Tag Archives: Medicine

Posts that relate to medicine in some way.

What do you know about colon cancer screening?

  • Colon cancer is the 3rd most common cancer diagnosed in women.
  • It is also the 3rd leading cause of cancer death.
  • The American Congress of Obstetricians and Gynecologists (ACOG) recommends that women without known risk factors begin screening at age 50.
  • The screening method with the best detection rate is colonoscopy every 10 years.
  • Women with African ancestry should begin screening at age 45.
  • Screening should begin:
    • At age 40 if:
      • A biological parent had either a colon polyp or colon cancer before age 60.
      • 2 or more biological parents or children had polyps or cancer at any age.
    • 10 years earlier than the age a biological parent was diagnosed with colon cancer. (If a parent was diagnosed with colon cancer at age 40, screening should begin at age 30).
    • Within 8 years following diagnosis of inflammatory bowel disease (ie ulcerative colitis or Crohn disease).
    • At age 21 in individuals with a family history of hereditary nonpolyposis colon cancer (HNPCC). They should also consider genetic counseling and testing.
    • At puberty in individuals with a family history of familial ademomatous polyposis (FAP). They should also consider genetic counseling and testing.

Care of the prematurely retracted foreskin

Dear Dr Pate,

I’ve read some of your (awesome) posts and have a random question I’m hoping you can answer! 🙂 I know of a mom whose son was forcibly retracted when he was 7 months old. Unfortunately, she was told that after that point, she needed to continue doing it, which she did for another year following that incident. Now she knows that was wrong. The problem is that he’s fully retractible now (even though not “naturally” so), and she doesn’t know if she should continue asking him to retract himself to clean it (as she would a naturally retractible child), or not. He’s only 2 years old, and resistant to doing so. I’m inclined to say leave it alone and that just soaking in the bath will be good enough, but wanted to double-check. If he doesn’t retract to clean, would it encourage adhesions or infection?

Dear KD,

Thank you for your kind comments and your excellent question! I am inclined to tell her to leave it alone as well given that kiddos do not have the same amount of body secretions as teens and adults. Likewise, I can’t image that other cultures around the world pay even a 10th of the interest in either the excision or maintenance of the foreskin as we do in the U.S. Do little girls really need to be taught anything more to wash briefly in the tub? The same should apply to little boys. However, I am not a pediatrician so I asked my colleagues for their opinions which follow below. Best of luck to the little tyke and thanks again for writing.


James Pate, MD

I agree with you and would have advised the same. If he is resistant to retraction, I would leave it alone. It may re-adhere, but I would imagine that it will detach over time without undue intervention despite the earlier forcible retraction. If not, he can use steroid cream if indicated. I don’t see it becoming infected.

On the other hand he may become more amenable to retraction and cleaning in the coming months which would make it a non-issue. He may be objecting because he’s two years old. But I see no reason to compel him to do something he doesn’t want to do at this time.
―Dr Paula Brinkley, pediatrician

I just wanted to assure you that your advice was just right! We need not retract the eyelid to wash under it, and mucous membrane will keep adjacent tissues from adhering one to the other. In most non-circumcising countries, from what men have told me, they often are taught little and generally figure out hygiene on their own. If they are told something, it’s usually around puberty, probably when secondary sex hormones are produced.

We don’t teach girls to pull their prepuce back to wash under it and we don’t put Q-tips or anything else into their vaginas to wash them. The body is self-cleaning. And, little boys need a normal sense of unconcerned boyhood. The baby’s objections to having his foreskin messed with is the message to which everyone should listen.

There are three great articles that you might find helpful at http://www.nocirc.org/articles. They are:

―Marilyn Milos, RN, Executive Director, National Organization of Circumcision Information Resource Centers (NOCIRC)

In my opinion, you don’t have to be a pediatrician to answer this question – most pediatricians don’t know anything about taking care of the foreskin anyway! – so I’m going to offer my own take on this.

There are no controlled studies on correct care of the intact penis, so the best we have to go on is a good understanding of the structure and development of the foreskin, plus common sense.

