Obstetrician–Gynecologists and Primary Care: Training during Obstetrics–Gynecology Residency and Current Practice Patterns

Abstract

Purpose 

To assess obstetrician–gynecologists’ perceptions of their residency training in primary care, document health issues assessed at annual visits, and identify practice patterns of both generalist and specialist obstetrician–gynecologists.

Method 

Questionnaires were mailed to a random sample of 1,711 American College of Obstetricians and Gynecologists Young Fellows in September 2005. Information was gathered on perceptions about adequacy of residency training, how well training prepared obstetrician–gynecologists for current practice, and typical practice patterns for various medical diagnoses. Data were analyzed using univariate analysis of variance, t tests, and chi-square tests.

Results 

Of 935 respondents (55% response rate), physicians estimated that 37% of private, nonpregnant patients rely on them for routine primary care. Approximately 22% report that they needed additional primary care training, specifically for metabolism/nutrition and dermatologic, cardiovascular, and psychosexual disorders. A wide range of topics, except for immunizations, were typically discussed at annual visits. Patients with pulmonary diseases, vascular diseases, and nongenital cancers were most often referred to specialists, whereas patients with urinary tract infections, sexually transmitted infections, or who are menopausal are most often managed totally. Self-identification as a generalist or specialist was associated with some practice patterns. Respondents were neutral about the role of primary care in obstetrics–gynecology residency training.

Conclusions 

For several primary care issues, obstetrician–gynecologists assumed sole management for obstetric patients but deferred to a primary care physician for gynecological patients. There is a continuing need for primary care training in obstetrics–gynecology residency, although it is unclear whether current training is adequate to meet their needs.

The American College of Obstetricians and Gynecologists (ACOG) describes the role of obstetrician–gynecologists as primary care providers through acknowledging their broader role in women’s health maintenance, which includes health screening and disease prevention, evaluation and counseling, and immunization services appropriate during a woman’s life span.¹ As the field of obstetrics and gynecology evolves to address a greater number of primary care concerns, it is important that training during residency adequately prepares physicians to deal with a wider variety of health issues.^1–3

In January 1996, the Residency Review Committee Special Requirements for Obstetrics and Gynecology were instituted in an effort to provide additional primary care training to residents, encompassing nongynecologic areas such as geriatric care, family medicine and internal medicine, and continuity of care.² The primary care residency training requirement implemented in 1996 significantly affected obstetrics and gynecology residency curricula, mandating a minimum of six months of primary care training within the four years of residency training. A 1997 study assessing physicians’ interest in primary care training found that obstetrician–gynecologists are more likely than medical subspecialists in gastroenterology, allergy/immunology, pulmonary, and critical care to have interest in educational programs to enhance primary care skills and knowledge.³ A study of obstetrics–gynecology residents was conducted one year before the accreditation mandates to assess baseline data on obstetrics–gynecology residents’ perceptions of themselves as primary care physicians.² At that time, 87% of respondents considered obstetrics and gynecology to be a primary care specialty. Community-based residences offered more primary care teaching than university-affiliated programs, with residents in the former group spending significantly more time counseling on exercise, diet and nutrition, work-related health risks, cognitive and emotional functioning, and immunization. Another study conducted in 1998 revealed that 93% of practicing obstetrician–gynecologists routinely saw primary care patients in their practice.⁴ Most recently, a 2005 study assessing care and referral for various primary health care problems found that most graduates felt well prepared to care for urinary tract infections, immunizations, tobacco use, thyroid disease, psychosocial problems, and diabetes, but poorly prepared to care for dermatologic disorders, lipid disorders, cardiovascular disorders, obesity, breast disorders, and gastrointestinal disorders.⁵ However, this study sample was limited to physicians who graduated from a single residency program.

