For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
Jeff Lendrum, Lendrum Photography, LLC of Neenah, Wisc.
Dr. Rachel Hartline
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.