FPs not doing gynecology?

[zambo]

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Many FPs don't include obstetrics in their practice for various reasons (medico-legal liability being probably the main reason).

Can they not do gynecology also?

 

[deleted87716]

Many FPs don't include obstetrics in their practice...Can they not do gynecology also?

One of the great things about family medicine is the flexibility that the physician has to tailor their practice to their own preferences. That being said, if you don't want to do gyn, you don't have to.*

It might be difficult to completely avoid doing gyn exams, however, as you can't always control who presents to your office with what, and sometimes a pelvic or breast exam is a necessary part of the evaluation. However, if you prefer not to do routine womens' health exams, you can always refer those patients to a gynecologist.

FWIW, gyn doesn't increase your malpractice premiums like OB does. Just curious...why wouldn't you want to do gyn?

*Note: I'm not suggesting that I think this is a good idea.

 

[sophiejane]

Many FPs don't include obstetrics in their practice for various reasons (medico-legal liability being probably the main reason).

Can they not do gynecology also?

This is of course unscientific, and completely my opinion, but I would think that if FPs start refusing gyn exams, it takes away from the public perception of our scope of practice. Already, I know a lot of women who go to an OBGYN for their annual exams, when their FP would be just as competent to do that. (I stopped going to an OBGYN because I never saw the doc, only the PA--although she was good, I figured I might as well have my FP who knows me do this exam which really amounts to a yearly physical).

If your patients want you to do it, I think you should oblige. It's preventive medicine and well within the scope of an FP. It's not like they are asking you to do their colectomy.

If you refuse to do gyn exams, you should probably also refuse prostate checks and treating men for STDs, just to be fair.

 

[deleted87716]

I would think that if FPs start refusing gyn exams, it takes away from the public perception of our scope of practice.

I agree with you. Further, I can't imagine why anyone wouldn't do routine gyn. It's certainly not the most challenging thing we do, and it's an important part of continuity of care. I imagine trying to duck gyn exams at every turn would result in some awkward conversations with patients, as well.

 

[Faebinder]

You all know that it is a matter of comfort... I think patients that see male family medicine physicians would rather go pap smear with a female OBGYN physician.... Of course this doesnt apply to everyone... but it certainly does to many... for religious or personal comfort reason.

 

[deleted87716]

You all know that it is a matter of comfort... I think patients that see male family medicine physicians would rather go pap smear with a female OBGYN physician.... Of course this doesnt apply to everyone... but it certainly does to many... for religious or personal comfort reason.

The OP's question had nothing to do with patient preference, however.

 

[Hard24Get]

The only reason I LOATHED my family medicine rotation it wasn't family medicine. I had done ob/gyn, peds, medicine, and then FM, so FM was supposed to be a nice summary of those 6months. Yet, the practice I got assigned to doesn't do kids under 16 and doesn't do ob/gyn! It was a freaking outpatient IM rotation in disguise!

There were times when patients wanted to bring in little Jimmy. "Sorry, we don't do kids" 😡. We had a patient come in once for a check up, and she mentioned she was concerned about a discharge. I got excited because I thought we were finally going to do something, and he told her to go see her gyn! 😡 😱 😡 I almost offered to do it myself...

These people should have their license taken away and only IM students should be sent there. Of course, because I had just done IM I got honors in the rotation, but it feels like a lie because I never DID FM.

Great, this post reminded me of how cheated I feel. No wonder FM is in shortage, no one gets to do it. I'm gonna ask to do another rotation....

One of the great things about family medicine is the flexibility that the physician has to tailor their practice to their own preferences. That being said, if you don't want to do gyn, you don't have to.*

It might be difficult to completely avoid doing gyn exams, however, as you can't always control who presents to your office with what, and sometimes a pelvic or breast exam is a necessary part of the evaluation. However, if you prefer not to do routine womens' health exams, you can always refer those patients to a gynecologist.

FWIW, gyn doesn't increase your malpractice premiums like OB does. Just curious...why wouldn't you want to do gyn?

*Note: I'm not suggesting that I think this is a good idea.

 

[deleted87716]

the practice I got assigned to doesn't do kids under 16 and doesn't do ob/gyn! It was a freaking outpatient IM rotation in disguise!

You should definitely tell your school about that preceptor, as they really shouldn't be sending students there for an FM experience if that's all they're going to get.

