What Do Women Want?

Liz Szabo asks, “What do women want?” in Southern California Physician. When it comes to menopause, mammograms and premenstrual syndrome, many female patients prefer a female physician. In fact, many gynecological practices now market themselves as all-female.

Shawne Bryant, MD, a solo practitioner in Virginia Beach who markets her practice as “healthcare for women by women,” says many of her patients prefer doctors who have experienced the same medical problems.

She states, “It’s like when I think of how I practiced medicine before I had a baby. It’s completely different from how I practice now. Once you’ve had a child get sick, you understand why a mother can be so persistent or insistent.”

In response to why more women physicians are attracted to Ob-Gyn today, she states, “Years ago, some female doctors with children were reluctant to enter a field that often called them away from home to deliver babies at 3 a.m. Today, large group practices allow more flexibility in scheduling.”

Women now make up 70 percent of Ob-Gyn residents, according to the American College of Obstetricians and Gynecologists. The number of women in the field has grown from 7 percent in 1970 to 36 percent today and is expected to reach 50 percent by 2013. An Ob-Gyn specialist tells me that women gynecologists command a higher income than male gynecologists.

Donald Miller, MD, of Norfolk, VA, notes that some expectant mothers bypass physicians — male or female — altogether in favor of nurse midwives. He states, “There are some groups that limit themselves to female doctors only, but that raises the question of ‘who is chauvinistic now?’”

Portion Patrol

JAMA reports that doctoral student Samara Joy Nielsen and Barry M. Popkin, PhD, a professor of nutrition at the University of North Carolina at Chapel Hill, analyzed data from three national surveys conducted during 1977–1978 and 1989–1996 to determine trends in food portion sizes consumed in the United States, by eating location and food source.

The authors used nationally representative dietary intake data that sampled 63,380 individuals aged 2 years and older. They reviewed the surveyed responses to the average portion size consumed from specific food items (salty snacks, desserts, soft drinks, fruit drinks, french fries, hamburgers, cheeseburgers, pizza and Mexican food) and to the eating location (home, restaurant or fast food).

“Between 1977 and 1996, food portion sizes increased both inside and outside the home for all categories except pizza,” the authors report. “The energy intake and portion size of salty snacks increased by 93 calories, soft drinks by 49 calories, hamburgers by 97 calories, french fries by 68 calories, and Mexican food by 133 calories.

The authors believe their study provides evidence of a trend toward larger portion sizes of food in the United States. An added 100 calories per day of unexpended energy is equivalent to an extra 10 pound of weight gain per year, so it is easy to see the potential impact of large increases in portion sizes. Fast-food establishments served the largest portion sizes, and restaurants served the smallest portions, they note.

“The most surprising result is the large portion size increases for food consumed at home — a shift that indicates marked changes in eating behavior in general,” they add. “These findings suggest that the public requires better education about control of portion size both inside and outside the home.” It isn’t generally appreciated that the average soda now approaches 150 calories. Adding one per day increases one’s weight by 15 pounds per year.

The Obesity Epidemic

Greg Rosa, MD, a Sebastopol physician, writing in Sonoma Medicine states, “We need to develop a combination of clinical tools and community health programs to stem the tide of overweight.”

According to a recent RAND study, three out of every five Americans are either overweight (36 percent) or obese (23 percent). Obesity has replaced smoking as the leading cause of preventable morbidity and mortality in the United States. The problem of tobacco abuse seemed overwhelming and impossible 25 years ago. California has since reduced tobacco consumption by 50 percent, cut lung cancer rates by 14 percent and prevented 33,000 deaths from heart disease.

Physicians are advising only 40 percent of their overweight patients on the health hazards of overweight. To address obesity clinically, Rosa suggests we need to assess patients with a new vital sign: body mass index (BMI). This allows us to develop the clinical strategy: brief negotiation. We can advise our patients about the common behavior associated with overweight: inactivity, excessive television, inadequate fruit and vegetable intake, excessive sodas and processed foods, and missing breakfast.

We should take heart from a recent study of more than 3,000 overweight people who reduced their incidence of diabetes by 58 percent over placebo after implementing an exercise program.

Dr Rosa advises us to be aware of our power as individual clinicians and community members to effect change. We can emulate our success with smoking cessation and begin to reduce the prevalence of obesity.

Office Practice Under the HIPAA

The major portion of the recent issue of the San Mateo County Medical Association Bulletin is “A Tragicomedy in Four Acts, Hip on HIPAA.” Act II is reflective of general opinion.

“ACT II: ’A Day in the Life of an Office Practice Under the Curse of HIPAA Compliance’” by Jonathon F. Feinberg, M.D, a family practitioner in San Mateo.

“My devoted office manager of 16 years was tearing her hair out. ’No way; we can’t do this; we need to have a staff meeting,’ she groaned in frustration. The pizza is ordered; shades drawn; CIA and FBI security clearances obtained to assure the safety of confidential patient information on pain of death. Forms are spread over every desktop and run onto the surrounding floor. There is a tower of bureaucratic mumbo-jumbo and regulations prescribing behavior-all to solve a problem that does not exist.

“Of course we will keep personal medical information confidential: we always have; it comes with the profession. Of course we are sensitive to family dynamics. The issue of discussing diagnosis and treatment with family members can indeed be problematic at times. The point is, situations vary so significantly they cannot be regulated by proscriptions couched in impenetrable legalese as a substitute for careful, personal judgments made in the course of a doctor-patient relationship.

“What are we to do? Can we remain viable as a small business and still be close enough to compliance to survive should we have to endure an inspection?

“The decision is made. We will give patients a one-page form and hope that we understand enough of it to explain the rationale to those who are already confused by a system run amok. Our schedules will be further delayed as we try to accommodate our patients’ need for timely care.

“We cannot possibly translate our form into all of their languages. We cannot build locked shelves for our charts. We can only trust that the janitor is not an undercover spy for some unknown enemy. It is our fervent hope that Big Brother is smiling and will be satisfied until the next regulatory assault.”