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Taking Risks: Getting Comfortable in an Uncomfortable Spot

It’s hard to believe it has been one year since I retired from medicine.

It was a big leap to make that decision and a scary one at that. However, if I have learned nothing else over this past year, the one thing that has proven itself over and over is the value in pushing myself into uncomfortable and unknown scenarios.

Fear of failure has held me back from opportunities in the past. I think most people can agree with this statement. We may make excuses for why we didn’t apply for a certain job, try a new fitness class, or learn how to invest. In addition, it’s easier to stay where we are in the comforting cocoon of understanding the “rules”. We know what to expect and what is expected of us. It makes us anxious to go into an unfamiliar setting.

My goals for 2018 will include pushing into more unknown but exciting endeavors. I may certainly fail, but I’ve learned to be ok with that.

Some positives from the past year:

1.  Writing

It was terrifying to put my first article on a public forum, but I attended a writing conference that pushed me to try it. Since I wrote that first piece, I have since started a blog (accumulated over 260 Regular Followers- thank you readers!), accepted a position as a Doximity Fellow (I am a contributor for this “Linked In” for physicians website), wrote a couple of guest posts for other websites, was interviewed for 2 different podcasts

http://www.doctormoneymatters.com/episode-17,

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(Link up today for “Doctor Money Matters” Podcast! This physician led podcast is more finance related, so if interested- please check it out- and follow his podcast!)   This is something new for me- pushing into an unknown again, hoping I don’t sound too foolish…

…. Lastly, I had had several interviews with reporters leading to quotes in articles published on Yahoo News, SELF, and STAT regarding topics important to me in health care. It still seems crazy to think that one year ago I had never written anything! Apparently “good things happen to people who write” as a wise person once told me.  If you ever thought about writing or have something to say, Go for it.

2.   Coaching a youth sports team.

Sure it may just be 4 year old girls soccer, but its harder than it looks to keep 4-year-olds entertained for an hour! Plus, I haven’t played soccer in over 20 years. This was a fun endeavor that both my daughter and I enjoyed immensely.

3.   Investing.

I jumped in head first, all while soaking up as much information as I could. It proved to be a lucky year to get involved. I would encourage other readers to learn about the stock market and get the courage to learn about something new, like personal finance. It can be quite empowering and beneficial to your ability to retire early if you so choose.

Some failures:

You may remember from my post back in May, soon after retiring You Retired From Medicine- Now What? ,where I where I discussed wanting to learn how to cook. I really did try but haven’t quite figured this one out. Perhaps its just a lack of passion but when it comes down to it, I really don’t like cooking. I have been unable to manage to make more than 1-2 homemade meals a week. We still tend to eat out way more often than we should, or my husband will sometimes cook. Until I can get 5 people on the same page about whether to eat steak/salmon and broccoli, as opposed to dinosaur chicken nuggets, I just don’t think it will happen.  So, macaroni and cheese/pizza/nuggets it is for now!

Plans for the future:  hold me accountable!

1. Continue my quest/love for travel. Scheduled for 2018 so far:
I’m a big believer in the value of experiences instead of things…

Orlando, FL (Disney World with the kids)
New York, NY (“Frozen” on Broadway with my oldest),
San Francisco (conference)
New Orleans (celebrating a friend’s 40th)
Boston (conference),
Punta Cana, Dominican Republic
Kiawah, SC
Outer banks, NC

2. Continue learning more about finances/investing.
On my book shelf:


3. Grow the blog
I will have a regular posting schedule in the future- expect more content!

4. Continue to speak my mind regarding Health Care in our country and topics of importance to both physicians and patients.

I’ve learned that the more risks you take, the easier it becomes. So, this year I will be pushing the limits even more. I am not sure what my life will look like 1 year from now, but if the dramatic change from last year is any indication of the unpredictable twits and turns life can take, I know one thing for sure- I have no idea where I will be.

I would love to hear what risks you are thinking of taking in 2018.  Any ideas?

physician, Uncategorized

Do Patients Pay Less for Cheaper Care? Why the CVS/Aetna Deal Matters

On a recent trip to urgent care for my child, I began to more clearly see how the changes in medicine are affecting our patients and who is benefiting from the bottom line of what is occurring in the US health care system.

