SASGOG/CUCOG Joint Session:
The Future of Surgery in Obstetrics and Gynecology

The 2023 SASGOG Annual Meeting was a wonderful experience for a number of reasons, but the best part was getting the chance to see the community that I am joining as an academic specialist in general Ob/Gyn. Many sessions during the meeting were focused on looking ahead to the future of our specialty, and the session I found the most provoking was the joint SASGOG/CUCOG session that involved a panel discussion regarding the future of gynecologic surgery for the specialist in general Ob/Gyn.

While this was not a typical PowerPoint lecture-style presentation, there was much to learn just by listening to the discussion among the panelists and other physicians in the audience. The panel included Dr. Ogburn, Dr. Huh, Dr. Reed, and Dr. Gecsi, which brought voices from a range of perspectives to the table. Every institution has its own structure for its generalists, and there is a wide range in the amount of gynecologic surgery typically performed by a given generalist based on each physician’s areas of interest and the department structure and needs. Some institutions, including the Kaiser Permanente system, maintain a structure that typically keeps generalists either in the realm of obstetrics or in the realm of gynecology. Though many residency graduates want to begin their careers as full-scope generalists, does the future of our specialty hold a separation of obstetrics from gynecology?

One point that Dr. Huh highlighted is that gynecologic oncologists across the country are receiving more and more referrals to perform benign gynecologic surgeries, including minor procedures like hysteroscopy and D&C. Complex benign surgeries are increasingly being referred to gynecologic oncologists and minimally invasive gynecologic surgeons who have completed fellowships with additional surgical training. A group of academic generalists at a given institution might all want operating room block time in order to maintain their gynecologic surgery skillset, which often means block time must be divided evenly across the group, leaving a limited number of operating room days for each generalist. Some statistics were mentioned during the panel discussion, including that on average, many academic generalists are only doing two to three hysterectomies per year. It is well-established in the literature that high-volume surgeons have better patient outcomes and less complications. So, how do we reconcile keeping our academic generalists in the OR while also doing our best to maintain the best possible outcomes for patients?

Panelists and other contributors in the audience discussed potential next steps that might impact residency training for our field moving forward. Our specialty is the only one involving surgical training that only lasts four years—other surgical specialties involve five to seven years of residency training, not to mention further training should fellowship be pursued. The possibility of extending residency to five years was brought up during the discussion, with the potential benefit being additional time to bolster gynecologic surgical training for all graduates. Another possibility on the horizon could be creating a “track” system during residency that would involve the same general training for the first two years, but then division into an obstetrics-focused track or a gynecology-focused track for the next two years based on each resident’s personal interest. The goal of a track-based system would be to divert a larger number of gynecologic surgeries to residents who know that they want to continue performing gynecologic surgery during their career. For residents certain they would like to be obstetric hospitalists or apply for maternal fetal medicine fellowship, surgical requirements would be decreased in accordance with this shift in cases. Several points were raised in response to discussion of these possible high-level changes—not all residents will know what their desired career plan is at the two-year mark prior to choosing a “track”, and should a resident not match into a desired Ob- or Gyn-focused fellowship, they would potentially have a limited amount of time to finish their training in order to graduate as a competent generalist. Comments were also shared about the distinction between graduating from residency with surgical confidence, versus graduating with surgical competence; the number of surgeries required to achieve competence is certainly different for different trainees.

I spent some time reflecting after this panel discussion since I am about to begin my career as an academic generalist hoping to continue a full-scope obstetric and gynecologic practice. All of the above possibilities have pros and cons, and it will be very interesting to see how the structure of training in our field evolves over time. A major takeaway for me is that I am excited to watch my own niche develop over time as I begin my practice. Should I remain passionate about performing gynecologic surgery, it will be important to work with my leadership and my co-workers to make it a focus in my practice, so that I maintain volume adequate to support the best patient outcomes possible.

SASGOG-CUCOG Joint Session: The Future of Surgery in Obstetrics and Gynecology

At the 2023 SASGOG conference, I had the pleasure of listening to Drs. Reed, Ogburn, Gecsi, and Huh – experts in gynecologic surgery — discuss the future of the field and give their insights for what I can expect moving forward in my practice.  Over the years, advancements in surgical techniques and technology have revolutionized gynecologic surgery. This has allowed for more effective treatment options in management of a variety of conditions. Yet, as we look to the future, it is becoming increasingly evident that generalist Ob/Gyns may face limited opportunities for performing gynecologic surgeries. This essay explores the factors presented by the expert panelists as major contributors to this limitation and its potential impact on the career of academic specialists in general Ob/Gyn.

