For the Times They Are A-Changin’

Come gather ’round people…  

…If your time to you’s worth savin’  

Then you better start swimmin’ or you’ll sink like a stone  

For the times they are a-changin’ ~Bob Dylan

I began my ACOG Presidency this past Wednesday by reciting some of Bob Dylan’s famous verse from the 1960’s. It rings true today, especially in medicine and our specialty as obstetrician-gynecologists.

As the times change I thank our now past-president, Dr. John Jennings, for his leadership and friendship during this past year. With the counsel of his past president, Dr. Jeanne Conry, John tackled some of the very difficult issues facing our practices and our workforce. I will continue his fine work and advance it on behalf of our patients, our specialty and our organization, ACOG.

When I chose the ob-gyn specialty some 35 years ago, it was in part because of the ability to provide a continuity of care over the course of a woman’s life and also the privilege of witnessing the birth of a new family. But now I worry that the excitement and enthusiasm that I felt then are being thwarted by many external forces, resulting in physician dissatisfaction. My concern is that unhappy physicians cannot provide high quality care.

The health care world talks about the “Triple Aim” of providing higher quality care, at lower cost, while at the same time enhancing patient satisfaction. We need to expand the “Triple Aim” to the “Triple Aim Plus One” and include physician satisfaction as an important metric.

My two immediate predecessors began addressing how we can provide more care for more people.  Dr. Conry’s landmark task force on Well Woman Care defined the important elements of women’s health care, and Dr. Jennings encouraged us to team up with collaborative health care professionals to provide more care more efficiently.  Now, it is time to really take charge of health care and focus on two problems which together contribute more to morbidity and mortality in this country than all of the cancers and specific diseases for which we routinely screen and treat: smoking and obesity.

Oftentimes, ob-gyns are the only regular contact many of our patients have with the health care system. We meet many of our patients when they are very young, often before they become obese and certainly before they build up 20 or 30 or more pack-years. We should not let this happen on our watch!   

To help you help your patients, I will ask ACOG’s standing committees to develop a toolkit specifically designed for obstetrician-gynecologists to address obesity and cigarette smoking in their daily practice.  First do no harm? Let’s go way beyond that: let’s do even more good than we do right now!

Along with our patients, we must always be the ones making the health care decisions — not the administrators and certainly, not the politicians. So let’s take charge of health care. Let’s step outside of our comfort zone of Pap smears and pelvic exams and provide care for the whole patient… For the times, they are a-changin’.

18 thoughts on “For the Times They Are A-Changin’

  1. i don’t have a study i can quote, but just what i am seeing in our community. i do wholeheartedly agree with Dr. DeFrancesco in that this is more likely a generational problem than a gender issue. The generational part just overlaps with the gender shift. regardless, we need to be prepared for an Obstetrician shortage and the planning process needs to have started yesterday as this will hit our workforce hard and soon if we are not prepared.

  2. Welcome, Dr. DeFrancesco,

    I respectfully ask that, during your presidency, you make informed consent at time of hysterectomy with ovary removal a priority.

    Of the 600,000 hysterectomies performed in the U.S. every year (source: the CDC), 540,000 are for benign conditions, and another 60,000 are related to cancer risk or diagnosis. Of the 540,000 surgeries for benign conditions, at least 340,000 of the women also lose the function of their healthy ovaries alongside their hysterectomy (300,000 women allow them to be removed at the time of surgery, and those of another 40,000 fail within a few years due to loss of blood flow). These surgeries are so commonplace that they go virtually unnoticed. However, after undergoing the surgery myself, I knew something wasn’t right, something my doctor hadn’t shared with me, and since, I’ve learned what is well-known to the gynecological surgery community and within the American Congress of Obstetricians & Gynecologists (ACOG).

    Since at least the 1970s, the medical community has understood that a woman’s ovaries produce essential hormones throughout her lifetime. They know that, after menopause, the level of testosterone produced by the ovaries increases until, by her 70’s, a woman is making as much as she was when she was young. They also know that much of that testosterone turns into estrogen in fat cells and skin, and that the right balance of those endogenous hormones perform many important bio-protective, endocrine functions in women as they age.

    In addition, the doctors know that only 2% of all women have an increased risk of ovarian or breast cancer, and that the risk prevented by ovary removal in the average woman is less than 1/2 of 1%. Yet 55% of all women having a hysterectomy to address pain from fibroids, endometriosis, etc., 820 women every day, allow their ovaries to be removed at the same time, either because they believe that they are reducing a serious risk of cancer or that they are removing organs that will stop working in a few years, anyway.