A minor injury to my 2 year old son had me waiting patiently to be seen at a local urgent care center.  Eventually, a nurse practitioner evaluated, correctly diagnosed, and successfully treated my son.  (I make it a habit not to treat my own children as I feel it more appropriate to be “mom” instead of “Dr. Jones” to my children in these types of situations).  I appreciate nurse practitioners and feel they provide a great service and are filling in gaps in areas of need, especially in this time of physician shortage.

My concern arose as I considered how this medical care visit was truly playing out financially.  I paid a copay with my insurance- no big deal, it was $30.  My insurance would be covering the majority of the visit.  However, ultimately the company running the urgent care facility would be charging the same rate to my insurance, and same copay to me, for my care regardless of whether I saw a physician or a nurse practitioner.  I even went as far as calling a billing specialist in membership services at my insurance company to ask if this was the case.  She indeed confirmed that there is not a separate charge for urgent care visits depending on the level of provider seen.

My question to anyone who has seen a nurse practitioner or other qualified individual, is your co-pay lower for the service? Do you receive a discount for not seeing the higher paid/more trained physician?  In my situation, there was no reduction of copay.  So, if they are collecting the same amount for the service provided despite a disparity in income level of the provider, who benefits from this profit?

The company running the urgent care center reaps all of the benefits of employing a health care provider with a lower salary than that of a physician.  Their smaller salary likely means more profit for the company.

Again, I am in no way against using mid-level providers, nurse practitioners, midwives, etc.  They are here to stay and provide an important role in healthcare moving forward.  However, my argument is that if a company is benefitting financially from hiring “cheaper” people to provide care to their patients they should at least be passing the savings on to the patients who are receiving the care.  Often, these companies are looking for the financial bottom line and what they can get away with to reap the most profit.  It is a primary responsibility of top administrators to make money for the company, and we can hardly blame them for successfully completing the role they were hired to fulfill.

Transparency is required in these situations.  The patient must know they are not seeing a physician- when they could be- for the same cost to themselves and their insurance company.   They should have the ability to demand physician care if desired.

A prime example how this business scenario is becoming the future of medicine can be seen in the recent proposed merger of CVS and Aetna. The companies involved are in a massive media campaign to make patients think this is to their benefit.  Please remember, these are businesses at the end of the day and their ultimate goal is to increase financial return to investors.  The basic facts are still at play- a drug store is buying an insurance company.

On Wall Street, the widely held belief behind this merger is that by teaming up, CVS and Aetna can have a fighting chance against the behemoth that is “Amazon”, as this online giant attempts to get into prescription drug sales.

Often, the patient is the one to suffer in situations such as this merger, as they will actually pay more and receive less choice.  It’s a monopoly and if your insurance is owned by a drug store company, guess which prescription you will likely receive?  The one on formulary at CVS of course!  So, if the prescription chosen to treat your condition is on formulary at CVS, there most certainly is less overall cost in the health care transaction.  So, does the patient pay less since their prescription costs less or a lower copay for seeing a mid-level provider in a “clinic” that is now part of the plan to have in CVS stores?

You guessed it, the company will profit each time a prescription is written for a drug under their formulary instead of one that isn’t.  The company will also profit each time a midlevel provider sees a patient instead of a physician.  Again, is this in the best interest of the patient?

One last piece of information to consider, the Aetna CEO will walk away with $500 million in cash and stock if this deal goes through.  This executive, who is not a physician, has much to gain from this merger.  I don’t begrudge anyone good fortune, but I also don’t believe the media should portray that the patients are the primary ones to benefit in a deal such as this.

Patients and physicians are no longer accepting the status quo and what everyone outside of health care is telling us is “in our best interest”.  We see and understand what is going on.  We are speaking up and demanding better.

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Holding the Knife for the First Time

As an intern in ob-gyn, one of the things you look forward to the most is getting to be the surgeon while an attending is your assistant for a cesarean delivery.  In some residency programs this doesn’t happen until your second year of training.

Most of the time you are honing skills on uneventful vaginal deliveries.  You are learning about labor progression, shoulder dystocia, inserting cervical ripening agents and performing “scut” work around the labor ward.

