FRAX:Using the new fracture assessment tool

Transcription

CONTEMPOR ARY OB/GYN JULY 20 09, Vol. 54, No. 7 ◾ FR A X: FR ACTURE RISK ASSESSMENT TOOL ◾ REFORMING HE ALTH CARE , PART 2 ◾ OVARIAN & CERVICAL CA THER APY
JULY 2009
VOLUME 54, ISSUE 7
Translating Science into Sound Clinical Practice
www.contemporaryobgyn.net
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FRAX: Using the new fracture assessment tool
Bruce Ettinger, MD, and Katharine M. Ettinger, JD
Could capitation be the path back to the future? ▪ We need more diagnostic humility
NEWSLINE
Metoclopramide safe
during first trimester
OB safety plan
reduces adverse events
JULY 2009
Translating Science into Sound Clinical Practice
WWW.CONTEMPORARYOBGYN.NET
GRAND ROUNDS
22
FRAX: Using the
new fracture risk
assessment tool
BRUCE ETTINGER, MD, AND KATHARINE M. ETTINGER, JD
A more precise way to estimate the probability of
developing an osteoporotic fracture, FRAX offers
patients easy-to-understand percentages that can help
them decide the best course of action.
PRACTICE MANAGEMENT
30
Reforming health care:
Part 2: Could capitation be
the path back to the future?
CHARLES J. LOCKWOOD, MD
While waiting to see what shape health-care reform will
ultimately take, here are suggested ways to prepare for the
two most likely scenarios you' ll have to confront.
WEB EXCLUSIVE
W W W.CONTEMPORARYOBGYN.NET
CME
22
Update on anti-angiogenesis
therapy for ovarian and
cervical cancers
LESLIE M. RANDALL, MD, AND BRADLEY J. MONK, MD
Are we looking at a paradigm shift in treating these two
devastating gynecologic cancers? Experts share the latest
clinical trial results on adding targeted biological therapy
that can potentially improve survival in women who' ve
nearly exhausted other treatment options.
CONTENTS CONTINUED ON PAGE 6
4
JULY 2009
30
VOL. 54, NO. 7
CONTENTS CONTINUED FROM PAGE 4
12
VOL. 54, NO. 7
JULY 2009
NEWSLINE
EDITORIAL
We need more diagnostic
humility
18
LEGALLY SPEAKING
Vacuum extractor during C/S
causes brain damage
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WHAT WE KNOW
JAMES G. BROMER, MD
Should you give antibiotics
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OB/GYN BRIEFING
PROFESSIONAL UPDATE
■
Metoclopramide safe during
first trimester of pregnancy
■
Obstetrics safety plan significantly
reduces adverse events
■
Progesterone does not appear
to prevent twin preterm birth
■
Promotional items and treatment
preferences: Are they related?
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BY CHARLES J. LOCKWOOD, MD
We need more diagnostic humility
W
hile faulty systems and poor communication
lie at the heart of many preventable medical
errors, many other mistakes, especially those
that lead to a misdiagnosis, reflect faulty logic by individual
clinicians.1 Reducing such cognitive errors requires a
better understanding of how physicians reason. Dr.
Jerome Groopman goes into great detail on this topic in
How Doctors Think,2 dissecting several common errors in
medical decision-making. Although I would argue he is a
bit too critical of past and current Yale ob/gyns over their
support of postmenopausal hormone therapy, Groopman' s
thesis is spot-on when he talks
about the dangerous shortcuts that
physicians sometimes take to make
NETWORK
diagnoses and initiate treatment.
EXPERT OPINION
He points out that we are less
For more info on this topic, see
likely to make errors when we
www.contemporaryobgyn.net/360
really listen to our patients, and
apply our ª intellect and intuitionº
to aggressively reconcile seemingly
disparate signs, symptoms,
imaging, and laboratory test
results.3 Of course, in this present day frenzied discounted
fee-for-service environment, few of us have the luxury
to give each patient the amount of time and attention we
would like; ironically, health-care reform could afford us
more of this desperately needed time to listen to our patents
and quietly contemplate their cases (see Part 2 of my series
on Health-care reform in this issue). But in the interim, we
need to know when to call a time-out from our frenetic
pace, and really listen and think about a patient' s complaint.
SEE INDEX PAGE 8
XX
Consider these cognitive blunders
Through a series of case scenarios, Groopman illustrates
just how doctors think (and don' t think). First, he points out
that some patients are just hard to like. Unfortunately, we
sometimes tune out patients who frustrate us or make us
WE WANT TO
HEAR FROM YOU
12
Send your feedback to:
[email protected].
JULY 2009
angry, and it' s these patients who are too often saddled with
the most hurried diagnoses and treatments. Paradoxically,
these patients need our attention the most since they likely
evoked similar feelings in other physicians and are probably
the victims of numerous misdiagnoses. He describes a
particularly moving example of a difficult patient in whom
the diagnosis of celiac disease was long obscured by a
dismissive focus on her putative bulimia and anorexia.
Ironically, we also make the opposite error among
patients we like and with whom we identify. In this
setting, we so want things to turn out for the best that
we may underinvestigate; as Groopman puts it ª Doctors
may make decisions that stack the deck so that they
draw what seems to be a winning hand for a patient they
especially like, admire, or identify with.º 4 Maintaining a
discrete emotional detachment, even while being friendly,
is difficult to achieve, though absolutely critical. I would
argue that for ob/gyns who often make their toughest
decisions in the wee hours of the morning, buoyed by
caffeine and adrenaline, their primal feelings for a patient
can accentuate the tendency toward both types of errors.
Another set of errors comes from the use of heuristics or
attempts to employ shortcuts or use nonsystematic trialand-error approaches to quickly reach diagnoses. One such
heuristic error, sometimes referred to as ª availability,º is ª the
tendency to judge the likelihood of an event by the ease with
which relevant examples come to mind.º 5 I have frequently
seen this error committed by internistsÐ and a few
obstetriciansÐ caring
for pregnant patients
with HELLP syndrome
when they misdiagnose
the problem as acute
cholecystitis, hepatitis,
and, in one egregious
case, acute liver failure
on a liver transplant
service! This error is
often compounded by
ª confirmation bias,º
which occurs when
` Dr Groopman
talks about
the dangerous
shortcuts MDs
sometimes take to
make a diagnosis.'
EDITORIAL
clinicians selectively accept and reject data to support their
availability error.
Don' t get too comfortable with
your diagnostic conclusions
A related phenomenon is called ª anchoring,º which occurs
when one ª doesn' t consider multiple possibilities but
quickly and firmly latches on to a single one.º 5 Yet another
reasoning blunder Groopman
focuses in on is the ª satisfaction of
searchº error, which is the tendency
POWER POINTS
to stop searching for a diagnosis
When making a
once you find a plausible one.6 I have
diagnosis:
seen this type of error made in both
the overdiagnosis of fetal distress
Avoid snap judgments
and cephalopelvic disproportion
and shortcuts;
(especially at 6 and
11 pm), the underdiagnosis of preterm
Listen to patients
carefully;
labor, and the over- and underinterpretation of decreased fetal
Don' t just act, think!
heart rate variability (e.g., ascribing
the tracing to narcotics instead of
fetal distress and vice versa).
We are taught in medical school that when we hear
hoofbeats, think horses, not zebras. But sometimes the
sounds really are made by zebras. Groopman tells a poignant
story about a Vietnamese orphan in whom the diagnosis of
atypical Severe Combined Immunodeficiency (SCID) was
made, when in fact the infant was simply malnourished;
obviously the Harvard pediatricians caring for this baby
were more familiar with SCID than malnutrition!7 When
the data just don' t fit, one needs to think of zebras and avoid
an error called ª diagnosis momentum,º which results from
a diagnosis becoming fixed in a physician' s mind, despite
incomplete or contradictory supporting evidence.7 I have
seen this error several times in patients with recurrent
pregnancy loss associated with massive mid-gestational
abruption. The patients were repeatedly treated with
heparin for a minor thrombophilia, when in fact they
had a major hemorrhagic disorder that was exacerbated
by the anticoagulation! Similarly, I have seen thrombotic
thrombocytopenia purpura and severe antiphospholipid
antibody syndrome misdiagnosed as simple HELLP
syndrome, resulting in catastrophic outcomes in that or
subsequent pregnancies. Sometimes it really is a zebra!
The opposite problem occurs when ª expertsº make
diagnoses based on what Groopman calls the denial of
uncertainty.8 Rather than being a sign of hubris, he notes
that substituting certainty for uncertainty is a basic human
trait. I' ve certainly been guilty of this one. I jumped on the
14
JULY 2009
thrombophilia bandwagon early on, based on data from
rather sketchy case± control studies and what seemed like
perfect biological plausibility. As a result, I convinced myself
that these conditions led to all sorts of adverse pregnancy
outcomes linked to uteroplacental vascular insufficiency.
Now I am far less certain of their link to any such adverse
outcome, except maternal venous thromboembolism.
We ob/gyns are also particularly prone to ª commission
bias,º the almost uncontrollable impulse to act.6 How many
of the half million hysterectomies performed each year in the
United States are truly justified? Are C-section rates of 40%
rational? Do uncomplicated patients really need multiple
ultrasounds during their pregnancy? The ª availability errorsº
described above can lead to commission bias because we are
too influenced by an unusual event or prior error.9 I have
seen this kind of error among office-based sonologists who,
having missed a rare anomaly, spend the next 18 months
referring patient after patient to rule it out.
While in general, Groopman' s book does a great job of
exposing physicians' cognitive errors, he is somewhat biased
in favor of his own field of oncology when he advocates
heroic and ª creativeº anti-cancer treatments oddly out of
sync with our era of evidenced-based medicine and runaway
health-care costs.10 But he concludes with a powerful set of
questions patients should askÐ and we should encourage
them to ask. These questions would help us avoid many of
the errors described above. Such focused communication
is the very basis of patient- and family-centered health care.
The bottom line is: listen to all your patients carefully, avoid
snap judgments, and shortcuts to diagnosis; when in doubt,
always consider the worst case diagnostic scenario, and, in
the words of one of my wise former chief residents, don' t just
act, sit thereÐ and think!
DR. LOCKWOOD, Editor in Chief, is Anita O' Keefe Young Professor and
Chair, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale
University School of Medicine, New Haven, CT.
