training in urology or surgery in preference to studying reproductive function and dysfunction.By extension, it could be questioned whether doctors should have a uniform undergraduate medical course.Arguments premised on what doctors end up doing (or retaining) at the end of their career tend to advocate a much narrower (or more focussed) training or knowledge base.It has also long been recognised that medicine can be practised (though perhaps to a questionable standard) with a slim foundation of knowledge and it is now increasingly permitted that procedures e.g.hysteroscopy, endometrial ablation, instrumental delivery, are undertaken by nurse practitioners or by midwives (Black et al. 2013).It is remarkable that the factors that triggered fundamental changes in medical training in the UK were primarily political and economic (Working Group on Specialist Medical Training 1993).

Fit for the future
Medicine continues to advance.It is within the lifespan of some of the doctors currently in practice that textbooks contained descriptions of biological tests for pregnancy as the now ubiquitous pregnancy test was not available, while endoscopy, ultrasound, and MRI were emerging aspirations and whole medical disciplines did not exist.
Today's trainees and trainers alike need to be prepared for an even more rapid pace of radical change whether posed by emerging technologies or by changes to the status of medicine in society.This challenges current constructs that entail the demarcation of the end of training by the acquisition of a CCT or similar certification that training is complete followed by a move to the more ambiguous continuous professional development stage.Ewies (2023) points to the value of dedicated training such as in laparoscopic surgery.This raises several challenges.There is a question about how to provide real training opportunities at different stages of doctors' careers.On the other hand, there is a fundamental question concerning the essence of the specialty and whether it should be defined in reference to the care provided or to the number or type of procedures performed.It is perhaps also important to mention that whilst hysterectomy was traditionally regarded as a complex high-risk operation and positioned at the top of the hierarchy of gynaecological interventions, attitudes have shifted, and recent developments have enabled most uncomplicated cases to be seen as procedures of low complexity.More than half a century ago, Jeffcoate (1971, p.1) warned that the much-needed holistic approach to women's health can become undermined because 'the development of the highly specialised gynaecological surgeon advances operative technique but may also engender a narrow and harmful outlook'.The apparent contradiction between the reduction in gynaecological procedures performed and the need for more gynaecologists seems to underline that the field is not purely or even primarily surgically orientated.It also signals a shift towards office or ambulatory gynaecology and a need to emphasise gynaecology as a community-rather than a hospital-based specialties and so is most of obstetrics.
Consultants at the twilight of their careers can reflect on interventions they learned early in their training but which they no longer offer, and on others they acquired later.Some obstetricians and gynaecologists have moved to as well as away from providing complex surgery.Obstetrics has also undergone significant change.Most of the procedures practised half a century ago are now regarded as curiosities.Obstetricians in larger units have their own areas of special interest or subspecialisation and a few no longer provide intrapartum care.

A challenging speciality
When considering the future of obstetrics and gynaecology, an important factor is an ability to attract and retain trainees.The number of UK graduates opting for this speciality remains low, which is curious given that medical students tend to have a positive experience during their course.The move to subspecialisation has not addressed the low uptake.The factors that underlie the rejection of obstetrics and gynaecology as a career are complex but are unlikely to be related to it being a varied speciality.Indeed, such variety, which is a feature highly valued by students, provides prospective trainees with a range of career options and future flexibility.
The structure of training in the UK incorporates advanced training skill modules (ATSMs) which enable trainees to focus on their chosen area of interest and include options for subspecialisation (RCOG (Royal College of Obstetricians and Gynaecologists) 2019).Trainees' career choices will necessarily be influenced by their own interest and available training or job opportunities.Interest amongst UK graduates in the speciality fluctuates.The drop noted at the turn of the century was attributed to factors external to the speciality (Turner et al. 2006).A more recent report suggested a resurgence of interest but with a widening gender gap (Lambert et al. 2019).This recovery should not obscure the fact that the speciality has, for decades, remained more heavily reliant on overseas graduates compared to other specialities (RCOG (Royal College of Obstetricians and Gynaecologists) 2022).In many teaching hospitals in the UK, only a minority of consultants hold a job-plan that combines obstetrics and gynaecology.Many have a narrower scope of practice within their chosen area.The situation is perhaps different in smaller units where a wider scope of practice is required in order to enable service delivery and rota cover.These everyday practicalities and service needs are hard to overcome.It is not known whether the scope of practice impacts the high attrition rates amongst obstetrician gynaecologists.
The speciality and its component parts have common attractions but also significant drawbacks.Prominent amongst the challenges is perhaps an unavoidable inability to realise the increasingly high expectations placed on it, leading to a high burden of complaints, and litigation.In the changing legal landscape, poor outcomes attract a real risk of criminal liability.The high dropout after completion of training is a manifestation of emotional burden, burnout, dissatisfaction and lack of professional identity (Becker et al. 2006;Chakrabarti and Markess 2022).

Better understanding enables better planning
It could be said that today's landscape reflects the complex interplay of external influences whether social, political, or legal, and factors that are internal within the speciality.The future direction will emerge from the interaction between these and the workforce.The important question is how to enable informed planning for the future.Whether the growing separation between obstetrics and gynaecology as seen in larger units in the UK is an indication of future direction or a response to the particular manpower challenges in the NHS remains to be seen.Every healthcare system has its unique drivers and motivators.Because of this, it is important that advocates for women's health and guardians of the speciality assess and mitigate potential drawbacks when exploring the way forward.