How does/did your residency program handle OB?

[Xorthos]

I'm just posting this to get an idea of how other FM programs deal with OB patients in Labor.

Our program has always had "OB" rotations, when you primarily deal with the L&D floor and manage the labor patients. I've completed them in first and second year and have around 60 deliveries. However, lately we have become semi-affiliated with a private family practice office that practices heavy OB, but none of the private doctors who are managing the prenatal care wish to take call to come in and deliver their patients, leaving us to cover for them.

This has led to the inpatient team having to cover their L&D patients as well. Normally I wouldn't mind, however there is only one upper level on the service at night shift, and often we are covering 15-20 patients by ourselves, admitting ER patients, and now having to manage/deliver L&D patients at the same time, which can be incredibly cumbersome for one person to do, and feels unsafe.

How were most other programs dealing with OB? Was it part of your normal inpatient rotations, or was there an OB resident on during each month to handle these things?

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[Sardonix]

Sorry for the bump, but I would love to hear peoples' experience on this as well.

 

[Atlas Shrugged]

We deliver our own continuities only, if not on an LND rotation. Inpatient resident covers/sits on LND until they are in active labor (or before based on preference) then continuity resident is called in to finish management and deliver the baby. Continuity resident rounds on mom and baby, does circ if requested, etc. Inpatient team follows peripherally to make sure a critical bili isn't missed.

 

[smq123]

We deliver our own continuities only, if not on an LND rotation. Inpatient resident covers/sits on LND until they are in active labor (or before based on preference) then continuity resident is called in to finish management and deliver the baby. Continuity resident rounds on mom and baby, does circ if requested, etc. Inpatient team follows peripherally to make sure a critical bili isn't missed.

This is how we did it as well.

I'm confused by the OP's question - how does your program handle continuity deliveries, then? Or is that not a requirement any longer?

 

[LeroyJenkinsMD]

Separate service. OB team does it all.

 

[SLC]

We had a completely separate OB service that FM residents ran. It was in a women’s hospital, so there could be no general medicine patients (unless they were females and also pregnant). Fairly big census, but all OB/newborns. We covered our entire practice of about 20k patients, as well as a few of the community health centers, and a few private groups (who also donated some part time attendings to the service).


Generally one 2nd or 3rd year was on for 24h at a time; then two interns would split the day in half and each pull 12’s.

So 2 residents in hospital (senior and intern) at all times to cover our service. No general medicine duties. We also doubled as the code team for adults (and we’re members of the pedi-code team) in that hospital since the OB residents didn’t feel comfortable and the peds residents only knew PALS/NRP.

 

[septoplasty]

Our program we delivered continuity no matter what rotation (or if on vacation, covering resident), got our ''numbers'' from rotations on L&D w/ Ob+Gyn docs in our base hospital + busier hospital. Obviously always having attending oversight, never just residents.

Now they've started a OB fellowship, which I imagine the fellows cover the floor, which will supervise the deliveries vs. FM attendings (unless its their private patient).

 

[cabinbuilder]

I never did OB in residency. Assisted in 10 C-sections. That's it. No pre-natal. I was at an Internal medicine heavy FM residency. All the OB patients were private so we never did anything with OB.


This has since been changed. The class after me complained loudly and got an OB rotation developed.

 

[VA Hopeful Dr]

My program changed midway through my time.

Started out having our own OB service - clinic, deliveries, PP. We'd also get all unassigned patients.

Then we partnered with one of the PP groups in town. Did all of their deliveries. Our numbers went through the roof. Previously we'd all hit 40 deliveries but usually not too much more. Once we started this, the interns would get that many deliveries in a month (out of 3 OB service months). Still had our own patients to cover prenatal and PP care but now our grads are getting 100+ deliveries by graduation.

 

[mcat_taker]

looking for advice- As someone who is interested in OBGYN but might apply dual path with FM just in case, what kind of experience does FM really get you in OBGYN? As an FM doc would you only really get to manage deliveries in rural areas ? I'm not looking to settle down in rural small town America after residency. I envision myself living in a midsize to large city which presumably has access to full sub-speciality/tertiary care, so why would anyone come to see me, an FM doc for OBGYN care versus an OBGYN doctor?

This is really my biggest question as I explore FM. The training seems to be really broad with OR, OB, peds, etc in residency but if you don't want to live in the middle of nowhere will you actually put those skills learned in training and see those patients?? If I was a parent I would presumably want to take my kid to a pediatrician not an FM doc.

