The Institute of Medicine defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (4). Integrated care is further defined as being comprehensive, coordinated, and continuous. The definition states that primary care clinicians have the appropriate training to manage most problems that afﬂict patients (including physical, mental, emotional, and social concerns) and to involve other practitioners for further evaluation or treatment when appropriate. Using data from the National Ambulatory Medical Care Surveys, physician specialty groups were analyzed in a study to determine how well these Institute of Medicine primary care definitions applied to the care delivered by each specialty (5). In this analysis, obstetrics and gynecology as a specialty demonstrated some characteristics of primary care that applied to the traditional specialties of internal medicine, family and general physicians, and pediatrics. As a category, however, obstetrics and gynecology was more closely related to medical and surgical subspecialties (5). This analysis would be accepted by many practicing obstetricians and gynecologists who state that the specialty provides both primary and specialty care.
The Institute of Medicine definition includes referral, coordination, and follow-up care, but specifically does not include the function of “gatekeeper” as essential for a primary care clinician. As the US health care system has evolved, health maintenance organizations and insurers have responded to women’s resolute support of direct access to obstetricians-gynecologists, a concept also strongly supported by the American Congress of Obstetricians and Gynecologists (6).
There is an increasing emphasis on women’s health and gender-specific medicine. Physicians have become more knowledgeable about the differences in pathophysiologic aspects of diseases in women compared with men and thus better equipped to manage them. One example is an increasing emphasis on women’s cardiovascular health with preventive care and screening for risk factors.
Gynecologist as Primary Care Provider
The obstetrician-gynecologist frequently serves as a primary medical resource for women and their families, providing information, guidance, and referrals when appropriate. Routine health care assessments for healthy women are based on age groups and risk factors. Health guidance takes into account the leading causes of morbidity and mortality within different age groups. Patient counseling and education require an ability to assess individual needs, to assess stages of readiness for change, and to use good communication skills, including motivational interviewing to encourage behavioral changes and ongoing care (7). A team approach to care is frequently helpful, utilizing the expertise of medical colleagues, such as nurses; advanced practice nurses, including nurse midwives and nurse practitioners; health educators; other allied health professionals, such as dieticians or physical therapists; relevant social services; and other physician specialists. All clinicians, regardless of the extent of their training, have limitations to their knowledge and skills and should seek consultation at appropriate times for the benefit of their patients in providing both reproductive and nonreproductive care.
The National Ambulatory Care Surveys from the Centers for Disease Control and Prevention include obstetrician-gynecologists among primary care specialties as opposed to medical or surgical subspecialties (8). Women’s needs for primary care vary across their lifespan. One survey of women’s satisfaction with primary care found that women in their early reproductive years (ages 18–34) were more satisfied with care coordination and comprehensiveness when their regular provider was a reproductive health specialist, primarily an obstetrician-gynecologist physician as compared to a generalist, a generalist clinician plus an obstetrician-gynecologist, or no regular provider (9). The scope of services provided by obstetricians-gynecologists varies from one practice or clinician to another and may include more or fewer aspects of well-woman and reproductive health care. It is important to establish with each patient whether she has a primary care clinician and who will be providing primary care and preventive health services (1).