Why OB/GYNs are not primary care physicians

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: OB/GYNs (OBGs), 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.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

Comments are moderated before they are published. Please read the comment policy.

  • N N

    “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.”
    With a comment like that, meant to be derogatory, I would say it was well deserved.

    • http://twitter.com/DinoDocLucy Lucy Hornstein

      Actually, it was said admiringly. That’s why I was so surprised.

  • AT

    I think ob/gyns are primary care for a certain time in a woman’s life. Not only do they meet the medical needs of young, healthy women, these yearly visits also establish an important relationship with the doctor who will deliver any babies down the road.

    This is also just rude: “Over time, many OBGs become competent at outpatient medicine.” My ob/gyn is more than competent, and frankly very personable – and I don’t think she’s faking her cheerful attitude that shows she enjoys outpatient care.

    • minti cakes

      A “young healthy woman” does not need to see any doctor every year. She certainly does not need to see a OB/Gyn on a yearly basis who is using the excuse of a pap and a pelvic exam to hold her birth control hostage.

    • http://www.facebook.com/people/Michael-Rack/100001703895437 Michael Rack

      ‘My ob/gyn is more than competent’

      What is your ability to assess your OB/GYN’s competence in treating Diabetes, high cholesterol and high blood pressure based on?

      • buzzkillerjsmith

        OBs will refer (non-gestational) DM, HTN, dyslipidemia. They can screen as well as anyone else.

        • Ian

          In my experience OB’s or their NP’s will refer almost any non-gestational diabetes patient no matter how uncomplicated to a specialist. I’m sure once they are graded on how well their patient’s do the Endos will be happy to have them but it certainly isn’t cost effective.

      • amused bystander

        “What is your ability to assess your OB/GYN’s competence in treating Diabetes, high cholesterol and high blood pressure based on?”

        The fact that her OB/GYN is “nice”, apparently. Many Americans prefer “nice” to “objectively clinically competent”, it appears. I for one really enjoy the company of my electrician, but I’m not going to hire him to monitor and stabilise the chemicals in my swimming pool. Go figure.

      • http://www.facebook.com/mark.hoofnagle Mark Hoofnagle

        What about any of these conditions do you think is remotely challenging for any licensed physician? I buy John Wilcox’s arguments that family docs or internists might be better diagnosticians before I buy this nonsense that you need to be some kind of specialist to deal with these incredibly common conditions.

        • Suzi Q 38

          I had pre-eclamsia when I was pregnant.
          Th OB/GYN just kept saying with each pre-natal visit over and over…”your blood pressure is kind of high…..without doing much about it.

          Finally, I had to visit an FP on a business call.
          When we finished talking, he said: “How are you feeling?
          You look very tired. Do you mind if I take your blood pressure?”
          Highly unusual, but I agreed.

          He mentioned at it looked like I had gained a lot of weight.
          I had.

          He said that he wanted to call my OB, that it was very important.

          I really didn’t to, but I gave him my OB’s name and number.

          Next thing I knew, my OB called me at home and asked me to come in. He took my blood pressure again.

          Apparently the GP called him and told him that not only was I at risk, but my baby was at risk as well.

          I was hospitalized for 2 days, until my BP{ was controlled; I had to undergo weekly non-stress tests, to which there were some scary times……as I was put on complete bed rest. They taught me how to take my own BP, and when it was too high, I was told to go straight to the doctor’s office or hospital.

          Anyway my daughter had to be induced 5.4 weeks early, but she and I made it.

          Ditto for my son, but he was a little earlier 6.1 weeks early. He had lived in a tent for a week and was very yellow for a month.

          The pre-eclamsia happened both times.

          My point is that it was originally discovered as a huge problem by the GP. You would think that the GYN should have been the one to discover it.
          It just depends on who it is.

    • buzzkillerjsmith

      Correct. You don’t need an internist or an FP to check a bp and a cholesterol. Heck, nurses do it all the time. OBs are smart people.

  • trinu

    A non-pregnant woman seeing an OB/GYN for primary care makes about as much sense as a man seeing a urologist for the same.

    • SMH

      Having an OB/GYN cover all of your healthcare needs just screams “I AM NOTHING MORE THAN MY LADY-PARTS!” No, women. Just as a man is much more than just his dick, you are much more than just your lady-parts, and you DESERVE a doctor who understands your kidneys, liver and brain as much as they do your hoo-haa.

      • ninguem

        Gotta admit, I’ve wondered the same thing myself.

      • http://www.facebook.com/mark.hoofnagle Mark Hoofnagle

        This is wildly incorrect. OBGs are doctors too, and fully capable of treating any disorder that a family doc can. They also have the advantage of specialist knowledge of care of these conditions under more challenging circumstances like pregnancy. To say that OBGs only know how to deal with “lady parts” is profoundly ignorant of the role they play in women’s health, in particular their specialist knowledge of treatment of chronic diseases during pregnancy.

        Further, in the reproductive age group, they perform better in preventative health screenings than internists or family docs, an important consideration for this age group.

    • C.L.J. Murphy

      That is an American phenomenon which has always puzzled me as well. America seems to have a uniquely consumer-driven health system, and for whatever reason (marketing?), many women have been convinced to outsource all of their primary health needs to obstetric & gynaecological surgeons. From an economic rationalist position it seems like over-servicing (the majority of everyday health issues do not require the services of a specialist surgeon), and from the standpoint of women’s health it seems like underservicing (there is more to a woman than her “lady parts”, as others here have put it).

