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SASOG PRESIDENT'S NEWLETTER
OCTOBER 2009

Dear Colleagues,

During the last six months since my previous newsletter to you in March of this year, SASOG's affairs have been directed by a number of executive committee meetings and a full Council meeting in Johannesburg in September. Amongst several other initiatives, discussed below, much time and energy has been expended on the organization and implementation of the very successful XIX FIGO World Congress held in Cape Town from the 4th – 9th October, 2009.

FIGO XIX World Congress Cape Town

At a SASOG Council meeting held on October 4, 2003, (under the Presidency of Prof. Gerhard Lindeque) a decision was taken that SASOG should bid for the 2009 XIX FIGO World Congress to be held in Cape Town. This was duly done under the direction of Prof Lindeque at the XVII FIGO congress in Chile in November 2003 where our submission was of course successful.

Prof. Gerhard Lindeque

A Local Organizing Committee (LOC) was formed by SASOG under the Chairmanship of
Professor Gerhard Lindeque and included the following members:

Prof Franco Guidozzi (President of SASOG 2006- 2008), A B Koller (President SASOG October 2008- date), Drs, Paul Dalmeyer, Peter de Jongh, Toby de Villiers, Silke Dyer, Thinus Kruger, Christo La Grange, Ernst Rosemann, Gerard Theron and

Prof. Zephne van der Spuy. Since 2003 extensive ongoing strategic and operational planning has continued unabated, but particularly intensively during the 10 months This Committee worked in close cooperation with the International FIGO Organizing Committee working out of London

The LOC (which was tasked primarily with the organization of the extensive and subsequently very successful social programme), worked closely and met frequently in Cape Town with the South African conference organizers – Turner's Conferences – under Dudley Randall. We also met on a number of occasions with the main FIGO organizing committee from London under the chairmanship of Ralph Hale and co-chairmanship of Sir Sabaratnan Arulkunaran. I am pleased to report that a very successful congress ensued,- over 8000 delegates from more than 120 countries attended with South Africa flying the SASOG flag highly and proudly.

Apart from the extraordinarily extensive scientific and social programmes a number of official FIGO meetings,(and other non FIGO meetings- vide infra), were held and attended by the SASOG executive members (The President, the Hon Secretary Dr. Morgan Pillay and the Hon Treasure Dr. Ron White and at times other SASOG council members).

SASOG Hon Secretary Dr. Morgan Pillay SASOG Hon Treasure Dr. Ron White

Some of the key FOGO meetings held during the congress included The FIGO General Assembly (held every three years) and two meetings of the FIGO executive Board ( of which SASOG is a proud member) Several noteworthy decisions were taken at these meetings:-

In future the FIGO World Congresses will continue to be held every three years rather than every two, a proposal which was defeated in a vote by the general assembly.
The next (2012) World Congress will be held in Rome.
The 2015 Congress in Vancouver.

Prof. Dorothy Shaws' term of office ended during the congress and Professor Gamal Serour of Egypt duly took over the reins as President of FIGO for the next 3 years.
Professor Sir Sabaratnan Arulkunaran was elected as President Elect.
Professor Ian Fraser was re- elected as Secretary
SASOG was re- elected, in a vote by all members at the General Assembly, to the FIGO Executive Board.

A number of valuable guidelines and documents endorsed at these meetings are available on the FIGO website which is easily accessed via a link from the SASOG website, these include:-

"THE FIGO GLOBAL GUIDANCE FOR CERVICAL CANCER PREVENTION CONTROL", an extremely thorough document over 70 pages in length, dealing with all aspects of Cervical Carcinoma prevention and treatment.

FIGO GUIDELINES FOR THE MANAGEMENT OF PATIENTS SUBJECTED TO SEXUAL VIOLENCE.

THE TREATMENT OF OBSTETRICAL FISTULAE. (An ongoing initiative under the supervision of The Lord Naran Patel).

An indispensable position statement entitled "PROFESSIONAL STANDARDS: INTERACTION BETWEEN OBSTETRICIANS AND GYNAECOLOGISTS AND OTHER HEALTH PROFESSIONALS" published by FIGO in July 2009. This statement is included in full at the end of this newsletter, and I believe it should be perused by all SASOG members.