 

[LeroyJenkinsMD]

If you want to work in a big city do OBGYN. This will come at the cost of not managing the kids you deliver, the rest of the family etc. whether that cost matters to you is... up to you. I will say I am seeing more jobs here FPOBs will share call with a group of OBGYNs if they have completed a fellowship.

 

[Atlas Shrugged]

Honestly, even OBs don't want to do LND. I think the average is about 10 years out of residency before a majority start doing primarily GYN or something else.

FM OB would be much more favorable if there wasn't so much liability for so little pay. I am curious as to how CNMs work in the civilian sector with liability etc.

The only reason FM OB in the army is alive and well is reduced liability.

 

[VA Hopeful Dr]

Honestly, even OBs don't want to do LND. I think the average is about 10 years out of residency before a majority start doing primarily GYN or something else.

FM OB would be much more favorable if there wasn't so much liability for so little pay. I am curious as to how CNMs work in the civilian sector with liability etc.

The only reason FM OB in the army is alive and well is reduced liability.

That has not been what I'm seeing, any data on that?

 

[TableMD]

On a personal level, I loved having a family doc take care of my wife and act as pediatrician for our two little ones. The problem with the whole thing is that as part of the package deal they have to take care of me and deal with my BS...

Family Docs who do OB are super cool, in my opinion, which is why I get defensive about any limits to their ability to do it, even if it doesn't effect my practice personally. In some hospitals, OB-GYNs, can use the clout of the money they make for the hospital w/ surgeries to own L&D.

 

[mcat_taker]

@TableMD @cj_cregg @LeroyJenkinsMD thank you for your responses. It's def something I'm thinking about in case OBGYN doesn't work out since it is getting more competitive. @Atlas Shrugged OBGYNs now have dedicated hospitalists that strictly do L and D so I wouldn't say its becoming less popular, especially with less call now.

I also worry about training in FM since you get into the OR and L and D you step on other residents toes and get on their turf so you may not get the best experience or training competing w GS residents and OB residents and peds residents ? This is what I imagine happening but would it be true? Like them looking down on you and feel you're taking away from their procedures and cases or that you aren't qualified enough.

 

[LeroyJenkinsMD]

@TableMD @cj_cregg @LeroyJenkinsMD thank you for your responses. It's def something I'm thinking about in case OBGYN doesn't work out since it is getting more competitive. @Atlas Shrugged OBGYNs now have dedicated hospitalists that strictly do L and D so I wouldn't say its becoming less popular, especially with less call now.

I also worry about training in FM since you get into the OR and L and D you step on other residents toes and get on their turf so you may not get the best experience or training competing w GS residents and OB residents and peds residents ? This is what I imagine happening but would it be true? Like them looking down on you and feel you're taking away from their procedures and cases or that you aren't qualified enough.

I think you’ll learn that every field of medicine looks down on every other field and that in general medicine is full of type A narcissists. You’ll eventually stop caring what other people think after you realize this.

 

[mcat_taker]

Absolutely can be true at some programs. Many of the FM programs that have stronger OB training, OB fellowships, etc. are "unopposed," which means there are no other residency programs at the hospital other than FM. So that can help avoid issues that arise from competing with other residents for cases. There are also certain states and regions that are more FM friendly and tend to have more FM docs doing more stuff, so training in those areas might afford you a little more respect as an FM resident.

This is an incomplete list of FM programs known to have stronger OB training, and there's also some info on what to look for in a program if you know you want to do OB in practice. Looks like there are several in mid-size cities.

This is really useful thanks @cj_cregg. And if you do the fellowship you could be credentialed to work as an L and D hospitalist in any system ANYWHERE alongside OBs ? For example NYC and other major metros ?

 

[VA Hopeful Dr]

This is really useful thanks @cj_cregg. And if you do the fellowship you could be credentialed to work as an L and D hospitalist in any system ANYWHERE alongside OBs ? For example NYC and other major metros ?

Depends on the hospital. Plenty will still say no.

 

[TableMD]

The best thing you can do if you want to OB is talk to family docs that do it, and discuss
- culture w/ nurses/OBs on staff (if present)
- coverage/call
- med mal premiums (NSVD vs C-section) where I live, if you cross the threshold you go from simple office procedures (something every family doc/sports doc should have - injections, skin biopsy, lac repair, etc (12K, which ironically includes NSVD) but you bump to 100K if you want to do sections (that's a lot in the hole before breaking even on a surgical procedure that doesn't pay all that much, and you own those kids outcomes for life, i.e. later developing autism, other neurological issues). Gee doctor that was a category II strip, why didn't you section sooner?!?!
- most family OB docs that I know do the NSVD piece and have call worked out with OB for back up and section (even though the good family med OBs can do sections/or could have following training), they dont have the volume to support the med mal
- this is the game, to own women's reproductive health, and the pay off of surgeries (TAHBSO, etc), the OBs eat the med mal cost of being their full service OBGYN and are also, often/sometimes, more trigger happy with sections
- my wife was at 4 hours+ hours of pushing, our doc however was patient because she was delayed by her Epi in being able to push correctly, sadly most OBs would have not been as patient, and would likely have sectioned (some, not all, obviously there are the great ones and I mean no disrespect to that profession which I honestly admire greatly)
- if you do want to have C-section privileges, you MUST be supported by L&D and admin, since bad things WILL eventually happen, if they dont want you doing it, you will PAY when things go wrong (just because you can, doesn't mean you should). Don't be that person.

