International Urogynecology Journal (2001) 12:221-222.

Copywrite Springer Verlag London Ltd. 

            I have had an interest in incontinence since my earliest days in medicine. This probably reflects some grave deficiency in my potty training.  As a student, I don’t suppose I gave it too much thought, as I was too busy just trying to survive in the “pre-humanistic” days of the early seventies.  Unless one were truly brilliant and headed for the ivory towers of Academe, no one really cared what one was interested in beyond matching a decent internship. I think that I began to realize my interest in female incontinence during the few years I practiced Family Medicine.  Once the terrifying days of medical school and the long nights of Charity Hospital were over and I had spent two relatively relaxed years in a FP residency, I had time to luxuriate in the warmth of the long-term relationships I developed with my patients.  No longer did one hurry from clinic to clinic and rotation to rotation--abandoning patients to those who came after. For several years I was free to culture relationships and understanding with my patients, and to hope that they would invest me with their confidence. After a few years of this, I decided that I could better my skills and use my talents by training in Ob/Gyn. The specialty seemed to offer the combination of primary care that I found emotionally satisfying as well as the technical demands of surgery.   At that stage in my life I enjoyed the drama and intensity of the delivery suite and the intimacy of the bond between the mother and the obstetrician.  After 15 years of practice some of the shine wore off of that new toy but I still enjoyed the relationships I have with my patients.  While in training I had gotten interested in incontinence-- possibly this had something to do with a faulty relationship with my mother. We may some day have evidence that urogynecologists are united in having had a traumatic potty training and a longing to revenge themselves on a controlling “uro-god”.  I prefer to think that it is sympathy for women with a terrible burden as well a fascination for a complex but potentially understandable problem.

 I joined the ICS and tried to decipher the esoteric studies on rat bladders and rabbit vaginas, in vain mostly.  I still understand little of that stuff.  There were no urogynecologists in my training program.  There were a few luminaries on the national scene but in our neck of the woods in Georgia, if someone leaked you did an MMK.  If the bladder fell out you did an anterior repair.  If that didn’t work the urologist did a sling and patient had to pee standing up from then on.  A gynecologist seen touching a cystoscope had better be on the oncology service or else he would be taken out back and matters would be explained to him in words of one syllable.

            Well, I got out of training and went into practice in a small town.  There was a circuit-riding urologist who loved to teach, even ignorant gynecologists.  I had been exposed to the rudiments of urodynamics with an old Browne CO2 outfit and I could do rustic studies with a catheter and some tubing.  So I did. There was a new (to me) operation in the journals then called a Stamey.  It was, as I understood it, for people who had failed in the standard Burch operation.  The urologist was kind enough to teach me and I had several rather temporary successes.  I was pretty sure that I was moving into the circles of the erudite and elite.  I was the only gynecologist in King’s Mountain actually doing Stamey operations.  Actually I was one of the only two gynecologists in Kings Mountain. I thought that I understood something about anatomy and I was hungry for more knowledge.  But I also found that the kids had developed a habit of eating regularly and that it was bad form to leave the mortgage unpaid for more than a short time.  A fellowship was out of the question. So I kept reading and going to courses, visiting the nearby residency programs as often as was possible. The laparoscope and hysteroscope were coming into use more and more in the early 80’s. I began trying to do more and more through the minimally invasive route and in this way met some of the shining lights in the move to modernize the specialty. I also discovered how little I understood about pelvic anatomy and that much of what I did know was really wrong.  I read Cullen Richardson, DeLancey, Nichols and the others, and I did my best to understand what the hell they were talking about.  This new information was so foreign to the dogma I had processed into my system of belief as a resident.  About this time it became obvious that my Stamey’s and Gittes’ were almost useless though I did have a few long-term successes.  I had moved to a larger city where there were more instruments available.  I didn’t have to use a cystoscope for hysteroscopy any more but the urologists were little friendlier and just as dogmatic. I persisted and pretty much confined my continence efforts to Burch procedures all the while studying and going to meetings and courses.  I took preceptoships with Liu and Dorsey and began to feel that I was getting somewhere in understanding the anatomy and the pathophysiology of incontinence.  I heard Robert Rogers speak on pelvic anatomy and was dazed for weeks.  I heard Grody explain why the anterior repairs I had been so faithfully trying to perform were mostly useless. I felt that I had been given a glimpse of heaven but was unworthy to enter, like Moses looking into the Promised Land.  I persevered I got a simple cystometrics outfit and learned to do Burch repairs laparoscopically.  I began doing Contigen implants and slings.  Having given up the practice of Obstetrics, I began actively seeking incontinence patients.  But I was continually nagged by the philosophical question, “am I really a urogynecologist.” In the 80’s and early 90’s it was a pointless question.  There were damn few urogynecologists and those that existed were not fellowship trained and they mostly inhabited the heavenly spheres of Universities and conferences.  I read their pronouncements in the journals but they weren’t real down to earth people to me. Well, that has changed now and the subspecialty is a real entity and I am afraid that it is leaving me behind just as I am trying to jump on board. I have been a member of the ICS for many years. I joined the SUFU and AUGS as soon as I learned about them but somehow I still feel an outsider.  With all the running I can do, I am still not sure I am even staying in the same place.  The identification of Urogynecology with the tertiary care centers has become almost complete and those of us who are self-taught and lack the basic science knowledge are very definitely not part of the mainstream. If the urogynecologist is one who has special interest in incontinence and pelvic floor repair, one who has developed capabilities beyond that of the standard gynecologist, then the Urogynecologist is the true sub specialist with basic science and a year of research as well as surgical skills honed at the knee of a master.   I am sure that this is mostly for the better but I am sad nonetheless.  I think of myself as an urogynecologist (if not Urogynecologist) but as the specialty becomes more organized I realize that my designation is all the more tenuous.  I am a good surgeon and a fair diagnostician.  My years of family medicine left me with an educated intuition and an ability to relate to patients. As a generalist, one develops an appreciation of the patient as a whole person that is difficult to learn in a restricted environment like a residency, a fellowship or even a specialized practice. This allows an empathy and an understanding of the patient’s situation and the effect that a disease process can have on a person’s life.   But I lack much of the basic science and the mentor’s influence that is so important.  I think I do a pretty good job of diagnosing most urogynecology problems and treating them.  I am unlikely to write many papers or to train many fellows. I will provide a better treatment in my community for incontinent women than most gynecologists, but I will always be a community doctor and not an academic. What is more, that is what I want to be. But what is going to happen to us when the ABMS codifies the requirements for urogynecology?  Those of us who lack the research opportunities and basic science qualifications are pretty sure to be left out. As far as certification, I feel that the years of working with people on their incontinence, of operating and trying to master the field will be for naught to some in the world.  I will never be an Urogynecologist.