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By Kenneth Noller, MD
There are few topics that engender as much debate among obstetrician-gynecologists as the decision to include training in primary care in ob/gyn residency programs. Even though such training has been in all programs for several years, and despite the fact that there is absolutely no serious discussion about removing the requirement from residency training, many practicing ob/gyns do not understand why surgical specialists are required to learn about such things as immunizations, diabetes, hypertension, and other responsibilities. Perhaps the reasons behind this decision can be understood better by reviewing the concept of primary care in more detail.
A dramatic change in healthcare in the United States occurred shortly after the end of World War II. The advances in the biological sciences along with advances in surgical techniques (which had their roots in World War II) caused more and more physicians to seek specialty training rather than pursuing the time-honored "general practitioner" career. Specialty training soon spawned subspecialty training, and physicians eventually became so subspecialized that, often, they failed to view the patient as a whole. Patients became more and more dissatisfied with the fragmentation of their medical care; they might be forced to see five or six different physicians to accomplish little more than an annual health assessment.
Of course, there were still primary care physicians, and some prestigious institutions such as the Mayo Clinic recognized that each patient must have one physician who remained in overall control of the individual patients care. Approximately 30 years ago, the field of family practice was recognized as a separate medical specialty, primarily because of the large void that had been created by subspecialization. This group of physicians came forward and said "we can manage over 80% of a patients medical problems." This specialty became successful and was quickly joined by primary care internists. These physicians became the main providers of first contact healthcare for men and women in the United States.
During this same time period, ob/gyns became more scientific, established three subspecialties, and focused on operative deliveries and pelvic surgery. However, advances in medical care have dramatically reduced the need for hysterectomy, operative deliveries other than cesarean sections have almost vanished in many parts of the United States, Pap smear screening has markedly reduced the incidence of cervical cancer, and advances in in vitro fertilization have decreased (nearly eliminated) the need for tubal surgery. One needs only to review the case lists of young ob/gyns taking their oral boards to recognize how little gynecologic surgery is now being done by the non-subspecialist.
But what about the patient? For a young woman in good health, it is not unreasonable to assume that the majority of her healthcare during the next few decades will involve her reproductive system. She will likely become pregnant, may develop a disorder of menstruation, and will seek screening for breast and cervical diseases. Thus, many young women see their ob/gyn as the primary, if not sole, provider of healthcare. Yet, those of us who were trained in the 50s, 60s, and 70s were ill-prepared to function as primary care physicians. While a woman may primarily seek our services on an annual basis for breast and pelvic screening, it may be far more important, for example, for her to be certain that her immunizations are up-to-date. Few ob/gyns in the past have performed cardiac auscultation at the time of an "annual pelvic examination," and even fewer have screened for hyperlipidemia. While we might inquire about lifetime sexual partners and family history of breast cancer (both important issues), rarely have we inquired about use of seat belts, presence of hand guns in the home, and other issues of personal security. While we have provided excellent, absolutely outstanding reproductive healthcare, in the past we have done a rather poor job of providing care for the whole patient.
Given all of this background, I personally believe that the American College of Obstetricians and Gynecologists and the Residency Review Committee for Obstetrics and Gynecology showed great foresight in introducing the requirement for training in primary care into OB/GYN residency programs. There is no doubt that, in the future, there will be less pelvic surgery as there have become fewer and fewer indications for hysterectomy. Of course, there will always be genital neoplasia (primarily handled by gynecologic oncologists) and pelvic relaxation (now often handled by urogynecologists), but fewer and fewer general ob/gyns will spend much time in the operating room. More and more of our colleagues have decided to cease any operative activities and devote themselves completely to primary care medicine. Indeed, I do not think that it is at all unreasonable to expect that, at some time in the future, there may be another dramatic change in ob/gyn training with separate tracks for those who wish to pursue solely an ambulatory career, and for those who wish to pursue a surgically oriented career. However, there is virtually no likelihood that the requirement for primary care training in womens health will be dropped from training in the specialty of obstetrics and gynecology.
1. American College of Obstetricians and Gynecologists, Washington, DC, 1993.
2. Horton J, et al. Primary Care Update for OB/GYNs 1, 1994;5:212-215.
3. Department of Health and Human Services. Centers for Disease Control and Prevention. Advance Data: Office Visits to Obstetricians and Gynecologists: United States, 1989-1990, No 223. Washington, DC, 1993.
4. Benson Gold R, et al. Improving the Fit: Reproductive Health Services in Managed Care Settings. http://www.agi-usa.org.
5. McGee G, et al. Am J Man Care 1996;2:71-74.