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Dr. Lucy,
    This article was very interesting, but I also have to say that a good number of women do not actually see the doctor that is supposed to be their Primary Care Physician for annual visits because they go to the gyn every year for a well-woman visits. Some choose to use their gyn as a PCP even though the OB/GYNs are not actually PCPs because that’s who they are most comfortable with when it comes to talking about very sensitive topics. I had to see my gyn last month for something and she was able to take care of it. Yes, I could have gone to my PCP about this particular issue but it was not something that I personally felt comfortable with talking to him about although he knows what it is now. He knows what it is now because he gets all the notes from my other doctors because he wants to know how I am doing and about any complications that I might have. However, for me to sit and talk to him about the issue was not something I could do. Now, with that said I have a question. Since OB/GYNs are not Primary Care Physicians what are reasons (if any besides for surgical reasons) that a woman who is not pregnant should be going to a gyn?

    • amused bystander

      “a good number of women do not actually see the doctor that is supposed to be their Primary Care Physician for annual visits because they go to the gyn every year for a well-woman visits”

      In God’s name, why?

      Do American men consider themselves wholly “well” after having a urologist check out their genitals? Do you not feel that the rest of your organs deserve equal consideration?

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        As far as why a good number of women do not actually see the doctor that is supposed to be their Primary Care Physician for annual visits because they go to the gyn every year for well-woman visits” it’s because that is the choice they have made due to personal preference. We don’t know all the reasons why, but one example I gave is listed in my comment further up. Is it the right choice to make? Probably not, but it is what it is.
        About 15 years ago it used to be that you had to have a referral from a GP to see a Gyn if you had a female problem. That has not been the case since then depending on the type of insurance one has. With a kind of insurance we have here that is called a PPO referrals from GPs are not required for someone to see a specialist. Also, in many of them the OB/GYN is considered a Primary Care Physician under the plan. Not exactly sure what caused the change in status, but money could have been a factor. Its hard to say, but considering an OB/GYN to be a Primary Care Physician/Provider has been going on now for about 10 years.

      • Noni

        As a counterpoint…when I’ve seen my OB/Gyn for my pap smear/breast exam, she has also taken the time to listen to my heart and lungs and do an abdominal exam. No, she didn’t do a fundoscopic exam or check my reflexes, but as I’m fairly healthy I’ll allow that oversight.

        Personally, I do not see the need for a young otherwise healthy person to see ANY doctor on a regular basis. Why would you?

  • Fay

    Actually, Lucy, I still haven’t found a primary care physician that I like half as much as my OBG, so back to my OBG it is, until I can find a good PCP. The difference between your description and my reality, however, is that my OBGYN does not have the personality of a surgeon, he is personable, caring, and knows his limitations. When I ask him about something that is out of his league he tells me so, and refers me to the right resources.

  • http://www.facebook.com/people/Michael-Rack/100001703895437 Michael Rack

    The article you cite is about PAP smears and mammograms. As the original article mentions, OB/GYN’s are not trained to provide long-term care of HTN and diabetes. I am sure that OB/GYN’s do a reasonable job of preventive care in healthy women, but primary care is much more than that.

    • http://www.facebook.com/mark.hoofnagle Mark Hoofnagle

      I almost fell out of my chair with that one. For one, in a population of women of reproductive age (those that OBGs will take care of as PCPs) such screenings are probably the most important preventative interventions, and more likely to be relevant to morbidity and mortality than hypertension or diabetes in this group.

      Further, every doctor I know is perfectly capable of caring for hypertension and diabetes. This arguments are profoundly ignorant of what medical training entails, or the scope of practice of specialist physicians. Where has this idea come from that when a physician specializes they forget everything in medschool, or that they don’t have to treat the entire patient? You don’t think OBGs have to take care of diabetics? Hypertensives? They not only have to take care of and treat them, but these are critical elements specific to OB care. Ever hear of gestational diabetes or pre-eclampsia? Granted, not the same as the chronic conditions, but it’s not like when an OBG sees an elevated blood sugar they’re going to throw their hands and the air and say, “consult a PCP quick! The blood sugar is 225!” I may be a surgeon, but I routinely have to deal with situations as diverse as new onset type I diabetes (post pancreatitis for example), undiagnosed/untreated/undertreated type II diabetes, hypertension, malignant hypertension, surgical hypertension etc. While I don’t do primary care, the reason why isn’t because I can’t treat two of the most common medical conditions you’re going to find.

      Sheesh.

      Please. This is total nonsense. There is nothing that a PCP does that an OBG can’t do. And plenty of evidence that when it comes to women’s health, that in this age group is incredibly important, OBGs do better.

  • Jack Robertson

    My experience with GP’s practicing gynecology and obstetrics in much different from the authors. As a gynecologist i see many women that have consulted their GP for gyn complaints. Many of these women are shuttled to the PA or NP because those physician extenders are women and will therefore “better” understand the patient. Whether shuttled off or not, a simple complaint of vaginal discharge leads to 100′s of dollars in worthless cultures and blood tests that add nothing to the diagnosis. If the patient is complaining of pain, the GP or his/her minions have no faith in their pelvic exam and order 1000′s of dollars in lab tests and imaging studies. Most often the imaging study of choice is the CT scan which always is followed up by an ultrasound even if the only finding is an incidental 1 centimeter cyst.
    GP’s are paid so poorly these days that they are totally dependent on income from the tests that they order just to make ends meet. Were they qualified to do surgery they might supplement their income enough that they could see less than 10 patients an hour.
    I am sure there are some very good GP’s out there but I doubt that they, the good ones, really believe that they have the ability or the time to compete with a well trained specialist in the specialty for which that doctor has trained.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      You must have some crappy GP’s around you. I don’t know any that “shuttle” patients to NP’s or PA’s, be they male or female. Personally I love doing women’s health and most of my the family doctors I know do as well.