One of, if not the major factor driving the limited gynecologic surgery opportunities for generalist Ob/Gyns is the rise of specialization within the field. As medical knowledge and techniques continue to advance, sub-specialties such as gynecologic oncology, urogynecology, reproductive endocrinology, and advanced minimally invasive gynecologic surgery have become increasingly robust. These sub-specialists dedicate their entire practice to specific areas of gynecologic surgery, developing expertise and honing their skills in these specialized fields. Consequently, patients with complex gynecologic conditions are increasingly referred to these sub-specialists, leaving fewer surgical cases for generalist Ob/Gyns. Surprisingly, this has begun extending even to more general gynecology. I was astonished to hear from a gynecologic oncologist that the most commonly referred procedure to his practice in recent times is actually a hysteroscopy —  a procedure typically performed by first and second year residents and that may even be done in the office in some cases.

Another contributing factor is the rapid advancement of technology in gynecologic surgery. Minimally invasive procedures including robotic surgery, has gained popularity due to their benefits, including reduced pain, shorter hospital stays, and quicker recovery times. This is fantastic for patients, and we often seek approaches that are cost effective and improve patient satisfaction in addition to clinical outcomes. However, mastering these techniques requires specialized training and experience. As technology becomes more complex, generalist Ob/Gyns may find it challenging to keep up with the latest advancements and acquire the necessary skills to perform these procedures competently. Consequently, patients seeking minimally invasive gynecologic surgeries may be more likely to turn to specialized surgeons who have extensive experience in these techniques.

As the field of gynecologic surgery becomes increasingly complex, ensuring optimal outcomes and minimizing risks has become even more crucial. This emphasis on patient safety has led to the establishment of guidelines and protocols that govern surgical practices. Generalist Ob/Gyns, who may have limited exposure to certain complex surgeries, may face increased scrutiny and risk when performing these procedures resulting in more conservative management approaches, with generalists referring patients to specialized surgeons for higher-risk procedures.

Conversely, an academic specialist may train with these more advanced technologies and become so comfortable that they are then unfamiliar with more traditional approaches including straight stick laparoscopy or vaginal surgery. When faced with the challenge of a low resource setting, emergency cases, or lack of access to surgical robot for any other reason, they are unable to perform these necessary procedures. Again, the anecdote of having to call in advanced minimally invasive gynecology surgery or a gynecologic oncology staff to for an overnight ectopic case because no robot is available and a generalist may not be comfortable with straight stick laparoscopy is striking.

Despite the fact that general obstetrics and gynecology remains critical for providing the majority of women’s health services, academic specialists may face limited opportunities for gynecologic surgery in the future. Factors such as the rise of specialization, rapid technological advancements, risk management considerations, and evolving healthcare models all contribute to this limitation. It is important to note that generalist Ob/Gyns continue to play a vital role in providing comprehensive care, including primary care, routine gynecological services, and prenatal care; and their expertise in these areas remains indispensable in promoting women’s health and well-being.

It was both comforting and disheartening to learn that much of what I’ve heard about the outlook of gynecologic surgery is not unique to my community, and many of my colleagues across the country are experiencing the same. More importantly though, it was inspiring. It emboldens me seek out gynecologic surgery opportunities now during my training, recognize the importance of all approaches to surgery to ensure proficiency in each, and pursue career opportunities where strong mentorship and preceptors are available. As the field progresses, it becomes imperative for academic specialists – including my future self – to adapt to these changes, collaborate with sub-specialists, and continually update our knowledge and skills to ensure optimal patient care.

Dr. Kenneth Noller Lecture: AI in OB

What comes next?

The Federal Public Health Emergency for the COVID-19 pandemic came to an end on May 11, 2023. Aptly timed, the Society of Academic Specialists in General Obstetrics and Gynecology (SASGOG) conference took place on May 18, 2023 and focused on looking ahead to the future and envisioning the next transformative event for the field of Obstetrics and Gynecology- Artificial Intelligence (AI).

The conference kicked off with the Dr. Kenneth Noller Lecture by Dr. Melissa Wong, who delivered her keynote presentation, “AI in OB.” She initially presented on the functions and mechanisms of AI and focused on its adaptations for medicine and obstetrics.  

Artificial intelligence at its foundation is its ability to gather information and use probability-based methods to predict outcomes, generate new insights, and make autonomous decisions. Dr. Wong highlighted various forms of deep learning (the utilization of artificial multi-layered neural networks) to extract complex patterns from data. There is supervised learning, where pre-defined rules guide input and output by the model, and unsupervised learning, where algorithms analyze unlabeled data and identifies its own patterns and make predictions. This initial evaluation can then be enhanced with reinforcement learning, where the algorithm in question receives rewards or penalties based on responses to its output. Dr. Wong cautions, however, a limitation to AI is the difficulty to unmask the neural network that processes the data received and the output it delivers.