The few studies that I know of that looked at retractability, foreskin hygiene, and outcomes are so methodologically problematic and ignorant of the natural development of the foreskin as to be completely worthless guides (Kalcev 1964, Krueger and Osborn, 1986).

Most of the “literature” on care of the intact penis are merely opinion pieces. One would hope that this “opinion” would be based on a solid knowledge of the development of the intact penis, and/or extensive experience in conservative care of the intact penis, but unfortunately this is not the case, as we all know, and there is a lot of mistaken and potentially harmful advice given.

“I did an inservice on care of the intact penis 6+ years ago where I dug up as much literature on it as I could (17 articles, 2 of which were from CIRP and NOCIRC). I am attaching a summary of some of the advice from these handouts that I posted at Mothering.com some years back, plus some additional quotes that support the idea of “leave it alone”.

Here’s the general consensus from these handouts:

  • If the FS is non-retractable, no matter how old the boy is, all that need be done is to wash off the outside. PERIOD.
  • Once the FS is retractable AND the boy is developmentally able (generally have the motor dexterity and ability to follow instructions by about age 4-5), he can be taught to retract, rinse, replace. [Note, this makes the idea of requesting a 2 year old to retract and clean himself seem pretty pointless.]

Sources that specifically mention frequency suggest:

  • In childhood: this rinsing might be done say only “occasionally”
  • By puberty: more “regular”, or “daily” rinsing is suggested

Although some older articles will recommend that parents retract the child (based, I believe on a preconception of the foreskin as problematic, and ignorance of the natural development of the intact penis), most do NOT say this, and a number do support the idea of leaving it alone (see my Mothering post attachment). In fact there is one great quote from Canadian pediatric urologist Peter Anderson stating that “there’s no evidence there’s any need to clean under the foreskin before puberty.”

Remember that the foreskin is designed to keep the ooky stuff out (tight outlet in childhood, sphincter-like action of the peripenic muscle), and that it is flushed outward multiple times a day with sterile urine, thus keeping itself clean.

As a John Geisheker likes to point out, “Our primate predecessors were unlikely to head down to a nearby river every day to scrub their children’s genitals. Nature would quickly eliminate those who needed such care. Only those tough enough to not require genital cleansing would have survived. We are those survivors. … Mid-19th century English-speaking boys and girls did not suddenly require aggressive genital hygiene when their ancestors, for hundreds of generations, survived nicely on benign neglect.”

If this 2-year-old is resistant to having his foreskin retracted, by all means, leave it alone! It is unnecessary from a hygiene point of view, and could be more psychologically distressing than its worth. He will discover the joys of retracting himself when he’s ready and interested himself. In the meantime, it is quite possible that just playing with his penis in clean tub water might be all the cleaning needed. Since the average age to full retractability is somewhere are age 10, I would encourage this young mom to sit back, respect her son’s own time table and emotional boundaries, and just let nature take its course.

―Gillian Longley RN, BSN, MSS, Colorado NOCIRC

Rather than re-invent the wheel and write a longish, potentially unwelcome, or over-obvious email, I am attaching several articles we at DOC wrote for Psychology Today magazine on this very issue.

The short answer, (which I suspect you know instinctively), is that urine is sterile and the boy-child is ‘washed’ at each urination. The notion that intact (not C’d) boys need special hygiene is an invented one of Anglophone origin, its sources easily traced to the mid 19th century, a time of great anxiety about masturbation (even among toddlers) as a source of disease. This was before Koch (1879) and others identified pathogens.

In evolutionary terms, the notion that boys need special genital hygiene makes no sense. Our primate ancestors were likely far more concerned with foraging for food and finding a safe place to sleep each night. There was no time or motive to scrub the genitalia of their offspring (and my primatologist neighbor tells me no such behavior has ever been seen in the wild).

We are their descendants who never needed any such care. The infant vulva and infant penis, like the infant eyes and mouth, are self-defending and self-cleaning. It could hardly be otherwise.

―John V. Geisheker, J.D., LL.M. Executive Director, General Counsel, Doctors Opposing Circumcision (D.O.C.)

