GYNECOLOGIC
ONCOLOGY
47, 48-52 (1992)
The Specialty of Gynecologic Oncology as Perceived by the Public J. NOUMOFF, M.D., Division
of Gynecologic
M. MORGAN, M.D., Oncology,
Department
S. KING, M.D.,
R. GIUNTOLI,
of Obstetrics and Gynecology, University Philadelphia, Pennsylvania 19104
M.D.,
AND J. MIKUTA,
of Pennsylvania
School
M.D.
of Medicine,
Received January 22, 1992
The purposeof this study wasto obtain information about the public’sawarenessand perceptionof the disciplineof gynecologic oncology. The marketing of cancer care and related serviceshas resulted in substantialfunding being allocated to market individual institutions. However, little has beendone to educatepatients to the fact that there are physicians specifically trained who possessspecial expertise in the care of specific types of malignancy. The membersof The Division of Gynecologic Oncology at The Hospital of the University of Pennsylvaniaasked eachnew patient to completean anonymousquestionnairehoping to learn more about her prior knowledgeof the specialty of gynecologiconcology and her perceptionsof our discipline. Presentedis the analysisof the answersprovided by the 200 participants. The conclusionis that the public in general is poorly informedof gynecologiconcologyasa specialtyand consequently may not be taking advantage of optimal cancer care already available. Thus, as a specialty we must institute programs to educateand enlighten patients. Q Iwz Academic I+SS, IK.
INTRODUCTION It is now 22 years since the American Board of Ob-
and Gynecology established its Division of Gynecologic Oncology, and 17 years since the first certificates of special competence were issued. Since that time, the specialty of gynecologic oncology has grown considerably and has become an established and recognized discipline. By 1984, Underwood [l] in his presidential address to the Society of Gynecologic Oncologists stated that, “the subspecialty of gynecologic oncology has had an enormous impact on the health care of women with cancer during these 14 years; highly trained physicians, stimulation of research, professional and public education, and improved standards of care are but a few of our many accomplishments.” Though this statement is accurate and recognized by our fellow obstetrician gynestetrics
MATERIALS
48 Copyright All rights
0 1992 by Academic Press, of reproduction in any form
Inc. reserved.
AND METHODS
The Division of Gynecologic Oncology at the Hospital of the University of Pennsylvania is composed of a total of five trained gynecologic oncologists. Three are board certified in gynecologic oncology and two are in the process of completing the requirements for the oral examination. All members of the Division see a limited number
Presented at the 23rd Annual Meeting of the Society of Gynecologic Oncologists, San Antonio, TX, March 15-18, 1992.
oo!30-825892$4.00
cologists, the field of gynecologic oncology and its degree of expertise is often unknown to many physicians in other specialty areas. Equally important is the perception that the public appears to be uninformed as to the role of the gynecologic oncologist compared to the role of the practitioner of obstetrics and gynecology and in fact is often unaware of the existence of the subspecialty. The marketing of cancer care and related services to patients has become a major objective of many hospitals throughout the country. The recent past has seen the development of “cancer centers” associated with medical institutions ranging in size from the smallest community hospital to the largest tertiary care center. As a result, the public is now becoming informed of the role of “cancer programs” and the need for special treatment facilities; yet it appears to remain uninformed of the existence and specific role of cancer subspecialists other than the modality-centered subspecialists such as radiotherapists and medical oncologists. Although the above statements are generally agreed upon, there is no information in the scientific literature specifically addressing just how well (or poorly) informed the public is regarding the field of gynecologic oncology. This being the case, the Division of Gynecologic Oncology at the Hospital of the University of Pennsylvania devised a questionnaire, and presented it to each new patient, with the aim of evaluating how new patients referred to the Division perceived gynecologic oncology as a specialty, and to determine how well informed they were regarding the role of the gynecologic oncologist.
