How hard is it to be pro-life in Ob/Gyn residency?

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Ferrismonk

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I'm not trying to be controversial or stir up the pot here, but this is a topic I've been wondering about a lot lately and would appreciate any advice or first-hand experience anecdotes.

I'm a new 3rd year medical student (taking boards in a few weeks, eek!), father of 2, and a devout pro-life Catholic. I'm interesting in Ob/Gyn for a number of reasons, but am a bit scared by the dominant pro-choice mentality of the profession. ACOG has been particularly vociferous about it's pro-choice stance for instance. I know that once I'm done with residency I'll have the freedom to practice medicine in the manner I feel is most morally correct, but as a resident you are under the control of other physicians/offices/hospitals. Has anyone here had a problem with a superior dictating what you must do? And has anyone suffered because of their refusal?

I make a point of knowing the laws that protect my beliefs, but frankly they only do so much. The laws for protecting conscience rights don't have any teeth to them, and I'm acutely aware of how a bad word from the attendings or residents can sink your career goals.

I'm doing my clinicals, and plan on doing my Ob/Gyn residency, at a Catholic hospital. I've already informed the DME of my religious objections to certain procedures as is necessary by law to be protected. Beyond that there isn't much I can do right now.

For clarification, I won't prescribe contraceptives (for the purpose of contraception) or perform, recommend, or refer for abortions. I'm pretty sure the abortion thing won't be much of an issue, but I forsee the contraception thing being a stumbling block with many people.

Again, I'm not really trying to get into the whole pro-choice/pro-life argument here, but rather am looking for advice or anecdotes from people in this situation or who deal with this situation. Thanks in advance for your help!

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I'm in a similar boat as you although I will be an intern in a few weeks. The whole abortion thing almost made me want to switch specialties but after talking about it with various residents, attendings, and my program director you should be fine. I am not interested in performing elective abortions for religious/personal reasons.

(FWIW I went to medical school at a major academic institution with a very big OB/GYN department that had attendings who performed abortions and a mix of residents who did and did not feel comfortable performing them). None of the residents I talked to at my home program had any issues with not performing abortion.

If you do your residency at a Catholic hospital then you shouldn't run into any real problems. I'll say that on the interview trail, it was subtly assumed that all residents would be performing abortions during residency. I saw this mainly at programs on the east coast (specifically meaning that if you didn't perform abortions you will be the black sheep) versus the midwest or west coast where people were fine with residents not performing abortions.

The not prescribing contraception thing may be a bit more challenging to be honest. I'll have to defer to a resident or other member to better answer this.

No residency can legally require you to perform one, but certain programs cultures aren't very friendly to residents who go against this. All you have to do is ask at interviews and you will get a good idea of what the culture is like.
 
I know I'm not going into OB-GYN. But I have something to say regarding the questions based on my third year rotation.

Not referring people to get abortions may be an issue. You don't have to do anything you don't feel comfortable doing but you do but (according to attendings in my OB-GYN dept) you have to refer to someone who will. Can't abandon your patient. But at a Catholic hospital, may not even come up.

The not rxing OCPs - never heard about anyone refusing those.
 
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I know I'm not going into OB-GYN. But I have something to say regarding the questions based on my third year rotation.

Not referring people to get abortions may be an issue. You don't have to do anything you don't feel comfortable doing but you do but (according to attendings in my OB-GYN dept) you have to refer to someone who will. Can't abandon your patient. But at a Catholic hospital, may not even come up.

.

Patients are free to go online or pick up a phone and find a physician who performs abortions. I won't stand in their way to obtain one or give them false information about abortions.
 
I appreciate your feedback everyone, your experience does help.

Like I said before, I don't really want this thread to become a pro-choice/pro-life argument. But since this quote is relevant to the legality of the discussion, I thought I'd reply to it.
PATHMD2010 said:
Not referring people to get abortions may be an issue. You don't have to do anything you don't feel comfortable doing but you do but (according to attendings in my OB-GYN dept) you have to refer to someone who will. Can't abandon your patient. But at a Catholic hospital, may not even come up.
Patients are free to go online or pick up a phone and find a physician who performs abortions. I won't stand in their way to obtain one or give them false information about abortions.
I'm pretty sure this is how the law stands as of now. There isn't any law (yet anyway) that I'm aware of that mandates physicians to refer for procedures they feel are inappropriate. Even if there were such a law, I could honestly say I don't know of any physicians that perform the procedure, since I don't keep track of such things. Unless I'm wrong about the law, this isn't a legal issue but more of a pro-choice ethos issue in the Ob/Gyn field. Which is still relative to my original question. If every attending I work with thinks that there is a legal duty to refer patients for abortions, that will be a problem for me in residency.
 
I thought the thing about needing to refer what you would not do yourself was odd, too. It is precisly why I brought it up in response.

I also do not wish to get into pro life or pro choice but just commenting on the logistics of being a pro life ob gyn.

Added my 2 cents because I saw this exact scenario because of the very prolife area in which I live (I stopped on this thread when scrolling down to the path forum) and passed on only what the attendings at my hospital said. Have not looked into the law at all as this is not my area. I have no pony here.

Leaving thread.
 
If you haven't already done so you may also want to try to contact someone at the American Assoc of Pro-life Ob/Gyns about your concerns since they do take an interest in fighting against mandatory abortion training in residency. Their site is http://www.aaplog.org
 
I was at the ACOG conference in San Francisco this past weekend. I attended the information sessions for medical students, where the issue of abortion provision was discussed.

ALL attendings who were on the "information panel" stated that the residents can opt out of abortion training, or participate to the degree they feel comfortable. ie for lethal anomalies only, for specific cut-off dates, etc.

They also explained that on many occasions, the decision to undertake abortions is fluid. That is, that an individual's views change. ie at some stage in their career, someone might be comfortable in undertaking the procedure for all reasons, and other times in their career they will only do up to X weeks, and then at other times not undertake the procedure for any reason at any stage.

One attending, a family planning specialist, stated that up to 75% of practicing Ob/Gyns do not participate in abortion provision.
 
This is a very touchy topic which shows up quite frequently on these boards. I am surprised that it hasn't started any major arguments as of yet since everybody likes to be quite vocal about their preference/belief. Regardless, it is a very valid concern and I will try to offer my unbiased opinion without getting into the "right and wrong" of the issue..

