Tag : healthcare

BuzzFeed caused a stir when it published photos of the man it deemed the hottest gynecologist ever (featured image). While some commenters swooned, others were unsettled—“it” being the hot doc’s hotness, and, frankly, his gender. The fact that a doctor specializing in women’s health care was essentially turned into an international sex object raised an increasingly debated question: Are male gynecologists weird? More specifically, in this day and age, are they downright creepy?

Asked just that question, 28-year-old Pamela answered with a resounding “yes.” She said she’s never been treated by one and never would. The mere thought makes her uncomfortable, she added. That sentiment was echoed by Tiffany, who is in her 30s and said in an email, “My OB-GYN is a woman—all of mine have been, and that’s by design. I do think male OB-GYNs are a bit creepy.”

Malia, 32, was a bit more mixed. “I worked as a receptionist for three male OB-GYNs,” she laughed. “There was no creepy factor with them.” Even so, she would not want a male gynecologist treating her: “I just feel more comfortable with a female.” It was a common refrain in conversations and emails exchanged with women of various ages, races, and socioeconomic backgrounds.

That discomfort is helping to alter the landscape of women’s health.

“Younger women do not want to go to a man in his 50s and 60s,” said Rebecca C. Brightman, clinical instructor of obstetrics and gynecology at New York’s Mount Sinai School of Medicine. When women get into their 40s and 50s, she said, many begin to rethink what they want in a women’s health provider. Those who may have felt comfortable seeing a male doctor during their childbearing years may not feel comfortable talking to a man about their struggles with menopause. Women may wish to find a doctor who relates to them better, and today there are more female doctors to choose from than ever.

“I don’t need judgment when you’re looking up my skirt. That’s not worth shaving my legs for.”

Male doctors were once the norm. But over the last two decades, women have flooded the medical profession; in 2003, female applicants outnumbered male applicants at U.S. medical schools for the first time. The trend is even more pronounced among women’s health specialties. “There has been a significant gender shift in OB-GYN over the past two decades. In 1990, 22.4 percent of all OB-GYNs were women. In 2010, nearly 49 percent were women,” Jeanne Conry, president of the American College of Obstetricians and Gynecologists, said in an email. She pointed to figures showing bigger changes to come: “In 1990, 49 percent of all first-year OB-GYN residents were women. In 2012, 83 percent were women.”

But that still leaves plenty of men pursuing gynecology as a profession. When few doctors were female, the idea of a male OB-GYN may not have seemed odd. Today, a man specializing in an area of medicine that involves staring at vaginas for a good part of the workday does strike some as a bit strange. But is it?

Not at all, said Peter Schnatz, associate chairman and residency program director of OB-GYN at Pennsylvania’s Reading Hospital and one of the leading researchers on the subject of gender in the specialty. Male gynecologists don’t see their work through the lens that some critics might, Schnatz said: “We see it as providing care to a person, not the awkwardness of the exam,” which is the part that some women simply can’t get past.

Brightman also attempted to debunk the notion that men who practice gynecology are suspect. “I don’t feel it’s creepy,” she said. “OB-GYN is a very attractive field because it’s a great combination of internal medicine, a little psychiatry, and also surgery. I can totally understand why a man might be drawn to the field. But the problem is you have to look at patients, and a lot of patients want women, and more and more will continue to want women.”

She added: “I understand why women may feel it’s creepy, and I’ve heard stories from patients that they were made to feel uncomfortable. I’m sure it wasn’t the doctor’s intention, and unfortunately there are stories out there of men doing strange things with patients. It’s unfortunate because it casts a real shadow on the profession.”

To her point: In 2002, a Chicago gynecologist was convicted of raping a patient during a pelvic exam, while in 2005 another in Seattle was found guilty of sexually abusing patients.

And there are women who feel more comfortable seeing male gynecologists. Susan, 50, said in an email that her experiences with female gynecologists were overwhelmingly negative. She found them particularly judgmental and cold, she said. That sentiment was shared by Lisa, a 34-year-old who wrote that her female gyno “was great until she told me that I’d made bad sexual choices. Not sure if it was because my single sex life doesn’t fit in her married suburbia you-must-have-been-a-cheerleader, ‘What do you mean, you don’t want kids?’ mentality. But I don’t need judgment when you’re looking up my skirt. That’s not worth shaving my legs for.” She added that her OB-GYN “actually said, ‘It’s OK, you just made some poor choices.’ I nearly shoved that speculum down her throat.”

Asked if female OB-GYNs have a harsher bedside manner than their male counterparts, Brightman replied: “Because of the rules that govern sexism, some men can be perceived as kinder and gentler. A woman who is direct in her manner can be perceived as cool and detached and lacking empathy.”

