Fp & Ob

[Old_Mil]

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...seems like every family medicine residency out there is eager to impress upon graduating seniors the # of deliveries and heavy OB/GYN exposure that they offer. However, for those of us who OB/GYN is only slightly more tolerable than waterboarding are there residencies that brag about how little exposure they offer?

It doesn't make a lot of sense to spend time learning things you're immediately going to flush and never practice once you're out there.

I suppose going IM is one way of avoiding this, but then you lose the kids.

It seems to me that a low or no OB volume FP residency would be wonderful. Does such an animal exist, and if so, where?

 

[AFSmiley]

I'm pretty sure I'm beating one of our friendly moderators to the punch here😎, but I am aware of one FM Residency in the great state of Texas with such a program:

http://www.wacofpc.org/obstetrics.htm

My guess is a lot of programs have similar ideas.

 

[smq123]

It seems to me that a low or no OB volume FP residency would be wonderful. Does such an animal exist, and if so, where?

Did you consider Med-Peds? Internal Medicine + Peds, with no OB or surgery rotations to worry about.

 

[herpmed]

The AAFP has a long-standing requirement of a minimum of 40 deliveries in order to meet expected skill acquisition in any accredited FM residency program. Your inquiry and the follow-up contributions raise some oft repeated criticisms of this requisite for graduation. In my opinion, OB should be offered as an optional track (ie without any specific graduation requirement for those wishing to spend time acquiring skills in other disciplines). In my experience, this would reflect the reality of the majority of practicing FPs. Most do not include OB in their practice for a number of reasons (one of the major reasons here in the northeast is the litigation potential and concomitantly high malpractice premiums). I also personally feel that anyone wishing to include OB in their practice should certainly take an OB fellowship after graduation. In many programs, the OB requirement is just that: a requirement that needs to be fulfilled. Some programs have faculty that blatantly avoid OB and allow the residents to simply meet the requirements. Others strongly encourage committed involvement in far greater than the minimum OB training. This is disingenuous and inconsistent for those wishing to spend the critical years of residency acquiring knowledge and skills in a broad range of clinical disciplines relevant to their future individual practice.
IM/Peds certainly offers an alternative and often features a stronger peds emphasis in comparison to FM. It also opens the accessibility to all of the major sub-specialty fellowships. However, it tends to have little or no gyne and (not surprisingly) has a strong hospitalist emphasis.

 

[lowbudget]

I've always thought OB/Gyn makes you a better well-rounded doctor even if you never want to deliver a baby again.
1. OB helps you understand Peds
2. OB makes you conscience of medications you prescribe to young women
3. Gyn is part of every differential diagnosis
4. Gyn is a common complaint in the outpatient setting
5. A good doctor-patient relationship (in my opinion) is more important of a gateway to seeing Peds than the label of being a Peds.
6. You will lose a large population of patients (women) if you are not sensitive to their needs
7. At my program, you can practice your suture skills in C-sections
8. At my program, OB/Gyn helps your pelvic and abdominal physical exam.
9. OB is gateway to obtaining ultrasound skills which is the ultimate outpatient, real-time, non-invasive radiologic tool. Get comfortable with ultrasound and you can use it on other parts of the body.
10. You can provide prenatal care to your patient while that patient finds an OB/Gyn with whom they can get along.
11. Strong FP programs that have strong OB experiences opens doors to faculty positions, Community Health Centers, rural/remote/international work.
12. Comfort with OB will make you fearless in the ER, Urgent Care, or a long flight with a pregnant woman.
13. Most importantly, OB experience helps YOU be a better husband/father and a better wife/mother.

 

[Shinken]

The AAFP has a long-standing requirement of a minimum of 40 deliveries in order to meet expected skill acquisition in any accredited FM residency program. Your inquiry and the follow-up contributions raise some oft repeated criticisms of this requisite for graduation. In my opinion, OB should be offered as an optional track (ie without any specific graduation requirement for those wishing to spend time acquiring skills in other disciplines). In my experience, this would reflect the reality of the majority of practicing FPs. Most do not include OB in their practice for a number of reasons....

The AAFP and Family Medicine have very definite ideas of what constitutes the "specialty" of FM and what makes a Family Physician, and care of adults, children and pregnant women is part of that definition. It doesn't surprise me that in spite of what FM docs do in real life, the Board specifies certain requirements for training.

It's similar to Osteopathic medicine where many DOs do not practice OMT when out of residency, but it's still a requirement for DO schools and DO residencies to teach it. It's part of the identity of Osteopathic medicine and what separates it from allopathic medicine. Without OMT, it's no different than allopathic medicine (at least on the outside).

If you take Ob/Gyn out of Family medicine, it becomes like IM with kids, or like Med-Peds. I don't think the AAFP would like that.

