In planning this presentation, I asked many of you what I could talk about. It was not like I have spent the last 38 years dedicated to one small niche of one subspecialty in our profession. My career, however, has been all over the map. You see I am a “GENERALIST,” and I am proud of that fact. It is interesting that the term generalist , I don’t believe, was coined until well into my career, if not just here in the past decade. I, however, to make things more complicated, am a generalist who took a rather sharp fork in the road. Right about midcareer after 12 years of private practice, I launched into the training of medical students and residents and have spent the past 23 years in that role. I have had the opportunity to experience our wonderful specialty from 2 rather diverse viewpoints.

I would like to add that I am a generalist who I must describe as possessing “great vision.” For example, in 1975, I counseled my good friend, Ron Wade, to stop paying so much attention to a then new and upcoming technology that was going by the name of “ultrasound.” I remember telling him that it would never last. It is a good thing that he decided not to heed my sage advice for he has carved himself out a rather impressive career that is centered around this “fly-by-night” technology. Another fine example of my astute visionary capabilities was when a radiology colleague of mine asked my advice on the stock market. I told him he would be foolish to pay $8000 a share in 1989 for a stock by the name of “Berkshire Hathaway.”

Needless to say, I asked many of you about what I should talk about in this address. I received many suggestions. I asked my partner, and she said “Just talk about what you are passionate about in ob-gyn.” That advice reminded me of the ever slowly dying “art of medicine.” It also reminded me of something my father once told me when I was in medical school. He told me that a truly good physician is not one who takes care OF the patient but rather one who genuinely cares FOR the patient.

I asked my wife what I should cover, and she said that it didn’t matter as long as it was interesting for everyone in the audience and to keep it short. I asked what she meant by “everyone,” and she reminded me that one-half the people in the room did not go to medical school. Then I asked her what she meant by short, and she said that even our pastor, when he is spreading God’s word, only needs 20 minutes.

I asked our past-president what to talk about, and he said that “We’re all friends, you can talk about the weather or read us the phonebook if you want to. It doesn’t matter, just keep it short.” I asked Mitch what he meant by the word weather , and he answered “climate.” That reminded me of the “climate” that we find surrounding our new National Healthcare Plan.

When I asked my compadre and co-conspirator in the Charlotte Women’s Healthcare Mafia, he reminded me that the only thing standing between everyone in this room and a perfectly good lunch was my presentation … so be brief!

The changes that I have witnessed have been many. Too many to cover in my allotted time. Things that come to mind are

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  The development of the BHCG assay

  
  
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  The evolution of pelvic ultrasound scanning

  
  
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  Improvement in contraceptive technology

  
  
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  Ever rising cesarean delivery rate

  
  
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  Robotics and minimally invasive surgeries, and the list goes on and on.

And so, this morning, I would like to take a walk down “memory lane” with you. A lane that will visit just a few of these events and trends that I think stand out as significant over these past 38 years. One brings out the passion I felt in my career. That feeling that makes it fun to get up at 4:30 am to start the work day. Two are trends in the delivery of women’s healthcare that affect our clinical practice. And finally, one concerns the climate surrounding the delivery of care in which we find ourselves immersed. I promise to do all this in less time than it would take Rachael Ray to cook an entire meal that is both tasty and nutritious.

My career got started with a simple letter. It was signed by Dr Bryant Galusha who was the Director of Medical Education at The Charlotte Memorial Hospital. It was 3 paragraphs long and stated that it would serve as my contract. In July 1973, I became an intern and would be destined to make my way to being an obstetrician and gynecologist. My monthly salary was $735.00, and the hospital did not provide food. I should mention here that, in 1973, one really would not want the hospital to provide their food. Of all the advances I have witnessed in the field of medicine, this by far out shines them all. Hospital food is now tasty to the point that we even ask them to cater our social events.

As I mentioned before, I am a generalist. For the sake of this talk, I attempted to look up the meaning of this term. Not finding 1, I felt the need to provide you with 1 that I think you will all agree captures the true meaning. a Generalist is an ob-gyn physician who is identified early in their training to be advanced enough to span the breadth and the depth of our profession without boundaries or limitations and to do this exempt of a formal fellowship. I am sure that all of my specialist friends will agree with this definition without exception.

Let me spend just a few moments taking you back to 1973, when I began my career. This was the year of the following events:

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  President Richard M. Nixon

  
  
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  Withdrawal of troops from Vietnam

  
  
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  Roe vs Wade

  
  
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  Alaska Oil Pipeline Bill

  
  
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  World Trade Center completed

  
  
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  Rationing of gas

  
  
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  Water Gate hearings

  
  
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  Spiro Agnew—nolo contender

1973 was the year for the following average prices:

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  Dow Jones industrial average—850 points

  
  
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  Gas—$0.40 per gallon

  
  
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  Eggs—$0.45 per dozen

  
  
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  First-class stamp—$0.08

  
  
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  National debt—$466 billion

The first significant trend I would like to discuss is the rising cesarean delivery rate. In 1973 our countries cesarean section delivery rate passed 7%. The cesarean delivery rate officially had first been recorded in 1965 and was then 4.5%. A steady rise in the cesarean delivery rate has continued in this country and in other countries around the world. The United States cesarean delivery rate now averages 31.8%, which makes it the most common operative procedure performed in our country. This rate varies widely around the world from <1% in sub-Saharan Africa to nearly 80% in some South American countries.