However, one a day an attending notices the work you have been putting in.  He also notes the great rapport you have with this particular patient.  He asks you if you would like to perform her necessary surgery and you say “yes!” before he has finished asking.  You put on the surgical gown and knee high scrub boots about 30 minutes too early in anticipation.

You nervously sneak away for a few minutes to review the steps in your mind for the surgery.  You have scrubbed into dozens of c-sections as a medical student, but that involved holding the suction and retractors.  This was much different- you would be holding the knife for the first time.  You feel ready, and have been practicing your surgical knots and know the steps.

After you talk with the patient and help her onto the operating table, you begin the prep work.  You check the fetal heartbeat one last time and then cleanse her abdomen with a solution to help prevent infection.  Next, you cover her body with a drape that has a large hole in the middle designed to allow access to just the pregnant abdomen.  The drape extends upward and you can no longer see her face behind the drape.  You now understand why this is a good thing.

The drape helps you mentally separate from the attachment you have with the patient.

Before the drape went up, you were sensing and feeling your patient’s expected anxiety about having a surgical procedure.  You were also feeling the excitement from both she and her husband about the fact that their baby was about to be born.  The drape moves your focus to only the task at hand.  You stop thinking about the emotions involved with this person, and instead direct all of your attention to safely performing this surgery.

You confidently call out “scalpel” for the first time and the scrub tech hands you the instrument.  Your hand is shaking just slightly as you press it against the skin.  However, you notice the tremor disappears as you carefully and deliberately make the large incision on her abdomen.   You have started and the steps of the surgery proceed like second nature.

When you make the incision on the uterus you are particularly careful.  All you can think is “don’t cut the baby”.  The fetal head is firmly pressed against the uterine wall which is particularly thin after a long, stalled labor.  You cut through the thin uterine muscle layer by layer until you see the scalp of the baby.  At this point you gently slide your hand over the baby’s head and deep into the pelvis.  You have never done this part before, but the attending calmly guides you to keep your wrist straight and pull the baby’s head through the incision.

It takes more strength than you anticipated as the head was socked deep in the pelvis of a laboring patient, but you do it successfully and the baby is screaming immediately on delivery.  You look down and excitedly announce “It’s a girl!” to the parents waiting anxiously behind the drape.  For the first time since the surgery started, you allow your emotions back in.  A rush of adrenaline runs through you as you relish and acknowledge the gravity of the moment of this baby’s birth.

Finishing the surgery, you sew the uterus and fascia carefully back together.  You notice the scrub tech impatiently looking at the clock and you are acutely aware it takes you more time than most seasoned surgeons since this is only your first case.  However, your attending doesn’t seem to mind your meticulous fashion so you proceed without worry.  Finally, you sew the skin to complete the case.  Your attending physician says “nice job” and shakes your hand firmly.

You don’t think there could be a better feeling than performing your first case solo…..

Until, you get to walk an intern through their own “first case” and experience the growth, excitement and gratitude through their eyes.

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A Humbling Night at Taco Bell

This is a true story from my otherwise uneventful Monday night.

I was driving my 4 year old daughter home from swim lessons and planned to stop at Taco Bell, her current favorite, for dinner afterwards.

After I parked, I realized I forgot my wallet at home but luckily I did have my cell phone.  No problem, I thought. I have “apple pay” on my phone and could use that to pay for dinner as my credit card was uploaded.

My daughter and I waited in line as a large family in front of us completed their order.  The cashier was patiently compiling their customized order with a soft smile.  I noticed multiple tattoos on her arms as she was working the register, and wondered about the stories behind them. When it was our turn, I asked the cashier if they accepted apple pay as I didn’t have my wallet with me.  She wasn’t sure, but thought she had seen someone use it before and suggested we try.  So, after giving the order for myself and my daughter, we tried to pay.

However, it didn’t work.

Immediately, I felt very awkward and now had no way to pay for our dinner.  In my pockets I had about a dollar’s worth of change I found in the car.  The cashier noticed me checking my pockets.

Not a big deal, we would just go home to eat dinner.

