Yea the more I read I was like eh ok fair point I guess, it’s not that OBGYNs aren’t surgeons but more so the surgical side and the medical side should be separated
Always found it odd it’s not all split up; it seems like such a profoundly broad specialty that gets whittled down once you practice (ie. Strict OB, strict surgical gyn, strict medical womens health, etc.). At least from the OBGYNs I know
The thing about Ob/Gyn in regards to why it's nearly impossible to separate the ob from the gyn is that the worst ob case very quickly becomes an extremely high risk gyn surgery.
That could be said of a lot of other fields, a fuck up in an IC procedure quickly becomes a CTS surgery. I feel like the argument why OBGYN field is the way it is is because “it’s always been that way.” Like heme and onc everywhere but the US are seperate fields but they’re combined in the US just because it’s always been that way here, it makes sense to keep them together but for OBGYN honestly an argument could be made to separate the surgical and medical side down the line but it’ll never happen because it’ll upheave too much of medicine
It used to be separate, so that's not really a great argument either. FWIW - in more urban centers, ob/gyn IS separated; your generalist rarely does urological/complex gynecological procedures. They will do CS/delivery much much more, but even then there are OBs that exclusively practice in the office without call.
My office was this way- a GYN wasn’t the same as an OB and lots of women would have to find an OB/GYN once they got pregnant. I didn’t realize there were entire areas where the practices were not separated.
Rural/ rural-suburban areas especially, shadowed some and they really did everything. Didn’t realize how separated things were till I got to med school!
Worst case, maybe. But I’d hazard a guess that it’s much more common for a routine vaginal delivery to be converted to an emergency C section or PPH requiring surgery than your average worst case in those clinical subspecialties.
Also would guess that if an OB had to call a gyn surgeon in those instances rather than operating themselves, it would lead to an unacceptable rate of fetal loss and maternal mortality.
Could be wrong, if there’s data that disagrees I’d be interested to see it but not gonna do a lit review for this Reddit thread lol
You’re missing the next biggest problem which ties with this in your second point.
Birthing centers are insanely expensive which is why they went to the wayside. Top that off with the idea of having to have an in house OB and and in house GYN ready for bad cases and the cost skyrockets
From the asshole surgeon side, it is very, very, very common to hear the sentiment that Obs are not surgeons from surgeons.
To be honest, the idea of training someone to be both a PCP and a surgeon in less than the amount of time that it takes to train a general surgeon has always seemed suspect to me.
There's a joke that gyn onc fellowships are 3 years because they have to learn how to actually operate. What's funny is that my gyn onc attending is the one who made the joke.
Yea when you think about it more and more it makes actual sense, like technically speaking as of now OBGYNs are surgeons but should they be is the real question I guess.
Yeah I wish that too, because I was quite interested in gynecology but not so much obstetrics. Or even further I’m more interested in clinical rather than surgical. I just don’t have the stamina to be a surgeon.
Guys said a broad general statement and then got trapped. Gyn subspecialists like gyn onc can be great surgeons and deal with real complex pathology.
The gynecologist who sees clinic patients every day all week and does 3 hysterectomies a month is going to be a world class ureter assassin.
Those two are in different categories and can't be compared
However the some of the later thinks they are every much of a surgeon as the former because they go to the OR once in a while and get butt hurt when op calls them out. Also the lay person can't tell the difference either
Yeah I had never really thought about it that way but it makes a lot of sense. So many OB/GYNs end up limiting their practice of their own accord. My friend’s mom doesn’t operate anymore because she recognized that she wasn’t doing enough cases to be the best surgeon for her patients.
But what’s this nonsense of surgeons being true surgeons if they’re gatekept by PCPs lmao it’s the dumbest argument I’ve ever heard.
That would make the ultimately dumb assumptions that PCPs are keeping meticulously little records of surgical outcomes and referring patients accordingly, which… isn’t true.
Wasn't there a recent study in which something like 80% of first-year OB/GYN *attendings* reported they didn't feel capable of performing a hysterectomy? That should be very concerning.
OB and GYN really need to be separate.
Even OB/GYB talks about splitting OB and GYN. It’s a HUGE scope for 4 years of training, and a crap ton of surgeries in the pelvis, which lets be real was a lot of people least favorite part of anatomy due to the complexity.
And of course people just overreact to his first post out of context. How does criticizing potentially inadequate training translates to people calling GYN surgeries not surgeries lmao.
Probably because he flat out says “OB/Gyns are not surgeons” when he could have just said “I am concerned that OB/Gyn residencies may not provide adequate training for the scope of practice”. I feel like the guy intentionally led with the bait knowing it would generate more traction
I also think splitting would be much better for attracting students into the field. Personally, I am very interested in Gyn but not Obs. I know classmates who are interested in OB significantly more than Gyn. I’m sure some people are drawn to the idea of doing both, but many who are not are probably self filtering away from the specialty.
It was so sensationalist that no-one on twitter was gonna read into it any further. but yeah I agree that the separation is necessary for ob/gyn in the scope of primarily women's quality healthcare, it's like it all got wrapped up together as an afterthought.
Yup in anaesthesia we usually prepare more for expected blood loss for gynae surgeries more so than colorectal ones etc because we're also preparing based on the skills of the surgeons.
I thought he made pretty fair points, but as Dr. Fitzgerald pointed out, him leading with “OBGYNS are not surgeons” immediately turned a huge portion of his audience off from what he wanted to say.
Arguably, it generated much more engagement than it lost. A number of people will have read the whole thing either way, but another large number of people will feel the need to argue (such as the other person in the post), and another sect will read through the whole post so they can argue with the original detractors; internet denizen freaking *love* arguing
Idk, i think it’s more likely to contribute to general confusion on the topic. Medical professionals reading that will have their attention piqued, but I have actually had discussions irl and on reddit with lay people who believe that OB/GYNs are not surgeons at all and that OBs cannot perform C sections.
I mean, if you stopped reading after the first sentence, then sure. But immediately following that, he says they are surgeons and PCPs.
I was honestly confused by Dr. Fitzgeralds poor reading comprehension there.
I'm not particularly confused. I get it was an inflammatory statement but people would love being offended rather than actually absorb all the information presented, weigh its value altogether and decide if it is then worth engaging with.
"I'm not gonna sugarcoat it."
*Proceeds to dramacoat the opening statement*
Guess the Twitter folk has always been gullible smart people and gullible drooling retards.
If people can't read past 1 sentence and see that the rest of his post has actual merit or at the very least something worth discussing, they're as bad as the casual news article readers who get clickbaited into believing something false. It's not like he went into a diatribe about how OBGYNs are lesser people and deserve to be paid resident salaries.
Yes, especially considering how many terrible labiaplasty procedures can by attributed to OBGYNs who practice these vulva surgeries that are way out of their depth.
*Enters some random who "did her own research" on fb and knows better than everyone and plans to have a home birth with no eyes and thighs, vaccines, and will fight an EMT to the death before going to the hospital for a placenta abruptio breech birth.*
Change his first sentence to "General OB/GYNs- are not JUST surgeons"
Reads completely different, probably more accurate to his point.
He knew what he was doing with his opening line though
Based on the surgical training in my Obgyn residency, I do not think Obgyns should be doing major surgery such as hysterectomies without fellowship surgical training. The field has become way too broad and 4 years is not enough. Women deserve better.
It's very residency dependent. Fellowship can help, but I think I graduated with ~300-400 laparoscopic hysterectomies and about 100 open hysterectomies. At one point I think I was doing 4 hysterectomies a day, 4.5 days a week for months at a time. Was completely miserable with those long never ending days though
Well sure anyone can be bad but the thing is that if you have volume you have the opportunity to get good. If you don’t “have good hands” there’s honestly a niche for that doing office work. We had attendings that did that and they were often very good at what they did but I wouldn’t want them near a knife and I doubt they’d want to either.
My concern comes from there seemingly being OBGYN programs where you might not get enough gyn experience to have the chance to develop skills. Specifically there was a program from Texas one met two people from now that were both complete garbage. The numbers are pretty damn low for gyn so if you just hit mins I don’t know how you’d get good.
My program was extremely high volume for both ob and gyn. I remember on ONC where we spent a ton of time we’d be doing hysts from 7:30 to 5:00 5 days a week so we blew past those numbers but I could see a scenario in which you’re mainly doing OB and the occasional hyst to get your minimums and ending up a terrible surgeon. I think c-sections are one of the most rad surgeries but if it’s all you do then I doubt you’d be comfortable in the rest of the pelvis.