It is worth noting that having ample choice in choosing a women’s health provider is still a luxury. With few female doctors in the country, male gynecologists became crucial to women’s health care in Iraq. But over the last decade, these male doctors found themselves facing threats from Islamic extremists who disapprove of the idea of any man seeing a woman who is not his wife unclothed. According to reports, some male OB-GYNs in the country have been killed. And just days ago it was announced that Saudi Arabia’s top Islamic scholar had issued an edict prohibiting male doctors from seeing the bodies of deceased women, thereby preventing the involvement of male doctors in examinations of female corpses for medical or criminal cases.

Ultimately it appears that female patients here in the United States want what all patients want: the best health provider possible. “Interestingly, what we found is the vast majority of women, if you ask them, just want a good doctor,” Schnatz said of his studies on the topic. “They don’t really care if it’s male or female.” He cited a 2005 study he worked on that found that a little more than 70 percent of women said they had no preference when asked if they preferred a male or female gynecologist. Of the nearly 30 percent who did, the majority preferred a female gynecologist. A 2007 study he also worked, published in the American Journal of Obstetrics and Gynecology, found that when female patients were shown photos of male or female gynecologists and asked which they preferred to see, more women selected the female, even though gender was not mentioned in the questions. However, when descriptions of the qualifications of the two gynecologists pictured were added to the experiment, women overwhelmingly chose the more qualified candidate, regardless of gender.

A study published in October found that female doctors outperformed their male counterparts on patient care assessments. So maybe the real question isn’t “are male gynecologists creepy?” but “are they as good as female ones?”

About two months ago, Dr. Elizabeth Stier was shocked to learn that she would lose a vital credential, board certification as a gynecologist, unless she gave up an important part of her medical practice and her research: taking care of men at high risk for anal cancer.

The disease is rare, but it can be fatal and its incidence is increasing, especially among men and women infected with H.I.V. Like cervical cancer, anal cancer is usually caused by the human papillomavirus, or HPV, which is sexually transmitted.

Though most of her patients are women, Dr. Stier, who works at Boston Medical Center, also treated about 110 men last year, using techniques adapted from those developed to screen women for cervical cancer.

But in September, the American Board of Obstetrics and Gynecology insisted that its members treat only women, with few exceptions, and identified the procedure in which Dr. Stier has expertise as one that gynecologists are not allowed to perform on men. Doctors cannot ignore such directives from a specialty board, because most need certification to keep their jobs.

Now Dr. Stier’s studies are in limbo, her research colleagues are irate, and her male patients are distraught. Other gynecologists who had translated their skills to help male patients are in similar straits.

And researchers about to start a major clinical trial that is aimed at preventing anal cancer, with $5.6 million from the National Cancer Institute, say the board’s decision will keep some of the best qualified, most highly skilled doctors in the United States from treating male patients in the study. The director of the planned study and Dr. Stier have asked the gynecology board to reconsider its position.

But the board, based in Dallas, has not budged.

Anoscopy and other techniques aimed at preventing anal cancer have not been rigorously tested, and the purpose of the planned clinical trial is to determine whether they work. Five thousand patients, men and women, are to be studied for eight years, ultimately costing tens of millions of dollars.

If the trial shows that cancers can be prevented, it could change the standard of care, Dr. Douglas R. Lowy, a deputy director of the Center for Cancer Research at the National Cancer Institute, said in an interview.

Doctors planning to participate in the trial have had extensive training in high-resolution anoscopy. People with various types of medical training can learn the procedure, but experts say that gynecologists are the quickest to master it because of their experience in screening women.

“We need as many trained people as possible,” said Dr. Joel Palefsky, an infectious disease specialist at the University of California, San Francisco, who will direct the study. “The assumption all along has been that many of the gynecologists we trained would participate in the study and would see both men and women.”

Dr. Stier had been treating men for more than 10 years, and expected to enroll about 100 in the study. Now, she will be able to enroll only women. She is the only person with the special training at her hospital, so now another hospital will have to sign up more men.

But what really worries her is what will become of the men she has been treating. Those who had precancers need to be examined once or twice a year, because the growths tend to recur. Dr. Stier said the procedures are embarrassing and uncomfortable for patients, and it takes time for a doctor to gain their trust. Many of her patients are poor, from minority groups and infected with H.I.V. Some live in shelters, some have histories of drug use. And anal disorders add more stigma. “My main issue here is that I don’t think my patients are going to get the follow-up that they need, and I think they’re going to be lost to care, and we take care of a very vulnerable patient population,” Dr. Stier said.

Dr. Einstein had also been treating some male patients and had planned to enroll men in the new trial. Like Dr. Stier, he was blindsided by the gynecology board’s notice.

He said only three doctors at his hospital had special training in high-resolution anoscopy, and that was nowhere near enough. Now two of those doctors, including himself, have to stop treating men.

“I think we’ll see significant setbacks,” Dr. Einstein said.

