Outpatient internists: Are you doing paps?

[PlutoBoy]

I recently switched from inpatient to outpatient medicine. My group usually refers women to either the health department or gynecologists for pap smears but I kind of felt like I should provide all primary care myself and started doing them.

I am wondering if I am out of line or out of the standard of care. Looking back, I don't remember my clinic preceptor (also a man) doing paps during residency.

I am a man and so are all the other docs in my group (not that it really matters but I guess men are always afraid to be accused of sexual misconduct).

This question is directed towards internists. I assume FM doctors did much more of this during their training but I appreciate your input as well.

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[HelpPleaseMD]

I recently switched from inpatient to outpatient medicine. My group usually refers women to either the health department or gynecologists for pap smears but I kind of felt like I should provide all primary care myself and started doing them.

I am wondering if I am out of line or out of the standard of care. Looking back, I don't remember my clinic preceptor (also a man) doing paps during residency.

I am a man and so are all the other docs in my group.

This question is directed towards internists. I assume FM doctors did much more of this during their training but I appreciate your input as well.

we actually had a lot of pap days during our residency training. I don't see it as something a primary care doc does though unless they were there for some sort of GU complaint

 

[PlutoBoy]

we actually had a lot of pap days during our residency training. I don't see it as something a primary care doc does though unless they were there for some sort of GU complaint

Hmmm... Cool. I'd prefer to avoid doing them if I can! I just don't want to have the gynecologists rolling their eyes every time one of my patients shows up to their office for a pap.

 

[Crayola227]

we actually had a lot of pap days during our residency training. I don't see it as something a primary care doc does though unless they were there for some sort of GU complaint

weird I was always given this was under the purview of any PCP as it is preventative care at the level of Pap screening, and yearly pelvics without pap screening still indication to screen for ovarian cancer or other conditions (yes I know a yearly pelvic exam is not the best screening tool for ovarian cancer, but it's all we got for average risk women, not to mention the yearly pelvic exam can find other things)

even if the patient isn't due for a Pap, they are due for a yearly pelvic exam
and of course if they have specific complaints that makes the pelvic exam necessary

all of the above is absolutely in the scope of practice of internists, but of course some may choose not to and some may not have had enough experience to want to bother

I starting seeing an internist at the age of 12, and have always seen internists and I've had indicated pelvic exams from plenty of internists (that should not sound wrong)

in my clinic the only gyn care we don't do is LEEP
we place IUDs, do colposcopy, provide other forms of birth control, some prenatal counseling plus prenatal vitamins (and referral to ob if indicated), test for and treat STDs, other vag issues that come up as well, some might even do some HRT in post-menopausal but others haven't been comfortable with that

if there are other issues mucking up prenatal counseling they go to ob for sure before pregnancy

 

[Crayola227]

but for sure, being a dude, you need to always have some other staff in the room with you

EDIT:
add that this is true for ladies as well, I always have a chaperone

 

[wholeheartedly]

Around here the internists, male and female, perform the routine paps.

 

[PlutoBoy]

weird I was always given this was under the purview of any PCP as it is preventative care at the level of Pap screening, and yearly pelvics without pap screening still indication to screen for ovarian cancer or other conditions (yes I know a yearly pelvic exam is not the best screening tool for ovarian cancer, but it's all we got for average risk women, not to mention the yearly pelvic exam can find other things)

even if the patient isn't due for a Pap, they are due for a yearly pelvic exam
and of course if they have specific complaints that makes the pelvic exam necessary

all of the above is absolutely in the scope of practice of internists, but of course some may choose not to and some may not have had enough experience to want to bother

I starting seeing an internist at the age of 12, and have always seen internists and I've had indicated pelvic exams from plenty of internists (that should not sound wrong)

in my clinic the only gyn care we don't do is LEEP
we place IUDs, do colposcopy, provide other forms of birth control, some prenatal counseling plus prenatal vitamins (and referral to ob if indicated), test for and treat STDs, other vag issues that come up as well, some might even do some HRT in post-menopausal but others haven't been comfortable with that

if there are other issues mucking up prenatal counseling they go to ob for sure before pregnancy

Hmmm... Interesting. That's sort of how I feel about it. I think it is not unreasonable to offer this service at primary care offices and that's why I am doing them but some people are looking at me like I am a lunatic.

