Women's Health: Do You See the Big Picture?
I had a new patient come to me last year, a woman in her 60s, complaining of back pain. Over the course of several months and multiple visits, and after indicated tests and imaging, we worked together to formulate and execute a pain management plan. Her acute condition improved, but I found myself wondering: Had I done a thorough job? Or had I let myself get caught up in dealing with one specific problem and had failed to see the bigger picture? Had I offered this patient all of the other tests and screenings -- such as colonoscopy -- that were recommended for her age group?
Patients often, and understandably, focus on the problem that is bothering them right now. But back pain isn't what is going to eventually kill that patient. Cancer, heart disease and other factors are much more likely to cause serious, long-term problems. As physicians, it's our job to stress the importance of doing all the other things that can help keep patients healthier longer.
So how are we doing?
A CDC study published this month in JAMA Internal Medicine indicates that when it comes to women's health, we could do better -- possibly much better. Researchers looked at data from more than 60 million preventive health visits to OB/Gyns and primary care physicians and compared what services were being offered by the two types of physicians.
Perhaps not surprisingly, OB/Gyns were more than twice as likely as primary care physicians to offer screenings for breast cancer and cervical cancer and almost twice as likely to test for chlamydia. However, women who saw a primary care physician were likely to receive a much broader range of services.
For example, 34.5 percent of women 45 or older received cholesterol screenings from their primary care physicians compared to only 5.4 percent of those who saw an OB/Gyn. Women who saw a primary care physician were four times more likely to be tested for diabetes.
But both OB/Gyns and primary care physicians have room for improvement. Colon cancer is the third-leading cause of cancer-related death in women. But the study found that among women ages 50-75, a total of only 6.1 percent were screened -- 7.2 percent of women who saw a primary care physician and 3.9 percent of those who saw an OB/Gyn.
The study also examined whether women received counseling about four key health issues: diet, exercise, obesity and tobacco use. Researchers found that 81.5 percent of women who saw an OB/Gyn and 73.5 percent of women who saw a primary care physician did not receive counseling on any of those important topics. Although not all patients need counseling on these issues, the numbers seem shockingly high given that more than one-third of U.S. adults are obese and nearly one-fifth smoke.
Despite the low overall numbers, primary care physicians fared better than OB/Gyns in all four areas. A little more than 19 percent of primary care visits involved counseling for diet compared to 12.4 percent of visits with OB/Gyns, 14.3 percent of primary care physicians offered counseling about exercise compared to 9.9 percent of OB/Gyns, 7.5 percent offered counseling for obesity compared to 4.2 percent of OB/Gyns, and 3.4 percent offered counseling for tobacco compared to 2.6 percent of OB/Gyns.
Time is obviously a factor. There's only so much ground we can cover in a 15-minute appointment, and patients often come with their own questions and concerns that have to be addressed. But taking a few seconds to show a patient where he or she stands stand on the BMI chart can be powerful, eye-opening and the first step in pointing that patient in a new direction. Patients who want to stop smoking can be referred to quitlines. We also can schedule a follow-up for patients who need more time to address their issues.
Communication likely is another factor. We need to let our patients know what tests and screenings are recommended and appropriate for their age. For our patients who see both an FP and an OB/Gyn, we also may need to do a better job communicating with our OB/Gyn colleagues to ensure that someone is taking responsibility for offering the appropriate services.
It's worth noting that the study's data were drawn from visits during 2007-2010 -- before the Patient Protection and Affordable Care Act mandated that health plans cover a wide range of preventive services. If this issue is re-examined in a few years, it will be interesting to see how much our numbers improve.
How does your practice use electronic health records, patient registries or other tools to ensure that patients receive recommended tests or screenings?
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
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