To the Editor: The article “Intention Versus Reality: Family Medicine Residency Graduates' Intention to Practice Obstetrics” by Barreto et al1 illustrates the decline of obstetrics in family medicine. The accompanying editorial by Rayburn2 mentions a key barrier to this scope of practice: the lack of standardized pedagogy and supporting research to ensure quality care provided by family medicine obstetric physicians. The question becomes not only whether a sufficient number of family medicine physicians practice obstetrics, but whether our training and standards are rigorous enough to deliver quality care in the face of rising maternal morbidity and mortality.3
Regrettably, obstetric training in family medicine is inconsistently measured and inconsistently required. Several studies have concluded that family medicine physicians can deliver quality care, comparable to that provided by obstetricians, but unfortunately these studies are outdated, based in other countries, or limited to a few regional medical centers.4⇓⇓–7 The Accreditation Council for Graduate Medical Education recently lowered the number of deliveries that family medicine graduates have to complete in order to graduate from residency. The number of babies that family physicians deliver declines throughout the course of their careers, as does the percentage of physicians who choose to recertify.1,8 Fellowship programs vary widely regarding curriculum and graduation requirements.9 If obstetric practice is to survive in family medicine, we must consider the forces driving these decisions as we move forward.
Family medicine physicians who provide obstetric care offer a valuable service, especially in underserved rural areas of the United States. To align our outcomes with our intentions, however, we are faced with the option of adopting standardized and studied practices or abandoning obstetrics all together. The resolve of family medicine physicians to continue obstetric practice could be strengthened with specialized tracks in residency programs followed by standardized fellowships with consistent requirements. Rigorous studies of the outcomes of deliveries by family medicine physicians would permit self-evaluation and improvements in training. Insistence on quality and robust preparation must supersede concerns about the numbers of family physicians practicing obstetrics. The number of family medicine obstetricians may continue to decrease, but let them be the few and the proud rather than the many and the untested—our patients deserve nothing less.
Acknowledgments
The author thanks to Jennifer Middleton MD, MPH, FAAFP, for providing feedback on and editing this manuscript.
Notes
The above letter was referred to the author of the article in question, who offers the following reply.
