Friday, December 14, 2012

Reflections on trends FM Obstetrics

As an aspiring Family Medicine doc who also has her eye on Ob/Gyn, I wanted to take a look at the intersection of these two fields in order to understand the practical side of aspiring to “provide medical care throughout the life cycle.” I am drawn to the romantic idea of delivering a child to a mother who you had taken care of since she was a little girl, and then seeing them both back in the office for the first new baby check up a few weeks later.  As my “time to decision” (aka those lovely ERAS applications) creeps closer, I find myself wondering, are family docs really doing this anymore? Why or why not? This is a complex issue, but with a little research the answers I’ve come up are with so far look like this: “yes, somewhere in the ballpark of 10-20% of family docs still deliver babies” and  “we need ‘em, they love it, but it’s challenging for many reasons.”

On the decline, but still there.  Pulling some stats from an article in the JABFB, we learn that the decline in family docs practicing obstetrics has been quite dramatic, “in 1978, 46% of family physicians reported having privileges for routine deliveries; that rate 22.4% in May 2000.” The latest numbers from the AAFP’s yearly member surveys (which, granted, probably don’t include all practicing family physicians), just 10.1% of respondents delivered one or more babies in the previous year.  Broken down by geography, 8.2% of urban-practicing, and 17.0% of rural family docs report to be engaged in deliveries.  Before getting into the reasons for this decline, I want to quickly highlight a new program, which may impact this trend in coming years. The American Board of Physician Specialties recently established the Board of Certification in Family Medicine Obstetrics (BCFMO), with the first batch providers becoming board certified in 2009. This new board certification programs was added to “address the shortage of obstetric providers in rural and underserved areas and a desire by graduating family medicine residents to obtain additional training in obstetrics.”  There also has been an increase in family medicine obstetrics fellowship programs, further demonstrating in increase in interest and need for this training and services.
So why do it? The reasons family docs cite for wanting to provide obstetrical care to their patient’s are not surprising. In one study the most commonly cited reasons were enjoyment, desire to care for younger patients, having adequate training in residency, the ability to obtain privileges, a supportive practice and community obstetricians, adequate reimbursement and, (perhaps surprisingly) affordable malpractice insurance. And why not? The most commonly cited reasons for the exit of family practitioners from obstetrics are perceptions about malpractice risk, attitudes of obstetricians, difficulty obtaining hospital privileges / appropriate Ob, anesthesia and neonatal back-up, and the impact of obstetrics on physicians’ lifestyle and income. To address the malpractice piece for a minute, malpractice insurance carriers categorize the majority of family physicians who do not practice obstetrics as Class 1 liability risk. Those who do offer perinatal and obstetrical care are often classified up to a Class 4 (obstetricians are usually a Class 8). Premiums increase with each class, so there is a definite increase with the addition of obstetrical care, however it typically remains about half of that of a practicing Ob/Gyn. 
Is it necessary? I would argue that yes, there is a specific niche for family docs in the world of obstetrics that is distinct from other practitioners (namely obstetricians, and nurse-midwives). First, patients will tell you that family docs are different. It’s not just the continuity of care from mother to newborn, although this is a big part of it; a family doc intrinsically has a different perspective on the process of birth; viewing it first as the process of integrating in a new family member, not an isolated event for mother and child. Family doctors are in a unique position to provide pre-conception counseling to their patients and can build on existing rapport with their patient to address difficult behavior change issues for a safe and healthy pregnancy (smoking cessation, alcohol, diet, chronic disease management, etc.) Additionally, we simply need more providers of perinatal care.  Within obstetrics, there has been increasing specialization, more Ob’s dropping obstetrics from their practice, practicing in well-served areas and/or retiring early from the field. There are significant, unsafe gaps in the provision of effective perinatal care, especially to women who are under or un-insured, and/or live in rural or otherwise medically underserved areas.  Family Medicine is perfectly situated to step in and fill those gaps, accompanying our patients who already know and trust us through this exciting phase of their life. 
           In an effort to keep this short and sweet, I'll stop here, knowing I was only able to scratch the surface of a very complex topic. I do hope this will serve as the beginning of a conversation and I also encourage you to look for future posts & to contact me with any questions or comments you may have.