I have a handful of female patients who prefer to see a gynecologist for their annual exams, for whatever reason. I'll even refer them to a female gynecologist if they don't have one. However, I tell them that if they select a gyn for their routine womens' health issues, then I'm essentially out of the picture for anything related to that. In other words, they can't go to the gyn's office once a year for their Pap and OCPs, and then come to me with their intermenstrual spotting and pelvic pain. It's all or nothing, baby. After figuring out that it's a lot easier to get an appointment with me than their gyn, many of those patients end up switching back to me for everything. The grass isn't always greener on the other side. 😉

 

[sophiejane]

I have a handful of female patients who prefer to see a gynecologist for their annual exams, for whatever reason. I'll even refer them to a female gynecologist if they don't have one. However, I tell them that if they select a gyn for their routine womens' health issues, then I'm essentially out of the picture for anything related to that. In other words, they can't go to the gyn's office once a year for their Pap and OCPs, and then come to me with their intermenstrual spotting and pelvic pain. It's all or nothing, baby.

Very interesting take. I doubt I will have that problem (by the time I was in the last week of my FM rotation I was pretty much doing all the well woman exams because they were ASKING for me 🙄 ) but that's sound reasoning, and hard to argue with...

 

[lowbudget]

(I stopped going to an OBGYN because I never saw the doc, only the PA--although she was good, I figured I might as well have my FP who knows me do this exam which really amounts to a yearly physical).

Is this common? Same thing, I had a patient come to our clinic because she was always seen by an OB midlevel. Despite her liking the midlevel, she came to FM clinic because it was easier to get an appointment.

After a year, I hadn't gotten very many WWE/gyn in clinic (and the procedures that come with it). So I mentioned it to the front desk and my faculty/clinic director and I'm getting a bit more now in terms of WWE/gyn walk-ins. As a guy, it's a bit of an effort because there's the added step of making women feeling comfortable with you. But if you see this person in continuity for other non-gyn issues, you develop a trust and that discomfort goes away. Plus you save them time of having to go back and forth between doctors and re-telling their stories over and over again.

 

[Hard24Get]

You should definitely tell your school about that preceptor, as they really shouldn't be sending students there for an FM experience if that's all they're going to get.

Sadly, we don't have enough practices at near our school that do real family medicine, so they are largely aware of the problem, have cut out several practices off the rotation list. I did mark it on my eval, however. I forgot when I was ranting that the FM PD was kind enough to schedule me to spend Fridays in her clinic for a warm-up (finishing my PhD), so I guess I will get to do FM, afterall 😀

It seems smart for pts to not get to double-dip, though. What percent of time do most FPs spend on adults/kids/gyn?

 

[sophiejane]

As a guy, it's a bit of an effort because there's the added step of making women feeling comfortable with you. But if you see this person in continuity for other non-gyn issues, you develop a trust and that discomfort goes away. Plus you save them time of having to go back and forth between doctors and re-telling their stories over and over again.

You bring up one of my favorite topics...

There will always be patients who prefer to be seen by women for their gyn exams. But here are a few unsolicited pointers for men (and women) to make their female patients feel more comfortable...

1. NEVER, ever pat a patient on the back, leg, or god forbid the chest (I've seen it) in an effort to comfort them (a "there, there" pat, as I call them). It's condescending, even if you mean well.

2. Just like dogs and bears can smell people who fear them, women can smell male doctors who fear or are uncomfortable doing the gyn exam. Don't make comments about "getting it over with" or otherwise drawing attention to the unpleasantness of the exam, even if you are doing it in an effort to comfort the patient. Believe me, she's well aware of how unpleasant it is. Just be matter-of-fact, professional, attentive, efficient, and gentle.

3. Please, for the love of god, warm the speculum if you are using stainless steel. It's a small thing, but it goes a long way.

4. Do the interview part of the exam CLOTHED. Don't make a woman answer questions about her sexual or menstrual history while perched on an exam table, barely covered in that awful paper gown. After the exam, if you have instructions to give or scripts to give her, do it after she's dressed again. Basically, the less time in the paper gown, the better.

5. Do tell her what you are ABOUT to do before every step of the exam, even if she's had 20 of them before. Just get in the habit of telling her where your hands and instruments are at all times.

 

[lowbudget]

Correct me if I'm wrong, Kent, but I get the impression that if you can bring women into the practice, you have an opportunity to bring in kids too and keep the waiting room and practice young?

I guess the flip side is if you turn away gyn, you can crank through a higher volume of patients throughout the day.

Don't know what y'all thought about that from a practice standpoint...