The purpose of the present study was to examine obstetrician–gynecologists’ perceptions of their primary care residency training 10 years after the implementation of the Residency Review Committee obstetrics–gynecology primary care requirements. In addition, we documented which health issues were typically assessed at a patient’s annual visit, and we asked physicians about their practice patterns for various primary care health problems. Of particular interest were the factors influencing the practice patterns of physicians, such as type of residency training and professional self-identification as a generalist or specialist. Our goal was to determine which areas physicians felt they needed more training in during residency, which medical diagnoses were typically referred to specialists versus managed by obstetrician–gynecologists, and opinions regarding primary care training during residency. Our findings yield information that may influence the future of residency training and the development of curricula that more adequately prepare residents for practice in an increasingly demanding field.

Method

In September 2005, we mailed written questionnaires to 1,711 ACOG fellows, with three additional mailings distributed as follow-up to the nonrespondents in October 2005, November 2005, and January 2006. These individuals were randomly selected by computer from the subset of ACOG fellows who had not received an ACOG questionnaire in the past two years and who had completed residency training in 1996 or later. The intent of this computerized selection process was to avoid overburdening individual ACOG fellows with surveys while maximizing the probability that the sample was representative of ACOG membership in general. Over 90% of practicing obstetrician–gynecologists are members of ACOG, with fellows who have completed residency training no more than eight years prior defined as young fellows. We surveyed young fellows because of their recent connection to residency, thus allowing us to obtain a better sense of residency training. Because of the nature of this study, no institutional review for human subject protection was necessary. An accompanying cover letter outlined the purpose and benefits of the study and informed participants that their results would be anonymous and confidential.

The questionnaire was divided into two sections: demographic information and practice patterns/resident education. Demographic data encompassed the respondents’ age, sex, year of residency completion, residency type, practice type and location, average number of hours per week performing clinical practice activities, self-reported professional identity, and a percentage estimate of nonpregnant patients who see another physician for routine primary care.

The next section of the questionnaire inquired about practice patterns and adequacy of residency training for practice. First, respondents indicated which health areas they typically assess during a typical patient’s annual visit. Respondents then ranked the quantity and quality of their residency training in topics relevant to their particular area of practice as “inadequate,” “adequate,” or “excellent.” They then rated the adequacy of their training in a wider variety of areas as “needed more training,” “adequate training,” or “needed less training.” Respondents were presented with a list of various medical diagnoses such as bronchitis, arthritis, cardiac disease, and depression, and denoted what they typically do or are most likely to do for each: “total management,” “management with consultation,” or “refer to specialist only.” Finally, respondents ranked their level of agreement with two statements on a scale of 1 (“strongly disagree”) to 5 (“strongly agree”): “Primary/preventive care should remain a part of obstetrics–gynecology residency education” and “The postresidency educational opportunities from ACOG are appropriate to keep me up to date in my clinical practice.”

Data were analyzed using a personal-computer-based version of SPSS 14.0 (SPSS Inc., Chicago, IL). We computed descriptive statistics for the measures used in secondary analyses. Group differences in responses on continuous measures were assessed using independent sample t tests or univariate analysis of variance (ANOVA), and we assessed categorical data using the chi-square test. Data were analyzed for group differences using gender, age, residency type, and professional self-identification as between-subject factors. Each factor was evaluated separately. We evaluated statistical significance at P < .05.

Results

Nine hundred thirty-eight of 1,711 questionnaires were returned to ACOG after four mailings. We included completed questionnaires received by January 31, 2006 in the data analysis. Respondents did not differ from nonrespondents in terms of geographic location, age, or gender (Table 1). Three questionnaires were removed from data analysis because of reports of residency training completion before 1996, thus reducing the final sample size to 935 (55% response rate).

Table 1: Demographic Characteristics of 935 Fellows of the American College of Obstetricians and Gynecologists, 2005

Table 1 presents demographic data for the respondents. The majority of respondents completed a university residency (56.5%) between years 1999 and 2002 (95.3%) and consider themselves generalists (54.9%). No age or gender differences were observed in the type of residency completed or professional self-identification. Obstetrician–gynecologists estimated that they spend approximately 54 hours each week (SD = 20.5 hours) conducting clinical practice activities. With regard to routine primary care, respondents estimated that 63.4% of their private, nonpregnant patients see another physician.

