Connecting personally with women’s health care issues

A message to all physicians from Robert M. Wah, MD, chair of the AMA Board of Trustees.

By — Posted April 16, 2012.

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I have been privileged to care for women throughout my career, and my plan for this month was to write about women’s health care.

As most ob-gyns will tell you, one of the many rewarding parts of their career is to care for women from adolescence through the reproductive years and on through menopause. During this time, one gets to know the patient and her family quite well. I have often been the only doctor my patients have seen throughout their lives. So in reflecting on my career in women’s health care, I wish to write about some of the varied advances and perspectives in the field.

As I started writing this, the U.S. Supreme Court was holding three historic days of hearings about issues surrounding the Patient Protection and Affordable Care Act of 2010. The national focus and interest generated by these hearings is quite remarkable. People were camping out in front of the Supreme Court building in hopes of getting inside to see the historic events in person. The only time I have seen people camp out for a free government event was when my daughter was a toddler and we used to wait for tickets to the White House Egg Roll. In any case, these hearings remind us all just how personal and connected citizens are to health care and the issues surrounding it.

Women’s health care is often at the leading edge of this personal connection. Recently we have seen much focus on health, especially promotion of good health and prevention of disease — rather than intervention. These precepts have been a central part of women’s health for a long time. In less than a generation, we have seen cervical screening dramatically reduce cervical cancer and its devastating undetected and untreated course. Since widespread use of Pap smears began, cervical cancer deaths have dropped dramatically — from 13.1 deaths per 100,000 women in 1950 to 2.4 in 2007. Similar benefits have been seen with breast screening.

In addition to cancer prevention and early intervention, women also have benefited from prenatal care and screening for sexually transmitted diseases. Physicians attending to women extend their care beyond direct clinical issues to other related social issues that may well affect a woman’s health. A woman’s visit is also an opportune time to discuss, detect or avoid other problems like violence and abuse.

The day after the Supreme Court hearings ended, I attended the most recent meeting of the Physicians Consortium for Performance Improvement. It was, as always, an excellent meeting where the AMA has convened specialty and state medical association leadership to develop performance improvement recommendations for doctors, by doctors.

PCPI measures are being integrated into electronic health record systems, and as a result of these efforts over the years, 45% of measures in the Centers for Medicare & Medicaid Services EHR Incentive Program Stage 1 are PCPI measures. Additionally, more than 57% of measures in CMS Physician Quality Reporting System, are PCPI measures.

As PCPI measures also are being integrated into physicians’ EHRs and workflow, doing the correct thing also will be the easiest thing to do well. This is true with women’s care, where, in addition to seeing the value of preventive services and visits, we have analyzed the value of the various tests and visits. In this process, we have sought, as all physicians do, to maximize benefits and minimize risks and costs. Recently, as a result of the analyses it has become less clear to women and their physicians as to what the best frequency and content of visits should be. To assist in this, the American College of Obstetricians and Gynecologists has created recommendations and guidelines for women’s visits as they progress from adolescence to the reproductive years and on to menopause (link).

During the PCPI meeting, there were a number of speakers from HHS and CMS, and they all spoke of how they see a need to align the various government programs like e-prescribing, meaningful use and physician quality reporting. This is something the AMA has been recommending for some time now, and it is good to see they are acting on our suggestions.

At the meeting, we also heard about projects that are in place as a result of strong supporting data that will have maximal impact and savings. One of these projects is the campaign called Strong Start to end unnecessary early elective deliveries before 39 weeks gestation (link).

Some 12% of babies, or one out of eight, are being delivered before full term. While it is clear there are conditions that require delivery early, the elective delivery leads to significantly increased risks to a newborn. More than one out of three infant deaths are related to being born too early. The evidence is clear in this area: ACOG has had clear guidelines for nearly 40 years on not electively delivering before 39 weeks.

These nonmedical, elective deliveries are part of the intersection between women’s health care and our social, personal issues. The human cost in increased complications for infants and financial costs to the health care system are more overwhelming reasons to stop these elective deliveries.

Women’s health care also is enmeshed in another concerning trend, and that is of our examining rooms getting crowded with nonmedical requirements. We are all well aware of our flawed medical liability system that leads to billions of costs for defensive medicine. Now we also are seeing legislation that mandates activities in exam rooms that are not based on medical science. These intrusions involve issues across a wide range including hysterectomy consents, glomerular filtration rates, family planning, domestic violence screening, firearms safety and palliative care. An excellent commentary on this — “Three is a crowd: the new doctor-patient-policymaker relationship” — was recently published in Obstetrics & Gynecology by Erin Tracy, MD, MPH, of Harvard Medical School and a longtime member of our AMA House of Delegates (link).

This insertion of these legislative requirements into the cherished doctor-patient relationship, which we hold central to medical practice going back to Hippocrates, is creating huge potential conflicts for physicians who are in an untenable position of balancing their ethical obligations to their patients and their legal duty to follow the law.

So as I write this, it is clear how women’s health care and the larger health system reform are intertwined. Also, it is clear that the many personal, almost visceral connections that drive the high level of interest and discussions on health system reform also involve reproductive issues.

In looking at my career, it has been an honor and privilege to be part of women’s health care as a clinician at the bedside to local, regional and national policy as a past member of the ACOG executive board. Now as chair of the AMA Board of Trustees, I am honored to be leading the team addressing national issues around improving our health system for our patients and their physicians.

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