OB in FM

[Mirp]

I had a few questions about practicing obstetrics as an FM doc.. Realistically speaking:
1) Can you get enough numbers to stay fresh?
If you practice in an urbun or suburbun setting it seems like there are enough ob/gyns to cover everyone and local hospitals won't grant you privileges to deliver, let alone do CS. If you are rural can you realistically cover a large enough area that you'll get enough numbers and see enough difficult deliveries to maintain your skills?
2) How much is enough to stay fresh?
Talking to the local ob/gyns the numbers I get for sections is about 50 a year as primary surgeon and some of them won't even consider that an FM doc should do c-sections as primary regardless of what AAFP and ACOG write about it. Vaginal deliveries I assume at least twice that would be alright.
3) As an FM doc, let's say with an OB fellowship done, can you go anywhere in the English speaking world and do primarily obstetrics? As in, I'm happy to see moms and babies in my clinic, but I'm really not interested in managing uncle Ed's diabetes or grandpa's general polypharmacy issues. Where might that be? Assume salary is unimportant, but I prefer not to be dodging bullets on my way to/from/while at work.
4) Thoughts on burnout??
FM docs put in a lot of hours. OBs put in a lot of hours. I'm happy at the moment as long as I'm delivering babies or doing something remotely related to it regardless of hours, but I wonder how sustainable this lifestyle is.
5) Should I just bite the bullet and do an ob/gyn residency....? The more obstetrics I do (and the more general FM I do), the less I care about general FM and the more I want to do exclusively obstetrics.

Thanks a lot for any advice you might have!

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[DrMidlife]

I had a few questions about practicing obstetrics as an FM doc.. Realistically speaking:
1) Can you get enough numbers to stay fresh?

Yes. FM docs do obstetrics all over the country. I suggest meeting one who does. Soon. Preferably more than one.

If you practice in an urbun or suburbun setting it seems like there are enough ob/gyns to cover everyone and local hospitals won't grant you privileges to deliver, let alone do CS. If you are rural can you realistically cover a large enough area that you'll get enough numbers and see enough difficult deliveries to maintain your skills?

If there's a particular part of the country you want to target, then do inventory of the hospitals. Look at the doctor lists at the hospitals, as well as at the ObGyn practices and FM practices. That's how to find the docs who can more specifically guide you. Note that if you've only spent time in an academic hospital, the difference will be astonishing.

2) How much is enough to stay fresh?
Talking to the local ob/gyns the numbers I get for sections is about 50 a year as primary surgeon and some of them won't even consider that an FM doc should do c-sections as primary regardless of what AAFP and ACOG write about it. Vaginal deliveries I assume at least twice that would be alright.

"The local ob/gyns" probably means they're associated with your med school? They have no visibility into the obstetrics practiced by FM docs unless they've worked with FM+OB docs, which they generally haven't if they've only worked at academic centers and/or in wealthy areas. As above, find a community where there are FM+OB docs and talk to them directly about how they work with the local ObGyns.

Down the road, you'd generally do a job search on FM+OB, and part of the negotiation would be to understand how many births there currently are and how call is divided up. If you're Q2 for a community that has 80 births, you're doing 40, which is plenty to stay fresh. An example would be a community with a 100 bed hospital, with one ObGyn & one FM+OB covering call, with maybe 100 births per year. 50 is fresh. These numbers aren't hard to find.

3) As an FM doc, let's say with an OB fellowship done, can you go anywhere in the English speaking world and do primarily obstetrics? As in, I'm happy to see moms and babies in my clinic, but I'm really not interested in managing uncle Ed's diabetes or grandpa's general polypharmacy issues. Where might that be? Assume salary is unimportant, but I prefer not to be dodging bullets on my way to/from/while at work.

Other countries are no easier to get into than the US for medical practice. You generally have to repeat residency. The more underserved a location is, the fewer obstacles.

There are FM docs and FM+OB docs who only do women's health. Find some. Find out what they had to do to get/create those jobs.

4) Thoughts on burnout??
FM docs put in a lot of hours. OBs put in a lot of hours. I'm happy at the moment as long as I'm delivering babies or doing something remotely related to it regardless of hours, but I wonder how sustainable this lifestyle is.

If you've never had a real job before, yes, you should be concerned about how hard you have to work in residency and in any practice scenario where you're taking call. Part of med school is learning what long hours and call coverage is like.

ObGyns and FM+OBs in practice have to deal with their own pregnancies and life circumstances etc, and are often looking for jobs that have less call. Find some docs that have been through this.

5) Should I just bite the bullet and do an ob/gyn residency....? The more obstetrics I do (and the more general FM I do), the less I care about general FM and the more I want to do exclusively obstetrics.

