Maternity care is a core tenet of family medicine, and has been reaffirmed in the Future of Family Medicine report. Although there is wide regional variation in training experience, family medicine residency can prepare residents for competency in maternity care. Our nation, especially rural areas, needs family physicians who deliver babies and provide access to care. Some family medicine residency programs offer advanced skills, including management of high-risk pregnancy and operative delivery. However, many of our programs struggle with the current Residency Review Committee (RRC) requirements for maternity care. Delivery numbers (both continuity and total) vary widely across the country. Given geography, payor mix, and liability costs, some programs have no family medicine faculty to supervise residency training in maternity care. These facts produce a tension and a polarity. What is routine for some is unacceptable for others. What is routine for some is unachievable by others. The debate is not “to do” or “not to do” obstetrics; the question is “the dose.”
Although current RRC requirements hold all programs accountable to the same standard, the Residency Assistance Program Criteria for Excellence supports a 3-tiered level of competence. Concerns over changing the numbers requirement range from support for raising the bar of competence for those obtaining maternity privileges, to fear that family medicine is “giving up on OB” if all residents do not obtain a minimum number. These positions include the following options:
CONTINUE CURRENT RRC “NUMBERS”
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Obstetrical practice is at the heart of what it means to be a family doc, and through this experience, the practicing physician builds a practice of families.
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Maternity training is a battle that current family physicians cannot quit.
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The time for differentiation of providing (or not providing) maternity care should be after residency graduation, based on community needs.
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Although not all of our members actively practice maternity care, maternity care training is essential.
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The delivery experience is an excellent opportunity to evaluate the ability/competence of our residents.
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Leaders in family medicine must make difficult decisions. Obstetrical training requirements must be protected.
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Residency programs that struggle with issues of quality obstetrical care should be assisted by the AAFP.
REVISED “NUMBERS” APPROACH
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Only a portion of graduates will integrate maternity care in their practices. Although differentiation of services should occur after graduation, many residents make this choice during training.
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Those residents who plan on providing maternity care in practice must have a competency and experience level well beyond that attainable with current RRC minimum requirements.
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Prenatal care training is essential for all. Delivery experience should be maximized by those who are likely to choose to incorporate this into their practices.
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Quality family medicine residents providing competent maternity care will be more likely to attract medical students to the discipline.
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Respect for family medicine in the Academic Health Center is dependent on raising the bar on quality/competence in our programs. Maternity care represents an area where demanding a higher level of performance (including minimal numbers) may improve the credibility of family medicine training.
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Allowing programs to shift patient care during the third trimester to residents interested in intrapartum care would provide a maximized experience for residents whose practice interests may include maternity care. (eg, all residents participate in a minimum number of prenatal visits, yet the delivery is captured by those residents who plan on doing maternity care in practice. This would allow for the continuity delivery number to go up from the current 10, to a higher number.)
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Some programs will require all residents to participate in high-volume/risk maternity care. This differentiation will be beneficial to student applicants looking for low or high maternity care options.
As educators of tomorrow’s family medicine work force, we owe our patients, and the American public, the highest level of quality. We demand this of our consultants, and should consider nothing less of ourselves. Maternity care is much more than the act of delivering a baby. Those providing this service are committing to both a body of knowledge as well as a specific skill. It is time to raise the bar on quality and competence for the maternity care services that we bring to our patients. For those providing maternity care, we should demand numbers in excess of current RRC requirements. It is also time to unshackle the burden of numbers in regions of the country where maternity care is neither practical nor possible. It is time for dialogue.
- © 2007 Annals of Family Medicine, Inc.