REFERENCES
1. Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation,
classification, and consequences. Am J Med. 1989; 86:433-441.
2. Groopman J. How Doctors Think. Boston, Houghton Mifflin, 2007.
3. Ibid. p. 22
7. Ibid. Chapter 5, pp. 101-131
4. Ibid. p. 46
8. Ibid. p. 152
5. Ibid. pp. 64-65
9. Ibid. p. 196
6. Ibid, p. 169
10. Ibid. Chapter 10, pp. 234-259
OB/GYN Briefing
NEWSLINE
A R O U N D U P O F B R E A K I N G R ES E A R CH
Taking metoclopramide to relieve
nausea and vomiting during
the first trimester of pregnancy
does not increase the risk of
birth defects and other adverse
outcomes, according to a study
in the June 11 issue of the New
England Journal of Medicine.
Ilan Matok, from Ben-Gurion
University of the Negev in BeerSheva, Israel, and colleagues
investigated the safety of
metoclopramide during the first
trimester of pregnancy in 78,245
women who did not receive
metoclopramide and 3,458 women who received the drug.
Progesterone does not
appear to prevent twin
preterm birth
Vaginally administered progesterone has no impact on
the rate of intrauterine death, delivery before 34 weeks, or
adverse events in women with twin pregnancies, according
to a study published online June 11 in The Lancet.
Jane E. Norman, MD, of the University of Edinburgh
in the United Kingdom, and colleagues conducted a study
of 500 women with twin pregnancies, half of whom were
randomized to receive a 10-week course of 90 mg a day of
vaginal progesterone while the other half received placebo.
The researchers also conducted a meta-analysis of existing
data on prevention of preterm birth and intrauterine death
among women with twin pregnancies.
There were 247 women in both groups who completed
the study, and the rate of intrauterine death or delivery
before 34 weeks' gestation was 24.7% in the progesterone
group and 19.4% in the control group, the investigators
discovered. There was no difference between the two
16
JULY 2009
Metoclopramide is used to treat only the most severe
cases in the United States and Canada, while it is the
drug of choice in Israel and some European countries,
according to the authors.
The researchers found that
exposure to metoclopramide
did not significantly affect
the risk of major congenital
malformations (OR, 1.04), low
birthweight (OR, 1.01), preterm
delivery (OR, 1.15), or perinatal
death (OR, 0.87). Inclusion
of 998 therapeutic pregnancy
terminations, where 38 women had
received metoclopramide, did not
significantly affect the results.
Matok I, Gorodischer R, Koren G, et al. The
safety of metoclopramide use in the first trimester of pregnancy. N Engl J
Med. 2009;360:2528-2535.
groups in terms of adverse events.
ª Our results contrast with the randomized trials
and meta-analyses of high-risk singleton pregnancies
in which progesterone seems to be effective in
reducing preterm birth, although this reduction will
only be clinically useful if accompanied by long-term
improvement in the health of offspring,º the authors
write. ª The biological mechanism by which preterm
delivery occurs might be different in twin and singleton
pregnancy, and this hypothesis merits further study.º
Norman JE, Mackenzie F, Owen P, et al. Progesterone for the prevention
of preterm birth in twin pregnancy (STOPPIT): a randomised, double-blind,
placebo-controlled study and meta-analysis. Lancet. 2009;373: 2034-2040.
doi:10.1016/S0140-6736(09)60947-8.
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◾ Children' s insulin resistance may begin during pregnancy
◾ Acupuncture can alleviate prenatal dyspepsia
◾ Breastfeeding may reduce risk of multiple sclerosis relapse
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Metoclopramide safe during
first trimester of pregnancy
Professional Update
Obstetrics safety plan
significantly reduces
adverse events
After a comprehensive patient safety program
was implemented at Yale-New Haven Hospital in
Connecticut, adverse obstetric outcomes fell by about
40% during a 2-year period, according to a report in
the American Journal of Obstetrics and Gynecology
(5/09). Outcomes studied were blood transfusion;
maternal death, intensive care unit admission, or
return to operating room or labor and delivery; uterine
rupture; third- or fourth-degree laceration; Apgar
score lower than 7 at 5 minutes; fetal traumatic birth
injury; intrapartum or neonatal death; and unexpected
admission to the neonatal intensive care unit.
Major elements of the initiative include the following:
◾ outside review of obstetric services by two independent
consultants, both experts in perinatal risk assessment
and management;
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treatment preferences:
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Subtle exposure to small
pharmaceutical promotional
items influences medical students'
unconscious attitudes toward marketed
products, according to a report in the
Archives of Internal Medicine (5/11/09).
The report is based on an experiment
conducted in 352 third- and fourthyear medical students at the University
of Miami Miller School of Medicine
(Miami), which allows pharmaceutical
companies to distribute gifts, meals, and samples, and the
University of Pennsylvania School of Medicine (Penn),
which restricts such pharmaceutical marketing practices.
Participants in the exposed group used Lipitor
(atorvastatin) branded promotional itemsÐ Lipitor logos
on a clipboard and notepaperÐ to sign in for the study.
Participants assigned to the control group completed the
◾
◾
◾
◾
◾
◾
◾
NEWSLINE
development of a series of protocols and guidelines
delineating practice standards (including appropriate
dosing of oxytocin);
creation of the position of patient safety nurse, whose
primary responsibility is to provide a formal method of
evaluating clinical care and outcomes;
activation of a computerized tool for anonymous event
reporting;
establishment of a consistent system of inpatient
coverage and resident supervision via in-house oncall attending services provided by members of the
maternal-fetal medicine section, available 24/7;
formation of an obstetric patient safety committee that
reviews specific events on a case-by-case basis, then
addresses needs for protocols and policies;
implementation of a safety attitudes questionnaire to
assess health-care employee perception of teamwork
and safety; and
initiation of training in team skills and fetal heart
monitoring interpretation.
same procedures with a plain clipboard and notepaper.
Investigators then examined differences in attitudes
toward Lipitor and Zocor (simvastatin) in the two groups
at each school.
Overall, all participants favored Lipitor over Zocor. At
Miami, however, fourth-year students
exposed to Lipitor promotional items
showed stronger preferences toward
Lipitor than did the control group. In
contrast, this effect was reversed in Penn
fourth-year students exposed to Lipitorbranded items, with the exposed group
demonstrating weaker preferences
toward Lipitor than the control group.
No significant effect was observed
among third-year medical students.
Investigators also surveyed participants about their
attitudes toward pharmaceutical marketing in general.
Results of this survey suggest the reason for the divergence
in reactions to promotional items: Students at Penn, where
restrictive policies are in place, exhibited significantly more
negative attitudes towards marketing than students at
Miami, where marketing restrictions are absent.
JULY 2009
CONTEMPORARY OB/GYN
17
BY DAWN COLLINS, JD
R IS K M A N AGEM EN T I N O B S T E T R I C S A N D GY N ECO LO GY
Vacuum extractor during C/S
causes brain damage
A 39-YEAR-OLD CALIFORNIA WOMAN was pregnant in
2003 and elected to undergo a cesarean section for the
delivery of her first child. The pregnancy was complicated
by advanced maternal age, pregnancy-induced
hypertension, and gestational diabetes. The woman
claimed the decision to have an elective C/S was made
because her obstetrician told her that she had a narrow
pelvis and she would have difficulty delivering vaginally.
The day prior to the C/S, the patient and her husband met
with the obstetrician for a preoperative exam and consent
discussion. A neonatologist and nursery nurses attended
the delivery. A vacuum extractor was used during the
C/S to deliver the head. The neonatologist examined the
baby, found no problems, and gave Apgar scores of 9 and
9. No injury, bruising, or swelling of the head was noted,
but the nurses documented the presence of bruises on
the newborn' s chest and right hip. About 6 to 7 hours
later the infant became fussy, would not breastfeed, and
appeared pale and cold. He was transferred to the NICU
at approximately 15 hours of age and the neonatologist
was called. Intracranial hemorrhaging and disseminated
intravascular coagulopathy
(DIC) were diagnosed and blood
NETWORK
products were immediately
administered. He was then
LEGAL ISSUES
transferred to another hospital,
where massive subgaleal
and intracranial bleeds were
diagnosed, resulting in severe
brain damage. The infant survived
but about 75% of his brain is
damaged, he is blind, and will
probably never speak or walk. He will require 24-hour
care for the rest of his life.
The parents sued the hospital and obstetrician. They
claimed that the physician was specifically told that the
mother was choosing the cesarean to avoid any injury
to the baby and more specifically, that he was not to use
SEE INDEX PAGE XX
SEE INDEX PAGE 8
any forceps or vacuum during the delivery, and that he
told them that he did not use those devices. They argued
that the bleeding was caused by the vacuum and that
in 1998 the FDA had issued an advisory that subgaleal
bleeds and intracranial hemorrhages had been associated
with the vacuum extractors, and that extreme caution in
their use and postdelivery observation of the newborn
was required. The parents alleged the infant' s bruising
was abnormal for a C/S in a nonlaboring scenario and
required monitoring and follow-up. The patient also
claimed that when she asked the doctor if he had used
a vacuum, he did not answer her. They maintained
that there had been no indication for the vacuum, that
obviously the uterine incision was inadequate to deliver
the baby and should have been extended.
The hospital reached a $3.5 million settlement prior to
trial and the case went forward against the obstetrician.
He claimed the patient wanted a C/S from the beginning
of her care because she was afraid of a vaginal delivery
for the pain involved and the possibility the baby' s head
would be injured coming through the pelvis and birth
canal. He denied that any conversation involving forceps
or vacuum took place during the pre-op or any other visit.
He further claimed that while he did not use forceps,
he did use a vacuum if needed to assist in deliveries and
that if a patient refused to allow him to use a vacuum, he
would have referred her to another physician.
The physician
denied having the
conversation that he
did not answer the
patient about the
use of a vacuum. He
maintained that the
uterine incision was
adequate, that the
use of the vacuum
was appropriate, and
that discussion of
the possible use of a
vacuum during C/S
` Why did this
neonate develop
intracranial
hemorrhage and
DIC 15 hours
after delivery?'
Many times the factual information available about the case presented here is incomplete. Thus, it may not always be possible to discuss all of the elements of negligence or nuances involved in a given situation.