      I may not be as good as a specialist in some regards but I am fully confident that my ability to provide the majority of outpatient GYN care to women is just as good as that of an OB/GYN.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Dr. Beau ,
        Would that also include managing treatment of chronic gynecologic related conditions like endometriosis? The reason I ask is because sometimes surgery is necessary to treat this disease in order to try and help the patient function as close to normal as possible.
        I am glad that there are women out there that are comfortable with talking to their FM PCP about any gynecologic concerns they have. I wish that were the case for many more women, but sometimes talking about these things can be very uncomfortable especially if they have a male doctor as their PCP. So for them it’s much easier to go talk to their gynecologist about these issues instead.

        • Glenn

          If men en masse were to summarily dismiss the competence/suitability of woman PCPs the way so many women do men, they would be damned as “sexist”.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Glenn,
            Interesting comment. I have met some men that won’t have anything to do with female PCPs when it comes to the sensitive subjects regarding their areas. But as far as the women that choose not to have conversations with male PCPs about sensitive subjects regarding their female areas, there is a reason that they do that. I can see why you would think it’s about being sexism or gender bias, but that’s not it for them. They feel the way that they do because they are of the opinion that they are not capable of understanding how to deal with these topics that affect lady parts because they don’t have them. There are also some women that prefer using male doctors whether it’s a PCP, Gyn, or some other specialist because that’s just who they are most comfortable with. Nothing wrong with that. It’s all a matter of personal choice. This is especially the case for those that have been sexually assaulted, but know that they may need to see a doctor for the problem. Unfortunately after someone has been through that like some of the women I have met talking to a doctor, especially a male one is very uncomfortable because they feel ashamed about what happened. So for these women it’s better for them to go to a female doctor.
            But as I said yes, I can see why someone would have thought it was sexist. How would you feel about talking to a female PCP, or urologist about sensitive subjects related to your body?

          • Glenn

            My entire family sees the same family physician, who is a woman. She is a highly-trained doctor, and I view her as such. I do not inappropriate sexualize her, nor she me. Several years ago I had an infected pilonidal cyst near my anus, and it would not have occurred to me to demand a referral to a male doctor.

            A doctor is a doctor, a body part is a body part. If I refuse to be seen by any female doctor, I have just written off some of the most skilled practitioners out there. Sexism disadvantages the person who practices it as much as it does the group of people they’re discriminating against.

            Your hypothetical rape victim would probably do better to seek professional help to get over her unreasonable fears than to continue to discriminate against the 99.99% of men who did not, and who never will, abuse her.

          • EmilyAnon

            If a woman prefers female doctors over male, is that considered such a psychological disorder that you would actually suggest they seek professional help? Whatever the reason, their decision is theirs alone and has to be respected. Just leave those women alone, I’m sure they are just a small fraction of patients whose loss won’t affect any male doctor’s bottom line.

          • Glenn

            Personally, I don’t think gender-based discrimination is ever a good thing. If I refused to hire women in my business simply because I’d had a bad experience with one once, I’d be missing out on some very talented workers. If I refused to let our family physician treat either my son or myself simply because she’s female, it would be more our loss than hers.

          • EmilyAnon

            So what do you suggest, that they be denied care or even sued unless they allow a male physician to treat them? There is still freedom to choose your providers and no obligation to anyone as to their reasons for their choice.

            “Yes, I believe that if some phobia is causing someone to discriminate against half the population, they would probably do better to get some help dealing with that phobia ….”

            That it’s a phobia may be your opinion, but it’s just that. Otherwise, it’s none of your business. Unless of course you advocate some kind of mandatory brainwashing camp.

          • Glenn

            In her fourth pregnancy, my wife was rushed to hospital with what turned out to be an ectopic pregnancy. The surgeon on call happened to be male. I am glad she suffered from none of your misandrist “no male doctor shall touch my precious lady-parts” phobias, or she would be dead.

            I hope you get the help you need to overcome your issues. Kind regards, Glenn.

          • EmilyAnon

            “I am glad she suffered from none of your misandrist “no male doctor shall touch my precious lady-parts” phobias.”

            Glenn, you’re trying too hard to be cleverly provocative by presenting off-topic anecdotal stories, or attributing words I never said, to bolster your point of view. Instead you come off like a victim whose manhood is threatened.

          • M.K. Caloundra

            If you had had some sort of negative experience with a Black person once, would that justify your decision to discriminate against all Black people for the rest of your life?

          • EmilyAnon

            Rule #1 when you fail at logical reasoning, resort to race bating.

          • M.K. Caloundra

            Damning half the population based on a negative experience with n=1 is arguably as bad as or worse than damning 13% of the population based on a sample of n=1.

          • EmilyAnon

            Who’s damning half the population? I have never had a negative experience with a male doctor. All my doctors are male except for my PCP and dentist. Does that pass your litmus test?