"Just" ? ObGyn is one more year than FM. ObGyn is a surgical residency in an academic center. There are fewer than 300 residencies. Your numbers are your fate in getting one of those residencies. ObGyn residencies are notoriously toxic, and you can't really screen for that. ObGyns make $250k+ on average.

FM is 3 years, OB after is 1 year. If women's health is of interest, then you need to target OB-heavy FM residencies such as MAHEC or Alaska or Natividad or similar (check the numbers, "heavy" is subjective). In a heavy OB FM residency, 100+ vag & 40+ c-sections is typical. In a 1 year OB fellowship, you get lots more, and you typically get enough numbers to satisfy a hospital that wants FM docs doing OB. There are 500+ FM residencies and the sites vary dramatically - from academic centers to rural community clinics. There are FM residencies that are just as hard to get into as your average ObGyn residency, and other FM residencies that are easier. FM residencies can be just as toxic and a toxic residency is hard to identify. FM docs make as little as $100k or upwards of $400k depending on lots of things.

tl;dr: find an FM+OB doc and get in there. use school breaks if necessary.

Best of luck to you.

 

[cabinbuilder]

Sounds like you need to do an OB/GYN residency.

 

[Mirp]

I just started my 2nd year of FM residency in July, so that makes switching trickier if I were to try that route. I already have 50+ vaginal deliveries, a whole bunch of 2nd assists on CS and a much smaller number of 1st assists. Getting the obgyns to let me do more seems to be the sticking point since they aren't used to it and we're an unopposed program so they just do their own thing without residents most of the time, but I do have some time to work on them in that regard and some of the more confident/older ones are willing to let me have at it. Truthfully I'd rather not switch halfway through residency for lots of reasons. It's really do I shoot for 3 more years to get the full ob/gyn package after this residency or just try to cram enough numbers into 1 year of fellowship and then look for those positions DrMidlife mentioned. The total time required isn't a huge issue. I'm already "non-traditional" and my loans are smaller than most of my colleagues' thanks to what I had saved up before I started so while being done sooner is great I'm happy as long as I'm delivering babies or doing something related to that. I guess I'm just fishing for various thoughts on how best to get where I'd like to go. Thanks again for the advice!

 

[DrMidlife]

do I shoot for 3 more years to get the full ob/gyn package after this residency

if you choose to switch, assume 4 more years of residency, as obgyn is a 4 year residency. you might (MIGHT) get lucky and not have to start over as an intern. but that's 100% at the discretion of the PD, who would have to be motivated to investigate what your training has included so far and decide to take you as a PGY2. or not. obgyn PDs are busy people with too many candidates for too few openings.

anecdote: a FM+OB faculty member at my med school just started obgyn residency as a PGY2.

just making sure the facts are on the table.

 

[DrMidlife]

Getting the obgyns to let me do more seems to be the sticking point since they aren't used to it and we're an unopposed program so they just do their own thing without residents most of the time

Generally it's worse at an opposed program because you're competing with the other residents for obgyn time. If there are EM and/or IM and/or prelim interns, they take away L&D training opportunities for FM residents. If there are ObGyn residents, same thing times 4.

Your residency is required by the ACGME (or maybe the AOA) to provide obstetrical training. Your PD should be refereeing this problem with the ObGyn faculty.

 

[galactus]

I did an opposed program that had OB residents. Half my resident class does surgical OB. Mind you they all practice rural, and we have 6 FM physicians that had surgical OB privileges at the hospital, so that helped a lot in regards to obtaining our numbers. No one in my residency does an OB fellowship, as we have plenty of OB patients to go around.
Long story short - it's possible.

 

[TedStark]

How much does a cesarean section reimburse? How much does malpractice for a family doc doing OB cost/year?

 

[styphon]

3) As an FM doc, let's say with an OB fellowship done, can you go anywhere in the English speaking world and do primarily obstetrics? As in, I'm happy to see moms and babies in my clinic, but I'm really not interested in managing uncle Ed's diabetes or grandpa's general polypharmacy issues. Where might that be? Assume salary is unimportant, but I prefer not to be dodging bullets on my way to/from/while at work.

Theoretically in the U.S., you can. But in reality, in the cities you will face too high competition for patients to be sustainable.

But the statement above confuses me, if you don't care about the non-pregnant patients, why not just do OB/GYN and become a laborist?

 

[psychMDhopefully]

I did an opposed program that had OB residents. Half my resident class does surgical OB. Mind you they all practice rural, and we have 6 FM physicians that had surgical OB privileges at the hospital, so that helped a lot in regards to obtaining our numbers. No one in my residency does an OB fellowship, as we have plenty of OB patients to go around.
Long story short - it's possible.