Annual visit

The majority of obstetrician–gynecologists reported that they assess the following at a typical patient’s annual visit: fitness and nutrition, cardiovascular risk factors, sexuality concerns, alcohol/tobacco/drug use, psychological well-being, cervical cytology, breast health, and pelvic examination (see Table 2). Obstetrician–gynecologists least often discussed immunizations at an annual visit. Self-identified generalists were significantly more likely to assess all of the aforementioned areas during a patient’s annual exam (all at P < .01), the exception being immunizations, which were rarely discussed by obstetrician–gynecologists who identified as both generalists and specialists. Psychological well-being was more often assessed by respondents who completed a university-affiliated residency (69.7%) than by those who completed community residencies (63.6%) or university residencies (59.9%); P < .05. Similarly, a pelvic examination was more frequently conducted by university-affiliated respondents (90.0%) than by respondents from community residencies (83.0%) or university residencies (84.3%); P < .05. To further assess the effect size of these differences, we calculated odds ratios for the university-affiliated group (OR = 1.5; 95% CI, 1.1–2.0) versus the other two groups combined on the assessment of psychological well-being and the conduct of a pelvic examination (OR = 1.9; 95% CI, 1.2–3.1). Although statistically significant, the effects were modest.

Table 2: Topics Assessed at a Typical Patient’s Annual Visit, by Professional Self-Identification of 935 Fellows of the American College of Obstetricians and Gynecologists, 2005

Quality of residency training

The majority of respondents felt that the quality and quantity of their residency training was adequate or excellent for labor and delivery care, inpatient antepartum care, inpatient postpartum care, reproductive endocrinology/infertility (REI), gynecologic oncology office ambulatory care, general gynecologic surgery, and urogynecology general office evaluation and management. However, almost half of the respondents felt their residency training to be inadequate for advanced reproductive technologies and radiation therapy (see Table 3). Generalists and specialists were similar in their report of the quantity and quality of training received in all areas.

Table 3: Rating of Residency Training in Typical Obstetrics–Gynecology Areas of Practice, by Professional Self-Identification of 935 Fellows of the American College of Obstetricians and Gynecologists, 2005

Respondents felt that they had adequate training in general obstetrics, general gynecology, genetics, pathology, maternal fetal medicine, REI–medical, ambulatory care, major gynecologic surgery, minor gynecologic surgery, assisted reproductive technology, gynecologic oncology surgery, urogynecologic evaluation, REI–surgery, ultrasound, emergency medicine, critical care, geriatrics, immediate newborn care, pulmonary disease, endocrine disorders, psychosocial disorders, infectious disease, cardiovascular disorders, psychosexual disorders, and rheumatoid/collagen vascular disease. The only areas in which the majority felt they needed more training were urogynecologic surgery, metabolism/nutrition, and dermatologic disorders. A greater percentage of generalists in particular felt they needed more training for metabolism/nutrition, pulmonary disease, endocrine disorders, dermatologic disorders, infectious diseases, cardiovascular disorders, and rheumatoid/collagen vascular disease (all at P < .05; see Table 4). Obstetrician–gynecologists from university-affiliated and community residencies felt they needed more training in pulmonary disease, cardiovascular disorders, and rheumatoid/collagen vascular disease than physicians who had completed a university residency (all at P < .05).

Table 4: Rating of Residency Training in Primary Care, as Reported by Professional Self-Identification of 935 Fellows of the American College of Obstetricians and Gynecologists, 2005

With regard to primary care, 619 obstetrician–gynecologists (68%) believed their training to be adequate in this area, whereas 201 (22.2%) reported that they needed more training in primary/preventive care. Fewer specialists believed they needed more primary care training during residency than generalists (17.6% versus 22.2%, P < .01). No differences were observed in report of primary care training by type of residency.