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Glenn,
            I agree with you that a body part is a body part. No question there. And I also agree with you that a doctor is a doctor whether male or female. I also understand what you are saying about that sexism disadvantages the person who practices as much as it does the group of people they’re discriminating against. However, a woman who is sexually assaulted is not going to be comfortable with talking to a male doctor (whether a Gyn or a PCP) about any sensitive subject related to her reproductive organs, much less let them examin her for that very reason. And I agree that a woman who has been sexually assaulted should get help to deal with the trauma of what has happened. But to say that her fears are unreasonable is also unfair because to her they are very, very real. She has every right to be afraid that it might happen again even though you are also correct about the 99.99% of men who did not and will never abuse her. Because the trauma can be so bad from something like that sometimes even with help they never go to any doctor. That’s how fearful they are, and for good reason. Of course not going to any doctor whether male or female is not beneficial to their health if they have problems in that area. But as it is that is their choice. And if they (if they do get over the trauma) choose to use their OB/GYN as a Primary Care Physician because that’s who they are most comfortable with then that is their choice to do so. The same for any other woman just like the right to choose a female doctor over a male doctor.
            Even for women who have never been sexually assaulted it can be very awkward talking to a male doctor about female problems. And the reason it’s awkward is because they aren’t women. Also, in some cultures male physicians are not allowed to examine a woman in that area. That’s just the way it is in those cultures, and if the man tries to do that it can create all kinds of problems for everyone involved.

      • buzzkillerjsmith

        Women’s health is brainrot. Have the midlevels do it. If you’re IM or FP, get with the DM, CAD, acute sickies.

  • PollyPocket

    I’ve been told a neurosurgeon is a primary care doctor who also happens to do brain surgery.

    Of course, this was tongue-in-cheek, but there is some truth to the statement. Many patients do not have PCPs at all. Surgical specialists need to be able to manage medical conditions beyond their specialty, make referrals, and hope the patient will establish care. Many patients will not.

    • Guest

      “Many patients do not have PCPs at all.”

      But then who coordinates and manages all their care, “the big picture” as it were? Who’s at the hub of all this hectic hodge-podge self-referred specialist-seeking? If there’s no one primary doctor who has a complete picture of all the issues you believe you have, and all the care you are seeking, and all the treatments you are being given, how does that even work?

      • PollyPocket

        ER referrals and otherwise unmanaged care…

        It’s well and good to pretend that patients who need primary care phycisians will actually see them, but there’s a large population who seek care primarily at the ER and NO ONE manages the “big picture” until a specialist is required.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Guest,
        As to who coordinates and manages all their care “the big picture” as it were, and at the hub of all the hectic, self-referred specialist visits it is the patient themselves. Some people have had to become very familiar with the system and take care of it themselves because of bad experiences with GPs. We have had some regular readers of this blog that fall in to that category. There are also just some people that prefer to coordinate their own care because that’s just what works best for them. I know several people like this. Doesn’t necessarily make it right, but that’s their choice because that’s what works best for them. Also, some people here in the U.S. don’t have access to a GP (also sometimes called a Primary Care Physician here in the U.S., General Practicioner I don’t think is used much here in the U.S. anymore) to go to for care because there aren’t enough doctors available.
        Having enough doctors to be GPs is of very big concern to many in the Medical field here in the U.S. The reasons for this concern are numerous, one of which ties in to with the number of people that are getting older. Medical journals and other articles through other news organizations here have touched on this subject extensively. That’s in addition to blogs like this one.

  • dana

    I was born and raised in Europe, lived across 3 different countries on the continent in 32 years. No women in any of them has an ob-gyn as a primary care physician, it would be considered plain weird and useless. In fact, with a little luck most women can live their lives, take the pill or have a baby without evert having to cross path with an ob-gyn. Something very very strange is going on in the USA when it comes to medical care and women.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dana,
      Who takes care of the pregnancies that may be complicated, or the women who have a long history of having female problems?

      • dana

        An ob-gyn. Usually a referral is needed from a GP to seek out a specialist. But healthy, asymptomatic women do not have “well-woman exams” and certainly no-one would ever go to an ob-gyn with an eye infection or a flu. I do not see why should someone’s eye or ear be regarded so casually that they go to a specialist of the reproductive organs instead of a GP. Would a man ever go to a urologist with an eye problem?

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Dana,
          I think it’s understood by many that as you say no one would use the OB/GYN for an eye infection. They would tell the woman to either check with her GP that she uses for problems like that, or refer her to the eye doctor. That is common sense that a gyn would not take care of an eye problem, but if she does not want to use her GP for the eye problem or a flu that is her choice. Some specialists here also offer flu shots to patients as well when flu season occurs here. As for the healthy, asymptomatic women over there not having “well-woman” exams I find that a bit strange. Well-woman visits are a big deal over here just like with the issue of having annual physical exams done by a GP (see the blog entry posted by Dr. Davis Liu about whether annual physicals should become obsolete in this country) in order to make sure that those healthy, asymptomatic women stay that way. Does your GP do an annual physical exam to help insure that healthy, asymptomatic adults stay that way?

          • dana_

            Dear Kristy, in 32 years, I myself never had any “well-woman exam” or “annual exam”, neither my friends or family or the rest of the folk here have them, and people are just fine. In the USA women do not live longer, they do not have less female cancers, in fact if I remember
            correctly one woman in 3 ends up losing their uterus before menopause. I do not consider being female a condition that needs monitoring, or my reproductive organs more sickly than the rest of my body. I read this
            blog sometimes, because I am interested in social policy and health policy, and I have to say it really strikes me how women buy into this nonsense, that through the conditioning of fear and alienation from their own reproductive systems they are being turned into perpetual patients “for their own good”, when it so obviously is about money, and probably allowed to happen because to a certain extent it reflects the sexism prevailing in society. Men are not so docile and gullible, so when they have an eye infection etc no-one even assumes they would put up being treated by a doctor who specializes in reproductive health.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Dana
            Thank you for sharing the information you did. It’s very interesting.

