Impacts and solutions for the ob/gyn shortage in the US
Many women already face inadequate or difficult-to-access care for menopause issues. And for women in much of the US, that problem is only going to increase.
An Ob/GYN Shortage in the U.S.
According to an article in Fortune Magazine, the US could face a shortage of 8,800 ob/gyns by 2020. Because the current population of ob/gyns is older (16 percent below the age of 40; 36 percent over 55), and ob/gyns tend to retire younger than other docs (at age 59, on average), the problem is likely to get worse.
In this podcast, Gennev CEO Jill Angelo and Gennev Director of Health ob/gyn Dr. Rebecca Dunsmoor-Su talk about the potential impacts of the shortage on women's health, and how it disproportionately affects women in menopause.
Filling the health care gap for women in menopause
Enter technology, innovation, and passion for women's health: led by Jill and Dr. Rebecca, Gennev is helping fill the health care gap via our new telehealth service. Affordable, private, convenient video and text conferencing will give many more women access to healthcare practitioners who specialize in helping women manage menopause symptoms.
We'd love to know your thoughts about our telehealth offering. Are you excited about the possibility of having focused conversation with a menopause specialist? Eager to start getting answers via telehealth? Concerned about privacy?
Jill: A June 2018 article in Fortune claims that by 2020, the US will be short 8800 OB-GYNs. Why is that a problem?
Dr. Rebecca: So I think that’s a problem for a couple of reasons. OB-GYN training is focused specifically on women’s health and it’s focused on all aspects of women’s health from really adolescence through to old age. And there is no other specialty where women’s health is the primary focus, where that is all we learn.
So for women, OB-GYNs are key during the years of puberty. They’re key for birth control provision. They’re key for childbirth and they’re key for managing GYN concerns through adulthood and through menopause. And really menopause is a key time in the life of a woman and OB-GYNs are the ones best trained to help a woman through that time of life whether it be with advice or whether it be with medication, whatever that is.
So it’s a problem that a good portion of women in this country really won’t have access to these women’s health specialists. I know that primary care doctors do provide some of this care for women, and they do a good job within what they can do. But they have so many other things that they need to focus on, and I feel like there are times when you just need a specialist and women deserve to have a specialist just like men deserve to have a specialist.
You know, nobody is talking about not needing urologists in this world for men. You know, women need a specialist physician who can care for the things that are very particularly female.
Jill: You know, on the topic of – you brought up general practitioners because I think that’s probably where women have the greatest access is to the general practitioner. Can you talk a little bit about the amount of education that they actually get on this part of women’s health or the lack thereof?
Dr. Rebecca: Sure. It varies very significantly depending on where they trained and whether they’re trained as internal medicine physicians or as family practitioners. Family practitioners probably receive a little more focus on women’s health, and some of them can even do a women’s health specialization. However that’s within the structure of a residency that also covers pediatrics and male health and a lot of other things.
In terms of internal medicine, it’s a three-year residency. But again they focus on adult medicine and all aspects of adult medicine. They have to manage hypertension. They have to manage diabetes. They manage a lot of things. So while they will have some training in women’s health, it is not the sole focus of the training that they get, and when you’re talking about an OB-GYN physician, we spend four years in residency focusing exclusively on women’s health and we do rotations that vary from obviously obstetrics and delivering babies and high risk obstetrics and we do women’s oncology. So GYN oncology which is ovarian cancer and uterine cancer.
We do breast clinic time. We do regular GYN time. We do office hours and a lot of us even get some exposure to adolescent medicine. We do a lot of time worrying about and thinking about birth control and how to best manage that in all types of women and more high risk women and that’s the only thing we focus on during the entirety of our residency over four years.
So while primary care can do a lot of basic women’s healthcare, they are not the specialized provider for that.
Jill: What population of women or what women are most impacted by the shortage of OB-GYNs in your opinion?
Dr. Rebecca: I would say rural women are most impacted. OB-GYNs tend to congregate in larger metropolitan areas and the reason for that is complex. You know, a lot of us do enjoy living in cities. That’s part of it. A lot of it is financial. OB-GYN is one of the poorest reimbursed specialties there is. I’m not going to go into the whole politics of women’s healthcare and why we get paid so badly. That’s a topic for another podcast.
