So do FM docs do c-sections or not?

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MiesVanDerMom said:
I read a link someone posted in this forum where it was being argues FM dcos should be allowed to do c-sections. Is this common? I'm interested in FM with OB and I'm just wondering.
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Maybe I have been around some really bad ones (more likely average for FM) but I think they should not. They take twice as long, sometimes pushing the limits of a spinal. They lose twice as much blood. Are slow to make decisions and they can't perform hysterectomies when needed, like in VBAC's with uterine rupture, placenta accreta or increta etc. Their knowledge of the pregnant pt is limited in comparison to a obstetrician. So it is my opinion that the only time it is acceptable to have a FM performing c/s is when there are no obstetricians in the area and even then I would be worried if it were my family member.

I know this will be quite controversial for many of you but it is my experience and of course my opinion.

I just read your question again. My answer, I hope its not common.
 
MiesVanDerMom said:
I read a link someone posted in this forum where it was being argues FM dcos should be allowed to do c-sections. Is this common? I'm interested in FM with OB and I'm just wondering.
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I think you can do an OB fellowship from FM and learn how to do c-sections. If anybody is going to let you is the question. Even a lot of OB/gyns have stopped doing C-sections (and other obstetrics) because of the liability.

I have done a few OB rotations and will do my last one, thank God, in two months. I've seen quite a few C-sections and "first-assisted" in a handful. The only C-section I would even consider doing would be a post-mortem one and then imagine the awfullness of having to decide in less than two minutes if the mother was dead and this was the baby's only chance, especially since no one would fault you if you didn't do it.

It's not rocket science. On the other hand a lot can go wrong.
 
I'd be interested to hear more about your experience Noyac and your solution to who should care for obstetrical patients in remote / rural areas. It seems somewhat skewed, coming from a residency where we routinely turn out FPs who do C/S I can say it is most certainly in our scope of practice, this is supported both by ACOG and AAFP. One of our past residents did a study of outcomes of C/S performed residents versus community physicians and found no difference. Feel free to do a lit search for more details.

There are still great residencies that turn out competent FPs with surgical obstetrical skills, granted I'll agree you won't see FPs doing too many hysterectomies but there are certainly other ways to deal with bleeding besides hyst while your are in the abdomen performing c-section. So the answer to your question is YES, just find the right residency, alternatively there OB fellowships that train you even more in surgical obstetrics.
 
Personally, I think it is interesting that there's only a small percentage of FPs out there who do perform C/S. (http://www.aafp.org/online/en/home/aboutus/specialty/facts/41.html). I guess it's comparable to colonoscopies (http://www.aafp.org/online/en/home/aboutus/specialty/facts/56.html), but just pales when compared to number who do ICU work (http://www.aafp.org/online/en/home/aboutus/specialty/facts/48.html), or ER (http://www.aafp.org/online/en/home/aboutus/specialty/facts/49.html). It just seems like there would be an issue with sharing call with other FP's. I imagine you would have to live in a place where OB's and FP's cooperate instead of compete for patients if you were to share call with them.

My FP/OB attending who wants us to do C/S imparted to us that as FPs in general, we are under much higher level of scrutiny simply because we're FPs, by our patients, by our colleagues. Whenever we're involved in bad outcomes, there will always be a question whether or not FPs should be involved in such situations. In his words, "Those are the rules of the game, by which you chose to play." Freaked me out a little bit. It does make me wonder some days whether or not I made the right choice.
 
Noyac said:
They take twice as long, sometimes pushing the limits of a spinal. They lose twice as much blood. Are slow to make decisions and they can't perform hysterectomies when needed, like in VBAC's with uterine rupture, placenta accreta or increta etc.
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Those are some interesting numbers. Can you share with us your sources, particularly for losing "twice as much blood" and taking "twice as long" ?

I understand OBGYNs being protective of their turf, and their opinion that there is no way an FP can be qualified to do a C/S. But what is it that makes an OB better than an FP at C/S? I would offer that it's largely experience, and numbers.

I think it is entirely possible for an FP, particularly one who graduates from a program where they did a lot of deliveries and sections (these programs are more common than you think) who does a fellowship where they get high numbers of sections to be entirely competent to perform them.

