So You Want to Be an OB/GYN

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So you want to be an obstetrician and gynecologist, or OB/GYN. You like the idea of babies, mommies, and taking care of lady parts. Let’s debunk the public perception myths, and give it to you straight. This is the reality of OB/GYN.

Dr. Jubbal, MedSchoolInsiders.com.

Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as OB/GYN, and help you decide if it’s a good fit for you. You can find the other specialties on our So You Want to Be playlist.

 

What is OB/GYN?

OB/GYN is comprised of two components: obstetrics and gynecology. Obstetrics is the medical and surgical management of pregnancy, whereas gynecology is the medical and surgical management of the female reproductive tract. OB/GYN is a form of primary care and includes a heavy longitudinal care element. After all, you’ll be seeing your patients during puberty, through adult life, during pregnancy, and then continued through menopause and later.

As my OB/GYN colleague says, it’s “The perfect combination of primary care and surgery. The only thing you give up is the prostate and male reproductive organs.”

In obstetrics, the bread and butter includes delivering babies in the form of vaginal delivery or cesarean delivery, also known as a C-section. When caring for pregnant women, you’ll see them approximately once per month in the first trimester, every 2-4 weeks in the second trimester, and every 1-2 weeks in the third trimester. You’ll be making sure the mom and fetus are doing well, looking out for problems and symptoms. The interesting thing about this stage is that women are highly engaged with their medical care. Many people are usually less willing to see their primary care physician, but once they’re pregnant, they often reprioritize their own and their baby’s health.

In gynecology, you’ll be doing the annual well-woman exam in clinic, in addition to treating pelvic pain, infections like vaginitis or STI’s, and providing contraception options. If you’re on call, you’ll rush to the ED to treat ectopic pregnancy, ovarian torsion, and vaginal bleeding of various etiologies. And if you’re in the operating room, the most common surgery is the hysterectomy, or removal of the uterus. This can be emergent if there is bleeding, as the patient can exsanguinate, meaning they may experience a severe loss of blood. And for those who want to remove the possibility of future pregnancies, you can do a tubal ligation. Think of this as the female equivalent of a vasectomy.

There are a few ways to categorize the specialty.

Obstetrics vs Gynecology vs Generalist

First, you can divide the specialty as having an OB-focus, Gyn-focus, or being a generalist and dealing with both.

Immediately out of training, you’ll be a generalist, able to handle both the obstetrics and gynecology side of things. Some continue down this path and don’t want to give up either part of the practice, while others choose one to focus on. Being a generalist is the most common and dominant form of OB/GYN practice in the United States. You’ll be on call for both labor & delivery as well as on gynecology emergency department call, often at the same time.

Those that want to focus on pregnancy and delivering babies will focus their practice on just OB. Obstetrics is divided into office and labor & delivery. Office visits will be primarily around regular checkups with pregnant women across all three trimesters of pregnancy. Labor and delivery is when the woman is in the hospital and you help deliver the baby. As an obstetrician, you can be a solo-practitioner, although this is increasingly uncommon in modern times, or work in a group practice. Babies don’t care about your 9 to 5 working schedule and are delivered at all hours of the day, which means a more demanding schedule and lifestyle. Compared to being a generalist or pure gynecologist, obstetrics has the lowest compensation. The reason being that pregnancy is reimbursed as a single bundled payment from insurance companies and Medicare, including all office visits and labor and delivery.

Those that want to focus on women’s reproductive health will adopt a gynecology-only practice. This is more common as practitioners advance in their careers, as there’s a lower risk of being called in the middle of the night. When you’re 50 years old, you probably won’t be as eager to run to the hospital in the middle of the night. Compared to being a generalist or pure obstetrician, this is the more lucrative path, as there are more procedures. Think of the lifestyle as similar to a urologist, where you can be in the operating room more or less, depending on your desired balance, and can transition to a heavier clinic-focused practice in later years.

Academic vs Community vs Private Practice

OB/GYN can also be divided by practice setting – namely academic, community, and private practice types.

In academia, you’ll of course be teaching medical students and residents, in addition to conducting research on top of your clinical duties. Compared to other practice types, this generally has lower compensation. However, you’ll be more likely to see more complicated and often interesting cases in academia, as these are tertiary care centers with state-of-the-art equipment, copious resources, and experts in other specialties for consults if needed. Severely preterm deliveries are also best handled by academic centers, which can handle premies or babies with congenital issues in the NICU. Community institutions and private practice groups are generally not as well equipped. Remember, delivering babies isn’t just about making sure the mom is safe, but also the baby.

