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Private Practice (unreleased episode): In Which We Take a Look at Obstetrics and Gynecology with Dr. Lisa Gennari

by Prashanthi Thota (’23)

I had the opportunity to interview Dr. Lisa Gennari, an OB/GYN who works at Associates in Women’s Health here in Cincinnati. Since this is a field of medicine I’m interested in myself, it was really intriguing to hear her perspective on the field itself — everything from why she wanted to become an OB/GYN and how many babies she’s delivered (over 2000!), to the differences between private vs. hospital practice, to the best and worst parts about being an OB/GYN. This is a long read (but definitely worth it!), so sit back and let’s begin!

Q: Tell me a little bit about yourself and what you do!

A: I grew up in St. Louis, MO and am one of nine children. No one in my family was a doctor nor are any of my siblings. I knew I wanted to be an OB-GYN since 8th grade, not just a doctor but specifically and OB/GYN. Presently, I am an OB/GYN in a private group with two other doctors.

Q: For those who don’t know, what is the difference between obstetrics and gynecology?

A: Obstetrics is a specialty of medicine that deals with pregnant women: taking care of them during their entire pregnancy, delivering their babies, and taking care of them up to 12 weeks afterward.

Gynecology is a specialty that deals with women’s health in general. That includes working in the office: seeing patients for routine yearly exams and pap smears, as well as seeing patients for problems such as pelvic pain, endometriosis, vaginal and pelvic infections, problems conceiving, etc. Gynecologists also perform surgery on women for things such as removal of benign ovarian tumors, hysterectomies (removal of uterus), laparoscopic surgery to assess pelvic pain and take care of endometriosis, etc. An extremely important part of gynecology revolves around contraception (ways to avoid pregnancy), sexual health, and helping women with the effects of menopause. I also believe it is our job to make women feel comfortable about their bodies, teach them that their vagina is not “gross,” and let them know it’s okay to ask questions about things such as vaginal discharge and not feel embarrassed about it.

(By the way, teenage men and male adults need the same thing but there really isn’t a special doctor for them. Hopefully, they are comfortable enough with their family physician to speak to them.)

Q: How much schooling did it require to become an OB/GYN?

A: After high school, you have to obtain a 4-year undergraduate degree. Then you need to pass [the MCAT]. After that, you need to apply and be accepted into a medical school (MD, Doctor of Medicine) or a DO (Doctor of Osteopathic Medicine) school. In the old days, the curriculum between MD and DO schools used to differ greatly. Also, DOs were not respected as much as MDs, which was extremely unfortunate. Now, they are pretty much the same, except that DO school includes alternative medical treatments in their curriculum. Whether through an MD or DO program, the program lasts 4 years. The first two years are usually additional classroom work regarding anatomy, physiology, etc. The last two years are pretty much all clinical training in clinics and hospitals.

During clinical training, you have several rotations through different medical specialties. When you do your clinical rotations, you will start to get a feel for the different subspecialties, which will help you decide what you want to end up doing. Once you decide which field of medicine you want to practice, you then apply for residency programs. Residency programs last anywhere from 3-6 years, depending on the specialty. After that, you may choose to subspecialize. For example, OB/GYN is a 4-year residency. Then, if you decide to subspecialize in Maternal Fetal Medicine (high risk pregnancies) or Gynecologic Oncology (female pelvic cancer surgery), you have to do an additional 2–3-year fellowship. So, for general OB/GYN, you typically have to complete 4 years of college to get an undergraduate degree, 4 years of medical school, and 4 years of residency.

Along the way, you need to pass board exams. Part 1 is taken at the end of your second year of medical school. Part 2 is taken just before you graduate from medical school. Part 3 is taken near the end of your residency. If you pass all three of those, you graduate from your residency program and are considered “board eligible.” That means you are not yet a “board certified” physician, but you have passed everything up to that point. Then you go out into the world and practice your craft for a year or two before you are able to take Part 4 of your board exam. Part 4 includes keeping a list of every single patient you see and writing up how you took care of them. Once you create that list, you present it to a board of examiners, and they grill you on whatever they want to. They look for any inappropriate forms of treatment and also question how you came up with a particular diagnosis, why you did a particular surgery in the manner you did, how you handled any complications you may have had with a surgery or delivery, etc. In order to become board certified, which is mandatory, you need to pass all 4 parts of your board exam.

If I had known all of this before I went to medical school, it might have scared me away from doing it. You can NOT think of it that way! You didn’t decide not to learn to drive a car because you had to take the classroom course, then take the written test, then drive forever with your parents critiquing you, then drive with a scary examiner while you are sweating bullets…right? You need to decide what your goal is and just keep that in mind as you progress year by year.

Q: What made you decide to go into OB/GYN?