Literally every internist friend that I have discussed this with has said that they just have the gynecologist deal with this.

It will be interesting to see what the poll shows after a while.

 

[Raryn]

weird I was always given this was under the purview of any PCP as it is preventative care at the level of Pap screening, and yearly pelvics without pap screening still indication to screen for ovarian cancer or other conditions (yes I know a yearly pelvic exam is not the best screening tool for ovarian cancer, but it's all we got for average risk women, not to mention the yearly pelvic exam can find other things)

even if the patient isn't due for a Pap, they are due for a yearly pelvic exam
and of course if they have specific complaints that makes the pelvic exam necessary

all of the above is absolutely in the scope of practice of internists, but of course some may choose not to and some may not have had enough experience to want to bother

I starting seeing an internist at the age of 12, and have always seen internists and I've had indicated pelvic exams from plenty of internists (that should not sound wrong)

in my clinic the only gyn care we don't do is LEEP
we place IUDs, do colposcopy, provide other forms of birth control, some prenatal counseling plus prenatal vitamins (and referral to ob if indicated), test for and treat STDs, other vag issues that come up as well, some might even do some HRT in post-menopausal but others haven't been comfortable with that

if there are other issues mucking up prenatal counseling they go to ob for sure before pregnancy

Internists should be fairly comfortable doing pap smears, and it is actually one of the only procedures flat out required by ABIM to graduate residency. Central lines? Optional. Pap smears? Required. And being able to do a diagnostic pelvic exam when a patient complains of symptoms is also a reasonable skill to have. I was never trained in IUDs or colposcopy, but the former seems like something you can pick up after a weekend course, and the latter is something I can't see myself ever doing (rather have the gynecologist deal with it).

That said... there is absolutely no indication any more for a yearly screening pelvic exam. None. The USPSTF flat out recommends against screening of any sort for ovarian cancer, giving it a D recommendation. Most gynecologists still do it out of inertia, but a PCP actually practicing evidence based medicine would only need to do a pelvic when there's symptoms that warrant it, or every 3-5 years when a pap smear is necessary (depending on patient age and whether or not HPV cotesting was done).

 

[jdh71]

No way I'd do paps if the group practice was to let the gynos do it. **** it. Why?

 

[Crayola227]

Internists should be fairly comfortable doing pap smears, and it is actually one of the only procedures flat out required by ABIM to graduate residency. Central lines? Optional. Pap smears? Required. And being able to do a diagnostic pelvic exam when a patient complains of symptoms is also a reasonable skill to have. I was never trained in IUDs or colposcopy, but the former seems like something you can pick up after a weekend course, and the latter is something I can't see myself ever doing (rather have the gynecologist deal with it).

That said... there is absolutely no indication any more for a yearly screening pelvic exam. None. The USPSTF flat out recommends against screening of any sort for ovarian cancer, giving it a D recommendation. Most gynecologists still do it out of inertia, but a PCP actually practicing evidence based medicine would only need to do a pelvic when there's symptoms that warrant it, or every 3-5 years when a pap smear is necessary (depending on patient age and whether or not HPV cotesting was done).

No wonder the confusion.

according to this
http://www.health.harvard.edu/blog/...men-dont-need-yearly-pelvic-exam-201407027250
The ACP reviewed the evidence and said the yearly pelvic was optional.
However, they noted that the ACOG reviewed the same evidence and still stand by yearly pelvics.
http://www.acog.org/About-ACOG/ACOG...an-Recommendations/Screening-Ages-19-39-Years
This last link is from today. For 13-20 they recommend pelvic exam when indicated by history etc. For 21 and up they recommend yearly.

So it's a question of whose guidelines you want to follow. The internists or the ob/gyn. Seeing how quick the internists were to refer to ob/gyn, I think I'mma feel OK continuing to go by their recs instead.

I can do gc/chlamydia screening with urine, but if I want the full meal deal of what could be growing down there I gotta go digging.

I don't trust any of my sexually active patients' partners to be monogamous or wrap it up, so as far as I'm concerned even the women who otherwise might feel like they don't need yearly gc/chlamydia screening, still do. I think I still need to look all around if they are sexually active.

