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Gynecology Board Reverses Male Patient Ban

Thursday, February 20th, 2014

Back in December, I covered the issue of gynecologists treating male patients at high risk for certain types of cancer. At that time, the American Board of Obstetrics and Gynecologists had disallowed the practice. However, in response to protests from both patients and doctors, the board has lifted the ban and said that gynecologists who choose to do so are free to treat men.

The board’s executive director issued the following statement: “This change recognizes that in a few rare instances board certified diplomates were being called upon to treat men for certain conditions and to participate in research. This issue became a distraction from our mission to ensure that women receive high-quality and safe health care from certified obstetricians and gynecologists.”

This past fall, gynecologists who chose to treat male patients were ordered to stop and threatened with loss of certification for noncompliance. The board prohibited treatment of male patients with the exceptions of newborn circumcision, transgender patients, and men who were part of a couple undergoing fertility treatments.

The decision was made then in order to protect patients and uphold the integrity of the specialty of gynecology. This was due in large part to gynecologists who were branching out significantly into other areas, such as cosmetic surgery, for instance, and even advertising their services and identifying themselves as “board certified” without specifying that they were gynecologists. This practice could have misled patients who believed that they were being treated by board certified plastic surgeons, or other types of specialist.

However, one group of patients that the directive directly affected was men at high risk for anal cancer. The gynecologists who treated them said that not enough doctors had experience in this type of screening, and they feared the ban would interfere with patient care as well as government-funded studies aimed at determining the effectiveness of these cancer screenings.

In December, the board relented and agreed that gynecologists could continue to treat their current male patients, but not accept any new ones. And after further pressure, the board in January stated that the ban on treating male patients no longer existed. Gynecologists are now free to treat male patients as long as they devote “a majority” of their practice to gynecology – a change from the specific 75% that used to be the minimum portion of a gynecologist’s practice that must remain within the specialty.

Interesting, since the board’s own definition of what a gynecologist is includes, “Obstetricians and Gynecologists provide primary and preventive care for women and serve as consultant to other health professionals.”

Some are calling the board’s decision a victory for patients, but is it? As I stated back in December, “…there is no reason that I can see why the specialty of gynecology should expand into unrelated disciplines. The very reason why we have specialties is so that specific areas of medicine can be studied thoroughly and the treatments we are able to provide kept up to the minute. A gynecologist should specialize in gynecology – delivering babies, taking care of women. Other practices and treatments are important and helpful, but they aren’t gynecology.”

– Yvonne S. Thornton, M. D., M. P. H.

Gynecologists and Male Patients?

Thursday, December 5th, 2013

Gynecology is, by definition, the branch of medicine that deals with functions and diseases, especially of the reproductive system, specific to women and girls. However, recently, some gynecologists have been looking at this definition as more of a recommendation – and a flexible one at that. For example, a gynecologist at Boston Medical Center has added a new demographic to her patient roster: men.

Dr. Stier and other gynecologists who share her views have started caring for certain men; specifically, those at high risk for anal cancer. Anal cancer is rare, but it can be fatal and it is being seen more frequently, particularly among men and women who are HIV positive. Anal cancer is typically caused by the human papillomavirus (HPV) virus – the same virus that is often blamed for cervical cancer.

Dr. Stier sees mostly women, but last year she treated about 110 men as well. Using techniques she adapted from the ones developed to screen women for cervical cancer, she began screening men for anal cancer.

However, in September, the American Board of Obstetrics and Gynecology mandated that its members limit their practice to women with very few exceptions. In addition, they said that gynecologists were not allowed to perform the procedure Dr. Stier had been performing on men. Gynecologists, who often need their board certification to keep their jobs, cannot ignore directives like this.

Now Dr. Stier’s male patients are upset and her studies are in limbo. And she is not alone – other gynecologists who were engaging in the same practices have found themselves in similar circumstances. Researchers and doctors have asked the board to reconsider, but so far the board will not, pointing out that there are other doctors who could perform the screening procedures on men. The board also reiterates that the field of gynecology was specifically designed to treat women.

