It's more than ob-gyn. When that simplebut radicalmessage finally began to permeate the medical mainstream, women's health began to emerge from the feminist margins as a discipline to be taken seriously by all health care practitioners, regardless of gender. In my own case, the message began to crystallize soon after the 1970 publication of the first edition of Our Bodies, Ourselves (originally titled Women and Their Bodies), the seminal (and much reissued) manifesto and handbook on women's health by the Boston Women's Health Collective.¹ Until that time, most of the medical establishment regarded women's health as limited to women's reproductive functions, and, as such, the subject held limited clinical interest to me as a young physician.

Not that I hadn't encountered plenty of anomalies in the standard view that women's health was synonymous with men's health, plus reproduction. As a psychiatrist, I had struggled with mounting evidence that certain mental health disorders, such as depression and anxiety, had a higher incidence in women than in men. I was gathering a growing body of anecdotal experience on conditions like postpartum depression and perimenopausal depression, but clinical literature on the subject did not exist. Consequently, discussion of the relation between women's reproductive physiology and rates of mental health disorders remained outside the scientific mainstream.

Thanks to an entire generation of tireless, determined pioneers in women's healthsome of them within our own Permanente ranksyou no longer have to be a feminist to understand that it's more than ob-gyn. The domain of women's health today is widely understood to include the broad-ranging interface between women's unique physiology and virtually all other areas of healthboth physical and mentaland is vitally relevant to the great majority of health care providers.

In fact, as Dr Rhoda Nussbaum's revealing research has shown (see following article), we could even look at the subject of women's health as including women's dominant social role in providing health care. Dr Nussbaum's data show that in more than 90% of households, women play the primary (or at least equal) role in selecting a health plan for the family; and in most families, women coordinate the health care of all family members, including husbands.

This means, among other things, that health care providers have multiple reasons to focus on women's health: first, because quality health care means recognizing that women are different from men in ways other than reproductive functions; second, because women exert enormous influence over the selection of health plans and providers; and third, because women exercise that power at least in part on the basis of how well a health care organization meets their own needs as women.

We know that most of American health care still has a way to go to align medical practice with today's more enlightened principles of women's health. One recent study, for instance, documented the persistence of gender bias in physicians' diagnosis of coronary artery disease. Women initially seen for chest pain are significantly less likely to be referred for cardiac catheterization than men; and black women are less likely to be referred than white women.² Similarly, female physicians order more Pap smear and mammography screenings than male physicians do.³ The fact that these findings are not surprising only reinforces the relevance of such studies; we expect to find more anomalies.

At Kaiser Permanente (KP), we know we can achieve better health outcomes for women than most of our competitorsthanks to both our integrated delivery system and our growing technical ability to realize the promises of evidence-based medicine. But improving member satisfaction will depend on much more than women's health outcomes; it will also mean providing products and services that are responsive to women's needs across the entire spectrum of life care, from pediatrics to elder care.

Part of that challenge is to improve the gender balance among our Permanente workforce and leadership.⁴ The Permanente Medical Groups generally do rather well in attracting women physicians, though we have been less successful in promoting them to leadership positions. Although a November 1999 survey⁵ showed that 35% of all KP staff physicians were women, women constituted only 20.4% of "management" physicians (Chiefs of Service, Physicians in Charge) and 11.4% of "executive" physicians (Assistant and Associate Medical Directors). To date, only one of the nine Permanente Medical Groups has had a woman Executive Medical Director (Louise Liang, MD, of Group Health Permanente).

Given the unique advantages of our integrated structure and our ethics-driven practice principles, KP has a special responsibility to provide leadership in women's health. It's in our members' interest; and it is in our own interest.

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