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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Have we given up "We deliver" to Dominoes?
Prenatal Care in the Uniformed Services
Author reply: Access to care may be the more effective argument for ongoing maternity care by family
Promoting support for maternity care by family physicians
Documenting the maternity care cascade
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Kurtis S Elward, Charlottesville, VA, USA Family Physician, Family Medicine of Albemarle
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I read with interest and personal experience the article of Cohen and Coco. We have an excellent relationship with our OB colleagues, delivering VBACs and twins in our practice in a busy suburban area. Midwifery in our town has been decimated by malpractice premiums, while in Virginia FPs pay relatively reasonable rates. The average "lifespan" of a female OB is 5 years. A family physician, especially a female, would have an incredibly popular and young vibrant practices, even with a self-determined limit of 20 babies a year (that is $35,000-$60,000 in additional charges, by the way). Yet many of the residency graduates we are interviewing are coming out terrified of OB, under the impression that it ruins one's quality of life, and feeling unprepared for routine OB care. THEY state their faculty discourages OB as being a terrible drain on one's life. I am not sure where they get the impression that OB impairs lifestyle, unless this impression is consistently conveyed without an alternative perspective. Recently, I delivered little girl who was the result of a long labor. The parents were overjoyed, of course. Also there was the grandmother - with whom I had prayed six months earlier, before she underwent surgery for what was supposed to be a tennis ball size malignant brain tumor - which turned out benign. That miracle was almost overshadowed by the sight of this same woman, holding the grandchild she thought she would never see, thanking me for my role in their family. As I drove home at 3AM, I realized I have one of the best lifestyles in the world. If I had a chance, I might convey to the residents some of the joys of family medicine, the great movement in which they are a part, the dedication it takes, and the rich rewards it brings. I might, if I am lucky, be able to help them shed the ephemeral concerns about lifestyle in its most simplistic forms, and call them to think about the career of caring and personal relationships that bring meaning to their lives. I make my kids' ballgames - most of the time. I have a great marriage to a very wonderful woman and best friend. I don't recall many of the sore throats and cholesterol checks. I have memories of the delivery room that will be treasured by me and my patients for years. I am not only a part of the PCMH, I am a part of my patients' homes. Competing interests: none |
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Mark B Stephens, Bethesda, MD Associate Professor Family Medicine, USU, Pamela M. Williams, MD
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To the Editor It was with great interest that we read the recent article by Cohen and Coco [1] regarding the declining provision of maternity care services by family physicians across the United States. This decline parallels the general decline in interest in family medicine and we feel it is directly proportional to two primary factors: 1. Professional jousting. This phenomenon is a unique and sad product of the medical education system. Students interested in primary care are frequently dissuaded from pursuing that career path by staff and resident physicians in other disciplines who bombard them with negative comments regarding their chosen field. “You’re too smart to be a Family Physician” is a mantra often heard by students during their clinical years. It is unclear what other professional disciplines tolerate this blatant lack of respect in their educational pipeline. The (un)intended consequence of such professional jousting has been the steady erosion of interested and qualified candidates in all fields of primary care--family medicine, general internal medicine, general pediatrics and general surgery. A similar phenomenon and mantra is common, particularly within tertiary facilities: “Family physicians (or midwives) have no business delivering babies.” While there is certainly no outcomes-based data to back this statement, family physicians are clearly voting with their feet when it comes to providing maternity care services. 2. Economic reality. Students often graduate medical school with six- figure debts. It is no surprise, therefore, when they seek greener pastures economically [2]. Similarly, current malpractice requirements make the provision of maternity care very difficult for physicians in community family medicine practices. Until there is some modicum of payment reform (and/or tort reform), the exodus of family physicians from the world of maternity care will most likely continue. There is, however, one relative exception to this rule—the Uniformed Services—a population not reflected in the database used in Cohen and Coco’s study. The provision of maternity care services by family physicians within the Uniformed Services remains robust. A majority of family physicians in the uniformed services retain their obstetric credentials and actively deliver prenatal care. At facilities where family physicians provide routine prenatal care, operative delivery rates remain much lower than national averages with equivalent neonatal outcomes [3]. In reflecting upon the reasons why many uniformed family physicians remain active in the maternity care arena, the answer (for us) is obvious: 1. outstanding professional relations and 2. Fewer economic pressures. Within the armed forces, there is an unspoken credo of camaraderie and service. Rather than competing for individual gain, the goal is team success. In the end, everyone wins—physicians, hospitals and (most importantly) patients. References:
Mark B. Stephens, MD, Associate Professor, Department of Family Medicine, Uniformed Services University, Bethesda, MD
The opinions are those of the authors--they do not represent official policy of the Department of Defense, the Navy Bureau of Medicine and Surgery, the Deparment of the Navy, the Department of the Air Force or the Uniformed Services University. Competing interests: None declared |
