What is Rationalization?
Rationalization comprises of four key principles: calculability, efficiency, predictability, and control.
What is Gynecology & How Was It Established?
Gynecology is the medical practice focused on the healthcare of the female reproductive system. It has been around in many forms for thousands of years.
The earliest recorded knowledge of gynecology comes from ancient Egyptian papyri, which dates back to 1825 BC during the reign of Pharaoh Amenemhet. In 1889, Flinders Petrie found the Papyri on a site near Lehun - a modern Egyptian town. This papyrus was then translated and introduced into modern society as the ‘Kahun Gynecological Papyrus”. The papyrus was divided into 34 sections. First, the symptoms were briefly described, then the diagnosis and treatment. The Kahun Gynecological Papyrus did not contain any information about surgery, yet, it highlighted many procedures that were parallel to the teachings of Hippocrates. The section about pregnancy in the papyrus highlights the use of incense, fresh oil, and dates for conception. For example, a line in the papyrus for pregnancy contraception reads:
“ For preventing [pregnancy] … crocodile dung over HAS and awt-liquid, sprinkle…”
This line remains highly subjective as some scholars think it means that crocodile dung was pressed into and against a woman's cervix to prevent pregnancy. In contrast, other scholars debate if it means crocodile dung was just pressed against the body so its fumes prevent pregnancy. It was not until the 19th century that gynecology emerged as a distinct medical field.
Midwives & Medicine
Midwifery is an ancient profession that focuses on assisting women and childbirth. Midwives have played a large role in childbirth, pregnancy, and delivery. Hippocrates even wrote about midwifery in the 5th century. Furthermore, historically, childbirth was often thought of as a community event. Midwives were often experienced older mothers who had already gone through childbirth and were ready to assist other pregnant women through the process. Midwifery was not viewed as a branch of medicine until it was formalized during the Renaissance.
Despite its unorthodox nature, midwifery has faced many challenges from the already established medical front. Throughout history, physicians began to push for the medicalization of childbirth and the increased use of medical interventions such as forceps and anesthesia. This conflict between midwives and the medical establishment continued into the 19th and 20th centuries, as medicine continued to advance and midwifery faced increased regulation and scrutiny. However, midwifery has persisted as an important and respected profession, and today, many women choose to give birth with the assistance of midwives rather than medical doctors.
Predictability
The first principle of rationalization that we will explore is predictability. George Ritzer’s predictability definition derives from the concept that individuals should receive the same service and product no matter where they go. This can be achieved through standardization and implementing routine behavior that permits predictable outcomes. Predictability can be implemented in obstetrics and gynecology by standardizing certain medical protocols and procedures.
Minimally Invasive Procedures
More minimally invasive procedures are being introduced to even further minimize the risk of complications during childbirth, revolutionizing gynecology, and obstetrics. These minimally invasive procedures provide women with faster recovery times and less pain than regular surgery. Of course, all of this still depends on the type of surgery needed, but many procedures are now done laparoscopically.
Laparoscopic surgery is one of the most common minimally invasive procedures used in gynecology. It involves the insertion of a thin, lighted scope through a small incision in the abdomen. The scope allows the surgeon to view the internal organs and perform surgical procedures with small instruments inserted through additional small incisions. Laparoscopic surgery is commonly used to diagnose and treat conditions such as endometriosis, ovarian cysts, and fibroids.
As the popularity of laparoscopic surgery increases, the need for obstetricians and gynecologists to constantly learn new techniques and procedures increases. Physicians are needing to learn to quickly leave behind traditional methods of surgery and learn at a much faster pace. However, laparoscopic surgery also means more income. Laparoscopic surgery is more expensive than traditional surgery whilst reducing hospital stays.
Home Births Vs. Hospital Births
In developed countries, hospital births are the most common and preferred type of delivery. This is because hospitals are equipped with state-of-the-art medical equipment and staffed by healthcare professionals trained to handle all types of labor and delivery complications. Hospital medical staff can provide pain management options and are equipped to deal with emergencies such as premature labor, fetal distress, and postpartum hemorrhage. Also, hospitals have access to neonatal intensive care units, which are vital for caring for premature babies or babies with medical complications.