THE INTERNATIONAL FEDERATION OBSTETRICIANS & GYNAECOLOGISTS-
HONOURS PROF. ZEPHNE VAN DER SPUY.

Prof. Zephne M van der Spuy, who is the Academic Head of Obstetrics & Gynaecology at the University of Cape Tow's Medical School, is an esteemed and revered long standing SASOG Councilor, a past Chairman of the South African Representative Committee of the Royal College of Obstetricians & Gynaecologists and the immediate past President of the Colleges of Medicine of South Africa. She has altruistically devoted a life time of commitment, energy and effort to the health and well being of women not only in South Africa but also internationally.

As such, and I think entirely appropriately, I am delighted to report, that:
FIGO took a decision at a General Assembly during the 2009 World Congress to honour Professor Zephne van der Spuy with a "SPECIAL AWARD" in recognition of her "EXCEPTIONAL CONTRIBUTION TO THE IMPROVEMENT OF WOMEN'S HEALTH".

Congratulations Professor van der Spuy! SASOG, and indeed South Africa, are proud of you.

THE SASOG STAND IN THE EXHIBITION HALL.

Considerable interest was shown by numerous overseas delegates in the SASOG STAND in the congress exhibition hall. Several delegates signed up for SASOG membership and indicated interest in the coming the SASOG 2010 conference to be held in October next year under the patronage of the University of Pretoria. This stand was exceptionally well put together, (at short notice), and conscientiously manned by Londocor who are also to be the congress organizers for the SASOG 2010 congress. Sincere thanks to Sonja Du Plessis and her team.

THANKS TO ALL SASOG MEMBERS.

I would like to thank all SASOG members who supported The FIGO World Congress, whether by self-sacrificing time given to many organizational committee meetings, presenting at the various scientific sessions, chairing sessions or assisting with the social programme. This type of magnanimous service by members is what makes SASOG a wonderful society.

ESSENTIAL STEPS IN THE MANAGEMENT OF OBSTETRIC EMERGENCIES (ESMOE)

As outlined by the ESMO Group, (in the article by K Frank, H Lombaard and R C Pattinson) , it is clear, from the Fourth Report on Confidential Enquires into Maternal Deaths in South Africa in 2007 and the Saving Babies reports 2006-2007* (ref below), that:

Poor management of Obstetric emergencies is a major contributor to Maternal and Perinatal deaths.
An increasing number of Maternal and Perinatal deaths are occurring in Level 1 and 2 hospitals.
These hospitals are predominantly staffed by (usually junior) community service doctors.
The need for improved training of these colleagues is an urgent obligation.

In response to this crisis a team was created comprising representatives from all South African O & G Academic Departments supported by the MRC Maternal and Infant Health Care Strategies Research Unit, the International Office of the Royal College of Obstetricians & Gynaecologists, the World Health Organization, the South African Society of Obstetricians & Gynaecologists – (our representative on the ESMOE advisory board being Professor Franco Guidozzi,) the South African College of Obstetricians & Gynaecologists, the South African Representative Committee of the Royal College of Obstetricians & Gynaecologists, the National Department of Health and the National Committee for the Confidential Inquiries into Maternal Deaths.

This team has methodically developed, for South African conditions, a training package adapted from a 2007 RCOG "LIFE SAVING SKILLS PROGRAMME" aimed at improving emergency obstetrics care in developing countries. Permission for adapting their programme was of course obtained from the RCOG. Thus ESMOE was conceived and born and is being "brought up" by The ESMO Group & ESMO Board under the able chairmanship of Prof. Jack Moodley and members R C Pattinson, S. Velaphi, M Adhikari, F Guidozzi, P Macdonald, E Buchman, A Farina, EJ Langenegger, K du Plessis, S Fawcus, C Maise, M Kusumbi, K Frank, TJ Mashamba and Mrs. D Nyasulu and Mrs. S Majeke.
.
ESMOE's aim is to effectively train interns, community service medical officers, midwives and appropriate nurses in emergency obstetrical care by the development of a course which is regularly repeatable and can be used throughout South Africa, on site and by relevant appropriate instructors. Obviously this all requires considerable finance and I must, once again, in this regard thank Professor Franco Guidozzi for his untiring efforts in obtaining financial support for ESMOE mainly via an extremely generous, substantial grant ,which we thankfully acknowledge, from Discovery Health.