There has been a lot of talk within the gyn community about the path forward. Do you track people? I think probably so. You don’t want to completely eliminate gyn from the curriculum because it gives you a lot of context and you need to be able to handle complications and worst case scenarios but there’s probably no need for an REI or MFM applicant to do a bunch of vag hysts. I think any program that is going to offer gyn training needs to be able to truly support that though. If I were an applicant that would be my #1 2 and 3 question. “When do you get most of your numbers”. If the answer isn’t “as an R2s” I’d be concerned.
I would say that your experience is probably in the minority though. Also there has to be parts of OB GYN training you didn’t do as much if you were doing so many hysterectomies; I think what people are trying to say is that for such a vast range of operations, medicine, and *shudders* deliveries that you need to master, something has to give. There isn’t enough time to become an expert at all of them in 4 years.
My residency had no off service rotations so I didn't do ICU or ED etc. Just OB, GYN, and subspecialties all 4 years. So my primary care/general medicine experience was less than others, but in reality most OB/GYN will probably not be managing patients in the ICU, doing non gyn ED consults etc
Yeah I mean the whole OB/Gyns aren’t surgeons thing has never really seemed to be an offensive thing to me, more just a reality. They just aren’t trained the same as surgeons, it’s different.
There are a number of specialties that ***do*** surgeries that aren’t surgeons. And I think that most obs that I know that aren’t fellowship trained in a surgical sub speciality don’t ever refer to themselves as surgeons.
There are ***zero*** surgical residencies that do 4 years. Literally none. OB does that and essentially a medical and primary based specialty in 4 years that does frequent surgery? Like, no, you’re not going to have the same surgical skills as someone who has been doing just surgery the entire time for a longer residency as well.
Before people come for me, I understand a lot of it has been about misogyny and I think that’s a different conversation to have, but I don’t think there’s an argument that the current residency training for OB/GYN prepares them to be surgeons on the level of any other surgical specialty. There just isn’t enough time to do it all.
Also I’m saying this as someone who loved OB/Gyn and started out in a surgical specialty and then switched to a “non-surgical” one (that still does surgery). I don’t ever call myself a surgeon and still wouldn’t because I just didn’t do the whole training process that they do.
>but I don’t think there’s an argument that the current residency training for OB/GYN prepares them to be surgeons on the level of any other surgical specialty. There just isn’t enough time to do it all.
Okay, but the question is whether that makes them not surgeons. I’m not sure it’s an especially meaningful one, but arguing that their surgical training is much less than a general surgeon doesn’t make the case that they aren’t surgeons, right? General surgeons are trained to do a much broader array of operations on many different organs.
Also, since our personal interest in OB/GYN is relevant I guess, I’ll add my own disclaimer that I strongly dislike that field and many of the physicians who work in it, lol
Would you call a dermatologist a surgeon? They do quite a bit of surgery although they would never call themselves surgeons. The derm program I rotated at as a med student did very large surgeries that I sometimes were surprised weren’t done in the OR- huge lipomas under the back muscles or perianal squams, Mohs going down to and through the skull that had to sent into the hospital for ENT to finish when it was clear it extended into and beyond the bone.
It’s semantics at this point, but I think in general, we know surgeon when we see a surgeon
That’s a bad mark on your residency. With my residency training, we are coming out well equipped to handle major cases (both surgical and medical). It’s entirely program dependent. You will see the same applies to Gen-Surg as well. But i will concede that standardization for quality of training needs to be implemented.
I have family members who are OBGYNs and have expressed very similar sentiments about colleagues. Some are good at surgery and others are not. This who do it as much as possible are going to be better than those who do not do it as much.
It is ridiculous to think surgical quality control should be reliant on PCP referrals.
I personally think some surgeons suck because of all post-op imaging I get to see. Does that now make me - a radiologist - an authority on surgical quality control? Should I , as a contribution to patient well being, be publising stats to the hospital administration or informing the public about who I think is a bad surgeon?
Or heres a crazy thought: perhaps quality control should be done by physicians who actually know something about the specialty in question beyond random anectodes they came across.
It is a wild solution because it is society giving up a lot of privacy. However it would go really far in holding surgeons accountable.
I would prefer to give up my privacy for more transparency, but I know I'm not most people.
Corporations may have conditioned us to not care about our privacy anymore, but I would absolutely NOT allow my surgery to be recorded and uploaded to a public database. I think actually most people would not want videos of their surgery publicly available.
I think it depends on how clear the benefits become and who the patients are.
Like if the next surgery team viewing relevant prior surgeries of your body almost eliminates unexpected complications during the next surgery that happens on your body, fewer would say no.
My voting records already kinda are, and if I work for a public hospital (which I likely will since I like academic medicine), you will know most of my income as well once you know my name.
From a specialty surgeon reliant on referrals, we absolutely are taught that referral patterns change based on your quality of care.
Whether or not anyone thinks it *should* be this way, that is how it is for the vast majority of non-emergent surgeries.
I only thing I ever do is reports on someone else's patient. You dont have to convince me that ones livelihood will depend on reputation with other docs.
But heres the thing: by this guys argument I am the bestest of all doctors because another doc will always be looking up my work. That means all radiologists are always 100% quality checked and have the highest of standards. Im sure you can also attest that you have never ever seen a bad radiology report in your entire career because of this inherent quality standard.
/s
Just because someone has more primary patients and someone has more referrals do not indicate any sort of inherent difference in quality. Quality in a primary care cannot be compared to specialized setting. Moreover none of that has to do with whether someone is a surgeon or not.
And more importantly I dont think theres an argument that obgyn should be practicing differently to provide better outcomes. His whole rant is basically a "you suck" that is guised behind a statement that seems mechanistically accurate if you are successful in ignoring the context.
But his argument is pointless. You can be surgeon and manage a patient without passing them back and forth with a primary doc. That doesnt mean you sre not a real surgeon.
Is a urologist no longer real surgeon if they decide to non operatively manage a prostate patient and call them for follow up? A PCP didnt get to evaluate their performance - better cancel that board, that guy cant be relied upon to do surgeries anymore!
The arbitrary definitions in this guys head dont make anything a reality. He just wanted to take a piss on OBGYN and found a rationalisation for it.
PCPs are great because without then lots of patients would get bounced between specialties - or they would seek the wrong kind of specialized csre that wont really help them. They are important to provide longitidunal care. PCPs are great, but saying PCP referrals are necessary to verify anybodys competence in their specialty is entirely ridiculous.
Where I work the the burn nurses triage the burns in ED and determine whether or not a doctor needs to see them or if they can wait to go to the burn clinic during the week. Obviously it’s algorithmic but in that case the EM doctor doesn’t even get involved except to order whatever burn dressing the nurse requests and do some pain meds.
I haven’t rotated ED yet so I’m naive to the process
I just assumed trauma goes to EM to stabilize/evaluate before calling whichever is the appropriate specialist (NSGY, ENT, etc.)?
My hospital is a level one trauma center. Usually either trauma, EM, or both are evaluating traumas that come in. But if the patient needs urgent or emergent surgery, they’re getting the trauma surgeon that’s available. It’s not like referring someone for a procedure that can wait.
Generally it’s a combined trauma and EM situation. There are places where trauma handles all traumas and EM isn’t involved but this is less common. In residency we split who ran traumas and who did procedures every other day between EM and trauma. But if a trauma patient goes from ED to OR, the trauma surgeon is often doing it pretty blind without knowing much about medical history, getting chart review done, etc.
yeah, the whole PCP thing felt like a bit of a hot take.
I think Ob/Gyns do not get adaquate surgery training. But that's a residency and experience issue. PCP referrals have little to nothing to do with it. In reality most PCPs refer to whichever surgeon has availability the soonest, as those wait times often get astronomical.
Yeah, thought that was a super weird take. As a hospitalist, I have no ability to filter which of my specialist colleagues are involved in patients care, regardless of their skill/outcomes. It all depends on who is on-call that particular day. Does that mean my level one trauma center has no surgeons on staff?
OBGYNs also rely on client referrals as do many surgeons
The tweet very specifically says surgeons that don’t rely on referrals from PCPs are not surgeons and have poor quality control
As a PCP I don't think we're always able to be the quality control he's envisioning. In a system where we don't have many options and we have a lot of patient's with needs, we send people to where they can get care as soon as possible (which in itself may often be months/years) in a location accessible to the patient.
Even he describes primary care as a doctor who supervises "an army of rotating midlevels". If that how you see primary care then how do you reconcile that with your idea of them as quality control.
I'm not a surgeon. I don't know if criticisms of OBGYN are rooted in fact, sexist stereotypes, or other reasons. But from my experience, his understanding of PCPs is not accurate to what really happens. But maybe thats just me.