With all this said, I adore our doc, and if you are willing to go down this road, it can be done, but it is a specialized niche with requirements regarding:
1.) TRAINING you need to have close/bad situations that YOU manage competently before you are done
- i.e. if you can't do a legit repair/vac/emergent section or have access to emergent back up, you have no business in L&D
- get training with blades (if possible)/vac/epis/complicated repairs (well vascularized tissue, dont have to be fancy, but it has to heal correctly/anatomically w/o hematoma/infection/etc
2.) LOCATION and hospital culture - look where fellows and legit family OB docs PRACTICE, do you WANT/are WILLING to practice there
- in my case I wanted a hybrid of sports med and family med, plus support for some other oddities that I am into, so I was very flexible on location and salary since I cared more about practice style, I did however get lucky with location and salary(ish), bearing in mind I am a former teacher so anything over 60K is a big deal to me
3.) SCHEDULE/COVERAGE
- if you are the only family OB, your patients will need YOU for every little triage that comes up
- I slept in the hospital during my sports med interviews because I had a continuity patient on L&D and I stayed there when not flying (not because Im a hardcore OB person, but it was a respect thing)

If you do not do the work to find family med OBs, discuss their practice, take in the totality of what they do, then its probably not a good fit, as it takes extra work to be a good family doc AND a good/well trained/rounded provider of obstetric care on top. An example is someone telling me they want to do sports med but have no interest in coverage and being a part of the community at the schools (talks/training room/providing quick 24 hr access to any ATCs w/ concerns).

Like most specialists, you will have less job flexibility than general family med (w/o OB), BUT that's they way things work with specialty care, you need a base of support for the volume, to keep the lights on. Still, lot easier to end up where you want to compared to some other specialties...

Good luck

 

[Reboa]

The best thing you can do if you want to OB is talk to family docs that do it, and discuss
- culture w/ nurses/OBs on staff (if present)
- coverage/call
- med mal premiums (NSVD vs C-section) where I live, if you cross the threshold you go from simple office procedures (something every family doc/sports doc should have - injections, skin biopsy, lac repair, etc (12K, which ironically includes NSVD) but you bump to 100K if you want to do sections (that's a lot in the hole before breaking even on a surgical procedure that doesn't pay all that much, and you own those kids outcomes for life, i.e. later developing autism, other neurological issues). Gee doctor that was a category II strip, why didn't you section sooner?!?!
- most family OB docs that I know do the NSVD piece and have call worked out with OB for back up and section (even though the good family med OBs can do sections/or could have following training), they dont have the volume to support the med mal
- this is the game, to own women's reproductive health, and the pay off of surgeries (TAHBSO, etc), the OBs eat the med mal cost of being their full service OBGYN and are also, often/sometimes, more trigger happy with sections
- my wife was at 4 hours+ hours of pushing, our doc however was patient because she was delayed by her Epi in being able to push correctly, sadly most OBs would have not been as patient, and would likely have sectioned (some, not all, obviously there are the great ones and I mean no disrespect to that profession which I honestly admire greatly)
- if you do want to have C-section privileges, you MUST be supported by L&D and admin, since bad things WILL eventually happen, if they dont want you doing it, you will PAY when things go wrong (just because you can, doesn't mean you should). Don't be that person.