Remember that OBGyns spend half their time doing gynecology. How many sections do they do in 4 years, typically? A fellowship year doesn't include much beyond L&D, from what I understand. Fellows spend most of their time honing vaginal and C/S delivery skills. If you got a lot of sections during residency, and did a couple of your electives in OB, and do a fellowship where all you do is deliveries for a year, I would think your section numbers would become fairly substantial, though I do not have figures to back this up. It's just conjecture.

The other issue is knowing what your limits are and having a good relationship with OBGYNs in your area. I think FPs who get into trouble with sections probably have deficits in one or both of those areas.
 
sophiejane said:
...But what is it that makes an OB better than an FP at C/S? I would offer that it's largely experience, and numbers...
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Just a personal observation: The OB-Gyn residents where I rotated did a lot of C-sections, sometimes two or three a day.
 
Panda Bear said:
Just a personal observation: The OB-Gyn residents where I rotated did a lot of C-sections, sometimes two or three a day.
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Every resident did 2-3 per day? That's unlikely, as some will be on clinic rotations, etc. That would mean in a program with 21 residents, that there are >60 sections per day? I doubt that.

My estimate is that it's more like 3-4 per week per resident, depending on the rotation they are on.

Anyone have real numbers?
 
My wife as a FP resident did 3 months of OB, first month urban hospital with set schedule, essentially 12 hours a day x 6 days. Out of that she got ~34 Vag. and about 8 c-sections. Her second month was rural OB, essentially on call for this rural area with the GP for a month, not quite RRC friendly but a great learning experience. She had over 40 Vag. and about 10 CS and they did a few tubal ligations with them. In addition she also has OB's she sees and delivers in clinic, so long as they are low risk. High risk gets refered to OB. I think it just varies widely from one program to the next. Hope that helps.
 
sophiejane said:
Every resident did 2-3 per day? That's unlikely, as some will be on clinic rotations, etc. That would mean in a program with 21 residents, that there are >60 sections per day? I doubt that.

My estimate is that it's more like 3-4 per week per resident, depending on the rotation they are on.

Anyone have real numbers?
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There were perhaps five or six c-sections a day with two interns and four upper-levels on that particular rotation. I don't know what they did on other rotations but the OB intern who I worked with told me she was in the OR for 21 c-section in the month that I spent on OB.

They also have other rotations where they do other pelvic surgeries.

Another interesting thing to note is that "real" surgeons consider a typical OB to be something of a butcher due to their lack of surgical experience. I don't know the truth of this but I'm just relating my impression from what surgeons have told me.
 
Panda Bear said:
Another interesting thing to note is that "real" surgeons consider a typical OB to be something of a butcher due to their lack of surgical experience. I don't know the truth of this but I'm just relating my impression from what surgeons have told me.
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The joke that I heard in med school went something like this: OB-Gyn really only has five operations: abdominal hysterectomy, vaginal hysterectomy, c-section, cut the left ureter, cut the right ureter. 😉
 
sophiejane said:
Every resident did 2-3 per day? That's unlikely, as some will be on clinic rotations, etc. That would mean in a program with 21 residents, that there are >60 sections per day? I doubt that.

My estimate is that it's more like 3-4 per week per resident, depending on the rotation they are on.

Anyone have real numbers?
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I just Googled it. Apparently it's such an issue among applicants that OB/GYN programs publish their numbers freely. The people who grant C/S privileges are OB/Gyns, and AAFP's position is that privileges should given by looking at numbers and not by specialty. So it's not like hospitals are going to lower the bar just because you're FP (unless there's no competition). I would think as an FP you're numbers need to come close to a newly minted OB. I don't think my numbers will come close. So I'm gonna say, for me: "Not Desired." I think the real issue is how do you define competence? Is it 50? 100? 200? I think that's the debate that FP's are trying to answer when it comes to colonoscopy with outcomes data.

U Wisconsin
"In 2006, the average graduating senior resident reported performance as primary surgeon of approximately 228 uncomplicated deliveries, 52 forceps or vacuum deliveries, 219 cesarean sections, 133 major abdominal Gyn cases, and 130 major vaginal Gyn cases, including about 112 vaginal hysterectomies."

