What is the Role of the Gynecologist in Providing Preventive Services?
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Patients receive more preventive services from gynecologists than from general medical physicians.
Source: Lewis BG, et al. Preventive Services Use Among Women Seen by Gynecologists, General Medical Physicians, or Both. Obstet Gynecol. 2008;111:945.
The authors set out to determine the preventive services and counseling provided by gynecologists, general medical physicians, or both. Using the 2000 National Health Interview Survey, the study population included women aged 18-64 years of age (with regard to Pap smear, use of tobacco, and exercise/diet counseling) and women in the 50-64 age group (previous parameters plus breast examinations, mammograms, and colon cancer screening). Sixty-two percent of patients were seen by gynecologists, 15% by general medical physicians, and 23% by both. The rate of gender-specific services (Pap, mammography and breast examination) was 88-95% while gender-neutral services were only 23-53%. Patients seen by gynecologists only were significantly more likely to receive Pap smears, breast examination, mammography, and tobacco screening. Patients seen by both gynecologists and general medical physicians did not increase the likelihood that preventive services would be provided. The authors conclude that there remains a viable role for gynecologists in the provision of preventive services.
Commentary
Please! Don't read too much into what I'm about to say. Let me provide a disclaimer first. I am not trying to tell all OB/GYN physicians that they need to be primary care providers. Similarly, I'm not saying that general medical physicians, eg, general internists or family physicians, don't provide these services very well. What I am saying is the same message that I've tried to relate ever since the early 1990's when the "gynecologist-as-primary-care-physician" controversy started: you can control your own destiny.
No matter how you identify yourself professionally, you have the option to offer preventive health services to the women you serve. Whether you were trained as an obstetrician/gynecologist or as an internist or as a family physician, the importance of preventive health services cannot be disputed. Whether you offer some or all of the services mentioned in this study is a choice that you make, either through choice or merely through benign neglect. Once your choice is made, however, it does not mean you can't change your mind. Indeed, as many OB/GYN clinicians "mature" in their practice and they do less obstetrics, the gynecology portion of the practice increases to fill the availability in the office. As a result, how much preventive medicine they practice can potentially increase significantly.
The challenge for any of us (myself included), is how much to jump into the preventive services arena and/or primary care. What about hypertension or thyroid disease or dermatologic disorders? It is often argued that since we deal with these disorders during pregnancy, why wouldn't we logically deal with them when the woman isn't pregnant? Since the HPV vaccine is commonly on our radar screen, what about other vaccinations for at-risk populations such as for pneumonia or influenza?
My own practice serves as a microcosm for the world of choices we have. The physician who shares the same nursing station with me and my assistant adamantly contends that he is not a primary care provider and will not treat cold symptoms, headaches, etc. He routinely refers patients to their primary care provider. He was trained in an era where primary care was not an issue within the specialty. On the other hand, there are two young female providers in the practice who routinely treat primary care disorders as well as offer preventive services. They have finished residency within the past 3 years, an era in which this was part of their residency curriculum. Had they chosen (and they still may do so sometime in the future), they could have limited the scope of primary care they provide.
On the other hand, I know this will be read by many who were not trained in obstetrics and gynecology, but who serve as primary healthcare providers for many women. To you I say the following: Keep up the good work and consider how much you can provide in addition to what you are already doing. We all have a limited amount of time in the office, and we all have a finite amount of time we can spend on "keeping up" with what we're doing in our practice. Each of us can define our practice in whatever way we wish, acknowledging that there are downstream effects of the choices we make.
With medicine continuing to evolve, this article is a great opportunity for the reader to take a deep breath and consider what he/she is doing in practice. I think every now and then it behooves each of us to take stock of what we're doing and why we're doing it. As Yogi Berra said, "If you don't know where you're going, how do you know when you get there?" Is that question being asked of primary care, preventive medicine providers, or of specialists? I guess it depends.
The authors set out to determine the preventive services and counseling provided by gynecologists, general medical physicians, or both. Using the 2000 National Health Interview Survey, the study population included women aged 18-64 years of age (with regard to Pap smear, use of tobacco, and exercise/diet counseling) and women in the 50-64 age group (previous parameters plus breast examinations, mammograms, and colon cancer screening). Sixty-two percent of patients were seen by gynecologists, 15% by general medical physicians, and 23% by both.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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