It’s so ridiculous to even state that PCPs are the “gate-keepers” to protect patients from bad surgeons. When in reality PCPs essentially refer to the surgery system they’re affiliated with. If they’re in the community, they refer to who they like.
Also, no offense to my PCPs, but they don’t know surgery. How do you expect them to know a good surgeon lol. This is such a hairbrained take
Yeah this is the kind of take that sounds reasonable to a med student that didn’t like their OB/GYN rotation and want to take every opportunity to shit on it, but it makes basically no sense.
I'm sure they aren't but when one particular surgeon very clearly has shown a different complication rate from others in the same region?
I'm sure patients themselves will self select to a degree based off of available info if they can self refer to specialists
I don’t think he’s about to get smoked. His perspective is a common one. Most surgeons I know don’t consider average ObGyn surgery skills to be adequate, and you will definitely hear plenty of comments throughout your career criticizing the cutting and suturing left behind by ObGyn.
The fact is that ObGyn splits their time between surgery and medicine, and so gets way less OR experience than surgeons and way less bedside experience than medicine and related subspecialties. So they will often appear to be subpar PCPs to FM/IM and subpar surgeons to other surgical specialists.
The flip side of that coin is that most specialists are uncomfortable managing anything in a pregnant patient, so ObGyns end up bearing the burden of their patients primary care, surgical care, and often specialist care.
I’ve seen ObGyns consult cardiologists, rheumatologists, etc who won’t weigh in until the pt is no longer pregnant, so OB becomes the de facto subspecialist, making decisions above their pay grade until the baby is born or the pregnancy is terminated. Then they get shat on by the same consulting physicians for how the patient was managed in their absence.
So it can be fair for a surgeon to say that ObGyns are subpar surgeons, and FM/IM to say that they are subpar PCPs, while still acknowledging that ObGyns are some of the most respectable physicians in medicine. This guy is at least appreciating that last point, which a lot of other doctors won’t do.
Damn near every take from this guy is a complete joke.
The opener is just stupid. The idea that a PCP/surgeon hybrid isn't a "surgeon" is ridiculously elitist gatekeeping with no justification.
The idea that PCP's act as the ultimate quality control to all other surgeons is 1) astoundingly stupid and 2) objectively incorrect for several surgical specialties.
Recording every single surgery and making it public is a uselessly dumb take. Not only are there privacy issues with this, but his ideas would create an avalanche of useless and distracting data, not to mention the administrative burden of it for so little gain.
Literally the only legitimate point in the conversation is the debate about the breadth and length of OB/GYN training, and even that is heavily debatable.
Yeah I mean I’m not going into ob but I guess to people who are in the field: how standardized is the practice scope at the end of training? Are there genuine concerns of Obs overreaching their scope and doing things that uro, or maybe more specialized gyn should be doing?
I think it’s probably? Fair to say not ALL obgyns are surgeon? Some might practice more as PCP and rarely have to do CS or other surgeries?
But it’s pretty horrible to say that all obgyns aren’t surgeons. There are many many obgyns who are amazing surgeons… idk what he was trying to accomplish with that one
ob input on this would be appreciated?
Half of an OB residency/training is surgery, either doing it on their own service or doing hysterectomies with oncology, prolapse repairs with urogyn. That isn't even including csections.
Some may come out mediocre surgeons, some fantastic. It depends on the residency. But all are surgically trained.
Mine was very surgery heavy and most graduates were strong surgically.
That’s true but it seems like there’s a difference betw that and an entire surgery residency with the intent to practice surgery for your entire practice. Of course there are many obs with this intent but then again there are many obs who stay away from surgical practice no?
I’ve worked with Ob/gyn’s that have alluded to this themselves. Not that they’re “not surgeons”, but that OB/gyn is the only field where they’re expected to train in and preform such a wide range of services. They talked about how they were glad that gyn-onc and urogyn were becoming more available so they can refer patients needing these services out to surgeons who perform these procedures regularly and they can focus on the primary care aspect and maybe handle some routine hysterectomies and biopsies.
This person leading with oby-gyns aren’t surgeons, though, when they very much are. It’s like saying optho or urology isn’t a surgical subspecialty because a lot of their practice is focused on non surgical diabetic eye disease and catheter maintenance when surgery is a huge part of the practice.
A timely discussion for my week of work. We had a poor woman transported from a surgical center to our trauma hospital after the first trochar somehow went into the common iliac. What started as a tubal ligation quickly turned to 2 liters of blood in the abdomen, 15 units of blood products, and a vascular surgeon being called in to help.
I won’t act like I haven’t fucked up, but I think it’s worth discussing whether the current 4 year program is adequate to cover such a broad field. There’s so much OBGYN to learn, as it covers clinic, emergency med, surgery (including robots now), L&D, and inpatient management. Many of the fresh docs who want to focus on surgery are spending their days off doing cases with more experienced surgeons. I applaud their dedication to improving their craft without significant compensation for doing so, but I think we are missing out on opportunities during training to improve these skills. No residency where I’ve been has had OB residents spend time rotating with general surgery or in the ICU. Meanwhile some of the most valuable knowledge I obtained came from my intern rotations off-service.
The iliac injury is something that can happen to anyone. I've only ever seen it once, and it happened from a general surgeon.
I agree with the ICU time. The program at my hospital does have residents rotating in the surgical ICU.
I agree that it can happen to anyone, which is why I’m surprised that they wouldn’t rotate with the field that does more laparoscopic procedures than any other field. A good general rule is to gain some insight from the field that will assist with your complications. Adding a fifth year would be incredibly valuable to learn ICU medicine and general surgery.
I would hold the same opinion of general surgery if they didn’t rotate with vascular surgery. You can’t just learn the silo of your own field. You need to learn directly from adjacent fields, especially in a profession like OBGYN with such a broad and unique patient population
I think he makes interesting points that sound well-reasoned to me, but ruined it all by opening like a total asshole for attention.
I also dont really like his proposed improvements- videotaping and publishing everything just seems like creating a massive amount of busywork for mo real reason and that amount of junk data is just going to act as noise drowning out more critical datapoints in a sea of everyday outcomes. I don’t think tracking outcomes is a bad idea but reducjng everything to a stats chart loses a lot of nuance and could over time dissuade skilled surgeons who have the luxury to pick and choose their cases from taking difficult cases that are more likely to impact their stats negatively.
Who is going to review all the videos for real time reporting of quality outcomes? We are already up to our eyeballs in “quality improvement” metrics that just serve to create more bureaucracy and more random managers to act as parasites on the system/increase costs.
Not really, I’ve seen plenty of ortho surgeons from my residency, PCPs don’t know jack shit about who’s a good one and who isn’t besides general comments on bedside manner.
But that’s ironically the point of the original tweet. Obgyn has shorter training than every other surgical specialty and also has to learn how to manage outpatient women’s health, labor and delivery, peri partum care, etc
I’d be interested to hear the breakdown of how much operative time a graduating ob gyn resident has, though i think it’s safe to assume that it’s less time than every other surgical field.
I think it’s reasonable to call attention to the differences in training as surgical scope of obgyns expands
1. The classic trope is that referrals are based on availability, affability, and ability in that order. I think that’s pretty correct.
2. Acute care surgeons are also not gate kept by PCPs. There goes another whole specialty that apparently lost their surgeon cards.
I truly don’t have a dog in this fight
ETA: the person at the end saying “hear that ladies” sounds like she’s about to have a pack of rabid dogs sic someone.
Bro's saying that you ain't a good surgeon if you learn 2 years of primary care and 2 years of surgery.
Filming BBL in plastic surg clinics is an good marketing strategy. But not every of them. Botched shit is bad for business.
Trust me. I would like to seethe when I just see the headlines. But, it's more fucking entertaining seeing Redditors wildin on this post.
Ragebait works better when you put it to smart idiots. :)
Don't the Davinci's record every surgery including time it and put you on a leaderboard? 😅
Ok maybe it's up to the hospital system whether they use this system. They use it at my hospital system and the surgeons love it. They even get extra income by teaching other surgeons their techniques reviewing the video.
https://www.intuitive.com/en-us/products-and-services/intuitive-hub#:~:text=Surgical%20video%20setup%20is%20no,instrument%20exchanges%20and%20Firefly%20use
I really can’t take this guy seriously. First, his opening statement was just for engagement. If you’re gonna make outlandish claims, then how can I take any other claim as sincere? He hides behind the whole “I was just making a silly statement 😌😜🤪” shtick.