The outcomes described also may not reflect the current standard of care or the best practice in obstetrics and gynecology. What these cases do represent are the types of clinical situations in the specialty that
typically result in litigation and the variation in jury verdicts and awards across the nation. Some of the cases described here have merit but many do not.Ð Dawn Collins, JD
18
JULY 2009
LEGALLY SPEAKING
was not required in 2003. He further claimed that the
bruising on the chest and hip were not caused by the
vacuum and were evidence that the infant has a factor VII
polymorphism that prevents him from normal clotting
and contributed to the severe brain hemorrhaging and
subsequent damage. A defense verdict was returned for
the physician.
LEGAL PERSPECTIVE Even though this case was
successfully defended as to the physician, it was
problematic because neither the doctor' s operative
report nor the nurse' s notes reported the use of the
vacuum during the delivery of the infant. The physician
later amended his dictated note by hand and then again
by another dictation to reflect using the vacuum and
what he then believed the pressure that was used. The
nurse amended the patient' s chart and L&D records to
also reflect the use of the vacuum, but she noted a higher
pressure setting than the doctor' s note. The patient
alleged that the failure to document the use of a vacuum
in the chart potentially compromised the care of the baby.
As is usual in these cases, the issues are the
informed consent for using the device and the
indication for its use. The parents alleged that when
they mentioned concerns about the vacuum, the
physician should have discussed the possibility of its
use and the complications associated with a vacuum
prior to the operation. Since the damage was probably
caused by the device, the indication for the use of
the vacuum extractor during C/S became the major
issue, and the lack of documentation was a challenge
for the defense. The fact that the infant had an
abnormal bleeding/clotting disorder, which most likely
exacerbated the injury, probably aided in obtaining a
defense verdict for the obstetrician.
Department editor DAWN COLLINS, JD, is an attorney specializing in
medical malpractice in Long Beach, CA. She welcomes feedback on this
column via e-mail to [email protected].
JULY 2009
CONTEMPORARY OB/GYN
21
GRAND ROUNDS
FRAX: Using the new
fracture risk assessment tool
A more precise way to estimate the probability of developing an osteoporotic fracture,
FRAX offers patients easy-to-understand percentages that can help them decide
the best course of action.
BY BRUCE ETTINGER, MD, AND KATHARINE M. ETTINGER, JD
W
NETWORK
SEE INDEX PAGE 8
PATIENT CARE
hen Mrs. Adams, 53 years old,
sees Dr. Santano for her ob/gyn
visit, it' s obvious that she' s afraid of
developing osteoporosis, no doubt because of her
mother' s recent diagnosis. She wants to know if
she should be tested. Dr. Santano recently heard
about FRAX and wonders how it might help
this patient' s fracture risk.
FRAX, a new fracture risk assessment tool,
estimates the 10-year probability of hip
fracture alone and the 10-year probability
of a major osteoporotic fracture at any one
of four fracture sites: hip, wrist, proximal
humerus, or clinical vertebral.1 In contrast
to often inscrutable bone mineral density
(BMD) T-scores or vague recommendations
to consider clinical risk factors, FRAX
provides an individual' s risk in the familiar
format of percentages. Fracture probabilities
are based primarily on clinical risk factors
22
JULY 2009
Understanding the limitations of FRAX
Of course, the FRAX tool has limitations;
many of which are discussed elsewhere
in more detail. 2,3 For example, it does not
GETTY IMAGES/ VISUALS UNLIMITED/ ALAN BOYDE
What is FRAX?
(Table 1) and may be further refi ned with
BMD scores; however, FRAX estimates may
also be obtained without BMD. This tool
is accessible on the Web at www.sheffield.
ac.uk/FRAX. By late-2009, FRAX results
will also be integrated into the BMD reports
of most bone densitometry machines.
FRAX has sound scientific underpinnings.
The World Health Organization (WHO)
collated data from observational studies
involving more than 60,000 subjects, then
calculated relative risks for key clinical risk
factors and for hip BMD1; these data were
validated in large population databases.
FRAX calculates an individual' s fracture risk
relative to US population data and adjusts for
gender, age, and race/ethnicity.
Osteoporosis in an 89-year-old female
JULY 2009
CONTEMPORARY OB/GYN
23
FRAX
ª Does your patient see her risk optimistically
(e.g., 1 in 10 means a 90% chance of no fracture)
or pessimistically (e.g., ` I' d be the one to get it.' )?º
POWER POINTS
The FRAX tool
estimates the 10-year
probability of a hip
fracture alone and the
10-year probability of
a major fracture at
any of four sites.
The assessment tool
is available at www.
sheffield.ac.uk/FRAX.
Absolute risk provides
patients with more
concrete, accessible
information than
relative risk.
consider all relevant risk factors (including
falls, frailty) and is not well-suited for
patients with several disorders contributing
to osteoporosis, nor for those already
taking osteoporosis drugs. It uses yes/no
answers when quantities would be ideal; for
example, it doesn' t consider the durationdose of corticosteroid therapy beyond the
3-month period that yields a ª yesº . It uses
only femoral neck BMD values, while widely
accepted practice is use of the lower hip and
spine BMD values.
Using the tool interactively may provide
more accurate results. For example, the tool
recognizes only hip fracture of a parent,
yet spinal fractures due to osteoporosis in
a parent may also increase fracture risk in
the offspring. Thus, a clinician could run
the tool twice, obtaining estimates for both
ª yesº and ª noº answers for a parent with a
hip fracture, and then averaging them. The
astute clinician should consider low spine
BMD and other factors not included in the
tool when interpreting results for patients.
for a major osteoporotic fracture 5 ; these
thresholds replace the vague prior criterion
ª T-score below ± 1.5 with risk factors.º
Dr. Santano decides to use FRAX to teach
Mrs. Adams about fracture risk and to help
them decide whether to order a bone density
test. Mrs. Adams, who is white, doesn' t
smoke or drink, is overweight (BMI 28), and
whose mother recently suffered a hip fracture,
answers the Web-based FRAX questions with
the help of the doctor' s assistant.
National Osteoporosis Foundation
guidelines for osteoporosis drugs
Use ª framingº to explain risk
At what f r ac t u re r i sk le vel shou ld
osteoporosis drug therapy be recommended?
To answer this question, the National
Osteoporosis Foundat ion (NOF) has
performed cost-effectiveness analyses 4
and has published new guidelines. 5 In
doing their analyses, NOF summarized
many clinical trials that examined the
impact of bisphosphonates on the risk of
fracture. They concluded that by taking a
bisphosphonate for 5 to 10 years, patients
can expect to reduce their risk of fracture by
about 35%.4 NOF' s new guidelines also use
FRAX 10-year risk results to recommend
treatment in patients with osteopenia when
risk exceeds the following thresholds: 3%
or more for hip fracture and 20% or more
24
JULY 2009
Communicating risk
Understanding risk requires patients to do
fairly complex math. 6 The field of health
numeracy studies how communication
of numeric information impacts patient
decisions and care. 6,7 As providers of risk
information, we serve a critical role as
number interpreters.6 As such, we need to
be aware of the language gap and the bidirectionality of communication. 8 When
communicating fracture risk data, we need
to keep in mind this ª two-wayº street.
Dr. Santano explains ª age is the most
important risk factorÐ most fractures occur
among women in their 70s and 80s. Over
the next 10 years, based on your risk factors,
your risk of having a hip fracture is less than
1% (actually 0.5%). In other words, more than
99 out of 100 people like you will probably
not suffer a hip fracture. Your risk for any
one of four common osteoporotic fractures,
such as wrist, arm, spine, or hip, is 10%,
meaning that you have a 90% or 9 out of 10
chance of being fracture-free over the next
10 years, or a 1 in 10 chance of having a
fracture in the next 10 years. At your age, the
kind of fracture that is most common is wrist
fracture, whereas for a woman over 75, spine
or hip fractures are more common.º
Framing is the way information is
FRAX
presented to give it context and meaning.
Numeric information can be presented
in a variety of ways (percentages, ratios,
pictographs, charts).6,7 The goal in talking
to Mrs. Adams is for her to grasp her risks.
Her physician anchors the dialogue with
age because presenting the most important
information first shapes how subsequent
information is understood and is best
retained. 6 Patients understand numbers
in different ways, so Dr. Santano frames
her risk in several ways. 6,9,10 Absolute risk
numbers provide more concrete, accessible
information than relative risk.6 Words like
low, medium, and high are best presented
in combination with real numbers. 6 By
presenting both sides of risk numbers
(10% fracture risk, 90% likelihood of no
fracture), the doctor enhances informed
consent, builds trust, and promotes belief in
health information.6 Graphic displays may
be more easily understood than numbers.11
While FRAX does not provide such visual
aids, other fracture risk tools show risk in
color coded zones: red (high; >20%), yellow
(moderate; 10%± 20%), or green (low;
<10%).12
TABLE 1
Risk factors for US FRAX
The following risk factors can be input into the calculation
tool, available at www.sheffield.ac.uk/FRAX
◾ Gender
◾ Race/ethnicity: non-Hispanic White, Black, Hispanic,
and Asian
◾ Age: (between 40 and 90 years)
◾ Weight (kg) and height (cm): used to calculate body
mass index (BMI); a converter from English to metric
units is provided on the FRAX Web site
◾ Family history: either parent with a hip fracture
◾ Personal history of fragility fracture: after age 45,
including radiographic vertebral fracture
◾ Corticosteroid use: prednisone 5 mg daily or more
for 3 months or longer, current or past
◾ Rheumatoid arthritis: confirmed diagnosis
◾ Smoking: currently, any
◾ Alcohol use: averaging more than 3 units daily
◾ Secondary osteoporosis: type 1 diabetes,
osteogenesis imperfecta in adults, untreated
long-standing hyperthyroidism, hypogonadism or
premature menopause, chronic malnutrition or
malabsorption, organ transplant, and chronic liver
disease)
◾ Bone mineral density: either femoral neck T-score
or femoral neck BMD can be entered; risk estimates
can also be produced without BMD; if only total hip
BMD is available, that can be used; the tool is not
designed for spine BMD input
Check your patient' s understanding
Dr. Santano continues, ª I' m not sure whether
I have been clear, perhaps you can help me by
explaining back to me your understanding of
this risk.º The doctor also probes Mrs. Adam' s
perception of this risk: ª How does living with
this risk feel?º Mrs. Adams explains that she
is comfortable with her small fracture risk.
