Correspondence
Preventive Care for Women -- Does the Sex of the Physician Matter?
N Engl J Med 1994; 330:215-216January 20, 1994
- Article
To the Editor:
I am amazed at the conclusions drawn in the Special Article on preventive care for women (Aug. 12 issue)1 -- namely, that “women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.” Since when is 57.9 percent (the best rate of Pap-smear screening for female internists and family-practice physicians) better than 80.4 percent (the worst rate for male obstetricians and gynecologists)? Also, when is 55 percent (the best rate of mammography for female internists and family-practice physicians) better than 61.3 percent (the worst rate of mammography for male obstetrician-gynecologists)? In fact, obstetrician-gynecologists had better rates with regard to all types of screening than internists and family-practice physicians, whether one focuses on the age of the physician, the sex of the physician, or any other comparison one chooses. Furthermore, although female obstetrician-gynecologists had a higher rate of screening with Pap smears than their male counterparts, female obstetrician-gynecologists had a lower rate of mammography.
The only conclusion that should have been drawn from this article is that obstetrician-gynecologists (male or female) are more aware of preventive care for women than internists or family practitioners, and thus only they should be considered as primary care physicians for women.
1 ReferencesRichard J. Gimpelson, M.D.
222 S. Woods Mill Rd., Suite 400, Chesterfield, MO 630171
Lurie N ,Slater J ,McGovern P ,Ekstrum J ,Quan L ,Margolis K . Preventive care for women -- does the sex of the physician matter? N Engl J Med 1993;329:478-482
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To the Editor:
Any female physician who has ever been in group practice could have informed the authors that patients decide whom they will allow to perform Pap smears. I have routinely encountered female patients who enjoy excellent rapport with their male primary care physician and still choose to have Pap smears performed by an unknown female physician, even after five years and a dozen visits to their “real” doctor.
In my current practice, consisting of one male and one female family-practice physician (both in the group 38 to 42 years old), we use a uniform system in which all patients are screened at entry into the practice, informed of their need for basic preventive care services, including Pap smears, and given yearly reminder cards for follow-up Pap smears. Despite this uniform effort, which is carried out by a nurse, we consistently find that I perform five times as many Pap smears as my male partner. Is this because I am a better physician? I think not.
Lisbeth M. Lazaron, M.D.
Western Family Physicians, Cincinnati, OH 45247To the Editor:
Are male physicians the only ones who deal inadequately with cancer-screening examinations centered on the genitalia? How well do female physicians screen men for testicular masses and prostate tumors? Are they performing these assessments of their male patients as often as male physicians?
To avoid any suggestion of male chauvinism, I think it would be equally interesting to determine whether male physicians carry out adequate preventive measures for their male patients. Perhaps male physicians are as derelict in checking the genitalia of men as they are those of women.
Savelly B. Chirman, M.D.
University of California at Davis Medical Center, Sacramento, CA 95817To the Editor:
Lurie et al. do not examine the appropriateness of the screening rates in any of the groups they study. Many experts have concluded that the appropriate recommendation for the frequency of screening by Pap smear is every three years, starting when women are in their early 20s and continuing into their 60s.1 Women who have had a hysterectomy for a noncancerous condition may not need screening at all. If one were to accept this recommendation, then in any given year only about 30 percent of women would require screening -- closer to the actual rate observed in this study for male primary care physicians. Since information on the appropriateness of screening could be obtained only through a review of the clinical chart, the appropriate screening rate for the study group is unknown. One could hypothesize that the female physicians and obstetrician-gynecologists in this study were performing an inappropriately high number of screening tests of their patients. Alternatively, patients may generally see female physicians or obstetrician-gynecologists when they are due for a Pap smear and less often when they seek other forms of medical care.
1 ReferencesDana A. Merrithew, M.D.
9 Monadnock St., Colebrook, NH 035761
Eddy DM . Screening for cervical cancer. Ann Intern Med 1990;113:214-226
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To the Editor:
Nationwide, 64 percent of internists consider themselves subspecialists,1 and many of them do not profess to offer primary care. Lurie et al. ignore the possibility that the ranks of the male physicians they studied may include a higher proportion of such subspecialists than the ranks of the female physicians, despite the striking difference in patient load reported, which strongly suggests a difference in practice patterns between the two groups.
1 ReferencesStephen A. Metz, M.D.
Baystate Medical Center, Springfield, MA 01199Author/Editor Response
The authors reply:
To the Editor: The intent of this study was to determine, within the scope of the claims data available to us, whether women patients who saw women providers received more preventive care than did women cared for by male providers. The next step is to understand the relative contributions of patient-related and physician-related factors. The points raised by Drs. Lazaron, Merrithew, and Metz suggest possible explanations for our findings that cannot be adequately addressed given the limitations of claims data. Patients' screening histories, patients' preferences for male or female physicians, and physicians' specialties are included among the data that we are collecting as part of a sequel study based on interviews with doctors and patients in addition to claims data.
Dr. Chirman inquires how well male and female physicians do with cancer-centered examinations of men. Because this study was based on claims data, we could identify mammograms and Pap smears. Claims data do not reliably identify genital-rectal examinations, and thus we cannot answer this question. However, another study based on surveys rather than on claims data recently reported similar findings for mammography and Pap smears.1
With regard to Dr. Gimpelson's comment that obstetrician-gynecologists should be the only primary care providers for women, we disagree. Women's primary health care needs go well beyond a focus on their reproductive organs. Simply screening for breast and cervical cancer does not require a physician, but it does require an organized system of care. Our data cannot be used to address the suitability of such systems or of obstetrician-gynecologists as compared with other providers as primary care providers for women.
1 ReferencesNicole Lurie, M.D., M.S.P.H.
Hennepin County Medical Center, Minneapolis, MN 55415, University of Minnesota, Minneapolis, MN 55455Karen Margolis, M.D.
Hennepin County Medical Center, Minneapolis, MN 55415Jonathan Slater, Ph.D.
University of Minnesota, Minneapolis, MN 554551
Franks P ,Clancy CM . Physician gender bias in clinical decisionmaking: screening for cancer in primary care. Med Care 1993;31:213-218
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