Pregnant Pause

Things are being stirred up in the stirrups these days. If you ask New York women, many will tell you that a trip to the gynecologist-never a walk in the park, even with the best doctor-has become more fraught with anxiety and unpleasantness, as the ob/gyns seem to be getting shorter in temper and longer on testiness.

But if you ask the doctors, many will tell you that New York patients have become more demanding than ever, as women who devoted their 20′s and 30′s to their careers are coming in expecting their doctors to work miracles with their reproductive plumbing.

What everyone agrees with, however, is that in the last few years, the pressures of managed care and rising malpractice-insurance rates (one of the highest in medicine) have drastically changed the lives of ob/gyns.

“We get reimbursed less and less and have to pay more malpractice,” said Ching-Lynn Chen, who sees up to 30 patients a day at OBGYN Westside in Manhattan. “You have to see more patients to make the same amount you used to. But our patient population is demanding, and they expect things to stay the same.”

“I’ve got patients who just sort of won’t stop talking,” said Frances Mary McGill, a former director of gynecology at St. Vincent’s Hospital who now has a private practice. “I think New York women are smart, savvy business women, and they expect and want every question answered, and they want clarification and reclarification. Sometimes I say, ‘We’ve covered this three times, so if you want to continue to discuss this, I could have you make another appointment,’ but they don’t like that. They get annoyed.”

Mary Conners-Ashmore started practicing before the current health-maintenance organization trend hit New York and made many fee-for-services policies obsolete.

“Now we all know there’s no money in medicine anymore,” said Dr. Conners-Ashmore. “But at the beginning, it was a shocker. You really need to see a certain number of patients per week, day and month, and have a required number of deliveries, to make obstetrics worth it.” She opted out of the H.M.O. system, dropped obstetrics and concentrated on a private gynecology practice.

“In Manhattan, women put off their child bearing, which means that they’re more informed when they do have their baby,” she said. “They have more education on average, and they don’t want to be marginalized, and they don’t want a paternalistic approach.” She said it’s impossible for doctors starting out of residency now not to be with big insurance companies. “I went into medicine to take care of women,” she said. “But thoughtful ob/gyns really are sort of out of the game.”

Although the overall birth rate is down in New York City, the birth rate for older women is on the rise. According to the Health Department, 30,403 woman between the ages of 35 and 39 got pregnant in 2002, up from 27,379 in 1995. For women over 40, the number jumped from 7,313 in 1995 to 9,820 in 2002. (Nationally, the C.D.C. reports that birth rates for women aged 40 to 44 years rose 5 percent between 2002 and 2003.)

“It’s sociological,” said Jessica, a 39-year-old magazine writer with two kids who lives in Brooklyn. “If everyone is 22, they’re having routine tests. If you’re having your first baby at 40, there are more complications. Women expect their doctors to understand that this is the most tender moment of their life, but they’re seeing people come in and out on a conveyor.”

After a bad experience with her gynecologist, Jessica said she decided to find someone new. “I had this test that was really awful, and I got kind of nauseous and sick, but they said they needed the room. So I left the hospital and had to sit down on the sidewalk in New York City. Someone came up to me and said, ‘Do you need a doctor?’ And I was like, ‘My doctor did this to me!’”

She found a new ob/gyn who spends time with patients, and when it comes to the long waits, she tries to change her personality.

“You have to enter the zone,” she said. “Normally I would be furious, but this is such an important thing that all rules of engagement are suspended.” She said she can always spot the first-timers-the ones huffing and puffing and looking at their watches. “I always see these high-powered women come in and get furious,” she said. “But if you find a great doctor, you have to be willing to put up with it, because what’s more important in your life?”

Scheduling an appointment at the Soho Medical Group wasn’t easy for Janet, a graphic designer. Several of her friends with more high-powered jobs than her own had put off a routine checkup for years, since they couldn’t expect to schedule an appointment over their lunch hour and return to the office much before closing.