But let’s just say that what we do is not paid well and the thing that is most profitable for OB-GYNs although it is not particularly profitable, it is probably the most reliable is obstetrics, so the delivery of babies. So for OB-GYNs to maintain a practice that is financially viable, they need to deliver a certain number of babies a year and you can’t do that in a rural practice. Often there just aren’t as many obstetric patients in that area.
I think there are a lot of great OB-GYNs who practice in rural areas and they do it for the love of the specialty and a lot of them do it in federally qualified health centers or other ways that they can perhaps make it financially viable. But there’s a certain proportion of patients and deliveries that you need in order to make it worthwhile to be an OB-GYN somewhere. So really rural women are the ones who are going to pay the price.
Jill: This shortage obviously has to impact OB-GYNs as well. What are the impacts that you feel – I’m sure you’re feeling overtaxed. Generally these specialists are busy. Like give it to us from the perspective of an OB-GYN.
Dr. Rebecca: So I think from my perspective, the key things that I feel with this deficit are that I spend a lot of time taking transfers in from – for our rural areas being in the Pacific Northwest. We do have a lot of rural areas and these are patients being transferred in because there is no OB-GYN accessible to them. So their primary care has attempted to do what they can for them but realizes that they need a higher level of care. So we’re spending money on ambulance, helicopter and air flights for these women to get to an OB-GYN. I think that’s a big impact and a waste of healthcare dollars that if we just were able to support OB-GYNs and provide enough, might not need to happen.
I find that women, when they get to me, are frustrated because they’ve been through so many providers who tried to do their best for them. It’s not that these providers are bad at what they do or not doing their best. It’s just they don’t have the same level of expertise and so they’ve been told multiple things and tried multiple things and by the time they get to me, they’re frustrated because they feel either there’s no answer for them or that they’re getting different answers. It takes a lot longer for me to explain that it’s not that the answers they’ve gotten previously are wrong. They were just first steps and that we now need to move to a more specialized level of care and it just takes a lot longer in that situation to care properly for a woman.
Jill: So let’s switch to then solution. We’ve kind of delved into the notion that there’s a real shortage for so many women. Why is telehealth a great answer to this shortage of specialists?
Dr. Rebecca: I think telehealth holds promise for a couple of reasons. I think one of the biggest issues is just you can talk to an OB-GYN specialist who is knowledgeable about the thing that you need to talk about. You can – a lot of what we do is face to face counseling. It’s not reliant on an exam. It’s not reliant on prescription even. It’s just that women need to talk to somebody who understands what they’re going through and can walk them through the process, give them reassurance where needed, talk to them about what things need to be followed up and a lot of that can be done just face to face over the computer.
There are times at which a prescription is needed or exam or even a biopsy type thing might be needed. But that can be referred out or at least a woman then knows that she needs to go find the specialist who may not be available in her community and it might be worth the trip in to see the specialist because she knows that these are the things that need to be done.
Jill: Yeah. Well, and especially for women in perimenopause and menopause, that notion of a conversation is so important. Talk a little bit about that and how video just really makes that an option for so many more women in terms of access.
Dr. Rebecca: Right. So in the perimenopause and menopause itself, a lot of what women are experiencing is natural and normal but it can be frightening if you don’t understand what’s going on and why it’s happening. So a lot of the work I do as a menopause provider is counseling. It’s just talking through symptoms and why they’re happening and how long they may last and if there’s anything that needs to be done about them.
A lot of women just really need reassurance as they’re going through this process. The biggest thing we reassure women about is that this process will end. You know, the perimenopause is not lifelong. It is a transitional time. It can be very crazy. It can be wacky for some women. When your hormones are fluctuating wildly, it can feel very, very different but that that will end.
You will go into a new normal which is different than the old normal and I can talk to them about natural remedies they might want to try. I can talk to them about diet and exercise and how those play into how a woman feels during this time. None of that requires an in-person visit.
