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PubMed1998

Reactions of residency directors to primary care requirements in obstetrics and gynecology training.

OBJECTIVE: To determine the opinions of obstetrics and gynecology residency program directors regarding the Residency Review Committee mandate, requires 6 months of primary care training in obstetrics and gynecology. METHODS: A ten-question survey was mailed to the 272 accredited obstetrics and gynecology programs in the United States and Puerto Rico. Program directors were asked about the adequacy of 6 months of primary care training, whether educational deficiencies in obstetrics and gynecology will develop as a result of the mandate, and whether residency programs should be lengthened to encompass primary care. RESULTS: The response rate for the survey was 92.3% (251/272). University-affiliated, community, and military-based programs were surveyed and all geographic areas of the country were represented. Of program directors responding, 53.4% agreed with the mandate, 43.0% disagreed, and 3.6% declined to answer this question or both agreed and disagreed. Fifty-one percent considered 6 months of primary care training to be adequate, and 60.2% of program directors thought that educational deficiencies would develop in obstetrics and gynecology training programs. Whereas 66.1% responded that extension of obstetrics and gynecology training programs beyond 4 years was unnecessary, 32.7% thought program length should be increased. CONCLUSION: The results of this survey demonstrate that a substantial proportion of U.S. residency directors do not agree with the Residency Review Committee mandate for primary care training and think that deficiencies in obstetrics and gynecology training will develop as a result of these changes.

Data Collection↗
PubMed2005

[Number of training positions in obstetrics and gynecology in France: results from a national survey of trainees].

OBJECTIVES: To evaluate of the actual and optimal number of training positions in obstetrics and gynaecology in France. MATERIAL AND METHODS: Between February and April 2004, we performed a survey of French trainees in obstetrics and gynecology on the available and optimal number of positions for training in their department according to the activity. We also performed a count of the trainees in obstetrics and gynaecology in France. RESULTS: There are 817 trainees in obstetrics and gynaecology in 26 towns in France. They are trained in 177 departments, of which 55 are academic and 122 non-academics. There are 571 positions for training in Obstetrics and Gynaecology: 334 in academic departments and 237 in general non-academic departments. There is therefore 0.7 position per trainee in obstetrics and gynaecology. Trainees estimate that there is a need and a possibility for at least 50 more positions. There is an uneven distribution in trainees between academic departments in Paris and elsewhere in France. CONCLUSION: Trainees consider possible the opening of at least 50 more training positions in obstetrics and gynaecology.

France↗
PubMed2001

Residency training in colposcopy: a survey of program directors in obstetrics and gynecology and family practice.

OBJECTIVE: Our goal was to identify how colposcopy is being taught to residents in obstetrics and gynecology and family practice programs and to see if the program directors think their residents receive sufficient clinical exposure to be adequately trained in colposcopy. STUDY DESIGN: A 30-question survey was sent to all obstetrics and gynecology and family practice residency program directors. The survey included questions about the didactic nature of the colposcopy curriculum, the type of supervision, how resident skills are evaluated, estimates of the numbers and types of patients evaluated, the numbers and types of procedures being done by each resident, and the program director's perception of residents' competence in colposcopy. RESULTS: The overall response rate was 485 of 752 program directors (64.5%). Significantly fewer family practice than obstetrics and gynecology program directors thought they had adequate numbers of colposcopy patients to train their residents. By their program directors' estimates, 86% of family practice residents evaluate 10 or fewer patients with high-grade lesions (versus 16.5% of obstetrics and gynecology residents); 51.4% evaluate 10 patients or fewer with low-grade lesions (versus 6.7% of obstetrics and gynecology residents), and 40.6% evaluate 10 patients or fewer with atypical squamous cells of undetermined significance (versus 3% of obstetrics and gynecology residents). Experience with vulvar disease is also limited. Program directors thought their residents' colposcopy skills were roughly comparable with their general obstetrics and gynecology skills. CONCLUSIONS: It is possible that many program directors underestimate the number of colposcopic examinations required to achieve and maintain colposcopic skills. Many training programs have insufficient clinical volume to properly train residents in colposcopy.

Colposcopy↗
PubMed2006

Specialist training in obstetrics and gynaecology: a survey on work-life balance and stress among trainees in UK.