Primary care practice patterns

In answering questions about their practice patterns with particular diagnoses, respondents could indicate total management, management with consultation, or referral to a specialist. The following are diagnoses which the majority of respondents manage totally: hypertension and diabetes mellitus in obstetric patients, bronchitis, urinary tract infection, osteoporosis, anemia, menopause/perimenopause, sexually transmitted infections, and sexual disorders. The three primary care issues most often managed totally were urinary tract infections (818/95.4%), sexually transmitted infections (831/96.1%), and menopause/perimenopause (764/91.4%). The majority of obstetrician–gynecologists report managing with consultation the following diagnoses: hypertension (nonobstetric patients), headaches (migraine and other), skin rash, obesity, endocrine disorder, depression, anxiety disorders, smoking cessation, and domestic violence. The majority of obstetrician–gynecologists refer to specialists for the following: hypertension and diabetes mellitus in gynecological patients, asthma, pneumonia, arthritis, back pain, chest pain, cardiac disease, vascular disease (noncardiac), pulmonary disease, gastroenteritis, allergies, genital cancer (including ovarian, cervical, uterine, vulvar, vaginal, and fallopian tube), nongenital cancer, substance abuse, eating disorders, infectious hepatitis, HIV/AIDS, immunizations, and influenza. The three most often referred primary care diagnoses were vascular disease (noncardiac; 696/81.3%), pulmonary disease (738/86.4%), and nongenital cancer (768/92.6%). Professional self-identification as a generalist or specialist was correlated with some of the practice patterns reported. Hypertension (in both obstetrical and gynecological patients) was more often managed with consultation among generalists (119/47.4%) and more often managed totally by specialists (64/47.8%) (P < .01). The difference between generalist respondents (78.2%) and specialists (57%) for the total management of osteoporosis was statistically significant (P < .001), as well as for depression (generalists, 25.4%; specialists, 15.4%). A majority of generalists (226/46.6%) referred patients to a specialist for back pain, whereas a majority of specialists (87/38.5%) managed this condition with consultation (P < .01). Specialists (123/62.8%) reported referring patients for genital cancer, whereas generalists (165/50.0%) managed this condition with consultation (P < .01). Generalists (198/40.8%) referred patients with influenza to specialists, whereas specialists (89/39.6%) managed these patients totally (P < .01). With several diagnoses, it was observed that the majority of generalists and specialists refer, but this pattern was more common among generalists. This pattern was found with the following diagnoses: arthritis, chest pain, vascular disease, pulmonary disease, gastroenteritis, vaginal cancer, fallopian tube cancer, nongenital cancer, substance abuse, eating disorders, infectious hepatitis, HIV/AIDS, and immunizations. When gender was considered in conjunction with professional self-identification, male specialists were most likely to manage diabetes mellitus, and female generalists were most likely to refer patients with asthma or allergies.

Respondents either agreed or strongly agreed with the statement “the postresidency educational opportunities from ACOG are appropriate to keep me up to date in my clinical practice,” with generalists (415/85.2%) significantly more likely to strongly agree (i.e., rating of 4 or 5) than specialists (167/73.8%) (P < .01). In general, the respondents neither agreed nor disagreed with the statement that “primary/preventive care should remain a part of obstetrics–gynecology residency education,” although male specialists were significantly more likely to disagree with this statement than female and male generalists (P < .001).

Discussion

The majority of obstetrician–gynecologists reported that they received adequate or better training in general obstetrics and gynecology, as well as in specialty topic areas such as labor and delivery care. Inadequate training was reported by half of the respondents for both advanced reproductive technologies and gynecologic oncology office and institutional care. Self-identified specialists were more likely than self-identified generalists to believe their training to be adequate to excellent across specialty topic areas.

Primary care training has recently become more integrated into obstetrics–gynecology residency training, partly because of a large percentage of women who consider their obstetrician–gynecologist to be their primary care physician. In support of the primary care component of obstetrics–gynecology residency education, all program directors in a 1998 study indicated that they participate with other disciplines, including internal medicine, emergency medicine, family practice, and pediatrics, to teach primary care to their residents.⁶ The majority of respondents in the present study estimated that more than one third of their private, nonpregnant patients rely on them for provision of routine primary care. Approximately two thirds of obstetrician–gynecologists believed their primary care training during residency to have been adequate. However, 22% reported that they needed additional training in this area. Generalists were more likely to report that they needed additional training in primary care topic areas, which may simply be indicative of their desire to incorporate more primary care into their practice. Regardless, it is of interest that the topic areas in which better training may be warranted were also reported in 2005 as being areas in which obstetrics–gynecology residents felt poorly prepared.⁴

