Comprehensive Care in the Land of Ob/Gyn

Many patients are starting to think of their OB/GYN as their primary care provider, but not every OB/GYN is comfortable with this designation, often simply because they don’t have the time to provide comprehensive general health care to every patient. However, Ilene S. Gewirtz, MD, FACOG, a gynecologist who takes a more holistic approach to her practice in East Islip, New York, believes that all OB/GYNs, regardless of whether they are part of a large group practice or a solo boutique-style practice, should be providing comprehensive care through education, if not expanded services.

"It's our job at well visits to discuss with patients the importance of good nutrition, healthy weight, exercise, blood pressure, and cancer screenings," she told ObGyn.net. Some patients might want the full primary care workup, with lipid testing, or even the option for a sick visit for cold or flu symptoms. A solo or small boutique-style practice (generally gynecology only) might offer all of these services, but a larger group practice serving both obstetric and gynecology patients may not. It's all about education and managing patient expectations when it comes to wellness care that goes beyond the usual services offered by OB/GYNs, says Gewirtz. Make sure your patients know what services you provide and what services you don't provide.

"I'm perhaps in the minority, but I carry a stethoscope and generally take vital signs and perform a chest examination. I may hear a heart murmur, but cardiology isn't my specialty, so I'll refer for a second opinion," said Gewirtz. If I'm the only physician my patient is seeing for preventive care, then I want to have the best chance of identifying a possible larger health problem.

Comprehensive Cancer Screening

In addition to the usual well-visit services, such as a pelvic exam and screening for breast and cervical cancer, OB/GYNs should consider more comprehensive cancer screening. Ovarian cancer, for example, may be asymptomatic for years, but there are often signs of the disease that could be discovered through a Q&A of symptom history. For example, symptoms such as urinary urgency or bloating should always be checked out, with a transvaginal ultrasound exam being a good place to start. If an ovarian mass is found, the ROMA (Risk of Ovarian Malignancy Algorithm) test is helpful in determining whether a GYN-ONC should be involved in the case.

Colorectal cancer screening is also an important part of the comprehensive well visit. Current guidelines recommend that women age 50 or older be screened for colorectal cancer, with screening intervals depending on the type of test used. Gewirtz, however, says women 40 years or older should be offered an at-home fecal screening test for colorectal cancer. High-risk women should be screened at this earlier age, and for other women, it may take them a good decade before they'll agree to the screening test.

Some OB/GYNs may not offer this screening test, but we can't assume that these tests will be offered by other providers, especially if we are our patients' only point of entry into health care, said Gewirtz. The problem with these mail-in kits is that some patients just refuse to handle feces. Some of the newer kits are more comprehensive and include everything a patient would need, even gloves, but the older screening kits tend to have just a swab and an envelope.

Another issue is the cost of the tests. Fecal occult blood tests are usually covered by most insurers, and the newest multi-target stool DNA test is covered by some private insurers and Medicare.

"Patients with a family history of colorectal cancer are usually pretty regular about colorectal screening," said Gewirtz. For those patients who are resistant to these screening test, it's our job to keep educating them about the importance of screening and to keep recommending these tests. Again, if we are the only physician our patients are seeing, we need to be as comprehensive as possible in our efforts to keep women healthy.

Follow Up

Follow up is such an important part of patient care and often the aspect of care that often slips down our office priority lists. If possible, have your staff try to follow up with patients to make sure they've had the tests you ordered. Also, tell patients outright to follow up about their test results. The "no news is good news" philosophy should never apply, advises Gewirtz. "Unfortunately, with EHRs and e-mail, it is possible that a lab test result was accidentally deleted, so our offices may not have a reminder that a test result came in," she reminded.

It's best to tell your patients that they need to be proactive about ensuring they've received the results of any test you order. Urge them to dismiss any feelings that they are being a "bother" or a "nuisance" when they call. These follow-up calls or visits can go a long way in improving compliance and helping patients get needed treatment faster.