    Doctors know that neither thing is true, but in 50% of the U.S., informed consent law is structured so that not sharing that information is entirely defensible. What the doctors also don’t share with their patients is that pre-menopausal women who agree to this surgery increase their risk of all-cause mortality 67%, and their risk of heart disease, the number 1 killer of both men and women in the US, about 45% with hormone treatment, or 85% without. The subsequent need for the adrenal glands to try to pick up the slack for their missing endocrine system counterparts leads to a ripple effect of compromised immunity and well-being. As a result, these women have a demonstrated doubled risk of lung cancer, cardiovascular disease, and Parkinson’s disease. Their risk of Alzheimer’s, dementia, osteoporosis, type 2 diabetes goes up significantly. They will never experience the natural, post-menopausal rise in hormone levels, but will remain at a 40% lower testosterone level than post-menopausal women, and all of the health benefits that that confers to muscle strength and bone.

    Though the risks are well-known, in a 2014 survey, 75% of doctors who responded said that they wouldn’t take a patient’s past or family history of heart disease or osteoporosis into account when evaluating her for ovary removal. Another 66% said that they would perform the surgery on women in their 30’s at the women’s request, even though the ACOG advises against it in women aged 50 and under. Whether that’s a function of the fact that this surgery is a $16B a year industry or a situation where doctors are simply doing what they’ve been taught to do is an open question, but the risks to the women is not. Today in the U.S., this is the condition that 12 million women are in, and most have no idea.

    It’s time to reassess how we look at the ovaries. By referring to them as “reproductive organs” and not as a fundamental part of the endocrine system, we’ve come to view them as disposable in cases where a woman either doesn’t want or is done having children. I’ve spent the last year and a half since my surgery in January 2014 conducting research, largely using NIH studies as my sources, and have finally pulled together enough information and citations to fight for more appropriate gynecological surgery and informed consent reform.

    With best regards,
    Deirdre Menard

      • Thank you very much for calling attention to this very important issue. I fully agree that informed consent for anything we do must be truly and accurately “informed,” so patients can make the best decisions for their care.
        MSD

  3. Good luck to the new president and to all of us practicing OB/GYN physicians.
    I have not given up obstetrics and I did my residency in 1985-1989. Yes, it is very hard to keep a practice going, and I am a solo practice- I know , extinct in a few years for sure at this pace. But I applaud the new president’s goal to address obesity and smoking. Haven’t we been doing this already routinely in our practices? We are labeled as specialists not primary care by many insurance companies in my area, but I feel as an OB/GYN I care for the whole person in many cases of my patients . As long as I can help my patients I will strive to continue my practice.

    • Dr. Vasilescu,
      You are absolutely correct… regardless of whether we are formally called PCPs or “Specialists,” we nevertheless all should (and most do) provide the best care for our patients… and that clearly includes addressing such basic issues as smoking and obesity. I salute you for your many years of dedicated service to your patients!
      With best wishes,
      Mark DeFrancesco

  4. Congratulations Mark! It has been a long time since we first met at the ACOG leadership course at the UNC campus when Robin Williams was filming Patch Adams, staying in the same UNC guest house as ourselves! While you are our president, please give serious thought to ACOG endorsing universal health care for all women in the U.S. as a human right. Personally, I would like to see workshops on promoting a national health plan (www.pnhp.org). The present health care system is unethical and immoral in my way of thinking. We cannot afford to remain the only industrialized country in the world without universal care for women. If the most capitalistic country in the world, Switzerland, can have a universal system for all citizens, the U.S. can do it— if we have the will. Physicians can change the system in short order by refusing to sign contracts with insurance companies. Let us stop blaming others for our dilemma, and lead health care rather than follow the will of health care corporations, whose only deep desire is to make as much profit off ill people and pregnant women as possible. You go brother. May you have peace and all good as you proceed to speak truth to power. When things get tough, just put that Patch Adams DVD in and renew your strong commitment to health care for all with compassion and healing………..just tupper

    • Tupper,
      Great to hear from you my friend… 1998 was a great class at the Leadership Institute!!
      Thanks so much for your thoughtful comments. As physicians, we have such a responsibility to society, and as you know, ACOG takes that responsibility very seriously. Now that I am in the “bully pulpit” for the next year, I will do my utmost to do the good work that we all want to do.
      I enjoyed giving my inaugural address in my white coat, to emphasize the importance of our vocation as physicians, but I now realize I missed the opportunity to also put on the red nose that Patch Adams made so popular in that movie!
      Best wishes Tupper, please let me hear from you again…
      Mark

  5. I congratulate you as well. Having practiced for near 30 years, your words ring true. The perk of being a doctor was having control in what was a respected profession. This is no longer true. If accountants and attorneys had to jump through hoops like we do, politics would look very different. Enjoying the job and feeling proprietary about the product we produce is dying. To speak to the previous writer, yes, I gave up OB earlier than my male colleagues. But it was not for raising my kids, it was for being treated like a commodity. The joy was in sharing experiences and wisdom with patients. Not in being available round the clock for “dial a doc” calls at all hours. And not dealing with the rudeness of people who instead of thanking me for driving to the hospital at 2 pm would instead say, “so when the f**k can I get my epidural?”