As the OP mentioned, the main issue is not the abortion stance since this has been appropriately addressed by most programs. As was previously mentioned, there is always an "opt-out" option and, quite simply, just don't apply to programs that perform abortions if you have a problem with them.

The main problem that I think the OP is inquiring about is the issue with the unwillingness/inability to prescribe contraception (I also imagine that this would include sterilization procedures) and how this would affect him/her in training. I trained with a resident that was in this very same boat and personally saw how this affects not only the person in question, but also their patients and co-workers. Contraception and sterilization forms a large part of what an OB/Gyn does and, as a result, the refusal to participate in these practices (for whatever reason) puts a large burden on the people around them. In my experience with this resident, her refusal led to uncomfortable situations with her colleagues who had to "take up the slack", which, in turn, led to strained professional relationships. Not to mention, once word got out that these services were not provided by her, it was tough to find patients that were willing to see her (consider also that I trained at an institution that does not perform abortions). Although most of the problems were with the patients and other residents, I did not observe or witness any negative occurences with the Faculty in regards to this resident's beliefs/preferences and she eventually completed the program without incident. This was just what I observed and by no means do I believe that this will happen to you. However, it should be food for thought since you are choosing to become part of this profession.
My advice would be to ask questions and do your research. Find those programs that will accomodate your beliefs and, quite simply, limit your applications to those programs alone since you don't want to end up somewhere that is not favorable to your situation. Good luck!
 
I posed this question to a couple of my attendings (one that just completed her residency) and got a pretty consistent response. They said that most often the choice to not perform abortions is not an issue, especially if you plan to do your residency at a Catholic hospital. For instance, I live in a small town that is very conservative, abortions are not performed in my town or at any of the hospitals that are used as training facilities. (If our residents want abortion training, it is offered to them at another institution) They did say that it can be a legal issue in some states if you refuse to refer them to someone who can help them. It comes back to patient abandonment and interpretation of the law is generally not in the healthcare provider's favor (not to mention OB/GYN can be a very litigious field anyway)

However, everyone I talked to said that you may have difficulty with an OB/GYN residency if you are unwilling to prescribe OCPs or counsel on birth control methods. They said this is such a major portion of what OB/GYN does on an outpatient basis that it would be difficult to not participate. It is tested on the boards and OCPs are one of the most prescribed medications by an OB/GYN. They said it would be fine to run a Catholic pro-life/no contraception practice after you are finished with residency but that if you want to be part of the team and get sufficient training that you might want to consider OCPs and birth control as part of your training and kind of "deal with it." Plus, you may have difficulty getting continuity numbers if you won't do these things because patients want them and you have to have a certain logged number in order to graduate your program.
 
I really appreciate all the candid comments, they really are helpful. The nuts and bolts of this issue are hard to pin down.

@jvarga. You mentioned that "professional relationships" were strained with the other residents and staff with the resident you worked with that did not prescribe OCPs. Could you elaborate on this? Did it create an unhealthy working relationship? Were there hard feelings either way or was it just a minor frustration? Was everyone open about the conflict in the office?

I'm curious, regarding those residents who did not prescribe OCPs, did they teach a natural family planning (NFP) method? If so, this this ameliorate some of the problems encountered?

Thanks again for your comments everyone.
 
Only a medical student here, but I plan to go into OB/GYN also, so I read this forum.

The only problem with NFP ameliorating the problem of either A. increasing your logged numbers or B. supplying an answer to a patient who would ordinarily want OCPs is that NFP isn't going to fix either of these in my opinion (perspective of a patient).

While I respect your perspective, and it is a perspective shared by my best friend who saw a Catholic OB herself and practices NFP, so I really do understand the success rate and practicality of it all - I don't share this perspective. So if, for example, I was your patient and you presented this as an option in lieu of OCPs to me - I would not be interested. I don't have the time nor desire to make the time to do all the charting and temp taking my friend does. I also don't have time to learn the correct procedure of NFP, which turns out is important, as I have another set of friends unfortunate enough to rush into it without the adequate studying of the technique and accidentally reversed it. :eek: Yes, they have a beautiful boy conceived almost immediately as a result!

Anyway, my point is - the patients who want OCPs aren't likely to be converted to NFP. And the patients who want NFP, would already be asking for it from the get go. Does this make sense? I just don't know many people who are willing to make the switch that don't already want it for religious reasons or for an already-known intolerance to OCPs. I'm not sure that offering NFP would then increase your patient base or fix the problem of not prescribing OCPs.

I hope this perspective is helpful. I felt I had something to contribute, since this discussion has come up often in the past with my girl friends and I since actually two of them are staunch Catholics and NFP users, and the rest of us would never do it.
 
The strained professional relationships that I alluded to were limited to the residents. The Faculty did not have any issues with her (at least related to her refusal to provide contraception or sterilization) and worked with her in a very professional manner. If they had any problems with it, they did a very good job of keeping them out of the public eye. As for the residents, they had a very valid issue. They were not only expected to handle their "quota" of patients, but they were also required to take on this resident's patients that either could not or would not see her. As you can imagine, "not carrying your load" is never viewed favorably by your colleagues and this was perceived by the other residents as her doing just that. The other residents came to resent her and to question her choice of becoming an OB/Gyn. This made for uncomfortable interpersonal situations, but, overall, things were always cordial. I was not aware of any major conflicts, but harmonious is not a word that I would use to describe their relationship. Please understand that I was quite removed from this situation as she was several years ahead of me, but the strain and tension that arose out of this situation was very obvious to me.
Hopefully, this is helpful to you and I definitely hope that you don't have the same experience. However, due to the very nature of your predicament (an old mentor astutely compared this to a peace activist joining the military) you will encounter a large amount of misunderstanding and adversity.
Is it possible for you to become an OB/Gyn? Absolutely.
Can you complete residency without prescribing contraception? Yes (contrary to other reports, residents do not currently need to keep track of these numbers).
Can you become board cetified? Only if you know what is required and practice according to the accepted standard.
Can you be successful? Only if you have the drive and determination and if you are wise in choosing your practice location.
 