(nice post, lowbudget. My feelings exactly)

 

[herpmed]

I've always thought OB/Gyn makes you a better well-rounded doctor even if you never want to deliver a baby again.
I am a FP attending and it would take quite some time to detail the multiple flaws in your assertion. Simply, assuming one does not wish to include OB in one's practice, there are far more relevant areas of medicine that are of greater import. Devoting the precious and limited time during residency to disciplines such as dermatology, basic orthopedics, further training in various sub-specialties (and, yes, office gyne procedures) would be far more valuable to producing a "well-rounded doctor" than what amounts to terminal involvement in OB. Believe me, if you want to practice FP w/o OB, erudition in these will be FAR more important.
1. OB helps you understand Peds
Only neonatal. It sure doesn't help with the most common presentations of adolescence (unless you intend on managing teenage pregnancies).
2. OB makes you conscience of medications you prescribe to young women
You absolutely do NOT need to be actively practicing OB in order to be conscious of appropriate prescribing practices for young women.
3. Gyn is part of every differential diagnosis
EVERY DD? Not quite.
4. Gyn is a common complaint in the outpatient setting
Yes it can be, and it doesn't require that you parctice OB.
5. A good doctor-patient relationship (in my opinion) is more important of a gateway to seeing Peds than the label of being a Peds.
I don't get your point here at all.
6. You will lose a large population of patients (women) if you are not sensitive to their needs
Again, this does not by any means need that you need to be practicing, or extensively trained in, OB (ie knowledge of gyne doesn't necessitate extensive OB training). One should have sensitivity and empathy for ALL patients!
7. At my program, you can practice your suture skills in C-sections
You can also practice suturing in many, many venues to your heart's content without going near a C/S.
8. At my program, OB/Gyn helps your pelvic and abdominal physical exam.
You can practice these with gyne and stay clear of OB.
9. OB is gateway to obtaining ultrasound skills which is the ultimate outpatient, real-time, non-invasive radiologic tool. Get comfortable with ultrasound and you can use it on other parts of the body.
This is clearly without any sense of the "real world". Certification in U/S is highly specific and, if used inappropriately, can lead you down a litigation-strewn road.
10. You can provide prenatal care to your patient while that patient finds an OB/Gyn with whom they can get along.
While this is true, how long should that take? Two visits??
11. Strong FP programs that have strong OB experiences opens doors to faculty positions, Community Health Centers, rural/remote/international work.
This is an exaggeration at best. One can find plenty of work in all the environments listed w/o OB. There are a few faculty positions that seek OB-interested FPs. However, they usually strongly prefer those with OB fellowship training.
12. Comfort with OB will make you fearless in the ER, Urgent Care, or a long flight with a pregnant woman.
These are sensationalist and dramatic assertions. While one would feel more comfortable with pregnant patients presenting urgently, "fearless" is a foolhardy term.
13. Most importantly, OB experience helps YOU be a better husband/father and a better wife/mother.
Huh? If one has the components of becoming any one of these, it shouldn't take OB training to be "better".

 

[Old_Mil]

Did you consider Med-Peds? Internal Medicine + Peds, with no OB or surgery rotations to worry about.

Hi smq,

Thanks for that suggestion - after reading about Med-Peds, it certainly sounds like it would cover my areas of interest very well. Time to do some more research...

 

[lowbudget]

Ok. Well listen to the attending and go Med-Peds then. I don't care.

I've always thought OB/Gyn makes you a better well-rounded doctor even if you never want to deliver a baby again.
I am a FP attending and it would take quite some time to detail the multiple flaws in your assertion. Simply, assuming one does not wish to include OB in one's practice, there are far more relevant areas of medicine that are of greater import. Devoting the precious and limited time during residency to disciplines such as dermatology, basic orthopedics, further training in various sub-specialties (and, yes, office gyne procedures) would be far more valuable to producing a "well-rounded doctor" than what amounts to terminal involvement in OB. Believe me, if you want to practice FP w/o OB, erudition in these will be FAR more important.
1. OB helps you understand Peds
Only neonatal. It sure doesn't help with the most common presentations of adolescence (unless you intend on managing teenage pregnancies).
2. OB makes you conscience of medications you prescribe to young women
You absolutely do NOT need to be actively practicing OB in order to be conscious of appropriate prescribing practices for young women.
3. Gyn is part of every differential diagnosis
EVERY DD? Not quite.
4. Gyn is a common complaint in the outpatient setting
Yes it can be, and it doesn't require that you parctice OB.
5. A good doctor-patient relationship (in my opinion) is more important of a gateway to seeing Peds than the label of being a Peds.
I don't get your point here at all.
6. You will lose a large population of patients (women) if you are not sensitive to their needs
Again, this does not by any means need that you need to be practicing, or extensively trained in, OB (ie knowledge of gyne doesn't necessitate extensive OB training). One should have sensitivity and empathy for ALL patients!
7. At my program, you can practice your suture skills in C-sections
You can also practice suturing in many, many venues to your heart's content without going near a C/S.
8. At my program, OB/Gyn helps your pelvic and abdominal physical exam.
You can practice these with gyne and stay clear of OB.
9. OB is gateway to obtaining ultrasound skills which is the ultimate outpatient, real-time, non-invasive radiologic tool. Get comfortable with ultrasound and you can use it on other parts of the body.
This is clearly without any sense of the "real world". Certification in U/S is highly specific and, if used inappropriately, can lead you down a litigation-strewn road.
10. You can provide prenatal care to your patient while that patient finds an OB/Gyn with whom they can get along.
While this is true, how long should that take? Two visits??
11. Strong FP programs that have strong OB experiences opens doors to faculty positions, Community Health Centers, rural/remote/international work.
This is an exaggeration at best. One can find plenty of work in all the environments listed w/o OB. There are a few faculty positions that seek OB-interested FPs. However, they usually strongly prefer those with OB fellowship training.
12. Comfort with OB will make you fearless in the ER, Urgent Care, or a long flight with a pregnant woman.
These are sensationalist and dramatic assertions. While one would feel more comfortable with pregnant patients presenting urgently, "fearless" is a foolhardy term.
13. Most importantly, OB experience helps YOU be a better husband/father and a better wife/mother.
Huh? If one has the components of becoming any one of these, it shouldn't take OB training to be "better".

