Hysteroscopy

Becoming an Ob/Gyn

A number of people have expressed confusion about the education and qualifications one must possess in order to become an obstetrician/gynecologist. This brief summary is an effort to clarify this issue and to provide insight into the training and lifestyle of ob/gyns.

High School

Many physicians know they want to become a doctor during high school (or even earlier). In many respects the training of a doctor begins as early as high school, where the future doctor must obtain grades high enough to be accepted to a 4-year college. Students must balance the need for high grade point average (GPA) with their social needs, such as sports, dating, and school events.

College

In college, students hoping for an acceptance into medical school must take a large number of required science courses, such as biology, chemistry, genetics, physics, and organic chemistry. Some medical schools also require one or more writing or literature classes. Most "pre-med" students major in biology, chemistry, or physics. Some schools have a "pre-med" major while others do not. However, a number of college students major in non-science disciplines or have dual majors, for example in literature and biology. As long as a student takes the required courses to gain acceptance into medical school the major is not particularly important, and, to my knowledge, medical school admission committees do not favor one major over another.

College is an extremely stressful time for many pre-med students. *Nobody* is more grade-conscious than a pre-med student. Science classes are generally more rigorous than non-science classes, in part due to the huge volume of material, and also because of labs. Labs usually occur in the afternoon after regular classes are over, and I can recall many afternoons where I would look out the lab window and watch other students
heading to the pool or beach! Pre-med students all know that excellent grades, usually above 3.5 and often above 3.7 or 3.8, are necessary to compete with other pre-med students around the country applying for application to medical school. A "C" in a particular class may mean an academic death sentence to a worried student, so dedicated studying is the norm, often at the expense of athletics and social activities. Most pre-med students are "weeded out" during the first year of college, and it is not uncommon to have only 10-20 percent of the freshman pre-med class actually graduate as pre-med students. Of course, not all of these students will be accepted to med school. I usually advise pre-med students to have a "second choice" career plan in case they are not accepted to med school, or in case they are unable to complete the rigorous course requirements.
Although academics are the most important requirement for medical school admission, college students should not forget to take non-science classes, nor should they neglect socialization. Nobody wants a "science geek" as a doctor! Patients expect that their doctor be a good listener and be able to relate to them as people, and a well-rounded social environment is a must. Volunteerism is also important, although not absolutely necessary, and most pre-med students attempt some type of volunteer activity. Contrary to popular belief, is it not critical that this volunteer activity take place in a hospital.

The last 2 years of college are spent getting ready for the MCAT (Medical College Admission Test) and applying to various medical schools. The MCAT is a grueling day-long test that covers physics, chemistry, biology, and reading and writing comprehension and skills. It is every pre-med student's nightmare, as a substandard score usually nullifies any hope of medical school admission. An entire industry has developed to "coach" students to take this test, which is the first of many exams required during medical training, as discussed later. By the second or third year of college, students should have a pre-med advisor, who will be able to help that student decide on how many schools to apply to and how to fill out the application form for medical schools. Most (and perhaps all) U.S. medical schools now use an electronic (computerized) form. The admission interview to med school is yet another trial by fire, where students meet faculty from the medical schools they have applied to, and answer all sorts of questions about
their career goals, background, and activities.

Medical School

Medical school lasts 4 years. Most schools use the first two years for classroom learning in subjects like biochemistry, anatomy (including the complete dissection of a cadaver), microbiology, and pathology. In addition, students are introduced to clinical medicine by taking coursework in physical examination, use of a stethoscope and other medical instruments, and by actually performing examinations under the direction of a physician. Each med school sets it's own "hours." During my first 2 years of med school, classes were held roughly 8-5 Monday through Friday. We would eat dinner then begin studying late into the night. There was certainly time for some leisure activity, but studying took up the bulk of one's day (outside of class). I do not think it is unreasonable to state that my classmates and I went to class and studied about 70-80 hours per week, although this
increased as tests approached. In my opinion the information presented in med school is not unreasonably difficult; it's the unbelievable amount of information that makes the first 2 years of med school so hard. This can come as a huge shock to some students, who "sailed" through high school and college but find themselves with their first C or lower grades during med school. Of course, med school parties are legendary, since students need to unwind after being tested on such things as the location of every nerve in the body!

