Pulse
Rural Delivery
A new fellowship prepares family physicians to do much-needed obstetrics work in rural communities.
Dan Milbridge is acutely aware of the toll that the rural physician shortage has exacted on clinics in northern Minnesota. As administrator of Duluth Clinic sites in Aurora, Chisholm, Hibbing, and Virginia, he has seen the availability of obstetric services decrease rapidly. In Virginia, for example, three of the four obstetricians/gynecologists are still practicing, and two of those physicians are close to retiring. “We’re the biggest clinic in town, and we’re essentially out of the ob service,” Milbridge says. The plan now is to recruit family physicians who can provide obstetric care.
Milbridge has discovered, however, that finding family physicians who can confidently and skillfully practice obstetrics is easier said than done. “Keeping obstetrics viable in rural communities will require family physicians, but not all family medicine residency programs provide adequate obstetric training,” explains James Koberstein, M.D., an obstetrician/gynecologist who practices at SMDC Health System’s Duluth Clinic in Duluth.
Koberstein and Milbridge were not the first to recognize the need for better obstetric training for rural family physicians. For some time, residents in the University of Minnesota’s Family Medicine Program in Duluth had been asking for more training in obstetrics. They often felt uncomfortable because of their lack of experience, especially with difficult deliveries. That and concern from administrators at nearby hospitals and clinics about the need for family physicians who could do C-sections prompted a group of Duluth physicians, representing family medicine, rural practice, emergency medicine, and obstetrics, to design a one-year fellowship focused on better preparing rural family physicians to practice obstetrics. The Duluth Clinic Obstetrical/Procedural Medicine Fellowship accepted its first fellow in 2008.
A Perfect Storm
The paucity of physicians who can do obstetrics in rural areas is the result of a number of converging factors. First, there’s the general decline in the number of medical students choosing to go into primary care. Between 1997 and 2005, the number of U.S. medical school graduates entering family medicine residencies dropped by 50 percent, according to a 2006 article in the New England Journal of Medicine. In rural communities, which often rely on family physicians for obstetric services, the effect of the plummeting interest is particularly pronounced.
Then there’s the fact that fewer family physicians everywhere are doing obstetrics. According to a 2008 article published in Family Medicine, only 23 percent of family physicians reported delivering babies in 2005, compared with 46 percent in 1978. One reason for the decrease, Koberstein believes, is that many practices don’t have enough partners to adequately cover call duty. Another is that many rural doctors don’t feel comfortable doing high-risk deliveries. This at a time when the percentage of babies delivered by cesarean section (C-section) in the United States has been rising dramatically—from 4.5 percent in 1965 to more than 29 percent in 2004.
To add to the challenge, family physicians who have been offering ob services are retiring at a rapid rate. According to estimates from the American Medical Association, close to 340,000 physicians who began practicing in 1970 are expected to start retiring in 2010. And few new physicians are showing up to replace those who have practiced in remote areas. Rural medicine is often not the first choice for newly graduated family physicians because of lifestyle factors and more intensive call schedules.
To Koberstein, who is also director of the fellowship, those realities presented the set-up for a perfect storm. “Family physicians are often the only physicians accessible for obstetric care in rural communities, and for rural hospitals to provide obstetric services, they must have physicians available 24 hours a day who are capable of performing C-sections,” he says. “Rural hospitals not capable of providing C-sections will have to cease providing obstetric services altogether, and patients will be forced to travel long distances for obstetrical care and delivery.”
Building Skills and Confidence
The new obstetrics fellowship is designed for physicians who have just completed their three-year family medicine residency, although it is available to practicing physicians as well. The heart of the curriculum is four months of obstetrics training, which includes being on call at least once a week at St. Mary’s Medical Center. But the program also includes two months of training in the emergency department, two months of electives, and nearly four months working at one of the 12 rural Duluth Clinic sites. “The goal is to produce physicians who will be comfortable doing high-risk deliveries and C-sections in a rural setting,” says Joseph Bianco, M.D., a family doctor at Duluth Clinic-Ely and member of the fellowship committee. “But we also thought it was important that fellows learn trauma assessment and stabilization in ER settings and perform common medical procedures with confidence,” he says.
The fellowship differs from family medicine residencies in terms of both the intensity of the obstetrics training and the volume of deliveries performed. Brielle Loe, M.D., the program’s first fellow, completed the curriculum in June 2009 and began practicing at Duluth Clinic in Ely, where she grew up. During the fellowship, Loe performed more than 65 C-sections at SMDC, which she says increased her skills tremendously. (Loe estimates she performed only 10 C-sections during her family medicine residency training in Duluth.) “Of course, the first C-section I had to do in Ely was nerve-wracking because I was doing it without the watchful eye of an ob/gyn doc, but it went very, very well,” she recalls. As the only female family physician at the Ely Clinic, Loe says she now sees the majority of the obstetrics/gynecology patients. On average, about two to three patients who are seen at the clinic each year require C-sections.
Koberstein says interest in the fellowship has grown in the last year. Eight residents applied for the slot in 2010, up from three in 2009. In addition, a number of family physicians have inquired about the program. Koberstein says the fellowship is accomplishing what he wants it to, so far. And he credits the willingness of the physicians at SMDC to teach and mentor the fellows for making it happen. Loe credits them as well. “They were excellent at getting me the skills I needed,” she says. “Coming to this small rural town, where I don’t do C-sections every day, I will always be glad that I did this fellowship. It’s been absolutely invaluable.”—Jeanne Mettner