September 20, 2021, 1:21 p.m. David Mitchell — As a family medicine resident training in Albuquerque, Lee Dresang, M.D., looked forward to working locum tenens on the weekends in rural New Mexico. There he saw small-town physicians face difficult decisions that compelled him to learn more about high-risk obstetrics. When pregnant patients presented with complications, like preeclampsia with thrombocytopenia, the question of whether or not to transport them to the nearest tertiary hospital — sometimes more than 100 miles away — made an impression on him.
“Docs in rural areas and low-resource settings and other underserved communities can face some special challenges,” he said. “Even in a country with lots of resources and good transportation there are times where you’re the one, and you need to know how to manage these emergencies that can arise without warning. With imminent breech delivery, fetal bradycardia, shoulder dystocia or postpartum hemorrhage, transport is not an option. Each caregiver and delivery team needs to know how to provide coordinated, evidence-based, top-quality care in the moment.”
Dresang found what he was looking for in what was then a relatively new course, Advanced Life Support in Obstetrics. ALSO was developed in 1991 by John Beasley, M.D., and Jim Damos, M.D., of the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health to help rural physicians learn and maintain emergency obstetric skills. The course, which was purchased by the AAFP in 1993, has been attended by more than 75,000 U.S. clinicians.
“I really wanted to be as prepared as possible, and the course was really developed exactly for that setting by Drs. Beasley and Damos,” Dresang said. “They often referred to it as preparing people in low-volume, high-acuity areas that may not attend as many deliveries, but they can be really serious situations.”
Dresang loved the course and soon after, he took the ALSO instructor course, too.
“I knew right away it was something that I wanted to get involved in,” said Dresang, a professor who has been with the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health for more than two decades.
Now in its 30th year, ALSO has been taught in more than 60 countries. Dresang has taught it in Costa Rica, Ecuador, Guatemala, Honduras, Mexico and Paraguay, and has helped coordinate its introduction to Argentina, Chile, Colombia, Uruguay and Venezuela.
Dresang helped implement a teach-the-teacher model for rapidly introducing ALSO to a new country. An international team teaches a two-day clinician course followed by a one-day instructor course. The international team then assists and evaluates as the newly trained host country’s leaders teach a two-day clinician course to a new group of participants.
“By the end of the week, the host country is running and teaching its own courses,” Dresang said.
Dresang collaborated with ALSO leaders from Colombia, Guatemala, Honduras and Tanzania to publish data documenting decreased maternal mortality, episiotomy, postpartum hemorrhage and severe postpartum hemorrhage rates, and increased active management of labor and vacuum-assisted delivery after the introduction of ALSO.
Dresang is one of three associate editors who assist in writing and reviewing content for the ALSO program (which is updated every three years) as well as the Basic Life Support in Obstetrics program, which prepares participants to manage normal labor and obstetrical emergencies. As the ALSO medical advisor, he serves as chair of the course’s advisory group and acts as a liaison between the advisory group and the editorial group.
Dresang doesn’t devote as much time to international instruction as he once did, but he continues to be involved in ALSO courses in Wisconsin.
“I definitely still teach it,” he said. “I think it would be hard to be involved in the editing and writing part without being in the teaching part.”
Dresang delivered about 120 babies a year when he was new to practice. Last year, he attended 60 births.
“I think 60 is kind of a nice, sweet spot for me where it’s a good number but not so many that it keeps you from having a life outside of deliveries,” he said.
The percentage of family physicians who deliver babies has declined significantly in recent years, but Dresang hopes to show the students and residents he teaches that full-scope family medicine with obstetrics is possible.
“I think you make them realize that this is something that communities need, and that comes through exposure and involving residents and students in what you do,” he said. “They can see this is a viable model that works well for a number of people. We have about 40 family docs in our department who attend deliveries, so there’s an example there for them to see that, ‘Yes, you can do this. It works. It’s compatible with your lifestyle, is exciting, worthwhile and meeting needs.’“
Dresang also is the chair of the AAFP’s annual Family-centered Maternity Care Conference, which was held in August. While ALSO focuses on preparing clinicians for emergencies in obstetric care, FCMC offers evidence-based updates and hands-on workshops for a broader range of topics, such as induction, pain management, pregnancy loss, culturally congruent care, maternity care disparities, documentation and billing, and breastfeeding.
Dresang said that although the percentage of family docs delivering babies has declined, the number of FPs attending the conference has been increasing, with more than 300 clinicians now participating each year.
“The Family-centered Maternity Conference is another tool to help family physicians develop and maintain their skills,” he said. “The need is so high, but there are a lot of barriers to practice. Although the number of family physicians attending deliveries has gone down due to various factors, including malpractice insurance, politics and the closure of hospitals, the interest is certainly there in family medicine. It really is an inspirational experience to be around that many people devoted to and excited about attending deliveries and working to make sure that each delivery is as safe and positive an experience as possible.”