Family Practice OB: To Be or Not To Be? Liability Is the Question
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* Thomas E. Norris

Will the family physicians (FP) of the future (including the near future and not just the distant future) be able to include maternity care (OB or obstetrics) in their practices? The title of this editorial, with apologies to William Shakespeare for my literary license, focuses on both a frightening current reality and a very timely study in this issue of the *Journal of the American Board of Family Practice*.

One can begin consideration of “the question” by asking what factors determine whether or not family physicians practice OB. The list of determinants is fairly short. Some of the items on the list are within the control of an individual family physician, some fall into the control of the family medicine educational community, some can be impacted by the discipline of family medicine or even organized medicine, and some are societal in nature. Factors involved include the following: 

*   Interest in maternity care of the part of the family physician.

*   Adequate training and experience in maternity care in residency, fellowship, or other setting.

*   Adequate patient availability to allow the FP to build an OB practice and to provide care for enough OB patients to maintain currency of experience and competency.

*   Proximity to an adequate facility at which deliveries can be accomplished and where newborns can be cared for.

*   Availability of adequate “back-up” for complicated or high-risk cases (both maternal and neonatal).

*   Presence of a “culture” or community standard in the area that allows FPs to provide maternity care (some regions of the US seem almost devoid of FP OB care).

*   Availability of professional liability insurance at an affordable price that covers FP maternity care.

The last item listed, the availability and affordability of professional liability insurance, is a highly critical determinant in answering the question of whether FPs will provide OB care. This factor is outside of the individual control of a family physician. It is sometimes within the control of our discipline or organized medicine, but is usually a larger issue involving society, the law, and economic cycles. Let us consider the situation in Washington State, a place with a strong tradition of family practice obstetrics and a state with a serious liability insurance crisis, as an example. Currently, 54% of Washington State family physicians include obstetrics (maternity care) in their practices. In the last 4 years, however, 25% of Washington’s rural family physicians have stopped practicing OB; more than half of them cite malpractice rates as one of the reasons. A staggering 45% of Washington family physicians who currently practice obstetrics are considering stopping OB because of increasing malpractice insurance rates (Marshall JH, personal communication). The simple economic reality is that the cost of malpractice insurance for a family physician providing the maternity care is rising above the revenue associated with the care.

The discipline of Family Medicine currently seems destined to deal with several negative forces that seem to conspire to decrease the percentage of family physicians who include maternity care in their practices. Some of these forces, such as regions of the US where *no* (or almost no) family physicians do OB, seem to have a continuing erosive effect. Others, such as rapidly increasing rates for professional liability insurance, seem cyclical in nature. Many states are now facing “crises” in professional liability insurance—caused by either rapid rate increases or a complete lack of availability of malpractice insurance policies. In October 2002, AAFP Board Chair Richard Roberts highlighted the crisis in a *Family Practice Management* article:

In certain areas of the country, sky-rocketing medical liability insurance premiums are pushing physicians out of practice and denying patients access to needed services. In eight states, premiums increased an average of 30% or more last year. Another 12 states saw average premiums increase 25% during the same period, and problems are emerging in several other states as well.1

In family practice, one of the major determinants of a physician’s professional liability premium is the presence or absence of maternity care in the practice. Thus, it is not uncommon for FPs in these “crisis locales” to be forced to drop maternity care from their practices so that they can continue in an economically viable situation. This “Sophie’s choice” damages not only the individual family physician, who is forced into discontinuing a beloved part of the specialty, but also can create a significant access to care and public health problem in their communities—a situation that is especially common in rural sites.

What can be done about the cost and the relative lack of availability of professional liability insurance that would allow a family physician to practice maternity care? The most commonly used approach at the present time seems to be an attempt to gain legislative, constitutional, or judicial “tort reform.” This approach has been successful in some cases, with California’s Medical Injury Compensation Reform Act (MICRA) serving as the oldest and most enduring example. Rather than simply seeking to change the rules, it would also seem logical to undertake actions to decrease obstetrical problems and increase patient safety by the use of carefully designed, educationally oriented risk management programs. The article by Nesbitt and his colleagues on page 471 of this issue describes 10 years of experience with such a program and includes documentation of its efficacy.

It is urgently imperative that our discipline and our society undertake efforts to keep obstetrical liability insurance affordable and to keep family physicians in birthing rooms and delivery suites. Nesbitt has previously documented that one of the most important factors influencing FP maternity care is the access to affordable liability insurance.2–4 He has also provided us with evidence that family physicians who drop OB are not likely to return to obstetrics if insurance premiums decline.5 Finally, using rural obstetrical care as the “canary in the coal mine,” Nesbitt and his colleagues have previously demonstrated that a loss of rural family physicians providing maternity care leads to “high-outflow” of OB patients from their communities, with a concomitant increase in complicated deliveries, prematurity, and higher costs of neonatal care.6

Nesbitt’s current article, coupled with his past work, provides not only indisputable evidence that we are in the midst of a crisis but also long-term proof that educationally oriented risk management programs in obstetrics may give us another opportunity to undertake actions to improve this situation. If FP OB is “to be,” we need to act now.

*   Revision received September 21, 2003.

## References

1.  Roberts RG. Understanding the physician liability insurance crisis. Fam Pract Manag 2002; 9(9): 47–51.
    
    

2.  Nesbitt TS, Scherger JE, Tanji JL. The impact of obstetrical liability on access to perinatal care in the rural United States. J Rural Health 1989; 5: 321–35.
    
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3.  Nesbitt TS, Kahn NB, Tanji JL, Scherger JE. Factors influencing family physicians to continue providing obstetric care. West J Med 1992; 157: 44–7.
    
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4.  Nesbitt TS, Baldwin LM. Access to obstetric care. Prim Care 1993; 20: 509–22.
    
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5.  Nesbitt TS, Arevalo JA, Tanji JL, Morgan WA, Aved B. Will family physicians really return to obstetrics if malpractice insurance premiums decline? J Am Board Fam Pract 1992; 5: 413–8.
    
    

6.  Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA. Access to obstetric care in rural areas: effect on birth outcomes. Am J Public Health 1990; 80: 814–8.
    
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