Posted by: notdeaddinosaur | March 20, 2013

OBGs are Not Primaries

You may have heard of the “Dean’s Lie“, the artificial padding of numbers allowing medical schools to claim ever-increasing percentages of their graduates are going into Primary Care medicine. This is accomplished by counting everyone going into Internal Medicine, Pediatrics, and Med-Peds, in addition to Family Medicine as “Primary Care.” It makes their schools sound more attractive by seeming more progressive, but it does nothing to enhance the supply of actual physicians who take care of undifferentiated patients at their entry into the medical care system, because as it turns out, significant percentages (90% or higher for IM, 60-70% for Pediatrics) end up specializing and subspecializing after their initial postgraduate training. But I see another problem: Obstetrician/Gynecologists, who are typically thought of as providing primary care to women.

OBGs are not primaries.

Obstetrician/gynecologists are surgeons. Surgery is hard. It takes a long time to learn to do it well. There’s a reason why General Surgery residencies are five years long. OBG’s get four. Their training curriculum is all surgical. Oh, they have their clinics, but by training and temperament, they are surgeons through and through. The only time I ever had my knuckles literally rapped was in a c-section, when I commented that the resident was doing something “just like a surgeon.” He whacked my hand with a clamp (it hurt!) as he retorted, “We ARE surgeons.”

Over time, many OBGs become competent at outpatient medicine. Still, their knowledge base and skill set are limited to the female reproductive system. News flash: there’s more to women than lady parts.

Primary care for women is more than just pap tests and mammograms. Sure, the OBGs check blood pressures and order studies. But they don’t diagnose or treat hypertension, hyperlipidemia, thyroid disease, or diabetes. Many of them think they’re diagnosing osteoporosis when they order DEXA scans. Then they write for bisphosphonates and order the DEXA every year or two (the test should not be repeated for at least 3-5 years, and the drugs don’t do anything more after 5-7 years) and pat themselves on the back for providing such “comprehensive” care.

Women also get sick and hurt in ways that have nothing to do with their reproductive systems. OBGs have no clue how to deal with these kinds of conditions, even in pregnant patients. Swimmers ear is not treated with amoxicillin. Coagulopathy workups are not the first thing to order for slight bleeding of the gums. And ordering blood work for diabetes is not particularly useful for corns on toes. Real primary care physicians take care of problems like these, as well as many others — the figure quoted is 90% or more of what walks in the door.

Family docs who do office gynecology (like me!) are the right way to do real primary care for women. I’m happy to refer when my patients need procedures beyond my training (colposcopy, biopsy, and obstetric care, although many of my Family Medicine colleagues provide these services), just like other specialists. But when they don’t need surgery or gynecologic specialty care, I diagnose and manage their blood pressure, diabetes, asthma, allergies, and tend to all the rest of their general medical needs. I can also diagnose and (appropriately) treat acute conditions for them; their pneumonias and ear infections and sprained ankles. I can even keep them healthy by offering age appropriate immunizations, diet, exercise, and lifestyle advice for which I have been specifically trained.

I can’t perform a c-section or a hysterectomy, and I appreciate the knowledge and skills of my OBG colleagues who do. But they are not Primary Care physicians. I understand the ramifications of the primary care shortage in this country, but roping surgeons with specialized expertise into serving as “Primaries for Women” does them — and women — a disservice.

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Responses

  1. DIno –

    I think most Ob-Gyns would completely agree with you. I much prefer it if my patient has a primary and is not just seeing me. But the reality is that many of our patients – for whatever reason, and usually the younger ones – do not have a primary doc, and call and come to us with all sorts of non-surgical issues. So I end up do a fair amount of screening that I would prefer to hoist off onto the primary, and treat a fair number of non-gyn conditions that interface with my specialty – menstrual migraine, mood disorders, osteoporosis. I also admit to peering into a throat or ear once in awhile for an acute problem (While I’m here, doc…) and have diagnosed a fair number of non gynecologic conditions over the years.

    I also know very very few primary care docs who do pelvic exams, and truth be told, a significant percentage of them don’t do breast exams, knowing that the patients are seeing me. Many of the primary care docs I know tell me that managing the diabetes and the hypertension and the rest take up all the visit time – adding in the time to do a pelvic is just not tenable for them.

    So I think in the end, we each do our piece, and our patients get the care they need. Call it Primary care, call it non-surgical care, we do it.

    Always enjoy your posts.

    Peggy

  2. Including pediatrics in the term “primary care” allows the Deans to be even bigger liars. Pediatrics after all is a limited specialty, limited by age. Family medicine is the only specialty which can claim to be “primary care” because it is not limited by age or gender.

  3. @Peggy:

    If your patient said, “By the way, while I’m here, Doc, my car has been making funny noises lately,” would you feel justified in going ahead and trying to diagnose something completely out of your field of expertise* (assuming you knew nothing about cars, of course), or would you say (politely), “How the hell should I know. Go see [someone who knows.]” By going ahead and looking in that ear or throat or listening to that chest, you are giving the impression that you know what you’re doing. I had a patient whose ear infection didn’t respond to her gynecologist’s amoxicillin prescription, mainly because it was an otitis externa.

