Why don’t more doctors teach their patients about FABMs? What are the biggest barriers for women learning to chart? A doctor answers these questions and more.
by Alison Contreras, PhD Time and time again, the same questions come up after we give our FACTS Intro to Fertility and Family Planning presentation:
“Great, now that I know this, how can I actually talk with my patients about information about charting their fertility? Do they even want to hear it? Where do I go from here?”
Sometimes the best place to get answers is from the people who have been there and asked the same questions themselves. At the AAFCP Conference in South Bend, Indiana this past July I had the opportunity to interview Dr. Althoff, a family physician who regularly educates her patients about the benefits of charting their signs of fertility using evidence based fertility awareness methods (FABMs). We talked about her experiences in the trenches, hopefully to illuminate the path for other physicians interested in incorporating this information in their own practices.
In this interview, Dr. Althoff shares how she came to incorporate FABMs into her treatment philosophy, how she set up her practice, what her experience with patients has been, what she thinks is keeping other physicians from learning more about FABMs, and what advice she might have for medical students or other physicians seeking to help their patients chart. The following is a transcript of our exchange.
Good morning Dr. Althoff!
Before we get started, would you mind starting off by telling us a little bit about yourself and how you came to learn about fertility awareness?
Sure! My name is Dr. Jennifer Althoff. I graduated from Notre Dame and then went to medical school at Medical College of Wisconsin, Milwakee. I then did residency in Family Medicine in Greenwood, South Carolina. Through my family culture I had heard about fertility awareness and charting growing up, but it wasn’t until I got to college that I learned more from a group of other students and I got really excited about it. I learned that it would be something that would be good for women and help to make marriages stronger. I was premed in college, but it wasn’t until after my first year of medical school that I knew I wanted to teach about NFP in my practice. I had this great idea, and I think I just googled together, “medical school” and “NFP”, and what came up was the Pope Paul the VI Institute in Omaha, which is where the Creighton method was developed.
Wow, so, you didn’t really have any mentors in medical school?
I had no mentors. In my medical school, probably the only exposure I had was maybe they showed us a basal body temperature shift chart. Even when I worked at a Catholic medical hospital, there was no formal teaching on it. There were two OB-Gyns who worked at that hospital who did not prescribe birth control and that helped me see how it was possible to have a practice without prescribing.
Ok, back to your life-changing internship during medical school.
So there is a time in medical school where you have a few months off, between the first and second year. Typically medical students will try to gain experience and do something that will be beneficial for your future career. At that point I emailed the Institute and Dr. Hilgers and asked if there was any capacity I could work there between my first and second year. I came into a student research internship where I worked for two months. He let me come on over the summer and I helped with the NaProTechnology textbook that was being published soon, in 2004. There were 3 of us interns that summer and Dr. Hilgers would direct us in what research to do and we would meet weekly, where he would encourage us and answer any questions that we had about being a pro-life physician. From there I finished up medical school and attended residency. It was during residency when I became officially trained to become a natural family planning medical consultant and it was the big thing that gave me the knowledge I needed for my practice. Typically you do the training over one year but it was hard to find time off to do the training so I finished it over two years. In residency, it was a bit hard to put what I learned into practice, but I graduated residency in 2008. I was then able to start putting it in practice, which was helpful to have that training because in this field you do need support to get started because there are not that many physicians you work beside who understand it. There is a great community through the AAFCP and the IIRRM is really helpful as well, especially initially.
Are there any pointers you’d give to someone just starting their practice and wanting to incorporate FABMs?
One of the key things is to get into a situation where you have access to a teacher of a method that you can refer to. It doesn’t always work with billing or time to teach patients yourself, and for me it wasn’t very fruitful the first year without an FABM teacher. My second year I moved to Des Moines where I had access to an educator and that made all the difference. The flow between the patient and practitioner is critical to serving the patient.
One of the key things is to get into a situation where you have access to a teacher of a method that you can refer to. It doesn’t always work with billing or time to teach patients yourself, and for me it wasn’t very fruitful the first year without an FABM teacher.
So for example, patients would come to me, and I would identify that they had a problem, and the way I approach their problems is through this method. It would be very helpful if the patients could give me more information about their cycle. Charting reveals biomarkers and as physicians we can look at a patient’s chart and it gives me a great wealth of information. So that’s one way, I’ll see patients in my office and they will come with gynecological problems such as infertility, PMS, irregular bleeding and I’ll refer to a teacher who will teach them how to chart.
