State of the Specialty: 12 ObGyns describe critical challenges to their work
It’s no quiet time in the specialty. More and more chronically ill patients, falling reimbursement, a struggling economy, rapid evolution of guidelines, and other issues are devouring your time and attention. Twelve physicians tell OBG Management what they each think is the most pressing challenge facing the specialty. They offer solutions, too.
We are at the threshold of a new era in American medicine. Federal health legislation will catalyze changes that will reconfigure how we provide care to our patients. At such a critical juncture, we thought it was important to explore the professional and personal challenges of our colleagues, a few of which are offered here. The perspectives of our fellow ObGyns are illuminating and inspiring. They reflect the high quality of physicians in our field, and their deep commitment to providing the best care for their patients.
We are the few, the proud, the ObGyns!—Robert L. Barbieri, MD
CHALLENGE 1: Maintaining the privilege of private practice
Barbara S. Levy, MD
Dr. Levy practices gynecology in a solo private practice in Federal Way, Wash, where she also serves as Medical Director of the Women’s Health Center for Franciscan Health System. She serves on the OBG Management Board of Editors.
Of the many challenges ObGyns face today, the “monopolization” of medicine may be the most pervasive. In Federal Way, Washington, where I practice, the local hospital system has acquired many of the private primary care practices in town, including many of those that regularly recommended my practice to their patients. Once they become part of the hospital system, these practices are encouraged to refer patients to ObGyns in that system.
Many older physicians are throwing in the towel and selling their practices to the hospital system, and many younger physicians, just entering the workforce, would prefer not to have to run a business, and so they go to work for a hospital.
Although I still see a full slate of patients in my solo private practice, I have noticed that people aren’t booking appointments as far in advance as they used to, and the number of patients sent to me by other practitioners has declined. In response, I’ve beefed up my Web site for marketing purposes, and I do my best to keep it up to date and to ensure that it is well listed in the search engines. I also work with my patients to increase word-of-mouth recommendations, and I work with vendors of slings and other products I regularly utilize in my practice to encourage them to support public education symposia and materials that market my practice.
As patient volume declines, it obviously becomes more difficult for a gynecologist to maintain competence in surgical procedures. If this trend continues over the long term, I wonder whether GYN generalists are going to be able to maintain competence in every aspect of the job—or are subspecialists going to be the only ones who have enough experience to perform surgery safely and effectively? It would be a shame if general ObGyn care lost the surgical component.
Here’s to preservation of the private practice!
Dr. Levy reports no financial relationships relevant to this article.
CHALLENGE 2: Adhering to revised guidelines
Raksha Joshi, MD
Dr. Joshi is Chief Medical Officer and Medical Director of Monmouth Family Health Center in Long Branch, NJ. She serves on the OBG Management Virtual Board of Editors.
Physicians and patients have followed mammography and Pap testing guidelines comfortably for a number of years—that is, until the US Preventive Services Task Force (USPSTF) revamped mammography screening guidelines in November 2009. The USPSTF now recommends biennial mammography rather than annual screening for women 50 to 74 years old, no mammography for women younger than 50 years (unless it is indicated), and the elimination of self breast examination from the list of recommendations.1
Shortly after the USPSTF made its revisions, ACOG announced changes to Pap screening guidelines, moving the age for the first Pap test to 21 years (rather than 18 years or 3 years after sexual debut), followed by biennial screening. ACOG also recommended that women 30 years and older who have had three consecutive negative Pap tests switch to screening every 3 years.2
What I tell my patients
I continue to teach self breast examination and encourage women to “know their breasts.” Many of my patients have noticed changes that merited a workup and sometimes led to discovery of a malignancy—even before the age of 40.
I also make it a point to discuss the possible “harms” of screening mammography with my patients. So far, every one of them has been happy to undergo additional testing—including biopsy—for the reassurance of knowing that they do not have cancer.
My great fear? That insurers will use the USPSTF recommendations to deny screening mammography—even though, so far, they have asserted that they will not do so. Who among us has not seen at least one case of early—and, therefore, curable—breast cancer detected by an annual mammogram when the previous year’s test was perfectly normal?
Will women fall through the cracks?
The new Pap testing guidelines are easier to accept because we are learning more about HPV, the causative agent of cervical cancer. Nevertheless, I worry that many women will fall through the cracks as we extend the Pap testing interval to 2 and 3 years and that we will become static in the battle against this almost completely preventable cancer. And because the ObGyn is the only physician many women of reproductive age see with any regularity, screening for diabetes, hypertension, and other chronic conditions often falls to us. These conditions may all go undetected if the woman does not come to see us for a Pap test. Cancer of the cervix may not kill her, but a stroke or myocardial infarction certainly can!
Guidelines are just that—guidance. I am mindful of the new recommendations, but I tailor my advice to the risk profile of the individual and remain cognizant of the prevalence of diseases in the population I serve.
Dr. Joshi reports no financial relationships relevant to this article.
CHALLENGE 3: Responding to atypical glandular cells
Larry C. Kilgore, MD
Dr. Kilgore is Gynecologic Oncologist at the University of Tennessee Medical Center in Knoxville, Tenn. He serves on the OBG Management Board of Editors.
From my vantage point as a gynecologic oncologist, one of the most pressing issues facing gynecologists and primary care providers who screen patients for cervical cancer is ensuring proper management of women whose Pap smears reveal the presence of atypical glandular cells (AGC). In more than 30% of cases involving AGC, a serious condition is present. Although squamous cancer precursors are the most common finding, other possibilities include:
- adenocarcinoma in situ or adenocarcinoma of the cervix
- hyperplasia or adenocarcinoma of the endometrium
- adnexal malignancy, including ovarian and tubal carcinoma.