    • Thanks for your message.. and thanks for your many years of service to your patients. I hear your frustration and that is what in part has sparked my campaign to “Take Charge of Healthcare” once again. We need to address many of the issues you raise, in a meaningful way. Please don’t give up… we can still do a lot of good out there.
      Best wishes,
      Mark DeFrancesco

  6. Congratulations on your new position!

    One area that I hope your new administration will address is the issue of pregnancy loss. One positive way that “times they are a changin'” is that pregnancy loss is more spoken about than in years past and more supports are available for grieving families.

    In my experience as a woman who has experienced two miscarriages and a stillbirth, not all medical professionals have the tools to respond appropriately in supporting patients and their partners through these painful losses.

    Below is a link to an article I published on Huffington Post offering a parents’/patients’ perspective on this issue. I would welcome your feedback and insights.

    http://www.huffingtonpost.com/alana-rosenstein/pregnancy-loss_b_7179414.html

    • Thanks for sharing your insightful and poignant article. I am so sorry for the painful losses you experienced.
      I appreciate the fact that you magnanimously acknowledged that most likely the poor way things were often handled by your doctors resulted less from poor intentions and more from lack of appropriate education and sensitivity about this area.
      I will pass your article along to our organization and hope it will contribute to our educational programs in a meaningful way.
      Sincerely,
      Mark DeFrancesco

  7. Congratulations on your recent election to ACOG president
    I would ask that over your tenure, you address the real issues facing OB/GYNs.
    We must stop being victimized by Big Insurance companies both in their collusion with federalized payment systems and their new assault on surgical techniques and technologies. While I applaud the ACOG joining every other medical establishment in taking credit for repealing SGR, a very archaic venture, I wonder what will become of IPAB and how much further OB/GYN’s will fall behind the other specialties in reimbursement? I watched my 22 year old practice whittled down under the previous regimes and could take it no longer so I walked away from a wonderful practice, like so many others to join Corporate medicine. We are still at risk of sinking further until we take a stand. We are one of the hardest working specialties with one of the highest liabilities and should be seeking increases in reimbursement rather than rejoicing over repealling 15 years of threatened demoralizing cutbacks.
    Thank you

    • I could not agree more with the above comment. Addressing and reversing the continued slashing of reimbursements should be ACOG’s number 1 priority, period!!

    • Thanks for your message. We are hard at work attacking the IPAB, and will focus on that (again) during our next Congressional Leadership Conference. Your comments also resonate with the theme we’ve adopted for this Presidential year, “Taking Charge of Healthcare.” Times are changing, no question about it, but we need to be at the table having input into those changes. It will never be fast enough, or vast enough, but we can’t give up. Our Government Relations department has been hard at work getting us a seat at that table. Stay tuned….

  8. I am pleased to have new leadership at ACOG but I also thank your predecessors. I believe we will have a specific OB workforce shortage faster than anticipated. I trained from 94-98 at Baylor College of Medicine in Texas. During my residency, the shift to predominantly female residents occurred which I believe is a great thing for our specialty. However, it is well documented that their productivity is less than the male doctors. This is almost always likely to be by choice. The lady doctors almost always have mothering responsibilities at home which I encourage to ensure they are raising strong, educated families like we encourage for our own patients. However, I have already seen that my contemporaries are stopping Obstetrics sooner than the men. This will eventually lead to significant issues with covering Obstetrics for communities. I believe some of the solution is mid level providers in office and CNM’s in the hospital but we are still necessary to be on call to cover them.. I also believe the growth of OB hospitalists is necessary for this reason but is limited by financial constraints in it’s design. Please let me know how I can help at levels you feel appropriate for this problem. Monte Swarup, MD

    • Thanks for your message. During our recent years of focusing on these issues, one thing that’s become clear is that many of the workforce changes are not so much “gender-based” but “generation-based.” More men are helping with child care, so traditional roles are changing greatly.
      That being said, you are right on target that we need to work in teams, and bring into our practices collaborative providers like midwives and advance practice nurses, to help us provide more care for more people in a smart and efficient way.
      Hospitalists/laborists will also help significantly, as will adoption of electronic tools to connect our patients better with our practices, and our practices better with each other, our hospitals, labs, and other referring physicians.
      We’ll get there… but it’s a painful process in the meantime.
      Thanks for your thoughts.

    • Monte,

      I’m curious where it’s well-documented that female doctors are less productive than male doctors. Can you share a study?

      Thanks

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