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Donna Cohen, Lancaster, USA Associate Director, Family Medicine Residency Program, Lancaster General Hospital
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Dr. Lin makes a compelling argument that further studies are needed examining the impact of the declining trend in prenatal care by family physicians. Studies demonstrating the cost-effectiveness and increased value of FP-provided maternity care may indeed substantiate the argument for ongoing maternity care training in family medicine. However, there are some inherent difficulties in structuring such an analysis. Unlike other analyses of usual sources of care, a large number of family physicians may rely on their obstetrical colleagues for assistance in managing obstetrical conditions both during prenatal care and delivery, making it difficult to determine the impact of care by specialty on outcomes, cost, or value. In addition obstetricians caring for patients with higher-risk conditions or requiring surgical procedures would expectedly result in higher medical expenditures, making the interpretation of such findings less clear. There may be greater value in future studies exploring the impact that this decline by family physicians may have on access to prenatal care, particularly in rural communities where no other providers may exist and women may be forced to travel in order to obtain prenatal or delivery care. As discussed in the current article, ongoing attrition of FP prenatal care services will undoubtedly have major public health implications. Research to demonstrate the specific consequence of this attrition may be the single most effective way to inform future health policy and training and ultimately the case for supporting ongoing maternity care by family physicians. Competing interests: None declared |
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Kenneth W Lin, Washington, DC Associate Editor, American Family Physician, Georgetown University School of Medicine
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Drs. Cohen and Coco demonstrate convincingly that the proportion of maternity care in the U.S. provided by family physicians continues its historic decline. I agree with the authors that this phenomenon will likely be connected with decreases in the quality and comprehensiveness of care received by pregnant women in the U.S., and possibly care of infants and young children as well.
However, to make the case for supporting continued maternity care training in family medicine outside of the circle of committed family physicians (especially those, like Drs. Cohen, Coco, and myself, who trained at one of the top FP residencies for maternity care in the country), we need studies to demonstrate the increased value, effectiveness, and cost-effectiveness of FP-provided maternity care. For example, Bob Phillips et al. (Health Affairs 2009 Mar-Apr; 28(2):567-77) recently used data from the Medical Expenditure Panel Survey to demonstrate that patients whose usual source of care is family physicians, compared to pediatricians and general internists, incur substantially lower medical expenditures. Given differences between FP and OB training in maternity care, I would not be surprised if a similar analysis of FP vs. OB data showed the same spending discrepancy.
Competing interests: None declared |
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Randall L Longenecker, Bellefontaine, Ohio Program Director, The Ohio State University Rural Program
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This article makes a very important contribution to ongoing discussions around maternity care – discussions about the unavailability of care in rural communities especially and it’s implication for the health of women and children who live there, the wisdom of a continuing maternity care requirement in family medicine residency training, and the future of integrated low-intervention care of the family in the peri-partum period and early childhood. The authors make several important points in their discussion, and I would like to highlight two of them: 1. I can certainly attest anecdotally to decreasing access to care for women in rural communities and to the adverse effects upon the lives of these women –women are failing to get early prenatal care or any care at all, particularly in counties adjacent to ours that have had to close their maternity units with a loss of providers and coincident loss of numbers; intervention rates, in particular Cesarean section rates, have increased dramatically. 2. Dropping maternity care does have far reaching consequences. Just this week, I heard news of increasingly frequent RRC citations for inadequate ambulatory pediatric training in residencies who also find it challenging to meet their required numbers in obstetrics. This “death spiral” actually affects three major areas of family medicine (obstetrics, pediatrics, and women’s health) and threatens not only our specialty and generalist practice, but the health of our communities as well. The maternity cascade described by Klein et al is being played out before us, even as advances in perinatal medicine fail to solve the problem of low birth weight infants and preterm birth. Unfortunately, documenting the demise of maternity care in family medicine does little in making the case for its survival unless it can be directly tied through further research to important patient-oriented outcomes. “Looking in the rear-view mirror” is a very limited and hazardous way to plan for the future. For rural communities, this research needs to be done using higher resolution definitions of rural (e.g. RUCA methodology) than the MSA/non- MSA dichotomy allows. External market forces beyond our control may indeed determine who provides prenatal care in the future. That doesn’t mean we shouldn’t advocate for family physician care as a means to increasing access, lowering costs, and increasing health. The market has been wrong before! Klein M; Johnston S; Christilaw J. “The Maternity Cascade” The Rural News from the Society of Rural Physicians of Canada, March 4, 2002; 4(6) http://www.srpc.ca/news/issue406.html (Accessed 3-13-2009) Competing interests: None declared |
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