PUBLIC
PERCEPTION
OF GYNECOLOGIC
TABLE 1 Patient Perception of Reason for Visit Reason Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
No.
o/c of total
24 32 18 34 72
13.3 17.8 10.0 18.9 40.0
of patients for routine gynecologic care, patients with benign problems requiring special surgical expertise, and patients with preinvasive and frankly invasive disease. Each new patient presenting for her initial visit with a member of the Division was asked to complete an optional, anonymous questionnaire containing questions regarding demographics, her understanding of the reason for seeing a gynecologic oncologist, and her perception of the special expertise held by the subspecialist. A total of 200 consecutive patients were asked to complete the questionnaire while waiting to see the physician, and 186 (93%) complied. RESULTS
The patients ranged in age from 17 to 85 years with a mean of 41 and median of 40 years. Education
The respondents’ educational level was tabulated by these categories: (1) completion of high school or less, (2) college, and (3) postgraduate-level education. Of those 184 patients responding, 78 (42.4%) were at the first level of education, 62 (33.7%) had attended college, and 44 (23.9%) had postgraduate education. Reason for Visit
Patients were asked to indicate the category best describing their reason for seeing the physician. These were categorized as (1) routine visit, (2) benign problem not related to cancer, (3) problem related to a premalignant condition, (4) malignancy related, and finally (5) reasons not clear to the patient, though potentially representing a malignant process. These results are tabulated in Table 1. Whether this initial visit represented a second opinion is tabulated in Table 2. Source of Referral
How the physician’s name was acquired by the patient was then evaluated. Table 3 tabulates this information subdivided by the reason for the visit and whether this
49
ONCOLOGISTS
represented a second opinion. Sources of referral were divided into categories of (1) friend/relative, (2) physician, (3) hospital referral service (“hot line”), and (4) other. Data regarding this issue were available for a total of 174 patients. Of those, 48 (27.6%) were referred by friends and relatives, 110 (63.2%) by physicians, 10 (5.7%) by the hospital referral hot line, and 6 (3.4%) from other sources. In those cases where the patient was referred by a physician, the specialty of that physician was noted and is tabulated in Table 4. A total of 28.6% of patients were referred by internists or family practitioners, 59.2% by gynecologists, and 12.2% by medical oncologists. Though the numbers in this study are small and no definite conclusions can be reached, none of the referrals were by physicians of other specialties. Specific Choice for Seeing a Gynecologic
Oncologist
The specific choice of seeking the opinion of a gynecologic oncologist is tabulated as a function of the reason for the visit in Table 5. Awareness
of the Specialty of Gynecologic
Oncology
All patients were asked if they had prior knowledge of the specialty of gynecologic oncology before they had either elected to see or were referred to a gynecologic oncologist. One hundred twenty of 186 (64.5%) stated that they had prior knowledge of the existence of the specialty. This is tabulated in Table 6 as a function of the educational levels previously outlined. Table 7 outlines what patients described as the source of their knowledge regarding their prior awareness of the specialty. In many cases multiple choices were checked. Table 8a outlines how patients who previously knew of the specialty perceived the training necessary to become a gynecologic oncologist. Table 9a outlines how these same patients perceived the gynecologic oncologist’s func-
TABLE 2 Reason for Patient Visit as a Function of Whether Second Opinion Sought Second
opinion
Yes Reason
for visit
Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
No
No.
%
2 22 14 26 34
Y.1 68.8 17.8 81.3 48.6
No.
5%
20 10 4 6 36
90.9 31.2 22.2 18.7 51.4
50
NOUMOFF
ET AL.