          • C.L.J. Murphy

            “In the USA women do not live longer”

            That is correct, Dana. A recently published study, “U.S. Health in International Perspective: Shorter Lives, Poorer Health”, shows that of a bloc of similar, high-income countries, American women’s life expectancy comes in second-last (American males come in last; paradoxically, Americans are also most likely to self-rate their health as “good” or “very good”).

            The paper is available online or as a downloadable PDF; just google “National Academies Press U.S. Health in International Perspective: Shorter Lives, Poorer Health” and it should be top of the results. Cheers.

        • amused bystander

          “if she does not want to use her GP for the eye problem or a flu that is her choice.”

          That, @disqus_KLjfzgdu3T:disqus , is why it’s useless to try and talk common sense at American women. They are not serious people. The term “hysteria” came about because ancient medical practitioners saw women as ruled by their uteri (“hister” = “uterus”), and the unreasonableness and ridiculousness of women was blamed on uterus problems.

          American women have not got beyond the idea of basing all medical treatment on the fact that they have a uterus. I believe that a disproportionate number of them are, in fact, hysterical (in the original sense of the word).

    • SMH

      I have a friend from Australia who had never seen an OB/GYN in her life. And she’s 45 with three children. She doesn’t understand Americans women’s obsession with specialist “lady-doctor care” either. Apparently you’re not even allowed to see a specialist there unless your medical condition is such that you require it. “Having A Vagina” is not such a qualifying medical condition.

      EDIT: I’ll add, I wonder whether this obsession with specialists isn’t partly to blame for our out-of-control medical system? I don’t think the average Aussie is less healthy than us, despite the fact that they don’t generally ever come into contact with a specialist unless/until there’s some dire medical reason to do so. Are their family doctors/PCPs/GPs better than ours, to be able to handle so much, so well? Or are we just so used to getting what we want, when we want it, from whomever we want it, that we devalue ours?

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        I also have a friend from Australia and has one son, but she was put under the care of OB/GYN for her pregnancy. Now I don’t know if that’s because she was considered high risk or not, but she was.
        Every country is different as to the way they handle things, and just like with each healthcare system you will have those that think good of it and those that think bad of it. As for the issue of the specialists one reason we have so many is because healthcare is forever changing. The other reason is because of concern about liability issues. There have been numerous posts on this blog about the issue of how frequently people are referred out to specialists, etc.

        • Guest

          In Australia, generally family doctors and midwives take care of antenatal care and birth, unless there’s an indication that leads your GP to refer to a specialist. If you’re already in hospital, getting ready to birth, and something suddenly comes up, the hospital’s OB/GYN will take care of it.

          But, once whatever that one specific issue you were referred to an OB/GYN for is over (i.e. if it was for a high risk birth, you’ve now had your baby and all is well), that’s it. You don’t need the services of an OB/GYN specialist anymore, and if something else comes up that your GP is not qualified to handle you’ll need another referral. For something like endometriosis, your GP might refer you to see an OB/GYN to treat that, but only that (you can’t also ask the OB/GYN to check your blood sugar or write you a script for cough medicine “as long as you’re there”). So you’d still have to talk to your GP about your “sensitive” problem, because your GP needs to know whether to issue a referral or not and how urgently you need to be seen.

          But certainly no woman goes to an OB/GYN unless she specifically has an OB/GYN issue that a GP can’t handle (GPs do routine pap smears, STD screenings, birth control pills, routine antenatal care, etc). A woman wouldn’t think of fronting up to an OB/GYN with a cough, or a turned ankle, or a nosebleed, or for a regular annual check-up, any more than they’d front up to a neurosurgeon for those issues. That’s what GPs are for.

          In basic, you can’t just go to a specialist for any old problem just because you like them. If you don’t feel comfortable talking to your GP about “women’s troubles”, you find a new GP.

          Talk to anyone from anywhere outside America and they’ll find it more than passing strange that so many American women have their own OB/GYN and see them for non-obstetric or non-gynecological problems.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            If someone is not comfortable talking to their GP about a sensitive issue when it comes to the female area, it doesn’t matter how many doctors they could switch to. If they don’t want to talk to the GP about it they won’t do it.

          • amused bystander

            Sounds like American women need to grow up a little bit, then. If you’re not paying your own way, but demanding that others do so, claiming that you don’t especially like mince so therefor you as a precious privileged petal with XX rather than XY chromosomes should be allowed to have eye fillet for breakfast, lunch and tea, and bill it to everyone else, you’re arguing for a 1950′s mentality of the fragile inferior woman and you’re also making your healthcare system more unsustainable for everyone else.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            If you had a very sensitive subject on the female front that you didn’t want to talk to your GP about, especially if that GP was male, you wouldn’t do it either. You also wouldn’t like it if someone told you that you needed to grow up a little bit. They have the right to not tell their doctor about a sensitive subject when it relates to the female area if that is their choice. And one reason they may choose not to have that conversation about a sensitive subject may be due to bad experiences in their life regardless of what the experience is.
            And while I agree that you should be able to tell your doctor anything regardless of what gender the doctor is, you can’t make a woman do so if they don’t want to. That is going to be something that they have to make the choice to want to do. Then if they don’t, what else is there to be said other than that their health might be greatly affected. Also hoping that by the time that they finally choose to say something that it isn’t too late to do something about. Have you ever known a woman that has been sexually assaulted in any way? The reason I ask this is because I have met women that fall in to this category. They are terrified of talking about sensitive subjects related to the female area because of this type of experience. Does it make it right? No, of course not because then their health would be affected. However, it’s their choice not to talk about it.