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Maybe I wasn't clear in my post. In response to JVarga, the attendings I spoke with did not say that you would have difficulty getting numbers for prescribing contraception...they said you may have difficulty getting enough continuity patients as many patients in a resident OB/GYN clinic are seeking contraception. At my institution, you have to log continuity patients. I hope that clears up what I was saying.
 
FerrisMonk - I know it's been awhile since this thread has been active, but I was wondering if there were any new developments in your specialty choice or thoughts about being a Catholic OB/GYN while in residency? I'm a MS3 as well, and in the same boat as Catholic who's interested in OB/GYN and not interested in performing sterilizations or blindly writing Rx's for OCPs. I know there are some family medicine programs out there that are more friendly, but wasn't sure if you had come across any OB programs that weren't hostile to this position. I think I would love being an OB/GYN (after already having done the majority of my 3rd year clerkships), but I don't know if I love it enough to deal with the ob/gyn contraceptive culture during residency - I would to enjoy my residency, not merely survive it!
 
wow...why even be a doctor, your and my beliefs aside, if your gonna be a doctor in a certain field, I believe that you should do what ever is best/wanted by your patient, if you cant do, you should refer her, its not your beliefs on your patients, by not reffering and not doing what they wanted.
 
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wow...why even be a doctor, your and my beliefs aside, if your gonna be a doctor in a certain field, I believe that you should do what ever is best/wanted by your patient, if you cant do, you should refer her, its not your beliefs on your patients, by not reffering and not doing what they wanted.

That is a bit harsh!

First, after hitting the interview trail this season - I only had 1 place that even offered elective Abs, let alone did them. Medicaid does not fund them, so out of pocket payers go to cheaper places.

Also, I'm pretty sure the law requires a doctor to refer a pt to someone who offers those services. So, even if you wont do ABs, you have to refer the pt to someone who does.

For the record, I don't plan on performing them.
 
Also, I'm pretty sure the law requires a doctor to refer a pt to someone who offers those services. So, even if you wont do ABs, you have to refer the pt to someone who does.

That is completely untrue. At my residency program I have never performed an elective Ab and have never been asked to. We simply don't do them here. Occasionally patients will come in asking for them but we are not obligated to refer to anyone. To tell you the truth, I have no idea who even does them in our city. Probably planned parenthood or something. At any rate, its under "A" in the phone book.
 
FerrisMonk - I know it's been awhile since this thread has been active, but I was wondering if there were any new developments in your specialty choice or thoughts about being a Catholic OB/GYN while in residency? I'm a MS3 as well, and in the same boat as Catholic who's interested in OB/GYN and not interested in performing sterilizations or blindly writing Rx's for OCPs. I know there are some family medicine programs out there that are more friendly, but wasn't sure if you had come across any OB programs that weren't hostile to this position. I think I would love being an OB/GYN (after already having done the majority of my 3rd year clerkships), but I don't know if I love it enough to deal with the ob/gyn contraceptive culture during residency - I would to enjoy my residency, not merely survive it!

I am a Catholic OB/GYN resident but I don't have a problem with contraception or sterilization. If you do, then OB/GYN will be a difficult residency for you because that is what you are going to be an expert in. I also happen to think Humanae Vitae was a misguided encyclical. I think that at some point in the future the Church's prohibition on contraception will change.
 
I did not get a chance to read all of the post, but I am in the process of interviewing now, and you concern comes up quite often. I agree with a resident who indicated that sterilization and contraception is part of the career, but the bigger concern for me was would I have to consent to providing an abortion versus being very well educated and knowing where to send my pt is the issue comes up. So in all the programs, you can opt out of providing abortions. However, even at programs established at catholic hospitals, contraception was indeed prescribed, and tubuligations were completed, but it had to be completed during the c-section, or peripartum verses s/p. I hope this helps a little.
 
Thanks for reviving this thread, I'm glad that someone else out there is thinking about this too. I'm still up in the air personally, but I've done quite a bit of research into this area and might actually have some helpful information to share.

Legally, you do not have to perform abortions, tubal ligations, or prescribe artificial birth control. This is a bit of a grey area because so many people think you have to, and if you refuse on religious grounds there are always ways to punish you without punishing you if you know what I mean. Getting your attending and fellow residents upset at you (since they would have to take over those cases) can hurt your residency and career in weird ways. That being said, for someone who feels that they answer to a higher power than their program director, it's not so hard a decision. To be compliant though, you must submit, in writing, that you object to certain procedures on a religious ground. Otherwise your objection would never stand in court.

I do know of a few Ob/Gyns who do not prescribe artificial contraception or do objectionable surgical procedures, but they usually have had some difficulty along the way. I've heard second hand of Ob/Gyn residents who refused to write contraception or perform abortions/tubals and they apparently passed just fine.

The easiest way to protect yourself, however, is to do your residency at a Catholic hospital. Each hospital is faithful to the teaching of the Church to a different degree though, so it's worth doing your homework once you've identified a potential residency program. For example, at my current (Catholic) hospital, they don't perform abortions, but will do tubals after 3 c-sections, and they prescribe birth control all the time. At a different nearby Catholic hospital, I'm told that they don't do abortions, but will do tubals on request as long as you are already in the abdomen for a different procedure (i.e. c-section).

Another good resource is the American Association of Pro-Life Obstetricians and Gynecologists (www.aaplog.org). They have some information on friendly programs and have a list of friendly docs. I know that the program director of the Osteopathic Ob/Gyn program at Mercy in Muskegon, MI is a member if that helps.

Remember though, you do need to know about contraception methods and such for your boards. Refusing to perform certain procedures doesn't excuse you from learning about them.

I'd love to go into the details of the Church's position on contraception/abortion/sterilization, but I fear that would simply lead to a flame war and a lot of accusations back and forth so I'd prefer not to go into that in this forum. I'd like to clarify however, that to those of us who hold the Church's position to be true, refusing to prescribe contraception or perform abortions/tubals/etc, is not harming, but helping the patient. We aren't refusing the patient a legitimate service, we are saying that in our best clinical judgement, those procedures are harmful to the patient(s), either physically, socially, and/or spiritually.

I hope this helps. If you have any further questions or I can be of other assistance, please either post/email/or PM me.
 