I told my daughter, “sorry, we’ll have to come back another time”.  Immediately, the cashier jumped in and said she couldn’t let us leave without our dinner.

“I’ll pay for it”, she told me.

“No, no, absolutely not” I replied.  Then my 4 year old piped in with “what’s going on Mommy, I want to eat here”.  Before I could say anything else or leave the restaurant, the cashier was literally running to get her wallet and paid for our dinner with her credit card as she would not take “no” for an answer.

“I’ve been there too” she replied.  “You know, left my wallet at home”.

However, I am quite certain that’s not what she meant.  I thanked her profusely and felt strangely awful for accepting her money yet also completely humbled at her generosity.  I told her I would return to pay her back, but she just asked me to pay it forward.  At this point I didn’t know what to say to a woman who doesn’t know me or my situation, but just sees a mother and a daughter and wants to help.

I asked for her name- it is Christie- and she wrote it on the receipt for me.  My bill was $9.29.  As we sat quietly eating dinner, I was lost in thought.  I wondered how much minimum wage was.  I was also embarrassed by the fact that I didn’t know.  (I looked it up- ironically, it’s $9.25).

I thought about how quickly and selflessly the cashier paid for our dinner despite the fact it very well may have cost her an hour’s worth of work.

Her act of kindness stayed with me all night.  I couldn’t shake how profoundly this was affecting me.  I kept thinking how it must feel for mothers who truly don’t have the money to pay for a meal must feel.  Helpless?

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I thought about victims of domestic violence.  I have actually had discussions with patients and talked with them about developing a plan to leave an abusive partner.  They are often afraid to leave an abusive situation out of fear for how they will care for their families on their own.  In my ob-gyn practice, it was a standard question for new patients at their annual exam, “do you feel safe at home”? Unfortunately, pregnant women are at an increased risk for domestic abuse and I have seen this with more than one of my patients.

In the past, I have discussed with patients some practical measures such as hiding away a small amount of money so that they would have a way to care for themselves and children when first escaping the situation.  Often, these women have zero resources of their own.  I was wondering if this caring cashier thought perhaps I may have been in a similar situation.

The truth of the matter is that I have never been in this terrible situation, and can’t possibly understand what it is like for these women.

That night, I was wearing pretty typical clothes for a Monday night swim lesson- nice pair of jeans and a t shirt.  My daughter was in a cute matching Minnie mouse outfit. Definitely not the definition of needy but also not clearly one of wealth.

This cashier didn’t stop to question or judge our situation.

My plan is to go back next Monday night after swim lessons.  I have an envelope with Christie’s name on it that will pay her back many times over.  I also plan to talk with her manager about the kind of person they are lucky to have working the cashier. Most importantly, I want to tell Christie that her small gesture impacted me profoundly.   With stories of hate, mass shootings, and natural disasters filling our news lately, her kindness showed me that love and compassion for strangers is still present.

And, needless to say, I will also “just pay it forward” as she requested.

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Investing in the Stock Market? I Never Learned About This in Medical School!

How Can I Start Investing if I Don’t Even Know What the Terms Mean?

People have different opinions on how, when, and what to invest in.  A good rule of thumb is to SAVE (emergency fund and college funds for kids), PAY OFF DEBT, and INVEST all at the same time.  This means you do not have to wait until all debt is gone to start investing (you will have missed the potential for large profits during this time through compounding).  Most can consolidate medical student loan debt at reasonable rates.

However, in order to do all 3 of the above, you might have to cut back on spending and most likely live below your means. If you use the example of living off half your salary, or on the salary of one person (if married and both are working), you can do all 3.  However, the point of this article is not to preach about how you decide to manage your money but how to actually invest.

What even makes up the Stock Market?  What do these numbers mean?

If you pick up the Wall Street Journal, watch CNBC, or look to any source for information about the stock market you will find three things mentioned when tracking how things are going.  What if you don’t even know what these terms/numbers represent?

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S & P 500: Tracks the price of 500 large US stocks (account for more than 70% of total value of the market despite tens of thousands of stocks).  This is a broad representative index of large US stocks.

Dow Jones Industrial Average “the Dow”: Tracks 30 companies in US that are thought to represent the diversity of the economy of the US.  The stocks included change over time.

