The Training of Obstetricians: a Resident's View

THE FUTURE OF OBSTETRICS AND GYNAECOLOGY: The Fundamental Right To Practice and be Trained According to Conscience: An International Meeting of Catholic Obstetricians and Gynaecologist

Organised by the World Federation of Catholic Medical Associations (FIAMC) and by MaterCare International (MCI)
Sponsored by the Pontifical Council for the Health Pastoral Care ROME, June 17th-20th, 2001

Reproduced with permission

In a first part Dr. Hefter will share some questions we are actually faced with as residents and give some reflections about residents situations in different countries.

Further I'll share some thoughts about conditions and options for the future. First I want to introduce myself: Susanne van der Velden, I'm in the 5th year of residency, I'm working in Germany, living in the Netherlands.

Almut Hefter: My name is Almut Hefter. I attended medical school in Germany and I am now in the 6th year of training in O&G. The decision to enter the specialty became clear during my final year. O&G had always been my favourite subject, but I was afraid of the difficulties regarding termination. I learned that Dr. Ehmann does not prescribe the pill and does not do sterilizations. This was a foreign but also challenging view to me. To explore this issue I did part of my final year in Stans in his department, where he patiently answered my questions. During this time it became clear to me that the teaching of the Catholic Church on contraception was true and although things were now even more difficult, I felt that O&G is what I want to do.

I have worked in Germany, Stans and now three years in England. Contrary to Dr. van der Velden I am happy to work in non-Christian hospitals as I prefer large units. My consultants and colleagues only know part of my objections, especially regarding contraception. Surprisingly none of the big units I've worked in did abortions for social reasons, a fact I did not know when applying for the job. This has been a great relief for me and a sign for God's provision and mercy.

What is the actual training situation in the different counties?

Firstly Great Britain: The professional body is the Royal College of Obstetricians and Gynaecologists and membership is mandatory to work as a consultant or specialist registrar. The College runs a structured training program for registrars and places are very limited. The training program includes contraception and termination, but it is - at least on paper - acknowledged that there might be conscientious objections to some of these issues. So far, whenever I expressed objections to a procedure in theatre, this was readily accepted.

Having said this, there are plenty of guidelines published by the Royal College, which define standard practice and it is expected - especially for trainees - that they are closely followed. This includes for example that the contraceptive pill or Mirena-coil are recommended for certain medical conditions or that termination of pregnancy has to be offered in a non-directive manner. Within these guidelines there is a large bias on evidence based medicine and alternate ways of treatment, which might be more acceptable to a Catholic doctor or patient are often not accepted due to lack of good quality studies. Also it is virtually impossible for me to offer alternatives as I can't guarantee to see the patient at a follow-up visit. Due to the structure of the NHS, most people attending antenatal or gynaecologic clinics see a different doctor every time. More detailed explanations are difficult as there is usually a tight time schedule. And last not least it is the Consultant who is ultimately responsible for the care of the patient and he can dictate me what to do.

Now to Switzerland: The entire training to become a specialist must be done in Switzerland. One year of training must be done at a University Hospital where it is nearly impossible to object to terminations. At present there is a single post in the whole country that is suitable for a pro-life doctor.

The situation is even worse for midwifes; they are unable to enter training at all if they are not prepared to take part in the care of women undergoing termination of pregnancy. In Germany it is possible to obtain the specialist degree without undertaking abortions, sterilizations, or, for example, amniocentesis as these procedures are not explicitly required. There is no fixed national training program and training in other countries is accepted. But the working atmosphere is generally less tolerant and one is more dependent on the good will of the registrars to receive training than in other countries. Here we have both experienced difficulties and hardships although this was not consciously linked to our Catholic beliefs.

True for all countries is that training posts are limited and there is fierce competition. Frequent and busy night shifts lead to constant tiredness and make it more difficult to reflect critically on our own practice or to keep our own Catholic spirits up. You are tempted to give in to mainstream. There is a special hardship for women as a hospital job and family with children can only be combined with great difficulties.

To sum things up: difficulties exist in every country and at different levels: within the professional body, political reasons or on a personal level. So far we have been able to practice according to our conscience most of the times and received good medical training despite our objections. However, we had to make compromises - or at least we felt that we had to do them - in some areas for practical reasons, for example assisting sterilizations or signing the consent for or prescribed the pill for medical reasons if directed by a senior colleague.

Now, during our training several questions have arisen for which we still struggle for answers: Humanae Vitae admits that even for Christian couples faithfulness to the teaching can be very difficult. Our patients come from all walks in life and most of them do not share our belief and can't find strength in prayer or are in tremendously difficult situations. How can we show them the love of Christ and that we care for them when we are than asking just another difficulty from them? Are we doing the second step before the first one?

What exactly is the definition of a Catholic gynaecologist? Is there one? Would he or she be allowed to prescribe the pill? Under which circumstances? We have been given conflicting information even from moral theologians. And how do we look at the pill or Mirena coil for medical indications? Further suggestions for alternate treatments are welcome. We have come across couples that were definitely unsuitable for natural family planning. What do we offer them? To change their doctor? What do I do if my patient is requesting generally accepted treatment to which I have conscientious objections, but I am the only doctor who is able to do it? I just imagine a patient coming for her fourth caesarean section with planned tubal ligation in the middle of the night, contracting. What do I do? Place her under the risk of a further operation in the future because I'm not happy doing it?