TABLE 3 Sourceof Referral as a Function of Reasonfor Visit Reason for visit
Friend/relative
Routine visit
Physician
Hospital referral
Other
-
14 (63.6%)
Gyn problem second opinion No second opinion
6 (18.7%) 6 (18.7%)
14 (43.7%) 2 (6.3%)
-
2 (6.3%) 2 (6.3%)
Premahgnant condition second opinion No second opinion
8 (44.4%) -
6 (33.3%) 4 (22.2%)
-
-
Malignancy second opinion No second opinion
-
24 (75.0%) 6 (18.7%)
2 (6.3%) -
-
Possible malignancy second opinion No second opinion
6 (8.6%) 8 (11.4%)
22 (31.4%) 26 (37.1%)
6 (8.6%)
2 (2.9%)
tion. Tables 8b and 9b outline the same information for those respondents who claimed no prior knowledge of the specialty. DISCUSSION There is little debate that the development of gynecologic oncology as a subspecialty within the field of obstetrics and gynecology has resulted in a positive impact on women’s health care. The function and expertise of the gynecologic oncologist is well known and regarded by obstetrician gynecologists. However, many medical practitioners in other fields are unaware of the subspecialty. Of equal importance is the impression that though large sums of money are spent by institutions in attracting the cancer patient, very little information is disseminated regarding the fact that some physicians are specially trained to manage specific types of malignancy. A review of several informational booklets provided by organizations involved in patient education, such as the American Cancer Society, usually refer the patient to “her physician” but rarely specify physicians with expertise in special
cancers. It is a perception among gynecologic oncologists that the public (often including physicians who are not gynecologists) is poorly informed regarding our existence and function. Consequently, optimum healthcare to the women with gynecologic malignancy, though potentially available, is not provided. It is interesting to note that since the members of our Division do not limit their practice to the management of frankly invasive cancer, 31.1% of patients seen presented either for routine care or for some specific benign problem requiring additional expertise. Premalignant or frankly invasive disease was the reason for visit in 28.9% of patients, and the largest percentage (40%) presented with problems that the patient stated could well be related to an undiagnosed malignancy. Though it was our general impression that many of these patients had symptoms of a malignancy (postmenopausal bleeding, ascites, and pelvic mass) we are unable to provide specific data regarding how many of these women actually did have cancer because of the anonymous nature of the questionnaire. Not surprisingly, over half (56.3%) of respondents stated that they were being seen for a second opinion.
TABLE 4 Specialty of Referring Physician as a Function of the Reasonfor Patient Visit Specialty of physician Reason for visit Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
Internist/family practitioner 4 4 2 6 12
Obstetrics/ gynecology
Medical oncologist
Other
2 10 4 18 24
4 8
-
PUBLIC PERCEPTION
OF GYNECOLOGIC
TABLE 5 Choiceof a GynecologicOncologistas a Function of Reason for Visit Choice of gynecologic oncologist
Reason for visit Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
12 of 10 of 14 of 34 of 40 of
22-54.5% 32-31.3% 14-100% 34-100% 70-57.1%
The majority of patients seeking second opinions did so for a premalignant or frankly invasive condition which had been diagnosed previously. Although over 63% of the patients were referred by other physicians, referral by friends and relatives accounted for a significant percentage (27.6%). In fact, 44.4% of those patients with premalignant disease were referred to the Division by a friend or relative, and the remainder were referred by a physician. All but one patient with a malignant diagnosis was referred by a physician, and 68.6% of patients with a possible malignancy were referred by a physician. This may indicate that a good number of these patients did have a malignancy but were either unaware of the diagnosis or chose to deny it. Because of the anonymity of the questionnaire, this issue is one of conjecture only. The fact that no patients in this study were referred by physicians other than family practitioners/internists, gynecologists, and medical oncologists is of interest and may reflect the relatively small number of patients studied. It does, however, emphasize that if we as a specialty are to embark on a program of professional education, the initial target should be doctors who are primary care physicians, i.e., family practitioners and internists, since they are more likely to be the first to see patients in need of a gynecologic oncologist. It is not surprising that all patients with premalignant and frankly malignant disease specifically chose to see a gynecologic oncologist. However, 31.3% of those patients with special benign problems specifically chose a gyneTABLE 6 Knowledgeof the Specialty of Gynecologic Oncology as a Function of Level of Formal Education
