Category: Association News
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Joint Statement: Collective Action Addressing Racism
Released: August 27, 2020American Association of Gynecologic Laparoscopists (AAGL), American College of Obstetricians and Gynecologists (ACOG) along with American Board of Obstetrics & Gynecology (ABOG), American College of Osteopathic Obstetricians and Gynecologists (ACOOG), American Gynecological and Obstetrical Society (AGOS), American Osteopathic Board of Obstetrics and Gynecology (AOBOG), American Society for Colposcopy and Cervical Pathology (ASCCP), American Society for Reproductive Medicine (ASRM), American Urogynecologic Society (AUGS), Association of Professors of Gynecology and Obstetrics (APGO), Council of University Chairs of Obstetrics and Gynecology (CUCOG), Council on Resident Education in Obstetrics and Gynecology (CREOG), Infectious Diseases Society for Obstetrics and Gynecology (IDSOG), National Medical Association (NMA), Society for Academic Specialists in General Obstetrics and Gynecology (SASGOG), Society for Maternal-Fetal Medicine (SMFM), Society for Reproductive Endocrinology and Infertility (SREI), Society of Family Planning (SFP), Society of Gynecologic Oncology (SGO), Society of Gynecologic Surgeons (SGS) – release a unified action plan addressing racism as outlined below.
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As our nation confronts systemic racism and consequences of persistent inequities and disparate outcomes in health care, our organizations—which include the leading professional organizations in the fields of obstetrics and gynecology—are committed to changing the culture of medicine, eliminating racism and racial inequities that lead to disparate health outcomes, and promoting equity in women’s health and health care. Our commitment to a better future requires an honest examination of the past and the present.
Recognizing that race is a social construct, not biologically based, is important to understanding that racism, not race, impacts health care, health, and health outcomes. Systemic and institutional racism are pervasive in our country and in our country’s health care institutions, including the fields of obstetrics and gynecology.
Many examples of foundational advances in the specialty of obstetrics and gynecology are rooted in racism and oppression. For example, the mid-1800s surgical experimentation of James Marion Sims leading to successful treatment of vesicovaginal fistula was performed on enslaved Black women, including three women, Betsey, Lucy, and Anarcha, who underwent repetitive gynecologic procedures without consent.
Additionally, among many injustices, women of color have been subject to sterilization and experimentation with high-dose hormonal contraception without consent.
It is beyond the scope of this document to describe all the injustices inextricably linked to the fields of obstetrics and gynecology or recognize all the contributions made both willingly and unwillingly by oppressed and marginalized persons. Our organizations commit to working with scholars, advocates, and activists with diverse expertise and experiences as part of an intentional, sustained, and team-based effort to more extensively acknowledge the wide range of injustices.
We recognize that history weighs upon on the present and the future. Racism in overt and covert forms persists in the delivery of health care. Black women are three times more likely to experience maternal mortality or severe maternal morbidity than white women. American Indian and Alaska Native women experience adverse maternal outcomes at a greater rate than white women. Black and Latinx populations experience higher rates of mortality from cervical cancer than white women. Unacceptable inequities in access to care and outcomes are not limited to these examples; inequities are found across our specialty including reproductive and gynecological health care. Differences in outcomes result from many factors, including racism and bias in access to and delivery of quality health care, and must be acknowledged and addressed.
Eliminating inequities in women’s health care requires transformational change. Our organizations are committed to making this change and pledge, individually and collectively, to undertake the following initial actions:
• Collaboration: Our organizations recognize that transformative work is being done within the profession and the broader public health community by committed advocates, activists, scholars, and leaders. We will collaboratively consult, support, and partner with those presently engaged and leading work to achieve racial justice, reproductive justice, and equity in women’s health care.
• Education: We are committed to active listening and education in obstetrics and gynecology and in the broader women’s health community about the profession’s history and role in the oppression and mistreatment of Black enslaved women, Black women, and other women of color in the name of scientific advancement. Drawing upon the expertise of scholars, advocates, and activists, curricula will be developed and available to medical and health professional students, residents, faculty, practicing obstetricians, gynecologists, and all health care professionals.
• Recognition: We are committed to officially designating February 28 and March 1, the dates that bridge Black History and Women’s History months, as days for formal acknowledgment of Betsey, Lucy, and Anarcha, the enslaved women operated on by Dr. J. Marion Sims, and other enslaved Black women who were subjected to abuse in the name of advancing science.
