In any year, leading the American College of Obstetricians and Gynecologists (ACOG) could be challenging; in 2020, when Eva Chalas, MD, became ACOG’s 71st president, it came with the additional complexities of COVID-19. As Dr. Chalas used her tenure to help colleagues around the country navigate urgencies of the pandemic—from obtaining personal protective equipment to encouraging preventive care—she continued to advance and promote an idea she has long espoused: redesigning practice to personalize care delivery and increase health access and equity for women.
Dr. Chalas, a gynecologic oncologist, vice chair of the Department of Obstetrics and Gynecology at NYU Long Island School of Medicine and physician director of Perlmutter Cancer Center at NYU Langone Hospital—Long Island, remarked during her presidential address in April 2020 that obstetrician–gynecologists are “uniquely positioned to identify gaps in healthcare that women may experience, work with them through many different stages in their lives, and create and implement solutions to make sure that no patient is left behind.” In this interview, she discusses her thoughts on the importance of practice redesign and ACOG’s work toward advancing this issue.
Why is practice redesign so urgently needed?
I first recognized this as a resident more than 35 years ago: some aspects of care aren’t making a positive impact, and, sadly, our patients are sicker, not healthier. For example, Pap tests used to be annual, regardless of risk. Then, the United States Preventive Services Task Force changed guidance based on individual cervical cancer risk—which changed obstetrician–gynecologist practice. Now, women who used to visit for a Pap test as part of annual preventive health aren’t coming every year. The question is are they getting their care elsewhere? Unfortunately, they’re not.
How, as an obstetrician–gynecologist, could you serve as a primary point of care?
If a patient has gaps in care, you can address them yourself or guide them to other physicians. So if a patient’s hemoglobin A1-C indicates prediabetes, you can direct them to establish regular care with a primary care physician, and if they need further treatment, to an endocrinologist. In other words, we can help patients navigate their care to be sure that they maintain good health.
What does redesigning care look like in practical terms?
Personalized care still includes preventive screenings, but you adjust the visit to that patient’s risk factors. Preconception counseling, for instance, covers prior pregnancies and the patient’s risk profile because those factors can forecast future health. If a woman had hypertension during pregnancy, she’s at risk for high blood pressure 20, 30 years later—so we could intervene.
As ACOG president, I appointed a task force that developed educational materials and coding resources to help our physicians shift to a more comprehensive model of care centered on each patient’s unique health circumstances. We focused on the most common conditions that can adversely impact the health of our patients, with the goal of preventing disease, first and foremost, and secondarily, to foster awareness and enable intervention. We further sought to promote the preventive model by developing a rubric for physicians and patients to evaluate health apps, including what the apps do and how to use them to mitigate risks. We have submitted both the rubric and recommendations for several apps that provide education on each of the common conditions—cardiovascular disease, obesity, diabetes, hypertension, cancer prevention, and inherited cancer syndrome—for publication in a peer-reviewed journal.
The COVID-19 pandemic highlighted the perils of women as caregivers for others, often putting aside their own health. Are women engaged enough in their own care?
Women are big consumers of health information, yet they generally don’t know the basics about their personal and family history to see how that knowledge can help guide their own care. Particularly within marginalized communities, there’s tremendous reluctance to actively participate in healthcare—more women use episodic or urgent care, but not routine, preventive care. To aid women in choosing health apps that enable more informed engagement, ACOG recently launched a patient-facing website with consumer-friendly information that uses the rubric we developed.
How can pregnancy, which for many women is a period of their most consistent medical care, serve as a conduit for overall preventive care?
That conversation should begin before pregnancy. In New York State, more than half of pregnancies are unplanned, and nearly half are covered by Medicaid. There is no reason to have unplanned pregnancies based on available contraceptives covered by Medicaid, and planning pregnancies has a positive impact on mother and baby. During pregnancy, health changes can forecast future problems including diabetes, hypertension, and cardiovascular disease. So if we can get a message about healthy habits to a 25-year-old patient expecting a baby, that will impact both her and the baby for years to come. We need to focus more on health maintenance and less on disease treatment. Even if disease develops, if we intervene early, we can aim to keep people as healthy as possible, while maintaining high quality of life.
How did COVID-19 impact your ability to promote practice redesign?
We faced complications like other organizations: virtual events, staffing concerns, financial challenges. ACOG staff worked diligently to support its members by advocating on the federal level for access to personal protective equipment and financial assistance for practices adversely affected by the pandemic. We supported national efforts by providing education on telehealth implementation and by disseminating expert-led information on COVID-19. Although we took all responsible steps for safe delivery of care to our patients, some didn’t want to deliver in high-risk states and opted to travel to neighboring states or stay at home for their deliveries.
Many patients, including those with cancer or worrisome symptoms, opted to avoid medical care. ACOG joined public officials in highlighting the safety precautions already in place in medical settings and the importance of continued pregnancy and medical care to prevent risk of harm. We worked with other medical organizations to call for resumption of preventive care, including cancer screenings. These messages dovetailed with the personalized medicine platform at the center of my time leading ACOG.
Now that your ACOG presidential term has come to a close, how will you continue to bring the idea of practice redesign into your care delivery and to the specialty in general?
This presidential initiative was designed primarily to improve the health of our patients, but also to help our physicians change the pattern of practice. This includes helping them to more effectively deliver personalized preventive care and to equip them to assess new technology that could increase their efficiency. The task force has written a call to action paper, which we plan to publish in July, to summarize some of this work. Our webinars highlighting each high-risk condition and associated apps are live on the presidential page of the ACOG website, and I have personally promoted this topic at academic institutions through invited lectures throughout my term. Of course, the ultimate test will be the adoption of the resources developed by the task force members.
Many gaps in care remain for patients who have access to medical care, and even more for those who do not. I am firmly convinced that obstetrician–gynecologists can help bridge at least some of those gaps, while playing a vital role in disease prevention and early intervention.