1. Maintaining Inpatient Medicine and Obstetric Care in Family Medicine Beth Choby, MD FAAFP Wendy Barr, MD,MPH Sarina Schrager, MD, MS

2. Session breakdown and timelines Welcome and introduction (5 minutes) Background and review of 2008 presentation (5 min) Implications of the changing scope of practice in family medicine (15 min) Small group discussions (45 min) Large group discussion– future plans (15 min) Wrap up and networking (5 min)

3. 2008 STFM Choby and Schrager Is obstetrics in family medicine an endangered species? Review of practice statistics Discussion of models of care Lifestyle issues, work life balance Increasing limitation in scope of care

4. Rationale for today’s seminar Inclusion of inpatient medicine Expansion of future planning to maintain specialty’s generalist focus Brainstorming Charge for STFM

5. Obstetrics and Inpatient medicine Both urban and rural family physicians who practiced obstetrics (27% and 46% respectively) were also more likely to practice inpatient medicine. Practicing obstetrics increased the average hours worked per week for rural (55.4 vs 50.2, P=.005), but not for urban (47.8 vs 49.5, P =.27) family physicians. Dresden, Annals of Family Medicine, 2008

6. Small group discussions 3 topics, 15 minutes each Recorder—write down ideas Share with large group at the end Brainstorming Share ideas, what has worked, what has not worked. Networking with fellow maternity care FPs

7. Topic 1: The current state and future trends for obstetrics and maternity care

8. What is Family Centered Maternity Care? Not just a concept in nursing care The extension of the ideal of a personal medical home and the ideals of family medicine to maternity care – Pregnancy is part of the natural process of building a family – Care should be individualized to the needs of the woman and family – Care of the mother and child is continuous from preconception, through pregnancy, and into postpartum and well child care

9. Current Models of FP Involvement in Maternity Care Shared Care – FP provides all or some of prenatal care and other provider (FP, OB, or midwife) delivers “Low-risk” Care – FP provides prenatal, intrapartum, and postpartum care to “low- risk” women – Has OB (or FP-OB) consultants to perform cesarean sections and to refer high risk cases – Different communities have different definitions of “low-risk” Comprehensive Care – FP provides prenatal, intrapartum, and postpartum care to both low risk and high risk women – FP performs cesarean sections

10. The Current State of Affairs 28% of family physicians report that they deliver babies 7% of women report that their babies were delivered by a family physician 6% of prenatal visits are done by family physicians ***% of family medicine residency programs have violations related to maternity care training

11. Prenatal Visits by FPs is declining From: Cohen D and Coco A. Declining trends in the provision of prenatal care visits by family physicians. Ann Fam Med 2009;7:128-133

12. The decline in Prenatal visits is greater in rural areas From: Cohen D and Coco A. Declining trends in the provision of prenatal care visits by family physicians. Ann Fam Med 2009;7:128-133

13. The Future – Training Programs The most common violations for family medicine training guidelines are in maternity care Proposed changes to family medicine residency training requirements in maternity care – Reduced numbers required – No longer require FM deliveries – No longer require FM faculty to deliver

14. Topic #2: Novel arrangements for call- sharing, co-management of patients, and creative approaches to managing inpatients

15. Continuity of care during labor Women who knew the provider during labor said it is important Women who were delivered by an unknown practitioner said it wasn’t important No solid evidence that women prioritize having a known clinician at their birth. No evidence of relationship with satisfaction Green, Midwifery, 2000; Freeman, Women and Birth, 2006

16. Call sharing Large group Small group FP + OB FP + midwives Continuity vs. lifestyle issues Continuity for prenatal and post partum care Delivery by “on call” person

17. Managing inpatients Rotating hospitalist model Inpatient service Balance between continuity (biggest issue with med changes and discharge planning) and lifestyle. Role modeling for residents

18. Is there lifestyle friendly maternity care? Lessons from the Maternity Centre (MC) in Hamilton/Ontario Canada – Opened in 2001 – First year medical team made up of 11 FP/OBs, with help from NP, part-time SW, lactation consultant, public health nurse and receptionist – Each FP had a set half-day clinic weekly – Patients saw the same FP for entire gestation – Price D, Howard M, Shaw E, et al. Family medicine obstetrics. Can Fam Physician 2005;51:68-74.

19. Hamilton MC FPs took 24 hour rotating call for L&D Regular meetings to discuss clinic functioning, best clinical practice Referring FPs in community could either share care or transfer (FPs who delivered promised to transfer patients back to their primaries) Option open to care for newborns; MC would provide care for 6 weeks and transfer back 4 Ob/Gyns provide emergency backup

20. How did it work? 63% of FPs satisfied with call system 82% reported improved lifestyle 55% reported improvement in clinical skills Patients very pleased with care, even when not delivered by FP they had met before

21. Topic 3: Negotiating a “normal” life when delivering babies Why our residents are opting out of maternity care – “Too frightening” – “Too high stakes” – “Too much time away from my family” – “Too easy to stay in the office”

22. Some ideas about negotiating a better life Do most physicians really enjoy call? Call causes more dissention among MD/Dos than money Call is more complicated for FPs because “we do it all” Even more complicated when you deliver babies and see newborns 90% of physicians would not take more call for money Ref: Daugird A. Call RVUs: One way to make call more equitable. Fam Prac Management 2002;9(6):31-34.

23. Some ideas Call RVUs (relative value units) – Define what a night of call is worth – Define what a night with ob/nursery call is worth – People can arrange their call according to their needs – It needs to add up at the end of the month/year, etc.

24. What’s a day of call worth to you? Inpatient attending w/o deliveries/nursery – Sat or Sun = 2.0 RVU/day – Fri= 1.5 RVU – Mon-Thurs= 1RVU/day OB/Newborn care – Sat or Sun= 2.3 RVU/day – Fri= 1.7 RVU – Mon-Thurs = 1.2 RVU

25. Other ideas Call for money (yes some folks actually have done this) Trade off for what you like Call for time – Set time off weekly – Sabbaticals – Flex days to save

26. Rotating small group discussions