Opportunities and obstacles in adult women's medicine

1. Lack of interest in the big picture 

Having practiced advanced reproductive medicine for 27 years, I find a steady decline in interest among not only our subspecialty, but all physicians, in the general welfare of patients. Physicians are too preoccupied with procedures and self-pay fee-for-service to be interested in whether patients have diseases that require comprehensive long-term management, such as endometriosis, metabolic syndrome, polycystic ovary syndrome with insulin resistance, pituitary tumors, or eating disorders. Too often it is assumed that someone else is taking care of the problem, yet too often no one is.

I ask each of my patients how she perceives my role in her care: as a subspecialist, a specialist, or a generalist. If I am not managing the patient's comprehensive care, I encourage her to see an internist or family practitioner. I try to coordinate the care that I render with the care of other physicians. I have 3,500 active patients and provide adult woman's care to 1,900 of them, some of whom are second- and third-generation patients and some of whom I have treated for 25 years, an unusual situation for an academic.

2. Lack of available primary care 

A second major impediment to optimal delivery of women's health care is the lack of primary care givers. Who will take care of the women of this country? The number of young physicians entering internal medicine, family practice, and mixed internal medicine/family practice has been declining since about 1998. While residents continue to match to internal medicine programs, less than 2% of them go into general internal medicine practices, and in many of our communities it is virtually impossible to find a family practitioner or general internist.

This reading audience is certainly aware of a decline in the interest in obstetrics and gynecology among medical students in the United States. Articles in our leading publications indicate that many of our residencies are not being filled in the match, and those that are filled are disproportionately populated with graduates of foreign medical schools.

We are well aware that men have been traveling a path to extinction in obstetrics and gynecology, declining from 42% of residents in 1999 to 29% in 2003. This will have a tremendous impact on the availability of care for adult women in the future, as many women OB/GYNs start out or end up in part-time practice. In addition, there continues to be a clustering of all specialties in large urban areas with few physicians available in smaller cities.

3. Changing demographics 

Isaacs and Schroeder demonstrated that health status is linked to class, education, income, occupation, and wealth.7 People earning less than $15,000 a year have a 3-fold increased risk of premature death compared to those earning more than $75,000 a year. Individuals with bachelor's degrees or higher smoke about 10% of the time, whereas those with no high school diploma or equivalency degree smoke about 30% of the time. Understanding the impact of socioeconomic and behavioral factors on personal health is critical to our recognizing and addressing treatable problems in our practice.

Jeffery Garten, Dean of the Yale School of Management, suggested in 2004 that there are 3 major problems facing our society today: the retirement of the baby boomers, the rise of China and India, and the economics of the developing world.8 The retirement of the baby boomers poses a serious problem; it has been estimated that by 2040 there will be 20.3 million Americans of working age, versus 77.2 million over age 65. In 1960, there were 5.1 taxpayers per Social Security beneficiary; by 2030 there will be just 2 per beneficiary.

Meanwhile, we are becoming a more diverse country, with 50% of immigrants coming from Latin America and 25% from Asia. This brings into our country significant changes in language and cultural beliefs, different views of alternate and complementary health care, and different expectations of the health care system.

The economic development of third world countries poses a serious political and economic problem for this country. Approximately 50 nations in the world are living at the poverty level. While the United States is pressured on the global stage to give increasing amounts to foreign aid programs, we will need more dollars at home to take care of our aging population, which will be primarily female.

4. The aging population 

The future is one of escalating Social Security benefits, soaring Medicare costs, ballooning fiscal deficits, and plummeting savings rates. We are headed for some wrenching economic and social tensions as the health care needs of an aging nation collide with the economic realities of globalization. This raises serious questions about the longevity of our social structure.

In 1787, the Scottish historian Alexander Tyler analyzed the fall of the Athenian republic. He said that democracies last about 200 years, the reason being that when citizens discover they can vote themselves any entitlement (in today's frame of reference, Social Security, Medicare, Medicaid) they will do so until they bankrupt the government and destabilize the political structure. This is something we should keep in mind as we approach the future.