U Florida
"Resident Surgical Experience
The table below lists the average number of major surgical cases performed by the senior residents who graduated from this program in 2005.
PROCEDURE AVERAGE NUMBER
Obstetrics:
Spontaneous Vaginal Delivery: 294
Forceps & Vacuum Delivery: 51
Cesarean Delivery: 297
Gynecology:
Abdominal Hysterectomy: 88
Vaginal Hysterectomy: 32
Laparotomy: 47
Hysteroscopy: 28
Endovaginal Sonography: 111
Diagnostic & Operative
Laparoscopy (excl sterilization): 55
Endocrinology/Infertility Surgery: 45
Surgery for Urinary Incontinence: 49
Surgery for Invasive Cancer: 112"

CAMC-WVU
"By the end of the four years of residency training, an average resident will perform or will assist in over 200 vaginal deliveries, between 250-300 Cesarean sections, as well as multiple Ob/Gyn ultrasounds and several antepartum diagnostic and therapeutic procedures."

Atlanta Medical Center
"At the completion of the four years of training, the resident will have performed an average of 400 deliveries, 176 cesarean sections, 88 abdominal hysterectomies, 28 vaginal hysterectomies, and 82 operative laparoscopies. "
 
Panda Bear said:
Another interesting thing to note is that "real" surgeons consider a typical OB to be something of a butcher due to their lack of surgical experience. I don't know the truth of this but I'm just relating my impression from what surgeons have told me.
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In med school, my vascular surgery attending called the general surgery attendings "butchers" also. And there was some eye rolling when general surgeons were talking about plastic surgeons.

It was hilarious. Because as far as I'M concerned, my sh_t don't stink either.
 
sophiejane said:
Those are some interesting numbers. Can you share with us your sources, particularly for losing "twice as much blood" and taking "twice as long" ?

I understand OBGYNs being protective of their turf, and their opinion that there is no way an FP can be qualified to do a C/S. But what is it that makes an OB better than an FP at C/S? I would offer that it's largely experience, and numbers.

I think it is entirely possible for an FP, particularly one who graduates from a program where they did a lot of deliveries and sections (these programs are more common than you think) who does a fellowship where they get high numbers of sections to be entirely competent to perform them.

Remember that OBGyns spend half their time doing gynecology. How many sections do they do in 4 years, typically? A fellowship year doesn't include much beyond L&D, from what I understand. Fellows spend most of their time honing vaginal and C/S delivery skills. If you got a lot of sections during residency, and did a couple of your electives in OB, and do a fellowship where all you do is deliveries for a year, I would think your section numbers would become fairly substantial, though I do not have figures to back this up. It's just conjecture.

The other issue is knowing what your limits are and having a good relationship with OBGYNs in your area. I think FPs who get into trouble with sections probably have deficits in one or both of those areas.
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I'm sure you noticed that I was stating opinion from my experiences which I was trying to make clear. My experience has been with a few FP's doing c/s in residency and now in private practice. We had one that was fairly good in residency b/c he did a fellowship which focused on c/s's. He was slower than the OB's but not necessarily any worse. Since he took longer, so therefore, his blood loss was greater. I don't really think you need a study to show that if you take longer to do a surgery then your blood loss will also be greater.

Currently, I am in a practice in a fairly small town that has 7 OB's (not underserved at all) an one FP that does all the c/s for his partners when their pts go to the OR. He is flat out awful. His decision making skills are questionable at best. His surgical skills are even worse. We are in the process of revoking his priviledges for surgery. He is a fairly nice guy but surgery is not his fortay.

So I have given you a few examples (I have worked with more) one was the best that I have seen and one was the worst but the others fall more towards the last example. But I will repeat that this is my opinion.

I think the difference is the surgical training that the two receive and who is training them. If my wife were to need a hysterectomy I would have a gen. surgeon do it since their skills are better than the OB's in the OR. Its all about training and frequency of procedures. And Kent was pretty right on about the 5 surgical procedures in an OB's practice.
 
Noyac said:
I'm sure you noticed that I was stating opinion from my experiences which I was trying to make clear. My experience has been with a few FP's doing c/s in residency and now in private practice. We had one that was fairly good in residency b/c he did a fellowship which focused on c/s's. He was slower than the OB's but not necessarily any worse. Since he took longer, so therefore, his blood loss was greater. I don't really think you need a study to show that if you take longer to do a surgery then your blood loss will also be greater.

Currently, I am in a practice in a fairly small town that has 7 OB's (not underserved at all) an one FP that does all the c/s for his partners when their pts go to the OR. He is flat out awful. His decision making skills are questionable at best. His surgical skills are even worse. We are in the process of revoking his priviledges for surgery. He is a fairly nice guy but surgery is not his fortay.

