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Tuesday Jul 10, 2012

Changing Training Standards for Maternity Care

As we enter a pivotal time for family medicine to be the basis of the health care infrastructure in the United States, family medicine residencies are questioning what the practice environment of the future will look like and how to train their residents.

There are emerging trends for family medicine scope of practice which vary regionally and by patient and community need. One particular ongoing challenge for many family medicine residencies is how to provide adequate maternity care training.

This is a hotly debated issue that academic family medicine has been struggling with for years. In areas with a paucity of family physicians providing maternity care, many educators have favored lowering the minimum curricular requirements. Others, however, have stood firm and called for maintaining the full scope of training within family medicine. 

During the past year, a proposal was finally agreed upon by the Association of Family Medicine Residency Directors, the Review Committee for Family Medicine (RC-FM), and the Review Committee for Obstetrics and Gynecology (RC-OB-GYN). The proposal created a two-track system. The first track would cover a minimum of two rotations, or blocks, in maternity care for all family medicine residents with no requirements for continuity deliveries. Providing this track, which was for those not intending to deliver in practice, would have been required for all family medicine residencies. 

A second, optional advanced track would have required at least four months of rotational work as well as 80 deliveries and continuity deliveries. This track was meant for family medicine residents who want to deliver in practice.

In June, the world of academic family medicine was waiting for the final vote from the board of directors of the Accreditation Council for Graduate Medical Education (ACGME). With all the key players on board, the big question was when (not if) to implement the new plan -- for the incoming class of 2012 or for the class of 2013?

As program directors were making curricular plans for this system, however, the ACGME denied the proposal on the grounds that it does not allow optional requirements. By default, residency programs have to continue the current requirements of 40 total deliveries per resident, including 10 continuity deliveries. 

The RC-FM now has been asked to revise the proposal as a clear, minimum standard. The new question is what should that standard be? Should we set a floor for maternity care exposure? The original priorities were to reduce citations for programs unable to provide 40 deliveries for each resident while providing structure for residents who desire a more robust training environment. 

The RC-FM has its work cut out. This a critical decision for maternity care within family medicine because it will determine what all family physicians will learn in order to care for pregnant patients. In addition, this issue is demonstrative of the widening diversity of family physicians and our training needs. We have reached a critical time for our specialty. We must produce family physicians that can respond and adapt to the needs of our communities. Let's send our residents out to practice fully trained.   

AAFP Board member Daniel Spogen, M.D., wrote about the growing concern regarding shrinking scope of practice in his March blog, which asked compelling questions about the issue. We received some interesting and helpful answers. To further the discussion, I'll leave you with these questions: Should we continue to advocate for full scope of training as an Academy? How do we define ourselves as a specialty now and in the future?

Julie Wood, M.D., of Lee's Summit, Mo., is a first-year member of the AAFP Board of Directors.


As a resident who wants to do OB, I think that this would be an appropriate and helpful change. Two tracks would allow my colleagues who are more interested in other areas of family medicine to develop their interests while providing more solid foundational training for those of us who do want to practice OB (and then, in programs where numbers are harder to come by, those who do want to practice OB have more patients to see!)

Posted by Matthew Loftus on July 10, 2012 at 08:53 PM CDT #

Thanks for posting, Julie. This really is a critical issue. As a long-time family medicine faculty member and maternity care advocate, I have really struggled with this. When our program changed from 6 required months to a minimum of 4 with 2 available to substitute something else needed for the chosen career (sort of "tracks" without calling it that), I initially resisted. But then I realized that having residents who really wanted to be on the OB service--and not having residents who didn't really want to be there--was actually better for everyone. I think every family physician needs to experience maternity care. Childbirth is a central event in the life of families and family physicians need to be intimately familiar with that process. And family physicians must be able to provide medical care to pregnant women and appropriate newborn and new-mother care. The experience of those things are all enhanced by maternity care training. But I do think "tracks" are probably the best way to go. It saves the births for the residents who need to attain competency, and keeps mostly cheerful residents doing the maternity care. I was part of the group that developed the article on tiered training that appeared in Family Medicine last year. http://www.stfm.org/fmhub/fm2011/October/R.%20Aline631.pdf The other side of this equation is that we need to preserve training in operative obstetrics and cesarean sections for those residents who want and will need these skills to serve their communities.

Posted by Anne Montgomery, MD, FAAFP on July 10, 2012 at 10:22 PM CDT #

As someone who didn't particularly enjoy OB during my training until my first rural rotation, I worry that residents may not always know what they want going in. I now treasure doing OB as part of my urban practice, and I am one of a few FPs doing OB in the city. How many residents will never know what they missed? Who will replace me and my colleagues?