However, in light of her mother' s fracture,
she would like to know how her own risk will
change as she gets older.
Ensuring that patients understand
information is a key part of the counseling
process.13 Methods, such as ª teach backº
(sharing clinical information, then asking
the patient to teach the information back to
you), help to clarify information.14 Patients
tend to underestimate real risk while
overemphasizing rare risk.15 Does Mrs.
Adams see her risk optimistically (e.g., 1
in 10 means a 90% chance of no fracture)
or pessimistically (e.g., ª I' d be the one to
get it.º )? Acknowledging the emotional
component of risk responses and reframing
risk information, including using visual
representations, may provide a means to
address emotion-based responses.6,10
Interacting: using FRAX dynamically
Dr. Santano responds, ª While family history
of hip fracture increases your risk, your
personal history weighs more heavily. Based
on your clinical factors, your risk is small
(10%). Let' s explore the influence of age by
adding 5 years to your FRAX profile (Dr.
Santono now uses the tool interactively,
changing the age); in 5 years, your 10-year
risks, as expected, will be higherÐ still less
than a 1 in 100 (0.9%) chance for hip fracture,
but you will have a 15% risk of developing
a fracture at one of the four sites mentioned
previously. That is to say a 6 out of 7 chance
of being fracture free over the 10 years after
that, or a 1 in 7 chance of fracture.
JULY 2009
CONTEMPORARY OB/GYN
27
FRAX
The doctor goes on to explain: FRAX
does an excellent job of predicting risk from
clinical factors alone. According to WHO
experts who developed the assessment tool,
BMD data contribute minimally to the risk
calculation. Thus, they recommend BMD
testing only when a patient is within 20% of
the 20% treatment threshold (~16%).16 With
your 10% risk, the BMD result is unlikely
to change your risk category (low) but in 5
years, when your risk is higher (15%), BMD
could have a significant impact on your risk
calculation.º Dr. Santano pauses, ª I want to
make sure we have the same understanding
and to give you a chance to ask any
questions.º Mrs. Adams states tentatively,
ª My risk is so small now that testing won' t
tell us anything, but my risk increases with
age, so a bone test later will help us know if I
should start treatment. So when should I get
this test done?º
The physician asks, ª Based on our
understanding of your current low-risk
profile, waiting 3 to 5 years seems reasonable.
Are you comfortable with that?º Mrs. Adams
agrees to wait a few years before BMD
testing.
Just as Gail Model17 and the National
Cholesterol Education Program 18 have
provided 10-year risk numbers for breast
cancer and cardiovascular disease, FRAX
now provides 10-year fracture risk numbers.
Ideally, it should be used interactively,
with providers and patients observing the
rate changes as risk factors are added or
subtracted. But keep in mind that the way
we present these risks to patients is critical.
Risk counseling techniques like framing,
using absolute risk (not relative risks),
presenting both sides of risk numbers,
and practicing ª teach backº promote our
patients' ability to grasp risk meaningfully
and support shared decision making.
[Editor' s note: Doctor and patient names in this
article are fictitious.]
DR. ETTINGER is Emeritus Clinical Professor of Medicine at
University of California, San Francisco, CA. MS. ETTINGER,
a Senior Fellow, Center for the Health Professions, UCSF,
San Francisco, CA, is a clinical ethicist and mediator.
28
JULY 2009
REFERENCES
1. Kanis JA on Behalf of the World Health Organization
Scientific Group (2007). Assessment of Osteoporosis at
the Primary Health Care Level. Technical Report. WHO
Collaborating Centre for Metabolic Bone Diseases,
University of Sheffield, UK. Printed by the University of
Sheffield.
2. Watts NB, Ettinger B, LeBoff MS. FRAX Facts. J Bone
Miner Res. 2009;24:975-979.
3. Ettinger B, Black DM, Pressman AR, et al. Updated
fracture incidence rates for the US version of FRAX.
Osteoporos Int. 2009 (in press).
4. Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, et al.
Cost-effective osteoporosis treatment thresholds: the United
States perspective. Osteoporos Int. 2008;19:437-447.
5. Dawson-Hughes B, Lindsay R, Khosla S, et al. Clinician' s
Guide to Prevention and Treatment of Osteoporosis. National
Osteoporosis Foundation, Washington, D.C. 2008.
6. Apter AJ, Paasche-Orlow MK, Remillard JT, et al.
Numeracy and communication with patients: they are
counting on us. J Gen Intern Med. 2008;23:2117-2124.
7. Rothman RL, Montori VM, Cherrington A, et al.
Perspective: the role of numeracy in health care. J Health
Commun. 2008;13:583-595.
8. Schenker Y, Lo B, Ettinger K, et al. Navigating language
barriers under difficult circumstances. Ann Intern Med.
2008;149:264-269.
9. McNeil BJ, Pauker SG, Sox HC Jr, et al. On the elicitation
of preferences for alternatives therapies. N Engl J Med.
1982;306:1259-1262.
10. Peters E, Hibbard J, Slovic P, et al. Numeracy skill and
the communication, comprehension, and use of risk-benefit
information. Health Aff (Millwood). 2007;26:741-748.
11. Hawley ST, Zikmund-Fisher B, et al. The impact of
the format of graphical presentation on health-related
knowledge and treatment choices. Patient Educ Couns.
2008;73:448-455.
12. Ettinger B. A personal perspective on fracture risk
assessment tools. Menopause. 2008;15:1023-1026.
13. Schillinger D, Piette J, Grumbach K, et al. Closing the
loop: physician communication with diabetic patients who
have low health literacy. Arch Intern Med. 2003;163:83-90.
14. Oates DJ, Paasche-Orlow MK. Health literacy:
communication strategies to improve patient comprehension
of cardiovascular health. Circulation. 2009;119:1049-1051.
15. Moore RA, Derry S, McQuay HJ, et al. What do we know
about communicating risk? A brief review and suggestion
for contextualising serious, but rare, risk, and the example of
cox-2 selective and non-selective NSAIDs. Arthritis Res Ther.
2008;10:R20. doi:10.1186/ar2373.
16. Kanis JA, Oden A, Johansson H, et al. FRAX and its
applications to clinical practice. Bone. 2009;44:734-743.
17. www.cancer.gov/bcrisktool. Accessed June 12, 2009.
18. Expert Panel on Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults. Executive Summary
of The Third Report of The National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) JAMA. 2001;285:2486-2497.
PRACTICE MANAGEMENT
Reforming health care:
Part 2: Could capitation be
the path back to the future?
While waiting to see what shape health-care reform will ultimately take, here are
suggested ways to prepare for the two most likely scenarios you' ll have to confront.
BY CHARLES J. LOCKWOOD, MD
NETWORK
SEE INDEX PAGE 8
PRACTICE MANAGEMENT
L
Enthoven and colleagues:
system-based competition
Compared with Porter and Teisberg, Dr.
Enthoven and Laura A. Tollen map out
a starkly different model for health-care
30
JULY 2009
reform.2 At the core of their paradigm are large
integrated health-care delivery systems (IHS).
These could consist of very large multispecialty
medical groups, or ideally, such groups linked
to hospitals, labs, imaging facilities, and
pharmacies, all reimbursed on a per capita prepayment system (i.e., capitated payments) or
through their own health plan offering.
The locus of competition. In their model,
competition would occur at the system level,
with consumers choosing an IHS and not the
best provider for a given medical condition.
(Table 1 compares the two models' basic
principles.) Unlike Porter and Teisberg' s highly
decentralized, medical condition-specific,
narrowly-focused, integrated practice unit
(IPU)-based model, for Enthoven and colleagues,
control is top-down, and care is full service and
very broad. Whereas Porter and Teisberg focus
on value, Enthoven and colleagues focus on cost.
Cost focus over value. Enthoven and colleagues
GETTY IMAGES/ STOCK ILLUSTRATION RF/BRUNO BUDROVIC
ast month, we examined one of two
proposed long-term remedies for our
country' s looming health-care crisis, a
viewpoint articulated in the landmark book,
Redefining Health Care by Porter and Teisberg.1
We now move on to the other leading model.
My goal in this second part of the series
is to explain the system-based competition
model of Stanford University economist Alain
Enthoven and colleagues. Then I' ll compare the
two models and suggest which model is likely
to win out. I' ll also lay out potential reforms of
primary care and Medicare on the immediate
horizon and suggest ways to prepare your
practice and institution for this future.
HEALTH-CARE REFORM
contend that only the IHS-based model can
ensure that providers are carefully selected,
trained, and proficient in specific evidencedbased diagnoses and treatments.2-4 However, they
do not spell out how to achieve such assurance.
Presumably, it will be through administrative
controls on appointment, reappointment, and
credentialing processes, as at present.
They also hold that only IHS can deploy
physicians in adequate yet appropriate numbers
and specialties to meet a population' s needs.
Again, they are short on details, but presumably
decisions on resource allocation would be made
by top management, after analysis of the market
and with a focus on cost reduction. Enthoven
and colleagues argue that IHS are needed to
finance and support the type of electronic
health record (EHR) platforms required. These
would be embellished with decision-support
software that insures the presence of accurate,
current patient medical histories, imaging and
lab test results, and computerized provider
order-entry systems designed to reduce errors.
They state that IT platforms are crucial to
minimize practice variations and errors while
maximizing care coordination and efficiency.
Enthoven would return to capitation
Their most controversial contention is that
only capitated, per-member-per-month, global
payments reward doctors for keeping patients
healthy, solving problems economically,
avoiding costly errors, and using less expensive
ambulatory care settings. Capitation would
focus IHS on reducing costs and adopting the
most cost-effective technologies. And it would
end the vicious cycle of escalating procedure
volume that' s inherent in the current fee-forservice (FFS) system, they say. To back up this
claim, Enthoven and Tollen point to empiric
evidence that total per capita health-care
costs are 25% to 30% lower in prepaid group
practices than in FFS practices.2 Moreover, IHS
are more likely to use care teams, employ better
IT systems, and implement clinical guidelines,
they note.2 They also maintain that outcomes
reports and quality bonuses will check the
tendency to ration care.