So I have given you a few examples (I have worked with more) one was the best that I have seen and one was the worst but the others fall more towards the last example. But I will repeat that this is my opinion.

I think the difference is the surgical training that the two receive and who is training them. If my wife were to need a hysterectomy I would have a gen. surgeon do it since their skills are better than the OB's in the OR. Its all about training and frequency of procedures. And Kent was pretty right on about the 5 surgical procedures in an OB's practice.
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So, you would be OK with an FP if he had say fellowship training in OB and did 5 to 6 c sections per week (about average for an ob) and was not slower or worse than the other obs?

Becuase if you are, then I know about 30 of them that would to say the least impress you.
 
lowbudget said:
I think the real issue is how do you define competence? Is it 50? 100? 200? I think that's the debate that FP's are trying to answer when it comes to colonoscopy with outcomes data.
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I asked this question specifically at one program. They quoted 100 sections required for privileges at their hospital. True, that is half the number of OBGYNs, but if that's where the hospital sets the bar, that must mean something.

So if we assume 200 sections, divided by 4 years, that's 50/year, so an FP OB fellow could easily expect 50 sections that year, likely more since all they will do is L&D for the year, no gyn or clinic. Add that number to a 3 year FP residency where you do at least one or two electives in OB in addition to the required 3 months, if it's a busy L&D service, I think the 100-150 figure is entirely attainable.

Please understand that I am not advocating for FPs to take over OB turf. But in communities desperate for delivery docs where OBGyns are not willing to practice, or where there is a shortage of them, I think FPs filling that need should be actively encouraged.
 
sophiejane said:
Please understand that I am not advocating for FPs to take over OB turf. But in communities desperate for delivery docs where OBGyns are not willing to practice, or where there is a shortage of them, I think FPs filling that need should be actively encouraged.
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This is what I have said as well. If in an under served area, then fine.

And erichaj, I would be open to an FP that could impress me in the OR. But I have yet to see that. Now I haven't seen them all but I have seen a few. And none have impressed me. But it is rare that any surgeon really impresses me and I'll bet that I don't impress them either. But I do perform my job very well and efficiently which has been supported and rewarded by my current job. So I don't feel that every person in the OR should be impressive but they should be deft at their job which to me means skilled and efficient.
 
Look...

There is a lot of research out there that shows that the more you do something... the better you are at it...

But at a certain point .... you gotta draw the line.... If doing 100 C-sections per week gives you better results than the person who does 50 a week, well DUH! Of course you it does...

The question is... is the 50 the minimum accepted level to practice at... and the answer is up to the hospital is willing to go to risk wise. Otherwise we are going to start to see some OBGYN guys labeled 'designated c-section guy/gal'. (My name is Al and I am designated c-section guy in this hospital. I only do c-sections so we can get the best results we can.)

Let it go... more is better but doesn't mean it needs to apply.
 
Noyac said:
This is what I have said as well. If in an under served area, then fine.
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I think an FP doing sections in a non-underserved area is an anomaly rather than the norm. It doesn't make financial sense, so I think your self-described limited experience is just that.
 
sophiejane said:
Every resident did 2-3 per day? That's unlikely, as some will be on clinic rotations, etc. That would mean in a program with 21 residents, that there are >60 sections per day? I doubt that.

My estimate is that it's more like 3-4 per week per resident, depending on the rotation they are on.

Anyone have real numbers?
Click to expand...

Actually, that number is not that off. At my school, the L&D team for that month do about 5-8 c-sections per night and the first and second years, who do all the sections with the senior residents assisting do at least 2 per night. So, not all the residents do 2-3 per shift, but rather, the junior residents on L&D for the month. Our program has 8 residents per year, and they do way too many sections for my comfort. We have a very large pregnant and high risk pregnant population.
 
Still, the averages posted from websites above by lowbudget indicate that the average number of sections at OBGYN residencies for the 4 year period is ~200.
 
Where I'm at there is a ob fellowship within family med. Last year's graduate now works for the ob group. She performs c-sections but there has to be a ob/gyn within the hospital - not at home on call, but physically on site. Her 1st assist is either a ST or one of the fam med residents.

Last years stats for the fellow were over 300 c-sections and the fellow was primary on 200. Also 30 d&c's, 11 hysterectomies.

My view is why didn't she do a 4 year ob/gyn residency? She's now done 4 years anyway and is essentially the mid-level provider for the ob/gyn group. I suspect her pay reflects that position as well.