ESMOE is clearly a vitally important initiative in South Africa at this time, and in accordance with our vision to "PURSUE EXCELLENCE IN THE DELIVERY OF HEALTH CARE TO SOUTH AFRICAN WOMEN THROUGHOUT THEIR LIVES", SASOG is proud to be associated with ESMOE, to salute its members and to pledge our support .

ESMO Board Chairman Prof. Jack Moodley

Refs.
1. SAJOG 2009;15,3:94-99)
2. Saving Mothers 2005-2007. Fourth report on Confidential Enquires into Maternal Deaths in South Africa. - Expanded Executive Summery Pretoria Government Printer
3. Pattinson RC, Velaphi S.Hardy and Steyn DWS, Overview In: Saving Babies2006-2007 Sixth Perinatal Care Survey of South Africa Pretoria Tshepesa Press 2009 1-65.

SASOG/RCOG CO-OPERATION

One of the primary objectives of SASOG, as enshrined in our constitution, is to work in close co-operation with inter alia The Royal College of Obstetricians & Gynaecologists. In accordance with this, the Chairman of the South African Representative Committee of the Royal College (currently Dr. Peter De Jongh) is a co-opted member of the SASOG council. I believe that this is extremely important in order to perpetuate the existing and ongoing close relationship between the Royal College in London and SASOG.

Indeed, in the spirit of this close association, the President of the Royal College, Professor Sir Sabaratnan Arulkunaran, arranged for a tripartite meeting, during the FIGO congress, between the Executive of SASOG, the Chairman and Secretary of the South African Representative Committee of the Royal College and the RCOG represented by a number of very senior officers, including the President himself, the Senior Vice President Mr. Tony Falconer FRCOG the Honorary Treasurer Mr. Julian Wolfson OBE,LLM,FRCOG, the Honorary Secretary Mr. R Warren FRCOG and Professor Lesley Regan FRCOG.

The fact that the number of members and fellows of the Royal College in South Africa is dwindling at an alarming rate was acknowledged by all, and possible strategies to continue the close ties between SASOG and the Royal College were discussed at an extremely amicable and fruitful meeting. SASOG acknowledge and thanked the Royal College for their support of ESMOE and discussed various initiatives to maintain the close ties between SASOG and the RCOG.

This meeting was followed up with a meeting between the SASOG Executive and the Royal College Honorary Treasurer, Mr. Julian Wolfson, with a view to possibly making parts of the RCOG website (particularly electronic access to their library including Journals) available to non-RCOG members of SASOG. There are ongoing negotiations between SASOG Executive and the RCOG in this regard and we will keep you informed.

SASOG gratefully acknowledges the sterling work done by Dr. Peter de Jongh – Chairman of the South African Representative Committee of the Royal College, and his honorary secretary, Dr. Phillip Zinn, in their ongoing support of SASOG, and in particular of SASOG's endeavors during the FIGO World Congress.

SWINE FLU

A number of SASOG members approached me with regard to SASOG preparing guidelines for the management of pregnant patients with Swine flu, and I am pleased to report that Professor Franco Guidozzi rose to the challenge and produced a excellent set of guidelines for the management of pregnant patients with Swine flu, which are to be found on the SASOG website.

A GYNAE MANAGEMENT GROUP/
THE SOUTH AFRICAN PRIVATE PRACTICE FORUM

These two bodies led by Dr. Fred Hayward and Dr. Chris Archer ably assisted by Health man under Mr. Casper Venter, have tirelessly continued their work regarding the effects of the still unpublished 2009 national reference pricelist on the proposed National Health Insurance. The ongoing battle between the GMG and the SAPPF and the Department of Health, will shortly be coming to a head in the High Court, when it is hoped that the Department of Health will be ordered to finalize the matter of the 2009 NRPL. SASOG has, of course, contributed to the not insignificant legal costs involved in this action. Apropos of this expenditure by SASOG, a lawyer from Webber Wentzel, the attorneys handling the court action for the GMG & SAPPF, attended the last SASOG council meeting and explained to the council the status of the case, the extensive amount of work that has gone into the preparation of the case, and the frustrations associated with the intransigence of the Department of Health in this matter.