“We haven’t heard of any compelling reason to change anything,” said Dr. Kenneth L. Noller, the board’s director of evaluation. He said there were plenty of other doctors available to provide the HPV-related procedures that some gynecologists had been performing on men.

Dr. Larry C. Gilstrap, the group’s executive director, said the specialty of obstetrics and gynecology was specifically designed to treat problems of the female reproductive tract and was “restricted to taking care of women.” Of the 24 medical specialties recognized in the United States, he said, it is the only one that is gender-specific, and it has been that way since 1935.

Dr. Stier said that she, like many other doctors, had not understood the definition of their field to be quite so absolute.

The board had always regarded the treatment of women as its mission, Dr. Gilstrap said, but felt a particular need to emphasize it now because the specialty’s image was being tarnished by members who had strayed into moneymaking sidelines, like testosterone therapy for men, and liposuction and other cosmetic procedures for both women and men.

Dr. Mark H. Einstein, a gynecologic oncologist at Montefiore Medical Center in the Bronx, said, “The board’s approach is to be rather dogmatic and to draw a line in the sand.”

On Sept. 12, the board posted on its website a stringent and newly explicit definition of obstetrician-gynecologists, limiting the proportion of time they could spend on nongynecologic procedures and noting that, with few exceptions, members must not treat men. The notice specifically prohibited gynecologists from performing an examination called anoscopy on men.

Anoscopy involves using a tube and a light to examine the anal canal, which is about 1.5 inches long. The procedure is the same in men and women. A “high-resolution” version adds a magnifier to look for abnormal growths that may be cancers or precancers. Cancers usually require surgery, but doctors can burn off precancers in hopes of preventing cancer.

A similar approach led to a tremendous decline in cervical cancer in the United States, and doctors hope to accomplish the same for anal cancer. About 7,000 new cases of anal cancer, and 880 deaths, are expected in 2013 in the United States; the incidence has been increasing by 2.2 percent a year for the last 10 years.

Almost two years ago, pregnant with my daughter, I paid my first visit to the Cambridge Birth Center. Located inside an old Victorian house, the facility is hard to distinguish from a modestly appointed home, with blond wood floors and three spacious bedrooms, each attached to a bathroom with a large tub. If the interior is comforting, so is the view: the Cambridge Hospital, part of the same campus, is visible through most windows. Should you need to get there in a hurry, the trip would take about ten seconds.

Like most of my fellow patients, I chose the birth center because I wanted to avoid the high-tech approach typical of hospitals, but I didn’t feel entirely at ease with the idea of a home birth. The birth center hit the sweet spot. I loved the cozy environment designed expressly with birth in mind. I adored my unflappable midwife, Heidi, a genius at deflating anxieties. And when in labor, I benefited from the warmth and expertise of the midwife on call, Connie, who calmly coached me through delivery.

But I didn’t realize until later that there were other reasons to love birth centers—namely, hard economics. In light of this week’s big Times article on the staggering costs of maternity care in the United States, it’s time that birth centers receive the recognition they deserve as a viable alternative. A recent major study confirmed that for low-risk pregnancies, birth centers provide equally safe care for much lower costs than hospitals. Even the Affordable Care Act acknowledges their value; a little-noticed provision of the law mandates that Medicaid cover birth center services. Yet, thanks to a combination of unfriendly laws in some states, insurer resistance, and lack of public awareness, far too few American women have access to this form of excellent, cost-effective maternity care.

First, to clarify the terminology: a free-standing birth center is a homelike, midwife-led facility that offers prenatal care and delivery services and has emergency arrangements with a hospital. It can be located inside a hospital, but it must be separate from the acute obstetric care unit. (Some hospitals use the term “birth center” to describe conventional units, which has caused confusion.) Distance from the hospital varies. I must admit I would have felt much less comfortable with a more remote hospital. But in some rural areas, women live hours away from the nearest one, and it may be preferable to have a facility closer to their homes than to the hospital. All birth centers monitor patients throughout pregnancy to ensure that they are low-risk; if not, they are referred to hospitals.

According to the American Association of Birth Centers, the facilities operate according to the “wellness model” of pregnancy and birth, as opposed to the medical model that sometimes seems to treat these events like illnesses. As AABC executive director Kate Bauer told me, “In a hospital, all women are treated as if they are high-risk. In a birth center, every woman is seen as low-risk, unless her risk level is elevated…It’s appropriate use of resources.” You can’t get an epidural at a birth center. They rely on low-tech pain-management techniques such as warm baths and changing position, though some do offer conservative doses of Demerol and nitrous oxide.

