OB privileges: The battle continues for
family physicians When Robert Gobbo, M.D., decided to move from rural Oregon to Merced, Calif., he hoped to retain his obstetrics and Caesarean section privileges in his new practice.
Keeping current on techniques helps FPs deliver the best possible maternity care and can help them earn their privileges. Mark Deutchman, M.D., of Denver, demonstrates proper suture technique for a perineal laceration repair during the AAFP's Family-Centered Maternity Care conference last summer.
(Photo by Leigh Ann Bathke/AAFP)That was five years ago. And even though Gobbo's privileges include obstetrics and C-sections, he still feels the tension. He became the first family physician at Sutter-Merced Medical Center to have the privileges.
"I'll admit it was a long process," said Gobbo. "My privileges were negotiated before I got here. And my taking the position was contingent on my having these privileges."
FPs wanting obstetrics and C-section privileges usually face a battle. But studies show that family physicians deliver 20 percent of America's babies, and research shows that mothers and infants who have C-sections performed by family physicians can experience excellent clinical outcomes compared to standard measures of surgical care.
"It is the position of the Academy that clinical privileges should be based on each individual physician's documented training or experience," said Mark Deutchman, M.D., of Denver, who wrote the paper "Caesarean Section in Family Medicine" for the AAFP.
"What a lot of family physicians are facing is a numbers game," said Deutchman. "They are told they can have privileges if they've done some impossibly high number of C-sections. But these numbers don't prove skill. Some physicians are better at acquiring skills than others. The OB-Gyns are trying to set the stick at a different height for FPs to jump over."
Eric Runte, M.D., a California family physician, has taken his fight for obstetrics privileges to the federal courts.
In 1996, Runte filed an antitrust lawsuit against Sonora Community Hospital and three OB-Gyns. Runte directs the Primary Care Clinic at Tuolumne General Hospital in Sonora. Because this hospital doesn't have a birth center, he delivers babies at Sonora Community Hospital.
Although Runte had completed a family practice residency with training in obstetrics, had performed 110 C-sections and was the primary surgeon for 70 of them, he was denied C-section privileges at the community hospital.
While his application for C-section privileges was pending, the hospital adopted a policy precluding FPs with training in maternity care, including C-sections, from obtaining C-section privileges. The hospital had sought advice from a joint task force of FPs and OB-Gyns, but then refused to follow the task force's recommendation that C-section privileges not be specialty-based.
This February, the attorneys for both sides presented motions to the judge for a summary judgment.
"This means that each party says there are no facts in dispute, nothing for the jury to decide," said Barbara Hensleigh, Runte's attorney. "We're both asking for the judge to apply the law. But the judge can decide for either party or say there needs to be a jury trial."
Hensleigh said she would like to see the case go before a jury. "We want a jury to hear the facts in this case," she said.
A May 12 trial date has been set in the Runte case, contingent on the judge's decision.
"We believe that any policy for privileges should be based on demonstrated competency, training and experience and shouldn't have criteria discriminatory against family physicians," Hensleigh said.
Family physicians wanting to earn obstetrics and C-section privileges need to do careful paperwork. They should keep track of the number of procedures during training and practice, summarize data for each patient, and obtain letters from instructors, preceptors and proctors documenting training, experience, demonstrated abilities and current competence. Deutchman's paper for the Academy is available by calling the AAFP order department at (800) 944-0000 and asking for item #R715.
Family physicians moving to new practice sites should research the policies and procedures for privileging in their new locations.
Robert Gobbo, M.D., negotiated OB and C-section privileges when he moved to a new practice in Merced, Calif. Above: He explains proper ultrasound scanning techniques.
(Photo by Leigh Ann Bathke/AAFP)Although Gobbo made obstetrics privileges part of his negotiations for the job in California, his new family practice department had to work to get those privileges for him.
First they went to the OB-Gyn department for help, but received none. So the family practice department drafted its own criteria, which were approved by the hospital's credentials committee. Then the hospital's governing board approved the plan.
"The OB-Gyns were asked to contribute throughout the process, but most refused," Gobbo said. "As part of the credentialing procedure, I needed to be proctored for three C-sections by an OB-Gyn. One agreed to do it, and my privileges were granted."
Although the governing board of the hospital approved privileges for family physicians, the OB-Gyn department was still uncomfortable with the governing board's decision.
To ease tension between the departments, Gobbo and the head of obstetrics at the hospital tried to hammer out a compromise on paper. The agreement outlines guidelines for family physicians wanting to have C-section privileges.
"The family practice department approved the guidelines, yet the OB-Gyn department was unable to come to a consensus on it," said Gobbo. "I have been in this community now almost five years and have a good relationship with many of the OB-Gyns. However, many still have a serious objection to any family physician having C-section privileges. It is true that this process was not the easy road to take. Without the support of my wife, family and my partners, I don't think I would have been able to do it. I'll admit it was difficult, and processes like this are not something you can do in a vacuum. But it has been worth it to me and our residency program."
Deutchman said there's no excuse for family physicians being treated as second-class citizens at their hospitals.
"I'm saying that FPs with proper training, experience and demonstrable abilities should be able to have C-section privileges," Deutchman said. "And when residents see FPs doing obstetrics, they realize these skills are part of the job."
Gobbo agrees he serves as a role model for residents.
"Residents who come through the programs where the family practice faculty are practicing obstetrics are much more likely to feel confidence in their obstetric skills. They see obstetric skills as part of what they're expected to learn, and are more likely to provide obstetric care when they leave residency," Gobbo said.
FP Report is published by the AAFP News Department. Copyright © 1998 by American Academy of Family Physicians.