Aware of specialty Not aware of specialty
High school or less
College
Postgraduate
48 = 63.2%
38 = 63.3%
32 = 72.7%
28 = 36.8%
22 = 36.7%
12 = 27.3%
51
ONCOLOGISTS
TABLE 7 Sourceof Information Providing Prior Knowledgeof the Specialty of GynecologicOncology Friends/ relatives
Magazine articles 28 20.6%
54 39.7%
Television
Job in medical profession
Other
20 14.7%
20 14.7%
14 10.3%
cologic oncologist, and 54.5% of patients seeking routine gynecologic care specifically chose a subspecialist in our field. When patients’ awareness of the specialty of Gynecologic Oncology was tabulated as a function of their educational level, there appeared to be no significant difference. It is hypothesized that since there are essentially no public awareness programs currently in effect promoting our specialty, information is obtained by all individuals in the same manner. Support for this theory is provided by the fact that of those patients who had prior knowledge of the specialty, 39.7% acquired this knowledge from friends or relatives while sources such as magazine articles and television were described by only 20.6% and 14.7% of patients, respectively. The final information described was that of patients’ knowledge of our training and current practice patterns. Less than half of the patients realized that our initial training included obstetrics, and a similarly low number thought that there had been formal training in either general surgery (43.3%) or chemotherapy (31.7%). What is especially interesting is that the perception of our training and practice patterns by those who claimed prior knowledge of our specialty, when compared to those with no prior knowledge, indicated essentially no difference.
TABLE 8a Training of a Gynecologic Oncologistas Perceivedby 120 Patients Previously Aware of the Specialty Obstetrics Gynecology General Surgery Chemotherapy
52 114 52 38
= = = =
43.3% 95.0% 43.3% 31.7%
TABLE 8b Training of a GynecologicOncologistas Perceivedby 60 Patientswith No Prior Knowledgeof the Specialty Obstetrics Gynecology General Surgery Chemotherapy
25 58 27 21
= = = =
41.7% 96.7% 45.0% 35.0%
52
NOUMOFF
TABLE 9a The Practice Pattern of a GynecologicOncologistas Perceived by 120Patients Previously Aware of the Specialty Performs surgery Administers chemotherapy Administers X-ray therapy
102 = 85.0% 54 = 45.0% 40 = 33.3%
TABLE 9b The Practice Pattern of a GynecologicOncologistas Perceived by 60 Patients with No Prior Knowledgeof the Specialty Performs surgery Administers chemotherapy Administers X-ray therapy
50 = 83.3% 28 = 46.7% 22 = 36.7%
This suggests that even women who claim to have known of our specialty only surmised from the title “gynecologic oncology” as to what we do, and for the most part they have no greater knowledge of the expertise involved when compared to patients who simply learn that we specialize in the treatment of malignancy. The study presented above is small and therefore no definitive conclusions can be reached. However, this pilot
ET AL.
study does substantiate the general view among gynecologic oncologists that most individuals appear to have little knowledge of our specialty and the background, training, and practice of this field of medicine. Morrow [2], in his presidential address to the Society of Gynecologic Oncologists in 1991 specifically stated, “We are not well known to other medical specialists, but we are all but unknown to medical-related organizations in the public sector. More important, the community of women is largely ignorant of the specialty of Gynecologic Oncology. Patients come to us with little or no understanding of who we are or what we do.” This study substantiates the above statement. It is eminently clear that as a specialty we must make an effort both locally and nationally to make the public and medical community more aware of the expertise our specialty brings to women with cancer. REFERENCES 1. Underwood, P. B., Jr. Presidential address: 15th annual meeting. Society of Gynecologic Oncologists (1984). Gynecol. Oncol. 19,261267 (1984). 2. Morrow, C. P. Presidential address: “Who Are We?“: A Paean to Gynecologic Oncology, Gynecol. Oncol. 42, 111-113 (1991).