They contend that:
◾
Only large capitated IHS can support integrated
teams sharing the necessary goals, work
processes, and IT required for coordinated care
Comparison of the Porter vs. Enthoven models
of health-care reform
TABLE 1
Model
Porter and Teisberg pt
Enthoven and colleagues
Level of competition
Care for a given medical
condition over the full
cycle of care by competing
integrated practice units
(IPUs) based on value
(outcome/cost)
Price for comprehensive
system of care provided
by competing integrated
health-care delivery
systems (IHS) based on
price per member per
month
Who decides
Consumer seeks highest
value IPU for a given medical
condition or for primary care
based on published outcome
and price data aided by
advice from health plans
and their PCPs
Health plan chooses
IHS, and employer or
government or consumer
chooses health plan if there
are multiple health plans
Payers
Private plus individual
co-pays and deductibles
covered by MSAs
Private and public health
plans or single government
payer
Coordinator of care
PCP or specialist if
patient has a dominant
medical condition, based
on patient' s wishes and
available value data
PCP based on instructions
of IHS management
Area of competition
Global
Local
PCPÐ primary care physicians; MSAsÐ medical savings accounts
across many settings, with technology selected
based on safety and effectiveness, perhaps
with the help of a federal institute for technology
assessment.
◾ Only IHS can integrate the full spectrum of
primary and specialty care and deliver it in the
most appropriate setting, and since they cannot
cost shift, they will not overutilize care.
◾ Only large capitated IHS can achieve the
necessary economies of scale to maximize
supply chain leverage, consolidate ª hotelº
services, and cover large populations.
Problems with Porter approach
Enthoven and colleagues dispute the basic
Porter and Teisberg IPU premise that high
volumes in a focused service lead to better
results, by noting that only limited evidence
establishes a correlation between volume and
quality.2,4 They also argue that highly focused,
medical condition-specific IPUs are poorly
suited to care for patients with co-morbidities,
a major flaw given two statistics:
◾
93% of Medicare spending occurs among the
75% of beneficiaries with three or more chronic
conditions,5 and
◾ 83% of spending occurs among patients with
JULY 2009
CONTEMPORARY OB/GYN
31
multiple morbidities.6
POWER POINTS
To ` unclog' the
system, we need
a cheaper, simpler
approach offering
more convenient
services.
Primary care must
assume a far more
prominent role in
coordinating care and
maintaining wellness.
Enthoven et al. say
only capitated,
per-member-permonth, global
payments reward
doctors for keeping
patients healthy,
solving problems
economically, and
avoiding costly errors.
The Porter/Teisberg
model comports
with the practices
of successful US
businesses who
relentlessly seek to
increase value.
32
Similarly, they assert that Porter and
Teisberg' s proposal to eliminate network
restrictions would impair coordination of care
and that IPUs would be subject to the same
moral hazard as current discounted FFS systems
to increase volume. They believe that Porter and
Teisberg' s system of co-payments would simply
reduce the frequency of visits within a cycle of
care and not the volume of care provided.
In fact, these economists challenge the core of
the Porter and Teisberg modeÐ that consumers
will choose IPU based on published outcome
data and pricesÐ by contending that quality
reports are difficult to generate, impossible for
patients to interpret, and haven' t been shown to
drive volume.2 And patients won' t seek out the
best regional or national IPUs because they prefer
local care, they add. Finally, they refute the Porter
criticism that full-service IHS shield substandard
providers by pointing out that comparable large
companies, such as General Electric, have broadline strategies that only work ª if the company
maintains a rigorous environment of evaluation
and discipline on quality and efficiency.º 4
Problems with Enthoven approach
For their part, Porter and Teisberg note that
Enthoven' s IHS present numerous conflicts
of interest because of their lack of outside
competition at the level of specific medical
conditions. Capitation creates its own moral
hazard to ration care, a risk exacerbated by a
likely reluctance to publicly report providerspecific results, they say. Moreover, they
assert, large IHS are poor business models
since consolidating hotel services (e.g.,
laundry) and purchasing offer only scant
financial advantages that can be duplicated by
outsourcing.7
Porter and Teisberg note that many of
Enthoven and colleagues' arguments against
IPUs are refutable. For example, they say there' s
less risk of performing unnecessary procedures
with IPUs than with the current discounted
FFS system, since payments are bundled over
the care cycle. Conversely, there' s less of a moral
hazard for rationing than with capitated IHS,
since results would be widely available and
drive health plan referrals, recommendations of
referring physicians, and patient choice.
And what about Enthoven' s contention
JULY 2009
that quality reporting will not drive patient
behavior? Porter and Teisberg counter: (1)
Although there' s been only limited application
of such reporting to date, the few available
applications (e.g., cardiac surgery, cystic
fibrosis care, and organ transplants) have
produced remarkable aggregate improvements
in outcomes7; and (2) even if patients do not
respond to such data, their health plans and
referring primary care providers (PCPs) are
likely to react. PCPs would also be subject
to their own value and resource utilization
reporting and would be aware that their
patients may have perused these reports.
This has certainly been my experience in
recommending IVF providers, given public
reporting of each center' s results.
Ultimately, the best argument for the Porter
and Teisberg model is that it comports with
the practices of successful US businesses who
relentlessly seek to increase value. In contrast, the
Enthoven and colleagues model mirrors the less
attractive features of European health systems
(highly bureaucratic, command and control,
socialized) that, though achieving better results
than our current dysfunctional FFS system, are
generally unpopular with the public, since they
ration care and lag in innovation.
What will be the long-term
future of health-care reform?
While the Porter and Teisberg model makes a far
more compelling long-term economic argument,
the Enthoven and colleagues plan would be
easier to implement in the short run. The current
severe recession and massive federal budget
deficits make its immediate short-term cost
reductions to employers and taxpayers very, very
attractive. Fear of a renewed consumer backlash
to capitation could be at least partially assuaged
by emphasizing there are no gatekeepers, and
that some form of pay-for-performance (P4P)
safeguards could be etched into contracts. While
providers are likely to be intensely opposed,
health plans may view it as the only option left
to restrain costs. Given their large size, IHSs
could easily accept patients participating in state
or federal government insurance ª poolsº of
individual and small company employees, thus
eliminating current premium discrimination for
large employers.
Given the minimal administrative require-
HEALTH-CARE REFORM
ments of capitation, the Enthoven model could
easily lead to alternative federal or state government payers. Indeed, President Obama proposed
such a government payer during the campaign,
and this is becoming a major bone of contention between liberals and conservatives debating health-care reform in Congress. Although
Congress is likely to limit the competitive advantage of such a payer vis-a-vis commercial health
plans, since government-based plans would have
no obligations to stockholders and lower marketing overhead, they could prove attractive to subscribers. Indeed, in the Enthoven model, such
an alternative government payer could quickly
evolve into a single-payer system. However, federal and state payer(s) would be subject to unrelenting political pressure to ratchet down costs
to taxpayers. Similarly, if they survive, thirdparty private payers would also be under intense
employer pressure to relentlessly lower per
capita payments to maintain/capture employer
contracts.
I would postulate that the inevitable pressure
on IHS to ration care and eschew expensive
innovation would ultimately lead to consumer
unrest and the development of a ª grayº market in
IPU-like providers, paid directly by consumers.
Since IPUs would likely generate better results
than comparable IHS-based providers, over time
the entire market would eventually evolve to a
Porter and Teisberg model or some mixture of
IPUs and IHS akin to the United Kingdom' s
National Health Service and its so-called Harley
Street private practices.
Regardless of whether we evolve to a
governmental single payer, or retain employerfinanced health plans, or create some hybrid
of the two, we need fundamental reform of
governmental health-care regulations. State
Certificates of Need (CONs), Stark laws, antikickback regulations, and the like impede the
essential elements needed to support either
health-care model: joint physician-hospital
funds flow arrangements, gain-sharing, and
risk-sharing, as well as cost-saving or valueenhancing technical innovations.
Likely short-term fixes:
resuscitating PC and debuting
disruptive innovations
In either model, and with any payer scheme,
primary care will need to assume a far more
TABLE 2
Minimal requirements for a medical home
(1) Primary care includes coordinating care, preventative care, health maintenance, and
acute health-care services.
(2) Must employ an electronic health record with decision-support capabilities. Medicare
(or presumably private health plans) would also provide timely and periodic reports
listing covered patients and resources used. The latter would ultimately become part
of a P4P payment or deduction.
(3) Must have a quality assurance and improvement program.
(4) Must allow 24-hour communication.
(5) Must maintain up-to-date advanced directives.
(6) Have a contract with each patient designating a provider as their medical home.
(7) Payment would be by capitation or combination of monthly payment for medical home
infrastructure (e.g., IT) and care coordination, plus fee-for-service for discrete care
provided, plus a P4P bonus.
(8) Employ care managers (RNs) to assist patient in self-management, enacting life-style
changes, and monitoring progress.
(9) Monitor medication use (necessity, dosage, potential for adverse drug reactions).
P4PÐ pay for performance
Source: based on MedPAC Report to Congress13
prominent role as the site of care coordination
and wellness maintenance. In the Porter and
Teisberg model, PCPs would play a crucial role
in directing patients to high-value specialty
IPUs for specific conditions and collaborating
with specialists for chronic care. In the
Enthoven model, PCPs would also serve to
integrate, coordinate, and possibly ration care.
R.I.P. primary care? The problem is that
primary care is dying in this country just when
we need it most. In the past 10 years the number
of US medical school graduates entering family
practice residencies and the percentage of
internal medicine residents planning careers in
primary care plummeted by more than 50%.8
During the same interval, medical subspecialty
fellowship positions rose by 40%. While the
primary-care pipeline is drying up, one quarter
of general internists are leaving their practices
after only 15 to 20 years.
Crucial to coordinate care. In today' s frenetic
health-care environment, PCPs have no time and
receive no pay for coordinating care, arguably
their most important function. Despite all these
limitations, patients with a PCP versus those
with a specialist as their personal physician have
33% lower health-care costs and 19% lower riskadjusted mortality.9 There' s abundant evidence
that increased access to PCPs is associated with
reduced all-cause mortality.10 Thus, of all the
broken aspects of the US health-care system, this
is perhaps the most serious.