With all this said, I adore our doc, and if you are willing to go down this road, it can be done, but it is a specialized niche with requirements regarding:
1.) TRAINING you need to have close/bad situations that YOU manage competently before you are done
- i.e. if you can't do a legit repair/vac/emergent section or have access to emergent back up, you have no business in L&D
- get training with blades (if possible)/vac/epis/complicated repairs (well vascularized tissue, dont have to be fancy, but it has to heal correctly/anatomically w/o hematoma/infection/etc
2.) LOCATION and hospital culture - look where fellows and legit family OB docs PRACTICE, do you WANT/are WILLING to practice there
- in my case I wanted a hybrid of sports med and family med, plus support for some other oddities that I am into, so I was very flexible on location and salary since I cared more about practice style, I did however get lucky with location and salary(ish), bearing in mind I am a former teacher so anything over 60K is a big deal to me
3.) SCHEDULE/COVERAGE
- if you are the only family OB, your patients will need YOU for every little triage that comes up
- I slept in the hospital during my sports med interviews because I had a continuity patient on L&D and I stayed there when not flying (not because Im a hardcore OB person, but it was a respect thing)

If you do not do the work to find family med OBs, discuss their practice, take in the totality of what they do, then its probably not a good fit, as it takes extra work to be a good family doc AND a good/well trained/rounded provider of obstetric care on top. An example is someone telling me they want to do sports med but have no interest in coverage and being a part of the community at the schools (talks/training room/providing quick 24 hr access to any ATCs w/ concerns).

Like most specialists, you will have less job flexibility than general family med (w/o OB), BUT that's they way things work with specialty care, you need a base of support for the volume, to keep the lights on. Still, lot easier to end up where you want to compared to some other specialties...

Good luck

Excellent response, thank you. I don't mean to derail the thread too much. But do you mind going a little deeper into what your practice looks like and what you do procedurally with your sports and fm hybrid job?

 

[mcat_taker]

The best thing you can do if you want to OB is talk to family docs that do it, and discuss
- culture w/ nurses/OBs on staff (if present)
- coverage/call
- med mal premiums (NSVD vs C-section) where I live, if you cross the threshold you go from simple office procedures (something every family doc/sports doc should have - injections, skin biopsy, lac repair, etc (12K, which ironically includes NSVD) but you bump to 100K if you want to do sections (that's a lot in the hole before breaking even on a surgical procedure that doesn't pay all that much, and you own those kids outcomes for life, i.e. later developing autism, other neurological issues). Gee doctor that was a category II strip, why didn't you section sooner?!?!
- most family OB docs that I know do the NSVD piece and have call worked out with OB for back up and section (even though the good family med OBs can do sections/or could have following training), they dont have the volume to support the med mal
- this is the game, to own women's reproductive health, and the pay off of surgeries (TAHBSO, etc), the OBs eat the med mal cost of being their full service OBGYN and are also, often/sometimes, more trigger happy with sections
- my wife was at 4 hours+ hours of pushing, our doc however was patient because she was delayed by her Epi in being able to push correctly, sadly most OBs would have not been as patient, and would likely have sectioned (some, not all, obviously there are the great ones and I mean no disrespect to that profession which I honestly admire greatly)
- if you do want to have C-section privileges, you MUST be supported by L&D and admin, since bad things WILL eventually happen, if they dont want you doing it, you will PAY when things go wrong (just because you can, doesn't mean you should). Don't be that person.

With all this said, I adore our doc, and if you are willing to go down this road, it can be done, but it is a specialized niche with requirements regarding:
1.) TRAINING you need to have close/bad situations that YOU manage competently before you are done
- i.e. if you can't do a legit repair/vac/emergent section or have access to emergent back up, you have no business in L&D
- get training with blades (if possible)/vac/epis/complicated repairs (well vascularized tissue, dont have to be fancy, but it has to heal correctly/anatomically w/o hematoma/infection/etc
2.) LOCATION and hospital culture - look where fellows and legit family OB docs PRACTICE, do you WANT/are WILLING to practice there
- in my case I wanted a hybrid of sports med and family med, plus support for some other oddities that I am into, so I was very flexible on location and salary since I cared more about practice style, I did however get lucky with location and salary(ish), bearing in mind I am a former teacher so anything over 60K is a big deal to me
3.) SCHEDULE/COVERAGE
- if you are the only family OB, your patients will need YOU for every little triage that comes up
- I slept in the hospital during my sports med interviews because I had a continuity patient on L&D and I stayed there when not flying (not because Im a hardcore OB person, but it was a respect thing)

If you do not do the work to find family med OBs, discuss their practice, take in the totality of what they do, then its probably not a good fit, as it takes extra work to be a good family doc AND a good/well trained/rounded provider of obstetric care on top. An example is someone telling me they want to do sports med but have no interest in coverage and being a part of the community at the schools (talks/training room/providing quick 24 hr access to any ATCs w/ concerns).

Like most specialists, you will have less job flexibility than general family med (w/o OB), BUT that's they way things work with specialty care, you need a base of support for the volume, to keep the lights on. Still, lot easier to end up where you want to compared to some other specialties...

Good luck

Thanks! Is your practice of this hybrid OB/FM/sports med type of care in a large metro area or rurally?