NASDAQ: This is an index focused on technology stocks

Why do you care about these indexes and why do they talk about them on the news every day?  It gives you a general idea overall how the stock market is doing (percentage gains or losses).  You can also compare your stock market investments to these indexes based on the types of stock you invest in.  If you own facebook (FB) or Google (GOOG) you may be interested in the NASDAQ numbers.

Mutual fund:

Contains many securities (stocks, bonds, etc) in one “investment portfolio” and is actively managed for you.

– automatically provides you with diversification (and therefore decreased risk) by owning many different stocks

– no time investment is needed for you to research stocks, determine which stocks to buy- but you should spend some time researching the actual mutual fund

-small fee associated (these fees have come down quite a bit in recent years and some mutual funds can have very low costs)

-may be a minimum amount necessary to invest

You can pull up your brokerage account website, select “mutual fund”, choose to invest in a diversified mutual fund yourself and call it a day.  Alternatively, you can have a financial advisor do it for you as well.  Just remember, you will not only be paying the fee for the mutual fund management but if you have an advisor you will also be paying a fee to them as well.   I’m not saying having an advisor is a bad thing- for some people really feeling overwhelmed, a good advisor can really get you on the right track.  However, I also think if you are motivated with just a little time commitment you can put money into a mutual fund and invest on your own too.

How do I pick a mutual fund?

You can google some top mutual funds; take a look at the performance over 10 years (including recent data too) and the fees with each.  Pick one.  If you are paralyzed by indecision, it may be worth your time to get an advisor.

Find a good finance app to help you look at these charts quickly and for brief summaries of the important info you need.

Download one today (they are free)- I use yahoo finance; Charles schwab, and cnbc.  You may need to try a few to find one that works well for you.

One particular mutual fund over different time frames (Vanguard 500 index Fund):

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3 months

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1 year

IMG_162910 years

Mutual funds (namely index funds comprised of stocks) are often more likely to mirror the overall stock market trend than an individual stock given its diversification.  Luckily, the overall trend in the market is typically UP.  Your mutual fund will not guarantee the typical 8% yearly return of the stock market, but may be closer than if you bought an individual stock.

Remember, I am not a financial advisor.  I have no crystal ball.  I don’t know which mutual fund will do better than another.  However, I do know that people who have invested long term in the stock market have done well and will continue to do well.  You can decrease your risk with diversification (owning more than one stock as in a mutual fund).  There is minimal time commitment (which is a plus for busy physicians).  You can build wealth if you invest in the stock market early in your career and leave the money alone.  Put the money in and let it grow for you over the years- no need to check back too frequently or you will just make yourself panic when the stock market dips down occasionally, as it always does.  Even if we hit a Bear market or serious downturn in the coming years, it will be important to keep invested as the market will eventually recover.

By this point, seasoned investors will be rolling their eyes at me for the basic nature of this post.  On the other hand, I am certain some readers will be feeling overwhelmed with information overload on pretty boring and dry topics.  It’s not as exciting as learning a medical procedure, as gratifying as building a lasting relationship with a patient, or as rewarding as delivering a baby.  However, you owe it to yourself and your family to develop a basic understanding of finances.  It’s not selfish to invest and maximize your potential earnings.  Doing so will provide you a future with more control over your life (when to retire), be able to handle an emergency (unexpected health bills, loss of job), and have the ability to give more generously through charity and donations.

Again, I am not endorsing any particular mutual fund.  Don’t make financial decisions from me, but your own research.  A mutual fund is a nice place to start, but if you are ready to try buying individual stocks stay tuned for the next article.

 

 

hospital birth, Uncategorized

Rising Maternal Mortality in the US: Real or Just Hype?

The statistics are staggering.

The high maternal mortality rate in the US has been a matter of great interest and debate, spurring a reflective look into our healthcare system to determine why our country is on the wrong end of this statistic. The reasons and numbers vary across the country and notably in the state of Maryland, which has had a higher than average maternal mortality rate, the number of maternal deaths continues to increase at a rapid pace.