If a woman is really struggling and might need to consider hormone therapy, then it’s worthwhile going to see an OB-GYN and she goes in armed with the knowledge that she has tried some of these other things and they’re just not sufficient and she might need hormonal intervention.
Jill: Well, let’s talk a little bit about prescription. How comfortable are you in terms of prescribing medication via telehealth? We see more and more of that happening and especially for women in perimenopause and menopause. We’re talking hormone replacement therapy.
Dr. Rebecca: So I think the ability to prescribe via telehealth is very much dependent on what we are prescribing. In terms of hormone replacement therapy, a lot of the conversations surrounding prescribing hormone replacement therapy relies on history and a woman’s symptoms. It doesn’t really rely that much on physical exam and I am certainly comfortable prescribing a hormone to a woman who I feel I have a complete medical history on, who is getting regular and routine exams by her primary care physician. I don’t need to do a specialized exam for that.
The one thing that a woman would need to understand before getting hormones prescribed online is that there are side effects of hormones and if any of these come up, she will need to see an OB-GYN perhaps for a biopsy. But that’s pretty rare and if she’s using the hormones correctly, it really shouldn’t become a big issue.
So I think this is one area where telehealth prescribing is actually very beneficial and we see that in other areas of telehealth where people are being prescribed birth control or things like that.
I think the area where it’s not as good is things like antibiotics for infections because that does require more of a physical exam which you can’t do via video camera. So I think there are areas where it makes a lot of sense and this is one of them and there are areas where it really doesn’t make sense and you still need to be seeing a physician.
Jill: You know, obviously many women and people in general but women are understandably nervous about entrusting their care to a video appointment. What would you say to a woman who’s uncertain about telehealth?
Dr. Rebecca: Well, I think the biggest point in establishing that level of trust is the conversation you have with a woman. If you’re involved in conversing with her, if you’ve read her history forms, if you understand the problem that she’s coming to you with and if you listen, then they will feel comfortable and certainly women who think that this is a bad method of healthcare don’t need to use it. They can go and find a physical physician to see. But that’s not an option for a lot of women and I think just having the resource and being able to try it and feel comfortable with it reassures a lot of women.
I think that Gennev, when we do our telehealth, one of the things that we do very well is we ask a lot of questions upfront. They fill out a good health history form so that we know what we’re dealing with and then I explore that with them when we’re face to face on the video camera. So I understand – you know, do they have any risk factors? Do they have medical problems I need to take into account? I think they feel very reassured that I’ve read about them before I come into the phone call and that we can discuss their issues face to face.
It really does feel like a face to face conversation. It’s almost easier than when you go into the office because a lot of times in the office, we’re having to chart while we do things or write prescriptions or do all sorts of different things and we’re not necessarily looking at your face whereas on telehealth, really all we’re doing is looking at you and talking.
Jill: Yeah, that’s true and it’s a private conversation. You’ve obviously been conducting appointments. Talk a little bit about privacy and how a woman – it is a one-on-one exchange but talk a little bit about privacy because that’s probably the most kind of scary aspect of a video appointment.
Dr. Rebecca: Right, and I think the key thing for women to understand is that these video appointments and all the paperwork that goes with them does need to remain HIPAA-compliant. So we have systems in place to keep these conversations private. They’re not recorded and then any documentation or paperwork that we send back and forth between each other is also protected, so that it is kept private between me and the patient. It’s not shared with a bunch of different people and that’s really key in terms of maintaining that compliance for healthcare affordability.
I think women are worried that this is going out to lots of people. It’s not. I’m the only one seeing what they say. They’re the only ones seeing what I’m saying and we do not record these visits for the future. We just – it’s a one-on-one conversation just like you would have in the office.
Jill: Now as Gennev’s Director of Health, you’ve kind of truly been the visionary for establishing a telehealth practice specialized around menopausal care. Talk a little bit about that vision. It has been a dream of yours. You’ve been doing it brick and mortar for a while locally. Talk a little bit about that vision and it’s finally really launching.