The object of this study was to evaluate perceptions about work-life balance and levels of stress in obstetrics and gynaecology trainees in the UK. This was a questionnaire survey conducted at the National Obstetric and Gynaecology Specialist Registrar Meeting (SpROGs 2004, Birmingham, UK). A total of 190 trainees in obstetrics and gynaecology attended the meeting. Trainees at the meeting were given a questionnaire to fill in regarding their perception of work-life balance, stress at work and their attitude to training in obstetrics and gynaecology. The response rate was 128/190 (67%). Half of the trainees (64/128, 50%) felt that they had achieved satisfactory work-life balance. There was a trend towards more men achieving this balance compared with women (25/42 (60%) vs 38/83 (46%), p = 0.19). Unsatisfactory social life (82%) and scarce time with the family (74%) were cited as the most common reasons for not achieving a satisfactory work-life balance. More than two-thirds of the trainees (83/128, 65%) found their work moderately or very stressful. Senior trainees (years 4 or more of specialist training) found work more stressful than junior trainees (years 1 - 3 of specialist training) (29/35 (83%) vs 54/93 (58%), p = 0.01). However, 77/128 (60%) of trainees would still recommend a career in obstetrics and gynaecology to medical students. A majority (85/128, 66%) claimed that they would choose obstetrics and gynaecology again if given a second chance. A large number of trainees (110/128, 86%) were looking forward to their future in this field. In spite of the high levels of perceived work-life imbalance and stress at work, most trainees would choose the same specialty given another chance and would recommend the same to others, indicating a certain level of satisfaction with the specialty. However, our study shows that improvements in the working lives of obstetrics and gynaecology trainees are still needed, especially given the current context of difficulty with recruitment and retention of trainees.

Attitude of Health Personnel↗
PubMed2000

Obstetric triage and advanced practice nursing.

Obstetric triage is a rapidly growing area of obstetric care where most pregnancy complaints are evaluated starting at 20-24 weeks' gestation. This renewed interest in establishing obstetric triage units and using advanced practice nurses as care providers has heightened the visibility of obstetric triage for administrators and practitioners alike. This article reviews the history of obstetric triage, the role dimensions of advanced practice nurses in triage (specifically midwives), the increased clinical risks associated with obstetric triage, risk reduction strategies, and obstetric triage practice trends and liability issues in the future.

Female↗
PubMed1986

Obstetric and gynecologic operations in the United States, 1979 to 1984.

An in-depth analysis of numbers of obstetric and gynecologic operations from 1979 to 1984 was performed using data from the National Center for Health Statistics. During the study period, there was a decrease in total numbers of obstetric and gynecologic procedures of 1%. During the same five-year period the numbers of physicians who label themselves as obstetrician-gynecologists increased 22%. In 1983, a total of 809,000 cesarean sections were performed. It has become the most common hospital-based operation in this country. Twenty-one percent of all live births are now by cesarean section. The second most common obstetric and gynecologic operation is hysterectomy (673,000), and diagnostic dilation and curettage of uterus (632,000) third. These operations are also the second and third most common procedures performed in the United States. In 1983, obstetric and gynecologic operations represented 23% of all surgery completed in this country. These figures demonstrate the dynamics of obstetric and gynecologic surgical practice. They show that numbers of obstetric and gynecologic operations have decreased over the last five years, in spite of constantly increasing numbers of obstetrician-gynecologists. If current trends continue, future individual operative workloads, on average, will decrease with possible adverse effects on quality of obstetric-gynecologic surgical care.

Cesarean Section↗
PubMed2006

Improving hospital systems for the care of women with major obstetric hemorrhage.

OBJECTIVE: When 2 maternal deaths due to hemorrhage occurred at New York Hospital Queens in 2000-2001, a multidisciplinary team implemented systemic change. Our objective was to improve outcomes of episodes of major obstetric hemorrhage. METHODS: We report outcomes before (2000-2001) and after (2002-2005) the introduction of a patient safety program aimed at improving the care of women with major obstetric hemorrhage. Process changes were instituted in late 2001 at the direction of a multidisciplinary patient safety team. A rapid response team was formulated using the cardiac arrest team as a model. Protocols for early diagnosis, assessment, and management of patients at high risk for major obstetric hemorrhage were developed and communicated to staff. RESULTS: There were significant increases in cesarean births (P < .001), repeat cesarean births (P = .002), and cases of major obstetric hemorrhage (P = .02) between the periods of 2000-2001 and 2002-2005. There was a significant improvement in mortality due to hemorrhage (P = .036), lowest pH (P = .004), and lowest temperature (P < .001) when comparing 2000-2001 with 2002-2005. There were no differences in measures of severity of obstetric hemorrhage between the 2 periods, including Acute Physiology and Chronic Health Evaluation II scores, occurrence of placenta accreta and estimated blood loss. CONCLUSION: Despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal deaths after implementing systemic approaches to improve patient safety. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage.

Adult↗
PubMed2001

Pervasive developmental disorder and obstetric complications in children and adolescents with tuberous sclerosis.