In china,the Catholic hospital is a Profit-making hospital or Private hospital.
Surely,Patients are free to go to them to abortion,the doctors make it.
 
In china,the Catholic hospital is a Profit-making hospital or Private hospital.
Surely,Patients are free to go to them to abortion,the doctors make it.

Knowing how the Catholic church works I highly doubt the hospital is offering elective abortions.
 
That touches a whole other issue, but the dynamics of the Church and China is convoluted at best. There are repeated controversies about the government trying to control the Church, even to the point of appointing Bishops without Vatican approval. But like I said, the Church in China is a whole other issue.

That being said, each Catholic hospital is under the jurisdiction of the local Bishop, and frankly, each Bishop is faithful to the Church to a different extent. And individual doctors that might work at a Catholic hospital aren't necessarily Catholic. That is why you'll see birth control prescribed at Catholic hospitals and different rules about sterilizations from hospital to hospital. Abortions are usually banned across the board, but I wouldn't be surprised if some get away with it.
 
Do you have a list of which residencies (DO, in particular) perform or don't perform abortions, give OCPs, etc.?

Coincidentally, I'm on the other side of the issue and am curious to know which programs offer education in these areas. I'm not here to start a war or cause trouble, and before you condemn me, I'd just like to say that I don't plan to go around aborting babies left and right. I simply would like the opportunity to learn the procedure, whether or not I ever choose to do it in my own practice.

Also, I could be mistaken, but I thought someone mentioned Good Samaritan in NY as a program that does not do abortions or provide contraception of any kind. If it wasn't that program, it was one of the other two DO residencies near NYC.

Thanks.

To each his own, and best of luck to you and everyone else in your applications/residencies/etc. :)
 
Would you be able to adapt your own education and expand your potential list of possible residency sites by requesting to limit your D&C/MVA experience to only those patients who are receiving the procedure as part of "spontaneous pregnancy loss" treatment plan? The procedure is the same, if it were a required learned skill, but merely be surgical care for treatment of your patient in the event of a miscarriage and, therefore, would not (in theory) conflict with your religious ideology.

GL with your future goals.
 
Well, let me take a step to the side here. As I have been in private practice now for several years I can shed some light here...


First, be aware that most tier1 residency programs will not take a student who is already talking about what they will and will not do, particularly when it comes to contraception. That's just life. Quote the law if you want, you just won't get in. Now, since we are talking about Catholic hospitals that will not likely be an issue as they are generally smaller programs and less desirable.

Second, it will strain your relationship with other residents and fellows because of how it will cause workloads to shift. When you refuse to help a patient and it must then get bounced to another resident, they will not be happy.

Third, consider what happens after residency. Who will hire an OB/GYN who refuses to do all sorts of things? Sure, the abortion thing is not an issue there, not at all. However the tubals? That's annoying. The contraception? That's unemployment. A huge number of patients request contraceptives and if you refuse to offer them they will find another physician who will.

This is your big problem. If you are in a private practice they won't hire you because this will cost the practice money. If you are in your own practice this will cost you even more money. If you are an employed position it will last for a bit longer, but most of their models are also revenue driven and you are now alienating a huge portion of your patient population.

So, my conclusion is this.

You can do whatever you want, no one will legally force you to do anything. You will however kneecap your career before it starts. It will severely impair your ability to join a private practice, it will completely eliminate your ability to run your own practice, and it will impact your earnings as an employed physician.

So either way, if this is your viewpoint then my suggestion would be that you need to consider another specialty. You are walking into a business model like an academic. Physicians don't operate in a vacuum, you simply cannot throw away such a huge number of customers and expect to be employed or make any money.
 
Well, let me take a step to the side here. As I have been in private practice now for several years I can shed some light here...


First, be aware that most tier1 residency programs will not take a student who is already talking about what they will and will not do, particularly when it comes to contraception. That's just life. Quote the law if you want, you just won't get in. Now, since we are talking about Catholic hospitals that will not likely be an issue as they are generally smaller programs and less desirable.

Second, it will strain your relationship with other residents and fellows because of how it will cause workloads to shift. When you refuse to help a patient and it must then get bounced to another resident, they will not be happy.

Third, consider what happens after residency. Who will hire an OB/GYN who refuses to do all sorts of things? Sure, the abortion thing is not an issue there, not at all. However the tubals? That's annoying. The contraception? That's unemployment. A huge number of patients request contraceptives and if you refuse to offer them they will find another physician who will.

This is your big problem. If you are in a private practice they won't hire you because this will cost the practice money. If you are in your own practice this will cost you even more money. If you are an employed position it will last for a bit longer, but most of their models are also revenue driven and you are now alienating a huge portion of your patient population.

So, my conclusion is this.

You can do whatever you want, no one will legally force you to do anything. You will however kneecap your career before it starts. It will severely impair your ability to join a private practice, it will completely eliminate your ability to run your own practice, and it will impact your earnings as an employed physician.

So either way, if this is your viewpoint then my suggestion would be that you need to consider another specialty. You are walking into a business model like an academic. Physicians don't operate in a vacuum, you simply cannot throw away such a huge number of customers and expect to be employed or make any money.

You make a number of good points, and I agree with most of what you said in the beginning. Yes, Ob/Gyn is becoming more and more competitive and if you go in saying "I won't do xyz" then yes, you'll run into more roadblocks. But there are residencies/residents/program directors out there who don't mind as much. It does require a tough skin though.

As far as working out in the real world, you're repeating what I've heard from many other sources as well. I think people tend to overemphasize how much contraception and tubals make up an Ob/Gyn practice. Will you lose out on some patients? Yes. Will you starve? No. I'd venture to say, however, that those who love OB/Gyn are more concerned with their personal and patient's welfare than money. Besides, there is an untapped market out there for NFP-only physicians. My wife's current Ob/Gyn, who is an NFP-only physician, it the one bringing in most patients to his practice (with 6 partners).

Will it be hard? Yes. Is it impossible? No. Can you make a living? Yes.

Do you have a list of which residencies (DO, in particular) perform or don't perform abortions, give OCPs, etc.? ... I simply would like the opportunity to learn the procedure, whether or not I ever choose to do it in my own practice.

