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By Kenneth L. Noller, MD
Several years ago, the special requirements for specialty training in obstetrics and gynecology were amended to increase exposure to preventive medicine and other primary care. Some pundits spoke out loudly against this change as it took time from other areas of training. The most cynical suggested that the reason behind the changes was purely financial (access to patients) and had nothing to do with providing high quality healthcare to women. Despite these opinions, the changes were enacted, and all residency programs in the United States now include such training. Nonetheless, naysayers still protest the changes and point to the fact that most states now have enacted legislation that preserves the access by women to their OB/GYNs. I believe that there is an important and different way to view the emphasis on primary care training in Obstetrics and Gynecology that is unemotional and pragmatic.
What will the practicing OB/GYN be doing 10 years from now? I think there is no doubt that the vast majority of the approximately 4 million deliveries which occur in the United States each year will continue to be attended by OB/GYNs. Although other specialties and some nonphysician practitioners have obstetrical practices, at the present time they account for only a small proportion of deliveries, and I see no reason to expect it to grow significantly in the next 10 years. In fact, I strongly suspect that the best way for an OB/GYN to maintain a busy practice is to continue to provide prenatal services throughout her/his career.
The practice of gynecology, in the past, was largely devoted to the evaluation of women with gynecologic problems. Indeed, the preventive care aspects of gynecology (annual visits) did not become a major reason for a woman to see a gynecologist in the United States until approximately 1960. The development of the oral form of contraception, as well as the widespread recognition of the usefulness of regular cytology screening, led to more and more annual visits. There were few medical solutions to common gynecologic problems and, thus, the practicing OB/GYN spent a considerable amount of time in the operating room.
As everyone knows who is actively practicing gynecology, fewer and fewer surgical procedures are now indicated, as many gynecologic abnormalities are amenable to medical therapy. In the future, it is likely that even more conditions will be treated with medications. Because gynecologic problems will continue to occur, practitioners can expect a steady stream of patients with gynecologic complaints in their offices. However, it is likely that less and less surgery will be performed by the general practitioner of obstetrics and gynecology.
Thus, in order to stay busy, the practicing OB/GYN will need to spend an ever-greater proportion of her/his time practicing preventive medicine. But we must be prepared to change our approach to the "annual visit." In the past the annual gynecologic visit was comprised of a gynecologic interim health history, and breast and pelvic examinations including a pap smear. Some offices even included routine hematology testing and urine analysis. I believe that this approach to preventive care will need to change dramatically if we wish to maintain our patient base.
What is wrong with the annual visit as described above? Let’s examine the four components: interval gynecologic history, breast examination, pelvic examination, and cervical cytology.
The interim gynecologic history should be negative for all women who are having a screening visit. Indeed, if it is otherwise the visit becomes "problem oriented." The screening gynecologic history takes only a few seconds to perform.
Many practitioners routinely perform breast examinations; the gynecologist has no particular advantage.
The pelvic examination has long been the backbone of the office practice of gynecology. Many other specialists refuse to perform these examinations. Unfortunately, the practice of screening pelvic examinations is coming into more and more dispute. Despite the fact that all of us perform these examinations day in and day out, there has never been a study which has shown any benefit to screening pelvic examinations (i.e., pelvic examination in a woman without a gynecologic complaint). I strongly suspect that there will be greater and greater pressure from third-party carriers to eliminate this as an annual procedure.
That leaves cervical cytology. Many other specialists perform this procedure. In addition, there has been recent emphasis in the medical literature on the lack of demonstrated need for annual cytology in women who are at low risk for the development of cervical neoplasia. The additional financial burden of the costs of some of the new pap smear technologies has led some payers to reexamine their payment for annual cytology. Several recent documents (and several that will be published in the near future) have emphasized the lack of support for cytology screening in women who have undergone hysterectomy for benign changes.
Therefore, overall, the gynecologist has no advantage over other specialists for routine annual screening visits. In my opinion, the way to overcome this problem is for us to incorporate a full range of preventive services in our annual visits. For example, an internist may tell her/his patient that, "There is no reason to see your gynecologist. I can perform all the procedures that would be done at that visit." We also should be prepared to tell our patients, "There is no reason for you to see an internist this year as I can provide all of the services you need." Of course, this requires that we become familiar with recommended screening procedures at all ages, vaccinations and other active preventive measures, and perform significant in-office counseling. We can use as our guide the excellent documents prepared by ACOG, those which are available from other specialties, and the U.S. Public Health Service guidelines.
The future of gynecology in the United States is not surgery, and it is not annual well-woman pelvic examinations. Rather, it is preventive care which starts at the top of the head and ends at the soles of the feet. Thus, the emphasis on primary care in our residency training programs is both appropriate and expedient.