In 1939, my Father wrote in his journal, at a time when the cesarean delivery rate was in the range of 1%, that, if the trend continues, this country will see a 100% cesarean delivery rate. Maybe this is where I got my gift of vision.

I have long asked myself the reason that the cesarean delivery rate continues to climb. Reluctance to deliver breech presentations vaginally, decreasing numbers of operative vaginal deliveries, fear of malpractice, and the ever-improving safety of the procedure have all been suggested.

It has been my opinion that cesarean sections have gotten too safe. Remember that this procedure has come from 1 of last resort, often writing off the life of the mother. Before the development of antibiotics, many mothers would die as a result of postoperative infections and sepsis.

In William’s original text, there were but 2 indications for cesarean section. An absolute indication was a conjugata vera of <5 cm. A relative indication was a conjugata vera of 5-7.5 cm. Today the list gets longer and longer to include primary cesarean delivery at the patient’s request.

Cost is driven up by surgical delivery, and cost will be a major factor going forward in our National Health Care Plan. In 2015 The Physician Quality Reporting Initiative, which was started in 2006, will be made mandatory for all ob-gyn physicians. Physicians who do not participate will receive a 2% payment cut by 2016.

In answer to my father’s original prediction, I can say that the trend has continued. The forces that influence the cesarean delivery rate in this country are complex and varied; however, if history is any indication, we are headed for a much higher rate than we have today.

In 1988 after trying to shake hands with a circular saw, I found that rather sharp fork in the road that my career was about to take. Those dark days taught me the importance of the support of good friends, the love of one’s family, and the security of a well-planned disability policy. With those ingredients, there is nothing that one can’t do.

In October 1988, I began the second part of my career. One in the academic side of our profession. I showed up for work remembering the all male ranks of the residency program that I had experienced in the 1970s only to find that things had changed. Someone had accepted a rather large number of female applicants into residency in ob-gyn. This is a trend that has continued to this day and that may be a good thing.

Next is a trend that is not such a good thing. Unbeknownst to me in 1988, the United States would be enjoying the lowest maternal mortality rate that it would for the next 20 years. The fact that has chilled me since I first heard it is that, ever since 1987, the maternal mortality rate in this country has tripled. In 1987 the maternal mortality rate was 6.6 deaths/100K live births; in 2008 it was 17.0 deaths/100K live births. Some say that we are doing a better job in identifying these deaths and that the rise reflects that accomplishment, but others say that you can’t explain such a dramatic rise based on better record keeping.

We cannot argue that we are not spending enough money on this problem. The United States spends more per capita on healthcare than any other country but ranks forty-first among the industrialized countries in maternal mortality rate. We spend $86 billion annually on pregnancy and childcare. This represents the largest line item expenditure by diagnosis in our national healthcare dollar.

The cause for this rise is argued by many. The World Health Organization points to 2 factors: (1) the rising cesarean delivery rate and (2) the increasing incidence of obesity in our country. Whatever the reason, it is up to us to focus our local efforts on this problem. There is a maternal death for every 6000 live births in this country. Everyone in this room should see to it that we are better than the national average.

I think the most profound and important event that I have witnessed in recent years is the passing of the Patient Protection and Affordable Care Act of 2010. The practice of medicine in this country will look very different in the future because of it. Where many of the intricacies of the bill have yet to be defined, there are 3 aspects that deserve mention. First, the Secretary of the US Department of Health and Human Services gains enormous new authority under this law. The Secretary will now have the authority to override the Specialty Society Relative Value Scale Update Committee. Second, the Physician Quality Reporting Initiative will become mandatory for all ob/gyn physicians in 2015. This will serve as the basis for “pay for performance.” Third, the Independent Payment Advisory Board is established of 15 members serving 6-year terms. They are appointed by the President and can only be removed by him for negligence of duty or malfeasance. They must submit proposals for reducing spending. Congress cannot filibuster or add amendments. Committees have a deadline of April 1 of each year to report recommendations. Some vow to attack its constitutionality; some promise to strip it of its funding, and some say they will repeal the very bill. This rhetoric sounds much like what was said in 1965 about Medicare. Since that time, this country has had 2 Democratic administrations and 2 Republican administrations, and still we have Medicare. Whether you agree with the concepts of a Physician Quality Reporting Initiative or an Independent Payment Advisory Board, it is law, and my guess is that it will remain law. It will be up to the young physicians of the future to keep the caring art of medicine alive in a day of regimented control.

I want to thank each and every one of you for letting me serve you as President for the last year. It has been my honor to be able to say that I am a member of the South Atlantic Association of Obstetricians and Gynecologists for these past 25 years. You, the members, set the bar for quality and integrity in women’s care in our area. It honors me beyond expression to be allowed to walk and work among you. I thank you for your time and thank you for all you stand for as members of the South Atlantic Association of Obstetricians and Gynecologists!