The number of women over the age of 65 is projected to almost double in the next 20 years, and clinicians need to be comfortable treating conditions common to this cohort. This review covers several common gynecologic conditions seen in older women, including atrophic vaginitis, lichen sclerosis, pelvic floor disorders, and postmenopausal bleeding. We conclude with evidence-based screening recommendations for gynecologic cancers in older women and tips on doing a pelvic examination.
Background: Physician quality of work life is a key factor in career choice, satisfaction, and retention. The majority of physicians are currently employed by large health care organizations where physician loss of autonomy is common, yet some physicians have opened micropractices. There have been no previous studies comparing physician satisfaction between employed physicians and micropractice physicians.Methods: A previously validated survey of physician satisfaction was sent to 72 physicians practicing in a residency setting, 111 physicians in community, nonresidency setting, and 42 physicians in a micropractice setting.Results: Physicians in micropractices had the lowest satisfaction with income, but the highest satisfaction with family time and the ability to provide continuity of care. Micropractice physicians rated the overall quality of medical care they provide higher than employed physicians. Micropractice physicians reported a much smaller scope of practice.Conclusions
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We agree with Victor Fuchs and Ezekiel Emanuel (Nov/Dec 05) that radical, comprehensive health care reform is needed. Because incremental reform neither achieves health care for all nor controls spiraling costs, we support creating an "independent Institute of Technology and Outcomes Assessment" to determine which services and products provide health benefit at affordable cost.We remain skeptical, however, that universal health care vouchers (UHVs) would be better than a single-payer system. The authors note that "only a relatively small number of plans would be qualified to enroll beneficiaries under the voucher system." Although profits for those plans are predictable, exactly how a UHV system would lead to cost-effective, universal health care is less clear. With a mandated list of basic services, only price and addons could vary, leaving the UHV-supported plans little room to reduce price through competition.Annual per capita U.S. health spending tops $6,400 (far more than in comparable nations), fails to cover millions of people, and achieves among the worst health outcomes in the developed world. The cost of administrative waste alone might be enough to cover the forty-five million uninsured Americans. Multiple billing, marketing, and administrative systems lead to redundancy, inefficiency, waste, and confusion. Huge amounts are spent on advertising-driven medications that are ineffective or cost-prohibitive. Although there is very little evidence that any drug within a class is better than any other, expensive brand-name pharmaceuticals are routinely chosen over less costly alternatives. The single-payer plan includes a national formulary with negotiated prices. The UHV system does not.If done right, a universal health care system would cost less than the status quo, providing better care to more people. We take issue with the statement that a UHV approach is "more congruent with fundamental American values than single-payer proposals that emphasize equality or [health savings accounts] that emphasize freedom." Equality and freedom are perhaps the most fundamental of American values. With a single-payer universal health care system, all Americans would have equal access to basic health care and the freedom to buy insurance or pay directly for services deemed unproven or cost-prohibitive by an independent scientific body. What could be better?
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