          • Bonnie

            I’m not sure why you think you have to be so mean about it user_kl. I happen to agree with the author of this article about the importance of seeing a primary care physician, but “both sides” of the debate are interesting to read. Being able to debate things politely, and accept that “the other side” might make some good points too, is what we GROWN-UPs, do.

      • http://www.facebook.com/jonwilcoxnz Jon Wilcox

        In NZ up until the 1990s almost all GPs had DipObst qualifications, delivered babies and stuck speculums into women, put in IUCD’s and did VE’s all day long. Just didnt do much surgical stuff for women but then mostly they dont need anything done. For that the women get charged a small surcharge of maybe $35 for their smear and maybe $90 for an IUCD or Mirena over and above their standard (subsidised) GP fee of around $40. The US needs to either glamorise or pay more for primary care or their system will eventually completely fail. The Democrats are surely the ones to do it, but it MUST be done. Here in NZ we have few problems and most people get affordable care whether they have insurance care or not.

        • amused bystander

          American women are such prima donnas, they are too posh to see a “mere” GP. How dare you! /sarcv

          But realistically, although a preponderance of women voted for Obama and love his idea of free socialised healthcare for all, tell them that like any other country with socialised healthcare they will no longer be allowed to just cart themselves off to a specialist on whim, because they feel they “deserve” it, and watch 150 million over-entitled livid women march on Washington with their “WAR ON WOMEN” placards.

          American healthcare is failing and will continue to fail so long as entitlement-minded citizens demand that they should get whatever it is their little hearts desire, whether it’s clinically indicated or not, with “someone else” picking up the tab.

          It’s the same as if a country had socialised single-payer restaurants combined with 100% “consumer choice”, and any citizen anywhere was allowed to walk into any restaurant and order any meal, and only be up for the $15 “co-pay” (unless they were low income, in which case any meal at any restaurant would be completely “free”).

          America is stuffed. They’ve combined the freeman’s “It’s my right to have anything I want any time I want it” mentality, with the anti-authoritarian’s “You’re not the boss of ME!” mentality, with dole-bludger’s “Gimme dat for FREE, it’s my RIGHT!” mentality.

          Tears. It’ll end in tears. No question about it.

          • Molly_Rn

            Why do you hate American women so much? Obviously you do not like the Affordable Care Act, but you don’t seem to know the correct name. Your post had little to do with the blog so why don’t you keep your thoughts to yourself.

          • F_150

            You surely mean the UNaffordable Care Act aka Obamacare…

          • Molly_Rn

            Your ignorance is showing. Are you against him because he is black or because you don’t really understand the bill and how it helps Americans get healthcare?

          • Guest

            Being opposed to the “Affordable” (lol) Care Act has nothing to do with racism or hating black people – that’s a ridiculous assertion. I was against Hillarycare as well – does that mean I’m sexist and hate women? Good grief. You guys got nothin’ left. Nothin’.

          • Molly_Rn

            How about ignorance and Republican for characteristics….and add no compassion for others.

          • Suzi Q 38

            He is not black. He is a mixture. Fifty-fifty.
            Our kids are 50%-50%. We call this “half” or “hapa” in Hawaiian.

  • buzzkillerjsmith

    OBs are not trained as PCPs but do a lot of it by default, at least in my community. You can’t blame them. PCP shortage.
    Plus, they see a lot of young gals who are basically healthies who might require a bit of cutting. No fools, they tend to refer the heart failure patients.

  • ninguem

    OB/GYN’s get to consider themselves primary care AND specialist under most insurance plans. Sometimes it’s been formalized into official regulation or law.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Under my insurance OB/GYNs are considered Primary Care Providers, but when I talked to my gyn last month she made an interesting comment. Even though she is considered a Primary Care Provider by my insurance she still considers herself to be a specialist. It was a rather interesting discussion because when I went to pay my co-pay before the visit they wanted to charge me the specialist copay when it should have been the Primary Care Provider copay instead. The issue got straightened out.

  • http://www.facebook.com/mariapimentelmd Maria Pimentel-Alvarez

    Funny because as obgyns we do treat a lot of primary care diseases because a majority of internists do not want to deal with pregnant women’s thyroid condition, diabetes, hypertension, flu, asthma, etc so we treat them in pregnancy…and many times they show up to us first and we do work ups for thrombopholias, lupus and other disorders. Just because we did not train as residents in as much detail as you did in these areas doesn’t mean we can’t start a basic work up and do basic treatment. We don’t get any training in hormone replacement therapy or depression/ anxiety yet we learn in practice to do so. As a physician we are constantly learning and evolving. I often try to refer patients out to internists or FPs but if there is an issue I try to address it first as it may take awhile to get in to see a new doc. And to those primary docs who pride themselves at doing paps please do us all a favor and order the HPV and if you see a nabothian cyst or a cervical polyp don’t freak the patient out because you aren’t sure at what your looking at….And for the record we are not just surgeons.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dr. Maria,
      Thank you for this post. Why is it that the majority of internists do not want to deal with pregnant women’s thyroid conditions, diabetes, HTN, flu, etc?