Let's just say I've seen women in decades-long relationships be surprised and danger averted because they had their yearly testing, on the basis of being sexually active at all.

 

[Crayola227]

From the USPTF, they give yearly gc/chlamydia B* level of evidence.

Recommendation: Chlamydia: Screening -- Sexually Active Women

Grade: B*

Risk Factor Information:

• 
  Age is a strong predictor of risk for chlamydial and gonococcal infections, with the highest infection rates occurring in women aged 20 to 24 years, followed by females aged 15 to 19 years. Chlamydial infections are 10 times more prevalent than gonococcal infections in young adult women. Among men, infection rates are highest in those aged 20 to 24 years.
  
  Other risk factors for infection include having a new sex partner, more than 1 sex partner, a sex partner with concurrent partners, or a sex partner who has an STI; inconsistent condom use among persons who are not in mutually monogamous relationships; previous or coexisting STI; and exchanging sex for money or drugs. Prevalence is also higher among incarcerated populations, military recruits, and patients receiving care at public STI clinics. There are also racial and ethnic differences in STI prevalence. In 2012, black and Hispanic persons had higher rates of infection than white persons. Clinicians should consider the communities they serve and may want to consult local public health authorities for guidance on identifying groups that are at increased risk.
  
  

 

[Crayola227]

It said basically the same thing for gonorrhea testing.

We all have different practice styles. In my clinic, I want all my female patients who have been sexually active even once since their last negative result to be tested yearly.

I'm with the ACOG because the sooner you stamp out an asymptomatic gc/chlamydia infection the better. Most asymptomatic infections of gc/chlamydia need more than a year of time to cause fallopian scarring based on what someone in my ob/gyn rotation told me years ago. Not going to drag more citations out, I feel pretty good so far with review of USPTF, ACP, and ACOG guidelines, my own studies of the prevalence of cheating in relationships and inconsistency of condom usage.

USPTF
Screening Tests
Chlamydia trachomatis and Neisseria gonorrhoeae infections should be diagnosed by using nucleic acid amplification tests (NAATs) because their sensitivity and specificity are high and they are approved by the U.S. Food and Drug Administration for use on urogenital sites, including male and female urine, as well as clinician-collected endocervical, vaginal, and male urethral specimens. Most NAATs that are approved for use on vaginal swabs are also approved for use on self-collected vaginal specimens in clinical settings. Rectal and pharyngeal swabs can be collected from persons who engage in receptive anal intercourse and oral sex, although these collection sites have not been approved by the U.S. Food and Drug Administration. Urine testing with NAATs is at least as sensitive as testing with endocervical specimens, clinician- or self-collected vaginal specimens, or urethral specimens that are self-collected in clinical settings. The same specimen can be used to test for chlamydia and gonorrhea.

Screening Intervals
In the absence of studies on screening intervals, a reasonable approach would be to screen patients whose sexual history reveals new or persistent risk factors since the last negative test result.


The big diff between me and another clinician might be how much of a "persistent" risk factor is a woman's husband. I see him as a persistent risk factor as long as she has unprotected sex with him.

They say urine is at least as sensitive. So sure, just do that. Yes, ovarian cancer screening is grade D. I said it was a weak reason to go down below. I think to accomplish all the good I want to do for the patient I would still offer yearly pelvic exams

 

[Raryn]

Note that the CDC, USPSTF, or any other organization that comes to mind don't recommend yearly gc/ct testing for all sexually active women forever. They recommend universal screening... up until age 25. And then as needed based on risk factors. And their definition of risk factors is different than crayola's.

Given that the vast majority of sexually active women are above age 25... she's overdoing it.

 

[VA Hopeful Dr]

No wonder the confusion.

according to this
http://www.health.harvard.edu/blog/...men-dont-need-yearly-pelvic-exam-201407027250
The ACP reviewed the evidence and said the yearly pelvic was optional.
However, they noted that the ACOG reviewed the same evidence and still stand by yearly pelvics.
http://www.acog.org/About-ACOG/ACOG...an-Recommendations/Screening-Ages-19-39-Years
This last link is from today. For 13-20 they recommend pelvic exam when indicated by history etc. For 21 and up they recommend yearly.