Posted by Marin Granholm, MD on July 10, 2012 at 11:21 PM CDT #

As a FP who did full operative OB for 7 years in rural practice I worry that our scope of practice is shrinking very rapidly. I had to stop delivering due to economics at a small hospital, and I could not secure delivery privileges at other hospitals despite a lot of experience and great outcomes. What ever we do we must make sure new FPs are well trained. I feel our colleagues in other specialties don't perceive us as properly trained to do things like OB. I think all FP's should support FP's who do OB and other procedures, or we will see our scope of practice continue to shrink.

Posted by Bill Swofford, MD on July 11, 2012 at 11:00 AM CDT #

Family Medicine IS full scope. We should all be trained to do OB, even if we decide to focus on other things besides OB in practice. I was not sure that I wanted to do OB coming into residency only because I didn't know how to practice OB logistically with such a lack of FP-OB's in densely populated areas, but I fell in love with it during training and now have a booming OB practice and do c-sections. To me, this is not a question of what residents want to do. Rather it's question of how we define the specialty of Family Medicine to our colleagues. I wonder if general surgeons have this conversation as well. Should they have a special track for residents that want to focus on bariatric surgery at the risk of missing out on laproscopic cholecystectomies? In otherwords, we expect a general surgeon to have exposure to perform appendectomies and cholecystecomies, even if they eventually decide to focus on other things in practice. It does not seem any different with regards to our specialty. #docramas

Posted by Marie-Elizabeth Ramas, MD on July 11, 2012 at 03:04 PM CDT #

I believe it is important for all family physicians to have adequate training in OB. However, the reality is very few do obstetrics in the real world. Lower the time committment towards OB. The requirements are outdated and not suited for what a new family physician should know....it's time for change. More importantly, I am concerned about the lack of skills family docs have regarding urgent care and emergency medicine. We need to focus and train more FP's in this field.. Alll rural ER's are facing shortages which need to be met by adequately trained FP's like they were before. Residents nowadays don't even know how to suture or don't want to do procedures. We should be filling this niche which happens to be very rewarding.

Posted by Alexander Zotos, MD on July 12, 2012 at 07:52 AM CDT #

The two track system is logical. All FPs should have some OB/GYN exposure but the vast majority of us do not deliver and never will. The academics must provide relevant training to prepare residents for real world practice. The truth is that we could have used extra training in other areas. When I was in residency, we had to perform more continuity deliveries..after a certain point, it was a poor use of my training time. In reality, we needed more practice management, dermatology and musculoskeletal medicine. Cheers on the two track system. Same kind of change should be reflected on our board exams, if we don't practice, we should have no significant testing on OB.

Posted by John on July 12, 2012 at 08:07 AM CDT #

The two-tier idea was logical but is dead. It cannot be revived. We have to agree on a minimum standard. Without doing any continuity deliveries, and therefore no significant prenatal care, graduates will not be prepared to care for medical problems of their patients who become pregnant. In order to work in rural ERs, there needs to be some experience with delivery babies urgently and stabilizing labors, addressing triage issues of pregnant patients, etc. The new minimum will undoubtedly be lower than the current, but needs to maintain continuity, family medicine modeling, prenatal care, hosp/ER assessment and some delivery skills.

Posted by Tony on July 12, 2012 at 10:56 AM CDT #

This question of what our scope of practice should be, and what it ultimately becomes, and how to train for it, involves more than just protecting our turf. We need to find ways to become relevent to medical students. Students entering Family Medicine and primary Internal Medicine have been in decline. If we don't have students entering, it won't matter whether we train them to do OB or any other procedure. Despite the arrival of the medical home, there has been no movement to reimburse primary care at a level that attracts students with their large debt. The conspiracy theorist in me believes this is intentional, and that the plan is to turn much of what we do as PCPs over to PAs and NPs at a much reduced cost. I believe there should be a discussion with the ACP and AAP to join together and form a primary care residency that includes basic training in all areas, but allows for selection of added training in areas like OB, endoscopy, sports medicine, geriatrics, etc. Our practice, which does not include OB, has just hired a Med-Peds residency graduate. (Who have they been practicing with?) I don't think it's a stretch to consider adding a 4th year of training that would add experience and increase our credibility and influence. Time to think outside the box.

Posted by John Lohrberg on July 12, 2012 at 05:33 PM CDT #

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