to the editor: My thanks to Dr. Harr and his colleagues from both the American Academy of Family Physicians (AAFP) and the American College of Obstetricians and Gynecologists (ACOG) for their hard work on the new core educational guidelines for obstetrics and gynecology.¹ I support these recommendations wholeheartedly, with one exception.

The guidelines state, in essence, that only residents who plan to go into rural practices where immediate back-up by obstetricians is not available should receive training in advanced procedures such as cesarean section, external cephalic version and management of multiple gestation. I disagree with this restriction. I believe that any physician who has the appropriate training, experience and competency should be privileged to perform a given procedure in any environment, regardless of other available medical services in the community in which he or she practices.

I currently practice in a community of 250,000 persons, with approximately 40 obstetricians-gynecologists on our hospital staff. However, I have earned the privilege to perform cesarean sections and versions, and to deliver twins. I obtained this training as part of my regular three-year residency, using elective time to obtain experience beyond the required period of training in obstetrics and gynecology. I believe that I offer enhanced service and care options to the patients in my group (I perform all of these obstetric procedures for my entire group) without compromising quality of care.

The battle to earn these privileges took almost two years, but it was won, mostly without rancor. Had the current guidelines been in place, I believe it would have been difficult to achieve the training I desired, and I would not have had such a strong position in seeking these privileges in such a community. Furthermore, the current guidelines seem inconsistent with the strong position that the AAFP has taken regarding clinical privileges that are based solely on a physician's knowledge, training and demonstrated competence.

in reply: We would first like to thank and congratulate Dr. Steiner for seeking and obtaining privileges to serve her patients at an advanced level of maternity care. Dr. Steiner has expressed important concerns regarding the section on advanced skills in “Maternity and Gynecologic Care: Recommended Core Educational Guidelines for Family Practice Residents.”¹ Drafted from the original recommendations² by the Subcommittee on Graduate Curriculum and Review of the American Academy of Family Physicians' Commission on Education, the new core educational guidelines were developed and finalized by a Joint Task Force of the American Academy of Family Physicians (AAFP) and the American College of Obstetricians and Gynecologists (ACOG). It was important to both groups that the educational guidelines be paired with the “AAFP–ACOG Joint Statement on Cooperative Practice and Hospital Privileges.”³

The language in the section on advanced skills in the guidelines states that additional training is recommended for “family practice residents who are planning to practice in communities without readily available obstetric–gynecologic consultation and who need to provide a more complete level of obstetric–gynecologic services for the proper care of patients...”¹ This language is nearly identical to that of the original document published in 1980. Moreover, the joint task force agreed that such additional experience “may occur within the three-year family practice residency,” to avoid mandatory fellowship training for family physicians who wish to arm themselves with the skills necessary to provide a more advanced level of maternity care.

The joint task force felt that it was important to couple the educational guidelines with the joint statement on privileges. For this purpose, they are printed as four attached pages rather than as separate documents stapled together. In at least nine sentences of the joint statement on cooperative practice and hospital privileges, both specialties reiterate their common orientation toward privileging, perhaps best summed by the statement, “Privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to ensure the provision of high-quality patient care.”

The document goes on to say, “The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice.” It is important to note that the policies of both ACOG and AAFP, as well as the American Medical Association, are virtually identical in support of privileging any physician, regardless of specialty, who is able to document training, experience and demonstrated current competence. For this reason, both organizations felt strongly that the joint statement on privileges be permanently attached to the educational guidelines.

Most family physicians are satisfied with their hospital privileges. Only 4 percent (regional variation: 1.9 to 5.8 percent) of family physicians feel that their hospital privileges are unduly restricted.⁴ Among those privileges most contested, unfortunately, are surgical and advanced obstetric privileges. While 25.3 percent of family physicians deliver babies (regional variation: 11.8 to 49.3 percent),⁵ only 7.3 percent of family physicians in the United States perform cesarean sections (regional variation: 0.8 to 15.6 percent).⁶ Among those who do not perform cesarean sections, the lowest percentage (1.3 percent) is among family physicians whose privileges have been denied. Other reasons that physicians do not perform cesarean sections include issues of liability, the absence of a hospital practice or not desiring the privilege.

The 1980 core educational guidelines on obstetrics and gynecology have anecdotally resulted in family practice residency programs that have obtained training in obstetrics and graduates who have obtained obstetric privileges. Indeed, again anecdotally, no other set of core educational guidelines published by the AAFP has had the impact on training and privileges than has the original AAFP Reprint No. 261. We hope that the 1998 version will be as useful to the discipline, its trainees and graduates as was the original document. We also hope that more graduates will choose to serve their communities with a full scope of family practice, including maternity and gynecologic care, and will be as successful in their local application for privileges as has Dr. Steiner.