Please take these questions as an expression of how much we still struggle despite our own belief in the truth of the Catholic teaching.

Susanne van der Velden: Dr. Hefter has pointed out that there is a big and still growing number and variety of obstacles we as Catholic gynaecologists and obstetricians are faced with.

This rising number of obstacles leads to the second problem: We're concerned about the small number of young Catholic doctors choosing for gynaecology. So there are two questions arising:

1) is there a future for Catholic gynaecologists, and

2) will there be future Catholic gynaecologists?

Personally I'm absolutely sure that there is a future for Catholic gynaecologists and that there will be future colleagues. But in order to achieve this aim there are several conditions we have to discuss.

I think the problem is not that there are no human resources. Although there is a decline, there is still a number of Catholic students and doctors who would like to choose for gynaecology. But most of them finally decide to work in another specialty.

Asking why they do so, there are repeatedly these two reasons:

1. They are afraid about the struggles they may be faced with, and

2. They do not really know what it means to be a Catholic gynaecologist.

Considering this as a "diagnosis" of the problem I want to share some proposals for treatments with you.

Someone thinking about becoming a Catholic gynaecologist needs help and guiding in order to choose for this profession. He must know the medical and ethical challenges of this job in order to be able for a free and definite decision making. Of course this decision has to be renewed permanently, but there has to be a first "yes".

Further, I consider it to be important to know exactly, "What is the definition of a Catholic gynaecologist?" As Dr. Hefter pointed out, this remains a very important question for us also after having made the decision. In our society the terms "Catholic" and "gynaecology" seem to be contradictory and impossible to combine. In order to stay a good Catholic, it seems to be better not to become a gynaecologist and as a gynaecologist it seems to be better not to be a Catholic. So I consider it to be important to give a true and reliable definition of the whole term.

Further we have to ask ourselves: What can we do to make our job attractive for young students and acquire more colleagues? How can we help young doctors to make their choice for the Catholic way of practising gynaecology and to pursue this way?

In a first step I propose to give a structure to already existing training options. These should be analysed and listed for example by a co-ordinating institution. This includes the following three aspects:

Make a sum-up of all already existing training centres. There are possible training centres all over the world, Catholic or not.

Make a sum-up of all Catholic gynaecologists. This could be done in co-operation for example with Catholic institutions, medical associations or gynaecological boards.

Added to these two systematic sum-ups there should be an analysis of the particular difficulties as well as advantages in the different countries, as Dr. Hefter pointed out.

This Evaluation of all our actual resources would serve our own plans for the future and - making it accessible to others - it could be a guideline for students.

Most information I got derives from personal experiences or experiences I heard from others occasionally.

In order to acquire new colleagues there is a second step which I consider to be essential: Making our job popular - I exaggerate: wherever possible and with all possible means. Some examples:  There could be information week-ends, contacts with Christian students groups or with Christian communities n I already mentioned a list of all Catholic gynaecologists: there could be national and international contact persons from this list for interested students and colleagues. These contact persons know the situation of their own country and could co-ordinate publicity. n Creating accessible information - for example information folders or advertising in Christian journals or medical journals.

I think we have to use all our knowledge and our imagination to get access to young Catholic medical students, to make them curious and to give them the possibility to think about gynaecology as an option for them.

The next step is to support these students to become able to make their decision and also to give them good training options. Some suggestions could be:

Regular contact between Catholic gynaecologists. This could be through local meetings or meetings as here. Another option for regular contact also on a long distance could be the Internet. Why shouldn't there be a virtual "journal" for Catholic gynaecologists and of course all interested colleagues with training elements, for example, contributions about medical and ethical questions, discussions, job offers and demands, and so on ?

The second suggestion is to give everybody interested access to existing training options - for example by the above mentioned list of training centres.

Finally - and the question is urgent: Is there a possibility of a combined medical and ethical training centre? Where could it be? For whom would it be accessible?

To conclude: in the beginning I asked two questions: "Is there a future of Catholic gynaecology?" and "Will there be future Catholic gynaecologists?" I already gave the answer: yes, considering three conditions:

The first was: defining our job and making it popular

The second was: giving interested colleagues a good medical and ethical training and personal encouragement

The third and last condition I didn't mention yet - I consider it to be the most essential and the fundamental one: We need to have a positive view about our profession as Catholic gynaecologists! Often we say:

"Sorry, I'm a Catholic, I don't do this or that, I'm not allowed to".

That's a poor testimony - and not attractive for any young student to imitate. Why don't we say:

As gynaecologists we perform an important and wonderful profession: we're supporting life from it's very beginning till the birth, we're caring for women in different, often very important steps of their life, sometimes till their death.

As Catholics - I prefer to say Christians - in our daily work we are the first and immediate witnesses of the miracle of God's creation and of the mystery of the transmission of life, discovering God's face in each of our patients. I wish us all arising from this congress a profound renewal of ourselves: that we re-discover the beauty of the profession God gave to us and that we testimony it to others.