ONCOLOGY
47, 48-52 (1992)
The Specialty of Gynecologic Oncology as Perceived by the Public J. NOUMOFF, M.D., Division
of Gynecologic
M. MORGAN, M.D., Oncology,
Department
S. KING, M.D.,
R. GIUNTOLI,
of Obstetrics and Gynecology, University Philadelphia, Pennsylvania 19104
M.D.,
AND J. MIKUTA,
of Pennsylvania
School
M.D.
of Medicine,
Received January 22, 1992
The purposeof this study wasto obtain information about the public’sawarenessand perceptionof the disciplineof gynecologic oncology. The marketing of cancer care and related serviceshas resulted in substantialfunding being allocated to market individual institutions. However, little has beendone to educatepatients to the fact that there are physicians specifically trained who possessspecial expertise in the care of specific types of malignancy. The membersof The Division of Gynecologic Oncology at The Hospital of the University of Pennsylvaniaasked eachnew patient to completean anonymousquestionnairehoping to learn more about her prior knowledgeof the specialty of gynecologiconcology and her perceptionsof our discipline. Presentedis the analysisof the answersprovided by the 200 participants. The conclusionis that the public in general is poorly informedof gynecologiconcologyasa specialtyand consequently may not be taking advantage of optimal cancer care already available. Thus, as a specialty we must institute programs to educateand enlighten patients. Q Iwz Academic I+SS, IK.
INTRODUCTION It is now 22 years since the American Board of Ob-
and Gynecology established its Division of Gynecologic Oncology, and 17 years since the first certificates of special competence were issued. Since that time, the specialty of gynecologic oncology has grown considerably and has become an established and recognized discipline. By 1984, Underwood [l] in his presidential address to the Society of Gynecologic Oncologists stated that, “the subspecialty of gynecologic oncology has had an enormous impact on the health care of women with cancer during these 14 years; highly trained physicians, stimulation of research, professional and public education, and improved standards of care are but a few of our many accomplishments.” Though this statement is accurate and recognized by our fellow obstetrician gynestetrics
MATERIALS
48 Copyright All rights
0 1992 by Academic Press, of reproduction in any form
Inc. reserved.
AND METHODS
The Division of Gynecologic Oncology at the Hospital of the University of Pennsylvania is composed of a total of five trained gynecologic oncologists. Three are board certified in gynecologic oncology and two are in the process of completing the requirements for the oral examination. All members of the Division see a limited number
Presented at the 23rd Annual Meeting of the Society of Gynecologic Oncologists, San Antonio, TX, March 15-18, 1992.
oo!30-825892$4.00
cologists, the field of gynecologic oncology and its degree of expertise is often unknown to many physicians in other specialty areas. Equally important is the perception that the public appears to be uninformed as to the role of the gynecologic oncologist compared to the role of the practitioner of obstetrics and gynecology and in fact is often unaware of the existence of the subspecialty. The marketing of cancer care and related services to patients has become a major objective of many hospitals throughout the country. The recent past has seen the development of “cancer centers” associated with medical institutions ranging in size from the smallest community hospital to the largest tertiary care center. As a result, the public is now becoming informed of the role of “cancer programs” and the need for special treatment facilities; yet it appears to remain uninformed of the existence and specific role of cancer subspecialists other than the modality-centered subspecialists such as radiotherapists and medical oncologists. Although the above statements are generally agreed upon, there is no information in the scientific literature specifically addressing just how well (or poorly) informed the public is regarding the field of gynecologic oncology. This being the case, the Division of Gynecologic Oncology at the Hospital of the University of Pennsylvania devised a questionnaire, and presented it to each new patient, with the aim of evaluating how new patients referred to the Division perceived gynecologic oncology as a specialty, and to determine how well informed they were regarding the role of the gynecologic oncologist.