Our findings indicate that a wide range of topics are typically discussed at a woman’s annual visit, including fitness and nutrition, alcohol/tobacco/drug use, psychological well-being, and cardiovascular risk factors, as well as breast health, sexuality concerns, cervical cytology, and pelvic exam. However, immunizations were rarely discussed. Not surprisingly, generalists were more likely than specialists to assess all areas during an annual exam, with the exception of immunizations. It is unclear why immunizations are not discussed as often as other primary care issues, although a 2000 study similarly found that in gynecologic patients, almost 40% of physicians did not assess for any vaccine-preventable disease.⁷ That study partly attributed the discrepancy found between perceived responsibilities and actual practice patterns of obstetrician–gynecologists regarding vaccine-preventable diseases and the immunization of women to limitations in current knowledge and practical concerns specific to vaccine administration. It has also been suggested that appropriate primary care training during residency may not affect practice patterns to the extent that would be expected.⁸

When dealing with primary care issues, it is of interest to ascertain which patients are most often being referred and which are most often managed totally by obstetrician–gynecologists. Patients with pulmonary diseases, vascular diseases, and nongenital cancers were most often referred to specialists, whereas patients with urinary tract infections or sexually transmitted infections, or who are going through menopause, are most often managed totally by the obstetrician–gynecologist. It would seem that for several primary care issues (e.g., diabetes mellitus and hypertension), obstetrician–gynecologists would assume sole management for an obstetric patient but refer to a primary care physician for a gynecological patient. Interestingly, many self-identified generalists refer patients with certain primary care issues more often than do specialists. Some of these issues are arthritis, chest pain, gastroenteritis, substance abuse, eating disorders, infectious hepatitis, HIV/AIDS, and immunizations. It is possible that after assessing for a greater number of primary care issues, time constraints do not permit obstetrician–gynecologists to treat some of these conditions.

Professional self-identification as a generalist or specialist was correlated with some of the practice patterns reported. It is unclear from our data whether professional self-identification influenced practice patterns or whether practice patterns had some effect on professional self-identification. However, we found that generalist respondents were more likely to totally manage osteoporosis and depression, and to manage patients with genital cancer with consultation. Specialist respondents were more likely to totally manage influenza and manage back pain with consultation, whereas generalists more often referred these patients. When gender was considered in conjunction with professional self-identification, male specialists were most likely to manage diabetes mellitus, and female generalists were most likely to refer patients with asthma or allergies.

The majority of respondents believe that the postresidency educational opportunities from ACOG are appropriate to keep them up to date in their clinical practice. The fact that the majority of respondents neither agreed nor disagreed with the statement that primary care should remain a part of residency education suggests a degree of ambivalence about its role in the field of obstetrics and gynecology. Male specialists in particular were most likely to disagree that primary care should continue to be a part of obstetrics–gynecology residency, which could be related to a 2005 study finding that primary care opportunities have significantly greater appeal to female residents than male residents.⁹

Possible limitations of this study include response bias and specification error. Respondents did not differ from nonrespondents in terms of geographic location, age, or gender, but some may have returned the questionnaire because of a greater interest in primary care issues. Therefore, our findings may overestimate the level of primary care training and practice among obstetrician–gynecologists. Another caveat is that our results may be related to physician characteristics that were not measured in our study, such as geographic location or level of time constraints that limit total management of certain medical conditions.

Despite these possibilities, we believe this study offers a unique glimpse into the current primary care practices of recent graduates of obstetrics–gynecology residency programs and provides an assessment of the primary care training that their residencies provided. Approximately one out of four obstetrics–gynecology respondents indicated that they received inadequate training in primary care, and this may influence why they may not have a strong desire to take on this role completely. Residency programs should address this issue such that obstetrics–gynecology residents feel prepared to take on the generalist practitioner role that has been promoted by ACOG and to which many already ascribe.

Acknowledgments

This study was supported by Grant #R60 MC 05674 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.