After 12 years as a private practice ob.gyn., Dr. Brigid McCue was beginning to feel overwhelmed. She loved her work, but keeping up with the kaleidoscope of care components and ever-changing clinical developments was daunting.
“I felt like it was hard to stay really good at all the different aspects of care,” Dr. McCue said. “I was doing fine with obstetrics, and I felt like I was managing my office well, but it’s hard to stay on top of the latest developments, especially in surgical areas. The other thing that was really hard to keep up with was the business aspect of medicine and running a private practice.”
So when an opportunity presented itself, Dr. McCue leaped at the chance to narrow her expertise to obstetrical hospital medicine. She helped establish the ob.gyn. hospitalist program at Beth Israel Deaconess Hospital-Plymouth in Massachusetts, and now serves as chief of ob.gyn. and midwifery for the hospital.
“I love the fact that I now have the time to get really good at [what] I really like, [such as] labor and delivery,” said Dr. McCue, who is president of the Society of OB/GYN Hospitalists. “Since I made this change, I feel like I’m so much more on top of things. I do simulations here on my unit over things like shoulder dystocia. When I was in private practice, I would go to one meeting a year and pray that I never had a shoulder dystocia [case]. Now I really understand the whole process and I take the time to run through that with my midwives and my other nurses and doctors.”
Dr. McCue is one of a growing number of ob.gyns. who have chosen to target their expertise to a single subspecialty or concentrated practice area. Data show subspecialization is on the rise in ob.gyn.
From 1985 to 2015, certificates issued by the American Board of Obstetrics and Gynecology (ABOG) for gynecologic oncology nearly tripled, and certificates issued for reproductive endocrinology and infertility more than doubled, according to data provided by the American Board of Medical Specialties (ABMS). Certificates issued for maternal-fetal medicine rose from 35 in 1985 to 100 in 2015.
Opportunities for ob.gyns. to subspecialize have steadily increased over the last 50 years. The subspecialties of maternal-fetal medicine, gynecologic oncology, and reproductive endocrinology and infertility were first approved for certification by ABOG in 1973. In 1983, ABMS approved a certificate of “added qualification” for ob.gyns. who complete fellowships in critical care. In 1995, ABOG and the American Board of Urology started the subspecialty of female pelvic medicine and reconstructive surgery, which was approved for certification by ABMS in 2011.
ABMS also approved a certificate of “added qualification” for ob.gyns. who complete a fellowship in hospice and palliative medicine in 2008. And fellowships now exist for minimally invasive gynecologic surgery and ob.gyn. hospital medicine.
The reasons that ob.gyns. choose to subspecialize are multifold, said Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill., and one of the medical editors of the Ob.Gyn. News column, Master Class.
“Physicians subspecialize so that they can provide more medical and surgical expertise for a given population,” he said. “Secondly, physicians may be driven to subspecialize for lifestyle reasons. Generalists refer to subspecialists when technical expertise is desired to help with a clinical situation and potentially reduce medical legal risk.”
Ultimately, it’s patients who benefit from the increased care provided by subspecialists, noted Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology, and women’s health at Rutgers, the State University of New Jersey, Newark. Generalist ob.gyns. are tremendously knowledgeable and experienced, he said, but there’s no way for them to know every area, he said. It’s the difference between someone who might be doing a complicated surgery one or twice a year versus someone who is doing that surgery once or twice a week, he added.
“That is ultimately helpful for patients,” Dr. Einstein said. “It’s really about outcomes. This is all better for the patient. That’s the most important thing.”
Not every consequence of subspecialization is positive, however.
“As with everything, subspecialization has both positive and negative effects,” said Dr. Sandra Ann Carson, vice president for education at the American College of Obstetricians and Gynecologists. “The more time one has to focus on a small area, the better that area becomes. However, if all you have is a hammer, everything looks like a nail. The larger population may not need the care that someone with a rare disease may need.”