CONTINUED ON PAGE 40
JULY 2009
CONTEMPORARY OB/GYN
33
Patient-centered medical homes
and ` mall' clinics
One proposed solution to the primary care crisis
is implementing the patient-centered medical
home (PCMH). The exact nature of such a facility
is under debate, but the minimum requirements,
as outlined by the Centers for Medicare and
Medicaid Services' (CMS) Medicare Payment
Advisory Committee (MedPAC), are listed in
Table 2.11
The PCMH is designed to insure that
essential preventative and wellness programs
are carried out and reimbursed, that care is
coordinated, and that earlier diagnoses are made.
It' s also meant to reduce emergency department
visits, hospital readmissions, and unnecessary
procedures. Simultaneously, PCHMs will reduce
adverse drug events (ADEs), and duplicated lab
tests and imaging. The potential costs savings
and better outcomes are substantial.
However, PCMHs cannot work unless we
can decant much of the low-acuity acute care
that now clogs PCP offices, such as simple
upper respiratory infections, UTIs, strep
throat, viral syndromes, pregnancy tests, and
even routine vaccinations. These cases require
simple rule-based diagnostic and treatment
algorithms and not a physician' s analytical
skills or specialized knowledge.
What' s needed to unclog the system is a
ª disruptive innovation,º that is, an approach
that offers cheaper, simpler, more convenient
services.12 Retail health care, as developed
by such companies as MinuteClinics,
MedExpress, Urgent Care, and other mallbased providers, offers such a solution. For
a modest fee, a nurse or nurse practitioner
obtains a medical history, conducts a physical
examination, and employs point-of-service
testing to make the diagnosis and provide a
prescription and/or treatment plan for a small
fee ($35± $50). The patient receives a bill, which
can be paid from her medical savings account.
Such patients are currently sought after by
many PCPs since they can be churned for quick
revenue. However, they clog the system and
represent a horrific waste of PCP talents and
resources. Once payments become bundled,
capitated, or a mix of the two, such patients will
be far less attractive to PCPs. With their offices
unclogged, their reimbursements increased,
PCP can do a better job of preventative care,
40
JULY 2009
making earlier diagnoses and reducing
expensive referrals to specialists.
The first steps to reform
are already underway
Signs that change is coming are the CMS' s P4P
demonstration project and its Quality Monitoring
System. MedPAC is now proposing large-scale
testing of patient-centered medical homes
(PCMH) paid for with a mix of per capita and FFS
reimbursement.13 The former would cover the cost
of coordinating care and IT investments, while
FFS reimbursement would cover unique services
rendered. MedPAC is also proposing bundled
physician-hospital payments for episodes of care.13
For example, there would be a single payment
for the care of a patient with congestive heart
failure that would cover all hospital and provider
services both for inpatient care and post-discharge
ambulatory care for 60 days. Given that private
health plans usually follow CMS' s lead, medical
homes and bundled payments will likely be the
norm throughout the health-care system within 3
to 5 years. Thus, physicians and hospitals will need
to dust off their previously discarded PhysicianHospital Organization (PHO) arrangements.
Moreover, these MedPAC proposals could easily
serve as the foundation for either of the models
I' ve discussed.
Preparing your practice¼
In many ways, ob/gyns are in a uniquely
advantageous position to confront this new
world. In obstetrics, we are already paid
for providing the complete cycle of care. In
addition, ob/gyn practices with a primary care
focus could potentially serve as a women' s
care-focused PCMH, either alone or partnered
with PCPs. To qualify, such practices will
undoubtedly require the kind of political
muscle displayed by ob/gyn organizations
that ensured direct access to patients and
primary care designation during the first round
of capitation in the late 1990s. It will also be
crucial that ob/gyns prepare to partner with a
hospital or re-form PHOs to be able to manage
bundled payments for gynecologic surgeries.
¼ for an Enthoven world. If health care moves
to the Enthoven model, ob/gyn practices will
need to become affiliated with or owned by
large IHS. In this model, ª laboristsº would
likely dominate inpatient care. Alternatively,
midwives may be increasingly integrated into
very large ob/gyn practices. Payments could be
through straight salaries or heavily discounted
FFS contracts negotiated with the IHSÐ and
not a health plan. It' s also possible that ob/gyns
could marshal the nearly superhuman political
clout that could gain them direct access to
patients and be carved out of IHS-capitated
contracts, but given the enormous costs to
health plans related to ob/gyn care, I doubt it.
¼ for a Porter world. What if the Porter
and Teisberg model dominates? In many
ways, single-specialty ob/gyn groups already
represent early-stage IPUs. Their evolution
to fully functioning IPUs requires a careful
examination of their strengths and weaknesses
in managing various medical conditions.
Perhaps one group would focus on chronic
pelvic pain and another urogynecology.
An obstetrically oriented group might offer
birthing center care, while another provides
high-tech patient-requested cesarean deliveries.
There also needs to be a focus on results
measurement, reporting capabilities, and
other IT functions, as well as access to needed
ancillary and consultative services. You will
need to undertake simultaneous and careful
examination of the care pathway for a given
condition, including methods of monitoring/
preventing conditions, and diagnosing, treating,
and monitoring outcomes.
While waiting to see which direction healthcare reform goes in, and not abandoning other
aspects of your practice, consider focusing on a
specific ob/gyn condition and publicly reporting
your results. This is likely to have the immediate
short-term benefit of capturing market share and
the long-term benefit of preparing the practice for
evolution into an IPU or making your practice
more attractive to an IHS. Within any given
large generalist practice or one that includes
subspecialists, different groups of providers
can generate numerous nascent IPUs. These
structures have the added expedient of being
able to serve as PCMHs or to allow participation
in inpatient bundled payment programs.
No tort reform in sight. Unfortunately,
regardless of the long-term evolution of healthcare reform, tort reform is unlikely to be a
part of it. The political maelstrom that tort
reform would generate could well kill healthcare reform. However, the advent of high42
JULY 2009
quality IPUs is more likely to reduce errors and
to improve patient-provider rapport, a key to
avoiding litigation. I do not see such immediate
benefits accruing from the IHS model.
Like it or not, the practice of medicineÐ
including ob/gynÐ is about to change in a far
more fundamental way than any of the failed
short-term fixes generated over the past 35 years.
This future offers unparallel opportunities to
improve health care and render physicians' lives
more rewarding. It will also be disruptive in ways
we cannot possibly begin to imagine.
DR. LOCKWOOD is Anita O' Keefe Young Professor
of Women' s Health and Chair, Department of Obstetrics,
Gynecology and Reproductive Sciences, Yale University
School of Medicine. He is also Editor in Chief of this magazine.
REFERENCES
1. Scoping the problem (Chapter 1). In: Porter ME, Teisberg
EO. Redefining Health Care: Creating Value-Based
Competition on Results. Boston, MA: Harvard Business
School Press; 2006:17.
2. Enthoven AC, Tollen LA. Competition in health care: it
takes systems to pursue quality and efficiency. Health Aff
(Millwood). 2005;Suppl Web Exclusives:W5-420-433.
3. Enthoven AC, van de Ven WP. Going DutchÐ managedcompetition health insurance in the Netherlands. N Engl J
Med. 2007;357:2421-2423.
4. Enthoven AC, Crosson FJ, Shortell SM. ` Redefining health
care' : medical homes or archipelagos to navigate? Health Aff
(Millwood). 2007;26:1366-1372.
5. Thorpe KE, Howard DH. The rise in spending among
Medicare beneficiaries: the role of chronic disease
prevalence and changes in treatment intensity. Health Aff.
(Millwood). 2006;25(5):W378± 388.
6. Partnership for Solutions, Chronic Conditions: Making
the Case for Ongoing Care: September 2004 Update.
http://www.partnershipforsolutions.org/DMS/files/
chronicbook2004.pdf (accessed June 4, 2009).
7. Principles of value-based competition (Chapter 4). In:
Porter ME, Teisberg EO. Redefining Health Care: Creating
Value-Based Competition on Results. Boston, MA: Harvard
Business School Press; 2006:97-148.
8. Sepulveda MJ, Bodenheimer T, Grundy P. Primary care:
can it solve employers' health care dilemma? Health Aff
(Millwood). 2008;27:151-158.
9. Franks P, Fiscella K. Primary care physicians and
specialists as personal physicians. Health care expenditures
and mortality experience. J Fam Pract. 1998;47:105-109.
10. Starfield B, Shi L, Macinko J. Contribution of primary care
to health systems and health. Milbank Q. 2005;83:457-502.
11. MedPAC. Promoting the use of primary care. In: Report to
the Congress: Reforming the Delivery System. June 2008;2151. Accessed at: http://www.medpac.gov/documents/
Jun08_EntireReport.pdf.
12. Christensen CM, Bohmer R, Kenagy J. Will disruptive
innovations cure health care? Harv Bus Rev. 2000;78:102112, 199.
13. MedPAC. Direction for delivery system reform. In:
Report to the Congress: Reforming the Delivery System.
June 2008;1-20. Accessed at: http://www.medpac.gov/
documents/Jun08_EntireReport.pdf.
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or 630.978.2709 (fax)
www.vnafoxvalley.org
MAINE
MAINE COAST
Excellent, general OBGYN, group practice
opportunity located in community known
as the ªJ ewel of the Maine Coastº.
Join team of OBGYN' s and nurse midwives in
freestanding women' s center adjacent to regional
referral center. Extensive educational programs.
Well-equipped and staffed facility. Offer
includes competitive salary, full benefits,
assistance with student loans. Four-day
workweek. Community offers good schools;
choice of town, coastal, or country housing;
many cultural and recreational activities.
Contact Susan Edson
New England Health Search
Phone 207-866-5680
[email protected]
MASSACHUSETTS
BOSTON
SUBURBS
Contact Suzanne Sherman at
[email protected]
4 physician practice
looking for 5th
BC/BE OB/GYN.
Call 1:6. Competitive
salary and benefits.