I don't have a list of programs that don't do those procedures, but every one I've talked to makes time for out-rotations available in which people may go to learn those procedures. Even the most pro-life ones.
 
You make a number of good points, and I agree with most of what you said in the beginning. Yes, Ob/Gyn is becoming more and more competitive and if you go in saying "I won't do xyz" then yes, you'll run into more roadblocks. But there are residencies/residents/program directors out there who don't mind as much. It does require a tough skin though.

That's just training, it doesn't matter nearly as much as real world life. You just won't make many friends in residency and you likely won't get matched into a top program, unless your boards are stellar, even then it would be tough to get through an interview with a student telling the interviewer they won't do X, Y, and Z.

As far as working out in the real world, you're repeating what I've heard from many other sources as well. I think people tend to overemphasize how much contraception and tubals make up an Ob/Gyn practice.

Nono, you are missing the point. People won't care about the tubals that much, like I said. It is a terrible RVU procedure anyway, only incidental to an open CS. What will, absolutely, be a problem is your theories on contraception. This will cost you patients, period. It will cost you the patients that pay the bills (ie: OB). People will not go to an OB/GYN they feel is going to give them a moral lecture and restrict their options. This isn't opinion, this is fact. Almost every physician I know that has restrictions such as these has done one of two things. Work in an insulated/low comp/hospitalist environment for a catholic hospital. Or they have given their beliefs up in order to survive.


Will you lose out on some patients? Yes. Will you starve? No. I'd venture to say, however, that those who love OB/Gyn are more concerned with their personal and patient's welfare than money.

It's not the money, and I am sorry, but you have the viewpoint of a student with no real experience. Take it from someone who has quite a bit of PP experience. You will not starve, but you will be in the 1-10th percentile of MGMA, if that. So, 120k a year. Not only that you will struggle with finding patients, be frustrated, and deal with a lot of crap trying to run a business that way.

You simply will not be able to start a private practice this way, the numbers will not allow you to do it. Your ramp up will be terrible and you won't make overhead.


Besides, there is an untapped market out there for NFP-only physicians. My wife's current Ob/Gyn, who is an NFP-only physician, it the one bringing in most patients to his practice (with 6 partners).

Bringing in patients means nothing. Bringing in the right patients and procedures means everything. It is not Wal-Mart, where you simply want volume. You want the right volume. The people who are going to be NFP are, generally, going to be high risk OB. One thing I learned in my career is that High Risk OB is the fastest way to both lose money and sleep all at once. So sure, he may bring in a lot of patients, but who cares if they are medicaid or annuals?

The key is that he is going to end up missing out on the two biggest RVU generators in the industry, OB globals and ablations. Skip either of those and you are going to get murdered comp wise.

Will it be hard? Yes. Is it impossible? No. Can you make a living? Yes.

I agree, you can make a living, but not the way you want to. You can take a whole bunch of anecdotal evidence if you want, but I talk to 40-50 practices on a regular basis. I don't know who would hire you, I wouldn't even interview you honestly. The reason is simple, I don't think you can pull your weight in a private practice with these parameters. It sucks, but it is life, I am not going to hire an anchor. You will simply be restricted in where you work and what you make, that is basically your choice.

The problem is the "what you make" part is not a 10% pay cut, it is a 60-70% pay cut.

I don't have a list of programs that don't do those procedures, but every one I've talked to makes time for out-rotations available in which people may go to learn those procedures. Even the most pro-life ones.

Again, residency in your case is the least of your problems. You won't get into an A program with a pro-life restriction. If you get into a B or C program that isn't going to limit your job options, your business practices will do that on their own.
 
An OB/GYN who doesn't prescribe contraceptives. :laugh: That's funny.

No big deal about not performing abortions. Women who want abortions know where to go. No big deal about not prescribing contraceptives. Women who want contraceptives know where to go.

So I figure your patient base will be all the women attending your Catholic church and the new-age naturalists that want NFP.

You better get those ads ready!
 
I think the contraception thing would be tricky. Yes ob/gyns do a lot more than just hand out scripts for OCPs. If a patient is coming to you for her annual exam, prenatal visits whatever... and at the end of the exam asked for OCPs or after delivering requests Depo and you say that you can't provide that, she's going to go to another ob/gyn and get what she wants. And then for the next annual or pregnancy she's going to return to the other doctor. And where are they going to refer their friends and family? Plus women spend how many years visiting ob/gyns in their life?

Maybe a subspeciality would be better? urogyn maybe?
 
wait, what happens when you have to rotate through REI? Are you okay with fertility treatment?
 
To address wannabeOBGYN and others, I'll share my experience on the interview trail. At every program, someone would bring up "what's the family planning training like?" At at all but one program, I heard, "we do terminations to the latest date allowable by law. You can opt out of everything, or just certain circumstances. In every class, there's at least one resident who doesn't do elective terminations. The attendings are really good about calling her for missed ABs so she can still get training with D&Cs. And obviously, you need to know how to treat complications."

Now, I didn't apply to any Catholic programs, so obviously my ratio is skewed. But even the most liberal, pro-choice program expects that people will opt out and is fine with it.

As far as contraception, I imagine it would be tricky but survivable during residency. After residency, I think it would be fine as long as you weren't trying to build up a practice of 15-35 year old healthy women who want preventative care. If you went into Onc or Urogyn, it would be no problem. If you dealt mostly with menopausal patients, again not an issue. If you find a niche in a conservative area with people who are looking for NFP, then great. If you love the specialty, you'll find a way to make it work, but just know that it will be a struggle at times.
 
I think the contraception thing would be tricky. Yes ob/gyns do a lot more than just hand out scripts for OCPs. If a patient is coming to you for her annual exam, prenatal visits whatever... and at the end of the exam asked for OCPs or after delivering requests Depo and you say that you can't provide that, she's going to go to another ob/gyn and get what she wants. And then for the next annual or pregnancy she's going to return to the other doctor. And where are they going to refer their friends and family? Plus women spend how many years visiting ob/gyns in their life?

Maybe a subspeciality would be better? urogyn maybe?

Heh, good luck getting into a fellowship with this mindset. Fellowships are competitive and they *will* absolutely frown upon an applicant telling them what they will and will not do. Particularly since he would likely be coming from a sub-par program in the first place.