In a community-based practice, you’ll be working at a medical group not affiliated with a teaching hospital. This is the most common practice type and serves the majority of the population. They’re able to handle the bread and butter straightforward cases and presentations, such as hysterectomies and other basic gynecologic surgeries. In terms of labor and delivery, they can again handle straightforward deliveries, but will often transfer out moms or babies requiring more advanced levels of care.

Private practice groups can have an affiliation with an academic center or community hospital. Private practice physicians own part of their practice, and the more work they put in, the more money they earn. While private practice OB/GYNs make more money than either academic or community based ones, they have more pressure to see more patients, schedule more cases, take more call, and work harder overall. The smaller your practice, the more frequently you’ll have to take call, but the fewer people you’ll have to split the profits with. Whereas academic institutions take all patients, including those without insurance, private practice groups may only accept patients with insurance and who are less complicated in terms of medical presentation.

Misconceptions About OB/GYN

There’s a lot of misinformation floating around about obstetrics and gynecology. Let’s set the record straight.

First, no, they don’t all wear pink scrubs (like in Grey’s Anatomy), although you’re free to should you decide to become an OB/GYN.

Second, many surgeons from the traditional surgical subspecialties look down on OB/GYN as not being real surgery. This comes from C sections being less refined than other types. There’s wiggle room involved in a cesarean section and multiple steps will be done with blunt dissection, meaning with your hands, rather than a surgical dissection using scissors and pickups, which is much slower and more precise. Still, this requires knowledge of the anatomic planes between the bladder and uterus and other anatomical structures to be wary of. The stakes are high too – things often go well, but if things go sideways, you have the baby’s and mom’s lives in your hands. The closure is also much faster and less precise, but this view oversimplifies the complexity and intensity of the procedure, even though it may appear straightforward from the surface.

This “not real surgery” mindset also overlooks the surgeries that gynecologists do on the female reproductive tract, such as hysterectomies. Gynecologists are surgeons just as much as urologists. The main difference being the former operates on females and the latter primarily on males.

The third misconception is that residencies are malignant and it’s full of unsavory personality types. My OB/GYN colleague states “this is a byproduct of any residency filled with women who are very tired and overworked. Let’s acknowledge our potential gender biases!”

 

How to Become an OB/GYN

After medical school, OB/GYN residency is 4 years in duration. You can go either down the categorical or advanced paths. With categorical, you attend all 4 years at one institution. With advanced programs, you’ll first complete your intern year at one institution. This can be in the form of a preliminary year or transitional year, after which you’ll complete your three years of OB/GYN residency at a separate program.

In your first year of residency, or PGY1, known as your intern year, you’ll rotate on emergency medicine, ICU, medicine, and sometimes a NICU rotation, with other rotations depending on the program. During PGY2 through PGY4, you’ll rotate on labor and delivery split between days and nights. You’ll also have benign gynecology rotations and gynecologic oncology rotations. In your later years, you’ll get subspecialty exposure opportunities, such as family planning, high-risk obstetrics, urogynecology, and infertility.

According to my OB/GYN attending colleague, there are two primary types of medical students who apply into the specialty: shiny pretty women with perfect manicures or women who eat granola for breakfast and perform at the vagina monologues. Regardless of the stereotyping, these are medical students who can handle the gamut of pap smears to emergency c-sections. In the early 2000’s the field was more evenly split between men and women, but now close to 90% of OB/GYN residents are female.

In terms of competitiveness, OB/GYN is middle of the pack, between internal medicine and pathology. The average match rate is 89%, the average Step 1 is 229, Step 2CK is 245, and an average number of publications hovers around 4 and a half.

 

Subspecialties within OB/GYN

After completing OB/GYN residency, you can opt to further subspecialize with a fellowship.

Maternal Family Medicine

Maternal family medicine, or MFM, is the only obstetrics-specific fellowship and is 3 years in duration. There’s a high degree of ultrasound, labor & delivery, and it may include some neonatal surgery. You’ll primarily be dealing with more complicated diseases of pregnancy, like cardiovascular issues, diabetes in pregnancy, or a patient with mechanical heart valves requiring fine-tuning of the patient’s anticoagulants. You’ll also help coordinate care for fetuses that are ill or have rare conditions.

This is the fellowship for the OB/GYN nerds who want to sit down and review 3 papers to make one decision, hours later.

Gynecologic Oncology

Gynecologic oncology, or gyn-onc for short, is also 3 years in duration. There’s generally 1 year of research and 2 years of surgical training. These are the cowboys and cowgirls of surgery – nothing scares them. If something goes down with the female reproductive tract in the hospital, you can count on gyn-onc to help save the day, even if it isn’t cancer.