I’m on the hunt

On 6/11/12 I officially enter my LAST year of residency and am finally starting to see the light of a very long and arduous tunnel. My senior resident colleagues and I are just now starting to be inundated with emails and phone calls from recruiters and practice representatives from across the nation. As the Baby Boomers move into retirement, and along with them the physicians of the same generation, the demand for new recruits continues to grow. As is true of real estate, for many of us it’s all about location, location, location! Positions in coveted downtown city locations are never short of applicants but beyond the cityscape and adjacent suburbia lies an ever expanding need for medical professionals.

The Washington Post recently posted the above image generated with esri software that geographically identifies areas of increasing medical need. Areas that are dark orange are already in great need of medical providers and they are likely to continue to grow in dimension.

Having grown up in a suburb of Seattle (Kent, WA), I don’t think I would have given rural medicine any consideration prior to medical school which I completed at Oregon Health & Science University in Portland, OR. OHSU prides itself in fostering a love of primary care among its students as well as an appreciation for rural medicine. During my time there I completed 4 rural rotations in primary care, family medicine, neurology and surgery lasting approximately 8 weeks each.

I was required to complete a community project in my primary care rotation in Coos Bay, OR. I elected to research the issue of rural physician shortage in terms of physician recruitment and retention. I had the opportunity to interview local recruiters as well as rural physicians of multiple specialties. I also conducted a survey of the 3rd and 4th year medical students regarding their experiences with and interest in rural medicine. I then compiled this data into a written manuscript: Recruiting and Retaining Physicians in Coos Bay: Assessment of Medical Student Interest in Rural Medicine and Rural Physician Perspectives on Their Practice. I later presented this data at the 25th Annual Oregon Rural Health Conference. My presentation can be found here.

I discovered that there are a lot of benefits to working rural areas including making a difference for an underserved population, becoming part of a “close-knit” community and having a larger scope of practice. Fringe benefits include outdoor activities, simpler lifestyle, lower cost of living and potential student loan repayment.

Some of the more challenging aspects of working in a rural area are cultural and political differences. It seems that the more diverse and populated communities are, the more liberal and tolerant they are as well. Rural America is more homogenous in character and conservative in opinion. White Anglo-Saxon Protestant (WASP) physicians tend to find a home away from home more easily, especially when they share the same values as the communities they enter. Those of us who are different often feel like outsiders who are simply extended cordial hospitality with an arms-length handshake. The vast difference between city and rural amenities can also contribute to culture shock, homesickness and isolation.

My partner and I are willing to consider rural locations among our opportunities. Both of us have moved extensively, Patrick more than I, and we enjoy the adventure of new experiences and making new friends. The issues I foresee being problematic pertain to the differences I alluded to: I am a partnered gay father in addition to being an OB/GYN resident physician; my personal life cannot be separated from my professional life. Patrick and I have been committed to each other for the past 10 years. I have been a father even longer. I feel that it is a travesty that we live in the 21st century yet continue to be treated as a second class citizens. Because our relationship is not recognized in the majority of States we suffer mentally and financially. Although more and more insurance companies are choosing to include same-sex partners, many do not. I have worked too long and too hard to accept employment with a group that will not allow me to insure my family.

Another issue is abortion. The Republican-lead War on Women is in full force and a record number of anti-choice ballots continue to make their way through state and federal legislatures. We are rapidly returning to the pre-Roe Vs. Wade era. Some sobering statistics are the following:

  • Approximately 1/3 of women require an abortion procedure over their lifetime.
  • Over 90% of OB/GYNs have had patients request abortion services.
  • ONLY 14% of OB/GYN providers provide them.

While this may be great news for the anti-choice audience, women AND children are already suffering much and may be soon forced to suffer more. The U.S. foster care system is overflowing with abused, neglected and unwanted children. Shall we increase their numbers? Women have many deeply personal reasons for seeking abortion. Sometimes they are truly in danger of dying because the pregnancy is too great a strain on their pre-existing medical conditions. Other times they simply cannot afford yet another mouth to feed. Although abortion access isn’t really one of my soap boxes, I cannot consider myself a defender of social justice and turn a blind eye to this dilemma. Abortion is legal in this country and is a part of comprehensive OB/GYN practice. I cannot ethically permit my scope of practice to be limited by religiously or politically motivated restrictive work covenants.