The third and fourth years of med school are spent in the clinic or hospital. The 3rd year is one of the hardest but most fulfilling times in a physician's training, as this is the first real experience with direct patient care. Third- year students "rotate" through such departments as surgery, internal medicine, psychiatry, pediatrics, family medicine, ob/gyn, and perhaps anesthesia or radiology. Students are expected to awake at the crack of
dawn (and sometimes earlier), go to the hospital, and "round" on their patients before the resident physicians (doctors who are still in training for their particular specialty) arrive. Rounding consists of taking vital signs, asking the patient how he or she is doing, examining the patient, then writing a progress note in the chart. Each of these steps is reviewed and supervised by a resident and attending physician (who is essentially the
doctor in charge of teaching the residents and students and who bears ultimate responsibility for the patient's care). Third year can be grueling, as most schools require that students take call, which usually means spending the entire day and night (and often the entire next day) awake and in the hospital to help care for sick patients. After rounds and teaching, it's off to the clinic, operating room, labor and delivery unit, or library. While students are allowed to do some procedures, surgeries are conducted by residents with the attending physician supervising and assisting. Call can be brutal. Some schools have gotten away from 36-hour call, but others have not. If you are really interested in how third-year med students, many residents, and some doctors in busy practices live, simply stay awake and work for 30-36 hours at a time, without naps or a shower, about 5-10
times a month! Although much of the third year is hard, some rotations during the third year are less demanding than others, with hours ranging from 40-50 per week and only a few days of call per month.

The fourth year is spent in many elective rotations and is much easier than the third year. There is almost always much less call, less stress, and more time to concentrate on selecting a specialty to practice. Plus, most attending physicians "lighten up" on 4th-year students and ask them fewer questions than their 3rd-year colleagues. Some students actually spend a month or two at another hospital or city. The months of December-February are spent interviewing for a residency position at a number of hospitals, as it can actually be harder to land a good residency spot than get in to med
school! Residency is handled though a process called "the match" where student's choices are matched with various residency programs via a computer to select the optimal choice for each student. Top-notch residencies in competitive specialties are extremely difficult to land. Excellent programs can have over 1000 applicants for 5 or 6
positions! Less competitive programs may have only several dozen applicants. To get in to a "star" residency program one must be a star med student, with a class rank near the top 1/4 or perhaps 1/3. This is not nearly as easy as in college or high school, as med schools usually have only outstanding students, who are competitive and want to be ranked as high as possible. In addition, excellent recommendation letters and perhaps
published research is necessary for the better programs. Less competitive programs are certainly easier to obtain and usually provide a high quality education.

Cost of Medical Education

Medical school is expensive. Some schools "only" cost $10,000-12,000 per year, while others can exceed $35,000 per year. Scholarships are very limited, so most students take out student loans. It is not at all unusual to find modern med students who owe over $50,000 for 4 years of med school, and I know of many young doctors who owe over $120,000. The minimum student loan payments for a loan this size can be $2000 per month for around 10 years! Physician incomes are slowly decreasing in many areas due to managed care, and young doctors are often hard hit when student loans come due. It is difficult to work during med school due to the long hours, but some students manage to get in a few work hours each week. Parents of young students who are considering medical or other professional education should consult a financial planner and a financial aid officer, who can advise which investments or forms of aid are available to help pay for medical school.

