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. 


  1. This was a great post. At the moment I'm a senior in college, and unsure whether to become an FNP/CNM (eventually DNP) through a second-degree program, or become a Family MD. Recently I found out about the opportunities to get a fellowship for OB specialization, and think that it would be amazing to have that scope of care within a community, especially in rural medicine.

    What is your perception of the pros/cons of each field and the scope of practice?

  2. Just graduated residency this year and I'm an FP delivering babies in a town of 15000. Great support from ob docs and 2 other FPs. We all have section privileges, too and I love it! Great post.

  3. Great post. However, I still can't be sure whether I should go for FM or Ob/Gyn. It's a hard decision, and I don't know what to expect from FM. I should add that I intend to work and live in a town with no more than 100,000 habitants. As you can see my goal is not a rural underserved area nor that big urban area. I'm affraid that if I choose FM I might not get to practice the Ob as much as I would like. Also, as a ObGyn, would the bonding with patients not be enough, because I would probably miss the post-natal phase? As a third year med student, I'm still struggling to decide.

  4. As an FP who practiced OB in suburban New York City for 18 years I cam tell you that it is a great feature of an active FP practice. It also builds a pediatric following as well. My partner and I enjoyed immensely offering these services and never missed a delivery. We had C-section assist privileges and used pitocin with minimal OB backup. Then our Med Mal rates suddenly doubled and more so, the OB s themselves became increasingly skidish about backup, NOT because of us but due to their own concerns about covering even their own colleagues. Thus we became caught up in that tangle of malpractice worries.

    Bottom line ..OB services in an active Family Practice is great and highly rewarding but... One MUST evaluate the OB support in the community to most effectively offer such services.
    Good luck !

  5. I am a 50+ yo family doc, attended births for 25 years after residency, stopped about 2 years ago. Main reason for stopping was (I think) age related challenges, just got harder to work the day after being up a good part of the night. Some of that may have been exacerbated by my own difficulty sleeping when labor was not proceeding smoothly. Some colleagues were better at that, and they are still doing OB!

    That said, I did love doing ob while I did it, and the relationships I have with the families is quite special. Support from obstetricians makes a big difference, so I can see that varying from town to town.

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  7. I am a family physician who has had the honor of delivering babies (and teaching medical students and residents) since finishing my own residency in 1998. And each year as I grew my own family, I would say, "let's see how it goes" and it has been going...great! I have been amazed with how gratifying as a family doctor it is to know my patients before they have children and even find the person they want to be parents with and then to follow them through all the milestones before, during and after childbirth. I have had the honor of caring for 4 generations in one family and the richness this provides in knowing all members that much better than if I only cared for one of the generations is difficult to describe. It s fulfilling, amazing, and never boring. And it never grows old to see my young patients that I have delivered reply when I ask them who am I, "You're my delivered me!"