And then there are my professional interests which include issues pertaining to the LGBTQI (lesbian, gay, bisexual, transgender / transsexual, queer / questioning, intersex) communities, Mayer-Rokitansky-Kuster-Hauser syndrome (Mullerian anomalies) and polycystic ovarian syndrome (PCOS). The majority of gender and sexual minority patients receive sub-optimal and inadequate care. And although PCOS affects around 7-8% of women it is often the elephant in the exam room that is repetitively ignored. I must also make myself available to these underserved populations.

One recruiter wrote to tell me that “the 232 clients my colleagues and I are working with nationwide will not be able to provide you with all of those items. If they are really non-negotiable factors, I will not be able to assist you with your search.” Fortunately there are many other recruiters that do not share his lack of vision.

Although my personal life and professional ambition may “offend” some I am confident that I will find the right place for me. The map is wide open and opportunity calls.

Contrary to marketing in Africa, circumcision does NOT prevent HIV transmission and may increase it

Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns. Journal of Law & Medicine. 19(2):316-34, 2011 Dec.
“In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.”

If the WHO/UNAIDS really wants to turn the epidemic tide, distribute free condoms!

Considering circumcision?

Circumcision has been a “traditional” procedure in the U.S. for many decades. However, more and more parents are choosing to leave their sons intact in spite of  a great deal of pressure from other family members and/or religious leaders to follow their traditions. Why do these parents refuse? What’s the big deal?


Well I could tell you, “Go ahead! It’s just a little skin,” and pad my wallet with the extra money I could make from these “simple” procedures. Or I can speak to you as a father who regrets his decision to have his son circumcised and try to provide you with the information you should know before making this life-altering decision for your son(s).

I have written multiple posts on this subject and am what is known as an “intactivist” — an activist for the preservation of intact genitalia for all minors unless medical necessity (not preference) dictates otherwise. However, that is not the point of this post. I simply desire to give you information so that your decision, whichever it may be, may be fully informed.


If you are interested in finding out more about circumcision I highly recommend the following resources:

Finally, if you are just nervous about how to care for an intact penis, it’s much easier than you think. Check out the following pamphlets on how to care for your infant son and what to expect as he ages.


Women’s Work?

I was recently interviewed for an article published in the March 2012 edition of Minnesota Medicine, the journal of the Minnesota Medical Association.

In Women’s Work? Obstetrics/gynecology struggles with the gender question, author CArMen PeOtA addresses the gender shift of OB/GYN physicians from once a predominantly male to a now predominantly female presence.

My input lies toward the end of the article, under the “The Value of Gender Balance” section heading. She writes:

Those concerns didn’t put off third-year University of Minnesota ob/gyn resident James Pate, M.D. “There’s such a strong need for providers in every specialty that there will always be jobs available.” His plan is to specialize in caring for patients
with atypical gender experience. Like most men and women who go into ob/gyn, Pate says the appeal of the specialty is that it offers physicians the chance to do both primary care and surgery. Pate actually thinks it’s a good thing that nine out of 10 of his colleagues in ob/gyn residencies are female. “In the past, all of medicine was heavily dominated by men,” he says. “Having the majority of providers [be female] makes sense. They are women, and they care about women and want to provide excellent health care to women.” But he believes both males and females bring a perspective to practice that’s valuable. “Both our female colleagues and our patients appreciate the male presence,” he says.

10 seconds of fame

On 2/7/12 I was interviewed by CBS Minnesota news reporter, Esme Murphy, for her story, Mannequins Become Test Patients For Regions Doctors. The linked interview and video shows me discussing the benefits of simulation for improving patient care. I include this post in my blog not because I’m trying to toot my own horn — 10 seconds on a local channel is so groundbreaking! — but because I have been asked by several readers to consider video blogging and I figured that this was a quick way for those interested to see a more life-like representation of myself.