So it's a question of whose guidelines you want to follow. The internists or the ob/gyn. Seeing how quick the internists were to refer to ob/gyn, I think I'mma feel OK continuing to go by their recs instead.

I can do gc/chlamydia screening with urine, but if I want the full meal deal of what could be growing down there I gotta go digging.

I don't trust any of my sexually active patients' partners to be monogamous or wrap it up, so as far as I'm concerned even the women who otherwise might feel like they don't need yearly gc/chlamydia screening, still do. I think I still need to look all around if they are sexually active.

Let's just say I've seen women in decades-long relationships be surprised and danger averted because they had their yearly testing, on the basis of being sexually active at all.

Welcome to one of the frustrating things about medicine. Sure, if you test every woman every year then you are going to pick up asymptomatic cases. But its not a cheap test and assuming an average population you'll end up doing a few hundred to pick up that one. Plus you've tied up your schedule doing it meaning you're less available for other things.

This is why the USPSTF and ACOG differ. The former factors in things like cost and resources while the latter does not.

 

[VA Hopeful Dr]

No way I'd do paps if the group practice was to let the gynos do it. **** it. Why?

Yeah, unless the group brings you in to be the "something" guy then just go with the flow.

 

[Raryn]

Welcome to one of the frustrating things about medicine. Sure, if you test every woman every year then you are going to pick up asymptomatic cases. But its not a cheap test and assuming an average population you'll end up doing a few hundred to pick up that one. Plus you've tied up your schedule doing it meaning you're less available for other things.

This is why the USPSTF and ACOG differ. The former factors in things like cost and resources while the latter does not.

Agree completely. In addition, the problem of false positives is a huge one in the consideration.

 

[VA Hopeful Dr]

Agree completely. In addition, the problem of false positives is a huge one in the consideration.

Maybe its just me, but that one doesn't usually enter into my consideration. Overwhelmingly, patients almost seem to like me maybe finding something then getting a more invasive/expensive test that tells them they're actually fine. That does factor into resources as mentioned, but much less so than a regular screening program will. For example, even if yearly FOBT screening for colon cancer had a 20% false positive rate that's still a bunch fewer scopes than we're doing now.

 

[jdh71]

ITT: dorks

 

[PlutoBoy]

No way I'd do paps if the group practice was to let the gynos do it. **** it. Why?

Well, sometimes I think that referring for this is a misuse of resources unless the patient wants to be referred. I've had patients ask me to refer them to the gynecologist though. I love those patients.

 

[Cytarabine]

Welcome to one of the frustrating things about medicine. Sure, if you test every woman every year then you are going to pick up asymptomatic cases. But its not a cheap test and assuming an average population you'll end up doing a few hundred to pick up that one. Plus you've tied up your schedule doing it meaning you're less available for other things.

This is why the USPSTF and ACOG differ. The former factors in things like cost and resources while the latter does not.

I was under the impression uspstf specifically did NOT factor in cost effectiveness to their recs

 

[HelpPleaseMD]

definitely have a chaperone of the opposite sex when doing pap smears. I agree that it is a procedure an outpatient docs should know how to do and something that primary care docs should ideally do. it wouldn't be something I would do if i were an outpatient doc when there are so many gyns in my part of the country.

 

[wholeheartedly]

I think access to gyns is probably a huge factor. I also wonder if ibsurance coverage and cost to patients come into olay as well.

 

[deleted547339]

Agree completely. In addition, the problem of false positives is a huge one in the consideration.

Really? One shot of rocephin or one azithro tab is a huge consideration?

 

[Raryn]

Really? One shot of rocephin or one azithro tab is a huge consideration?

That post was in reference to screening pelvics, not STD screens (which can be done with urine). Screening pelvic exams aren't done to screen for GC/CT. They're done to screen for ovarian masses and god knows what else. False positive considerations end up being surgeries, not one shots of abx.

 

[dozitgetchahi]

That post was in reference to screening pelvics, not STD screens (which can be done with urine). Screening pelvic exams aren't done to screen for GC/CT. They're done to screen for ovarian masses and god knows what else. False positive considerations end up being surgeries, not one shots of abx.