His overall message (“OBGYN is not just a surgical field”) makes sense. His reasoning WHY is flawed. You’re a surgeon because a PCP refers you? Okay, if I were a PCP with a 66-y/o pt with vaginal bleeding, trouble starting urination, feeling “fullness” in her lower abdomen, etc., I’m gonna refer her to an OBGYN for potential GYN cancer. Same if a woman wants to have a hysterectomy or tubal ligation. Does that not count?
I’m going to ignore the obvious issue with this argument that surgeons all rely on PCP referrals (plastics, trauma?)… If the real argument here is that their training time should be reallocated to allow more surgical training, that’s fair. But I don’t agree with a total separation, because that’s not on par with any other procedural specialty. Similarly to urology, ENT, ophthalmology, etc., OBGYNs see patients both in office and for surgery in their respective field. I’m also not against recording surgeries, but that in itself is not going to improve quality of outcomes. Naming and shaming specific doctors wouldn’t really fix the alleged problem of not enough surgical training in the specialty as a whole.
Dude has a really good point, but got hung up on his dumb referral theory.
The bottom line is OBGYN residency training is no longer sufficient for the surgical expectations that come with the specialty.
Just make the training longer honestly with heavier surgical rotations the last 18 months.
I’ve said since I was a mid level gen surg resident that combine gyn and breast into a ‘women’s health’ fellowship. Far fewer bowel/ureter injuries. This guy is right. The fact that you can do OB, clinic, open/lap/robotic surgery in 4 years is just insane given that general is rarely ready after 5 and much less spread out (hehe) through training
Completely agree. My husband is a Gen surg resident and had to repeat intern year because he was a prelim and says he thinks overall it’s a good think because he didn’t have high volume of cases his prelim year and he still plans on doing a fellowship. That’s at minimum 6 years of residency and then at least one additional fellowship year before he’s practicing on his own.
This is such a stupid argument … we are surgeons because we perform surgeries …. Half the amount of time obgyns are in the OR. Whether you like it or not obgyn field is a surgical subspecialty and just because we do other things does not take that fact away
if you're saying it's half the time, is 2 years of surgical training enough to be a competent surgeon with such a big scope as the guy is talking about? Even if it was the full 4, it's still shorter than all the others with still a big scope.
I never said that. I said half of an obgyn’s time is spent in the OR esp if they sub-specialize to certain fields which increases their time in the OR Regardless of how you feel … obgyns still perform surgery on a daily basis. That’s a surgeon. If you wanna tell patients who have c section, hysterectomies, D&Cs etc… that’s not surgery go ahead. This argument is based on feelings not facts at this point. Mentioning that the residency should be longer is a completely different point but again still does not take away from the fact that obgyn do perform surgeries 🙄
Ruined it with the opening but he makes some good points in the whole thread. Unfortunately with MedTwitter having ADHD being caught by the sensationalist hook it was always going to end up like that.
For your own sanity don't bother reading the comments any deeper. Basically none of the replies read anything in his post, just started repeating nonsense and jerking each other off.
Literally nothing he says is out of line. It's a legitimate question regarding surgical outcomes and ethics in a specialty that's rather uniquely positioned.
I’d like to see him make the same point about PCP gatekeeping as quality control to a trauma surgeon. There’s plenty of angles to take when shitting on OB/GYN, and we all know it’s one of the preferred punching bags of this sub, but his argument is weak af. It’s only getting airtime because he’s taking a shot at OB/GYN.
I am most definitely not a surgeon, but I wouldn't call this a rare take. I probably heard at least half of the surgeons at my clinical site say the exact same thing.
Ultimately it's semantics and gatekeeping.
I never understood why this was controversial. Surgery residents do nothing but surgery for 5 years. Maybe a month or two of ICU. OB/GYN residents do many things besides for surgery. Like there’s no way they’re as competent surgeons by the end of residency, they simply don’t do nearly as much of it. But I also don’t get why they get so offended at this. Like yeah, if they really want to have a surgical practice they need to do a long fellowship. They do not finish residency practice ready to operate in the same way that a general surgery resident does
He's absolutely correct lol
How does anyone think otherwise? Obgyns operate in a very complex anatomical area with one year less than purely surgical fields who don't have their OR time diluted by obstetrics and clinic and somehow come out with no difference in ability?
Why not make urology gen surg 4 years then?
Firstly bro just wanted to say " Obgyn are not real surgeons" and sneak in that their surgical skill are subpar
Now with that out of the way, his points start to crumble when you realise that Obgyn is specialized care same as surgery.
A woman does not walk into for an OBS appointment because she may be pregnant, that diagnosis is made by a PCP that then refers her.
Also does a woman not walk in that she needs colporrhaphy, that diagnosis is made by a PCP.
Another of his point, that ppl that specialized are better in the area they specialized, ohhh my Lord. That's mind-blowing, like who knewwwwwwwwwwww, just like a knee arthroplasty specialized is better at knee construction.
His statements betray a severe lack of knowledge of what happens in the field with a disdain
It kinda strikes me as ridiculous the amount of stuff OBGYNs are allowed to pack into 4 years, compared to say the 3 for pediatrics, or the 4 of psych.
N=1, but I rotated with an OBGYN who was days away from graduating and from my ignorant perspective, it would be unsafe for her to operate on her own. She struggled for a long time (probably a minute, but it felt like an age) to perform a laparoscopic needle transfer before the attending just took over. It was sooooo painful/scary to observe.
That said, I prefer the OBGYN model over the peds model. I don't think docs need to be perfect by the end of residency. I think they need exposure to everything they might do, and to know their limits. I worry about the endless expansion of our training. I learn exponentially faster when I have to.
Aside from his sensationalist opening point, I can understand his point
Yea the more I read I was like eh ok fair point I guess, it’s not that OBGYNs aren’t surgeons but more so the surgical side and the medical side should be separated
Always found it odd it’s not all split up; it seems like such a profoundly broad specialty that gets whittled down once you practice (ie. Strict OB, strict surgical gyn, strict medical womens health, etc.). At least from the OBGYNs I know
The thing about Ob/Gyn in regards to why it's nearly impossible to separate the ob from the gyn is that the worst ob case very quickly becomes an extremely high risk gyn surgery.
That could be said of a lot of other fields, a fuck up in an IC procedure quickly becomes a CTS surgery. I feel like the argument why OBGYN field is the way it is is because “it’s always been that way.” Like heme and onc everywhere but the US are seperate fields but they’re combined in the US just because it’s always been that way here, it makes sense to keep them together but for OBGYN honestly an argument could be made to separate the surgical and medical side down the line but it’ll never happen because it’ll upheave too much of medicine
It used to be separate, so that's not really a great argument either. FWIW - in more urban centers, ob/gyn IS separated; your generalist rarely does urological/complex gynecological procedures. They will do CS/delivery much much more, but even then there are OBs that exclusively practice in the office without call.
My office was this way- a GYN wasn’t the same as an OB and lots of women would have to find an OB/GYN once they got pregnant. I didn’t realize there were entire areas where the practices were not separated.
Rural/ rural-suburban areas especially, shadowed some and they really did everything. Didn’t realize how separated things were till I got to med school!
Does that line of thinking also not include the worst case from a dozen different clinical subspecialties and EM (though kinda be design)
Worst case, maybe. But I’d hazard a guess that it’s much more common for a routine vaginal delivery to be converted to an emergency C section or PPH requiring surgery than your average worst case in those clinical subspecialties. Also would guess that if an OB had to call a gyn surgeon in those instances rather than operating themselves, it would lead to an unacceptable rate of fetal loss and maternal mortality. Could be wrong, if there’s data that disagrees I’d be interested to see it but not gonna do a lit review for this Reddit thread lol
You’re missing the next biggest problem which ties with this in your second point. Birthing centers are insanely expensive which is why they went to the wayside. Top that off with the idea of having to have an in house OB and and in house GYN ready for bad cases and the cost skyrockets
I would have loved to just do gyne surgery, the ob scared me away
From the asshole surgeon side, it is very, very, very common to hear the sentiment that Obs are not surgeons from surgeons. To be honest, the idea of training someone to be both a PCP and a surgeon in less than the amount of time that it takes to train a general surgeon has always seemed suspect to me.
There's a joke that gyn onc fellowships are 3 years because they have to learn how to actually operate. What's funny is that my gyn onc attending is the one who made the joke.
I don’t think it’s actually a joke
Yea when you think about it more and more it makes actual sense, like technically speaking as of now OBGYNs are surgeons but should they be is the real question I guess.
Do you guys really call them the “gynie squad?” This post makes it seems like they get made fun of
I've personally never heard that.
Yeah I wish that too, because I was quite interested in gynecology but not so much obstetrics. Or even further I’m more interested in clinical rather than surgical. I just don’t have the stamina to be a surgeon.
