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 declined....to 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. 

Expectations: Where and How to Set the Bar for Family Medicine?

The first thing you should note is that I titled this post with a purposeful question mark.  My fourth grade teacher labeled me "most inquisitive", and I'd like to believe that superlative still rings true.  But I challenge you to stop and think about it for a second - how do you set the "bar" of expectations in your own life? With your patients? With your family? With your commitments?

Are you the kind of person to place the bar nice and low and manageable, allowing you to gracefully step over?  Perhaps you have your own sort of personal limbo bar, and are flexible enough to test it out at various heights :)  But my guess is that you, like most high achieving and hard working doctors and students I know, have a bar that is set so high that you couldn't even jump to reach for a pull-up.  That's just the problem with expectations - we often experience disappointment when we fail to meet them.

So what happens to our patients, then, who have been raised with an admiration for the miracle of medicine; who are ever more present members of a society that glorifies instant gratification; and who are now emboldened by the political momentum guaranteeing health care as a natural right? Expectations are high, indeed.  And we stand with a perfect opportunity to disappoint our patients if we fail to set the bar to that perfect height.

So taking a step back......Have you ever had the kind of day in which you expected you'd be working until 8pm, but when you got off at 6pm it felt like you won the lottery?  Conversely, we have all experienced the opposite - planning and looking forward to getting off by 4pm, only to be waylaid and stuck until 6pm.  In reality both sorts of days end at the same time, but it is our expectations at the outset that ultimately dictate our emotional response. 

Translating this, how do we create that "I expected to get off at 8, but was home by 6" feeling within our patients?  I believe that we can set realistic expectations at the forefront of our practice of medicine, rather than offer graceful apologies as we wave goodbye. 

I have a few thoughts on how we can set these realistic bars in family medicine:

1) Be willing and forthcoming in surrendering the role of omniscient provider
   Let's get real for a second.  Each and every one of our patients now carries a device that contains more information with the stroke of a few keys, than all the textbooks we read in training.  We are no longer purveyors of information, but rather intuitive and experienced interpreters for our patients.  I think that we already do a pretty good job of acknowledging this in family medicine, where we are often willing to defer and consult to our specialist colleagues.  I suggest we be transparent and upfront about our role, from the point of our first patient encounter. We need to be clear that we are supportive guides for our patients in their health as they move through the stages of life and the intricacies of health systems.

2) Create an office environment that thrives in its consistency 
   Provide an experience such that, when patients walk in the door, they know what to expect from front to back.  By this I am referring not to the exam room door, but the front door.  The second they walk in, they should feel at home and have a good sense of what will be happening.  This is the reason that so many people choose to shop at Target or buy Apple products - the reliability, consistency, and comfort.  This is the best way to prevent that "I thought I'd be home by 4pm, but got stuck working till 6pm" feeling as they leave a clinic appointment.

3)  Be willing to respond to change - Be willing to move the bar
   When was the last time that you "moved your bar"? In concert with what has been written about all good being the enemy of great, many bars are set in concrete.  Conversely, as previously mentioned, some bars are set far too high with no hope of finding accomplishment.  As family physicians, we need to be adaptable in our goals and transparent in our abilities.  When we reach that figurative double aim, then our patients can realistically expect accountable and consistent action.

Doing this, we will never let them down. 

Future of Family Medicine Blog Celebrates National Primary Care Week 2012

After much anticipation, National Primary Care Week 2012 is finally here!

We have a surprise cross-post that will be published on a prominent national blog and set to go up on Wednesday, so stay tuned!

In the meantime, we would like to take this opportunity to look back to our many blog posts. We have put together a list of 10 posts with some relevant links of interest to help students (and residents) accumulate a source of information to reference when speaking with your institutions about the importance of Primary Care.  We encourage you to utilize these links for your reference as well as to share with your classmates, colleagues, and mentors across the country.  We enjoy your comments as they indicate that we are stimulating conversation, which is what this blog is all about!

1. Family Medicine is a Waste of Your Talent
We would like to start out by saying: Family Medicine (and Primary Care) is NOT a waste of your talent.  You are not too smart for Primary Care, and, in fact, it is impossible to be too smart for Primary Care.

2. The Dean's Lie about Medical School Primary Care Workforce Production
Did you know that medical schools inflate their numbers by skewing statistics in their favor when reporting how they contribute towards primary care workforce production?  Liken the lies about these statistics to falsifying a company's quarterly/annual report to its members - immoral and illegal!  Hold them accountable!

3. Is There an Underlying Specialty Bias at your Medical School?
A hidden curriculum?  A hidden agenda?  Be cautious about comments/suggestions/mentorship by those involved with your medical education.

4. Has the RUC Destroyed Medical Student Interest in Primary Care?
A small group of physicians formed by the American Medical Association provides payment formulas to the Center for Medicare and Medicaid Services which sets payment for services provided by physicians.  Private insurance companies use these formulas and rates as well.  Less than 1/3 of members on this committee are primary care physicians.  Since starting in 1991, the salary gap between primary care and subspecialist physicians has widened to a point of crisis.  Learn more about it here.

5. Incorporated Patient-centered Medical Home training throughout all 4 years of medical school
PCMH is the model of primary care moving forward.  It is the responsibility of medical schools to ensure that students are learning in this environment starting on the first day of medical school.  Early exposure to primary care and its innovative model is crucial to increase our workforce.  Encourage your medical school to ensure that PCMH is the foundation of your education.

6. The 20th Report by the Council on Graduate Medical Education: Advancing Primary Care
This report is the bible of Primary Care delivery moving forward and provides recommendations to accomplish the strengthening of Primary Care in the United States.  This is a must read.

7. Does Building a Primary Care Workforce Start With Medical School Admissions Committees?
Admissions committees will deny this, but they have the ability to select from its applicants a strong set of potential medical students who are more likely to choose a career in Primary Care.  Studies upon studies confirm these characteristics.

8. The Hazing of Family Medicine
Building off of the Waste of Talent post, this post goes into depth about the struggles medical students face when proclaiming their desire and passion for Family Medicine and Primary Care to faculty throughout the clinical years of medical school.  Say no to hazing and bullying by faculty!

9. Medicine is a Team Game - And every team needs a good Family Physician!
Primary Care physicians are the quarterbacks, the point guards, and the one in charge of coordinating the care provided by a multi-disciplinary team of other specialty physicians and providers.  Fragmented care is unacceptable.

10. Living out our Personal Statements
A medical school dean once said that upon evaluation of personal statements for medical school admissions, more than 90% would choose primary care careers.  If you are currently writing a personal statement for residency, compare it to your personal statement for medical school.  If you are currently in medical school and trying to figure out what specialty to pursue, open up your personal statement and reflect on what you were feeling when you wrote it and how your medical education has influenced your career path.

Thank you for reading and we hope you have an enjoyable Primary Care Week!