The outcome of this court action is, of course, of extreme importance to all specialists in the country, not just those in private practice, as it will materially affect all of our incomes in the future.

SASOG is therefore extremely grateful to GMG and SAPPF under the able leadership of the above-mentioned colleagues who are expending extensive time and energy on this ongoing battle.

MILLENNIUM DEVELOPMENT GOALS / SASOG/ MINISTRY OF HEALTH

South Africa is, as you may know, a signatory to the United Nations Millennium Development Goals (MDG's), a number of which relate to health matters and, in particular, mother and child health. In response to this, SASOG has detected an particularly welcome "wind of change" in the Ministry of Health and in particular the new Minister of Health, Dr. Aaron Motsoaledi, who has an truly affable and energetic demeanor and appears to be particularly accessible and open to opinions and advice from senior health professionals in the country.

Indeed, through the good offices of Professor Gerhard Lindeque, SASOG secured a meeting in Cape Town recently with the Minister of Health and a senior member from the Department of Health. SASOG was represented by the President, the Honorary Secretary – Dr. Morgan Pillay, the Honorary Treasurer – Dr. Ron White, Professor Lindeque and Professor Bob Pattinson.

A frank, open and amicable discussion ensued in which Professor Bob Pattinson very clearly presented the statistics associated with maternal and neonatal death in South Africa, and in particularly the massive impact of HIV aids on these statistics, the Minister paid intense attention as he informed us that both he and President Zuma shortly have to report back to the United Nations on South Africa's progress in achieving the MDG's.

The question of making antiretroviral available to all pregnant patients irrespective of CD4 levels was discussed, while the need is recognized this becomes a predominately economic decision.

The awfully poor conditions of service under which many public service doctors are compelled to work was brought up and the Minister acknowledged that this problem was largely associated with poor hospital management which he assured us was being addressed.

The question of private public initiatives in which private practitioners would be brought back into the fold to do part-time sessional work at hospitals was brought to the Minister's attention, and he suggested that SASOG makes a proposal regarding public/private co-operation which he would give personal attention to. Council will be addressing this shortly.

This meeting was seen by SASOG as an particularly encouraging turn of events, especially when compared with the dark days of the previous minister's administration where very little contact, if any, between senior members of the medical profession and the Ministry of Health took place.

RESEARCH EDUCATION AND TRAINING

SASOG's Research Education and Training sub-committee, under the Chairmanship of Professor Leon Snyman together with Professor Hennie Cronje and Dr. Ron White as members, has been active in organizing CPD lectures throughout the country with the assistance of the very generous Wyeth Laboratory educational grant to. Lectures have been held in the Pretoria area, Johannesburg, Northern Natal and the Eastern and Western Cape as a result of this initiative, and I thank Professor Snyman and his committee for their hard work in organizing these meetings.

COST CUTTING OF LABORATORY INVESTIGATIONS

Dr. Ron White, the SASOG Honorary Treasurer, in consultation with Discovery Health has indicated that the ordering of "group investigations" is often done without the knowledge of the costs involved by the practitioner concerned. For example, a haemoglobin and white cell estimation would cost significantly less than a full blood count, or a potassium and creatinine estimation far less than a urea, creatinine and electrolytes. Without in any way restricting the doctors' choices, Discovery has suggested producing a document which illustrates the costs of various laboratory investigations, so that the ordering doctor can give thought to this aspect when ordering investigations.

SASOG CONSTITUTION REFORM COMMITTEE

This committee comprising Dr. Alan Alperstein and the Honorary Secretary, Dr. Morgan Pillay, has been considering a number of possible changes to the SASOG constitution. Specifically the question of a succession plan for office bearers is receiving attention.

The SASOG council takes note of the "STATEMENT ON SURGERY FOR PELVIC ORGAN PROLAPSE" penned by Professor Hennie Cronje on behalf of the gynaecologists on the South African Urogynaecology Association Council and which is displayed on this web site.

