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Tuesday Aug 15, 2017

Drop in Number of FPs Who Deliver Babies May Create Rural Crisis

It is the middle of the week, Wednesday afternoon, and in between patients with diabetes, hypertension and heart failure, and those who need skin biopsies, mole removals, sports physicals and well-child exams, I am doing an 18-week prenatal visit and an anatomic survey ultrasound.  

These are fun for me and offer a chance to use a highly technical and precise skill I work hard to maintain. At the same time, it's an exciting opportunity for parents (and often extended families) to get to "meet" the new baby.

Today is particularly fun because my "assistant," who is helping me move the transducer around her mom's tummy, happens to be the baby's 3-year-old big sister Erika. It is hard to tell who is more excited about the process of discovery as we systematically work through my anatomic survey ultrasound checklist.

The crowd of spectators is not the biggest I have had at any one time, but the maternal grandmother and great-grandmother have a special connection with me. They have been my patients from the first day I started practice. I delivered Erika's mother, who is being patient with her rookie ultrasonographer, and I delivered Erika. I plan to be around to deliver our ultrasound subject as well. But I wonder, will there be family physicians to deliver the generation after that?

A report the Robert Graham Center for Policy Studies in Family Medicine and Primary Care released in June showed that the percentage of family physicians who practice high-volume maternity care (defined as more than 50 deliveries per year) dropped by 50 percent between 2009 and 2016. At the same time, there has been a gradual decline in the number of family physicians who provide lower volume maternity care and a rising trend in family medicine residency training to reduce the requirements for maternity curriculum hours and continuity maternity patient experiences.

There also is an increasing trend in obstetrical residency programs for graduates to enter subspecialty fellowships, leading the American College of Obstetricians and Gynecologists to predict a nationwide shortage of 9,000 obstetricians by 2030.

The long-term impact that declining numbers of family medicine and obstetrics graduates entering community maternity care practices will have on the provision of maternity care in rural communities remains to be seen. Here in Washington, where we have robust data collection through the Obstetrics Clinical Outcomes Assessment Program, part of the Foundation for Health Care Quality(www.qualityhealth.org), we can identify the percentages of deliveries by practitioner specialty and hospital size and pinpoint communities where the loss of family physicians who practice maternity care, including surgical obstetrics, will likely precipitate a severe crisis in access to safe maternity care.

There are communities in Washington where family physicians provide the only maternity care services -- including operative and surgical obstetrics -- and initial care for newborns who may need IV fluids, antibiotics and respiratory support. In some cases, the nearest hospital with more advanced capabilities may be 100 miles away, over a mountain pass that is closed during winter storms or where airlift capabilities are limited by weather. Losing physicians in these areas, or the nursing staff and other technical staff who support them, could cause a crisis for pregnant women.

In my hospital, 25 percent of deliveries are performed by family physicians, a trend that has held steady for 22 years because of the ongoing influence of our family medicine residency program and the daily presence of family medicine residents and faculty on our obstetrical floor.

Twenty-three years ago, our family medicine residents got their only maternity care exposure in a 30-bed community hospital located 20 miles away that had about 300 deliveries a year. When I joined the residency faculty as the obstetrical coordinator, my first challenge was to negotiate the opportunity for our residents to experience high-volume maternity care here at our regional perinatal center, where our volumes are typically 3,000 deliveries per year.

With that successful transition, we have continued to grow a family medicine obstetrics service, and many of our graduates go on to family medicine obstetrical fellowships to prepare them for rural practices where surgical obstetrics skills are needed. Despite being a high-risk, level III hospital and regional perinatal center, we have the lowest cesarean delivery rate in the entire state, and we are the model for obstetrical quality and outcomes.

We have used the Advanced Life Support in Obstetrics (ALSO) program as part of our curriculum development since 1996. In 2006, we expanded our courses to include maternity nurses, and shortly thereafter, our obstetricians and our family physicians voted to require the course for all department members. We now teach the course twice a year as a multidisciplinary teamwork and patient safety course and regularly perform drills based on scenarios derived from the ALSO workshops.

Our family medicine residency program is committed to preparing family physicians for rural practice, and whether or not those family physicians choose to provide maternity care, the philosophy of our residency director is that preparation for that possibility is paramount. Although two months of maternity care training is a residency requirement of the Review Committee for Family Medicine, in our program, the graduation requirements are four months of hospital training -- five months for our rural training track.

The crisis is real. Supporting family physicians who want to provide maternity care in their communities requires adequate training during residency, ongoing support for privileging and credentialing, continuing education and maintenance of skills, support for resiliency and prevention of burnout, tort reform, regionalization of perinatal support services, interprofessional education, and support.

We must continue to support our colleagues who provide maternity services and encourage the next generation to carry forward that tradition.

By the way, Erika is getting pretty good with the transducer. She has managed to steer to all the spots I needed to see and has discovered she is going to have a baby sister! Perhaps I have given her a start on her way to becoming a family physician who is excited about delivering babies.

Carl Olden, M.D., is a member of the AAFP Board of Directors.

Posted at 01:30PM Aug 15, 2017 by Carl Olden, M.D.

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