Children with autism have an increased risk for obstetric complications but it is not known whether these are of primary aetiological significance. It is also unclear whether obstetric complications play a secondary role in shaping phenotypic expression in individuals at genetic risk for autism. We investigated this question by studying the role of obstetric complications in determining phenotypic manifestations in tuberous sclerosis, a single gene disorder frequently associated with autism spectrum disorders. Obstetric histories of 43 children with non-familial TS and 40 unaffected siblings were obtained using a structured parent interview. ADI-R, ADOS-G and IQ evaluations were undertaken. Children with TS experienced more obstetric complications than their unaffected siblings, but these were related to mild rather than severe adversities. No differences in obstetric complications were found in children with and without autism spectrum disorders and there was no positive correlation between obstetric adversities and severity of autism spectrum disorders or intellectual impairments.

Adolescent↗
PubMedDate not supplied

An enhanced obstetrics track for a family practice residency program: results from the first 6 years.

BACKGROUND: Advanced training in obstetrics for family physicians occurs through a variety of methods. The program described has developed an obstetrics track for family practice residents. METHODS: Five residents have completed the 4-year residency program with enhanced obstetric training developed, and the results, in terms of procedural experience and examination scores, have been reviewed. RESULTS: These 5 family physicians performed a similar number of obstetric procedures compared with their Obstetrics and Gynecology resident counterparts, and they performed as well as their family medicine resident counterparts on national in-service examinations. CONCLUSIONS: A 4-year enhanced obstetrics track is an effective means of improving the training of family medicine residents in obstetric procedures while maintaining the other fundamental training and residency review committee requirements for family medicine residents.

Curriculum↗
PubMed2002

Factors that influence obstetrical care by Mississippi family physicians.

OBJECTIVE: The objective of this study was to investigate factors associated with cause for attrition from obstetrics among family physicians in Mississippi and to identify enhancing factors for those practicing obstetrics. STUDY DESIGN: A twenty-two item self-addressed survey was utilized. POPULATION: All identifiable allopathic and osteopathic family physicians currently practicing in Mississippi. OUTCOMES MEASURED: Factors that contribute to decisions by family physicians to practice or not practice obstetrics. RESULTS: Of the 652 surveys mailed, 235 (36%) were returned. Twenty-seven respondents indicated that they provide prenatal care. Fifteen of these performed non-emergent vaginal deliveries; ten provided the full spectrum of obstetrical care. There was a significant difference in the number of months of OB training between respondents who do non-emergent vaginal deliveries and those who did not. Personal interest and training ranked highest as influences for physicians practicing obstetrics. Factors associated with the decision not to practice included high malpractice premiums and the perception that other local physicians provide obstetrics. CONCLUSIONS: According to study results, most Mississippi family physicians are not practicing obstetrics. The influence of high malpractice premiums and the influence of the length of OB training on the physicians' choice to practice OB require additional investigation.

Adult↗
PubMed2004

Obstetric admissions to the intensive care unit.

OBJECTIVE: To describe clinical characteristics, interventions required, and outcome of critically ill obstetric patients admitted to a general intensive care unit (ICU). METHODS: All obstetric patients admitted to ICU at Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia from 1997 to 2002 were included in the study. The data related to demographics, obstetric history, pre-existing medical problems, indications for ICU admission, intervention required, length of stay, and outcome of ICU admission were collected by retrospective review of medical records. RESULTS: The 99 obstetric admissions to ICU were represented by 0.2% of all deliveries and 1.6% of all ICU admissions. Most patients were young (median age of 30 years) with parity (median) of 3 and stayed in ICU for an average of 2 days. All except one patient were admitted during the postpartum period. The majority (76%) were admitted after cesarean section. Obstetric hemorrhage (32%) and hypertension (29%) were the 2 most common indications for admission. The majority (59/99) of patients also had pre-existing medical problem and most common (16/59) was rheumatic heart disease. Preeclampsia (23/99) and eclampsia 10/99 were the most frequent obstetric complication. Thirty-six percent of our patients required ventilatory support. In the majority of patients, direct arterial (81%) and central venous (73%) pressure monitoring was carried out. Pulmonary arterial and left atrial pressure was monitored in 4%. Almost one third of patients received antihypertensive therapy. Inotropic support was given to 9% and blood (and its products) was given to 46% of patients. Antibiotics (28%) and magnesium sulphate (25%) were the most frequently used medicines. Out of the total 99 admissions, one patient died and 16 patients developed complications. CONCLUSION: In our survey, the 2 most common indications for admitting obstetric patients to ICU were hemorrhage and hypertension. Invasive hemodynamic monitoring and ventilatory support are the 2 main interventions. Improving quality of care before and after admission to ICU may reduce maternal morbidity.

