The "Gyneco-Obstetric-Surgical" Stubbornness
and the Perpetuation of One of the Greatest Mistakes of Women's Medicine
Dr. Nelson Soucasaux, Brazilian gynecologist
"... there are neither solid 'scientific' reasons nor logical
ones that can justify the insistence on the need for the usual integrated
practice of gynecology and obstetrics by the same professional."
"... what seems to exist behind this stubborn position that
proclaims the gynecology-obstetrics 'fusion' as being essential is, above
all, a situation of 'convenience' in the practice of women's medicine. In
my opinion, it is a very well-planned professional strategy for getting
more patients, hidden behind pseudo-scientific and pseudo-logical justifications."
"... in a similar way to what happens in many other areas of
medicine, would it not be much more reasonable for gynecology to be an essentially
clinical speciality, the surgical part of it remaining as another speciality,
female pelvic surgery and breast surgery?"
(Nelson Soucasaux, "Novas Perspectivas em Ginecologia" ("New
Perspectives in Gynecology"), Imago Editora, Rio de Janeiro, 1990,
pages 33 and 112. )
Before starting this article, I must make it clear that since I live
and work in Rio de Janeiro, Brazil, I do not know exactly to which extent
the criticisms contained in it are still valid for the present-day situation
of women's medicine in other countries - though unfortunately the traditional
tie between gynecology, obstetrics and gynecologic surgery has always been
basically the same all over the world. (The origin of this traditional tie
between the three specialities lies in serious mistakes that are part of
the history of women's medicine.)
As I observed in my aforementioned book "Novas Perspectivas em
Ginecologia," contrary to many people's suppositions, the "intrusion"
of obstetricians and surgeons into gynecology has always been one of the
more problematic aspects of women's medicine. Obviously the obstetrician's
main interest is directed to pregnant women. This means that they look at
women from the point of view of obstetrics (just as gynecologic surgeons
look at women from the standpoint of surgery). Nevertheless, as women's
medicine, obstetrics is a speciality which by far transcends women, since
it is also devoted to embryos and fetuses. (Consider the enormous development
of fetal medicine, a new branch of obstetrics.) Obstetrics only takes care
of women in very particular periods of their lives, periods in which women
house inside their bodies beings other than women themselves and who equally
are subject of the speciality. Here we already have one of the enormous
differences between gynecology and obstetrics, since gynecology is exclusively
devoted to women.
Considering that the great majority of modern women only want to become
pregnant and have children in very few moments of their lives, it is easy
to see that obstetrics is a speciality that only takes care of women in
moments of exception. On the other hand and as opposed to obstetrics,
gynecology takes care of women during most of their lives. In this way,
as a consequence not only of the need for having more patients but also
of the frequent "longing for omnipotence" existing in women's
medicine, obstetricians never fail to also practice gynecology. In fact,
this is a highly smart "professional strategy" for gaining and
preserving the greatest number of patients as possible. Nevertheless, given
the increasing complexity of modern medicine, this "strategy"
inevitably implies a great loss in the quality of the medical assistance
that is provided, since presently it is humanly impossible for the same
physician to practice different medical specialities with the necessary
competence and expertise (see Note 1, below).
In "Novas Perspectivas em Ginecologia" I made it quite clear
that the enormous differences between gynecology and obstetrics concern
mostly their respective clinical, physiological, pathological and therapeutic
aspects, which are completely different - besides the obvious fact that,
while gynecology takes care only of women, obstetrics takes care of women
and fetuses. For all these reasons gynecology and obstetrics constitute,
without any possibility of reasonable doubt, separate medical specialities.
From the point of view of medical science, gynecology and obstetrics have
much less in common than it is usually supposed, though, unfortunately,
almost nobody wants to recognize this fact. Regarding what happens at least
here in Brazil, all the constantly repeated opposing arguments are totally
devoid of scientific basis and what they actually intend is, above all,
to protect the "tradition" and some professional and "corporate"
interests that cannot be publicly mentioned. (As to the increasing domain
of these "corporate" interests, what presently is going on in
Brazil is truly a shame.)
Considering the enormous technical progress of present-day medicine,
from the standpoint of medical knowledge and training it is humanly impossible
for the same physician to simultaneously and satisfactorily practice two
medical specialities so complex and different as gynecology and obstetrics.