That birth centers offer safe, economical care is not news. A landmark 1989 New England Journal of Medicine study reviewed records of 11,814 women at 84 birth centers and found that there were no maternal deaths, while the neonatal mortality rate was similar to that of low-risk hospital births. The rate of cesarean sections (which involved transfers to hospitals) was 4.4 percent. The article concluded, “Few innovations in health service promise lower cost, greater availability, and a high degree of satisfaction with a comparable degree of safety. The results of this study suggest that modern birth centers can identify women who are at low risk of obstetrical complications and can care for them in a way that provides these benefits.” (The authors emphasized that all of the birth centers in the study were accredited; the safety of unaccredited centers is uncertain.)

A new study published in January in the Journal of Midwifery & Women’s Health ratified those results. Because safety is such a concern, allow me to dwell again on the numbers. This study reviewed the records of 15,574 women at 79 birth centers from 2007 to 2010. Again there were no maternal deaths, and again the neonatal mortality was comparable to low-risk births in hospitals. Just 6 percent of the women ended up having cesareans at affiliated hospitals, compared with about 25 percent of low-risk women who started out at hospitals. (The total nationwide rate of cesareans in 2010 was 32.8 percent.) The study estimated that given the lower cost of the facilities, and the much less frequent interventions, these birth-center deliveries saved approximately $30 million.

Despite these positive outcomes, only a tiny minority of women (.3 percent in 2010, according to the CDC) give birth in such centers. The AABC estimates that if just 10 percent of the 4 million women who give birth annually did so in birth centers, the savings would come to at least $2.6 billion. The provision in the Affordable Care Act—stipulating that Medicaid programs reimburse birth centers—was included because it was projected to save money.

By some indications, trends are favoring birth centers. According to the AABC, their numbers have grown from 170 in 2004 to 251 today. Forty-one states license birth centers, the American Public Health Association has issued guidelines for licensure, an entity called the Commission for the Accreditation of Birth Centers does what its name suggests, and the AABC also has standards for members. All of this constitutes what the recent journal article calls an “infrastructure of standards, accreditation, and licensure” that contributes to the safety and reliability of accredited centers.

Historically, tensions have simmered between the midwife community and ob-gyns, but even the American College of Obstetricians and Gynecologists has endorsed birth centers—albeit in a somewhat roundabout manner. In a 2008 statement reiterating their strong opposition to home births, ACOG asserted that delivery “in a hospital or accredited birthing center is essential” (emphasis mine).

Birth center advocates were also thrilled by the Medicaid provision in the health care reform law, sponsored by Senator Barbara Boxer: not only should it mean expanded birth center coverage for low-income women, but private insurance often takes its cues from the federal programs, so a ripple effect is conceivable. Now, despite the potential savings, private insurance often resists covering birth centers. (I was fortunate on this front: my total out-of-pocket expenditure was a $15 co-payment for my first prenatal appointment.)

But amid this progress, serious gaps remain. Nine states do not license birth centers, and the Medicaid provision applies only to those who do. The AABC claims, too, that some states have not properly implemented this part of the law. State laws vary widely, with some much more hospitable to birth centers than others. These differences don’t always break down according to familiar patterns: In Texas, for instance, birth centers flourish, while Maine does not license them.

As a result, many women who would prefer birth centers don’t have the option—and many of these end up having c-sections and other interventions in hospitals. I blame not greed or evil but the so-called law of the instrument: the tendency to rely on the tools you have. The debate about childbirth is particularly polarized—with some convinced that pregnancy should not be treated as a medical condition—but not unique. Take mental health. If you suffer from anxiety and you go to a psychiatrist, you will likely leave with a prescription in hand. Some people know they want Zoloft, but others would like to try a less medical approach first.

A final obstacle for birth centers in reaching their full potential is cultural. The majority of women seem to think that birth centers are a risky option for a hippie fringe, one step removed from giving birth in a field under a full moon, orgasmically. Granted, birth centers will never be right for everyone. I know women who don’t see the point of trying to give birth without an epidural. (As writer Anne Lamott memorably put it: “I have girlfriends who had their babies through natural childbirth—no drugs, no spinal, no nothing—and they secretly think they had a more honest birth experience, but I think the epidural is right up there with the most important breakthroughs in the West, like the Salk polio vaccine and salad bars in supermarkets.”) Then there are women who wouldn’t consider leaving the privacy and comfort of their own home to have a baby. But there’s a good-sized contingent that wants to try for a low-tech birth in a relaxed setting that’s been proven safe. Birth centers are more likely to provide this experience than hospitals are. They should be seen not as sites for New-Age-y, hazardous adventures, but as places that offer mainstream, high-quality maternity care.

One last advantage of birth centers: the parties. The Cambridge Birth Center has thrown two afternoon shindigs for families since my daughter was born last July. She got to meet the midwife who listened to her heartbeat in utero, and the one who delivered her, as well as other kids who were born there. And I got to return again to the place I’d visited so frequently, this time eating chips and salsa.

From Rebecca Tuhus-Dubrow