As documented in the statement, SASOG concurs with the suggestion that gynaecologists should be involved with anterior, middle and posterior prolapse, whereas urologists should confine themselves to the former and surgeons to the latter. SASOG recognizes with thanks the commitment by Professor Cronje and members of the South African Urogynaecology Association for their commitment to the management of all women with pelvic organ prolapse.

SASOG is extremely grateful to Prof Cronje and SAUGA for their efforts to convince Discovery health and possibly other medical aids to accept additional treatment codes for new uro-gynaecological procedures treatment codes. This initiative has SASOG's support.

FIGO POSITION STATEMENT ON PROFESSIONAL STANDARDS: INTERACTIONS BETWEEN OBSTETRICIANS AND GYNECOLOGISTS AND OTHER HEALTH PROFESSIONALS. JULY 2009

Statement of Principle:
The obstetrician and gynecologist should not only maintain clinical competence, but should also work collaboratively with other health professionals to reduce medical error, increase patients' safety, minimize overuse of healthcare resources, and optimize the outcomes of care.

The obstetrician and gynecologist should:

Ensure that interactions with other health professionals are always respectful and considerate and recognize the skill sets of the other health professionals.

Communicate truthfully and sensitively with all other health professionals with whom he/she interacts.

Not discriminate when interacting with other health professionals on the grounds of age, race, color, ancestry, place of origin, political belief, religion, marital status, physical or mental disability, sex, sexual orientation or unrelated criminal convictions.

Respect the personal boundaries of others including, but not limited to, refraining from making unwanted physical or emotional approaches, protecting personal information, and respecting individual workspace.

Treat patients and families with respect and dignity in all discussions with other members of the healthcare team.

Not criticize any other health professional in an untruthful, misleading or deceptive manner to patients or other health professionals or the general public.

Appropriately acknowledge contributions made by other health professionals to research projects and to other publications.

Communicate and cooperate with other health professionals to the full extent necessary to serve the best interests of the patient.

Maintain an open and professional relationship with other health professionals by: (1) clear communication, with due regard to privacy and confidentiality; and (2) cooperation, collaboration, and teamwork (to reduce medical error, increase patients' safety, minimize overuse of resources and optimize the outcomes of care).

Not engage in exploitative relationships with other health professionals for emotional, financial, research, educational or sexual purpose.

Provide ethical and professional support to other health professionals.

Report professional misconduct and insufficiently-skilled practice to the appropriate authorities, respecting the need to avoid unjustly discrediting the reputation of other health professionals. The doctor should also facilitate professional help and care for the other health professional if it is indicated.

Act with scrupulous fairness when required to act as an expert commenting on the professional practice and behavior of another health professional.

Advocate for the rights and security of each health professional to practice their profession within the law and with protection from interference or intimidation from any source.

Not compel another health professional to act contrary to their moral conviction or religious belief, except as required by law and as delineated in FIGO's position on conscientious objection.

Promote professional behavior and help to resolve disputes between health professionals.

With specific reference to the trainer/trainee–teacher/student relationship:

The obstetrician and gynecologist should:

Model professional behavior for trainees.

Teach the concepts of professional behavior, ethical research,
and practice.

Provide trainees with challenges to learn, without abuse,
harassment or humiliation.

Not engage in sexual or romantic relations with those being
taught or supervised.

Provide teaching, supervision, and training while respecting
personal boundaries.

Allow the expression of disagreement without the fear of
punishment, reprisals or retribution.

Provide clear guidelines to trainees and others regarding
assignments, examinations, and test environments.

Provide objective, timely, fair, and constructive evaluations of
trainees.
Ensure that the research and clinical teaching environment
experiences are appropriate for the needs of the trainee.

Clearly outline for students and trainees the appropriate levels
of clinical responsibility.

Allow trainees to decline to perform procedures which they
feel are outside their area of competence or inconsistent with their personal beliefs.

References

Discussion
This statement represents the position of FIGO on standards of behavior and communication for the obstetrician and gynecologist in his/her relationships with all other health professionals, whether medical or otherwise.

To serve our patients and our communities we must behave ethically and professionally, not only toward our patients, but also toward all of the other health professionals with whom we work. Such behavior cannot be assumed; more than ever, relationships with other health professionals are being challenged and are proving more challenging.