Well, a questionably positive pelvic exam is likely to result in pelvic US and/or other imaging modalities that can sometimes help distinguish between 'something' and 'nothing'. I agree about the futility of doing these exams 'just because', however.

And PCPs should be able to do paps and manage basic OB issues. Period.

 

[Crayola227]

ITT: dorks

I'm glad.

 

[VA Hopeful Dr]

Well, a questionably positive pelvic exam is likely to result in pelvic US and/or other imaging modalities that can sometimes help distinguish between 'something' and 'nothing'. I agree about the futility of doing these exams 'just because', however.

And PCPs should be able to do paps and manage basic OB issues. Period.

Y'all get much OB in residency now?

 

[Raryn]

Y'all get much OB in residency now?

Basic gyn issues we should be able to manage. Basic medical issues in a pregnant patient we should be able to manage. Actual Ob issues? Ain't touching that with a ten foot pole. As a consultant (or even primary depending on the situation) I've helped manage things like CHF, infections, even ARDS and some rare malignancies/congenital heart conditions/endocrinopathies in pregnant patients (and a LOT of syphilis... very common admission for pen desensitization where I trained)... but I'm not even considering managing the actual pregnancy. That's crazy talk.

 

[gutonc]

Y'all get much OB in residency now?

None...as it should be.

But we should be able to manage basic medical issues related to the female GU tract, just as we should for the male GU tract.

Management of pregnant patients will vary by institution. Where I trained, pregnant patients admitted for non-pregnancy medical issues not requiring ICU level of care (or not already patients of one of the few sub-specialties with their own service...CHF, adult congenital heart or Hem/Onc) were admitted to OB with medicine (or usually the sub-specialty) consulting.

 

[dozitgetchahi]

Basic gyn issues we should be able to manage. Basic medical issues in a pregnant patient we should be able to manage. Actual Ob issues? Ain't touching that with a ten foot pole. As a consultant (or even primary depending on the situation) I've helped manage things like CHF, infections, even ARDS and some rare malignancies/congenital heart conditions/endocrinopathies in pregnant patients (and a LOT of syphilis... very common admission for pen desensitization where I trained)... but I'm not even considering managing the actual pregnancy. That's crazy talk.

Yeah I meant to state 'basic gyn issues'. I'd never touch OB. But for whatever reason, there seems to be this movement away from IM PCPs doing even basic gyn stuff, which I find surprising and a bit embarrassing. Consulting OB for a pap is just silly.

 

[IMreshopeful]

Yeah I meant to state 'basic gyn issues'. I'd never touch OB. But for whatever reason, there seems to be this movement away from IM PCPs doing even basic gyn stuff, which I find surprising and a bit embarrassing. Consulting OB for a pap is just silly.

There's a reason. Money, time, and liability.

Where I've trained we were required to do the bare minimum to get trained to see gyn patients and that was it because frankly most of our residents went into fellowship or hospitalist careers and nobody felt it was necessary to know these things. I think it's a shame we don't get some basic OB, and subpar GYN training, but this is largely a function of the institution where you train.

As an internist I can also see the Pap smear - which requires time to set up and do appropriately - simply taking away time from seeing other patients and therefore it not being profitable.

 

[gutonc]

As an internist I can also see the Pap smear - which requires time to set up and do appropriately - simply taking away time from seeing other patients and therefore it not being profitable.

Unless you do a bunch of them, or have a "pap day" on your schedule, it really isn't profitable. You need to have well trained MAs to help you, a well stocked supply room, appropriate exam rooms (every exam table doesn't have stirrups), etc, etc. With all these things in place, you can power through 3 or 4 of them an hour as long as nobody wants to actually ask a question.

 

[PlutoBoy]

Well, a questionably positive pelvic exam is likely to result in pelvic US and/or other imaging modalities that can sometimes help distinguish between 'something' and 'nothing'. I agree about the futility of doing these exams 'just because', however.

And PCPs should be able to do paps and manage basic OB issues. Period.

OB? No. No way.

I guess you coukd argue that everyone should be able to manage basic issues but for better or worse that's not what we are doing in real life.

Should a gynecologist or a surgeon manage hypertension and dyslipidemia? They probably can but they don't. It is just not worth it to them and I am confident that I can manage it better than most gynecologists/surgeons.