Apparently, Dr. Stier and others had not understood how absolute the definition of the field of gynecology was. But the board has drawn the line, emphasizing that its mission is treating women, not dabbling in spin-offs for their potential profitability. The screening process used by Dr. Stier, anoscopy, is not the only procedure in question nor is this the only incident of gynecologists straying from the original framework of gynecology; others had begun providing treatments such as testosterone therapy for men and cosmetic procedures such as liposuction for both men and women.

This trend is changing, however, thanks to the new rules the board posted on its website on September 12.  The new rules are explicit, specific, and outline exactly what gynecology should entail: treatment of women, with treatment of male patients limited to very specific circumstances, such as fertility evaluation, newborn circumcision, and emergency care.

Some doctors are upset by the new guidelines, including Dr. Stier, who is concerned that her male patients won’t get the follow-up they need now that she can no longer see them. However, there is no reason that I can see why the specialty of gynecology should expand into unrelated disciplines. The very reason why we have specialties is so that specific areas of medicine can be studied thoroughly and the treatments we are able to provide kept up to the minute. A gynecologist should specialize in gynecology – delivering babies, taking care of women. Other practices and treatments are important and helpful, but they aren’t gynecology.

– Yvonne S. Thornton, M. D., M. P. H.

Technology in Medicine: Robotic Assistance in Surgeries

Monday, May 20th, 2013

“Robots” are being used to assist in surgeries throughout the world. It sounds like something out of a movie, doesn’t it? The use of this kind of technology in medicine is raising a lot of questions for patients. Some may believe that the more technology that is used during their surgery, the better—others may have problems with the idea of a “machine” doing a lot of the work during a surgery. Doctors and surgeons are divided in much the same way, which is why studies are currently being done to assess the differences between robotic-assisted surgeries and traditional surgery methods.

In one study, women who were scheduled to receive hysterectomies were divided into two groups. One group received robotic assistance during surgery and the other did not. Researchers found that there were no significant differences in the outcomes of the surgeries—however, the robotic-assisted surgeries did take longer to complete. It may not seem like much of a finding, especially for patients, but studies like these may help ease the mind of individuals who worry about advances in medicine and whether or not they will be safe during their own surgeries or medical procedures.

Surgery—especially gynecological surgery—is becoming increasingly sophisticated, and that is good news for patients. Procedures that were once much more invasive can now be performed via laparoscopic methods, with only a few small incisions. While the outcomes at present are still very much the same for surgeries that do and do not use robotic assistance, there is a strong likelihood that in the future, as the technology advances, robotic-assisted surgeries could actually be much more advanced, and have much better postoperative outcomes compared to traditional surgical methods.

On the other hand, robotic surgery is very expensive (The DaVinci system costs 1.3 million dollars) and is labor-intensive (increased operating time), which means the patient is under anesthesia for a longer period of time, which may have serious sequelae.  All this has to be factored into the equation.  As a surgeon myself, the only advantage I see is that the surgeon gets to sit down during the entire procedure.  As a Catch-22, using robotic technology also reduces the training of young surgeons in the traditional approaches to operations, and thus the skill and “tried and true” surgical techniques are lost because they are no longer taught and performed on a daily basis.  The robot may have to be the wave of the future, by default, because surgical residents will no longer be taught how to do surgery the traditional way, and thereby fulfilling the prophesy.

The reason I find this so important to point out is to ease the minds of patients who worry about new methodologies in medicine—the simple fact is that even though surgery is growing more complex, it is also constantly improving in its ability to treat patients with a wide range of problems. While some of the newest trends in medicine may seem like science fiction more than anything else, our surgeons need to know and to be comfortable with both forms of surgery in order to have outcomes most advantageous for the patient.

– Yvonne S. Thornton, M. D., M. P. H.