Are most women initially receptive to learning to chart?
I would say most patients don’t understand the value of it until they get into the classes. Some are hesitant to go and it’s really just jumping over the first hurdle to get to the classes. But, once they pass that first hurdle, the scales fall from their eyes and they ask “why have I not been taught this before?” They wonder why they’ve never heard about this in school or anywhere else.
What do you think is their biggest barrier to wanting to chart?
Time commitment. They are used to quicker results. There has been criticism that charting is difficult, but I haven’t seen that in practice. If they hear from me it’s worth it and if they are able to go to the first class, they see how worth it is. Our greatest “cheerleaders” are those who have been helped by it, because they understand the benefits and can share that with others.
There has been criticism that charting is difficult, but I haven’t seen that in practice. If they hear from me it’s worth it and if they are able to go to the first class, they see how worth it is.
So, you mentioned working in conjunction with an educator. But what would you recommend to physicians who want to learn more to incorporate this into their practices?
My office was connected to the Creighton method through the Medical Consultant training. Creighton has a very big network and it also has a medical aspect and formal training for physicians. Marquette now has formal training also for physicians, so this is the way things are set up now. A physician who would like to get certified should make herself available to the teachers. You know, physicians don’t have a lot of time, so we need to use those teachers and have them help you educate patients on the method directly, so you can spend time diagnosing. Educators can do a lot of that work for you. You don’t need to go it alone.
How does it work at your practice?
The center I work at is a center that does primary care for adult women. So it is a really good situation. It is a Catholic hospital, so I would say it was easier to get our services in the family medicine department since the values align. I would identify a patient who had a problem and it was incorporated into how I practice. My philosophy was to look at their cycles, look at the underlying problem and fix it in cooperation with their cycle rather than using a suppressive approach. I would get referrals from patients who wanted treatment with this type of philosophy.
When I would see clients who were asking for contraception, I’d do a little survey first. I’d ask them “When do you think you can get pregnant during your cycle? Do you think it’s during your period, right before your period, or sometime in the middle?” And most people would get it wrong.
When I would see clients who were asking for contraception, I’d do a little survey first. I’d ask them “When do you think you can get pregnant during your cycle? Do you think it’s during your period, right before your period, or sometime in the middle?” And most people would get it wrong. I would then bring out my chart and use it as an opportunity to teach women more about their cycle. Even in a short office visit you can use it as an opportunity to introduce this information to patients just so they might have exposure to it at some point. It was difficult to work with our Ob-Gyn department. They respect what I do but don’t necessarily advocate for it themselves. One of the main problems is that they don’t understand it, It’s a lack of education. The main thing that made it difficult was that I had those patients on medications that they hadn’t been trained in so they invited me to come give a presentation and to open up the conversation. I think that was a fruitful discussion. I do think there is no education about this, so they don’t understand how much information is there.
What is one thing you’d tell a medical student who is interested in learning more about these methods?
If there is anything that FABMs has taught me, its that I really understand reproductive physiology. I just have a very good understanding of it. I’m not a specialist, but in clinical practice you need to have a very good understanding of the systems that you work with and I really understand the endocrine system and if any medical student wants to be good at what they do, hands down by learning FABMs you will understand reproductive physiology inside and out. And that’s what I’ve found the patients do too. They are partners in their healthcare and its helpful to have a patient who understands what’s going on. The patients appreciate it because they are more involved in their care and I appreciate it because we are on a similar level of understanding what their treatment is.
Have you ever had patients start to notice changes in their charts and bring it into you to aid in their healthcare?
I had this one patient who was charting for gynecological health, and not for birth control. She had cycles that looked pretty normal. She was charting with an ovulation based method so it was mucus based, and she would see mucus within her fertility cycle and all of a sudden she had a completely dry chart with no mucus observations, so she knew this was a problem. If she was just a regular patient not charting, she wouldn’t have even known that that had happened. So she came in, brought her chart in, I confirmed what she was seeing and we looked into it. One thing that’s associated with low mucus is a low estrogen state. One cause for that is a high prolactin level, amount other causes, and long story short, we did check her prolactin level and it was elevated. Not to the point of serious pathological problems like a brain tumor (pituitary adenoma), but we were able to put her on a medication that lowered her prolactin and her mucus cycles returned. In that interim she got married, wanted a baby, and now is pregnant and due next month. So, that’s something that proactively, she could have gone for years with difficulty conceiving through the regular reproductive endocrinology workup. Whereas, before she had problems conceiving we were able to fix the problem and at the time she wanted to achieve pregnancy she was able to, so, without any real heartache for her.