Also, there's a big difference between a surgeon and someone who performs specific surgical procedures. It's like the difference between a cook and a chef. One has to work from recipes while the other has an intimate understanding enabling them to turn their hand to something new by applying the principles that are second nature to them. Where are you eating tonight - Denny's or the Bellagio (Vegas)?
 
George85 said:
Last years stats for the fellow were over 300 c-sections and the fellow was primary on 200. Also 30 d&c's, 11 hysterectomies.
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I rest my case.

As to what FPs do after fellowship, it is up to them. I think the majority continue to practice family medicine but also do OB. I think it would be unusual for every FP post-fellowship to join an OBGYN group and function as a "midlevel" as you describe.

Most folks want the fellowship so they can confidently add OB (not gyn!!) to their scope of practice, and most do this in a rural or underserved area.
 
I personally hate C-Sections and that is the main reason I ruled out OB. I have no desire to cut people open and then saw them up after pulling a baby out. Or even just plaine cutting into people, doesn't do it for me. I hate the OR. I don't think I would doing minor surgical procedures such as I&D's, stitches, or derm stuff though. Anyhow, glad there are people out there who do it, but I sure as hell won't.
 
George85 said:
Also, there's a big difference between a surgeon and someone who performs specific surgical procedures.
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????

-Orthopedic Surgeons perform "specific surgical procedures" and are surgeons.

-Neurosurgeons perform "specific surgical procedures" and are surgeons.

-ENTs perform "specific surgical procedures" and are surgeons.

-Urologists perform "specific surgical procedures" and are surgeons.

-Ophthalmologists perform "specific surgical procedures" and are surgeons.

-OB/GYNs perform "specific surgical procedures" and are surgeons.

-Plastic Surgeons perform "specific surgical procedures" and are surgeons.

-and, BRUM ROLL, General Surgeons perform "specific surgical procedures" and are surgeons.

Any surgeon can be "creative" within his OWN SPECIALITY.

According to the American College of Surgeons, Surgeons (and official branches/fellows of the ACS) are:

http://www.facs.org/medicalstudents/answer1.html

http://www.facs.org/fellows_info/other_sites/boardurls.html

http://www.facs.org/fellows_info/other_sites/wbstsurspec.html

🙄
 
Noyac said:
This is what I have said as well. If in an under served area, then fine.

And erichaj, I would be open to an FP that could impress me in the OR. But I have yet to see that. Now I haven't seen them all but I have seen a few. And none have impressed me. But it is rare that any surgeon really impresses me and I'll bet that I don't impress them either. But I do perform my job very well and efficiently which has been supported and rewarded by my current job. So I don't feel that every person in the OR should be impressive but they should be deft at their job which to me means skilled and efficient.
Click to expand...


Are all surgeons impressive in the OR? Are they ALL fully skilled and good at what they do?

As far as doing c-sections in a rural area vs a big city, the problem is mostly economic. Last time I checked the female anatomy did not change due to geographic reasons.
 
Afte a 3 year residency in FP the physician has an excellent understanding of General medicine.

I feel that if there were fellowships available for the following (and there is for some, I will just list all I feel are needed):

Derm.
Ob
Hospitalist
sub-specialties like endocrine, cardiology, GI,
etc.

Then, there would be little need for individual specialist. I know, you will have to adjust to the real fact that an FP who chooses to sub-specialize his practice to mostly one of the above may actually provide a better service to the patient.

You may ask, Ok but what about the more difficult cases?

Those would go to the few specialist that are needed.

I mean really guys, Don't tell me that you need to be an anesthesiologist to learn how to do an injection under fluoro for pain in the back. Are you kidding me.

And don't tell me that you have to do a whole 3 years of residency to do a colonoscopy or EGD. OH, and derm there is another myth. Yes, the rare cases could use a derm but most other cases the common ones, come on.

I always wondered why fellowships were restricted to the IM guys. Now, I know that it's all about turf. It has nothing to do with skill.
 
There are more than 24 OB fellowships. For example, there is one at our residency program here in Knoxville, TN. I assume it is not listed on the AAFP website because it is open only to those who completed their residency here at our program. It more often than not goes unoccupied. However, there is a third year at our program this year that is doing the fellowship next year. And I will almost certainly do it after I complete residency (I am an intern). And there is a second year who is strongly considering it. So, we seem to have a run going on it. I encourage anyone interested to consider it. you typically get over 100 c-sections.
 
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