In health care, AI has been adapted to address two primary areas: operational efficiency and risk prediction. With operations, AI can be used to assist with staffing, scheduling, optimization of workflow, and streamlining administrative tasks. With the ability to intake mass amounts of data, risk predictions models have also been created and may enable the future of personalized medicine and targeted therapies. Notably, utilization of various “-omics,” such as genomics/proteomics/metabolomics, may expedite the discovery of future drug development and treatment.  

Looking specifically at the field of obstetrics and gynecology, AI already plays a role in our daily practices. It takes place behind the scenes with pap test identification and processing to bedside with robotic surgery by augmenting precision and safety of these uses. In obstetrics, it can be found in ultrasound imaging, where automated caliper measurements make assessments of images and predicts targeted areas for measurement. Though still novel in its use, Dr. Wong suggests future possibilities for identification of anomalies or integration of education guidance for trainees.  

One of the most intriguing aspects of AI in obstetrics (OB) is its potential to assist in clinical decision-making. Dr. Wong’s research highlights a notable development in the field, focusing on the prediction of vaginal delivery during ongoing labor. In her article “Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients,” published in the American Journal of Perinatology, she presents models created from a comprehensive patient database.1 These models were evaluated to determine their accuracy in predicting vaginal or cesarean delivery after a 4-hour assessment, as well as their ability to provide ongoing predictions as labor progressed.

While this research is both exciting and innovative, Dr. Wong emphasizes the need to consider the limitations of these adaptive models. The neural network underlying these predictive algorithms remains complex and opaque, potentially limiting their generalizability to other patient populations. AI also absorbs information only from what it receives, possibly reinforcing or further driving implicit bias in practices. It is crucial to address these concerns to ensure the reliability and applicability of such predictive models in diverse clinical settings.  

Dr. Wong also remarks on the importance of considering whether the implementation of AI would alter decision making or patient outcomes. She poses the question to be asked as a benchmark of whether AI should be utilized is, “If I knew ____, then I would do ____ differently.” Ultimately, ethical considerations, patient privacy, and data security must also be prioritized to ensure the responsible and trustworthy application of AI technologies related to patient care.   

The SASGOG 2023 conference shed light to the immense potential of AI in the field of OBGYN through the insightful keynote presentation by Dr. Wong and the contributions of experts like Dr. Aphinyanaphongs, who presented on “Using Machine Learning to Advance the Tripartite Mission.” The application of AI techniques, through types of deep learning, may revolutionize OB practices and provide improvements in ultrasound, fetal heart monitoring, diagnosis, and personalized treatment. However, it is crucial to approach its implementation thoughtfully, ensuring that the integration aligns with the objectives of improved patient outcomes and enhanced decision making. By embracing the potential of AI while addressing these considerations, the field of obstetrics and gynecology can advance into a new era of precision medicine and improved patient care.  

¹ Wong MS, Wells M, Zamanzadeh D, Akre S, Pevnick JM, Bui AAT, Gregory KD. Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients. Am J Perinatol. 2022 Dec 29. doi: 10.1055/a-1885-1697. Epub ahead of print. PMID: 35752169.

Dr. Kenneth Noller Lecture: AI in OB

As a first-time attendee to the SASGOG Annual Meeting as a Resident Reporter, I was honored and humbled to be surrounded by role models passionate about the specialty of academics. What interested me the most at this conference was the motivation to remain on the forefront of academic medicine, which this year focused on the theme of artificial intelligence in medicine. There were several relevant artificial intelligence lectures throughout the meeting, and they had similar lessons and themes; notably, that artificial intelligence in medicine can allow us physicians to focus on the humanity in medicine by lifting our administrative burden. For example, through drafting in-box responses and medication refills through the electronic patient portal as suggested by one of the speakers, Dr. Aphinyanaphongs. However, there are far more benefits than just administrative tasks on the forefront of machine learning that was discussed at the conference.

The keynote lecture by Dr. Wong revealed eye-opening and groundbreaking technology, specifically in obstetrics, that can lead to improved patient safety outcomes. For example, she described how artificial intelligence in medicine can assist through improvement in ultrasound abnormality recognition and patterns in fetal monitoring. Additionally, she described a novel Cesarean Section prediction model that, unlike prior models, may aid in predicting delivery route by inputting data throughout labor. These technologic advances as it relates to OB/GYN were new information to me, and fascinating to learn from a pioneer in the field.

Artificial intelligence was also brought up in a breakout session on abstract and manuscript writing led by Dr. Wagner and Dr. Chauhan. While artificial intelligence and chat GPT have become increasingly popular, so has its use for writing. With increased use of AI in the non-medical world for writing, it remains as important to sustain our research writing skills as academic specialists. I learned and practiced the standards of writing for research, which is certainly an art requiring practice. More importantly, I learned how to formulate a research question and ways to inspire scholarly interests- specifically within general obstetrics & gynecology. Working in small groups during that session fostered a sense of camaraderie among similar-minded and academically interested physicians, whom I hope to network with in the future.