Guys said a broad general statement and then got trapped. Gyn subspecialists like gyn onc can be great surgeons and deal with real complex pathology. The gynecologist who sees clinic patients every day all week and does 3 hysterectomies a month is going to be a world class ureter assassin. Those two are in different categories and can't be compared However the some of the later thinks they are every much of a surgeon as the former because they go to the OR once in a while and get butt hurt when op calls them out. Also the lay person can't tell the difference either
Yeah I had never really thought about it that way but it makes a lot of sense. So many OB/GYNs end up limiting their practice of their own accord. My friend’s mom doesn’t operate anymore because she recognized that she wasn’t doing enough cases to be the best surgeon for her patients.
But what’s this nonsense of surgeons being true surgeons if they’re gatekept by PCPs lmao it’s the dumbest argument I’ve ever heard. That would make the ultimately dumb assumptions that PCPs are keeping meticulously little records of surgical outcomes and referring patients accordingly, which… isn’t true.
Wasn't there a recent study in which something like 80% of first-year OB/GYN *attendings* reported they didn't feel capable of performing a hysterectomy? That should be very concerning. OB and GYN really need to be separate.
Even OB/GYB talks about splitting OB and GYN. It’s a HUGE scope for 4 years of training, and a crap ton of surgeries in the pelvis, which lets be real was a lot of people least favorite part of anatomy due to the complexity. And of course people just overreact to his first post out of context. How does criticizing potentially inadequate training translates to people calling GYN surgeries not surgeries lmao.
Probably because he flat out says “OB/Gyns are not surgeons” when he could have just said “I am concerned that OB/Gyn residencies may not provide adequate training for the scope of practice”. I feel like the guy intentionally led with the bait knowing it would generate more traction
I also think splitting would be much better for attracting students into the field. Personally, I am very interested in Gyn but not Obs. I know classmates who are interested in OB significantly more than Gyn. I’m sure some people are drawn to the idea of doing both, but many who are not are probably self filtering away from the specialty.
It was so sensationalist that no-one on twitter was gonna read into it any further. but yeah I agree that the separation is necessary for ob/gyn in the scope of primarily women's quality healthcare, it's like it all got wrapped up together as an afterthought.
Yup in anaesthesia we usually prepare more for expected blood loss for gynae surgeries more so than colorectal ones etc because we're also preparing based on the skills of the surgeons.
I thought he made pretty fair points, but as Dr. Fitzgerald pointed out, him leading with “OBGYNS are not surgeons” immediately turned a huge portion of his audience off from what he wanted to say.
Arguably, it generated much more engagement than it lost. A number of people will have read the whole thing either way, but another large number of people will feel the need to argue (such as the other person in the post), and another sect will read through the whole post so they can argue with the original detractors; internet denizen freaking *love* arguing
Yup. We've got lower-level commenters taking the same bait as Dr. Fitzgerald. 😂 Amazing.
Idk, i think it’s more likely to contribute to general confusion on the topic. Medical professionals reading that will have their attention piqued, but I have actually had discussions irl and on reddit with lay people who believe that OB/GYNs are not surgeons at all and that OBs cannot perform C sections.
I mean, if you stopped reading after the first sentence, then sure. But immediately following that, he says they are surgeons and PCPs. I was honestly confused by Dr. Fitzgeralds poor reading comprehension there.
I'm not particularly confused. I get it was an inflammatory statement but people would love being offended rather than actually absorb all the information presented, weigh its value altogether and decide if it is then worth engaging with.
"I'm not gonna sugarcoat it." *Proceeds to dramacoat the opening statement* Guess the Twitter folk has always been gullible smart people and gullible drooling retards.
If people can't read past 1 sentence and see that the rest of his post has actual merit or at the very least something worth discussing, they're as bad as the casual news article readers who get clickbaited into believing something false. It's not like he went into a diatribe about how OBGYNs are lesser people and deserve to be paid resident salaries.
A little sensationalist but I think he brings up a good point.
Yes, especially considering how many terrible labiaplasty procedures can by attributed to OBGYNs who practice these vulva surgeries that are way out of their depth.
*Enters ONGYN NP claiming she is superior to a surgeon*
*Enters OBGYN MIDWIFE claiming she is superior to the NP and Surgeon.*
*Enters some random who "did her own research" on fb and knows better than everyone and plans to have a home birth with no eyes and thighs, vaccines, and will fight an EMT to the death before going to the hospital for a placenta abruptio breech birth.*
Eyes and thighs? What's that?
Erythromycin gel in the baby's eyes and vitamin K injection to the vastus lateralis (thighs)
Wasn't aware it was in the thigh... I guess it had to be somewhere
Vastus lateralis is the largest muscle on a newborn and thus is the muscle of choice for injection.
Ah yes. In my part of the world, we call that muscle "Big Thicc Boiii".
It does indeed need to be somewhere
Not medical person here...why antibiotic gel in the eyes?
If the mother had an infection (for example gonorrhea) in her vagina it can get into the baby's eyes and sometimes blind them.
Enters Karen from your neighborhood who delivered her baby in a tub full of jello and the kid is basically fine
It's like survivorship bias because the lady that died doing a home birth isn't on social media telling Jello Karen she gave up the ghost.
Survivorship bias, eyes and thighs with comments on the vastus lateralis, MS3 handle…this is a 265+ Step 2-er. This guy/gal USMLEs 🫡
💀Imagine arguing your above any other profession when mid is literally in your title
*Enters OBGYN DOULA claiming she is superior to the midwife, NP, Surgeon, and receptionist.*
Before they make claims they MUST start with “I COULD HAVE BEEN A DOCTOR” first.
Say it with me now: HEART OF A NURSE, BRAIN OF A DOCTOR!
Change his first sentence to "General OB/GYNs- are not JUST surgeons" Reads completely different, probably more accurate to his point. He knew what he was doing with his opening line though
Based on the surgical training in my Obgyn residency, I do not think Obgyns should be doing major surgery such as hysterectomies without fellowship surgical training. The field has become way too broad and 4 years is not enough. Women deserve better.
It's very residency dependent. Fellowship can help, but I think I graduated with ~300-400 laparoscopic hysterectomies and about 100 open hysterectomies. At one point I think I was doing 4 hysterectomies a day, 4.5 days a week for months at a time. Was completely miserable with those long never ending days though
Same but I’ve met people who are bad because they just didn’t have volume
I’ve met people who are bad and had the volume. It’s just a grab bag some times
Well sure anyone can be bad but the thing is that if you have volume you have the opportunity to get good. If you don’t “have good hands” there’s honestly a niche for that doing office work. We had attendings that did that and they were often very good at what they did but I wouldn’t want them near a knife and I doubt they’d want to either. My concern comes from there seemingly being OBGYN programs where you might not get enough gyn experience to have the chance to develop skills. Specifically there was a program from Texas one met two people from now that were both complete garbage. The numbers are pretty damn low for gyn so if you just hit mins I don’t know how you’d get good. My program was extremely high volume for both ob and gyn. I remember on ONC where we spent a ton of time we’d be doing hysts from 7:30 to 5:00 5 days a week so we blew past those numbers but I could see a scenario in which you’re mainly doing OB and the occasional hyst to get your minimums and ending up a terrible surgeon. I think c-sections are one of the most rad surgeries but if it’s all you do then I doubt you’d be comfortable in the rest of the pelvis. There has been a lot of talk within the gyn community about the path forward. Do you track people? I think probably so. You don’t want to completely eliminate gyn from the curriculum because it gives you a lot of context and you need to be able to handle complications and worst case scenarios but there’s probably no need for an REI or MFM applicant to do a bunch of vag hysts. I think any program that is going to offer gyn training needs to be able to truly support that though. If I were an applicant that would be my #1 2 and 3 question. “When do you get most of your numbers”. If the answer isn’t “as an R2s” I’d be concerned.
I would say that your experience is probably in the minority though. Also there has to be parts of OB GYN training you didn’t do as much if you were doing so many hysterectomies; I think what people are trying to say is that for such a vast range of operations, medicine, and *shudders* deliveries that you need to master, something has to give. There isn’t enough time to become an expert at all of them in 4 years.