• Scholarship, research, publication, guidance: Racism continues to be prevalent in research, in its conduct as well as its scholarship and publication. We will promote the conduct of research, publications, presentations, and other types of programming that incorporate anti-racism and address systemic and institutional racism manifested through disparate outcomes. We will make intentional and concerted efforts to support research that ethically addresses the needs of Black and Indigenous populations and populations of color and to promote the work and scholarship of physicians, clinicians, and public health professionals of color. We are committed to a comprehensive review of scholarship, clinical documents, research, and publication guidelines produced or directed through our organizations to address racism, in particular ensuring that race is not treated as a biological factor.
• Inclusive Excellence: We will work to achieve greater diversity and inclusion in the leadership of our own organizations at all levels. We will adopt policies and procedures that facilitate these goals and create an equitable and inclusive organizational culture. Within the specialty of obstetrics and gynecology, we will support policies, procedures, and the development of professional cultures where people of color are supported and promoted.
• Caring for patients and communities: We will work to ensure that health care is free from racism and bias. We will recognize the impact that history, racism, and violence have on our patients and their communities. We will treat discrimination and racism as evidence-based risk factors for poor health outcomes and will teach and encourage clinicians to recognize this in caring for patients. We will lift up, support, and amplify the work that community-based organizations, advocates, and activists are doing to advance reproductive justice and equity in the delivery of health care.
• Policy and advocacy: We will collectively advocate for public policies that seek to eliminate racial and other inequities in the delivery of health care and in health outcomes, including policies addressing systemic and institutional inequities outside of health care that lead to poor health outcomes.
Our organizations recognize that these actions require sustained, intentional commitment. We also recognize that to embark on this work will require team-based approaches with measurable goals and accountability structures. We also recognize that while these initial actions are a starting point, more work will need to be done. Through active listening, discernment, and humility, we will—individually and collectively—expand upon these actions and objectives as we undertake a commitment to embrace antiracism, learn and unlearn, change the culture of medicine, and eliminate racism and racial bias in the delivery of women’s health care.
To download the PDF, click here.
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AAGL 2020 Global Congress Goes Virtual!
Released: June 30, 2020Dear Colleagues,
We are excited to announce “Breaking Barriers” the theme of AAGL 2020!
Given the COVID-19 pandemic, we surveyed our members on their concerns about the potential challenges of attending an in-person meeting. What we found is that many of you will face difficulties due to travel restrictions from your institutions, the uncertainty of a possible second wave of COVID-19 or the financial barriers that many physicians and practices are encountering as a result of the pandemic. AAGL prides itself as an organization that embraces new opportunities for educational exchange and given these concerns, we have elected to present an entirely virtual meeting this year.
Although we will miss seeing everyone in person, this new virtual format offers exciting and important benefits:
- All aspects of the meeting will be available for both live, real-time streaming, and recorded content for future review.
- We will offer more live surgeries than in the past and for the first time, gynecologic master surgeons will be able to deliver their presentations in their native language with the benefit of simultaneous live translation.
- Our industry partners will be available through a virtual exhibit hall where they will present their products, symposia, live activities and one-on-one meetings with our attendees.
The first AAGL congress was held in Las Vegas in 1972. At this ground-breaking, inaugural event, a small group of gynecologic surgeons came together to share their surgical experience with new and disruptive technology. Fast forward, 49 years, our membership hails from 110 countries and includes master surgeons from around the world! It seems fitting that a forward-facing organization that developed out of a need to embrace new technology, now has an opportunity to redefine gynecologic education. We are again breaking barriers to help you scale the peak of your surgical performance!
Please stay tuned as we provide details on the congress schedule, registration, and social events over the next few weeks.
We look forward to seeing you virtually, November 6-14, 2020 for this historical congress!
With kindest regards,
Ted T.M. Lee, MD
AAGL Vice-President and 2020 Scientific Program ChairJubilee Brown, MD
AAGL PresidentLinda Michels
AAGL Executive Director
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AAGL Announces Publication of Essentials in Minimally Invasive Gynecology (EMIG) Validation Trial
On Thursday, June 18, 2020, the AAGL (American Association of Gynecologic Laparoscopists), the premier organization in minimally invasive gynecologic surgery with membership of over 8,000 physicians worldwide, announced publication of study results from a nationwide trial of the AAGL’s Essentials in Minimally Invasive Gynecology (EMIG). The full manuscript entitled “Essentials in Minimally Invasive Gynecology (EMIG) Manual Skills Construct Validation Trial” by Dr. Malcolm G. Munro, et al. has been published with open access online in the June 2020 edition of Obstetrics & Gynecology (the Green Journal), the official publication of the American College of Obstetricians and Gynecologists.