Professional groups closely allied to obstetrics and gynecology include midwifery and nursing. Role evolution within these professions and the substitution of roles traditionally undertaken by doctors is inevitably creating tensions between the groups concerned. In addition, the promulgation by many schools of midwifery of the "wellness" model in contrast to medicine's "sickness" model, is creating further challenges at all levels of professional interface. The doctor's relationships with all those involved in health management can also be trying, particularly when one considers the tempo of change in models of healthcare delivery, the alteration in traditional decision-making hierarchies, and the new paradigms being applied to allocation of leadership in healthcare delivery. Challenges by external bodies to the medical profession's construct of self-regulation, including by some government agencies and quality and safety monitors, bring their own pressures to bear on relationships between professional groups.

The doctor's relationship with students, trainees, and with more junior medical professionals has always carried specific dimensions and difficulties, but in recent times further potential stressors have emerged. Included here are changes over time in the demographics of these groups, such as in the age range and gender mix. Undoubtedly too, the introduction of "safe hours" legislation in many jurisdictions is placing pressure on relationships between senior and more junior doctors. There are increasing demands on specialists to not only teach/tutor but to be a "complete" teacher/tutor—a challenge that some doctors can and do find harrowing.

The trend in many countries to increasing specialization and subspecialization within obstetrics and gynecology is placing strains on relationships between doctors. Clear and logical boundaries, within which doctors with varying scopes of practice can base their interactions, are not always evident. Handover of patients and subsequent handback of patients can and does create issues in everyday working situations. The subspecialist/generalist interface can also raise perceptions of status inequalities that can result in tensions, particularly if income streams are affected.

It can be argued that matters of standards of behavior and communication simply form one part of the doctor's broader "Code of Ethical Practice" and that there is much already stated and written to guide the doctor in these areas. Equally, much has been written with regard to professionalism, its relationship to ethical practice, and its place in shaping and influencing the doctor's standards and behaviors. The underpinning of professionalism by humanism is also well described as a key enabler of true professionalism. Current guidance available to the obstetrician and gynecologist includes:

FIGO's document, "Ethical Issues in Obstetrics and Gynecology" by the FIGO Committee for the Study of Ethical aspects of Human Reproduction and Women's Health." Included within this document (page 26) is a statement alluding to "Professional Obligations to fellow Obstetricians Gynecologists."

Many of FIGO's member societies have their own codes of Ethics and/or Ethical Practice, some of which are based heavily on FIGO documents. In addition, member societies frequently have curriculum documents that may make reference to these matters.

Positions and statements of national licensing authorities and representative associations, including Medical Councils and Boards.

Professional charters and codes of Universities, Schools of Medicine, and faculties.

However, even within these resources there is a relative paucity of consolidated, clearly articulated, and readily accessible information relevant to a doctor's conduct and practice when interfacing with other health professionals. In presenting this statement, FIGO, as the lead body in the specialty, aims to guide the obstetrician and gynecologist in these matters and to shape practice across all of its member societies.

THE PAUCITY OF FEMALE REPRESENTATION ON THE SASOG COUNCIL.

I am personally most concerned about the paucity of female representation on the SASOG council. I am saddened by the seeming disinterest of female SASOG members to serve on the council, and in light of the fact that more and more female doctors are qualifying as specialist obstetricians and gynaecologists, I would like to challenge my valued lady colleagues to stand for election to the SASOG council and thereby contribute to SASOG's mission of "DELIVERING THE BEST POSSIBLE STANDARD OF CARE AND PROMOTING THE HEALTH AND WELLBEING OF ALL WOMEN IN SOUTH AFRICA."

I trust that you found the FIGO position statement on Professional Standards useful and thought provoking, and I hope that the rest of this year remains productive and enjoyable for all SASOG members.

With my best wishes.

TONY KOLLER

PROF. A.B. KOLLER
PRESIDENT SASOG

Last Updated: 13 Nov 2009

THE INTERNATIONAL FEDERATION OBSTETRICIANS & GYNAECOLOGISTS- HONOURS PROF. ZEPHNE VAN DER SPUY.

SWINE FLU

THE INTERNATIONAL FEDERATION OBSTETRICIANS & GYNAECOLOGISTS-
HONOURS PROF. ZEPHNE VAN DER SPUY.