PUBLIC
PERCEPTION
OF GYNECOLOGIC
TABLE 1 Patient Perception of Reason for Visit Reason Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
No.
o/c of total
24 32 18 34 72
13.3 17.8 10.0 18.9 40.0
of patients for routine gynecologic care, patients with benign problems requiring special surgical expertise, and patients with preinvasive and frankly invasive disease. Each new patient presenting for her initial visit with a member of the Division was asked to complete an optional, anonymous questionnaire containing questions regarding demographics, her understanding of the reason for seeing a gynecologic oncologist, and her perception of the special expertise held by the subspecialist. A total of 200 consecutive patients were asked to complete the questionnaire while waiting to see the physician, and 186 (93%) complied. RESULTS
The patients ranged in age from 17 to 85 years with a mean of 41 and median of 40 years. Education
The respondents’ educational level was tabulated by these categories: (1) completion of high school or less, (2) college, and (3) postgraduate-level education. Of those 184 patients responding, 78 (42.4%) were at the first level of education, 62 (33.7%) had attended college, and 44 (23.9%) had postgraduate education. Reason for Visit
Patients were asked to indicate the category best describing their reason for seeing the physician. These were categorized as (1) routine visit, (2) benign problem not related to cancer, (3) problem related to a premalignant condition, (4) malignancy related, and finally (5) reasons not clear to the patient, though potentially representing a malignant process. These results are tabulated in Table 1. Whether this initial visit represented a second opinion is tabulated in Table 2. Source of Referral
How the physician’s name was acquired by the patient was then evaluated. Table 3 tabulates this information subdivided by the reason for the visit and whether this
49
ONCOLOGISTS
represented a second opinion. Sources of referral were divided into categories of (1) friend/relative, (2) physician, (3) hospital referral service (“hot line”), and (4) other. Data regarding this issue were available for a total of 174 patients. Of those, 48 (27.6%) were referred by friends and relatives, 110 (63.2%) by physicians, 10 (5.7%) by the hospital referral hot line, and 6 (3.4%) from other sources. In those cases where the patient was referred by a physician, the specialty of that physician was noted and is tabulated in Table 4. A total of 28.6% of patients were referred by internists or family practitioners, 59.2% by gynecologists, and 12.2% by medical oncologists. Though the numbers in this study are small and no definite conclusions can be reached, none of the referrals were by physicians of other specialties. Specific Choice for Seeing a Gynecologic
Oncologist
The specific choice of seeking the opinion of a gynecologic oncologist is tabulated as a function of the reason for the visit in Table 5. Awareness
of the Specialty of Gynecologic
Oncology
All patients were asked if they had prior knowledge of the specialty of gynecologic oncology before they had either elected to see or were referred to a gynecologic oncologist. One hundred twenty of 186 (64.5%) stated that they had prior knowledge of the existence of the specialty. This is tabulated in Table 6 as a function of the educational levels previously outlined. Table 7 outlines what patients described as the source of their knowledge regarding their prior awareness of the specialty. In many cases multiple choices were checked. Table 8a outlines how patients who previously knew of the specialty perceived the training necessary to become a gynecologic oncologist. Table 9a outlines how these same patients perceived the gynecologic oncologist’s func-
TABLE 2 Reason for Patient Visit as a Function of Whether Second Opinion Sought Second
opinion
Yes Reason
for visit
Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
No
No.
%
2 22 14 26 34
Y.1 68.8 17.8 81.3 48.6
No.
5%
20 10 4 6 36
90.9 31.2 22.2 18.7 51.4
50
NOUMOFF
ET AL.