I thought unopposed meant, FM residents were the only residents there so they were"unopposed" when it came to doing procedures and everything else. I worked with an OB today, she had a mini rant about how FM shouldn't do ob, they arent adequately trained for it, how the OBs have to cover for the FM docs because they dont know what they are doing, etc. And even though this hospital was very rural non of the FM docs have OB privileges there. Seems FM doing OB is becoming harder and harder.

 

[Natividad Resident]

In general, if you're interested in FM and in doing OB as an FM:
do: find an FM doc doing OB
don't: ask OBs how the FM world works

 

[Freezeout]

I thought unopposed meant, FM residents were the only residents there so they were"unopposed" when it came to doing procedures and everything else. I worked with an OB today, she had a mini rant about how FM shouldn't do ob, they arent adequately trained for it, how the OBs have to cover for the FM docs because they dont know what they are doing, etc. And even though this hospital was very rural non of the FM docs have OB privileges there. Seems FM doing OB is becoming harder and harder.

There's a reason the ACGME did away with required delivery numbers.

 

[BigSib]

At an unopposed FM program in a suburban area and I have ~110 vaginal deliveries performed (+ several observed) at the beginning of 3rd year. First assist in 18 Cesareans. Feeling very comfortable with low and moderate risk OB. FM and OB residents come here from other programs to get experience, no deficiency of patients. There are plenty of FM docs doing OB here.

From what I've heard from the FM docs you have to have about 20 deliveries a year in order to break even with the malpractice, which is a bigger deal if you're not employed by a hospital system.

... 3) As an FM doc, let's say with an OB fellowship done, can you go anywhere in the English speaking world and do primarily obstetrics? As in, I'm happy to see moms and babies in my clinic, but I'm really not interested in managing uncle Ed's diabetes or grandpa's general polypharmacy issues. Where might that be? Assume salary is unimportant, but I prefer not to be dodging bullets on my way to/from/while at work.

I'm not aware that this exists, but if you searched hard enough in the 'English speaking world' I'm sure you could probably find it. As an FM doc you're going to manage chronic medical conditions...

 

[Makati2008]

I had a few questions about practicing obstetrics as an FM doc.. Realistically speaking:
1) Can you get enough numbers to stay fresh?
If you practice in an urbun or suburbun setting it seems like there are enough ob/gyns to cover everyone and local hospitals won't grant you privileges to deliver, let alone do CS. If you are rural can you realistically cover a large enough area that you'll get enough numbers and see enough difficult deliveries to maintain your skills?
2) How much is enough to stay fresh?
Talking to the local ob/gyns the numbers I get for sections is about 50 a year as primary surgeon and some of them won't even consider that an FM doc should do c-sections as primary regardless of what AAFP and ACOG write about it. Vaginal deliveries I assume at least twice that would be alright.
3) As an FM doc, let's say with an OB fellowship done, can you go anywhere in the English speaking world and do primarily obstetrics? As in, I'm happy to see moms and babies in my clinic, but I'm really not interested in managing uncle Ed's diabetes or grandpa's general polypharmacy issues. Where might that be? Assume salary is unimportant, but I prefer not to be dodging bullets on my way to/from/while at work.
4) Thoughts on burnout??
FM docs put in a lot of hours. OBs put in a lot of hours. I'm happy at the moment as long as I'm delivering babies or doing something remotely related to it regardless of hours, but I wonder how sustainable this lifestyle is.
5) Should I just bite the bullet and do an ob/gyn residency....? The more obstetrics I do (and the more general FM I do), the less I care about general FM and the more I want to do exclusively obstetrics.

Thanks a lot for any advice you might have!

Why not just do strictly ob/gyn


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[TedStark]

Why not just do strictly ob/gyn


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Normally I hate this question...

"I like X and Y."

"Why not just do X?"

"Because family medicine is the only specialty that allows you to pursue tons of interests at the same time."

However, it's a good question in this situation because you sound like you really enjoy OB only.

 

[hilseb]

if you choose to switch, assume 4 more years of residency, as obgyn is a 4 year residency. you might (MIGHT) get lucky and not have to start over as an intern. but that's 100% at the discretion of the PD, who would have to be motivated to investigate what your training has included so far and decide to take you as a PGY2. or not. obgyn PDs are busy people with too many candidates for too few openings.

anecdote: a FM+OB faculty member at my med school just started obgyn residency as a PGY2.

just making sure the facts are on the table.

From what I understand, it would be hard for them to get around the requirement that you have done 48 months of training in an ABOG residency without having a transferring resident repeat intern year. Then, that is an issue when Medicare funding eligibility gets cut, because that resident would have her funding reduced after two years of OB residency.