Dr. Rachel Rubin
Dr. Rachel Rubin

Until recently, I never knew sexual medicine was its own specialty. I mean, of course there has to be a field of sexual medicine, since there are medical fields for every other aspect of biological human life, but when I first heard about IntimMedicine Specialists, I had lots of questions. What does a sexual medicine specialist do? What can they offer that a general physician can’t? What could I expect at an appointment, and what would I make an appointment for?

I got to sit down with Dr. Rachel Rubin, an expert in sexual medicine and urologist on staff at IntimMedicine, and ask her some of these questions. She put me at ease right away, asking me about myself with genuine interest before we got to the questions I had for her. I hope you’ll find her answers as enlightening as I did!

Dr. Rubin trained as a urologist at Georgetown University Hospital. Early on she realized that talking about sexual issues was very uncomfortable for patients and even more uncomfortable for the doctors who were trying to train her. “Research has shown that medical professionals don’t do a very good job of bringing sexual issues up with their patients, often because they feel there is a lack of time and expertise to be able to follow up on the questions they get asked,” she said. Dr. Rubin found that she was not afraid to ask people questions about sexual issues, and her interest in treating sexual dysfunction only grew. She completed a sexual medicine fellowship in San Diego and then joined the team at IntimMedicine.

“Sexual medicine is a relatively unknown field made up of many different types of providers who believe strongly in quality of life and improving the sexual health of their patients and their partners,” said Dr. Rubin. “We see people with erectile dysfunction, low libido, penile curvature, pelvic pain, urinary incontinence, and hormone issues, among other things.”

Many times, Dr. Rubin said, patients and their doctors are not only uncomfortable discussing sexual health—they also don’t have time in a 15-minute visit to address such intimate issues. “We don’t see 50 patients a day. We spend a lot of time with our patients, and I pride myself on being able to work within the medical community to build a multidisciplinary team to help each individual patient and couple. Sometimes there needs to be medical treatments or surgeries, and sometimes we need specialized physical therapists to be involved. We often team up with mental health professionals as well, because no one ever taught us how to talk about sex and getting a ‘coach’ to help with that is extremely important. Sexual medicine is very much a ‘team sport’ in terms of figuring out which team members need to be involved with each individual case – it’s not a one-size-fits-all model.”

Another member of that team? The patient’s partner. Dr. Rubin encourages patients who feel comfortable doing so to bring their partners to appointments.

“It is not uncommon that I see a patient and then their significant other comes to see me later, realizing it ‘takes two to tango,’” she said. “Oftentimes you have to think of each patient in the context of a couple, and it’s important to help both people.”

Maybe you have something that is bothering you about your sexual health, but you’ve got too much else going on or you’d rather not think about it, and definitely not talk about it. I asked Dr. Rubin what she would say to people who keep putting off seeing a sexual medicine specialist. “Quality of life is incredibly important,” she said. “Focusing on yourself and your health as a couple is valuable.” Dr. Rubin went on to emphasize that sexual health is closely connected to general health. She also added that “focusing on your sexual health may actually benefit many other parts of your life.” For example, “Erectile dysfunction can be a sign of early cardiovascular disease.”

“Before I see a new patient, I always have a screening phone call with them first, just to make sure it’s a good fit for them before they make an appointment,” Dr. Rubin told me when I asked her what people could expect from an appointment with her. “When people come into my office, they sit across from me, fully clothed, and we just have a conversation. I spend a lot of time showing them anatomical diagrams and explaining everything we’re going to do before we ever do an exam or procedure. Nothing invasive ever happens without a full discussion and without the opportunity for lots of questions to be asked.”

Dr. Rubin’s tone became both more impassioned and gentler when I asked her to name one thing she wished people understood about sexual dysfunction. It was clear to me that she cared deeply about this when she answered. “People are often afraid to admit that they have a problem, because they’re so afraid that it means there is something different or abnormal about them. I understand that it can provoke a lot of anxiety to just come out and say ‘I have a problem, and it’s sexual,’ even to a doctor. Nobody taught any of us how to talk about sex to our partners, or to our doctors, so it can feel very isolating, but the truth is all of these issues are so incredibly common. After speaking with me, my patients are very comforted in knowing that they’re not alone and that there is help.”

As we ended our chat, Dr. Rubin said, “This is all we do,” referring to the team at IntimMedicine Specialists. “Our patients have access to all of the expertise we represent and receive very individualized care. We’ll take the time to get to know you and help you focus on your sexual health.”

So now, I have a question for you: why are you waiting to start working on your sexual health?

 

Call 202.293.1000 to make an appointment with IntimMedicine Specialists in Washington, D.C.

Also: follow Dr. Rubin on twitter @rachelsrubin1 and the IntimMedicine team @intimmedicine

USPTF Rebuttal: Why Women Still Need Pelvic Exams

Recently, the U.S. Preventive Services Task Force (USPSTF) concluded that there is limited evidence to support doing routine pelvic exams for women who are healthy and not pregnant. They say: “There is limited evidence regarding the diagnostic accuracy and harms of the routine screening pelvic examination to guide practice.”