Think about it from the Fellowship Board side. Why would they want someone who comes from a C-level program, at best, who is going to place restrictions on the way he or she practices medicine when they have a whole host of applicants from A programs willing to practice without large restriction.
 
As far as contraception, I imagine it would be tricky but survivable during residency. After residency, I think it would be fine as long as you weren't trying to build up a practice of 15-35 year old healthy women who want preventative care. If you went into Onc or Urogyn, it would be no problem. If you dealt mostly with menopausal patients, again not an issue. If you find a niche in a conservative area with people who are looking for NFP, then great. If you love the specialty, you'll find a way to make it work, but just know that it will be a struggle at times.

A few problems with this theory...

First off, to go either Uro or Onc you have to be a stellar resident, great boards, good program etc. That is simply very unlikely coming out of a catholic affiliated program, sorry they just don't have the reputation as producing the highest quality residents. Many practices won't even interview from those institutions for that reason.

Then, assume you are dealing with older patients, alot of them are going to want ablations, hystos, and tubals. How's that going to fly? Right, another problem.

Lastly, we both agree you are not going to get any traction or patient following with the contraception theory, meaning you will have to ignore the 15-35 year old patient population. That means you are a failing business model right off the bat for a few reasons.

First, patients tend to stick with physicians who have delivered their children unless there is a very good reason. Since you won't be delivering many children at all you won't have that draw.

Second, the majority of work an Onc/Uro or simple GYN-only physician is going to be problem visit doc referrals. They won't want to refer to a doc who is going to get them a headache when the patient comes back telling them about the restrictions that doctor imposed on what he would and wouldn't do.

Lastly, how do you expect to hit the RVU numbers by ignoring the largest source of revenue in the practice? Throw away the globals from deliveries and ultrasound and let me know what those revenues look like.

In conclusion, in a perfect world you could find an employed position working for a hospital that agrees with your philosophy. You will have to realize you will be delivering under 10 babies a month, at best. You will have to realize you will be uncompetitive in attracting new patients. Your payor mix will be terrible (all medicare/aid). You will miss out on most of the revenue by focusing on poorly playing procedures. Eventually the hospital will realize they are losing money on you and you will feel the pain financially.

It is possible, but like I said, expect to be frustrated and making 100-125 a year.
 
I appreciate the comments above, but I think you're overreacting a bit. Your logic is that by not prescribing contraception, you will have less deliveries? Seems a bit backward to me. Usually patients who accept the no-artificial-contraception have MORE babies, not less. Also, just because an OB doesn't provide contraceptive medications doesn't mean that people are left without a viable child-preventing choice. Modern NFP methods work just as well as most OCPs, and without side effects. Albeit it takes some patient self-control.

Also, you seem to be saying that if someone doesn't do abortions or contraception, they won't do hystos, ablations, D&Cs, or OCPs for medical purposes. That just isn't true. The rule of double-effect applies in those cases.

And why do you say that most of your patients will be Medicare/Medicaid? In my experience, people having abortions are usually those on Medicaid, not the other way around. Plus, most abortions are paid with cash anyway, not covered by insurance.

I'm not trying to fight here, just balance the conversation. I think gynogrl has the situation pegged pretty head on. :thumbup:
 
I appreciate the comments above, but I think you're overreacting a bit. Your logic is that by not prescribing contraception, you will have less deliveries? Seems a bit backward to me. Usually patients who accept the no-artificial-contraception have MORE babies, not less. Also, just because an OB doesn't provide contraceptive medications doesn't mean that people are left without a viable child-preventing choice. Modern NFP methods work just as well as most OCPs, and without side effects. Albeit it takes some patient self-control.

Also, you seem to be saying that if someone doesn't do abortions or contraception, they won't do hystos, ablations, D&Cs, or OCPs for medical purposes. That just isn't true. The rule of double-effect applies in those cases.

And why do you say that most of your patients will be Medicare/Medicaid? In my experience, people having abortions are usually those on Medicaid, not the other way around. Plus, most abortions are paid with cash anyway, not covered by insurance.

I'm not trying to fight here, just balance the conversation. I think gynogrl has the situation pegged pretty head on. :thumbup:

Take it how you want, but my take on it is from the real private practice side and consistent with all my colleagues from a large range of other private practices with a variety of models.

You say that not prescribing contraception will help drive deliveries, I disagree, here is why. You have to get them as patients in the first place, which usually starts before they are pregnant. So you will lose them on the front end before they get pregnant. You will get some people who had no prior physician and found themselves pregnant, but what is that demographic? Not good. Most patients who did not have an OB/GYN prior to pregnancy float in one of two categories, either very young or medicaid population. The very young is not necessarily a problem, but the medicaid is a problem. They have a higher risk and a lower production number associated with them. So you will have a high risk, low pay population for OB. The ones you want to keep, the young ones with good payors, will drop you and go elsewhere when you tell them you will not script for the pill etc. Trust me, seen it quite a bit before.

As for alternative pregnancy control are you really suggesting that you are going to recommend NFP's? Do you think that will be well taken by the 18-30 patient population?

As for abortions or contraceptives impacting other procedures I made no such claim, particularly for abortions. Not doing abortions will generally be a positive impact on your business, not negative. However the tubal/hysto issue is real and does happen. A lot of women who are older and suffering from chronic uterine problems often opt to simply have a hysto. Another huge portion plan to have a tubal at time of section as well, another problem for you.

Again, I am not talking about abortions. I am saying that if you go PP with the hardcore pro-life stance you will not be marketable and be a physician of last resort. You will get the patients that have nowhere else to go, medicaid/are and high risk. That's just the facts. We see it all the time. The physicians who draw well only take the top tier insurance and will never, ever, consider medicaid. Those patients all get dumped to either the local FMGs or clinic.

So, take it however you want, the difference is experience in the real world. The physician practice is an incredibly competitive place, both against other physicians and within your own business. If you don't think people will attack your pro-life position and restrictions to capture the good patients, you are absolutely dead wrong.

This is absolutely viable btw, you will just be in the bottom 10% of MGMA comp.
 