However, some expectant mothers may find the hospital environment impersonal and stressful. The presence of medical equipment and staff can be overwhelming, and hospital protocols and routines may not allow for much flexibility in the birth process. Some women may also find that they are limited in their ability to move around and try different positions during labor due to monitoring equipment. In contrast, home births offer expectant mothers a more intimate and personalized experience. A familiar environment can help women feel more relaxed and comfortable, contributing to smoother and faster labor. Home births also allow for more control over the birth process, such as moving around freely and trying different positions during labor. Some women may also prefer giving birth in water, which is impossible in a hospital setting.
However, home births also come with their own set of risks. While midwives and doulas can provide support during home births, they are not trained to handle medical emergencies that may arise during delivery. This lack of medical resources can be particularly dangerous for women with high-risk pregnancies or those who experience complications during labor. Furthermore, the need for transportation to a hospital in case of an emergency can take valuable time away.
Efficiency
The second principle of rationalization is efficiency. Ritzer defines efficiency as the means of maximizing output while minimizing input. In gynecology and obstetrics, efficiency is seen through the implementation of various standardized procedures and advancements created to save physicians time in the operating room, reduce recovery time for patients, and accurately diagnose and treat issues quicker. Despite its benefits, the drawbacks of such great advancement can lead to impersonalized care and higher costs.
Cost of Robots in the Field
Robotic surgery diminishes the various limitations that traditional laparoscopic surgery imposes. Traditional laparoscopic surgery faces a “lack of depth perception, camera instability, and decreased range of motion” (Stewart & Fader, 2017). In retrospect, robotic surgery helps with 3-dimensional stereoscopic vision, instrument stabilization, and instruments that greatly improve dexterity - allowing for more natural and easier movements of the surgeon’s hands - overall, improving surgical precision (Stewart & Fader, 2017).
The estimated per-patient total hospital costs for robotic, open, and laparoscopic surgery (with robot and maintenance costs included) were $8,770, $7,009, and $6,581, respectively. The total per-patient hospital costs for the robotic group, excluding robot and maintenance, were $7,478. When the authors added the value of lost wages and caregiver costs, the per-patient costs for robotic hysterectomy, open hysterectomy, and laparoscopic hysterectomy were $11,476, $12,847, and $10,128, respectively (Tsakonas E, Tran K, et al.).
Gynecology primarily deals with the healthcare of the female reproductive system, involving very intimate examinations which can be extremely sensitive and uncomfortable for women. Both fields require intensive relatability, personableness, and connection to offer emotional support and comfort.
This lack of emotional support and relatability is one thing that robotic care neglects. Furthermore, robotic care cannot attend to natural emergencies. At the moment, robotic care in gynecological surgery is binary - simple. This type of surgery is not suitable for all types of conditions. Some procedures require traditional methods, while others require open or laparoscopic methods. Every patient is different, and many factors come into play when deciding whether a patient is eligible for this type of surgery, such as other health conditions, obesity, and past surgical history.
Advancements in Gynecology and Obstetrics
Advances in prenatal screening and diagnostic tests have enabled healthcare providers to detect potential complications early in pregnancy, allowing for more effective interventions and better outcomes for both mother and baby.
Furthermore, another branch of surgery has emerged within the field. This emerging field is called Assisted Reproductive Technologies (ART). ART comprises in vitro fertilization (IVF) to treat infertility. ART consists of various fertility treatments, with IVF being the most common. The baseline of the ART process involves removing eggs and sperm separately, mixing them outside, and then placing them back into the embryo. ART does have a few complications, though, the most common being multiple pregnancies - which can be twins or triplets (MedLine Plus).
There have been great advancements in imaging techniques as well. These advancements provide physicians with a non-invasive way to scope issues within the body. Some of the most used imaging techniques used in gynecology and obstetrics are ultrasound and magnetic resonance imaging. However, many other emerging imaging techniques are sweeping the field by storm, such as sonohysterography.