Gyn-onc surgeons are unique in that they handle their own chemo, meaning they handle both the medical and surgical aspects of oncology. In most other parts of medicine, you’ll have separate medical and surgical oncologists.

The most common types of cancers they deal with include uterine, ovarian, cervical, and sometimes breast cancer, which is sometimes handled by general surgeons who have completed a breast fellowship.

Urogynecology

Urogynecology is another 3 year fellowship, and it has some overlap with urology. For example, both do plenty of cystoscopy and bladder procedures. As a urogynecologist, you’ll primarily be dealing with incontinence, the lack of voluntary control over urination, and prolapse, or the bulging or falling of certain body parts into others. There are various sling and mesh procedures to address continence, and various procedures to affix a prolapsing bladder, uterus, or rectum. This is for those who are comfortable with lots of urine and older patients.

Reproductive Endocrinology and Infertility

Reproductive Endocrinology and Infertility, or REI for short, is a 3-year fellowship focusing primarily on infertility. That means dealing with in vitro fertilization, egg transfers, polycystic ovarian syndrome, and hormonal issues like precocious puberty, also known as early puberty. You’ll be harvesting eggs, freezing them, defrosting them, injecting sperm, and making dreams come true.

Of all the subspecialties, this has the best lifestyle. These are the OB/GYNs with super fancy clothes and who are making serious bank.

Non-ACGME Fellowships

There are a few non-ACGME accredited fellowships, each of which are 2 years in duration. These include minimally invasive surgery, which deals with lots of laparoscopy. Family planning fellowship focuses on complex abortion and contraception. And reproductive infectious disease is rather self-explanatory.

 

What You’ll Love About OB/GYN

There’s a lot to love about OB/GYN. There’s the continuity of care. The specialty is truly womb to grave, taking care of patients for their entire lives, including their best and worst days. If you enjoy building longitudinal relationships with patients, this has a strong draw.

For those who enjoy excitement and adrenaline, there’s an emergency element to get your fix. There are enough gynecologic and obstetric emergencies to keep you on your toes. Plus, since you have two patients, the mom and the baby, there’s an added degree of uncertainty to add to the excitement.

OB/GYN is also unique in providing a strong primary care and advocacy element. There’s a strong public health focus that’s emphasized, particularly women’s health advocacy, and while that’s common amongst primary care specialties, it’s harder to find in other surgical subspecialties. If you care about infertility, abortion, contraception, and being a part of social and political change in women’s health, OB/GYN is where you want to be.

And finally, the patient population. Particularly in OB, you’ll be dealing with many young or middle adulthood patients, giving you the opportunity for meaningful and highly impactful intervention as they present for pregnancy care. On average, your patients will be younger compared to many other non-pediatric specialties.

 

What You Won’t Love About OB/GYN

While OB/GYN is a great specialty, it’s certainly not for everyone.

The lifestyle is more challenging than most, as you’ll often be on call for various OB or gynecologic emergencies.

In terms of compensation, you’ll be slightly below the middle of the pack, averaging $308,000 per year.

Some patients may truly challenge you – for example, the IV drug abusers who are pregnant. Patients do things you may not agree with but you still must provide them with care and do your best to help them and their baby.

While delivering babies is exciting and rewarding, it can be profoundly sad when your patients experience a pregnancy loss or cancer. It’s not all happy babies and flowers.

And last, it’s often a messy specialty. It’s a high blood loss specialty, which is often combined with other bodily fluids and solids during labor, if you know what I mean. Let’s just say there’s lots of fluids and smells on the job.

 

Should You Become an OB/GYN?

Who should go into the field of OB/GYN? If you’re high energy it helps, as you’ll be running between the office, labor & delivery, and emergency department. It’s a very active specialty and you’ll be on your feet frequently. If you’re not running around, you’ll be standing in the operating room. There’s often a lot happening at once, and it’s an often unpredictable field. You should be ok with uncertainty and controlled chaos, and maybe even the occasional uncontrolled chaos.

This is not the place for the stereotypical emotionally cold surgeon, meaning you’ll need to be more empathetic and willing to emotionally connect. In other specialties, anesthesia will put the patient under, but in OB/GYN, the patients are often awake. It’s best if you’re nice, warm, and tactful. After all, it can be incredibly awkward as you’re having a conversation with your patient while you have your hands in their intimate parts. Patients don’t want to go to the gynecologist – it’s on you to make it a positive experience, or at least as painless as possible.

Special thanks to Dr. Grace Ferguson, attending OB/GYN in Pittsburgh, and an Insider at Med School Insiders for helping me in the creation of this article.

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