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CONTROVERSIES IN OB/GYN
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The first practitioners of our chosen profession were generalists, but as medical knowledge expanded, it became more and more difficult for one individual to be able to maintain usable knowledge for the entire expanding database. Specialization was not only practical, but indeed necessary. Obstetrics and gynecology evolved to provide health care to women, and we all believe that step was an appropriate advance. How many times have I heard an ob/gyn lament a family practitioner's failure to obtain a timely consultation or transfer of care? If "practice makes perfect," then focusing ob/gyn practice on women's health care and delivery of obstetrical services should improve a generalist's diagnostic and therapeutic skills.
More recently, ob/gyn has further evolved with the advent of subspecialties in gynecologic oncology, reproductive endocrinology, and MFM in the last 40 years. Unfortunately, the latest trend in this process is a de-evolution of general ob/gyn back toward general practice as we've struggled with managed care and the concept of gatekeepers who would prevent women from receiving the traditional full scope of ob/gyn care. To maintain access to our patients, we had to devote 20% of residency training to primary care. It remains to be seen what effect this will have on the skills of our recently trained ob/gyns.
In 2003, our training programs were further impacted by implementation of the 80-hour work week for residents. Although this schedule is more humane, the repercussions will be strongly felt in the volume of experience to which our young colleagues will be exposed. These recent influences on our training will result in ob/gyn physicians who are not as well prepared as before, based on fewer months of exposure to core ob/gyn issues and fewer work hours. This is not a matter of intelligence, but only of exposure to the myriad problems confronting the practitioner.
The value of subspecialty training lies in the difficulty of knowing everything about everything. The subspecialist only has to know everything about a smaller universe of problems. An MFM specialist is available to participate in the care of women during the reproductive phase of their lives. The domain of practice involves any pregnancy that is "at risk" for a less-than-optimum outcome for the mother or fetus(es). MFM specialists spend several extra years focusing on the complications of pregnancy, which brings value to a specific pregnancy at risk. MFM specialists also may have technical skills that may be useful, such as skillful interpretation of a comprehensive ultrasound or experience with invasive procedures that general ob/gyns may not typically perform (such as chorionic villus sampling, percutaneous umbilical blood sampling/fetal transfusion therapy, selective reduction of multifetal gestation, or abdominal cerclage).
Consultation is an educational process for the patient and the referring obstetrical provider, in that an MFM specialist can provide insight and guidance about diagnosis and therapeutic interventions that inform everyone in the care process. Shared management or transfer of care to an MFM specialist is also appropriate for complex medical/obstetric issues that can benefit from ongoing input as a patient's condition changes. All this interaction with the specialist is appropriate because it helps individual patients receive the best possible care. Some ob/gyns can meet this goal for some patients without consulting with or transferring care to an MFM. But if help is needed, an MFM specialist should be available.
So, should all medically complicated pregnancies be referred to an MFM specialist? My answer is that our patients deserve the best possible care, which means providing accurate diagnostic information and a complete range of therapeutic options. How that happens is immaterial. It would be ideal if all such care could be provided by one subspecialist, rather than, for example, having an ob/gyn handle a patient's obstetrical management but consult with an endocrinologist to manage her insulin-dependent diabetes or hyperthyroidism.
Certainly, obstetrical patients in critical condition would be a perfect example of the need for consultation/management by an MFM specialist. The greater the risk to life of the mother or babies, the greater the need for advanced skills to best manage the situation. A typical ob/gyn may encounter such complications only every few years, whereas an MFM specialist deals with these issues weekly or monthly.
For management of high-risk pregnancies, we are incorporating an interesting new technologic development into our practice: telemedicine. The telemedicine unit at Banner Good Samaritan Medical Center interprets basic ultrasound examinations that are sent in to us, which allows rural obstetric services to have qualified professional readings of their U/S examinations. This use of perinatal services provides medicolegal backup for general obstetricians or family practice physicians.
When deciding about perinatal consultation or management, the only question should be, "What would I recommend for my wife and child?" Very often that would be a consultation with a perinatologist.
Controversies in OB/GYN focuses on controversial issues pertaining to the clinical practice of obstetrics and gynecology and reproductive medicine. The authors have been selected for their ability to articulate a particular point of view, regardless of their own personal convictions.
We hope that these short essays will provoke discussion and help Contemporary OB/GYN's readers clarify and refine their own practice management. You can join in the dialogue by completing and faxing in the response form at the end of this article or sending us your opinion (pro or con) via e-mail to firstname.lastname@example.org. A summary of the correspondence we receive will be published in a future issue.
David B. Seifer, MD, Department Editor
Department of Obstetrics, Gynecology, and Reproductive Sciences
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, N.J.
Most general obstetricians have adequate skills to manage high-risk pregnancies. Each individual obstetrician obviously must acknowledge his or her own limitations, based on pro-fessional experience and training. Typically a generalist will provide care for women with high-risk pregnancies and refer patients who are beyond the scope of his/her practice.
General obstetricians are trained well to think critically and to function safely. During their 4-year residency, they obtain the required knowledge and experience to become general ob/gyns by rotating through low- and high-risk obstetrics as well as other subspecialties. Each accredited residency has an obligation to expose residents to high-risk obstetrics. At the completion of their residency training, obstetricians should have obtained the broad-based knowledge necessary to diagnose, treat, and refer patients.