When she finally complained angrily to her doctor after her fifth or sixth two-hour-plus wait, her doctor said, “Wow, you’re really tense. Maybe you have a chemical imbalance.” The doctor then ordered up about $400 worth of non-coverable blood work.

If some gynecologists are silent and cold, others are alarmingly chatty. When Christina, a radio producer, went to an Upper West Side gynecologist for a routine yeast infection, she spent most of the visit trying not to cry.

“She asked me where I met my boyfriend, and how soon I had sex with him,” said Christina. “Then she asked me what I knew about him, and if I slept with a lot of people. She kept acting like I was a slut, and made me feel like if I had gotten anything from him, it was my fault. I was already feeling very vulnerable, and was afraid of her touching me after that because she seemed so powerful and scary. She’s a gynecologist, it happens every single day; she should know how to proceed with caution. When I lay down and put my legs up, I was totally terrified.”

When she moved to New York for a magazine job, Jen picked a gynecologist out of her health-care book and made an appointment. She found the battery of questions about her diet and sex life a little abrasive, but figured that this was New York. But the worst was yet to come.

“As soon as she saw my Brazilian, she started talking about how this is something men impose on women, the way men in China used to have women bind their feet and men in Africa made women remove their clitorises,” said Jen. “It made me uncomfortable, and looking back, I wish I had decided to leave right then.”

One doctor told Leslie, an office manager, that she had beautiful, perky breasts-right before feeling them for lumps. Then there was the doctor who offered a play-by-play during his examination of Samantha, an illustrator: “He stuck his finger in and said, ‘Oooh, nice and tight,’” said Samantha. “Afterward I felt uneasy and confused, like: ‘Is a doctor supposed to-or allowed to-say that?’”

Julie, a writer, had to clench her teeth through her doctor’s political rant.

“Right in the middle of the most vulnerable part of the examination-feet in stirrups, legs spread, hand rammed up me-he started ranting about how much he hated Hillary Clinton,” said Julie. “What was so unnerving about it was the obvious misogyny-because the only train of thought I could come up with for this sudden and bizarre tirade was that he was literally thinking ‘cunt’ as he was examining one-which of course made him think of the junior Senator from New York.”

Catherine Monk, a clinical psychologist and assistant professor of psychiatry at Columbia University who treats patients dealing with stress and psychological issues related to pregnancy and fertility, said that the kind of med students who go into gynecology don’t always have the caretaker personality.

“My assumption is that sometimes people go into fields to control something and make it right,” said Ms. Monk. “That can be antithetical to asking, ‘How are you?’”

She said she often hears patients complaining that they feel like their doctors are asking “How is your uterus?” instead of “How are you?” But she added that she also understood the reasons a doctors might not ask such an open-ended question-it’s uncomfortable, the doctor is under tremendous pressure, and if the patient answers “Not good,” it can mean more work for the doctor, such as giving the patient a referral to a shrink.

It’s not that hard to find a new gynecologist if you don’t like the way you’re being treated. Once pregnant, though, leaving is no longer an option. Most women feel that if they can’t make the relationship work, they’re the ones who are going to suffer. So most of the time, they suck it up.

Elizabeth, a hotel inspector, gained 60 pounds with her first child and used to dread her appointments.

“If I gained too much weight one week, my doctor would say, ‘Looks like someone had a good week!’” she said. “I burst into tears just about every other week.”

Another gynecologist on the Upper East Side who feels strongly about weight gain simply places a sticker of a pink pig on her patients’ charts if she thinks they’ve gained too much in a given week.

When Ellen, a TV executive, noticed that one of the partners in her medical group at Beth Israel, Dr. Allan Zarkin, was acting like Don Rickles during an appointment, she didn’t worry too much, because he wasn’t her primary doctor. But when her primary doctor went off duty an hour before she went into labor, Dr. Zarkin was next in line.

“I guess I have a baby-friendly body or something,” said Ellen. “Because he looked at me and goes, ‘Oh, this one’s like the midtown tunnel!’ Even in my daze, I remember my mother and husband being horrified.”