Dr. Rebecca: Yeah. I think the vision – from my perspective, I have been an OB-GYN practitioner in the Seattle area since 2005 and I was in Philadelphia before that and I love talking with women and over the years, what has really become a passion of mine is menopause and perimenopausal care and I think it has become a passion of mine because as my patients have aged, I’ve seen that that is the area where they have the least information.
We’re very good at educating women about childbirth. We do a lot of education surrounding birth control because it’s very important. But then we get into the perimenopause and there’s just less out there. It’s a non-reproductive time of life and for a lot of medicine’s history, that’s an unimportant time of life to the medical establishment. I think it’s a very important time of life. Women have a lot more life to live in the perimenopause and the menopause and properly approaching those times of life and those changes and understanding them completely helps a woman to live her best life through that time.
I love doing this face to face with my patients in clinic but there are a lot more patients who need this education and who need providers who are specifically trained in menopause care and there are very few of us in the country.
Many of us have gone through the North American Menopause Society’s certification program and you can find those on their website. But the likelihood of having someone with that certification near you is probably pretty low. It’s just there aren’t that many of us out there. So being able to provide this to women all through the country is just an amazing opportunity.
I know I’ve been doing the telehealth in our alpha testing and one of the women I’ve been speaking with is from a very rural area of Washington and there just isn’t anybody out there who can answer these questions and she’s a little bit more medically complex. Perfect. This system is perfect for her because she can ask questions.
None of them required a prescription. None of them required any testing. She just wanted to talk through some of the things she’s going through and telehealth is perfect for that. I feel like being able to do that kind of good for women all over the country is just an amazing opportunity.
Jill: In that circumstance, what would she typically do in the traditional healthcare system?
Dr. Rebecca: So every area of the country is very different. In Washington, often what we see is these patients need to make appointments in Seattle and so they need to drive three or four or five hours for each appointment and each appointment is maybe 15 or 20 minutes and then if they have more questions, they have to drive back three or four hours in three or four weeks whereas this patient was able to talk to me three times from the comfort of her home and get 45 minutes worth of counselling and not have to go anywhere.
Jill: Yeah, and that’s pretty amazing, the transition or the transformation I think that will have for women like her.
Dr. Rebecca: Yeah, exactly.
Jill: That’s great.
Dr. Rebecca: And it’s not useless to women in cities either. Even though people live in Seattle, there may be plenty of OB-GYNs around. Sometimes you just have a quick 10-minute question that you want to ask an OB-GYN about the perimenopause and your OB’s office is perfectly happy to see you but it’s going to take three or four weeks or you just don’t feel like it’s enough that you want to leave their house and go into the office and do all that.
You can just call into a telehealth service and ask the question and have it answered and if they say, “You know what? You really need to see your OB-GYN about this,” then you go in. If they say, “Nope, your question is answered. You’re good,” then you don’t have to do that.
So there’s a great deal of usefulness for women everywhere in the country. I tend to focus on the rural areas because I’m in an area that’s very under-served up here in the Pacific Northwest but there are a lot of areas where this is helpful.
Jill: Well, that’s I think super encouraging and obviously as a big believer in what Gennev is doing, I’m really excited about the notion of truly being this first ever online clinic for menopause care that makes it affordable to every woman and gives her the care and the access that she needs.
So thanks for being my partner in it, Dr. Rebecca and for bringing your expertise. I just am really excited what this can bring to so many more women and the practitioners who are looking for alternative work opportunities.
Dr. Rebecca: I agree. A lot of the people who will be doing this type of telehealth are people who practice in the traditional office setting. I’m one of those people and it just allows me to reach more women during off hours and times when maybe the office wouldn’t be open or on post-call days when I’m at home anyway and it gives me an opportunity to talk to all sorts of women all over the state of Washington which is really exciting for me.
Jill: Well, good. Well, for more information, women can come to gennev.com. We will be launching telehealth services state by state and we will continue to add more states to our listing. So if your state is not in the states that we report today, sign up to our wait list. Be part of that so that as soon as we do have a practitioner in your region, we can get the word out to you and you can get on to a healthier life.
So with that, thank you, Dr. Rebecca. Here we go. Here we go in launching the first ever clinic for women in menopause.
Dr. Rebecca: Thank you.
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