The whole experience was both somewhat unnerving and hilarious because my team and I were not forewarned until minutes beforehand. We had just found a lull in the day to grab some lunch from the cafeteria and headed back to our workroom when my attending stated that our presence was requested in the simulation lab for a news report. We were to simulate an uncomplicated delivery using NOELLE™, one of the pricey mannequins mentioned in the interview. However, when we arrived it became apparent that they also wanted to interview us and I, being the chief resident, got chosen to shoot from the hip. No preparation, just 1, 2, 3, action!

After my little blurb we moved over to NOELLE™ for the simulated birthing experience. While we had experience with various other components of the simulation center, none of us had ever worked with NOELLE™ before, a head shaking, blinking blonde who intermittently talked, asked questions and screamed through contractions. We did not have gloves, other safety precautions or any of our other tools needed for routine vaginal delivery. Thank god they refrained from simulating the gushes of amniotic fluid and maternal blood and excrement. Eventually NOELLE™’s baby was delivered via the conveyor belt through her pelvis by our bare-handed emergency department resident as she squatted on the floor. Fun times were had by all. 🙂

Dr Cary Gabriel Costello: Intersex Fertility

Dr Cary Gabriel Costello

Dr Costello writes in his blog entry, Intersex Fertility, that “My daughter was not of woman born. That is a concept that has fascinated people through the ages. My daughter’s gestation was perfectly ‘natural,’ I should point out–but I carried her, and I was never of the female sex; I am a so-called ‘true hermaphrodite.’ I was assigned female at birth, and was living as such when I gave birth to her, but I never identified as a woman, and am now legally male.”

He continues, “I’m glad that I was able to become a parent, but believing that this should have ‘cured’ me of my distress with my assignment is magical thinking along the lines of believing that procreating will ‘cure’ a lesbian or gay man and make them heterosexual. Gender identity, sexual orientation, and procreative status are independent characteristics. Lesbians and trans men and intersex individuals aren’t mystically “converted” by pregnancies. Gay men and trans women and intersex individuals who inseminate someone aren’t thereby made straight or cis or dyadically-male-sexed.”

He concludes: “Most of us who do reap the rewards of fertility do this in private, with no medical journal articles trumpeting a star in the east. In fact, some medical ‘corrections’ of our physical differences render us infertile, and I don’t see why that’s treated as unimportant when doctors are so very willing to write articles about their ‘cases’ who do prove fertile. And the magical thinking behind the idea that doctors can validate a sex assignment through the intersex person contributing the ‘correct’ component, egg or sperm, to a conception just boggles my mind. It’s time for some more sophisticated thinking about intersex fertility.”

I couldn’t agree more. Ready more about Dr Costello, his experiences and his scholarly opinions regarding intersex and trans issues on his blogs:

Am I intersexed?

Dear Dr Pate,

I was born with a DSD. Is penoscrotal hypospadias with severe chordee an intersex condition? Am I intersexed?

Dear J,

Your questions are more difficult to answer than one would think. The term “intersex” has changed in meaning over time, more so among doctors than perhaps many who consider themselves to be intersex. From a medical point of view, your condition would not necessarily have been considered an intersex disorder in the past. However, an international consensus reclassified disorders with either abnormal sex chromosomes (ie XO, XXY) or atypical genitalia under the umbrella term “disorders of sex development” (DSD) in 2006. Given that hypospadias is a condition where development of male external genitalia is halted prematurely, this is indeed a DSD. The term “intersex” however is no longer considered to be a contemporary medical word and has been replaced by DSD.

Adults who consider themselves to be intersex generally have a history of ambiguous genitalia, may or may not have been subjected to “normalizing” genital surgeries in infancy and/or childhood, but do not feel that they fit neatly into the binary boxes of male or female. They usually feel that if surgery occurred that it was undesired and destructive. Their gender identity may be the same as their sex of rearing, opposite, a combination, or something else. Adults who identify as intersex are generally offended by the new medical nomenclature “DSD”; they do not feel that their sex is disordered but rather a natural occurrence within the human spectrum. They are also quick to point out that they are not transgender or transsexual and do not feel that they are a part of those communities. Unlike the trans communities, they feel that their gender identities match(ed) their bodies, though they may not match their surgically altered bodies nor the sex of rearing that was chosen for them. The intersex community is still rather small given the shame, embarrassment and mistreatment individuals were subjected to while growing up as well as the continued ignorance of society regarding their existence.

