AOGS E D I T O R I A L
Obstetrics and gynecology – a specialty in crisis?
GANESH ACHARYA & MAGNUS WESTGREN
Department of Clinical Science, Intervention and Technology, Karolinska Institute and Center for Fetal Medicine,
Karolinska Universtity Hospital, Stockholm, Sweden
DOI: 10.1111/aogs.12946
Obstetrics and gynecology is a discipline of medical
science that studies women0 s health and reproduction.
The specialty is involved in ensuring the wellbeing of
women by taking care of their reproductive health both
when they are well and when they are sick. It concerns
itself not only with the prevention, diagnosis and man-
agement of diseases specific to women but also their
fetuses. Obstetric care starts from preconception and con-
tinues to the postpartum period. Gynecology is concerned
with the screening, diagnosis and treatment of disorders
of women0 s genital/reproductive organs throughout their
life.
Obstetrics and gynecology combines medicine and sur-
gery, which is a major appeal for many doctors entering
the specialty. However, it is a broad discipline. Despite
the fact that several subspecialties, such as maternal-fetal
medicine, reproductive medicine and infertility, urogyne-
cology (female pelvic medicine and reconstructive sur-
gery), sexual and reproductive health and gynecological
oncology have developed, and some others, such as com-
munity gynecology, pediatric and adolescent gynecology,
are evolving, today more than 70% of obstetricians and
gynecologists work as generalists. However, there is an
increasing trend among these professionals towards work-
ing exclusively as a gynecologist or as an obstetrician.
Our discipline is very broad, and it is difficult and time
consuming to evolve into a “jack of all trades” first,
before mastering the area of clinical practice you eventu-
ally choose to engage in. Whether and to what extent
general training is desirable and necessary demands some
reflection. Perhaps the time has come to discuss whether
splitting our discipline into two separate specialties, i.e.
obstetrics and gynecology, should be considered in the
long run. In this scenario, a reorganization of the spe-
cialty to include reproductive medicine and early preg-
nancy complications in obstetrics might be logical and
advantageous.
Although clearly a reproductive organ, disorders of
breast are managed by surgeons rather than by gynecolo-
gists nowadays in most countries, with a few exceptions,
such as Germany. In gynecology, some services, such as
contraception and abortion, are now being provided by
ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 1087–1088
specialized nurse practitioners in some institutions and
practices. Within obstetrics, in Nordic countries as well as
in many other European countries, midwives are the pri-
mary care providers for most women with uncomplicated
pregnancies and deliveries, and obstetricians attend only
about 35% of births. Women with complicated pregnan-
cies may have a normal delivery attended by a midwife
under close supervision of an obstetrician. Therefore,
midwives and doctors need to work together closely to
provide the best possible care to their patients. There is
an urgent need to harmonize and integrate training pro-
grams for midwives and doctors. Such integration could
potentially reduce waste of resources, develop better
understanding of each other’s roles in patient manage-
ment, improve communication and positively affect
results.
There has been a general perception among the public
as well as the medical community that obstetrics & gyne-
cology is a specialty in which doctors are privileged to
look after generally well, young patients, and clinical out-
comes are expected to be perfect. However, it is impor-
tant to recognize that working in our specialty can be
challenging, demanding and stressful, and perfect out-
comes might not always be possible to achieve. Moreover,
the risk of litigation is much higher compared to other
specialties. With the reduction in working hours, special-
ist training and acquiring practical skills takes much
longer. In the past, our specialty was dominated by male
doctors. Today, more than 75-80% of the trainees within
our specialty are women. Although this is a welcome and
positive trend, some find maintaining work-life balance
difficult due to night shifts, long duty hours and the
necessity of dealing with unpredictable, acute and stressful
situations. Dropout rates from the training programs
have been high and the specialty has faced recruitment
problems in some countries. Gender balance is important,
and branding of a specialty as predominantly male or
female should be avoided as it may have negative conse-
quences for recruitment and retention, working environ-
ment, and future development. Lack of sufficient time
for teaching, research, and personal development of fac-
ulty members in academic departments is also
1087

Editorial
increasingly perceived as a problem due to growing clin-
ical demands.
New challenges have emerged recently, especially in
Europe, as a result of mass immigration. A substantial
proportion of refugees are healthcare personnel and a fair
number of them are fully trained, well-experienced, skill-
ful and knowledgeable obstetricians & gynecologists,
nurses and midwives. Even though there is clear shortage
of physicians (and other healthcare personnel) in the
countries within the European Economic Area, refugees’/
migrants’ integration into the healthcare sector remains
difficult. It is clear that ethical and professional standards
cannot be compromised and regulation is needed for
quality assurance, to ensure patient safety and maintain
public confidence. However, the process needed to assess
qualifications and determine suitability to practice is quite
complicated and time consuming, subsequently putting
such healthcare professionals at risk of loosing their clini-
cal skills. Some countries have taken commendable initia-
tives to overcome this challenge. Scotland0 s New Refugee
Doctors Project is such an example. It aims to provide
training, language support, professional mentoring and
work experience to refugee doctors in order to enable
them to re-enter their profession (http://news.scotland.
gov.uk/News/Scottish-Refugee-Doctors-Project-2274.aspx).
Similarly, the Step-in Jobs for New Entrants in Sweden
program encourages employers to accept immigrants who
combine work with language studies, providing
government grants to the employers to cover up to 80%
of their salary (http://www.focusjokkmokk.com/blog/
2012/3/12/step-in-job-for-new-entrants-to-sweden.html)
in the form of special recruitment incentives. Swedish
authorities aim to improve the medical accreditation pro-
cess significantly and create fast tracks to work.
(http://sverigesradio.se/sida/artikel.aspx?programid=2054&
artikel=6295203).
Having refugee doctors and other healthcare profes-
sionals join medical teams in hospitals, providing
1088 ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 1087–1088
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mentorship, familiarizing them with local guidelines and
procedures, observing their progress and assessing their
competences in the work place can accelerate accredita-
tion/certification process and prevent deskilling. In addi-
tion to contributing to the medical work force, refugee
obstetricians & gynecologists can offer unique skills
regarding management of conditions uncommon and
unfamiliar to local physicians; they can be valuable assets
when it comes to communicating and building trust
between different socio-economic and ethnic groups of
society. Host countries must explore new ways of utilizing
the competencies and skills of refugee healthcare profes-
sionals (https://hbr.org/2015/10/europe-can-find-better-
ways-to-get-refugees-into-workforces), especially within
our specialty.
Obstetrics & gynecology remains a major specialty in
medical science. Our specialty has led and driven some
important advances in medicine, such as assisted repro-
ductive technologies, ultrasound imaging, pre-implanta-
tion and prenatal diagnosis, intrauterine fetal therapy,
minimal access endoscopic surgery etc. Some attributes
that are important for being able to work and develop
a career in our specialty include good communication
skills; empathy; respect and sensitivity towards patients0
choices, feelings and needs; ability to cope with pres-
sure, make decisions, take responsibility and work as a
member of a team. Manual dexterity can also be an
advantage, especially for developing advanced surgical
skills.
Our specialty might be facing crisis both in terms of
retaining its identity as a broad discipline dealing with all
aspects of women0 s health, as well as in terms of balanc-
ing quality of clinical service delivery with keeping in
pace with the advancement in science and technology to
meet the expectations of our patients. Despite these chal-
lenges, there are great opportunities ahead for those who
choose to engage themselves in this exciting and promis-
ing field of medicine.