Now, a pap smear is another thing. As a screening test I do agree that we should do it or at least be able to do so.

But even women seem to prefer a gynecologist for this. Just yesterday I offered a pap to another patient and she told me that she would rather be referred to a female gynecologist...

She is a white American woman so there is no religious issue.

I can probably manage amenorrhea (I recently did) but the patient is probably better off seeing her OBGYN.

I guess we all have our area of expertise.

 

[jdh71]

I like how everyone says we shouldn't have to manage any OB and we shouldn't. Every couple of months I get an OB or post-partum disaster bomb. I used to watch as my OB colleagues would slowly back away without making eye contact with horror. Sometimes you just do what you gotta do. Whatever that is. Be creative. Think outside a box. Read an ultimate article. Sometimes I feel like my job is like being dropped off in the arctic in my underwear only to show up in Miami ten days later in a three piece suit, a fist full of gold coins, and a million dollar smile.

 

[Raryn]

I like how everyone says we shouldn't have to manage any OB and we shouldn't. Every couple of months I get an OB or post-partum disaster bomb. I used to watch as my OB colleagues would slowly back away without making eye contact with horror. Sometimes you just do what you gotta do. Whatever that is. Be creative. Think outside a box. Read an ultimate article. Sometimes I feel like my job is like being dropped off in the arctic in my underwear only to show up in Miami ten days later in a three piece suit, a fist full of gold coins, and a million dollar smile.

In the ICU as a resident, I had my fair share of pregnant disasters, in addition to the ubiquitous pregnant woman with syphilis that needed pen desensitization. I personally intubated two pregnant women with ARDS, including one who ended up having to have a crash c-section *in the ICU*, then later that day decompensated due to an intra-abdominal hemorrhage... that culminated in a Hb of 1.7 only a few hours after it was 8 (the lab made us send a repeat sample b/c they didn't believe it... delayed care for 30 minutes). She walked out of the hospital minus her pituitary (Sheehan's is apparently not a myth) a couple weeks later.

That said, even with all of these pregnant ladies, at no point was I managing the pregnancy. If there was any question wrt to the fetus, I'd call Ob. I was managing the ARDS, septic shock, whatever, but that's not managing OB. If there was non-urgent decisionmaking regarding drug choice and both being class C (for example), I might just run it by the Ob colleagues... but in the acute setting, the mom is my patient (not the fetus), and I have nothing to do with the managing of Ob. Cards fall where they will.

 

[Crayola227]

I like how everyone says we shouldn't have to manage any OB and we shouldn't. Every couple of months I get an OB or post-partum disaster bomb. I used to watch as my OB colleagues would slowly back away without making eye contact with horror. Sometimes you just do what you gotta do. Whatever that is. Be creative. Think outside a box. Read an ultimate article. Sometimes I feel like my job is like being dropped off in the arctic in my underwear only to show up in Miami ten days later in a three piece suit, a fist full of gold coins, and a million dollar smile.

Yeah, OB literally isn't in the scope of IM practice... so that's like the worst lawsuit ever waiting to happen.

There's few specialties with true age/gender/pregnancy status divides. That's one of them.

 

[jdh71]

In the ICU as a resident, I had my fair share of pregnant disasters, in addition to the ubiquitous pregnant woman with syphilis that needed pen desensitization. I personally intubated two pregnant women with ARDS, including one who ended up having to have a crash c-section *in the ICU*, then later that day decompensated due to an intra-abdominal hemorrhage... that culminated in a Hb of 1.7 only a few hours after it was 8 (the lab made us send a repeat sample b/c they didn't believe it... delayed care for 30 minutes). She walked out of the hospital minus her pituitary (Sheehan's is apparently not a myth) a couple weeks later.

That said, even with all of these pregnant ladies, at no point was I managing the pregnancy. If there was any question wrt to the fetus, I'd call Ob. I was managing the ARDS, septic shock, whatever, but that's not managing OB. If there was non-urgent decisionmaking regarding drug choice and both being class C (for example), I might just run it by the Ob colleagues... but in the acute setting, the mom is my patient (not the fetus), and I have nothing to do with the managing of Ob. Cards fall where they will.