The primary objective of the study was to establish or refute validity for the EMIG Manual Skills Construct by distinguishing novice residents in obstetrics and gynecology (PGY-1) from mid-training residents (PGY-3) during the first 100 days of their training year. Secondary aims included the ability to distinguish “proficient” (ABOG-certified without additional fellowship training) from “expert” practicing surgeons who had completed an accredited two-year fellowship in minimally invasive gynecologic surgery (FMIGS).
The validation of EMIG skills is the result of a collaboration by the AAGL, the American College of Obstetricians and Gynecologists (ACOG), and the Council on Resident Education in Obstetrics and Gynecology (CREOG) to develop a system for training in and evaluation of endoscopic surgical skills. EMIG is uniquely applicable to gynecologic trainees and is based upon rigorously applied psychometric principles.
Developed and funded by the AAGL, EMIG is comprised of a validated cognitive examination, an accompanying web-based didactic component that is accredited by the Accreditation Council for Continuing Medical Education (ACCME) for 10 AMA PRA Category 1 credits and a manual skills training and testing platform of hysteroscopic and laparoscopic exercises specific to gynecologic surgery.
Dr. Jubilee Brown, AAGL President, commented that the EMIG project is, “the culmination of over eight years of dedicated work and diligence on the part of so many skilled AAGL members, surgeons and educators.” She continued, “I am just one of a line of former AAGL Presidents who have supported this important work, and it is my honor and privilege to see it completed.” She also thanked ACOG Immediate Past President, Dr. Ted Anderson for his partnership in providing the ACOG Simulation Centers that were used in the skills validation trial. Dr. Anderson remarked: “In addition to basic laparoscopic skills, EMIG assesses cognitive and skills performance in hysteroscopy, which is unique to gynecologic surgery and absent in other surgical skills assessment platforms.” Dr. Brown also acknowledged Dr. Mark B. Woodland, immediate Past CREOG Chair for CREOG’s support throughout the development of this platform, who stated, “As surgical technology evolves, it is imperative to have formative evaluation processes and outcome measures for our gynecology surgeons in training. EMIG presents a validated pelvic simulation platform to assess a surgeon’s progress and technical competency and has the potential to set a new standard in the education of gynecologists.”
For open access of the full manuscript please visit: https://bit.ly/37SG9eV
About AAGL:
AAGL is a professional medical association of endoscopic surgeons and is the global leader in minimally invasive gynecologic surgery. AAGL’s mission is to elevate the quality and safety of health care for women through excellence in clinical practice, education, research, innovation, and advocacy. For more information visit https://www.aagl.org.
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AAGL Statement to the FDA on Power Morcellation
The following statement was authored by Dr. Jubilee Brown, a member of the AAGL Board of Trustees and summarizes the presentation she made on behalf of the AAGL to the Obstetrics and Gynecology Devices Panel of the FDA Medical Devices Advisory Committee on July 11, 2014. The statement was approved by the Board of Trustees.
The AAGL is a member medical organization comprised of over 7000 physicians and health care providers. We are committed to advancing the care of women worldwide through minimally invasive surgery. The AAGL convened a 12-member panel of experts in the field to review all available data related to uterine power morcellation, and it is on the basis of these and other newly available data that we base our statement.
Approximately 600,000 hysterectomies are performed each year in the United States. The percentage of these cases performed using minimally invasive surgery (MIS) has increased from approximately 30% in 2002 to about 63% in 2012. The benefits of MIS have been widely documented in retrospective and prospective studies, and include significant improvements in morbidity and mortality compared with open surgery. When compared with hysterectomy through laparotomy, MIS results in a decrease of blood loss, transfusion, pulmonary complications, infection, thromboembolic events, hospital stay, and postoperative pain with an improvement in quality of life, body image, and return to baseline function (Level I evidence).
Technology such as power morcellation has allowed hysterectomy through MIS to be performed in 50,000 – 150,000 patients annually. However, this technique has come under scrutiny because of the risk of exposing the peritoneal cavity to an undetected uterine malignancy during morcellation. The elimination of power morcellation would result in conversion to open procedures in many of these cases; the risks of power morcellation would have to exceed the benefits of MIS in order for that to be justified.
The precise risk of undetected uterine malignancy in a patient undergoing a planned hysterectomy with power morcellation is difficult to determine. Most undetected uterine malignancies are leiomyosarcomas, a rare but aggressive histologic subtype of uterine malignancy. Prevalence estimates are difficult to determine, as limited data exist, studies are small and retrospective, or of poor quality, and all data from which statistics are calculated are subject to publication bias. Estimates range from 1:360 to 1:74001,2. Thus, the risk of an undetected leiomyosarcoma is not zero, but is low. The AAGL cautions against eliminating a beneficial technology based on such scant and imprecise data.