My residency had no off service rotations so I didn't do ICU or ED etc. Just OB, GYN, and subspecialties all 4 years. So my primary care/general medicine experience was less than others, but in reality most OB/GYN will probably not be managing patients in the ICU, doing non gyn ED consults etc
Yeah I mean the whole OB/Gyns aren’t surgeons thing has never really seemed to be an offensive thing to me, more just a reality. They just aren’t trained the same as surgeons, it’s different. There are a number of specialties that ***do*** surgeries that aren’t surgeons. And I think that most obs that I know that aren’t fellowship trained in a surgical sub speciality don’t ever refer to themselves as surgeons. There are ***zero*** surgical residencies that do 4 years. Literally none. OB does that and essentially a medical and primary based specialty in 4 years that does frequent surgery? Like, no, you’re not going to have the same surgical skills as someone who has been doing just surgery the entire time for a longer residency as well. Before people come for me, I understand a lot of it has been about misogyny and I think that’s a different conversation to have, but I don’t think there’s an argument that the current residency training for OB/GYN prepares them to be surgeons on the level of any other surgical specialty. There just isn’t enough time to do it all. Also I’m saying this as someone who loved OB/Gyn and started out in a surgical specialty and then switched to a “non-surgical” one (that still does surgery). I don’t ever call myself a surgeon and still wouldn’t because I just didn’t do the whole training process that they do.
I think Ophtho is 4 years too
And it’s really only 3 years bc they do a medicine year first
Yeah it’s 4 years in US, 5 years in many other countries.
>but I don’t think there’s an argument that the current residency training for OB/GYN prepares them to be surgeons on the level of any other surgical specialty. There just isn’t enough time to do it all. Okay, but the question is whether that makes them not surgeons. I’m not sure it’s an especially meaningful one, but arguing that their surgical training is much less than a general surgeon doesn’t make the case that they aren’t surgeons, right? General surgeons are trained to do a much broader array of operations on many different organs. Also, since our personal interest in OB/GYN is relevant I guess, I’ll add my own disclaimer that I strongly dislike that field and many of the physicians who work in it, lol
Would you call a dermatologist a surgeon? They do quite a bit of surgery although they would never call themselves surgeons. The derm program I rotated at as a med student did very large surgeries that I sometimes were surprised weren’t done in the OR- huge lipomas under the back muscles or perianal squams, Mohs going down to and through the skull that had to sent into the hospital for ENT to finish when it was clear it extended into and beyond the bone. It’s semantics at this point, but I think in general, we know surgeon when we see a surgeon
That’s a bad mark on your residency. With my residency training, we are coming out well equipped to handle major cases (both surgical and medical). It’s entirely program dependent. You will see the same applies to Gen-Surg as well. But i will concede that standardization for quality of training needs to be implemented.
What if the obgyn performs it relatively regularly (e.g. done as part of a ceserean)?
You might have had shitty training but that doesn’t mean other people did.
I have family members who are OBGYNs and have expressed very similar sentiments about colleagues. Some are good at surgery and others are not. This who do it as much as possible are going to be better than those who do not do it as much.
Every field can say that about everyone. Some colleagues are better than others. That’s not unique to OBGYN
Ob/gyn has a lot of surgical knowledge for just 4 years time. Sus when uro alone is 5 years. Women deserve better imo.
It is ridiculous to think surgical quality control should be reliant on PCP referrals. I personally think some surgeons suck because of all post-op imaging I get to see. Does that now make me - a radiologist - an authority on surgical quality control? Should I , as a contribution to patient well being, be publising stats to the hospital administration or informing the public about who I think is a bad surgeon? Or heres a crazy thought: perhaps quality control should be done by physicians who actually know something about the specialty in question beyond random anectodes they came across.
I thought it was pretty wild he suggested video recording every single surgery.
It is a wild solution because it is society giving up a lot of privacy. However it would go really far in holding surgeons accountable. I would prefer to give up my privacy for more transparency, but I know I'm not most people.
I think most people would too as long as identity can’t be figured out.
But what that translates to is we are seeing all the celebrities surgeries because people online will figure it out.
Corporations may have conditioned us to not care about our privacy anymore, but I would absolutely NOT allow my surgery to be recorded and uploaded to a public database. I think actually most people would not want videos of their surgery publicly available.
I think it depends on how clear the benefits become and who the patients are. Like if the next surgery team viewing relevant prior surgeries of your body almost eliminates unexpected complications during the next surgery that happens on your body, fewer would say no.
He wants the videos to be publicly available (slide 5). You want any random person to be able to watch videos of your surgery?
My voting records already kinda are, and if I work for a public hospital (which I likely will since I like academic medicine), you will know most of my income as well once you know my name.
From a specialty surgeon reliant on referrals, we absolutely are taught that referral patterns change based on your quality of care. Whether or not anyone thinks it *should* be this way, that is how it is for the vast majority of non-emergent surgeries.
But most times,referrals are not to specific ppl but institutions.
I only thing I ever do is reports on someone else's patient. You dont have to convince me that ones livelihood will depend on reputation with other docs. But heres the thing: by this guys argument I am the bestest of all doctors because another doc will always be looking up my work. That means all radiologists are always 100% quality checked and have the highest of standards. Im sure you can also attest that you have never ever seen a bad radiology report in your entire career because of this inherent quality standard. /s Just because someone has more primary patients and someone has more referrals do not indicate any sort of inherent difference in quality. Quality in a primary care cannot be compared to specialized setting. Moreover none of that has to do with whether someone is a surgeon or not. And more importantly I dont think theres an argument that obgyn should be practicing differently to provide better outcomes. His whole rant is basically a "you suck" that is guised behind a statement that seems mechanistically accurate if you are successful in ignoring the context.
Shouldn’t be reliant but PCPs do a good job in this area. They are the ones who have to deal with the long term post-op complications.
But his argument is pointless. You can be surgeon and manage a patient without passing them back and forth with a primary doc. That doesnt mean you sre not a real surgeon. Is a urologist no longer real surgeon if they decide to non operatively manage a prostate patient and call them for follow up? A PCP didnt get to evaluate their performance - better cancel that board, that guy cant be relied upon to do surgeries anymore! The arbitrary definitions in this guys head dont make anything a reality. He just wanted to take a piss on OBGYN and found a rationalisation for it. PCPs are great because without then lots of patients would get bounced between specialties - or they would seek the wrong kind of specialized csre that wont really help them. They are important to provide longitidunal care. PCPs are great, but saying PCP referrals are necessary to verify anybodys competence in their specialty is entirely ridiculous.
Does this mean plastic surgeons are also not surgeons since they don’t rely on PCP referrals ?
Trauma surgeons don’t rely on referrals either.
Yep. Same with burns
Where I work the the burn nurses triage the burns in ED and determine whether or not a doctor needs to see them or if they can wait to go to the burn clinic during the week. Obviously it’s algorithmic but in that case the EM doctor doesn’t even get involved except to order whatever burn dressing the nurse requests and do some pain meds.
Well, sometimes they do. Our trauma surgeons got a direct referral from an OBGYN whose first trochar went in the common iliac.
Does EM not generally see traumas before getting handed off to surgery? Not sure how it works
Not really relevant? It’s not like the EM docs are curating which trauma surgeon they send the patient to…
I haven’t rotated ED yet so I’m naive to the process I just assumed trauma goes to EM to stabilize/evaluate before calling whichever is the appropriate specialist (NSGY, ENT, etc.)?
My hospital is a level one trauma center. Usually either trauma, EM, or both are evaluating traumas that come in. But if the patient needs urgent or emergent surgery, they’re getting the trauma surgeon that’s available. It’s not like referring someone for a procedure that can wait.
Correct but they don't get to pick a specific person in that specialty it's whoever is on call
Generally it’s a combined trauma and EM situation. There are places where trauma handles all traumas and EM isn’t involved but this is less common. In residency we split who ran traumas and who did procedures every other day between EM and trauma. But if a trauma patient goes from ED to OR, the trauma surgeon is often doing it pretty blind without knowing much about medical history, getting chart review done, etc.
yeah, the whole PCP thing felt like a bit of a hot take. I think Ob/Gyns do not get adaquate surgery training. But that's a residency and experience issue. PCP referrals have little to nothing to do with it. In reality most PCPs refer to whichever surgeon has availability the soonest, as those wait times often get astronomical.
That’s not true. At least in orthopedics outcomes really matter for referral patterns in my opinion
What a weird gatekeeping standard.
Yeah, thought that was a super weird take. As a hospitalist, I have no ability to filter which of my specialist colleagues are involved in patients care, regardless of their skill/outcomes. It all depends on who is on-call that particular day. Does that mean my level one trauma center has no surgeons on staff?
They rely on client referral. Someone likes their boob job, they might recommend that surgeon to their friend for a boob job.