An Absence of Evidence
Does this lack of evidence mean there is no benefit to routine pelvic exams? Absolutely not. The absence of evidence does not indicate the evidence of absence. In other words, if there is absence of or limited evidence for the benefits of routine pelvic exams that does NOT mean there is adequate evidence to recommend against them. In fact, these most recent draft guidelines don’t make much sense to me at all. Here are just a few reasons why:

  • Possibility of bias- The authors are all women from the West Coast of the US, and there isn’t a single gynecologist among them, so there is a significant absence of diversity (by gender, by geography, and by specialty) which could be a source of bias. In fact, most of the authors are not physicians, nor have they ever performed a routine pelvic exam.
  • “Insufficient” evidence- The authors note that “the current evidence is ‘insufficient’ to determine the balance of benefits and harms of the pelvic exam,” however, this didn’t deter them in drafting recommendations in favor of stopping routine pelvic exams.
  • The authors judged the effectiveness of the pelvic examination in reducing all-cause mortality, cancer- and disease-specific morbidity and mortality, and improving quality of life. These are all very “blunt instruments” (aka insensitive assessments) which are particularly obtuse in younger women where death and cancer related morbidity are rarely relevant, and almost never proximate in time.
  • The authors found only eight studies looking at the diagnostic accuracy of pelvic exams, and for only four medical conditions: ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes. So in the studies evaluated, the only endpoint that would lead to mortality, cancer- and disease-specific morbidity and mortality, is ovarian cancer, and everyone knows that the pelvic exam is notoriously bad for detecting ovarian cancer. Furthermore, no one dies from bacterial vaginosis, genital herpes and vaginal trichomoniasis, all of which are treatable (and don’t cause death).
  • Finally, the authors did not recommend changes to current cervical cancer screening guidelines (aka pap smears with or without human papilloma virus (HPV) testing). Since these guidelines DO recommend routine cervical cancer screening, which does require–at a minimum–a vaginal speculum exam (not exactly the same as a pelvic exam), how is one to do this without a routine screening pelvic examination?

So, at the risk of being redundant, I strongly disagree with the conclusion of the USPSTF draft evidence review, but particularly as it applies to postmenopausal women. There is a lot more that goes into the routine gynecological visit, including the pelvic exam. The pelvic exam is needed to screen for conditions such as the genitourinary syndrome of menopause (vaginal atrophy, that affects more than 50% of postmenopausal women), fibroid tumors, abnormal or heavy menstrual bleeding, pelvic floor conditions, and cancers and precancers of the vulva, vagina, cervix and uterus, etc. Not to mention: gonorrhea, chlamydia, syphilis, hepatitis, HIV; spousal, alcohol and drug abuse; menopausal hot flashes and night sweats, sexual dysfunction, among many other conditions.

Missed Opportunities
Broadly, the conclusion to discontinue the routine pelvic exam runs counter to the goals of improving women’s health through preventive care. If pelvic exams are performed only when women complain of problems or have symptoms, we will miss opportunities to diagnose potentially fatal pelvic cancers and other conditions. Being asymptomatic is not the same as being healthy or not having a problem.
Sincerely,

Dr. James A. Simon, MD, CCD, NCMP, IF, FACOG

Electronic Medical Records (EMR) –A Balanced View

screenshot_5148_432x324One of the cornerstones of The New Government Health Plan is the use of the electronic medical record (EMR), sometimes called Electronic Health Records (EHR).  Proponents offer these as some of the advantages of those systems:

  • Universal coding of medical diagnoses and procedures so that insurers can better understand the public’s health and properly allocate resources
  • Avoidance of problems interpreting various handwriting styles
  • Ability to incorporate automated reminders and alerts (i.e. patient due for colonoscopy or bone density test, or vaccination) as part of the system.

Most hospitals and large practice administrators support the EMR concept. In addition to having the staff and resources to make the system  function, the system is effective in capturing more charges and assists in better collections.  And the federal government subsidizes the initial purchase an implementation of the system.

Practitioners are a little less enthusiastic.

Enormous amounts of time are required to fill out electronic templates, complete countless electronic forms and respond to automated questions not impacting patient care, while often negotiating frustrating electronic roadblocks. The time required for the process occupies the staff and diverts the practitioner’s focus from the patient to a computer process. As a result, practitioners are spending less time interacting with their patients and more time looking at the computer screen. Overall, patient’s best interests seem to have largely been lost in this conversation.

Our practitioners – James A. Simon, MD; Lucy D. Treene, MSHS, PA-C; Carol J. Mack, MSHS, PA-C, MPH – are not Luddites (people just down on technology). Quite the contrary!  We use many facets of the EMR systems, such as e-prescribing, e-scheduling, electronic billing to Medicare, all of which improve patient care, reduce medical errors, or, in the case of Medicare billing, are required by the government. But we are selective because we are, particularly in our field, first and foremost concerned with the privacy of our patients.

Consider the recent cyber attacks at the Department of Health and Human Services (DHS) and the successful electronic security breach at the Office of Personnel Management (OPM) affecting 22.1 million people (“Hackers stole vast amount of sensitive data” according to The Washington Post), which resulted in the resignation of OPM Director Katherine Archuleta. The Carefirst® BlueCross BlueShield family of companies was also recently and successfully hacked for personal information (including that of James A. Simon, MD, PC employees).

Being one of the foremost specialty medical practices in women’s sexual health in the world, the risk of our patients’ private records becoming public is simply not worth taking.  Our patients’ sexual problems, predilections and peccadillos are private and, unlike your FICO “credit” score which can be restored if your credit card is lost or stolen, once the details of your private sexual life are “out there,” that information can live forever on Google, Facebook or Twitter. And in case you should think, even for a minute, “who cares about MY sexual life,” don’t forget our offices are convenient to many in the public eye, five blocks from The White House, 2 ½ miles from The Capitol, and 3 miles from The Supreme Court.  Patients, many of them quite prominent, come to see us from all over the world as well.  No matter who you are, your health information is private at James A. Simon, MD, PC, and no one’s business but yours!

In our world of internet immediacy and electronic everything we agree with author Lisa Gardner’s comment, “There are things that once done can’t be undone, things that once said can’t be unsaid.”

 

Interested in women’s sexual health? Contact us for an appointment.

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