TABLE 3 Sourceof Referral as a Function of Reasonfor Visit Reason for visit
Friend/relative
Routine visit
Physician
Hospital referral
Other
-
14 (63.6%)
Gyn problem second opinion No second opinion
6 (18.7%) 6 (18.7%)
14 (43.7%) 2 (6.3%)
-
2 (6.3%) 2 (6.3%)
Premahgnant condition second opinion No second opinion
8 (44.4%) -
6 (33.3%) 4 (22.2%)
-
-
Malignancy second opinion No second opinion
-
24 (75.0%) 6 (18.7%)
2 (6.3%) -
-
Possible malignancy second opinion No second opinion
6 (8.6%) 8 (11.4%)
22 (31.4%) 26 (37.1%)
6 (8.6%)
2 (2.9%)
tion. Tables 8b and 9b outline the same information for those respondents who claimed no prior knowledge of the specialty. DISCUSSION There is little debate that the development of gynecologic oncology as a subspecialty within the field of obstetrics and gynecology has resulted in a positive impact on women’s health care. The function and expertise of the gynecologic oncologist is well known and regarded by obstetrician gynecologists. However, many medical practitioners in other fields are unaware of the subspecialty. Of equal importance is the impression that though large sums of money are spent by institutions in attracting the cancer patient, very little information is disseminated regarding the fact that some physicians are specially trained to manage specific types of malignancy. A review of several informational booklets provided by organizations involved in patient education, such as the American Cancer Society, usually refer the patient to “her physician” but rarely specify physicians with expertise in special
cancers. It is a perception among gynecologic oncologists that the public (often including physicians who are not gynecologists) is poorly informed regarding our existence and function. Consequently, optimum healthcare to the women with gynecologic malignancy, though potentially available, is not provided. It is interesting to note that since the members of our Division do not limit their practice to the management of frankly invasive cancer, 31.1% of patients seen presented either for routine care or for some specific benign problem requiring additional expertise. Premalignant or frankly invasive disease was the reason for visit in 28.9% of patients, and the largest percentage (40%) presented with problems that the patient stated could well be related to an undiagnosed malignancy. Though it was our general impression that many of these patients had symptoms of a malignancy (postmenopausal bleeding, ascites, and pelvic mass) we are unable to provide specific data regarding how many of these women actually did have cancer because of the anonymous nature of the questionnaire. Not surprisingly, over half (56.3%) of respondents stated that they were being seen for a second opinion.
TABLE 4 Specialty of Referring Physician as a Function of the Reasonfor Patient Visit Specialty of physician Reason for visit Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
Internist/family practitioner 4 4 2 6 12
Obstetrics/ gynecology
Medical oncologist
Other
2 10 4 18 24
4 8
-
PUBLIC PERCEPTION
OF GYNECOLOGIC
TABLE 5 Choiceof a GynecologicOncologistas a Function of Reason for Visit Choice of gynecologic oncologist
Reason for visit Routine visit Gyn problem Premalignant condition Malignancy Possible malignancy
12 of 10 of 14 of 34 of 40 of
22-54.5% 32-31.3% 14-100% 34-100% 70-57.1%
The majority of patients seeking second opinions did so for a premalignant or frankly invasive condition which had been diagnosed previously. Although over 63% of the patients were referred by other physicians, referral by friends and relatives accounted for a significant percentage (27.6%). In fact, 44.4% of those patients with premalignant disease were referred to the Division by a friend or relative, and the remainder were referred by a physician. All but one patient with a malignant diagnosis was referred by a physician, and 68.6% of patients with a possible malignancy were referred by a physician. This may indicate that a good number of these patients did have a malignancy but were either unaware of the diagnosis or chose to deny it. Because of the anonymity of the questionnaire, this issue is one of conjecture only. The fact that no patients in this study were referred by physicians other than family practitioners/internists, gynecologists, and medical oncologists is of interest and may reflect the relatively small number of patients studied. It does, however, emphasize that if we as a specialty are to embark on a program of professional education, the initial target should be doctors who are primary care physicians, i.e., family practitioners and internists, since they are more likely to be the first to see patients in need of a gynecologic oncologist. It is not surprising that all patients with premalignant and frankly malignant disease specifically chose to see a gynecologic oncologist. However, 31.3% of those patients with special benign problems specifically chose a gyneTABLE 6 Knowledgeof the Specialty of Gynecologic Oncology as a Function of Level of Formal Education
