I’ll admit, I’m emboldened. My previous effort was well received in this community, so we’ll see where this one takes us…
As noted in my previous diary, I am an obstetrician/gynecologist at a major military medical facility on the East Coast. What does this mean to the non medical types? We have a full complement of subspecialists in the field including Gynecologic Oncologists (physicians specializing in uterine, ovarian, cervical, vaginal and vulvar cancer), Maternal Fetal Medicine (high risk obstetricians), Reproductive Endocronologists and Infertility (specialists focusing on infertility and hormonal disorders), and Urogynecologists (surgeons specializing in pelvic floor prolapse and urinary problems). In addition, we have an ob/gyn residency program with six residents per year. We have 12 general ob/gyns (of which I am one), supervising over 4,000 deliveries per year. We have the busiest outpatient clinic in the Department of Defense.
A few observations regarding the care we provide our female patients: active duty, dependent spouses and retired beneficiaries.
- Obstetrically speaking, it is rare if not unheard of for women not to get prenatal care from the beginning of pregnancy. Frankly, I can’t overstate the importance of this fact. I often smile when a resident presents a patient to me who is in labor and “only” had four prenatal appointments. This is the exception rather than the rule. The rule is that women enroll in prenatal classes and are often seen prior to 12 weeks gestation. This is vital for a number of reasons- from being able to date her pregnancy appropriately and to accurately identif risk factors for potential complications in her pregnancy based on her prenatal and medical history. If something is identified, they are referred to the appropriate services, whether that is extra ultrasounds, endocrinology, or other subspecialists.
- Gynecologically speaking, all treatments are on the table and treatment plans are coordinated based on evidence based recommendations and the patient’s desires. If a women has abnormal bleeding, a full workup is performed, problems are identified, and information given to help the woman make the best decision for her given diagnosis. I often receive consults stating “patient with x diagnosis, evaluate for hysterectomy”. After a full evaluation, often these patients do not necessarily need such major surgery and opt for a more “conservative” treatment plan. If hysterectomy is indicated and desired, the least invasive route is offered, whether it be laparoscopic (small incisions with a camera) or vaginal (no abdominal incision). All the technology required to perform these advanced surgical procedures are available and used on a daily basis.
- Reproductive health and contraceptive options are paramount. This is vital all women, but especially for the active duty female population who deploy to inclement environments and and something I feel passionate about. All forms of contraception are available and offered to those women who desire this service. This includes the more expensive (in upfront cost) long-term forms of contraception including IUDs and injectables (Implanon). An interesting finding, in my opinion, is what women choose for their contraception when cost is removed. For example, our institution just reviewed the postpartum contraceptive choices of our population and found that over 30% of women desired an IUD for postpartum contraception and approximately 45% of women received a long-term or permanent form of contraception (IUD, Implanon, tubal ligation, or Essure tubal occlusion). For those that don’t know, this number is astronomical compared to the rest of the country. IUD use totals 1 to 2% of all contraceptive use in this country. The reasons for this are multiple, but I find it intriguing that the numbers in our institution compares similarly to the "socialized" countries in Europe and Asia when cost of the devices is not a consideration.
- The system is not perfect. Obviously, abortions are not offered in military facilities and this will not likely change. Women have to navigate the administrative maze during what is inevitably a difficult and stressful time in her life whether it is pregnancy (desired or undesired) or infertility or concern for malignancy.
- Evidence based practice is the rule rather than the exception. The hope of my previous diary was to debunk this misconception and wish to reiterate this again. My colleagues and I simply try to practice medicine with the best evidence we have at the time with the best interest of our patients in mind. Isn’t this the goal?
Thanks for your time . Again, let’s get universal healthcare for all women (and men). We need this! Peace.