Wow. So charting be used for preventive medicine?
Exactly. And typically, when you have slightly elevated levels of prolactin she might have a micro adenoma, but not one that needs to be removed. It is something that we check yearly to make sure the prolactin isn’t getting worse and that we’ll keep an eye on for the rest of her life. I had another pretty interesting patient story. This woman came to me because she understood I was a “hormone doctor.” She had been through years and years of difficulty with what we call premenstrual disphoric disorder (PMDD). It is a disorder that involves very severe PMS type of syndrome. She had suicidal thoughts within a week prior to her period starting. She had severe anxiety, she would have to take off work, and she had symptoms where she couldn’t function, from after ovulation to her period. She wasn’t charting at the time but saw that it was cyclical and had been seeing her primary care doctor, she had seen a psychiatrist and had been trying many, many different psychiatric medications. When she came to me she was on at least one anti-psychotic and an antidepressant.
So, I talked to her and told her this is a different approach than what has been tried on you before and she understood it would take an investment of her time but she was at her wits end because because everything else that she’s tried really had not helped or its had these side effects from the treatment. So he thought, I’m going to try it. She did get started and I referred her to the practitioner to learn how to start charting. And I did notice from her chart that late in her post-ovulatory phase when she was having the symptoms she had evidence of low hormone levels and I was able to work that up with lab levels. I put her on hormonal support in her post-ovulatory phase and she has done wonderfully. She’s probably been my patient for 3 years now and I see her annually to renew her medications and she’s doing wonderfully. All of her symptoms went away and she was able to get off of all her psychiatric medications. She is just using the hormone replacement in conjunction with her cycle. A lot of my community doesn’t think that this works for PMDD, but the studies that have shown that it doesn’t work do not introduce the medications in a targeted fashion to the post-ovulatory time. There have been hypotheses that PMDD can be hormonally related, but the studies introduce the hormones on a certain day each month rather than targeted to when a woman ovulates each month, which might not be the same day.
What do you see as the biggest barriers to further use of FABMs by physicians?
Physicians think patients don’t want to do it. Or they think its too complicated, and their patients wouldn’t be able to do it. I really haven’t had a problem that my patients weren’t able to do it because they weren’t educated enough. Even simple minded people are able to get it. You might have to use one method or another to find one that they can adhere to. Even as a physician who works nights, there are certain careers you’re working through the night you won’t be able to take basal body temperature because you’re not waking up at the same time every day. So the ovulation method or a hormonal method might be easier for them. I think the biggest barrier is that physicians think its too difficult and I’ve not found that to pan out.
Physicians think patients don’t want to do it. Or they think its too complicated, and their patients wouldn’t be able to do it. I really haven’t had a problem that my patients weren’t able to do it because they weren’t educated enough.
Everyone who wants to be success in it, as long as you give them the time, they will be successful at it.
Any advice for students in med school who are looking for supportive residency programs?
I would very much advise if you’re going into family medicine, to talk about it in your interview. I don’t think it’s a detriment and you will find a program to match at. If you’re limited to a certain area of the country that might be a little more difficult. I really only had a bad experience in one interview but really lay it out in the beginning and frame it in terms of what you can offer by educating patients about forms of fertility awareness. Before you go into the interview, have this down pat so that you are well versed in what you can offer because we really do have a lot to offer women. Be proactive and involved in scheduling your rotations. I think it was probably harder 10 years ago but now there have been many people who have paved the way before you.
Thanks again to Dr. Althoff for taking the time to answer our pressing questions! If you’re interested in pursuing additional training programs yourself, find our list of additional FABM educational opportunities here. As Dr. Althoff mentioned, trainings for different methods are offered both in person and online, so you’re sure to find something that fits your schedule! You might also find that having patient handouts already printed off in your office might be a way to be proactive about having the conversation about FABMs with your patients. Please send any additional questions to our email at in**@FA*****************.org.