Aware of specialty Not aware of specialty
High school or less
College
Postgraduate
48 = 63.2%
38 = 63.3%
32 = 72.7%
28 = 36.8%
22 = 36.7%
12 = 27.3%
51
ONCOLOGISTS
TABLE 7 Sourceof Information Providing Prior Knowledgeof the Specialty of GynecologicOncology Friends/ relatives
Magazine articles 28 20.6%
54 39.7%
Television
Job in medical profession
Other
20 14.7%
20 14.7%
14 10.3%
cologic oncologist, and 54.5% of patients seeking routine gynecologic care specifically chose a subspecialist in our field. When patients’ awareness of the specialty of Gynecologic Oncology was tabulated as a function of their educational level, there appeared to be no significant difference. It is hypothesized that since there are essentially no public awareness programs currently in effect promoting our specialty, information is obtained by all individuals in the same manner. Support for this theory is provided by the fact that of those patients who had prior knowledge of the specialty, 39.7% acquired this knowledge from friends or relatives while sources such as magazine articles and television were described by only 20.6% and 14.7% of patients, respectively. The final information described was that of patients’ knowledge of our training and current practice patterns. Less than half of the patients realized that our initial training included obstetrics, and a similarly low number thought that there had been formal training in either general surgery (43.3%) or chemotherapy (31.7%). What is especially interesting is that the perception of our training and practice patterns by those who claimed prior knowledge of our specialty, when compared to those with no prior knowledge, indicated essentially no difference.
TABLE 8a Training of a Gynecologic Oncologistas Perceivedby 120 Patients Previously Aware of the Specialty Obstetrics Gynecology General Surgery Chemotherapy
52 114 52 38
= = = =
43.3% 95.0% 43.3% 31.7%
TABLE 8b Training of a GynecologicOncologistas Perceivedby 60 Patientswith No Prior Knowledgeof the Specialty Obstetrics Gynecology General Surgery Chemotherapy
25 58 27 21
= = = =
41.7% 96.7% 45.0% 35.0%
52
NOUMOFF
TABLE 9a The Practice Pattern of a GynecologicOncologistas Perceived by 120Patients Previously Aware of the Specialty Performs surgery Administers chemotherapy Administers X-ray therapy
102 = 85.0% 54 = 45.0% 40 = 33.3%
TABLE 9b The Practice Pattern of a GynecologicOncologistas Perceived by 60 Patients with No Prior Knowledgeof the Specialty Performs surgery Administers chemotherapy Administers X-ray therapy
50 = 83.3% 28 = 46.7% 22 = 36.7%
This suggests that even women who claim to have known of our specialty only surmised from the title “gynecologic oncology” as to what we do, and for the most part they have no greater knowledge of the expertise involved when compared to patients who simply learn that we specialize in the treatment of malignancy. The study presented above is small and therefore no definitive conclusions can be reached. However, this pilot
ET AL.
study does substantiate the general view among gynecologic oncologists that most individuals appear to have little knowledge of our specialty and the background, training, and practice of this field of medicine. Morrow [2], in his presidential address to the Society of Gynecologic Oncologists in 1991 specifically stated, “We are not well known to other medical specialists, but we are all but unknown to medical-related organizations in the public sector. More important, the community of women is largely ignorant of the specialty of Gynecologic Oncology. Patients come to us with little or no understanding of who we are or what we do.” This study substantiates the above statement. It is eminently clear that as a specialty we must make an effort both locally and nationally to make the public and medical community more aware of the expertise our specialty brings to women with cancer. REFERENCES 1. Underwood, P. B., Jr. Presidential address: 15th annual meeting. Society of Gynecologic Oncologists (1984). Gynecol. Oncol. 19,261267 (1984). 2. Morrow, C. P. Presidential address: “Who Are We?“: A Paean to Gynecologic Oncology, Gynecol. Oncol. 42, 111-113 (1991).