      • azmd

        My guess would be that there are significant liability concerns with getting involved with the care of a pregnant woman. It’s pretty well established that if there’s any sort of bad outcome with the pregnancy, every doctor involved gets sued, whether there was malpractice or not. This is why the malpractice premiums for OB/GYN specialists are so astronomical. Your typical internist most likely does not want to expose his or her practice to that sort of risk.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          azmd,
          That makes sense to me. Thanks.

  • ConcernedMD

    Last Friday I got a phone call from a former patient. I had seen her two years ago for contraception, she had finished at local college and moved away. Her internist had ordered a CT scan for IBS. She had an ovarian cyst and was told by the office nurse “she might have ovarian cancer.” I called the office later that Friday and was told the a) the doctor did not work on Fridays and b) I could not get a copy of the CT scan until he was back on Monday.

    The patient drove 100 miles for her appointment on Tuesday and I got her records that morning. No pelvic or rectal exam. 2 cm cyst on cycle day # 14, patient had stopped birth control several months ago. My diagnosis was “normal 24 year old.”
    Until PCPs are willing to take care of the most mundane issues in women’s health, ob-gyns will still be provding office care for women.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      What is the woman who prefers to use her OB/GYN as a PCP supposed to do if she gets told by the gyn to go back to her regular doctor for the “mundane issue” if she doesn’t want to go back to her GP? She can’t be made to go, but if the gyn is telling her that she needs to go back to the regular doctor for the mundane issue and she doesn’t want to she has to have somewhere else to go.

    • http://www.facebook.com/jonwilcoxnz Jon Wilcox

      The internist was a PCP/GP ?

  • http://www.facebook.com/jonwilcoxnz Jon Wilcox

    Maybe some people dont know what primary care includes. Today I sent in a patient to ED for an LP for PCR for probable HHV6 encephalitis – previous Guillain Barre Syndrome back in 1984 (when I was also her GP) and the last 2 months intractable atypical “migraine” headaches with very atypical neurology. You wanna go to a OB-GYN for that ? Well darling good luck to you.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dr. John,
      You are right about that some people don’t know what Primary Care includes which is one of the reasons why it is not valued as it should be in this country. Would you mind sharing with us what all Primary Care includes? And as you list each item please break it down even further when it comes to explaining about what each item does exactly, and what it entails.
      But if a lady does not wish to use her GP for female related problems, even the mundane ones as someone already mentioned that is her choice. As for the example you gave, it is true that she would not use her OB/GYN for treating the problem. The OB/GYN would then in turn refer her to Neurology to take care of the “atypical migraine” headaches. Is there something wrong with the OB/GYN doing that?
      One of my relatives went to her gyn for her annual well-woman visit. The gyn noticed something and then referred her to GI for it. Was there something wrong with the OB/GYN referring her to the GI specialist to further investigate the problem? The OB/GYNs just like GPs (PCPs) know when to refer the woman out for needed care that is beyond the scope of the OB/GYN. Isn’t this also one of the reasons that a GP (PCP) refers someone out to other specialists?

      • http://www.facebook.com/jonwilcoxnz Jon Wilcox

        Kristy the crux is timely availability. For the above pt (still in hospital today) we dealt with the issue (which had been not taken seriously last time in ED) and she was also refused an MRI by the free public service because “it didnt fit the algorithm” – she got a timely referral same day this week with a detailed past history and the reasons why she did not have “ordinary” migraine. To get that organised with an OBGYN and a referral to a private (non-ED) neurologist (waiting time in private here is 6 weeks) would be a waste of time, and clinically inefficient. We are advocates for our patients and sometimes the young ED docs (bless their stroppy little cotton sox) are only 24 years old and have a lot to learn. This patient didnt have insurance either so didnt want to “go private”. Okay so we dont see encephalitis every day of the week but we see a lot of pain problems, neurogenic and otherwise; mood and stress disorders (primary care is where BPAD2 comes seeking that elusive diagnosis). It goes on and on. Most care is not supported with insurance and our role is to filter things – our Koreans have to be told they cannot have a free public system funded colonoscopy every year like at home in Seoul and to explain why, but in the cases that need it to refer appropriately to enable a timely endoscopy where necessary, I had to refer a Jehovahs Witness 3 weeks ago for a Pill Cam because two episodes of massive haemorrhage in the hospital system could not be localised. Their solution was a partial colectomy (hope they targeted the correct chunk) but we sent her back to the private sector for a PillCam so she could at least make a more sensible decision. In fact I dont look after corns, they are usually “while I am here doc” and thenh get referred to our nurses or to a podiatrist. This morning I had a 16 year old Korean girl I delivered who has some 8 keloid wounds from @#$% laser treatment of micro-nevi by some idiot out in the cosmetic industry. Trying to sort out the best management plan for that kind of stuff is not easy, but why spend $400 to see a dermatologist or plastic surgeon to get the same advice ?