 

[deleted87716]

But here are a few unsolicited pointers for men (and women) to make their female patients feel more comfortable

Whew! I'm relieved that I'm doing all of the things you mentioned already (and we use fabric gowns in my office for physicals...the paper stuff is only used for limited exams). 😉

 

[deleted87716]

Correct me if I'm wrong, Kent, but I get the impression that if you can bring women into the practice, you have an opportunity to bring in kids too and keep the waiting room and practice young?

Exactly. Not only the kids, but the husbands, too. And, hopefully, they'll tell all their friends. Word of mouth is the best form of advertising. 😉

 

[deleted87716]

What percent of time do most FPs spend on adults/kids/gyn?

It's hard to say exactly how much gyn I do, since the "well-woman" component of it is just part of a routine physical, which I do every day. I see quite a few gyn-related complaints every day, as well (pelvic pain, menstrual problems, vaginal complaints, menopause issues, etc.) I'd say I do a lot of gyn, but I can't give you numbers, percentages, etc. Peds is another matter. I've never really sat down and tried to run the numbers, but I'd estimate that only about 10-15% of my practice is peds (kids less than 21 years of age). I see about 25 patients a day on average, and usually only 3-4 of them are kids. Many FPs (like my partner, for example) see more than that. Part of my situation is that I "inherited" my original patient panel from a retired physician, so I'm a bit top-heavy in Medicare.

 

[zambo]

Yet, the practice I got assigned to doesn't do kids under 16 and doesn't do ob/gyn! It was a freaking outpatient IM rotation in disguise!

I can't help but think this type of practice would severely limit the FP's patient base. FP is supposed to cover men+women+kids. By completely removing women's health and kids out of the equation they're forfeiting something like 2/3 of their potential patient base. Is it feasible for a FP to practice only adult medicine?

 

[deleted87716]

Is it feasible for a FP to practice only adult medicine?

Totally feasible, due to the growing elderly population. Medicare patients are having increasing difficulty finding primary care doctors these days. Of course, if you cut out the kids and the gyn, you'd basically be doing general internal medicine.

 

[yazhi15]

Totally feasible, due to the growing elderly population. Medicare patients are having increasing difficulty finding primary care doctors these days. Of course, if you cut out the kids and the gyn, you'd basically be doing general internal medicine.

Hello there!!! I am planning to apply to FM residency this year.
Is it feasable for a FP to just do OBG/GYN and Peds, and no IM?
THanks! 🙂

 

[deleted87716]

Hello there!!! I am planning to apply to FM residency this year.
Is it feasable for a FP to just do OBG/GYN and Peds, and no IM?
THanks! 🙂

Feasible, but difficult, I would think. How would you market yourself? You couldn't call yourself a "family physician," that's for sure.

 

[McDoctor]

You bring up one of my favorite topics...

There will always be patients who prefer to be seen by women for their gyn exams. But here are a few unsolicited pointers for men (and women) to make their female patients feel more comfortable...

1. NEVER, ever pat a patient on the back, leg, or god forbid the chest (I've seen it) in an effort to comfort them (a "there, there" pat, as I call them). It's condescending, even if you mean well.

2. Just like dogs and bears can smell people who fear them, women can smell male doctors who fear or are uncomfortable doing the gyn exam. Don't make comments about "getting it over with" or otherwise drawing attention to the unpleasantness of the exam, even if you are doing it in an effort to comfort the patient. Believe me, she's well aware of how unpleasant it is. Just be matter-of-fact, professional, attentive, efficient, and gentle.

3. Please, for the love of god, warm the speculum if you are using stainless steel. It's a small thing, but it goes a long way.

4. Do the interview part of the exam CLOTHED. Don't make a woman answer questions about her sexual or menstrual history while perched on an exam table, barely covered in that awful paper gown. After the exam, if you have instructions to give or scripts to give her, do it after she's dressed again. Basically, the less time in the paper gown, the better.

5. Do tell her what you are ABOUT to do before every step of the exam, even if she's had 20 of them before. Just get in the habit of telling her where your hands and instruments are at all times.

Tell me if I'm way off here, but in our clinic, I don't do a bimanual exam on a routine PAP. If there is a complaint of pelvic pain, maybe that's different, but as a routine screening procedure I don't really see the value in it. I'll open up myself to criticism on this, but until now nobody has been able to give me any good reason why this part of the exam is routinely performed.

