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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.

Posted at 06:29PM Jul 10, 2012 by Julie Wood, M.D.

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