Residency

After medical school the med student is a physician, but cannot legally practice medicine without supervision until licenced. Medical students and resident physicians take a series of tests called "boards" which must be passed prior to obtaining a license. These are tough tests and a number of students fail, and must try again. Once licenced some states allow young doctors to practice unsupervised, while others desire that the doctor
complete a full residency program, which can last, depending on the specialty, from 3-11 years.....after medical school! Put another way, to become an ob/gyn one must have completed 12 years of education after high school, which means one cannot begin working in one's career until about age 30. We used to call doctors right out of med school "interns." Many programs still use this terminology, although they are technically a
"first-year resident." Ob/Gyn residencies are 4 years. Each year the resident is allowed increasing responsibility and is allowed to attempt more difficult procedures and surgeries. Becoming a skilled surgeon takes practice, therefore residents often "come in early and stay late" to learn surgery and care for extremely sick patients. Patients in residency programs are usually the sickest patients in town. My ob/gyn program had a night-call service which prevented 36 hour calls, but I still recall working between 70-100
hours per week, every week of the year, for 4 years. Both general surgery and ob/gyn are known as the hardest residencies in terms of workload, due in part to the large number of patients, and also because of the surgical cases. After all, one can't ask a patient with a ruptured tubal pregnancy to "see me in the morning" since she will likely be dead by then! Plus, babies often come at all hours of the night. A young doctor who chooses a career in ob/gyn should have a passion for the speciality, since the hours during
training (and in practice, since according to AMA information ob/gyn's work as many or more hours per week on average than any other speciality) are painfully long.

Practicing Obstetrics and Gynecology

After residency the doctor becomes eligible to take the specialty boards, and become "Board Certified." In ob/gyn this involves a day-long written exam right after completion of residency, then a grueling oral examination by 6 different professors 2 years later. Every Board Certified ob/gyn can remember specific questions asked during "the orals" even if they were taken decades ago! Women's magazines and other media often make a
big deal out of board certification, but patients should realize that doctors right out of residency (who are on many occasions the most up-to-date) cannot become board certified until about 2 years after they begin practicing. Many ob/gyns join a group practice once residency is over, while others start their own practices or join an academic setting so they can teach or do research. A smaller number go on to become subspecialists in cancer gynecology (gynecologic oncology), high-risk pregnancies (maternal fetal medicine), or infertility (reproductive endocrinology). The training for
these subspecialties is called a "fellowship" and these fellows must continue their formal education for 2-4 more years before they can practice in their chosen field.

Ob/gyns in practice can expect to work irregular and long hours, ranging from a low of 50 to a high of 90-100 per week. Joining a group practice (as I have done) allows my partners and I to split call, but as you will see it did not necessarily lead to fewer hours. Using myself as an example, an average workweek would include the following, although each week is a little different so hours will vary:

• Monday-office all day (10 hours).
• Tuesday-on call for 24 hours in the hospital, teaching and supervising residents and delivering our private practice babies (24 hours).
• Wednesday: Day off.
• Thursday: Office all day (9 hours).
• Friday: Operating room (8 hours).
• Saturday: on call (24 hours).
• Sunday: Day off.
  Total: (75 hours).

The week I wrote this I worked 101 hours, as I was on call 3 of the 7 days and had office and surgery on the other days! Most ob/gyns will have a variation of the above schedule and may, for example, work in the office every day except Thursday, when they are in the operating room. Thus, that doctor's hours would average to about 50, including time spent making rounds and delivering babies. I suspect 60-70 hours per week is closer to a national average for full-time ob/gyns.

Although it may sound as if medical education is punitive, I found it both very difficult and very rewarding. I have spent countless hours memorizing the location of tiny nerves, caring for sometimes hostile and violent patients, but have also held the hands of dying patients, told tearful parents that their baby has no heart beat, cured people of cancer,
and saved the lives of many babies and sometimes their mothers. Each of these experiences is a part of me personally and professionally, and while there were days along the way that I wondered if not going outside the hospital for days at a time was worth it, there have been countless times that I am grateful that I am able to practice medicine and care for my wonderful patients. The path to becoming an ob/gyn is long and
difficult, but if one is passionate about this speciality, the rewards of helping to bring babies into the world, treating conditions like endometriosis, infertility, abnormal Pap smears, painful intercourse, and abnormal bleeding, and knowing your patients personally is worth the many years of training and long hours in practice.

D. Ashley Hill, M.D.
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
Orlando, Florida
407-897-1668