Wish you were here…

They say that the only thing unchanging is change itself. Certainly, medical practice changes at a cracking pace. Senior (read, ‘older’) colleagues of mine reminisce about the age when there were whole nurseries of babies waiting for adoption. When general practitioners managed all the deliveries and only called a specialist as a last resort after many attempts of failed instrumental delivery. And, when hysterectomies were routinely done by your local doctor.

Fast-forward 30 years. It is 1995 and I am at the end of my fourth registrar year and I have done so many caesarean sections that I have stopped counting. My logbook bulges with the details of over 300 hysterectomies and about 200 sacrospinous colpopexies. For all intents and purposes, I am an independent operator for routine gynaecological surgery.

Fast-forward again, only 15 years this time, to the year 2010. The contents of my registrar logbook are the stuff of fantasy now. My registrars at John Hunter Hospital in Newcastle, New South Wales, can only sigh in almost mute anguish at the seeming debasement of their surgical experience. The figures in my logbook are, to them, like the bloated currency of the Weimar Republic in the 1920s, remote and ridiculous.

The weather is here, wish you were beautiful…

The bounty of my surgical experience has been a deep and abiding interest in areas that would be termed ‘urogynaecology’. During my time as a trainee and a specialist, the evolution of subspecialty areas has been almost tidal. I believe that the subspecialty of urogynaecology is unique in the degree of overlap that it has with both general gynaecological surgery and advanced endoscopic surgery. How this effects the specialist gynaecologist with ‘interests’ like mine depends a little on the state in which you practise and whether you work in a regional or metropolitan area.

I began practice as a specialist in regional New South Wales in the wonderful provincial town of Port Macquarie, where I worked for seven years. Times change and now I have settled in a metropolitan hospital (John Hunter Hospital in Newcastle) for the last five years.

There are no surprises when I say that regional practice is commonly broader in its scope than metropolitan practice. The regional or rural practitioner is much more clinically and surgically exposed than his or her city counterpart. I will be provocative and say that, in short, rural and regional areas are often where we need our most clinically experienced specialists.

With the generation of ‘baby boomers’ retiring for their ‘sea change’ or ‘tree change’, the demographic shifts have seen an increasing proportion of urogynaecological cases in these centres, a trend that can only increase. In my regional practice at Port Macquarie, almost two-thirds of my work was of this nature. I could count on one hand the cases I referred for subspecialty opinion.

Newcastle (and associated local government areas) has a population of about 600,000. The area hosts one urogynaecology subspecialist and a total of 20 obstetrics and gynaecology specialists across the public and private sectors. I dare say that the majority practise urogynaecology in significant amounts.

In the Australian state capitals, however, I suspect there are a large number of practising Fellows of RANZCOG with more limited opportunity for gynaecological surgical exposure. Who could blame them for being inclined to refer the limited number of urogynaecological cases they see to a subspecialist?

Back to the future…

We live in an era of medical marketing. Most of us have regular visits from ‘representatives’ who expound the merits of the latest mesh or the newest sling. As a lure, we are often informed in hushed tones that because ‘Dr Wonderful’ (it used to be ‘Professor Wonderful’) is using the mesh, we should use it also. An invitation is issued to a workshop hosted by ‘Dr Wonderful’, where we are shown the mesh (or sling) de jour and told how wonderful the apparatus is and why we should all be using it.

Furthermore, ‘Dr Wonderful’ gets the endorsement of the International Continence Society, saying that this treatment is the standard of care. To top things off, this treatment is so cutting edge that it is only just in the process of being scientifically appraised, but thankfully for me and ‘Dr Wonderful’, it has been approved for use on my patients!

May I confess that I find this hard to resist and many of you will know what I mean. Don’t we all long to lurk at the cutting edge of something and don’t we all want the best for our patients? Forgive me for what I am about to say, but aren’t some of us looking for a competitive edge over our rivals? Don’t we want our referring general practitioners seeing us as the ‘best’ doctor for the job?

My repertoire of urogynaecological procedural skills is reasonably broad. Beyond the standard native tissue repairs, I am experienced and comfortable with the use of meshes, sacrospinous hitches, tapes and laparoscopic urogynaecological procedures. I manage re-do surgery. I keep a very close eye on my results and feel reassured that I am offering my patients procedural care of a high standard. Of the few reasons I would refer to a subspecialist, perhaps the most common is when open sacrocolpopexy is indicated.

Yet I consider myself firmly in the camp of the general gynaecologist. I obviously have a strong interest in matters urogynaecological, but don’t want to completely limit the scope of my professional life. Variety is indeed the spice…

We should brook no argument that the women we see and treat should be managed in accordance with best practice and their care should be provided by doctors who are experienced and skilled in their field. Ideally, women should have access to such care in the region where they live. Self-evidently, there will be a need and a role for both the subspecialist urogynaecologist and the general gynaecologist with urogynaecology expertise. A challenge for the future is how to train and prepare such practitioners.

My own observations, reinforced in my role as the Integrated Training Program coordinator in my public hospital, confirm the reduced surgical exposure our registrars now commonly experience. There are many factors contributing to this and most are well-known to the readership. If we wish to ensure that women in regional areas are not disadvantaged in accessing urogynaecological skills, training programs must also make provisions such that subspecialist urogynaecological clinics and surgical lists are not the sole domain of the subspecialty Fellow. This is perhaps a matter of fairness in metropolitan areas where Trainees are honed, as it is unreasonable to expect or encourage all prolapse and incontinence surgery be performed by a subspecialist. Indeed, it is a matter of necessity in regional areas that we train our surgical gynaecologists well.

PS…

The inevitable demographic consequences of our aging population mean that there will be an ever-increasing demand for urogynaecological care over time. Such care can be provided by the subspecialist, the endoscopic surgeon or the surgical gynaecologist.