Sonohysterography visualizes the endometrial cavity. Traditionally, a transvaginal route ultrasonography is used, but sonohysterography provides physicians the visual with much greater detail and assesses tubal patency. Furthermore, sonohysterography permits physicians to evaluate “ abnormal uterine bleeding, abnormalities detected on transvaginal ultrasonography, including focal or diffuse endometrial or intracavitary abnormalities; congenital abnormalities of the uterus; infertility; and recurrent pregnancy loss” (Technology Assessment No. 12: Sonohysterography).
Calculability
Another principle of rationalization that plays a key role in gynecology and obstetrics is calculability. Ritzer defines calculability as using quantifiable measures, such as numbers, as assessing various outcomes. In this field, calculability can be measured by means of cost and surgical success rate, and mortality rate.
The Rising Cost of Healthcare and What it Means for ObGyn's
As healthcare costs continue to skyrocket, it's becoming increasingly difficult for individuals, families, and even nations to afford the medical care they need. The reasons behind the rising healthcare costs are complex and multifaceted, but the consequences are clear. The price in the United States is inevitable regarding healthcare in gynecology and obstetrics.
For gynecologists and obstetricians, the incidence of uninsured patients and rising healthcare expenses could have considerable consequences. Patients without insurance frequently put off or skip critical medical care, such as prenatal care and childbirth, which can have a negative impact on the health of both the mother and the child. This may translate into a higher percentage of patients who require more involved and expensive medical care for gynecologists and obstetricians. In addition, as healthcare costs escalate, healthcare providers may find it difficult to remain profitable due to inadequate reimbursement from insurance companies and government programs. This may result in fewer funds for medical supplies, staffing, and other necessities, which could eventually lower the standard of care that gynecologists and obstetricians are able to provide. Gynecologists and obstetricians may need to develop strategies to boost productivity, cut expenses, and enhance patient outcomes while fighting for laws supporting policies that increase access to healthcare and insurance coverage.
Control
Another key principle of rationalization is control. Ritzer’s definition of control centers around implementing the standardization of procedures in order to retain consistency. In gynecology and obstetrics, control is emphasized through the growing standardization of various tests and protocols so patients care so patients can receive consistent and evidence-based care. Despite the benefits, the drawbacks of control include generic patient care and the lack of flexibility for physicians in the field.
The Standardization of Tests and Procedures
Standardized procedures in gynecology ensure that patients receive consistent, high-quality care regardless of where they receive treatment. These procedures involve creating a set of guidelines and protocols for the diagnosis, treatment, and follow-up of gynecological conditions. This essay will explore the importance of standardized procedures in gynecology and their benefits and challenges.
A study conducted by Smith and Borders for publication in the American College of Obstetricians and Gynecologists found that implementing standardized procedures for managing postpartum hemorrhage reduced the use of blood products and improved patient outcomes such as “improving hemorrhage diagnosis and response time” (Smith and Borders, 2022). Ultimately reducing the length of hospital stays and healthcare costs. The benefits of standardized procedures in gynecology extend beyond improving patient outcomes and reducing healthcare costs. They also provide a framework for clinicians to work within, which can improve communication and collaboration among healthcare providers. This can lead to a more efficient and effective healthcare system.
Racial Disparity in Obstetrics and Gynecology
Despite growing awareness of their prevalence among patients and providers, disparities in health and healthcare continue to plague the healthcare system. Inequities are unfavorable variations in treatment or outcomes that are frequently not caused by variations in the patient's expressed preferences. Existing in both healthcare outcomes and the quality of care itself, they have been identified based on a patient's race or ethnicity, sex, gender, and sexual orientation, as well as socioeconomic situation, immigration status, geography, and other factors.
One common disparity is maternal death. In the United States, maternal death has been shown to be more common in non-Hispanic Black women. In the year 2021, the rate of maternal mortality for non-Hispanic Black women “ was 69.9 deaths per 100,000 live births” (Hoyert, 2023). This is consequently 2.6 times the rate of maternal mortality for non-Hispanic White women (Hoyert, 2023).