A cartoon in The Wall Street Journal showed two cowboys gazing out at the desert. “I can see it clearly, Sam, a wilderness tamed, a vast desert landscape made hospitable, and old people as far as the eye can see.” We complain about health care costs consuming 14% of today's Gross National Product. Health care economist Uwe Reinhardt has suggested that this figure will go as high as 30%, while others say it will reach 50%. A report from the Social Security Administration's Office of the Actuary shows Medicare recipients increasing from 9.5% of the population in 1970 to 19.5% in 2030.

Along with the aging population, several related trends are at play. By 65–69 years of age, some 37% of individuals do not have an independent lifestyle. By age 80–84, this rises to nearly 50%. Men die considerably earlier than women (we men know only too well). The average woman today can expect to live to 85 years, and by midcentury she could stick around until 100. The patient of the future will be an older woman who lives alone.

Given the finite dollars that are available for health care, how will we spend money caring for these women? Currently, we consume most of it with useless end-of-life care. We need to emphasize preventive medicine. The Centers for Medicare and Medicaid Services report that 37% of the $325 billion economic pie for Medicare is spent for inpatient care, 25% goes to physician care, 15% to managed care, 5% to nursing homes, 5% to outpatient hospital care, and 13% to others including home health care and hospice.9

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This pie will obviously be sliced differently in the future, and I submit that we can no longer spend most of that money in the last few weeks of life. One hears, “Poor mom… Doctor, do everything you can to save her, spare no cost.” One can't help but think that if the individual asking for this unlimited health care knew that Medicare would not pay for it but the cost would be deducted from his inheritance, there would be an abrupt change in the philosophy of care of the terminally ill patient.

5. The “living large” lifestyle 

Foreigners note wryly that in the United States the rich are skinny and the poor are fat. The Centers for Disease Control and Prevention describes obesity as epidemic in this country and a leading cause of death.10 At the poverty level 1 in 4 are fat, while at the $67,000 a year level 1 in 6 are fat.11 Among minorities, 1 in 3 are fat. This has been attributed to “food deserts”—that is, if the big supermarket in town is a 20-minute drive away, people will gain weight because they rely on nearby fast food instead. As Americans have gotten larger, the national rate of diabetes has ballooned from 2.8% in 1980 to 6.3% in 2002, according to the American Diabetes Association, and all age groups are affected.

How do we deal with this increase in obesity, with appropriate diet? No. We enroll in exercise programs, yet wait for an elevator to take us up a single flight to our stair master class. We turn to complementary and alternative medicine. We turn to a variety of therapies to correct our health problems including massage, yoga, chiropractic care, meditation, prayer, deep breathing exercise, and natural products. We increasingly turn to the web, for better or worse, to seek health advice and counseling.

6. The volatile legal climate 

As the number of older American women grows, they will change the legal climate through the political process. Why? They will be unable to find a primary care physician, and their granddaughters will not be able to find obstetrical care. If reimbursement rates do not improve, physicians will no longer accept Medicare. Emergency rooms will begin to close, and no high-risk physicians will agree to take call at the ERs that manage to stay open. Complex or risky therapies will be less available.

Everyone in the reading audience is aware of the skyrocketing insurance premiums that have hit our profession, and while many blame malpractice litigation for this rise, it is probably due to poor investment strategies by insurance companies seeking to recoup their losses. Increased litigation plus increased practice overhead plus increased insurance premiums plus decreased reimbursement equals no health care.

The solution is already upon us: We are moving to a 3-tiered system:

At the same time, some antitrust reforms must occur. Physicians can no longer be restrained by the government while allowing the insurance industry to price-fix. We have to address our society's poor lifestyle issues, and we need to take a different view of death and accept it as a reward. We would all like to die rich, in good health, in our sleep, and leave our families well-off, but the reality is that the older person in the future will be female with less money, no family, obese with diabetes, with diminished hearing and vision, some degree of dementia, and most likely some cardiovascular disease, perhaps a few broken bones, and quite possibly no teeth.

If that scenario seems harsh and bleak, keep in mind the words of the great Shaman of Belize, Don Julio Ponte, speaking about natural healers. He said, “They do not take themselves, disease, healing, life, or death, too seriously and believe that humor is an integral part of the healing process.” And a part of dying too. As a cartoon gravestone reads, “R.J. Harwell, born in 1914, gave up smoking 1959, gave up booze 1973, gave up red meat in 1983, died anyway in 1991.”