Adolescent↗
PubMed1991

Obstetric care, Medicaid, and family physicians. How policy changes affect physicians' attitudes.

Recent expansion of Medicaid eligibility for pregnant women and increased reimbursement to physicians who provide perinatal services were designed to improve access to care. Family physicians provide a relatively high proportion of care to pregnant women on Medicaid, especially in rural areas. We surveyed all family physicians who provide obstetric services in 26 northern California counties regarding these changes and perceived barriers to providing obstetric care to women on Medicaid. Of surveyed physicians who limited the number of their Medicaid obstetric patients, 58% stated that recent Medicaid policy changes had increased their willingness to accept new Medicaid obstetric patients. Despite these policy changes, administrative issues and poor reimbursement were cited as the two most notable barriers to providing obstetric care to women on Medicaid. Fear of being sued by Medicaid patients is still seen as a barrier by physicians who have recently discontinued practicing obstetrics and by those who continue to care for a large number of Medicaid obstetric patients.

Attitude of Health Personnel↗
PubMed1991

Tort reform and the obstetric access crisis. The case of the WAMI states.

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.

Alaska↗
PubMed1990

Restructuring a family practice obstetrics curriculum.

Maintaining a high-quality curriculum for family practice residency training in obstetrics has become increasingly difficult. In 1984 the faculty of the University of Vermont Department of Family Practice needed to upgrade its obstetric curriculum in a community where family practice obstetrics was nonexistent. The key steps to a new curriculum included the recruitment of family practice faculty with experience in obstetrics, expanded communication with the Department of Obstetrics and Gynecology, the development of baseline attending privileges in family practice obstetrics, the formation of educational tracks for residents, and the promotion of chart audits. Also important were faculty role modeling, intradepartmental meetings, intensive elective rotations, and community education. This case report of program development in family practice obstetrics may serve as a model to help other residency programs.

Curriculum↗
PubMed1988

Obstetrics in family practice in the state of Ohio.

Two hundred eighty-two active members of the Ohio Academy of Family Physicians responded to a survey questionnaire regarding the content of obstetrics in their practices. Factors that may influence physicians to discontinue obstetrics were also evaluated. Sixty respondents (21 percent) were performing vaginal deliveries in 1987. Only 45 (16 percent) planned to continue delivering babies beyond 1989. Family physicians who started practice within the past seven years were less likely to include obstetrics in their first year of practice than those who began practice prior to 1980. To those physicians who have eliminated obstetrics from their practice in the past five years, fear of litigation and increasing malpractice insurance costs were significantly more important issues than to their colleagues who had stopped doing obstetrics prior to 1976. Every year fewer family physicians choose to provide care to their obstetric patients. The results of this study suggest that only with changes in the medicolegal and liability environments will obstetrics continue to be a part of family practice in Ohio.

Costs and Cost Analysis↗
PubMedDate not supplied

Choosing to do obstetrics in practice: factors affecting the decisions of third-year family practice residents.

To investigate factors influencing a resident's decision to participate in obstetrical care, a survey was undertaken of program directors and third-year residents from the 16 Michigan family practice residency programs. Responses indicated that the majority of third-year residents (55%) intended to practice obstetrics on graduation. Rural practice plans were significantly correlated with a decision to practice obstetrics, but suburban practice plans were negatively correlated. Residents who reported the presence of a good family practice obstetric role model were significantly more likely to practice obstetrics; residents deciding against obstetrical practice expressed concerns about legal liability and malpractice fees. These findings have important implications for family practice training programs if obstetrics is to remain a central part of comprehensive family care.

Career Choice↗
PubMed1987

Rising malpractice premiums and obstetric practice patterns. The impact on family physicians in Washington State.

All 853 active members of the Washington Academy of Family Practice were surveyed in the summer of 1985 to determine the impact of rising malpractice premiums on patterns of obstetric practice. Of the 685 physicians who responded, 61% are currently practicing obstetrics. The median number of deliveries per year was 29, with a range of 1 to 130 deliveries per physician. Younger physicians, rural physicians and those in group practice were more likely to practice obstetrics than older, urban physicians in solo practice. Of the 266 respondents not currently practicing obstetrics, 77% had discontinued obstetric practice within the past five years-half because of issues related to professional liability. Of those practicing obstetrics, 50% stated that they would cease obstetric practice if malpractice premiums rose to $12,000.

Costs and Cost Analysis↗
PubMed1984

The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.

Canada↗