With the advent of competency as part of the curriculum, training programs are able to document and give feedback to residents about their knowledge and skill level. As a result, after 4 years, residents can readily identify the high-risk pregnancies they are comfortable managing and those they are not. If generalists did not manage medically complicated pregnant patients, they would be interchangeable with midwives and family medicine physicians. Why invest so much time and money in a long obstetric residency rather than going straight to midwifery school or into a 3-year family medicine residency if you do not want to manage high-risk pregnancies at some level?
A key aspect of prenatal care is to have maternal-fetal medicine (MFM) expertise accessible to the general ob/gyn. Successful comanagement of a high-risk pregnancy for identifiable risks is often complemen- tary. The generalist is the gatekeeper to the MFM specialist. According to a survey done by Vintzileos and colleagues, about 55% of obstetricians "always or frequently" refer to an MFM for a diagnostic or therapeutic procedure and in the presence of a high-risk condition.1 The researchers also concluded that more than 75% of generalists "always or frequently" refer to the MFM in the setting of a fetus with increased risk for adverse outcomes (conditions such as fetal hydrops, fetal anomaly/cytogenic abnormality, supraventricular tachycardia or congenital heart block, isoimmunization, and twin-twin transfusion syndrome). However, there are only a few medicosurgical conditions for which more than 75% of generalists think referral to an MFM specialist is required. These conditions include acute fatty liver of pregnancy, portal hypertension, pulmonary hypertension, and maternal organ transplantation. Therefore, most obstetricians refer commonly for prenatal diagnostic tests and procedures but seldom for medical or surgical conditions and only for those that are rarely encountered. This is in accordance with guidelines in the 1996 statement of the Society of Perinatal Obstetricians.
Ob/gyns view MFM specialists as taking the lead in optimizing outcome of high-risk pregnancies. Most generalists manage medically complicated pregnancies, and there are little data in the literature about outcomes in such cases. At this year's Society for Maternal-Fetal Medicine meeting, Robert Eden, MD, presented a retrospective comparison of outcomes of high-risk pregnancies managed solely by MFM specialists versus those managed by general ob/gyns in consultation with an MFM specialist.2 The numbers presented reflected a twofold decrease in preterm deliveries, primary cesarean sections, and perinatal mortality rates in the patients managed solely by an MFM specialist.
Eden concluded that the "system is broken" and that high-risk pregnancies have a lower complication rate when managed solely by an MFM specialist. The two groups he and his colleagues studied, however, are not comparable. First, patients who are transferred to an MFM specialist are usually the most acutely ill. These are women who require comprehensive care from a practitioner who has experience with the severity of their disease. One cannot conclude from Eden's abstract that primary prenatal care from an MFM specialist affords a better outcome. It would be more accurate, from the perspective of outcomes, to compare high-risk pregnancies cared for solely by an MFM specialist versus those with care provided solely by a general ob/gyn.
Lastly, the issues of access to care, malpractice, and insurance play a large role in referral to an MFM specialist. In many areas of our country, it is impractical for patients to be cared for only by an MFM specialist. Time, distance, and finances separate patients from referral centers where most MFMs are to be found. Therefore, the responsibility must fall upon the general ob/gyn to assume care for pregnancies complicated by high-risk conditions. Additionally, many who advocate for MFMs as sole providers of high-risk pregnancies argue that generalists "hold onto" medically complicated patients because of the potential loss of income. In the era of incredible malpractice liability and high incidence of lawsuits, some obstetricians are referring all patients with any complication to MFMs. Unfortunately, some generalists with the most experience with high-risk pregnancies (that is, those who are most senior) are giving up obstetrics altogether. In the future, high-risk patients may be forced to see an MFM not because of lack of knowledge or ability on the part of the generalist but because the generalist does not want to assume the liability.
High-risk obstetric patients can be cared for by a generalist and can get good medical care. Generalists are well trained in American ob/gyn residencies. Coordination of care between the MFM and the generalist is vital to practicing good obstetrics. Further studies need to be done to answer questions regarding outcomes of care solely by an MFM versus care solely provided by a generalist.
1. Vintzileos AM, Ananth CV, Smulian JC, et al. Defining the relationship between obstetricians and maternal-fetal medicine specialists. Am J Obstet Gynecol. 2001;185:925-930.
2. Eden RD, Penak A, Britt DW, et al. Reevaluating the role of the MFM specialist: lead, follow, or get out of the way. Am J Obstet Gynecol. 2003;189:S131. Abstract No. 250.
What's your call on the controversy presented by Drs. Elliott and Cherot? Let us know and learn later how your view compares with those of others when we print a sampling of reader responses.
Yes. Medicine has evolved toward specialization.
__ Strongly agree __ Agree __ Undecided __ Disagree __ Strongly disagree
No. The key is coordination between ob/gyn and MFMnot immediate referral.
__ Strongly agree __ Agree __ Undecided __ Disagree __ Strongly disagree
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Fax back to (201) 358-7260 or send an e-mail with your opinion
Elizabeth Cherot. Should all complicated pregnancies be referred to an MFM specialist?
Sep. 1, 2004;49:71-76.