 

[lowbudget]

OK I'll bite. Only cuz I can't resist.

Scope of FM is such an old debate that's driven by politics and economics, which are fickle forces at best.

Let me ask you this: what makes FM different from every other specialty? From a PA/NP? I think it's the breadth of training in FM that makes you the quintessential general doctor that patients, if you pay attention to the news these days, are demanding.

If you believe in Herpmed's philosophy in training general doctors and want to extend his argument to its logical conclusion, answer me this:

1. Why do Med-Peds spend so much time inpatient when a good number of them have outpatient practices?
2. Why do Med-Peds spend so much time in the MICU, NICU, PICU when the movement is restrict general physicians (i.e. non-board certified intensivists) from working there?
3. Why bother training Med-Peds to do thoracentesis and bone marrows when people send them out to be done by radiologists so that they can get back to seeing their 30 inpatients or 40 clinic patients a day?
4. Why bother learning about some zebra in a quaternary care hospital when you'll never see it again in common everyday practice?
5. Why even take in house overnight call in the hospital as a resident when most outpatient doctors after residency don't even work in the hospital or will have the ER doc admit them for you?

Bottom line, at least the way I see the world, is that practice patterns vary by geography and it changes over time as a function of politics, economics, and technological advances. Everything you learn in residency will change in 5-10 years anyways because society advances. That, I think we can all agree on.

So then why do we bother learning all this crap in residency?
1. It serves as a basis for understanding, learning, adapting throughout your career.
2. Human beings (notably physicians, meteorologists, stock brokers) are AWFUL at predicting the future. No matter how much you "know" your future practice pattern, you don't know 100% from today until you die.
3. There's something to be gained from something you hate the most.

The fundamental debate here is about generalism vs. specialty, what serves patients the best, and how do you train to be prepared for what's out there.

It's such an old tired debate. The only thing I've ever gotten out of it is that there is no right answer, no matter how much anyone (including myself) asserts themselves to be "right".

I am a FP attending and it would take quite some time to detail the multiple flaws in your assertion. Simply, assuming one does not wish to include OB in one's practice, there are far more relevant areas of medicine that are of greater import. Devoting the precious and limited time during residency to disciplines such as dermatology, basic orthopedics, further training in various sub-specialties (and, yes, office gyne procedures) would be far more valuable to producing a "well-rounded doctor" than what amounts to terminal involvement in OB. Believe me, if you want to practice FP w/o OB, erudition in these will be FAR more important.

 

[AwesomO]

There are FM programs with light OB tracks. For instance I've run across some that have 2 months of OB during intern year and only upper level backup OB call for the last two years. I've even run across one with no OB call what so ever after intern year.

In your situation I would research such programs. Especially if you see yourself in an office based practice when done with residency.

Personally I think the whole full spectrum or complete physician is relative. Yes if you do 6-7 months of OB rotations you will be well prepared to practice OB but it will be with a cost. Those extra 3-4 months could of been spent on Pulm, Nephro, Ortho, Neuro, or what not. In the end I don't think either is more of a complete physician than the other. Just a different area of focus. I think FM programs would be better served trying to impress on us the flexibility of their programs and allowing residents to tailor the residency to their needs.

 

[sophiejane]

I'm pretty sure I'm beating one of our friendly moderators to the punch here😎, but I am aware of one FM Residency in the great state of Texas with such a program:

http://www.wacofpc.org/obstetrics.htm

My guess is a lot of programs have similar ideas.

Well...let's just say there's more to the story. Everyone does 4 months of OB, period. The number of continunity deliveries is what makes you "high" or "low" OB track.

OB is intense in Waco, I won't lie to you. It's busy, we do a lot of sections and a lot of our pts are higher-risk (DM, HTN, drug abusers, teenagers, etc). Most get around 100-150 deliveries out of the 4 months, and about half of them are usually sections.

I'd choose a program with fewer months of OB (I think you can get away with two and still meet RRC req??) and lower volume. It's a great question to ask and there is no shame in asking it. You are right about most people not using OB in spite of bragging about how many deliveries they do. But for those that want it, there's no substitute for volume.