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Dr. John,
          Interesting. Thank you. What I was asking when I said about is there something wrong with the OB/GYN doing that it was in relation to being able to refer their patients to the particular specialists that they need for further evaluation of a problem. And the reason that I ask is because that’s what GPs (PCPs) do when it comes to the issues that may need help from a specialist such as Gastroenterology let’s say.
          Some women are more comfortable with using their OB/GYN as a Primary Care Physician, so I don’t see why that doctor can’t advocate for their patient just as well as the GP can. And same thing with being able to filter out the unnecessary care as in the examples that you gave. I do agree with you though that trying to sort out the best management plan for different conditions that occur in people’s lives.
          As for why someone would want to spend $400 to see a Dermatologist or Plastic Surgeon to get the same advice that was given to the young woman in the example you gave, because those doctors are considered the experts on treatment of those conditions. So the same thing for why a woman would prefer to choose an OB/GYN to be her Primary Care Physician: because they are experts on women and health issues of all sorts as it relates to them, not just about specific body parts.
          While I understand why so many such as the author of the article feel that OB/GYNs are not Primary Care Physicians you can’t force a woman to use their regular Primary Care Physician to the fullest extent possible if they don’t want to. As long as women have the right to choose who they want for their Primary Care Physician many will continue to choose their OB/GYN to fit this role. The reason as I said that many will continue to do this is because this is who are most comfortable with (and bad experiences may have occurred to cause them to feel this way). Is this the right choice? Based on stats and such probably not, but it’s their choice. And if something goes very wrong because of having made that particular choice because they choose not to talk to their PCP about female problems even of the mundane kind then they have to live with the consequences of that choice.
          If one takes away that right to choose then there are going to be outcries in the public about the right to freedom of choice. It’s too bad that sometimes the only way people are going to learn valuable lessons is by learning the hard way. Unfortunately, that’s their right to make that choice and all one can do is to hope for the best.
          Now here’s something interesting for you. When I saw my gyn about the sensitive subject that I could have gone to my male PCP about I asked her if my PCP could have taken care of the issue. Her answer to me: no he couldn’t have handled this as he doesn’t have all the tools that would have been necessary to care for it. So that confirmed to me that I would have been right in that had I gone to my PCP about this he would have sent me to my Gyn any way. So why should I have paid a $20 copay to my PCP to have him tell me to go where I knew I needed to go for the problem: my gyn (which was also $20 for a copay). If I would have let my PCP look at this issue and then went to the gyn to have it cared for I would have had to put out $40. It was cheaper for me to just go straight to the gyn for this and not my PCP and then the gyn which would have also meant more gas that got used.
          From what I am understanding it sounds to me like for every time I have a female issue come up even of the mundane I should always talk to my PCP first before I go straight to the gyn unless it’s surgical treatment that is necessary. And if that’s the case then that means I am going to be wasting about $120 every time because of going between the two. If I am understanding this wrong please let me know. I need to better understand this because some day I may be having this kind of a conversation with a female patient who wants to know why she can’t use her OB/GYN as a PCP when she’s told she needs to go back to her regular doctor for an issue after I graduate from Nursing School.

  • http://www.facebook.com/jonwilcoxnz Jon Wilcox

    … and I also delivered her last two babies 20 plus years ago

  • http://twitter.com/Clinician1 Dave Mittman, PA

    Totally agree.
    You don’t consider going to an OB with a sprained knee, a dark scary lesion, depression, acne, hair loss, vision changes, trouble sleeping, prostate problems, poorly controlled hypertension or diabetes, pneumonia, memory loss, sinusitis, syncope, etc. And the list could go on forever. All primary care problems.
    Dave Mittman, PA, DFAAPA

    • http://www.facebook.com/mark.hoofnagle Mark Hoofnagle

      Uh, prostate problems? I think we’re working from a more basic confusion here.

      • SMH

        Just above, you claimed “OBGs are doctors too, and fully capable of treating any disorder that a family doc can.” If you’re all that, why wouldn’t you welcome men as primary care patients as well, or at least see a patient’s PCP-less husband or father for his prostate problem?

        • http://www.facebook.com/mark.hoofnagle Mark Hoofnagle

          Actually, the article is about OBGs providing primary care exclusively for women, but yes they are doctors, and are perfectly capable of prescribing flomax if necessary.

          • F_150

            FALSE

  • Suzi Q 38

    I think in general, doctors “want the business.”
    That is good marketing and shows they are “hungry.”
    That being said, each specialty needs to readily refer when it is clearly better for the patient.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Interesting information to which I have been hearing for about 10 years now, but I don’t see how this is relevant to the discussion about OB/GYNs as to whether they should be considered Primary Care Physicians or not. Please explain how this relates to the discussion that surrounded the author’s entry.

    • Payne Hertz

      My point is that OB/GYNs who can’t be trusted to perform ethically within their own field, can hardly be expected to do so as primary care doctors.

      I am glad you found an OB/GYN you can trust. She may very well be worthy of your trust.

      But the fact remains that many caesarians are performed solely for profit and the convenience of the doctors and hospitals involved and this casts doubt on the profession as a whole.

      If I were a pregnant woman I would not play Russian roulette with my health but opt to go somewhere where there are no financial incentives to perform unnecessary procedures that are known to severely impact and even destroy women’s reproductive health.

      If you don’t have that option, I would be sure to go to a non-profit hospital with a record of performing few caesarians and be sure you understand the doctor’s philosophy on performing them.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        I can see where you are coming from about the OB/GYNs that can’t be trusted to perform ethically within their own field can hardly be expected to do so as Primary Care Physicians. And while it is true that many C-sections may be done solely for profit, the convenience of the doctors and hospitals involved that is not always the case. Sometimes the patients ask for a C-section as well when it may not be necessary. So the issue of the C-section rates being as high as they are and the reasons for such are a two-way street. You can’t automatically assume that every OB/GYN, and every hospital wants to have a C-section done. What would you suggest that the doctor do if the patient insists on wanting a C-section even after they have just told her no? If they let her go from the practice for that then they could be in big trouble for abandonment even if that is not the case. And nowadays it would be hard to find someone or a place that does not have financial incentives for doing the procedure. Makes me think that some of this also has to do with defensive medicine. Interesting to say the least.