You missed the point seabass.

And YOU weren't managing any of that your attending really was. They also carried all of the liability. Low hgb's like that isn't some kind of uncommon occurrence nor is an in unit csection.

OBs fade way to far into the background way too much in these types of cases for my liking. There's a bit of s moral hazard to their line of work that we all need to remember because their biggest disasters will be our problem even if we manage zero pregnancy issues.

 

[IMreshopeful]

You missed the point seabass.

And YOU weren't managing any of that your attending really was. They also carried all of the liability. Low hgb's like that isn't some kind of uncommon occurrence nor is an in unit csection.

OBs fade way to far into the background way too much in these types of cases for my liking. There's a bit of s moral hazard to their line of work that we all need to remember because their biggest disasters will be our problem even if we manage zero pregnancy issues.

I think part of the issue is that critical care experience in obstetrics is abysmal during training. I mean that's part of the reason people do it - other than your gyn onc disasters the patients are usually otherwise healthy.

 

[Raryn]

You missed the point seabass.

And YOU weren't managing any of that your attending really was. They also carried all of the liability. Low hgb's like that isn't some kind of uncommon occurrence nor is an in unit csection.

OBs fade way to far into the background way too much in these types of cases for my liking. There's a bit of s moral hazard to their line of work that we all need to remember because their biggest disasters will be our problem even if we manage zero pregnancy issues.

The attending sure was managing those patients... during the bits of their care that happened during the day. Normally I'd say during the bits of care that happened from 9am-2pm, but in that particular case attending actually stayed late till dinnertime. Otherwise, his valuable management took place from home, sleeping. Most of the critical issues happened on nights, and we don't even have fellows in house, much less attendings. Of course, with a pregnant lady that sick, I was on the phone with the fellow giving updates periodically, but the management really was mine in the couple cases I'm thinking of. For better or for worse.

And I'd have to say that my point was simple: The critical care team isn't managing Ob in these scenarios. They're managing a critically ill patient who happens to have an Ob comorbidity. Treat the mom, because the worst thing for any fetus is a dead mother, and the rest sorts itself out (with the assistance of the Ob/Gyn as needed).

 

[Crayola227]

ITT:

From outpatient attending management of paps, to inpatient ICU management of dying preggos by residents and Sheehan's
Wow. This thread escalated quickly.

I love you guys sometimes, I really do. I am laughing so hard.

EDIT: but no really, fascinating intercourse about the intersection between IM & ob/gyn

EDIT EDIT: lmao, @Raryn the fetus is an "ob comorbidity" lol there's an IM attitude for you 😎

 

[jdh71]

The attending sure was managing those patients... during the bits of their care that happened during the day. Normally I'd say during the bits of care that happened from 9am-2pm, but in that particular case attending actually stayed late till dinnertime. Otherwise, his valuable management took place from home, sleeping. Most of the critical issues happened on nights, and we don't even have fellows in house, much less attendings. Of course, with a pregnant lady that sick, I was on the phone with the fellow giving updates periodically, but the management really was mine in the couple cases I'm thinking of. For better or for worse.

And I'd have to say that my point was simple: The critical care team isn't managing Ob in these scenarios. They're managing a critically ill patient who happens to have an Ob comorbidity. Treat the mom, because the worst thing for any fetus is a dead mother, and the rest sorts itself out (with the assistance of the Ob/Gyn as needed).

As per my point thats a swing and a miss, twice. An unusual phenomenon for you usually.

Of course I didn't make the patient pregnant. Of course they are my patient. This is some sort of "no duh" type of observations. Wasn't my point.

 

[PlutoBoy]

Sick and tired of doing this crap...

 

[gutonc]

Sick and tired of doing this crap...

If you're finding crap when you do a PAP, you're doing it wrong.

 

[Crayola227]

If you're finding crap when you do a PAP, you're doing it wrong.

Actually, I had a patient like this. Crohn's. Fistula. Farting and more through her vagina.

 

[Crayola227]

Of course I didn't make the patient pregnant.

I don't believe you.

 

[PlutoBoy]

New clinic policy: If your BMI is greater than 35, you are going to be referred to GYN. Thanks.