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.

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