 

[RuralMedicine]

Tell me if I'm way off here, but in our clinic, I don't do a bimanual exam on a routine PAP. If there is a complaint of pelvic pain, maybe that's different, but as a routine screening procedure I don't really see the value in it. I'll open up myself to criticism on this, but until now nobody has been able to give me any good reason why this part of the exam is routinely performed.

If you don't do bimanual exams then how do you examine the uterus and the ovaries?

 

[McDoctor]

If you don't do bimanual exams then how do you examine the uterus and the ovaries?

In a thin person, maybe a bimanual exam allows for adequate palpation of pelvic structures. But the majority of the time, the bimanual exam seems to have poor sensitivity or specificity for picking up any pelvic abnormalities, due to either body habitus or less experienced examiner (how many do most FP's do in a week?) or both.
I can see the argument that it should routinely be done after age of 35 to 40 when one might have endometrial or ovarian CA. I just don't routinely do them at ages 20 through 30 every year.

 

[McDoctor]

http://www.greenjournal.org/cgi/content/abstract/96/4/593

 

[deleted87716]

In a thin person, maybe a bimanual exam allows for adequate palpation of pelvic structures. But the majority of the time, the bimanual exam seems to have poor sensitivity or specificity for picking up any pelvic abnormalities, due to either body habitus or less experienced examiner (how many do most FP's do in a week?) or both.
I can see the argument that it should routinely be done after age of 35 to 40 when one might have endometrial or ovarian CA. I just don't routinely do them at ages 20 through 30 every year.

Perhaps, but you're not doing a "pelvic exam" if you're not doing a bimanual exam...you're just doing a Pap, e.g., just screening for cervical CA.

Whether or not you agree or disagree with the published guidelines, it's a good idea to follow them from a malpractice standpoint. People who go too far out on the evidence-based limb have been known to have it snap under them (witness the well-publicised case about PSA testing a few years back).

As the saying goes, you can tell the pioneers by the arrows in their backs. 😉

 

[McDoctor]

Perhaps, but you're not doing a "pelvic exam" if you're not doing a bimanual exam...you're just doing a Pap, e.g., just screening for cervical CA.

Whether or not you agree or disagree with the published guidelines, it's a good idea to follow them from a malpractice standpoint. People who go too far out on the evidence-based limb have been known to have it snap under them (witness the well-publicised case about PSA testing a few years back).

As the saying goes, you can tell the pioneers by the arrows in their backs. 😉

I see your point. I could definitely envision a woman who develops ovarian cancer successfully suing a physician for not performing routine bimanual exams (despite the evidence that demonstrates said cancer would not have been diagnosed any earlier regardless). A good example of how fear of litigation influences standard of care.

 

[RuralMedicine]

In a thin person, maybe a bimanual exam allows for adequate palpation of pelvic structures. But the majority of the time, the bimanual exam seems to have poor sensitivity or specificity for picking up any pelvic abnormalities, due to either body habitus or less experienced examiner (how many do most FP's do in a week?) or both.
I can see the argument that it should routinely be done after age of 35 to 40 when one might have endometrial or ovarian CA. I just don't routinely do them at ages 20 through 30 every year.

Unfortunately you will see ovarian cancer (I have in my own practice) in women in the 20-35 range. I would agree that if you are uncomfortable with your ability to do bimanual exams that you should refer patients for their paps and pelvics. Pap smears alone screen for cervical cancer only. Personally I don't find bimanual exams as challenging as visualizing the cervix in 400+ pound patients. (Although with an adjustable table so you can drop down the pelvis even that is much easier.)

 

[McDoctor]

Unfortunately you will see ovarian cancer (I have in my own practice) in women in the 20-35 range. I would agree that if you are uncomfortable with your ability to do bimanual exams that you should refer patients for their paps and pelvics. Pap smears alone screen for cervical cancer only. Personally I don't find bimanual exams as challenging as visualizing the cervix in 400+ pound patients. (Although with an adjustable table so you can drop down the pelvis even that is much easier.)

But don't you think that the sensitivity of bimanual exam in detecting adnexal masses is unacceptably low regardless of experience of the examiner? I'm fairly certain that mortality associated with ovarian cancer has not been reduced by regular screening with a bimanual exam. Its not so much that I'm "uncomfortable" with the exam, rather I'm skeptical of its clinical value based on lack of evidence to support it, (as well as studies that show very low sensitivity and specificity like the one I provided a link to).

Those instances where I didn't perform one, I did cite my reasoning to patients. I'll start doing them regularly because I see the value from a malpractice standpoint as pointed out earlier. But I remained unconvinced that it is clinically useful as a disease screening mechanism.