Separate from the obstetric lens, when looking at racial disparity within the gynecological view, it is important to note that Ovarian cancer is more prevalent in White women than African American women. Ideally, ovarian cancer develops in older women (American Cancer Society, 2023). However, regarding the survival rate of ovarian cancer, researchers have found that “African American women with ovarian cancer, on average, do not survive as long as non-Hispanc white patients'' who have been affected by the same disease (NCI, 2020).
Racial Disparity for Physicians in the Field
Future of Obstetrics and Gynecology
While automation and artificial intelligence can revolutionize many aspects of healthcare, obstetrics, and gynecology may not be easily automated. This is due to the complex and nuanced nature of women's health, which requires a high degree of empathy, intuition, and personalized care that cannot be replicated by machines. Additionally, obstetrics and gynecology require expertise and specialized training that automation cannot easily replace. While technological advancements may continue to improve the efficiency and accuracy of certain medical procedures, the human touch and connection that OB/GYNs bring to their patients cannot be replaced by machines. Therefore, it is important to recognize and value the vital role that obstetricians and gynecologists play in the healthcare system and support their continued education and professional development.
Works Cited
Elson, M. G. (2009, May 19). Cultural sensitivity in OB/GYN: The ultimate patient ... - mededportal. Association of American Medical Colleges. Retrieved April 8, 2023, from https://www.mededportal.org/doi/10.15766/mep_2374-8265.1658
Davis, R. (2015, January 12). The doctor who championed hand-washing and briefly saved lives. NPR. Retrieved April 9, 2023, from https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives
Stephen Bamforth, Pregnancy and Birth in Early Modern France: Treatises by Caring Physicians and Surgeons (1581–1625). François Rousset, Jean Liebault, Jacques Guillemeau, Jacques Duval and Louis de Serres, French History, Volume 28, Issue 3, September 2014, Page 438, https://doi.org/10.1093/fh/cru053
Campbell, S. (2013). A short history of sonography in obstetrics and gynaecology. Facts, views & vision in ObGyn. Retrieved April 9, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987368/
Snyder, C. F., Wu, A. W., Miller, R. S., Jensen, R. E., Bantug, E. T., & Wolff, A. C. (2011). The role of informatics in promoting patient-centered care. Cancer journal (Sudbury, Mass.). Retrieved April 9, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146983/
Quirke, S. (n.d.). Manuscript for the health of mother and child. Kahun Medical Papyrus. Retrieved April 18, 2023, from https://www.ucl.ac.uk/museums-static/digitalegypt//med/birthpapyrus.html
Smith, L. (2011, January 1). The kahun gynaecological papyrus: Ancient egyptian medicine. BMJ Sexual & Reproductive Health. Retrieved April 13, 2023, from https://srh.bmj.com/content/37/1/54
Grunebaum, A., McCullough, L. B., Orosz, B., & Chervenak, F. A. (2020, February 7). Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant. American journal of obstetrics and gynecology. Retrieved April 13, 2023, from https://pubmed.ncbi.nlm.nih.gov/32044310/#:~:text=Results%3A%20The%20neonatal%20mortality%20for,for%20unintended%2Funplanned%20home%20births.
Brown, L. O., Kenton, K., & Bretschneider, C. E. (2020, January 11). Modern Trends in Operative Time and Outcomes in Minimally Invasive Hysterectomy. Journal of Minimally Invasive Gynecology. Retrieved April 13, 2023, from https://www-clinicalkey-com.libproxy.lib.unc.edu/service/content/pdf/watermarked/1-s2.0-S1553465020304131.pdf?locale=en_US&searchIndex=
Stewart, K. I., & Fader, A. N. (2017, August 13). New developments in minimally invasive gynecologic oncology surgery. Clinical obstetrics and gynecology. Retrieved April 16, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576030/
Tsakonas E, Tran K, et al. Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery: Clinical Effectiveness and Economic Analyses [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2011 Sep. (CADTH Technology Report, No. 137.) 5, ECONOMIC ANALYSIS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK168933/
MedLine Plus. (n.d.). Assisted Reproductive Technology | IVF. MedlinePlus. Retrieved April 12, 2023, from https://medlineplus.gov/assistedreproductivetechnology.html#:~:text=Assisted%20reproductive%20technology%20(ART)%20is,back%20in%20the%20parent's%20body.