Thus, mostly for technical and cognitive reasons, my opinion has always
been that only gynecologists should practice gynecology, and only obstetricians
Even so, the insistence on the integrated practice of both specialities
by the same professional persists. To my point of view, this attitude is
typically illusory and even "megalomaniac." And, to make things
worse, at least here in Brazil, that attitude is being stimulated and even
"established" by societies of gynecology and obstetrics that,
with growing stubbornness and great political power, advocate the continuation
of the scientifically irrational "fusion" of both specialities.
As most women regrettably are not aware of the problems resulting from
this traditional "fusion" between gynecology and obstetrics, they
naively consider the integrated practice of both specialities as "ideal"
and "normal." This mistake is understandable on the part of the
patients, but unforgivable on the part of the medical class. By the way,
sometimes we can even verify the existence of some "confusion"
between gynecology and obstetrics on the part of people who are not from
the medical area. This happens because most of the physicians who practice
women's medicine introduce themselves as "gynecologists and obstetricians."
Therefore their colleagues are those who collaborate the most for the maintenance
of such "confusion," since they have the greatest interest in
satisfying the naive and mistaken "aspirations" of most patients.
It is obvious that, professionally, the "gyneco-obstetricians"
take the maximal advantage of such position, while patients are frequently
harmed without being aware of that. As a result of all of this and regarding
professional competition, there is also a subtle process of "exclusion"
of the gynecologists who do not practice obstetrics.
Note 1: Because of the present-day accumulation of technical medical
knowledge, the possibility of each physician acquiring a complete mastery
of his own speciality becomes more and more restricted. This happens because
the medical specialities themselves are going through a continuous process
of division into subspecialities. In this way, the traditional habit of
the practice of gynecology, gynecologic surgery and obstetrics by the same
physician becomes more and more impracticable and absurd because it actually
implies the practice of three different specialities by the same professional.
Considering the human limitations - not only cognitive, but also of training
and continuous updating -, will it be possible for the same physician to
practice these three areas with the necessary competence? (Here I am also
criticizing the traditional view of gynecology as "surgical speciality,"
as a consequence of which almost all gynecologists are surgeons.)
Note 2: Regarding the aforementioned traditional view of gynecology
as "surgical speciality," it is also devoid of scientific basis,
since the clinical part of the speciality by far exceeds the surgical one.
This is another distortion coming from the past and that, along the last
decades, became entirely unjustifiable from the scientific point of view.
Therefore, there are no reasons at all for the insistence on combining the
practice of gynecology with the surgical activity.
Note 3: As to the already mentioned "longing for omnipotence"
in women's medicine: it is clearly demonstrated by the fact that almost
all physicians devoted to it insist on practicing gynecology, gynecologic
surgery and obstetrics, that is, three different specialities simultaneously.
For a better understanding of the subject exposed here, see chapter "O
Impasse na Medicina da Mulher" ("The Impasse in
Women's Medicine") from my book "Novas Perspectivas em Ginecologia"
("New Perspectives in Gynecology"). In my own site
see also the topics "The Traditional Tie of Gynecology to Obstetrics
and Surgery: Deep-rooted conditioning coming from the past and devoid of
scientific basis" and "The Obstetric Strategy in Women's
Medicine", at page "Temas Polêmicos" ("Polemical
Subjects"). ( Direct links to these topics can be found below ).
Nelson Soucasaux is a gynecologist dedicated to clinical, preventive
and psychosomatic gynecology. Graduated in 1974 by Faculdade de Medicina
da Universidade Federal do Rio de Janeiro, Brazil, he is the author of several
articles published in medical journals and of the books "Novas Perspectivas
em Ginecologia" ("New Perspectives in Gynecology") and "Os
Órgãos Sexuais Femininos: Forma, Função, Símbolo
e Arquétipo" ("The Female Sexual Organs: Shape, Function,
Symbol and Archetype"), published by Imago Editora, Rio de Janeiro,
Links to the articles mentioned above:
1) "The Traditional Tie of Gynecology to Obstetrics and Surgery:
Deep-rooted conditioning coming from the past and devoid of scientific basis"
2) "The Obstetric Strategy in Women's Medicine": http://www.nelsonginecologia.med.br/temas.htm#obstrategy