A road less traveled 
Obstetrics in family practice

by Davelyn Hood, M.D.

Now in my second year of private practice, I find myself looking back at the road that brought me here. That road is certainly the one less traveled, but for me it has offered the greatest rewards. The road to which I am referring is the inclusion of obstetrics in my family medicine practice. I actually do not advertise that I am an obstetric provider. Instead, I borrow the terminology of the AAFP and call myself a maternity care provider.

Choosing between a family-medicine or OB/GYN career was difficult. After all, I went to medical school so I could deliver babies. After completing my second year at the University of Texas at Houston, I was convinced that I was not bright enough to become a family physician. Who could remember everything there was to know in medicine and use it in everyday practice? I was sure that limiting my practice to the care of women would be an easier road. Upon completing the third year clinicals, I realized that placing such limitations on my career would not provide the fulfillment I sought in practicing medicine.

UT-Houston has a strong focus on primary care and a wealth of a terrific family medicine faculty. With their encouragement and that of my husband, who is also a family physician, I took the plunge and sought out family medicine programs strong in obstetric training. In order to stay in the Houston area where my husband was already in residency, I chose the community-based Conroe Family Practice Program. In addition to an away obstetric elective at Brackenridge Hospital in Austin, I immersed myself in obstetric training. The Conroe program employed family physicians for basic obstetric training and offered three fabulous obstetric mentors for the more high-risk patients. Every call night of my intern year was spent on the labor deck, making myself available to the nursing staff (from whom I learned immensely), private obstetricians and, of course, our patients. I spent 24 hours a day, seven days a week on call for cesarean sections during my second year, then four days a week and weekends. I was already on call during the third year.

By the middle of my intern year, I began to question my choice of family medicine. Everywhere I turned, the family physicians and family practice residents met with obstacles. No place was it more apparent than in labor and delivery. Over and over, I heard negative comments about other residents or family physicians. Almost like subliminal messaging, I began believing that family physicians were inferior. It was not until near the end of the second year, when I spent a week under the wing of Dr. William Rodney in Memphis, Tenn., that I gained a newfound respect for my colleagues. I became a strong family medicine advocate, but only in the small circle of my own residency program.

The advocacy was forced to expand when I began preparing for private practice. For personal reasons, it was not possible for me to spend an additional year in training for an obstetric fellowship although I still feel that is the best plan for any family practice resident who plans to include maternity care in their practice. My husband and I started looking in West Texas, where he was raised, for a rural area to practice. During a recruitment meeting with a hospital administrator, I was actually told that I could not possibly want to practice obstetrics. The administrator was sure that I did not want such an inconvenience to my family life.

Instead, I took my over 70 cesarean sections and more than 125 vaginal deliveries and looked elsewhere. I chose what I thought was a more family-practice friendly place to practice and sought privileges there. My training was met with skepticism by the lone obstetrician in town, who had made it clear from the day of my first meeting at the hospital that no family physician would have cesarean section privileges under his watch.

After a two-hour medical staff meeting where my biggest opponents were the obstetrician and a fellow family practice physician, I was awarded provisional obstetric privileges. The provisions for vaginal deliveries were the same for all new obstetric providers — three observed deliveries. However, I had to undergo proctorship for cesarean section privileges. The number was not set initially, but after the first few surgeries, the obstetrician felt comfortable enough with my skills to say that eight observed cesarean sections should be enough. It took me almost 18 months to reach that number. Upon receiving full cesarean section privileges, I performed two without an obstetrician present.

Within a month, a newly formed committee including all obstetric and pediatric providers, including family physicians, set out to develop required consultation criteria. As the only family physician with cesarean section privileges, I took the imposition of such criteria quite personally. It was difficult to do what I had already done, and without a backing of equally credentialed family practice colleagues, I lacked the drive to keep fighting. At our hospital now, except for extreme emergencies, an obstetrician must be in the hospital for a family physician to perform a cesarean section. In reality, this usually means that an obstetrician is the assistant.

Such a concession seems small on the surface, but the ripple effect is great. Family medicine providers rarely lose privileges in large chunks, but rather by constant nibbling and redefining of what a family physician can or cannot do. Only other family physicians truly understand the training that family medicine provides. My husband and I are good examples. He chose a program where he received strong internal medicine training especially in geriatrics and cardiology. In our clinic, I take care of mostly women and children; he cares for mostly men and elderly. We have a complete practice because we each fill a different niche in the spectrum of family medicine. Without the active involvement and strong support of family physicians on a local, state and federal level, the reality of full-scope family practice will fall by the wayside. One person cannot fight the fight alone. Every day there is a new threat to family practitioners whether it be in obstetrics or critical care or pediatrics or in-patient hospital care at all.

Without obstetrics, my practice would be similar to a pediatrician’s. Without pediatrics, I would be essentially an obstetrician. Neither of these fills the desire I have to apply the talents with which I have been divinely blessed. I chose family medicine so that I could care for the whole family. Family-centered maternity care allows me to get to know the entire family, from parents and siblings to grandparents and beyond. It is not only a more enriching experience for the patient, but offers the greatest reward to the family physician. No gaps exist in this model of obstetric care. It is one that has existed for centuries and only modern technology and litigation threatens to strip it away.