The general application of liquid-based Pap testing has not led to proper identification or adequate protection of women against glandular malignancy of the reproductive tract. At a time when the proportion and absolute number of patients who have glandular malignancy of the cervix are on the rise, the clinician is challenged to appreciate the gravity of these findings and follow management guidelines closely.
Regrettably, many practitioners do not adhere to the latest guidelines on AGC, last updated in 2006. According to these guidelines, the clinician is obligated to:
- perform colposcopy on each patient who has a test result classified as AGC
- obtain an endocervical curettage, regardless of the patient’s age
- test for HPV at the time of evaluation
- obtain an endometrial biopsy in women who are older than 35 years or who have unexplained uterine bleeding.
It is not appropriate to repeat the Pap test or otherwise delay thorough evaluation.
In addition to proper management, the gynecologist should educate other primary care health professionals who perform cervical cancer screening about the importance of following AGC guidelines. Proper respect for this important clinical issue is imperative.
Dr. Kilgore reports no financial relationships relevant to this article.
CHALLENGE 4: Meeting the specialty’s research needs
Anita L. Nelson, MD
Dr. Nelson is Professor of Obstetrics and Gynecology at Harbor–UCLA Medical Center in Torrance, Calif. She serves on the OBG Management Virtual Board of Editors.
Research in women’s health has grown tremendously since the late 1980s, when the Government Accountability Office (GAO) issued several reports revealing that women were being deliberately excluded from clinical trials. Despite a greater emphasis on women’s health since then, research is sorely needed in many areas.
Consider unwanted pregnancy as a disease that, every year, kills and mutilates millions of women worldwide and orphans untold numbers of children. We need new, inexpensive, reliable, convenient methods of birth control that are rapidly reversible and that do not require extensive training to implement. One option might be an intracervical contraceptive device. In addition, choices in injectable contraception should be expanded, and studies are needed to understand (and control) unscheduled spotting and bleeding.
Research is also necessary to find better ways to motivate couples to control fertility, and to plan and prepare for pregnancy. For women who have infertility, we need better, less expensive techniques that can be shared with low-resource regions.
Other areas ripe for research:
- Obstetrics. Given that preterm labor is one of the greatest challenges in the United States, it is amazing to realize that we do not yet understand what factors control the onset of labor. In addition, extended research on the pathophysiology of preeclampsia and eclampsia is needed to develop effective treatments and reduce the serious complications caused by these processes.
- Oncology. Ongoing efforts to identify new markers to detect gynecologic cancers at a very early stage need to be amplified. Simple interventions to prevent those cancers in high-risk women should also be studied. For example, obese postmenopausal women have a high risk of endometrial cancer; clinical trials of prophylactic progestin therapies are vital.
- Application of the Human Genome Project. The information that we glean about individual risk should be translated into targeted approaches to promote health and to tailor therapies to the individual patient.
Dr. Nelson reports that she receives grant or research support from Bayer HealthCare, Medicines 360, Pfizer, and Teva. She serves as a speaker for Bayer, Merck, Pfizer, and Teva, and as a consultant or advisor for Bayer, Pfizer, Ortho-McNeil, and Teva.
CHALLENGE 5: Providing targeted care to adolescents
Daniel M. Avery, MD
Dr. Avery is Associate Professor and Chair in the Department of Obstetrics and Gynecology at the University of Alabama School of Medicine in Tuscaloosa, Ala. He serves on the OBG Management Virtual Board of Editors.
Among the challenges of providing quality ObGyn care to adolescents are 1) preventing, identifying, and treating sexually transmitted infection (STI) and 2) screening for cervical cancer. The Centers for Disease Control and Prevention estimates that there are approximately 19 million new cases of STI each year in the United States—almost half of them in people 15 to 24 years old.3 Chlamydia and gonorrhea are the two most prevalent STIs.3 In my practice, where roughly 20% of my patients are adolescent, chlamydia is a major concern. I test patients annually for this STI.
As for Pap testing, what we tell adolescents next year may be different from what we tell them this year. Guidelines have changed regularly enough that ObGyns must make an effort to stay on the cutting edge. For example, late last year the recommended age for the initial Pap test moved to 21 years, regardless of the patient’s age at sexual debut.2
We have also learned to manage Pap tests less aggressively in adolescents. We perform fewer colposcopies, biopsies, and loop electrosurgical excision procedures (LEEP) than ever before because data indicate that many cervical changes spontaneously regress in these patients; moreover, unnecessary treatment can lead to incompetent, fibrotic, and scarred cervixes. The risk of invasive cervical cancer in women younger than 20 years is 1 in 40,000.
Nevertheless, our medical school referral practice has seen two women younger than 20 years who had invasive cervical cancer. One year after I vaccinated a 16-year-old virgin against HPV, she became sexually active and got pregnant. Her initial Pap test— during prenatal care—showed low-grade squamous intraepithelial lesions, and her postpartum Pap test was classified as atypical squamous cells of undetermined significance; a postpartum HPV test was negative for high-risk strains. This patient did not see me again for 1 year, at which time a repeat Pap smear showed atypical squamous cells with a high risk of neoplasia. Colposcopically directed biopsies were suspicious for invasive cervical cancer, which was confirmed by LEEP. The patient underwent a radical hysterectomy with pelvic and peri-aortic lymph node dissection when she was only 19 years old.