E. Blake Fagan, MD, MAHEC Family Medicine Residency Program, Asheville, NC

We have a tradition of teaching our residents to discuss five preventive care issues with every woman of reproductive age that they encounter in the outpatient setting. In our precepting room, the faculty ask the resident presenting the patient, “Did you talk to her about The Five Things?”

Why five things? I think it is hard to keep more than five things in your head. If you ask the resident to discuss 15 things every time they see a patient for any complaint, then they will not discuss any of them. I am asked why not tobacco abuse, domestic violence, obesity? Of course there are dozens of important things to talk to patients about. I tell the residents to consistently discuss and document The Five Things, demonstrating that you have them down pat, then you can add more. I talk to them about it from the beginning of their residency, all the way until graduation. You would be surprised how they forget one or two of them.

So, here they are: To every woman of reproductive age (arbitrarily 14 to 44), you should discuss or offer:

1) Multivitamin with folic acid
2) Birth control
3) Recommend condoms every time
4) Plan B
5) Pap smear up to date

1) Taking a daily multivitamin with folic acid has been shown to reduce the chance of having a baby with a neural tube defect by 70%. A women needs to be taking it BEFORE she becomes pregnant (probably for 3 months) to have the full effect. Fifty percent of the pregnancies in the United States are unplanned. I don’t know about your residency-based family health center, but anecdotally our unplanned pregnancy rate is around 75%. So, reproductive-age women should be on a multivitamin with folic acid every day. They should get into the habit of taking it every day, just like brushing your teeth!

2) I am floored by the number of times I see a reproductive-aged woman for a cold, UTI, knee pain, and I say, “OK, we are done with that. I do a lot of women’s health and deliver babies. So, just checking but do you need any help with your birth control?” They either answer, “Yeah. I was meaning to get a refill on my birth control pills” or they say, “No, I am fine.” In which case I inquire, “So what are you using?”—“Nothing.”—“Are you sexually active?”—“Yes.”—“So, you are trying to get pregnant?” If she is trying to get pregnant, it is good we started multivitamin with folate (see #1). If she is not trying to get pregnant, a discussion ensues. I also ask about the birth control status of female caregivers at every well-child check. You would be amazed at how many have stopped using their birth control.

3) I recommend you use condoms every time you have sex. They help reduce the risk of some sexually transmitted infections. Sexually transmitted infections can make you sick and damage your reproductive organs. Also, using condoms every time is a great back up in case your birth control fails or you forget to take it (See #2).

4) If you forget to take your pill (or put your Nuvaring back in, or come back for your Depo-shot) and you forget to use a condom or the condom breaks, do you know there is a pill you can take that reduces the chance that you get pregnant by 89%? You can take it up to 5 days after unprotected intercourse. It is called Plan B.

5) When was your last pap smear? Was it normal? When did your doctor tell you to come back for your next pap?

I tell residents, if you are behind, then don’t discuss these things. However, if you have time, discussing The Five Things could really impact the patient in front of you and her family unit. This simple framework has helped our residents and our patients. I hope it helps your residents and students also.