A: Every family has its issues and mine was no different. There was a lack of respect for personal boundaries and abuse occurred. My mother had to bring me to a gynecologist when I was 14 years old for a problem I was having. Back then, there were very few female OB/GYNs. So, I saw the doctor my mother went to. He was very nice and respectful. My mother stayed in the room with me the entire time. Nothing hurt at all. That was the first time I was ever touched in a respectful way. I wanted to be able to show other women that is not just possible, but should be the norm. In addition to that, my mother was extremely forthright regarding discussions about our bodies. She said you should be able to speak about your vagina and penis just as easily as you speak about your arm or leg. Anything we asked, she told us the real truth and the entire answer. Because of her, I wanted to pass those same lessons onto other people.

Q: What does an average day for you look like (number of patients per day, hours worked/general schedule)?

A: Typical OB/GYNs schedule 1 patient every 10 minutes. You will always have the patients you need to squeeze in for an emergency, too. Hours are usually 9-4 or 5 p.m. with an hour in there for staff lunch. Most doctors do 4 days in the office and do surgery on the 5th day of the week. So, typically a doctor sees 35 patients a day. For OB/GYN, your group also has to decide how to handle deliveries during the day. Some groups assign 1 weekday to each doctor for daytime deliveries, and that doctor also has patients scheduled to see in the office. If they have to leave the office to do a delivery, the other doctors will pick up the patients already there and, depending on the time of day it is, delay the other patients or reschedule them to a different day. Other practices do not allow the person on daytime call to also be scheduled in the office to see patients, because they do not want patients to be scheduled and later rescheduled. Evening and weekend call for patients in labor or emergency surgery is split on an even rotation between all the doctors. This is what will be expected of you.

Ninety percent of doctors graduating from residencies these days join a group owned and run by a hospital system. They will tell you how many patients you have to see in a day and how many days a week you must be scheduled in the office. I was in a private group the first three years after residency and kept a very busy schedule like this. Then I worked for a hospital-owned group for 1 year. Now I am in a private practice, not affiliated or owned by anyone else. We three doctors do not want to give up control to someone else. The good thing about that is I can take more time with my patients. I only schedule patients every 15 minutes and allow extra time if it is a new patient (we put aside 30-45 min for new patients) or a patient I know who needs to talk more than average. However, that certainly comes at a price! I now make less than half the salary I made my first year out of residency. I do not make a 6-figure salary, but I am also happier than when I was working so hard. Unfortunately, doctors are not paid for their time, as lawyers are. We are paid based on a very complex point system developed by Medicare and the insurance companies. This is not a plea for empathy, however. Physicians do not have trouble feeding and clothing their children or having a safe place to live; we are all doing just fine.

Q: Fun question: how many babies have you delivered in your career?

A: Since we have to keep track of our cases the first year or two after residency, I know exactly how many babies I delivered that first year: 221. However, over the years, I have decreased my schedule and our group stopped doing deliveries all together a few years ago. I have been in practice 24 years and estimate I have delivered about 2000 babies. Later, I hope to do deliveries again, but I can’t right now because my other partners do not want to. They are older than me and near retirement.

Q: I know you work as an OB/GYN in a privately-owned practice. Why did you choose to work in private practice rather than a big hospital setting, and do you think there are advantages and disadvantages to both?

A: I’ve tried it both ways and there are advantages and disadvantages to both. In a small private practice (3 doctors) we get to make our own schedules, hire the staff we want, and run the show. If I have to take a day off at the last minute for my kids, I can do it, and no one gets upset about it. I can also choose to see less patients, if I want to. We can make our own decisions about which electronic medical record system we want to use. If we don’t like how something is working, we ask our office manager to get it fixed, and she does because she works for us. She does not have to get things cleared by other departments.

However, we do not have a guaranteed salary and have to pay our own overhead (rent, staff salaries and benefits, health insurance, etc.) and malpractice insurance. We are paid on productivity, which means our salary is based on how many patients we see and surgeries we do. Therefore, if I do not work, I do not get paid. Although our contract agreement states we can each take 6 weeks of vacation, I have never taken more than 10 days off, and even then, not in a row. In a hospital group, there are usually more doctors in each group, so you take less call, you have a guaranteed salary, and the hospital pays the overhead and your malpractice insurance. You have a guaranteed salary (~$200,000). However, the hospital gets to tell you how many patients you have to see in a week. They also hire your staff, so if you don’t feel someone is working out, you cannot do anything about it. You have to use whatever equipment or systems they have decided upon. You cannot take off at the last minute if you have to, etc. If you want anything changed, it has to go through several layers of management before it gets done.

Q: What is something about the field of OB/GYN that surprised you the most, that maybe you hadn’t learned in medical school or residency?

A: We were not taught anything about running a business, the financial aspects of things, how insurance companies work, why reimbursements are different depending on a patient’s insurance plan, etc. I certainly did not realize that what we charge is much more than what we get paid. I also hope medicine is moving toward inclusion of a wider set up treatment options, not just pharmaceuticals and surgery. We certainly did not learn about more holistic approaches or preventive medicine.