Martha’s Vineyard
Hospital employed full time obgyn position joining one obgyn
physician and two certified nurse midwives in beautiful Martha’s Vineyard associated with a brand new hospital and labor/
delivery wing. 1-2 call backing up midwives. Excellent salary,
bonus and benefits including housing allowance. OBGYN
Search, 800-831-5475, © ax: 314-984-8246, [email protected],
www.obgynpractices.com
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7X.SLR«W© PMRMG6IGVYMXQIRX7IVZMGIW
4,*%<
)1%-0ERKMIEFVELEQ$QIVG]RIX %%)3)
OB/GYN Opportunities:
Lebanon, Rolla and
Springfield, Missouri
*LEBANON OB/GYN ELIGIBLE FOR UP
TO $1© 0K IN LOAN REPAYMENT!*
St. John’s Clinic, a 480-physician multi-specialty group, is seeking BC/BE OB/Gyn
physicians. Position offers a competitive One-Year salary guarantee and earning
potential in the © 0th percentile for specialty. Positions also offer excellent benefits
package including health, dental, and vision benefits, occurrence base malpractice, life
insurance, vacation and CME, retirement plan and more. St. John’s was recently ranked
the #1 Integrated Health System in the nation by Verispan!
Lebanon, Missouri offers a wide variety of activities; three major shopping areas
feature everything from outlet malls to antique shops. Lebanon is just 15 minutes from
the famous Bennett Springs State Park, a trout fisherman’s dream. In addition, Lake of
the Ozarks, one of the largest man-made lakes, and Pomme de Terre Reservoir,
Missouri’s newest lake, are about 30 minutes away, respectively. Lebanon is located
three hours from the St. Louis International Airport and just an hour from the
Springfield-Branson National Airport. http://www.lebanonmissouri.org/
Rolla, Missouri offers a healthy job market, wonderful people, beautiful neighborhoods
and top ranked schools. The growing city has superior health care facilities and a
brand new 108,000 sq. ft. state-of-the-art facility to house primary care and specialty
services. Additionally, Rolla has bountiful opportunities for outdoor recreation with
clear, fast-flowing Ozarks streams for fishing or canoeing. There are 100,000 acres of
State Parks and National Forest that offer a diverse selection of year-round outdoor
recreational activities. Rolla is home to the Missouri University of Science and
Technology, a top 50 best college as rated by America’s high school counselors, and a
top 25 entrepreneurial campus, according to Forbes.com. The city is © 0 minutes from
the St. Louis International Airport and © 0 minutes from Springfield-Branson National
Airport. http://wwww.rollacity.org/
For more information, please contact:
Angie Abraham, MBA, Director
St. John’s Clinic Recruitment Services
Phone: 877-880-6650
Fax: 888-2© 0-8300
E-mail: [email protected]
AA/EOE
JULY 2009
CONTEMPORARY OB/GYN
51
RECRUITMENT
NEW YORK
NORTH DAKOTA
GARDEN CITY, NEW YORK
Garden City Plaza
Women' s Health Center
We are currently seeking qualified candidates
for an OB/GYN position within our practice.
We are also seeking qualified candidates
for an MFM position within our practice.
The main practice is located in Garden City. We have State-ofthe-Art electronic medical records, State-of-the-Art ultrasound
machines, and a State-of-the-Art operating room within the
office with JACHO certification as well as in-house anesthesia.
Patient care consists of both high and low risk OB, major GYN
surgeries, laparoscopies, Infertility, Oncology. Most minor
surgeries are performed here in our Surgical Center.
The practice consists of OB/GYN physicians, one midwife,
one PA. We also have highly qualified nurses in addition
to our administrative and support staff.
Easy call schedule, excellent benefits with vacation,
paid CME conferences.
Part time and full time positions are available.
For more information, please contact Linda or Kathy at
516-873-6100 or Email [email protected]
www.gardencitywomen.com
NORTH CAROLINA
BE/BC OB/GYN
Fayetteville, North Carolina
Fayetteville, North Carolina. Well established solo practice looking
for BE/BC OB/GYN to join busy practice with excellent patient case
mix. Newest state of the art facility offering in office procedures.
Digichart EMR. Great family community with good cost of living.
Proximity to plentiful beach coast, mountains and lakes to thrill even
the most reluctant outdoor enthusiast. Desirable call arrangement.
Work from one 500 bed major regional hospital with level III NICU.
Office located two minutes from hospital. Competitive starting salary with great financial opportunity offering partnership track. Excellent benefits package. Relocation & sign on bonus. Spanish a plus!
Send CV & References: Ernesto J.F. Graham, MD, F.A.C.O.G.
1521 Owen Park Lane, Fayetteville, NC 28304
or email [email protected] Phone: (910) 223-7420
To see the latest
RECRUITMENT
ads, visit us at
http://Careers.ModernMedicine.com
52
JULY 2009
As the region’s most comprehensive healthcare system,
Trinity Health is home to an extensive network of providers
whose commitment and dedication to the practice of
medicine is second to none.
Competitive salary and benefit package to include
malpractice tail and relocation!
Our safe, clean community offers superior schools and an array of
activities in a four-season climate.
CURRENTLY SEEKIN© BC/BE
Obstetrician/© ynecologist
to join thriving practice of 6 OB/© yn's
and 2 CNM's.
Contact: Shar © rigsby
400 E Burdick Exp • Minot, ND 5© 702-14© 9
PH: 1-© 00-59© -1205, Ext. 7© 60, Pager #31©
[email protected]
www.trinityhealth.org
RECRUITMENT
UTAH
OHIO
NW Ohio
Hospital employed obgyn position joining one obgyn taking
over existing obgyn practice in family oriented community 30
minutes to © ort Wayne and Lima. Associated with modern and
financially stable 100 bed hospital doing 400 annual deliveries.
1-2 call. $250-$300K salary, bonus and benefits. $500K income
potential! OBGYN Search, 800-831-5475, © ax: 314-984-8246,
[email protected], www.obgynpractices.com
PENNSYLVANIA
Pittsburgh Area
Join well established 30 yr. old private obgyn practice doing
75% gyn and 25% obstetrics in desirable family oriented community 45 minutes from downtown Pittsburgh associated with
a progressive 259 bed hospital with modern Labor/delivery
unit. 1-4 weekend call. Excellent negotiable salary, bonus,
benefits and future partnership and takeover of practice.
$400K income potential. OBGYN Search, 800-831-5475, © ax:
314-984-8246, [email protected], www.obgynpractices.com
SOUTH CAROLINA
BC/BE, OB/GYN
Rock Hill, SC
Cedar City, Utah
Intermountain Healthcare needs one
BC/BE OB/GYN to join a BC OB/GYN.
Join our Medical Group in one of our busiest OB/GYN practices
located in Cedar City. Office space is located in the new Valley
View Medical Center. Call: one in four. Employment with the
Intermountain Medical Group. Guaranteed first year salary
with transition to compensation based on productivity. Full
Intermountain benefits. Relocation provided. EOE.
Cedar City' s population is approximately 26,000. Iron County' s
population is 42,000. The area has recently experienced major
population growth, and the trend is expected to continue. The
area is known for its breathtaking scenery and is the gateway to
the nation' s largest concentration of national parks. Recreational
activities for the entire family include camping, hiking,
backpacking, fishing and mountain biking. There is a moderate
four-season climate, and during winter months residents can
ski in the morning and play golf in nearby communities in the
afternoon. Educational opportunities are available through Dixie
State College and Southern Utah University. Summer activities
include the Utah Summer Games and the Utah Shakespearean
Festival, recipient of the 2000 Tony Award for Outstanding
Regional Theatre.
Send/e-mail/fax CV to: Intermountain Health Care
Attn: Wilf Rudert, Physician Recruiting
36 South State Street, 21st Floor, Salt Lake City, UT 84111
Phone: 800-888-3134 · Fax: 801-442-2999
Web: http://intermountain.net/docjobs
Carolina OB/GYN, an affiliate of Presbyterian Novant Medical
group, is a premier physician group located in Rock Hill, SC,
a bedroom community approximately 25 minutes south of
Charlotte, NC.
We are seeking a BC/BE OB/GYN for a professional challenge
in a sophisticated medical community. Enjoy a relaxing, 1:3 call
schedule and coverage at one hospital with a Level 2.5 NICU
located one block from our office. OB patients are shared among
providers. You will receive a competitive guaranteed salary
with great benefits which include retirement and a relocation
allowance and have access to the wonderful recreational
opportunities and quality of life offered in the Carolinas.
Send CV to: Robin Amos
Phone: 704-384-9950
Email: [email protected]
www.novantmedicalgroup.org
EOE
TEXAS
Texas
Take over 20+ year old practice from relocating physician and
join one other obgyn in dynamic family oriented community,
40 minutes to Abilene. Associated with a modern/financially
stable 85 bed hospital doing 300 annual deliveries. 1-2 call.
$250K-$300K net income guarantee, including all start-up
and overhead expenses. Very high income potential. OBGYN
Search, 800-831-5475, © ax: 314-984-8246, [email protected],
www.obgynpractices.com
LOGAN, UTAH
Intermountain Healthcare is seeking one BC/BE OB/GYN to join a
busy group of five. Call will become 1 in 7. Four day work week with
protected time off for family. Clinic is located within a new $42 million
Women' s and Newborn Center at Logan Regional Hospital. LDRs and
c-section rooms are one floor directly above the clinic. Nurse Midwife
takes Saturday 1st line call and triage with a walk-in clinic for urgent
issues, so weekend call is easier. Women' s and Newborn Center has
gated parking. Employment with the Intermountain Medical Group.
Guaranteed first year salary with transition to compensation based
on productivity. Full Intermountain benefits. Relocation provided.
Logan is a beautiful university community of over 100,000 which
fosters a wide variety of cultural, educational, recreational, sporting,
commercial and health care opportunities. A moderate four seasons
and majestic mountains allow for outstanding outdoor recreation
opportunities including fishing, skiing, backpacking and sailing. Along
with the academic stimulation of Utah State University, Logan offers
superb family living with quality school systems and reasonable living
costs generally 10 to 25% less than other areas of the country. Logan
is only 90 minutes from the metropolitan Salt Lake area which offers
an even wider assortment of cultural, recreational and sporting events.
Send/E-mail/Fax C.V. to: Intermountain Healthcare
Attn: Wilf Rudert, Physician Recruiting Department
36 S. State Street, 21st Floor | Salt Lake City, UT 84111
Ph: 800-888-3134 | Fax: 801-442-2999
Web: http://intermountain.net/docjobs EOE.