    Understanding regional variations, why is it okay to provide substandard medical care to women by going ahead and playing at primary care?

    *Now if someone asked you if you had a nice recipe for a dish to make with leftovers or something, I’d have no problem with that at all.

  4. Breast exams and pelvic exams are not recommended for asymptomatic women. Just another reason I avoid OB/GYNs unless I have a problem: unpleasant, invasive screening that’s worthless.

    One reason young women utilize an OB/GYN as a primary care physician is they’ve been indoctrinated to think they need a pelvic exam in order to obtain a birth control prescription. They don’t realize a good family physician can provide the prescription without pushing the pelvic exam. Of course, very few OB/GYNs counsel them otherwise. That annual exam is money in the bank.

  5. Dino –

    I thought you knew me better than to accuse me of doing anything in my practice that I do not do well. I know my limits, and practice well within them. I grant you the respect of assuming you do as well.

    All the best,

    Peggy

  6. Dear Dino – I appreciate the sentiment that ob/gyns think like surgeons most of the time and don’t have the training in comprehensive primary care. However, if you believe that we don’t diagnosis and treat diabetes, htn, thyroid disease, asthma, and other chronic conditions, you have no idea what our specialty entails. In fact, we diagnose and treat these conditions everyday. We see and treat women usually BEFORE they see anyone else, often at the beginning of end of their pregnancy when these conditions are newly diagnosed or more commonly transition from gestational problems to chronic problems. In addition we also provide vaccinations, lifestyle modification counseling, and continue to provide routine screening for the most common problems of the reproductive age woman.

    Now I agree with you, I would like nothing more than to have our specialty following national guidelines in terms of screening (pap every 3-5 years with an HPV test ) and a breast clinical exam yearly after age 50 in addition to mammography. I agree that particularly after completion of childbearing, women could and SHOULD transition their primary care to a family practitioner. I AGREE that these doctors SHOULD perform the same quality of cancer screening that we provide. But nothing makes me angrier than seeing a patient with cervical cancer that has been seeing a family physician for 10 years and never received a pap smear. As said above, let’s all get better educated about what we are good at, what services our fellow doctors provide, and work together for the good of our common patients.

    Sincerely,
    A concerned gynecologist

  7. I see a dermatologist annually for follow-up on some skin cancers I seem prone to, but it would never occur to me to ask him to diagnose and then treat my diabetes, htn, thyroid disease or asthma.

    Just because I have skin doesn’t mean I should rely on a dermatologist for all of my primary medical needs. Just because men have a penis shouldn’t mean that it’s a good idea for them to reply on a urologist for all of their primary medical needs. Just because a woman has a uterus shouldn’t mean that it’s a good idea for her to reply on an OB/GYN for all of her primary medical needs.

  8. I saw our primary care for my second pregnancy, and it was definitely the right decision, despite some doubting family and friends. He knew my medical history and my whole family (my older kids also go to him), and I think it is that which made him support me in having a VBAC at a VBAC ban hospital- he knew how much a c-section recovery would impact our family’s life, with an older SN kid and all.

  9. @Concerned Gyn:

    Your concern is duly noted (and appreciated), but when you say you “diagnosis and treat diabetes, HTN, thyroid disease, asthma, and other chronic conditions” every day, I (respectfully) call bullshit.

    What are the criteria for diagnosing essential hypertension? What are the first, second, and third line therapies? When do you consider secondary hypertension and how do you rule it out? How often do you order hemoglobin A1c’s? How do you screen for diabetic nephropathy? Do you do peak flows in your office to assess asthma control? How long do you need to wait to re-check the TSH between thyroid med dosage adjustments?

    You say you provide vaccinations. Anything besides Tdap and HPV (possibly Varivax and MMR)? Do you have Pneumovax? Do you know who needs Pneumovax before age 65? What about Hep A and Hep B? All those are adult vaccines, by the way.

    I looked at your training curriculum (http://www.mc.uky.edu/obg/Residency/2009%20CREOG%20Educational%20Objectives.pdf) and discovered that it does indeed discuss many of these conditions. Most of the time, all you’re supposed to do is be able to recognize them and refer. Some specific treatments mentioned are wrong (anxiolytics first line for anxiety). It doesn’t even say you should treat thyroid disease, just recognize the symptoms, order the tests, and refer. Then again, I didn’t see any rotations in your residencies during which you specifically learn these things. I guess you’re supposed to just pick them up in your continuity clinics over time.

    You may very well know these things. Maybe. Lots of antibiotics for URIs and Xanax for anxiety are written by OBGs. They may be doing primary care, but they’re not doing it very well. And that is NOT in the best interests of our patients.

    I still say that you have enough on your plate learning just obstetrics and gynecology during those your short years pf training. And for what it’s worth, I find the idea of women presenting with advanced cervical cancer because of FP’s failure to do paps just as infuriating as you do. But if your version of primary care is like that of the orthopod who once told me, “I can do primary care. I can measure a blood pressure and say, ‘That’s high. You need to see a cardiologist,'” (ie gatekeeper/referral traffic cop) then you have no idea what OUR specialty entails.


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