Technology Assessment No. 12: Sonohysterography. Obstetrics & Gynecology 128(2):p e38-e42, August 2016. | DOI: 10.1097/AOG.0000000000001588
Volondat, M., Fontas, E., Delotte, J. et al. Magnetic resonance hysterosalpingography in diagnostic work-up of female infertility – comparison with conventional hysterosalpingography: a randomised study. Eur Radiol 29, 501–508 (2019). https://doi.org/10.1007/s00330-018-5572-2
Cha, A. E., & Cohen, R. A. (2022, February 11). National Health Statistics Reports - CDC. CDC. Retrieved April 10, 2023, from https://www.cdc.gov/nchs/data/nhsr/nhsr169.pdf
N/A. (2012). International Federation of Health Plans 2012 Comparative Price Report Variation in Medical and Hospital Prices by Country . Harvard. Retrieved 2023, from https://hushp.harvard.edu/sites/default/files/downloadable_files/IFHP%202012%20Comparative%20Price%20Report.pdf
N/A. (2023, March 20). Trends in health care spending. American Medical Association. Retrieved April 11, 2023, from https://www.ama-assn.org/about/research/trends-health-care-spending
Sufrin, C. S., Davidson, A., & Markenson, G. (2021). Importance of social determinants of health and cultural awareness in the delivery of Reproductive Health Care. American College of Obstetricians and Gynecologists. Retrieved April 17, 2023, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/01/importance-of-social-determinants-of-health-and-cultural-awareness-in-the-delivery-of-reproductive-health-care
Gyamfi-Bannerman, C., Srinivas, S. K., Wright, J. D., Goffman, D., Siddiq, Z., D'Alton, M. E., & Friedman, A. M. (2018, May 9). Postpartum hemorrhage outcomes and race. American journal of obstetrics and gynecology. Retrieved April 14, 2023, from https://pubmed.ncbi.nlm.nih.gov/29752934/
Hoyert, D. L. (2023, March 16). Maternal mortality rates in the United States, 2021. Centers for Disease Control and Prevention. Retrieved April 13, 2023, from https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm#:~:text=In%202021%2C%20the%20maternal%20mortality,for%20White%20and%20Hispanic%20women.
Baruch Y, Gold R, Eisenberg H, Amir H, Reicher L, Yogev Y, Groutz A. High Incidence of Obstetric Anal Sphincter Injuries among Immigrant Women of Asian Ethnicity. J Clin Med. 2023 Jan 29;12(3):1044. doi: 10.3390/jcm12031044. PMID: 36769692; PMCID: PMC9917715.
American Cancer Society. (2023). Ovarian cancer statistics: How common is ovarian cancer. Ovarian Cancer Statistics | How Common is Ovarian Cancer. Retrieved April 14, 2023, from https://www.cancer.org/cancer/ovarian-cancer/about/key-statistics.html#:~:text=About%20half%20of%20the%20women,over%20the%20past%2020%20years.
NCI Staff. (2020, July 16). Ovarian cancer studies aim to reduce racial disparities. National Cancer Institute. Retrieved April 14, 2023, from https://www.cancer.gov/news-events/cancer-currents-blog/2020/ovarian-cancer-racial-disparities-studies
Boyle, P. (2023, January 12). What's your specialty? new data show the choices of America's doctors by gender, race, and age. AAMC. Retrieved April 14, 2023, from https://www.aamc.org/news-insights/what-s-your-specialty-new-data-show-choices-america-s-doctors-gender-race-and-age
N/A. (2018). Figure 18. percentage of all active physicians by Race/ethnicity, 2018. AAMC. Retrieved April 18, 2023, from https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018
Smith, C., & Borders, A. E. (2022). Quantitative blood loss in obstetric hemorrhage. American College of Obstetricians and Gynecologists. Retrieved April 18, 2023, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/12/quantitative-blood-loss-in-obstetric-hemorrhage
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