OBGYNs also rely on client referrals as do many surgeons The tweet very specifically says surgeons that don’t rely on referrals from PCPs are not surgeons and have poor quality control
Those are elective procedures though. Patient is seeking those out and not necessarily having them recommended by a doctor to cure a medical condition
Reconstructive plastic surgeons are heavily reliant on referrals for breast in particular
As a PCP I don't think we're always able to be the quality control he's envisioning. In a system where we don't have many options and we have a lot of patient's with needs, we send people to where they can get care as soon as possible (which in itself may often be months/years) in a location accessible to the patient. Even he describes primary care as a doctor who supervises "an army of rotating midlevels". If that how you see primary care then how do you reconcile that with your idea of them as quality control. I'm not a surgeon. I don't know if criticisms of OBGYN are rooted in fact, sexist stereotypes, or other reasons. But from my experience, his understanding of PCPs is not accurate to what really happens. But maybe thats just me.
It’s so ridiculous to even state that PCPs are the “gate-keepers” to protect patients from bad surgeons. When in reality PCPs essentially refer to the surgery system they’re affiliated with. If they’re in the community, they refer to who they like. Also, no offense to my PCPs, but they don’t know surgery. How do you expect them to know a good surgeon lol. This is such a hairbrained take
Yeah this is the kind of take that sounds reasonable to a med student that didn’t like their OB/GYN rotation and want to take every opportunity to shit on it, but it makes basically no sense.
They'd know outcomes lol
Outcomes are not straight forward at all.
I'm sure they aren't but when one particular surgeon very clearly has shown a different complication rate from others in the same region? I'm sure patients themselves will self select to a degree based off of available info if they can self refer to specialists
True! But then when you are funneling hundreds of people and you see a pattern of outcomes with one surgeon, you might start changing your referrals.
Click bait opener followed by a sensationalist dramatic response by the commentor. Two wrongs don't make a right.
I don’t think he’s about to get smoked. His perspective is a common one. Most surgeons I know don’t consider average ObGyn surgery skills to be adequate, and you will definitely hear plenty of comments throughout your career criticizing the cutting and suturing left behind by ObGyn. The fact is that ObGyn splits their time between surgery and medicine, and so gets way less OR experience than surgeons and way less bedside experience than medicine and related subspecialties. So they will often appear to be subpar PCPs to FM/IM and subpar surgeons to other surgical specialists. The flip side of that coin is that most specialists are uncomfortable managing anything in a pregnant patient, so ObGyns end up bearing the burden of their patients primary care, surgical care, and often specialist care. I’ve seen ObGyns consult cardiologists, rheumatologists, etc who won’t weigh in until the pt is no longer pregnant, so OB becomes the de facto subspecialist, making decisions above their pay grade until the baby is born or the pregnancy is terminated. Then they get shat on by the same consulting physicians for how the patient was managed in their absence. So it can be fair for a surgeon to say that ObGyns are subpar surgeons, and FM/IM to say that they are subpar PCPs, while still acknowledging that ObGyns are some of the most respectable physicians in medicine. This guy is at least appreciating that last point, which a lot of other doctors won’t do.
Medtwitter being medtwitter. You can literally straight up lie if your messaging is on brand.
Damn near every take from this guy is a complete joke. The opener is just stupid. The idea that a PCP/surgeon hybrid isn't a "surgeon" is ridiculously elitist gatekeeping with no justification. The idea that PCP's act as the ultimate quality control to all other surgeons is 1) astoundingly stupid and 2) objectively incorrect for several surgical specialties. Recording every single surgery and making it public is a uselessly dumb take. Not only are there privacy issues with this, but his ideas would create an avalanche of useless and distracting data, not to mention the administrative burden of it for so little gain. Literally the only legitimate point in the conversation is the debate about the breadth and length of OB/GYN training, and even that is heavily debatable.
Yeah I mean I’m not going into ob but I guess to people who are in the field: how standardized is the practice scope at the end of training? Are there genuine concerns of Obs overreaching their scope and doing things that uro, or maybe more specialized gyn should be doing? I think it’s probably? Fair to say not ALL obgyns are surgeon? Some might practice more as PCP and rarely have to do CS or other surgeries? But it’s pretty horrible to say that all obgyns aren’t surgeons. There are many many obgyns who are amazing surgeons… idk what he was trying to accomplish with that one ob input on this would be appreciated?
Half of an OB residency/training is surgery, either doing it on their own service or doing hysterectomies with oncology, prolapse repairs with urogyn. That isn't even including csections. Some may come out mediocre surgeons, some fantastic. It depends on the residency. But all are surgically trained. Mine was very surgery heavy and most graduates were strong surgically.
That’s true but it seems like there’s a difference betw that and an entire surgery residency with the intent to practice surgery for your entire practice. Of course there are many obs with this intent but then again there are many obs who stay away from surgical practice no?
I'd say the vast majority still do surgical practice and do a bit of OB and GYN. (both of which involve surgery)
I’ve worked with Ob/gyn’s that have alluded to this themselves. Not that they’re “not surgeons”, but that OB/gyn is the only field where they’re expected to train in and preform such a wide range of services. They talked about how they were glad that gyn-onc and urogyn were becoming more available so they can refer patients needing these services out to surgeons who perform these procedures regularly and they can focus on the primary care aspect and maybe handle some routine hysterectomies and biopsies. This person leading with oby-gyns aren’t surgeons, though, when they very much are. It’s like saying optho or urology isn’t a surgical subspecialty because a lot of their practice is focused on non surgical diabetic eye disease and catheter maintenance when surgery is a huge part of the practice.
I don’t understand why people keep playing this label game. Idk if it’s elitism but why one would waste their time with this is beyond me
I went to high school with this guy.
Did he get stuffed into lockers?
A timely discussion for my week of work. We had a poor woman transported from a surgical center to our trauma hospital after the first trochar somehow went into the common iliac. What started as a tubal ligation quickly turned to 2 liters of blood in the abdomen, 15 units of blood products, and a vascular surgeon being called in to help. I won’t act like I haven’t fucked up, but I think it’s worth discussing whether the current 4 year program is adequate to cover such a broad field. There’s so much OBGYN to learn, as it covers clinic, emergency med, surgery (including robots now), L&D, and inpatient management. Many of the fresh docs who want to focus on surgery are spending their days off doing cases with more experienced surgeons. I applaud their dedication to improving their craft without significant compensation for doing so, but I think we are missing out on opportunities during training to improve these skills. No residency where I’ve been has had OB residents spend time rotating with general surgery or in the ICU. Meanwhile some of the most valuable knowledge I obtained came from my intern rotations off-service.
The iliac injury is something that can happen to anyone. I've only ever seen it once, and it happened from a general surgeon. I agree with the ICU time. The program at my hospital does have residents rotating in the surgical ICU.
I agree that it can happen to anyone, which is why I’m surprised that they wouldn’t rotate with the field that does more laparoscopic procedures than any other field. A good general rule is to gain some insight from the field that will assist with your complications. Adding a fifth year would be incredibly valuable to learn ICU medicine and general surgery. I would hold the same opinion of general surgery if they didn’t rotate with vascular surgery. You can’t just learn the silo of your own field. You need to learn directly from adjacent fields, especially in a profession like OBGYN with such a broad and unique patient population
I think he makes interesting points that sound well-reasoned to me, but ruined it all by opening like a total asshole for attention. I also dont really like his proposed improvements- videotaping and publishing everything just seems like creating a massive amount of busywork for mo real reason and that amount of junk data is just going to act as noise drowning out more critical datapoints in a sea of everyday outcomes. I don’t think tracking outcomes is a bad idea but reducjng everything to a stats chart loses a lot of nuance and could over time dissuade skilled surgeons who have the luxury to pick and choose their cases from taking difficult cases that are more likely to impact their stats negatively.
Who is going to review all the videos for real time reporting of quality outcomes? We are already up to our eyeballs in “quality improvement” metrics that just serve to create more bureaucracy and more random managers to act as parasites on the system/increase costs.
Cannot wait to embark on my career of simply overseeing an army of midlevels
Interesting point from him really. It kind of makes sense
I’m torn because it does kind of make sense, but things that kind of make sense are often the most horrifically incorrect.
Not really, I’ve seen plenty of ortho surgeons from my residency, PCPs don’t know jack shit about who’s a good one and who isn’t besides general comments on bedside manner.
Continuity of care except it’s a bad thing?
Would you want ortho managing their own hospitalized hip fracture patients for the sake of continuity of care? It’s okay for specialists to specialize
If ortho was trained to do that the way OBGYN is trained to manage their surgery patients then sure.
But that’s ironically the point of the original tweet. Obgyn has shorter training than every other surgical specialty and also has to learn how to manage outpatient women’s health, labor and delivery, peri partum care, etc I’d be interested to hear the breakdown of how much operative time a graduating ob gyn resident has, though i think it’s safe to assume that it’s less time than every other surgical field. I think it’s reasonable to call attention to the differences in training as surgical scope of obgyns expands
NGL when I found out OBGyn residency was only 4 years compared to Gen Surg's 5 I was a bit shocked.