JULY 2009
CONTEMPORARY OB/GYN
53
RECRUITMENT
UTAH
UTAH
TREMONTON,
UTah
GREATER SALT LAKE CITY AREA
Intermountain Healthcare is seeking 3 BC/BE OB/GYN physicians.
SALT LAKE CITY: 1 physician is needed to join two other Ob/Gyns
in 2009. Office space is located at the Salt Lake Clinic, a large multispecialty clinic representing 24 specialties. Call will become 1 in 10
when recruitment is complete. Admit patients to and operate out of
LDS Hospital.
RIVERTON: 1 physician is needed to join another Ob/Gyn in 2009.
Work at the Southridge Clinic, located in the Physician Office Building on the site of Intermountain Healthcare' s new Riverton Hospital.
Call: 1 in 7 when recruitment is complete.
SANDY: 1 physician is needed to join two private practice OB/GYN
physicians in a shared expense arrangement. Office space is located
on the campus of Intermountain' s Alta View Hospital in Sandy, a
suburb of Salt Lake City. Call will be 1 in 5. Loan with forgiveness
through the hospital.
All positions except Sandy: employment with the Intermountain
Medical Group. Guaranteed first year salary with transition to
compensation based on productivity. Full Intermountain
benefits. All pos itions: re location pro vided.
Send/E-mail/Fax CV to: Intermountain Healthcare
Attn: Barbara Tarran | Physician Recruiting Dept.,
36 S. State St., 21st Floor | Salt Lake City, UT 84111
Ph: 800-888-3134 | Fax: 801-442-2999
Intermountain is an Equal Opportunity Employer
Intermountain Healthcare is seeking 1 BC/BE OB/GYN
Work in a new hospital that opened in February. Call: 1:3.
Employment with the Intermountain Medical Group. Income
guarantee of $300k in the first year with transition to production based salary. Full Intermountain benefits, including paid
occurrence malpractice insurance. Relocation provided. Tremonton is a beautiful community of 21,373 people located
in northern Utah. It offers the best of both worlds in that it
is a rural community but only 40 miles from a larger metropolitan city and 25 miles from Utah State University, where many
cultural and college sporting events are held. The area abounds
with outdoor recreational possibilities. Golfing, hiking, camping, water skiing, snow skiing, hunting and fishing are only
a few of the prospects awaiting the outdoor enthusiast. Bear
River Valley Hospital in Tremonton is a brand new facility staffed
by 46 medical personnel and other employees and services
Tremonton and the surrounding area. This new 44,000 squarefoot hospital includes physician offices, two Labor & Delivery
rooms, six same-day surgery suites, an expanded ER, and three
fully integrated operating rooms.
Send/e-mail/fax CV to Wilf Rudert at
Intermountain Healthcare, Physician Recruiting
36 South State St., 21st Flr. | Salt Lake City, UT 84111
For additional information, please contact us at
800-888-3134 | Fax: 801-442-2999
EOE.
VERMONT
VERMONT
RECRUITMENT WEB PACKAGES
Join one of the largest recruitment
networks on the Internet with
over 2,000 partner sites.
Advanstar Healthcare Network
From medicine to marketing and sales, the Advanstar
Healthcare Communications portfolio covers every
phase of the healthcare market cycle. There is no
better way to invest your recruitment marketing
dollars than with the power of these brands.
Find The Best Healthcare Candidates.
Call Today For Web Package Details!
Joanna Shippoli, Healthcare Recruitment Advisor
800.225.4569, ext. 2615 | [email protected]
54
JULY 2009
HOSPITAL-BASED OB/GYN OPPORTUNITY
in Outdoor Lovers Paradise!
Enjoy a 3-year contract that includes competitive salary and top
benefits, including sign-on bonus, home purchase allownce, medical,
malpractice, pension, loan repayment, relocation expenses, and 30
days vacation! After 3 years, go solo, or stay employed by the hospital.
Charming New England community located amidst the foothills of
the Green Mountains.
Contact Fran Nicoletti · 800-365-8900, ext. 224
[email protected] · Ref. #6511695
RECRUITMENT
VERMONT
WASHINGTON
LOOKING FOR OB/GYN
AND TEACHING PRACTICE
OPPORTUNITIES IN THE
PACIFIC NORTHWEST?
COLLEGE OF MEDICINE
General Obstetrician/Gynecologist
The Department of Obstetrics, Gynecology and Reproductive Sciences at
the University of Vermont College of Medicine is seeking a full time, General
Obstetrician/Gynecologist on the academic clinical track. Appointment will
be at the Assistant/Associate level in the Generalists' Division. Board certification
or eligibility in Obstetrics and Gynecology is required. Academic rank and salary are
competitive and commensurate with experience.
One of the primary duties of this position is to direct the 3rd year clinical Ob/Gyn
clerkship of the College of Medicine. These responsibilities include teaching,
administration, and coordination of the core curriculum with the remainder to
the 3rd year College of Medicine curriculum. Other duties will include teaching
resident physicians and providing patient care in both low risk obstetrics and
benign gynecology. Interest in translational or clinical research, or another specific
academic interest would be viewed positively.
Review of applications will begin immediately. Applications will be accepted until
position is filled. Please respond with a letter of interest and a copy of your current
curriculum vitae to:
Roger C. Young, M.D., Ph.D., Professor
Director, Division of Obstetric and Gynecologic Specialties
Department of Ob/Gyn & Reproductive Sciences
University of Vermont College of Medicine
Fletcher Allen Health Care
MCHV Campus ± MAIL STOP 251 SM4
111 Colchester Avenue, Burlington, VT 05401
Or you can apply on line at: www.uvmjobs.com
The University of Vermont is an Equal Opportunity/Affirmative Action Employer. Applications
from women and people from diverse racial, ethnic, and cultural backgrounds are encouraged.
WASHINGTON
Western Washington - ObGyn
Good Samaritan Hospital, part of MultiCare
Health System, seeks BE/BC ObGyn to join a
thriving group practice in a congenial setting.
Practice offers a great mix of patients, great call
schedule, electronic medical records and a Consulting
Nurse Service. Located 40 minutes south of Seattle
in Puyallup, WA, the area boasts the advantages of
an active Northwest Lifestyle; from big city amenities
to the pristine beauty and recreational opportunities
of the great outdoors. As an employed physician, you
will enjoy excellent compensation and system-wide
support, while practicing your own patient care values.
For more information regarding this
fantastic opportunity, contact
MultiCare Provider Services at 800-621-0301
or send your CV to ©la [email protected].
Refer to opportunity ID #731
www.multicare.org
One of the Pacific Northwest’s most progressive health systems is
looking for an OB/Gyn to join six other OB/Gyn physicians in a
group practice – just 40 minutes from Seattle. The practice complement is 3/4 private clinic an© 1/4 teaching of Family Practice
resi©e nts an© fellows. Skills in high-risk obstetrics preferre©.
THE RIGHT CANDIDATE WILL ENJOY:
• Privileges at an a© vance© regional care center, offering
Level III neonatal intensive care an© a complete perinatal unit
for high-risk mothers.
• System-wi©e support with the free©om to exercise your own
patient care values.
• An excellent compensation an© benefits package.
• The best of Northwest living – from the big-city amenities
to the pristine beauty an© recreational opportunities of the
great out©oors .
Position is open to B/E or B/C physicians who have
completed a fo© r-year residency program.
Contact MultiCare Provider Services 1-800-621-0301,
or send CV to: [email protected]
“MultiCare Health System is a drug free workplace”
www.blazenewtrails.org
Seattle GYN
Join well established nationally recognized multispeciality
clinic doing gynecology only without obstetrics in desirable
Seattle associated with brand new state-of-the-art 366 bed
hospital with two DaVinci Robots. 1-5/1-6 call schedule.
Attractive salary, bonus, benefits and future partnership.
OBGYN Search, 800-831-5475, © ax: 314-984-8246, obgynsrch@
aol.com, www.obgynpractices.com
WEST VIRGINIA
CERTIFIED NURSE MIDWIFE
Women' s Health Care of Morgantown is seeking a full-time, BoardCertified nurse midwife for its busy OB/GYN office located in
Morgantown, WV. Morgantown is located in North Central West
Virginia and has been voted one of the best small cities in America.
Responsibilities will include managing OB and GYN care, as well
as sharing call responsibility. Full benefits package offered along with
a competitive salary.
Please forward a resume to:
Women' s Health Care of Morgantown
200 Wedgewood Drive, Suite 201 · Morgantown, WV 26505
304-599-6353 · 304-598-3608 FAX · [email protected]
Visit Contemporary OB/GYN online today!
http://careers.modernmedicine.com
JULY 2009
CONTEMPORARY OB/GYN
55
ADVERTISER INDEX
ALOKA
ProSound
BAYER HEALTHCARE, LLC
Citracal
BAYER HEALTHCARE
PHARMACEUTICALS
YAZ
BD DIAGNOSTICS - TRIPATH
SurePath
COOPERSURGICAL, INC.
SpotLight Awards
DURAMED PHARMACEUTICALS,
subsidiary of BARR LABS INC
ParaGard
ELI LILLY AND COMPANY
Evista
GYRUS ACMI
PK® Technology
HOLOGIC, INC.
Cervista
IPAS
WomanCare
NATIONAL DOWN SYNDROME
Learn More About Down Syndrome
NOVO NORDISK US
Vagifem
PACIFIC WORLD
Bio-Oil
43
PALOMAR MEDICAL TECHNOLOGIES INC.
SlimLipo
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SCIELE PHARMA, INC.
Prenate DHA
25, 26
SOLVAY PHARMACEUTICALS, INC.
Prometrium
32A, 32B
UNIVERSITY OF CALIFORNIA/SAN DIEGO
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WYETH PHARMACEUTICALS INC.
Premarin Vaginal Cream
39
9
Inside Back Cover,
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16A, 16B
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Inside Front Cover, 1, 2
Copyright ©2009 Advanstar Communications Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
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photocopy items for internal/educational or personal use, or the internal/educational or personal use of specific clients is granted by Advanstar Communications Inc. for
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those listed above, please direct your written request to Permission Dept. fax 440-891-2650 or email: [email protected].
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CONTEMPORARY OB/GYN does not verify any claims or other information appearing in any of the advertisements contained in the publication, and cannot take
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JULY 2009

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