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I want to start by saying that I think that everyone should be entitled to their own views. However, I believe that when we take the Hippocratic oath we promise to place our patients first. This doesn't mean that physicians should do something that they are uncomfortable with. What it does mean is that you should not join a field in which the scope of practice is such that they will be placed in a position where they are unwilling to provide care (I'm talking about contraception) or refer for care (abortion) frequently. I just can not get over how selfish this is. How many other specialties could you do where yours and your patient's interest not be constantly opposed. Unless you are planning to do some fellowship like gynecologic oncology or reproductive endocrinology, being an OBGYN who will not prescribe contraception or refer for abortion is unconscionable. You will end up blocking your patient's access to the care they desire. Go into some other specialty!
 
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I'll start by saying I'm not Catholic. But I thought the reason contraceptives were not allowed is because the church thinks you shouldn't be having sex without without the intention of making a baby. Isn't NFP just another form of contraception? How is the intent of NFP any different than condoms or OCPs?
 
I want to start by saying that I think that everyone should be entitled to their own views. However, I believe that when we take the Hippocratic oath we promise to place our patients first. This doesn't mean that physicians should do something that they are uncomfortable with. What it does mean is that you should not join a field in which the scope of practice is such that they will be placed in a position where they are unwilling to provide care (I'm talking about contraception) or refer for care (abortion) frequently. I just can not get over how selfish this is. How many other specialties could you do where yours and your patient's interest not be constantly opposed. Unless you are planning to do some fellowship like gynecologic oncology or reproductive endocrinology, being an OBGYN who will not prescribe contraception or refer for abortion is unconscionable. You will end up blocking your patient's access to the care they desire. Go into some other specialty!

I think you need to read the Hippocratic Oath again. It directly prohibits abortion, and for those of us who believe life begins at conception, contraceptives are abortifacient (one mechanism of action is by preventing implantation).

"I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

Also, it states that physicians should only prescribe regimens they feel are best for their patient. I don't believe hormonal contraceptives are good for women, therefore I am bound by the Oath to not prescribe them.

"I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone."

blife said:
I'll start by saying I'm not Catholic. But I thought the reason contraceptives were not allowed is because the church thinks you shouldn't be having sex without without the intention of making a baby. Isn't NFP just another form of contraception? How is the intent of NFP any different than condoms or OCPs?

Because this question was asked, I'll give a short explanation. If you'd like to know more, feel free to PM me.

The Catholic church opposes contraception because it believes that the unitive and procreative aspects of sex shouldn't be separated. God intended them to be tied together for good reason. The Church actually supports people choosing when to have children, just not with artificial contraception. The abortifacient aspect of OCPs is another reason the Church doesn't condone them.

NFP is different, however, because it uses the woman's natural cycle to control fertility. This is ethically okay because God designed woman's cycle to have both fertile and infertile periods, therefore we aren't opposing God's design, we're working with it.

Like I said, if you (or anyone else) wants to know more about this stuff, please feel free to PM me. It's probably better that way that starting a potential flame war in a forum.
 
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I think you need to read the Hippocratic Oath again. It directly prohibits abortion, and for those of use who believe live begins at conception, contraceptives are abortifacient (one mechanism of action is by preventing implantation).

"I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

Also, it states that physicians should only prescribe regimens they feel are best for their patient. I don't believe hormonal contraceptives are good for women, therefore I am bound by the Oath to not prescribe them.

"I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone."



Because this question was asked, I'll give a short explanation. If you'd like to know more, feel free to PM me.

The Catholic church opposes contraception because it believe that the unitive and procreative aspects of sex shouldn't be separated. God intended them to be tied together for good reason. The Church actually supports people choosing when to have children, just not with artificial contraception. The abortifacient aspect of OCPs is another reason the Church doesn't condone them.

NFP is different, however, because it uses the woman's natural cycle to control fertility. This is ethically okay because God designed woman's cycle to have both fertile and infertile periods, therefore we aren't opposing God's design, we're working with it.

Like I said, if you (or anyone else) wants to know more about this stuff, please feel free to PM me. It's probably better that way that starting a potential flame war in a forum.


Love it!
 
Hmm, the original Hippocratic Oath also prohibits "cutting for stones," so I guess all of those urologists and GI docs are also in violation! There's a reason we update 2500 year-old documents...

Also, maternal mortality in this country is much higher than mortality related to OCPs. When you say that "I don't believe hormonal contraceptives are good for women," you're stating a belief, not a fact. When helping women decide what healthcare options are best for them, facts should take precedence over beliefs, no matter how much you wish everyone would follow Catholic doctrine.
 
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Hmm, the original Hippocratic Oath also prohibits "cutting for stones," so I guess all of those urologists and GI docs are also in violation! There's a reason we update 2500 year-old documents...

Also, maternal mortality in this country is much higher than mortality related to OCPs. When you say that "I don't believe hormonal contraceptives are good for women," you're stating a belief, not a fact. When helping women decide what healthcare options are best for them, facts should take precedence over beliefs, no matter how much you wish everyone would follow Catholic doctrine.

1. I'm a hippy liberal atheist pro-choice loud mouth. I agree with you but FerrisMonk was explaining his postion not preaching....so back on topic...

2. There is actual data to be argued here about the risks/benefits and such argument should probably be in a different thread.

3. I think there is room for Pro-Life Ob/Gyns I just urge appropriate referrals to physicians if they are unable to provide wanted and legal services to their patient pool. Heck, there's probably a MARKET for Pro-Life OBs.

4. Everything else should be argued from the science not politics or religion.

5. I hope, FerrisMonk, you find a program that fits your needs!

6. From a licensing perspective, I wonder if there are ACOG hours or cases needed in Family Planning that will be harder to get given your stance? That would be something to ask a PD.

7. Find some Pro-Life Ob/Gyns who can mentor you and find out where they trained.
 
Modern NFP methods work just as well as most OCPs, and without side effects. Albeit it takes some patient self-control.

Als

Ferrismonk, I'm wondering what data you are basing this on. I was under the impression with perfect use NFP ranged from 2-10% failure in one year and OCPs were <1%

For "actual use" (Hey, who's perfect?) OCPs are around 8ish percent and NFP 25%. (1/10 vs. 1/4)

There's probably a case for saying "almost as well" for perfect use, but may not reflect reality.
 