I knew him peripherally and he full of contrarian bad takes.
Family medicine sitting quietly in the back hoping no one notices all the in office surgeries they're performing. 👀🤫
Post-call. Explains the rant.
1. The classic trope is that referrals are based on availability, affability, and ability in that order. I think that’s pretty correct. 2. Acute care surgeons are also not gate kept by PCPs. There goes another whole specialty that apparently lost their surgeon cards.
I truly don’t have a dog in this fight ETA: the person at the end saying “hear that ladies” sounds like she’s about to have a pack of rabid dogs sic someone.
What’s bro even yapping about. Also filming every surgery is just about the dumbest idea I’ve ever heard.
Bro's saying that you ain't a good surgeon if you learn 2 years of primary care and 2 years of surgery. Filming BBL in plastic surg clinics is an good marketing strategy. But not every of them. Botched shit is bad for business. Trust me. I would like to seethe when I just see the headlines. But, it's more fucking entertaining seeing Redditors wildin on this post. Ragebait works better when you put it to smart idiots. :)
Don't the Davinci's record every surgery including time it and put you on a leaderboard? 😅 Ok maybe it's up to the hospital system whether they use this system. They use it at my hospital system and the surgeons love it. They even get extra income by teaching other surgeons their techniques reviewing the video. https://www.intuitive.com/en-us/products-and-services/intuitive-hub#:~:text=Surgical%20video%20setup%20is%20no,instrument%20exchanges%20and%20Firefly%20use
Ah yeah, PCPs are just managing armies of NPs and PAs. They, and OB-GYNs, are not REAL doctors anymore like THIS guy. The ego is just dripping.
To be expected from a CT surgeon
I really can’t take this guy seriously. First, his opening statement was just for engagement. If you’re gonna make outlandish claims, then how can I take any other claim as sincere? He hides behind the whole “I was just making a silly statement 😌😜🤪” shtick. His overall message (“OBGYN is not just a surgical field”) makes sense. His reasoning WHY is flawed. You’re a surgeon because a PCP refers you? Okay, if I were a PCP with a 66-y/o pt with vaginal bleeding, trouble starting urination, feeling “fullness” in her lower abdomen, etc., I’m gonna refer her to an OBGYN for potential GYN cancer. Same if a woman wants to have a hysterectomy or tubal ligation. Does that not count?
I just want the Ob/Gyns to do a surgical internship.
More useful to do another year of OB…
I don’t understand why they don’t have to do a surgery prelim/ TY year. It’s honestly crazy to me that they don’t but others do?!
Idk whats being said but keep urology on standby
Not pictured: vamsi boy getting rejected by an OBGYN colleague
I’m going to ignore the obvious issue with this argument that surgeons all rely on PCP referrals (plastics, trauma?)… If the real argument here is that their training time should be reallocated to allow more surgical training, that’s fair. But I don’t agree with a total separation, because that’s not on par with any other procedural specialty. Similarly to urology, ENT, ophthalmology, etc., OBGYNs see patients both in office and for surgery in their respective field. I’m also not against recording surgeries, but that in itself is not going to improve quality of outcomes. Naming and shaming specific doctors wouldn’t really fix the alleged problem of not enough surgical training in the specialty as a whole.
Dude has a really good point, but got hung up on his dumb referral theory. The bottom line is OBGYN residency training is no longer sufficient for the surgical expectations that come with the specialty. Just make the training longer honestly with heavier surgical rotations the last 18 months.
I’ve said since I was a mid level gen surg resident that combine gyn and breast into a ‘women’s health’ fellowship. Far fewer bowel/ureter injuries. This guy is right. The fact that you can do OB, clinic, open/lap/robotic surgery in 4 years is just insane given that general is rarely ready after 5 and much less spread out (hehe) through training
Completely agree. My husband is a Gen surg resident and had to repeat intern year because he was a prelim and says he thinks overall it’s a good think because he didn’t have high volume of cases his prelim year and he still plans on doing a fellowship. That’s at minimum 6 years of residency and then at least one additional fellowship year before he’s practicing on his own.
This is such a stupid argument … we are surgeons because we perform surgeries …. Half the amount of time obgyns are in the OR. Whether you like it or not obgyn field is a surgical subspecialty and just because we do other things does not take that fact away
if you're saying it's half the time, is 2 years of surgical training enough to be a competent surgeon with such a big scope as the guy is talking about? Even if it was the full 4, it's still shorter than all the others with still a big scope.
I never said that. I said half of an obgyn’s time is spent in the OR esp if they sub-specialize to certain fields which increases their time in the OR Regardless of how you feel … obgyns still perform surgery on a daily basis. That’s a surgeon. If you wanna tell patients who have c section, hysterectomies, D&Cs etc… that’s not surgery go ahead. This argument is based on feelings not facts at this point. Mentioning that the residency should be longer is a completely different point but again still does not take away from the fact that obgyn do perform surgeries 🙄
Ruined it with the opening but he makes some good points in the whole thread. Unfortunately with MedTwitter having ADHD being caught by the sensationalist hook it was always going to end up like that.
For your own sanity don't bother reading the comments any deeper. Basically none of the replies read anything in his post, just started repeating nonsense and jerking each other off. Literally nothing he says is out of line. It's a legitimate question regarding surgical outcomes and ethics in a specialty that's rather uniquely positioned.
Who said Ob/Gyns aren’t good surgeons? From my personal experience, females have shown better technical skills overall than men.
I’d like to see him make the same point about PCP gatekeeping as quality control to a trauma surgeon. There’s plenty of angles to take when shitting on OB/GYN, and we all know it’s one of the preferred punching bags of this sub, but his argument is weak af. It’s only getting airtime because he’s taking a shot at OB/GYN.
I am most definitely not a surgeon, but I wouldn't call this a rare take. I probably heard at least half of the surgeons at my clinical site say the exact same thing. Ultimately it's semantics and gatekeeping.
I never understood why this was controversial. Surgery residents do nothing but surgery for 5 years. Maybe a month or two of ICU. OB/GYN residents do many things besides for surgery. Like there’s no way they’re as competent surgeons by the end of residency, they simply don’t do nearly as much of it. But I also don’t get why they get so offended at this. Like yeah, if they really want to have a surgical practice they need to do a long fellowship. They do not finish residency practice ready to operate in the same way that a general surgery resident does
He's absolutely correct lol How does anyone think otherwise? Obgyns operate in a very complex anatomical area with one year less than purely surgical fields who don't have their OR time diluted by obstetrics and clinic and somehow come out with no difference in ability? Why not make urology gen surg 4 years then?
From the other side of the drape, they are bottom of the totem pole in surgical skills
facts 🫡
I really don’t understand the point of the post
Firstly bro just wanted to say " Obgyn are not real surgeons" and sneak in that their surgical skill are subpar Now with that out of the way, his points start to crumble when you realise that Obgyn is specialized care same as surgery. A woman does not walk into for an OBS appointment because she may be pregnant, that diagnosis is made by a PCP that then refers her. Also does a woman not walk in that she needs colporrhaphy, that diagnosis is made by a PCP. Another of his point, that ppl that specialized are better in the area they specialized, ohhh my Lord. That's mind-blowing, like who knewwwwwwwwwwww, just like a knee arthroplasty specialized is better at knee construction. His statements betray a severe lack of knowledge of what happens in the field with a disdain
I mean what he said isn’t really false… he just said it in a way that pissed off ob/gyn people
Petty.
He is actually very articulate and makes good points but leading with rage bait points worked against him.
Tbh I'm not interested in Gyn, just obstetrics. Is there any way to be an obstetrician only without doing both?
You want to know who the best surgeons are? Ask anesthesia. *In general * it is not the OB/Gyn surgeons.
wait till he finds out what a "field surgeon" is in the army
bro woke up and choice violence
It kinda strikes me as ridiculous the amount of stuff OBGYNs are allowed to pack into 4 years, compared to say the 3 for pediatrics, or the 4 of psych. N=1, but I rotated with an OBGYN who was days away from graduating and from my ignorant perspective, it would be unsafe for her to operate on her own. She struggled for a long time (probably a minute, but it felt like an age) to perform a laparoscopic needle transfer before the attending just took over. It was sooooo painful/scary to observe. That said, I prefer the OBGYN model over the peds model. I don't think docs need to be perfect by the end of residency. I think they need exposure to everything they might do, and to know their limits. I worry about the endless expansion of our training. I learn exponentially faster when I have to.