The AAGL agrees that morcellation is generally contraindicated in the presence of documented or highly suspected malignancy. Meticulous adherence to preoperative screening guidelines, including endometrial biopsy and cervical cytology, to exclude coexisting uterine or cervical malignancy or premalignancy is imperative. Certain types of uterine cancers, such as leiomyosarcomas, are more difficult to detect preoperatively, though 38-68% of leiomyosarcomas can be detected in this manner. Magnetic resonance imaging may also be useful in determining which masses represent benign uterine fibroids and are safe for power morcellation. Appropriate triage of candidate patients may further improve the safety profile of MIS hysterectomy with power morcellation, but at this time there exists insufficient data to discontinue power morcellation in low risk, appropriately screened patients.
The data on the risk of upstaging, or worsening prognosis, of a leiomyosarcoma after power morcellation are limited. Nine reports are available that specifically document leiomyosarcoma morcellated through a variety of techniques. In total, 4/19 patients (21%) were upstaged if reoperation occurred within 30 days of original surgery, and 8/19 patients (42%) were upstaged if both early and late/unknown data were included. The delay from morcellation to upstaging, however, was up to 600 days, which confounds these data.3 Other reports have unusually robust outcomes in the non-morcellated group compared with the morcellated group, which may lead to a falsely worsened prognosis in the morcellated group yielding questionable results. The AAGL does not believe that such limited evidence warrants removal of the option of power morcellation.
Unfortunately, leiomyosarcoma is an aggressive malignancy, and outcomes are suboptimal whether morcellation is used or not. Even when removed intact, leiomyosarcoma has an aggressive course and a poor prognosis. Therefore, determining the degree to which power morcellation contributes to worsened outcomes for patients with leiomyosarcoma is difficult, and the available data do not warrant discontinuing power morcellation.
The key question is whether the proven benefits of MIS are outweighed by the low risk of disseminating a leiomyosarcoma through power morcellation. Preliminary evidence suggests that MIS may be safer and result in fewer deaths compared with the open approach, even when using prevalence estimates that are high. Using the available literature, a decision analysis model was constructed to examine the risk of leiomyosarcoma in the population who are candidates for power morcellation, and compare morbidity and mortality of abdominal hysterectomy compared to laparoscopic hysterectomy with power morcellation4. In order to evaluate the “worst case scenario,” the median prevalence of leiomyosarcoma was conservatively estimated at 1:585. This corresponds very closely with the rate of 1:498 quoted by the FDA. Also, the risk of local spread due to power morcellation was varied from 15 to 35%. Specifically, the mortality from open hysterectomy was 0.085%, while the mortality from laparoscopic hysterectomy with power morcellation was 0.077%. This yields a difference in favor of laparoscopic hysterectomy with power morcellation even when controlling for all perioperative factors and when estimating the prevalence at 1:585. Based on these assumptions, the model suggests that the combined mortality from leiomyosarcoma and the potential dissemination through power morcellation would be less than the mortality from open hysterectomy. Converting all hysterectomies currently undergoing power morcellation to open surgery would result in an annual increase of 17 more women dying from surgery each year, and a substantial increase in morbidity from open surgery4.
Power morcellation is an important tool in treating symptomatic uterine fibroids which allows up to 150,000 women each year to undergo minimally invasive surgery when they would otherwise require laparotomy for an abdominal hysterectomy. While research, education, and improved tissue extraction techniques can probably further enhance the safety profile of power morcellation, the elimination of power morcellation and conversion of these women to open surgery would likely increase morbidity and mortality from open surgery and cause harm to more patients. Our obligation is not only to patients with leiomyosarcoma, but to all of our patients. We must not sacrifice our patients in response to a rare event.
Thus, it is the AAGL’s position that we should improve but not abandon power morcellation, and that power morcellation with appropriate informed consent should remain available to appropriately screened, low risk women.
References
1 Wright JD, et al, Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation. JAMA, Epub online, July 22, 2014.
2 Pritts et al, presented at the Obstetrics and Gynecology Devices Panel of the FDA Medical Devices Advisory Committee, July 10, 2014.
3 Pritts et al, submitted to J Minim Invasive Gynecol.
4 Brown J, regarding data by Naumann RW et al (submitted), presented to the Obstetrics and Gynecology Devices Panel of the FDA Medical Devices Advisory Committee, July 11, 2014.