Similarly, there were countless opportunities at the conference that garnered academic connections and community in this field. I was incredibly grateful for the mentor-mentee breakfast and faculty pairing, which gave me insight on what general obstetrics & gynecology in academics can look like in my future. I learned how it’s possible, and common, to find a clinical niche and teach that clinical expertise to learners, which is a practice I one day hope to emulate. Finally, I learned tips & tricks for crucial conversations by Dr. Isaacs, which was insightful as a resident to learn from experienced leaders.

Overall, this conference was instrumental in opening my mind to the possibilities of growth in academic obstetrics & gynecology. The lessons I’ve learned, skills I’ve obtained, and connections I made have been a privilege, and I look forward to continuing my involvement in SASGOG at future conferences and opportunities.

Optimize your M&M to Propel your Department to the Next Level

The 2023 SASGOG Annual Meeting carried an important theme — “The Future of the Academic Specialist” — which happened to be an especially compelling theme for me, at the end of my Ob/Gyn residency, as I transition to beginning my career and carving out my own future.  Several of the lectures focused on important innovations in medicine, such as artificial intelligence and its impact on shaping both the clinical and research aspects of our careers. Other sessions discussed the evolution of our roles as surgeons among an evolving split to more subspecialty fields within obstetrics and gynecology. However, the meeting also highlighted the importance of leadership, mentorship, and education within academic obstetrics and gynecology, and the session entitled “Optimize your M&M to Propel your Department to the Next Level” resonated with me as I begin my career in academic medicine.

This session began with an all-too-realistic parody of a sample Morbidity and Mortality (M&M) conference: a resident stood at the podium, nervously presenting a case with an adverse patient outcome, while attendings argued, blamed, and berated the team members involved in the case.  After concluding what was meant to be a satirical sketch, the presenters polled the audience afterwards and found that most attendees had M&M experiences quite similar to this. The skit and subsequent interactive poll effectively helped segue to the objective of the session: that Ob/Gyn departments need to transform the culture of M&M conference to ultimately create a safer environment for patients and providers.

The speakers provided clear objectives for how to approach and ultimately effect change to create a psychologically safe M&M conference, develop metrics to measure the effectiveness of M&M, and employ concepts to improve the department’s culture around M&M. First, in order to establish a culture of safety, they recommended establishing new ground rules for the conference, educating faculty members, and possibly even changing the name of “Morbidity and Mortality,” to a name such as “Quality and Safety Conference,” or “Error Reducing Conference.” These names set the stage for the rest of the conference and reflect the goal of inspiring a more proactive role for M&M, rather than a focus on negative actions and outcomes.

Next, the speakers proposed specific ways to approach M&M case selection and presentation, with a recommendation to choose cases representing systemic or communication errors, rather than those where one or two individuals may be at fault. Not only does this approach reduce blame, but it presents opportunities to point out specific areas of systematic failures or gaps to be addressed.  The speakers recommended active use of quality initiative analysis tools such as a fishbone diagram or the “five whys” in order to highlight weaknesses in the healthcare system, social determinants of health, and communication failures that impact patient outcomes in each M&M presentation.

Finally, the speakers focused on proposing a clear action plan to promote, implement, and track systemic and departmental changes after each M&M. They emphasized the importance of providing and requesting feedback after each presentation, as well as creating an action list to create specific changes and evaluate the effects of these changes to ultimately ensure the progress and productivity of the M&M conference. I was particularly interested in their recommendation to document and publish the changes and improvements made from each M&M.  This not only can help track progress throughout the department, but also helps showcase this model of quality improvement as an important standard for other programs and institutions to follow.

As I approach my transition into being an academic specialist in general Ob/Gyn, I am certainly relieved that I have already completed my ACGME-required M&M presentations in residency, especially after watching the opening skit. However, this presentation not only inspired principles that I plan to use as a mentor toward my residents and students in the future when helping with M&M presentations, but it also motivated me to contribute to directing change within my department’s culture as an attending.  In addition, I plan to take these principles with me throughout my career even beyond the format of M&M conference.  I hope that, throughout my career, the adverse patient outcomes that I encounter are few and far between, but I know that they will be inevitable.  Although being involved with these cases can be emotionally challenging, this presentation reminded me to focus on how to learn from the outcomes and promote change, rather than dwelling in self-blame and shamefulness.  As academic obstetricians and gynecologists, it is our role to become leaders in creating a positive and supportive learning environment, serving as mentors and role models for residents and students, and learning from our mistakes to create a culture of safety and quality improvement within our field.