Women’s health care: One size does not fit all

Abstract

When we started a women's health center at our institution 5 years ago, a female colleague who was in a general medicine practice asked, “If you're doing women's health, what am I doing?” At that time, she and many other physicians were asking the question, “Are women who go to women's health centers getting different care from those who do not?” In the past 10 years, women's health centers have become a common fixture in most academic health centers and community hospitals. If physicians are still puzzling over whether these centers offer any added value, women are not. With 3600 women's health centers in the United States serving nearly 15 million women, it appears that women's health centers are here to stay.1 But the question remains: Are women's health centers really improving the quality of care, or are they marketing ploys to attract more women patients to health centers? Two reports in this issue attempt to answer this question. Both studies conducted patient surveys in women's health centers and traditional internal medicine practices in the academic setting to determine whether the women's health centers performed better on patient satisfaction and gender-specific preventive care measures. In the cross-sectional survey by Phelan et al.,2 a significantly higher proportion of patients seen in the women's health center reported having had mammography and cholesterol screening compared to their counterparts in a general medicine clinic. Although the proportions of women reporting receipt of Pap smears and hormone replacement therapy counseling were slightly greater in the women's health center, the differences were not significant. When the subgroup of patients with female providers was considered, the same trends were found. These data are inconsistent with previous reports suggesting that patients of women providers are more likely to be counseled about hormone replacement therapy 3 and to receive preventive care.4 In the study by Harpole et al.,5 patients at women's health centers were more likely to have received counseling about hormone replacement therapy (odds ratio [OR] 1.6) and dietary calcium (OR 1.3) than patients in the general medicine clinics. Although there was no significant difference in proportions of patients receiving preventive screening tests in the two settings, patients in the women's health centers were more likely to receive their gender-specific preventive health services from their primary care physician instead of from a subspecialist. These data suggest that the women's health centers, if indeed fulfilling the promise of “one-stop shopping,” might offer a more efficient model of care with increased convenience and potentially lower cost. The data indicate, however, that the care of women in the general medicine clinics was also very good. It is worth noting that, in both studies, the patients who attended the women's health centers were significantly different from those who sought care in general medicine clinics. The women's health center patients were more often unmarried, younger, felt healthier, had fewer chronic medical conditions, and went to the doctor less frequently. Significantly greater proportions of women who attended the women's health center in Phelan's report expressed a preference for a women's clinic, preferred a female provider, and had a female provider. The screening rates for breast and cervical cancer were quite high in both studies, far exceeding national averages. For example, mammography rates were greater than 90% in both studies, compared with the national average of 68%. The preponderance in academic institutions of younger physicians, recently out of training, may in part explain the higher screening rates observed in these studies. The failure to detect a difference in screening rates in the two settings may reflect the similarity in practice styles between women's health providers and general internists in academic institutions. Perhaps, then, it would be of more interest and greater relevance to compare care in women's health centers versus traditional care in suburban or community-based settings, where the baseline screening rates might be closer to the national averages. Patient satisfaction in both studies was high regardless of setting. Notably, the patients from the women's health centers in the Harpole study were more likely to report satisfaction with particular aspects of the provider–patient relationship, such as being taken seriously by the doctor, having enough time with the doctor, and feeling that the doctor was not “talking down” to the patient. It should not be that surprising that physicians in general, and especially women physicians, provide roughly the same care to women patients within academic medical centers, irrespective of practice setting. However, the findings from these two studies indicate that there is something beyond the technical processes of care that is attractive to many women and has caused millions of women to change the site of their care. There are questions about care at women's health centers that should be explored, such as the true clinical and economic impact of “one-stop shopping.” For example, more women get their gynecologic care from their internists in women's health centers. Are these women's clinical outcomes as good as a strategy of once-a-year visits with a gynecologist? Is it really more efficient, and less costly? These are testable hypotheses that are worth testing. In conclusion, these two studies suggest that the care of women in women's health centers and general medicine clinics may not be appreciably different—but the patients are. These women, with their interest in information and easier communication with their physicians, are forcing academic medical centers to become more customer-oriented. The one-size-fits-all model no longer works for many women, and probably never did. The focus of future research should be not only on which setting provides better care for women, but how to make the care better in both.