People that continue to be born with chromosome abnormalities and/or varying degrees of genital ambiguity may feel that they are either truly male or truly female with a DSD medical condition, not intersexed. On the other hand, if their gender identity is the opposite of their sex of rearing then they may consider themselves to be trans. Others feel more comfortable with an intersex identity. Thus the matter of what is considered an intersex condition and who considers themselves to be intersex remains quite murky.

There are intersex groups that exist online and occasionally meet in person. If you are interested in chatting with others like you I would recommend checking out Organisation Intersex International (OII). They are “devoted to systemic change to end the fear, shame, secrecy and stigma experienced by children and adults through the practice of non-consensual normalisation treatments for people born with atypical anatomy, and the arbitrary assignment of a particular gender without an informed consultation with the individual concerned.”

Hope this helps and good luck to you. Happy holidays!


James Pate, MD

Ob-Gyns: Prepare to Treat Transgender Patients

Ob-Gyns: Prepare to Treat Transgender Patients
November 21, 2011
From: The American College of Obstetricians and Gynecologists

Washington, DC — To address the significant health care disparities of transgender individuals and to improve their access to care, ob-gyns should prepare to provide routine treatment and screening or refer them to other physicians, according to The American College of Obstetricians and Gynecologists (The College). In a Committee Opinion published today, The College also states its opposition to gender identity discrimination and supports both public and private health insurance coverage for gender identity disorder treatment.

Although the total number of transgender people in the US is unknown, studies suggest they make up a small, though substantial, population. Transgender is a broad umbrella term that includes people whose gender identity and/or gender expression differs from their assigned sex at birth. Female-to-male, male-to-female, crossdressers, bi-gendered, and intersex are the major groups that fall under the term transgender.

“Transgender patients have many of the same health care needs as the rest of our patients,” said Eliza Buyers, MD, former member of The College’s Committee on Health Care for Underserved Women who helped develop the new recommendations. Health outcomes for the transgender community are very poor due to their lack of access to health care, noted Dr. Buyers. “It would be wonderful if all transgender patients had the resources to be seen in a specialized clinic, but the reality is that many forgo care because they don’t. By increasing the number of ob-gyns providing care to transgender patients we can help improve the overall health of the transgender community.”

Transgender individuals who were assigned female sex at birth but are now living as a male will continue needing breast and reproductive organ screening, unless they’ve had mastectomy or had their ovaries, uterus, and/or cervix removed. Male-to-female individuals who have had genital reconstruction may need cancer screening of the neovagina and breast cancer screening if taking estrogen hormones.

“Services that ob-gyns should be able to offer transgender patients include preventive care, Pap tests, sexually transmitted infection (STI) screenings, and hysterectomy for standard indications like heavy bleeding or pain,” said Dr. Buyers. The College recommends ob-gyns first consult with transgender experts before performing hysterectomies as part of gender affirmation surgery. “Hormone replacement can be managed in consultation with experts in transgender care, as many patients will seek hormones on the black market if unable to obtain them from their providers.”

Many, if not most, transgender people face social harassment, discrimination, and rejection from family and society in general. Many of them are homeless, particularly youth who identify as transgender. Transgender individuals are at an increased risk for sexually transmitted infections (STIs), including HIV, and physical abuse.

“We need to make our offices settings that treat all patients with respect,” said Dr. Buyers. The College offers ob-gyns suggestions on how to create an office environment that is welcoming to transgender patients. For instance, asking patients their preferred name and pronoun, posting non-discrimination policies, ensuring confidentiality, and offering sensitivity training for staff are all steps that signal acceptance and let patients know that they will be treated with dignity. “We want the transgender community to know that we, as ob-gyns, care about their health.”

Committee Opinion #512 “Health Care for Transgendered Individuals” is published in the December 2011 issue of Obstetrics & Gynecology.