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I am very religious. I am very pro-life. I also understand that it is my duty as a physician practicing in a specialty that can be as controversial as just about any social, religious, economic, etc topic possible, to be competent enough and respectful enough to make patients aware of their options, etc......even if I am not willing to perform said procedures. It is not our place to try and convince pts that the decisions they are making are "bad" or "wrong" just because we disagree with them. Alot of docs will disagree (to themselves) with alot of decisions patients make on their own behalf; but it doesn't give doctors the right to try and press upon others their own opinions. If opinions were a currency, doctors would be trillionaires! We need to have enough tact (ie: respect for others, and just because we have an opinion, doesnt mean its an appropriate time to share it outloud), to council and to educate our patients about ALL of the risks, benefits, etc that are involved based on standardized facts and figures our journals, and current literature produce on the topics.

On the topic of the OP; I would also NOT perform a procedure knowing that it would contradict my own personal morals/values and my religious morals/values. But, there ought to be a tactful way to go about it. Honestly, I have a hard time believing some program would force a resident to do something he/she had a legitimate and justifiable reason, not to do it. But, this is just an opinion. :)

And as far as arguments being based solely on science and NOT politics/religion......well, if a topic like this becomes a matter of politics/legality in the future, we all are gonna have to change gears on the approach we all take I guess.
 
Because this question was asked, I'll give a short explanation. If you'd like to know more, feel free to PM me.

The Catholic church opposes contraception because it believes that the unitive and procreative aspects of sex shouldn't be separated. God intended them to be tied together for good reason. The Church actually supports people choosing when to have children, just not with artificial contraception. The abortifacient aspect of OCPs is another reason the Church doesn't condone them.

NFP is different, however, because it uses the woman's natural cycle to control fertility. This is ethically okay because God designed woman's cycle to have both fertile and infertile periods, therefore we aren't opposing God's design, we're working with it.

Like I said, if you (or anyone else) wants to know more about this stuff, please feel free to PM me. It's probably better that way that starting a potential flame war in a forum.

Working with God's design is a meaningless point. Taking OCPs is working with God's design. I am a Catholic OB/GYN and I have read extensively on this and I disagree with the logic used by the Church in this setting. Of course, the Church has millenia of well thought out positions, but there are many (even high up in the Church) who disagree with the Church on this. Of course this has been debated extensively all over the internet.
 
I am very religious. I am very pro-life. I also understand that it is my duty as a physician practicing in a specialty that can be as controversial as just about any social, religious, economic, etc topic possible, to be competent enough and respectful enough to make patients aware of their options, etc......even if I am not willing to perform said procedures. It is not our place to try and convince pts that the decisions they are making are "bad" or "wrong" just because we disagree with them. Alot of docs will disagree (to themselves) with alot of decisions patients make on their own behalf; but it doesn't give doctors the right to try and press upon others their own opinions. If opinions were a currency, doctors would be trillionaires! We need to have enough tact (ie: respect for others, and just because we have an opinion, doesnt mean its an appropriate time to share it outloud), to council and to educate our patients about ALL of the risks, benefits, etc that are involved based on standardized facts and figures our journals, and current literature produce on the topics.

I completely disagree with this. You do not give every patient, every possible option in every setting. What you do is recommend several possible efficacious options versus doing nothing and help the patient decide, based on our knowledge of possible outcomes and side effects. And in some settings you pretty much tell the patient what to do, for example fetal bradycardia.

If you think what a patient wants to do is immoral (ie elective abortion), you don't have to give them all the possible options. All you have to say is I don't perform that procedure but if you decide to keep the pregnancy I would be happy to take care of you. If I told a patient exactly how to arrange for her abortion I would feel complicit.

For all the arguing, this is something that is rarely an issue. In 3 years I have only had 1 patient ask me for this sort of information, and that patient was floridly psychotic. In our community the resident program and really none of the private groups offer abortions. There is a couple of places that do abortions exclusively and that's where the patients go.
 
I completely disagree with this. You do not give every patient, every possible option in every setting. What you do is recommend several possible efficacious options versus doing nothing and help the patient decide, based on our knowledge of possible outcomes and side effects. And in some settings you pretty much tell the patient what to do, for example fetal bradycardia.

If you think what a patient wants to do is immoral (ie elective abortion), you don't have to give them all the possible options. All you have to say is I don't perform that procedure but if you decide to keep the pregnancy I would be happy to take care of you. If I told a patient exactly how to arrange for her abortion I would feel complicit.

For all the arguing, this is something that is rarely an issue. In 3 years I have only had 1 patient ask me for this sort of information, and that patient was floridly psychotic. In our community the resident program and really none of the private groups offer abortions. There is a couple of places that do abortions exclusively and that's where the patients go.

Yes, but your not really helping your patient if you dont atleast refer them to a place where they can learn more about elective abortions. I think it is fine to say, I dont do that, perhaps you should try hospital x. You wouldn't be telling them anything they couldn't find out on their own, but at the same time your still helping them.

On your other point, only psychotic patients have asked you about elective abortions.....
 
Yes, but your not really helping your patient if you dont atleast refer them to a place where they can learn more about elective abortions. I think it is fine to say, I dont do that, perhaps you should try hospital x. You wouldn't be telling them anything they couldn't find out on their own, but at the same time your still helping them.

On your other point, only psychotic patients have asked you about elective abortions.....

If a patient comes to me asking for an elective abortion I don't tell them not to do it, but I also don't help them do it. I don't think it is my role to lecture them about that decision.

Yes, the only patient who has requested an abortion was a floridly psychotic schizophrenic patient admitted to the hospital. She also had hyperemesis. She was completely incapable of taking care of a child. That certainly tested my belief system. (she ultimately did get an abortion by the way, and it wasn't me who did it). They just don't come into clinic asking for them.
 
Yes, but are you helpig your patient by not giving her any information? I think the role of a physician is to do whats in the patients best interests (including their interests/preferances) without forcing my beliefs/ideas on them. I may be against abortion, but if a patient asks about about it and I tell them nothing...I would feel I have lied or mislead them...referring them to another place or doctor isnt helping them to do it, its to get the facts and allow them to make an informed decsion. I understand that may be hard to do, but its a physicains job to transcend their beliefs and look after their patients wishes.


On your second comment: I understand
 
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