When it came time for the episiotomy discussion, Dr. Zarkin said he thought it would be a good idea: “I told him I didn’t want one, and he said, ‘But I can sew you up-you’ll be tighter than you were.’” As luck would have it, he also happened to be on call for her next baby. A few years later, he made tabloid-headline news for carving his initials into the stomach of a patient. Ellen found a new gynecologist.

A book editor named Holly was so disgusted by her gynecologist, she sued. On July 3 of the Fourth of July weekend, her doctor told her that she had an ectopic pregnancy and asked her to come in on Monday. She also told her not to move around much over the holiday weekend. Holly asked if this was because she could die if she moved around, and the doctor said it was possible.

“I told her she had to see me immediately,” said Holly. “But she said she was going to the beach and hung up.” Holly found another doctor to treat her that day, and then wrote a letter to the original partnership asking for her money back, as well as their word that this would never happen to another patient.

“They wouldn’t give me their word, or the $100, so I sued them in small-claims court,” said Holly. “She had to take half a day off work, her malpractice insurance probably tripled, and of course I won.”

Margot, a screenwriter, liked her doctor as a gynecologist, but hated her as an obstetrician. When she noticed low fetal movement in her 32nd week, she checked herself into the hospital and spent the day hooked up to a fetal-heart monitor. She saw her own obstetrician the next day, who said, “Whoa, this looks like pre-eclampsia to me.”

“I asked her what that meant,” said Margot, “and she said, ‘It means your baby isn’t getting enough oxygen and you both could die.’ I was so vulnerable, I didn’t know how to defend myself. And you can’t change doctors mid-treatment, so I knew I couldn’t make a big stink and make her dislike me.”

On the street, Margot tried to reach her husband, but she couldn’t find a cab and her cell phone was in a dead zone. When she finally reached her husband, he did some research and soon realized that she had a very good chance of not dying.

At the beginning of the pregnancy, Margot and her husband had felt lucky to have found their doctor. “She was dry and terse and not very shakable,” said Margot’s husband. “We liked how she was off the cuff and not making a big deal of things. But that’s what sort of backfired.”

Dr. Linda Mullen, the director of Women’s Mental Health at New York Presbyterian Hospital Columbia University Medical Center, said she hears lots of complaints about too-short exams from patients. She teaches a course to ob/gyn residents specifically on how to talk to patients, but acknowledged that this is simply the nature of the job.

“The training for ob/gyn teaches you how to get in and solve the problem and do things quickly,” said Dr. Mullen. “And once you get out, you have to see a lot of patients, because all of it is financed with managed care. Then because malpractice costs are what other specialists are paid for their salaries, there’s increased pressure to see a lot of patients. Getting the baby out and doing the surgery is a risky business, and at the same time it’s a field where you’re expected to talk to people like a primary-care physician.”

Lisa, a psychologist with a private practice, had been trying to get pregnant for seven months before leaving her gynecologist because she wasn’t getting the attention she wanted. She found her doctor cold and hard to communicate with, and she felt like she was always mad at her.

“One time she returned a call and I said, ‘Thanks for calling back, do you have a minute?’ She responded, ‘Thirty seconds.’ I know I’m one of those typical New York women who’s overanxious about getting pregnant, but my heart just sunk. When I explained that it’s just really hard every month when I get my period, she didn’t say anything. I finally said, ‘I guess you don’t understand.’ And she still didn’t say anything.

“I completely thought, ‘This is my fault,’” said Lisa. But when her shrink told her to find someone new, she decided to take his advice. “Pediatricians spend 50 percent of their job calming down parents,” said Lisa. “And a gyn spends at least a third of their time dealing with people like me. So, you know, I don’t know-deal with it.”

“They’re getting appropriate care, but because of the pressures, there’s less time to explain,” said Dr. McGill. “There’s less time to meet emotional needs. And there’s a lot of emotionality involved in female issues.”