Q: Over the past several years, the percentage of men specializing in OB/GYN has decreased significantly. Why do you personally think that is, and what would you say to a guy (or anyone!) who might want to specialize in it in the future?

A: I feel bad for my male colleagues. One of my partners is male and he is a really nice person and a very good doctor. He is not overbearing, he listens to his patients, and they love him, if they allow themselves to see him. When new patients call to schedule appointments, the first thing they usually say is they only want to see a female physician. At the same time, I understand it from the patient’s point of view. For the most part, people aren’t really embarrassed about a male doctor examining their vagina because a chaperone is always in the room. It has more to do with their reluctance to talk to a man about certain things.

Some women feel they will be judged if they talk about having multiple sex partners. Others feel embarrassed to tell a man they are experiencing vaginal discharge or an odor because they think a man will think they are dirty or disgusting. When women are older, they are not comfortable discussing the fact that their sex drive has decreased and it is causing strain in the marriage because their husband does not understand and wants more sex. For the same reason, most men do not want to see a female urologist to discuss erectile dysfunction or the fact that they feel less masculine after prostate surgery and treatment. These days, if a man wants to do OB/GYN and have a robust practice, he either needs to practice in a city where there are so few female doctors the patients don’t have a choice but to see a man, or subspecialize. If they like obstetrics, go into Maternal Fetal Medicine. If they like gynecologic surgery, go into Urologic Gynecology or Gynecologic Oncology. I am not saying this is fair, I am just saying this is how it is.

Q: What is the best and worst part about your job?

A: The best part is becoming part of a person’s family when you deliver their baby or doing a surgery that makes a patient feel so much better. The worst part is making a mistake and knowing it will affect someone else so much. None of us are perfect, but we are all perfectionists. There are very few doctors who are cavalier about the way they practice and are not bothered when complications occur. OB/GYN is especially horrible if you make a mistake that causes or is not able to stop a fetal death. Fetal deaths are not stillborn, which are babies who died in the womb before labor, and usually for no definable reason. Fetal deaths are babies who were alive in their mother’s uterus when Mom was admitted to the hospital but died either during labor or right after they were born due to a problem that occurred during labor, such as decreased blood flow or oxygen to the placenta. When this happens, it is such a catastrophic blow that you want to quit medicine right then and there.

My first fetal death happened in my second year of residency. I thought the baby’s heart rate tracing looked good, but I misinterpreted it and it was not a good tracing; the baby was not getting enough oxygen from the placenta. When we finally took the patient for a cesarean section, it was too late, the baby died the next day. I seriously almost quit. I sat down the next day with the doctor in charge of the high-risk pregnancy department. I asked him if he ever lost a baby and he said he had. I asked him how he got over that, how could he keep doing obstetrics? He said there is a difference between causing something bad to happen and not stopping something bad from happening. I did not cause the placenta to be inadequate, but I did not catch it in time to save the baby either. I don’t know, this part of medicine is REALLY hard. In every specialty, physicians can make mistakes, which negatively affect patients. I would say the gravity of those mistakes is less in fields where surgery and obstetrics are not done. Before you go into medicine, make sure you can handle the fact that your mistakes will affect a lot of other people. We all think we are going to be so conscientious that we will not allow ourselves to make mistakes. That is just not how life works. The best doctors in the world make mistakes. We all make mistakes.

Q: Is there anything else you would like to add?

A: Medicine is changing a lot and almost no one who is just entering medical school now will be working for themselves. So, understand that. Also, realize if you are paying for school yourself, the average medical student who had to pay their own way through undergrad, and medical school comes out with a debt, on average, of $300,000. I paid my way through school and my debt was $100,000, when I graduated in 1991. It is not surprising that 30 years later it has tripled. Also, if you like women’s health but you are not interested in surgery, becoming a nurse practitioner is not a bad way to go. They can do everything we can, deliver babies, write prescriptions, see patients in the office, etc. The only things OB/GYN nurse practitioners cannot do is surgery, including cesarean sections, and forcep deliveries. Your training is not as long (usually 7-8 years instead of 12-15) and costs less (probably half as much). Furthermore, since every medical practitioner will be an employee no matter what your degree, you aren’t giving up autonomy because there won’t be any. In addition to that, the hospitals know they can pay nurse practitioners less than doctors, so they hire just as many if not more nurse practitioners than they do doctors. On average, nurse practitioners make $115,000 a year. So, the earning potential is less but you also come out with less debt and don’t have to stay in school as long.

Remember to set your goal and go for it, no matter what others tell you. At the same time, if you are halfway through and in your own heart you have changed your mind and do not have a passion for that original goal, don’t be afraid to stop and change course. It is very hard to know what you want to do for the rest of your life when you are in your 20s. Absolutely do not do something just because your parents or other people tell you that you should or say you would be good at it. Life is hard. You have to really like the career you ultimately go into, or the bad days will be terrible and the good days only mediocre.

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