Managing Your Practice

State of the Specialty: 12 ObGyns describe critical challenges to their work

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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.



We are at the threshold of a new era in American medicine. Federal health legislation will catalyze changes that will reconfigure how we provide care to our patients. At such a critical juncture, we thought it was important to explore the professional and personal challenges of our colleagues, a few of which are offered here. The perspectives of our fellow ObGyns are illuminating and inspiring. They reflect the high quality of physicians in our field, and their deep commitment to providing the best care for their patients.

We are the few, the proud, the ObGyns!—Robert L. Barbieri, MD

CHALLENGE 1: Maintaining the privilege of private practice

Barbara S. Levy, MD
Dr. Levy practices gynecology in a solo private practice in Federal Way, Wash, where she also serves as Medical Director of the Women’s Health Center for Franciscan Health System. She serves on the OBG Management Board of Editors.

Of the many challenges ObGyns face today, the “monopolization” of medicine may be the most pervasive. In Federal Way, Washington, where I practice, the local hospital system has acquired many of the private primary care practices in town, including many of those that regularly recommended my practice to their patients. Once they become part of the hospital system, these practices are encouraged to refer patients to ObGyns in that system.

Many older physicians are throwing in the towel and selling their practices to the hospital system, and many younger physicians, just entering the workforce, would prefer not to have to run a business, and so they go to work for a hospital.

Although I still see a full slate of patients in my solo private practice, I have noticed that people aren’t booking appointments as far in advance as they used to, and the number of patients sent to me by other practitioners has declined. In response, I’ve beefed up my Web site for marketing purposes, and I do my best to keep it up to date and to ensure that it is well listed in the search engines. I also work with my patients to increase word-of-mouth recommendations, and I work with vendors of slings and other products I regularly utilize in my practice to encourage them to support public education symposia and materials that market my practice.

As patient volume declines, it obviously becomes more difficult for a gynecologist to maintain competence in surgical procedures. If this trend continues over the long term, I wonder whether GYN generalists are going to be able to maintain competence in every aspect of the job—or are subspecialists going to be the only ones who have enough experience to perform surgery safely and effectively? It would be a shame if general ObGyn care lost the surgical component.

Here’s to preservation of the private practice!

Dr. Levy reports no financial relationships relevant to this article.

CHALLENGE 2: Adhering to revised guidelines

Raksha Joshi, MD
Dr. Joshi is Chief Medical Officer and Medical Director of Monmouth Family Health Center in Long Branch, NJ. She serves on the OBG Management Virtual Board of Editors.

Physicians and patients have followed mammography and Pap testing guidelines comfortably for a number of years—that is, until the US Preventive Services Task Force (USPSTF) revamped mammography screening guidelines in November 2009. The USPSTF now recommends biennial mammography rather than annual screening for women 50 to 74 years old, no mammography for women younger than 50 years (unless it is indicated), and the elimination of self breast examination from the list of recommendations.1

Shortly after the USPSTF made its revisions, ACOG announced changes to Pap screening guidelines, moving the age for the first Pap test to 21 years (rather than 18 years or 3 years after sexual debut), followed by biennial screening. ACOG also recommended that women 30 years and older who have had three consecutive negative Pap tests switch to screening every 3 years.2

What I tell my patients

I continue to teach self breast examination and encourage women to “know their breasts.” Many of my patients have noticed changes that merited a workup and sometimes led to discovery of a malignancy—even before the age of 40.

I also make it a point to discuss the possible “harms” of screening mammography with my patients. So far, every one of them has been happy to undergo additional testing—including biopsy—for the reassurance of knowing that they do not have cancer.

My great fear? That insurers will use the USPSTF recommendations to deny screening mammography—even though, so far, they have asserted that they will not do so. Who among us has not seen at least one case of early—and, therefore, curable—breast cancer detected by an annual mammogram when the previous year’s test was perfectly normal?


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