In a comparison of two study periods (2005–2009) to (2010–2014), while the maternal mortality rate increased by an astounding 32% nationwide, it increased by an even more astounding 51% in Maryland. https://www.acog.org/-/media/Sections/MD/Public/MarylandMMRposter2017.pdf?dmc=1&ts=20170927T1731113112

I must admit, as an obstetrician-gynecologist I was skeptical of the media hype regarding maternal mortality in the US (compared to other countries with less advanced technology and more limited access to medications and high quality medical care).

However, there is no denying the fact that the rate is indeed increasing. As I think about these statistics, it becomes clear to me that there are two major crises in the field of women’s health.

Maternal Mortality

The causes vary, but as discovered in the “Maryland Maternal Mortality Review Program” in 2014, the leading cause of death of pregnant women was substance abuse disorder – unintentional overdose. Meanwhile, the leading cause of death directly associated with pregnancy was hemorrhage.

Death by drug can be experienced by anyone, but death directly associated with pregnancy can only be experienced by the pregnant. This difference is important. 

On news outlets, social media, and magazines you have likely heard stories about the loss of a pregnant mother or postpartum patient under horrible circumstances of medical negligence or some preventable health cause. These stories are heartbreaking and infuriating and should not happen, especially in this country. These types of stories also bring ratings, clicks, followers, etc. and are unfortunately also a contributing cause for the growing distrust of physicians based on a very small minority picture of the problem at hand.

The important piece to consider is that a woman who overdoses while pregnant is also considered in overall pregnancy death statistics. Again, overdose was the #1 cause of pregnancy-associated death. The US is facing an opioid epidemic and pregnant women are not spared from this.

Substance abuse prevention and treatment programs during pregnancy will be paramount in reducing the number of maternal mortalities.

More research is needed to determine the complete impact drug use is having on our maternal mortality statistic.

Hemorrhage treatment is also an area where we can improve, and an effort has been made to have massive transfusion protocols and training in hospitals. This is a start.

Ob-Gyn Shortage

Is our country’s shortage of obstetricians linked to our high maternal mortality rate? I don’t think we have the evidence to support this notion. However, we may start to see concerns in the coming years as this shortage becomes more pressing.

The American Congress of Obstetricians and Gynecologists (ACOG) put together a workforce to assess the situation. https://www.acog.org/-/media/Departments/Government-Relations-and-Outreach/WF2011NV.pdf?dmc=1&ts=20170927T1856198056 Facts that emerged are as follows:

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In the state of Nevada there are 11 (out of 17) counties without a single practicing ob-gyn. Nevada’s female population is expected to increase by 64% by 2030, while the total US female population is expected to increase by 17%.

There are 2.08 ob-gyns per 10,000 women in this state.

By the year 2030, the US is expected to have an 18% (9000) shortage of ob-gyns.

These numbers are outrageous and it is obviously not limited to the state of Nevada, but a nationwide concern. What is causing this ob-gyn shortage, seen not only in Nevada but across the country? Well, the task force also noted an increase in the population of women in the US of 26% since 1980, but the number of ob-gyns trained has remained stagnant due to limited residency training spots (which are still filling each match day). Medical students still remain eager to enter the field of ob-gyn, although with some trepidation and concerns regarding lifestyle and malpractice premiums/lawsuits. The problem arises after they finish residency.

We are starting to see an aging ob-gyn workforce. In addition, physicians are working decreased hours and are retiring early from obstetrics. More recently, ob-gyn residents are opting to avoid obstetrics altogether and are choosing to sub-specialize at increasing rates in fields such as Minimally Invasive Gyn Surgery, Urogynecology, and Gynecologic Oncology. Work-life balance can be better in these fields and malpractice premiums are also much lower. Maintaining our current ob-gyn workforce should be top priority. This starts with supporting them by finally obtaining meaningful liability reform, sustainable working conditions, a positive PR campaign, and increasing the number of residency spots (especially in states such as Nevada with urgent needs).

If we don’t address the obstetrician shortage, we will burn out the ones still in the field. It is not good for our physicians, or more importantly, our patients to have a limited supply of medical knowledge and expertise. In our efforts to decrease the maternal mortality rate in the US, the ob-gyn shortage must also be addressed.