State of the Specialty: 12 ObGyns describe critical challenges to their work
It’s no quiet time in the specialty. More and more chronically ill patients, falling reimbursement, a struggling economy, rapid evolution of guidelines, and other issues are devouring your time and attention. Twelve physicians tell OBG Management what they each think is the most pressing challenge facing the specialty. They offer solutions, too.
People often ask me, “How do you do it?” They mean, of course, how do you maintain calm among throngs of stressed-out women on excessive doses of hormones; give lectures; write papers; go to meetings; run the practice (billing, collections, hiring, firing etc.); make sure that the 13-year-old and the 15-year-old do all their homework and get to activities on time with the requisite baked goods in hand (why is there such a frequent demand for baked goods?); see your husband often enough that he remembers your name; make time for friends; and so on. I usually just smile and say, “Well, I am never bored!”
Perhaps the trick is to find balance in the moments between the chaos—a moment in which you share a belly laugh with your husband or hang out with the kids on the couch or connect with a patient on a personal level about something other than her diagnosis or treatment.
Perhaps we should stop struggling to find something that might not exist. Perhaps it is enough to enjoy the search for balance, to revel in the energy and chaos now and understand that work-life balance will eventually materialize and is perhaps not three words but one: retirement.
Dr. Chen reports no financial relationships relevant to this article.
CHALLENGE 11: Caring for the indigent
Takeko Takeshige, DO
Dr. Takeshige is Physician in Charge of Ambulatory Care in the Department of Obstetrics and Gynecology at Lincoln Medical and Mental Health Center in Bronx, New York, and Assistant Professor of Clinical Obstetrics and Gynecology at Weill Medical College of Cornell University in New York City. She serves on the OBG Management Virtual Board of Editors.
Serving patients in the inner city is a big challenge, even with full implementation of electronic health records. I practice in a hospital where the majority of patients are immigrants, many of them undocumented and with limited education. Compliance with medical care is a major issue. Pregnant patients often seek prenatal care late—or show up in labor without any care. It is extremely difficult to initiate evaluation and treatment of these patients, particularly in cases involving intrauterine fetal demise, preeclampsia, uncontrolled diabetes, abruptio placenta, or drug overdose, when the well-being of both mother and baby is compromised. The same holds true for women who have significant gynecologic pathology but wait as long as possible before seeking care.
Despite our best efforts and thorough medical evaluation, follow-up of these patients is difficult. They often give us inaccurate contact information. Some reside in shelters, and others relocate frequently. Explaining the importance of follow-up care to these patients is sometimes complicated by their limited language ability or education.
To meet these challenges, our hospital has:
- assigned a prenatal care coordinator to follow up patients referred for poor compliance or complicated obstetric care
- initiated classes as a means of educating patients about their medical condition and plan of care
- taken a proactive approach to gynecologic care, conducting the work-up, planning treatment, and counseling the patient in regard to medical and surgical management at the same visit
- provided on-site social services
- performed laboratory testing and imaging studies on the day of the visit to improve compliance
- updated contact information at every visit.
Our specialty faces many challenges ahead. Therefore, it is imperative that we recognize our practical needs and implement new ideas to meet these challenges. Ultimately, an optimal patient outcome depends on the patient as well as the medical team.
Dr. Takeshige reports no financial relationships relevant to this article.
CHALLENGE 12: And last, managing high-risk pregnancy
Marwan Saleh, MD
Dr. Saleh is Senior ObGyn Resident at Crouse and SUNY Upstate University Hospital in Syracuse, NY. He serves on the OBG Management Virtual Board of Editors.
High-risk pregnancy is an increasingly common challenge in obstetric practice, with approximately 5% to 10% of all pregnancies in the United States falling into this category.6 In referral centers, that figure can be much higher. For example, at Crouse Hospital in Syracuse, New York, where I practice, 18.3% of deliveries in 2009 were considered high-risk, and the total number of new high-risk patients seen for a consultation at the out-patient regional perinatal center in Syracuse rose from 2,047 in 2005 to 2,963 in 2009—an increase of 44.7%!
The rising prevalence of high-risk pregnancy is of concern because perinatal mortality is twice as high in these gestations as in normal pregnancy.7 With proper care, however, 90% to 95% of high-risk pregnancies produce healthy, viable infants.6
Among the variables contributing to the rise in high-risk pregnancy are advanced maternal age, morbid obesity, and an increasing prevalence of chronic maternal conditions such as heart disease, hypertension, and diabetes.
