By Jonathan Nelson
Womb to tomb. That’s how Shawn White, M.D., describes the brand of family medicine he and his partners practice in the rural north Texas town of Decatur and the communities around there. Cradle to grave. Along with Jeff Alling, M.D., Brad Faglie, M.D., and Lara Pierce, M.D., White considers maternity care an essential part of their busy practice, a part they almost lost when the hospital in town denied them obstetric privileges.
“If you want to be a full-service doctor and you want to take care of multiple generations of a family, then obstetrics is a way to keep your practice young and vibrant and to provide that truly full-service family medicine, and that is needed in so many Texas counties,” White says.
This is a story about how these doctors fought and won back their privileges, but it’s also a story about the shrinking scope of family medicine in a time of great change. Whether by choice or by constraint, a diminishing number of family physicians deliver babies today. On the 10th anniversary of AAFP’s landmark Future of Family Medicine report, should FPs keep obstetrics in their basket of services?
In 1990, Dr. Alling began practicing full-scope family medicine in Wise County, 40 miles north of Fort Worth. Since then, he’s delivered more than 2,000 babies. He’s trained family medicine residents in obstetrics and built a thriving practice.
Dr. White joined the practice in 1997, and for a while they delivered babies at Wise Regional Health System in Decatur, but the doctors grew to believe the hospital administration’s vision had diverged from their own. “Along about 2002, we started to anticipate the writing on the wall,” Alling says. “[The hospital in] Decatur wasn’t interested in supporting family practice at all.”
Later that year, Alling, White, and several other physicians decided to build a new hospital in a town 11 miles to the west, and six years later, they moved their practice to the newly opened North Texas Community Hospital in Bridgeport. Dr. Faglie joined the practice a little later and Dr. Pierce came on in 2012 after completing her residency training.
“Then we trekked along, nice and happy, until November of 2012 when the hospital got in financial difficulties,” Alling says. After bankruptcy and reorganization, Wise Regional purchased the hospital and announced they would shut down the maternity ward in Bridgeport.
Pierce had delivered five or six babies there, she says, and was beginning to build her practice with about 20 expecting mothers in her care. “I was just getting going and I had to hit the brakes.”
One day after the acquisition, she was called to meet with the CEO of Wise Regional to discuss her contract with the hospital. “In the process of talking to me, he said, ‘Oh by the way, I’m sorry about your OB privileges,’ and I was like, ‘What do you mean, my OB privileges?’” Then he told her that according to hospital policy, physicians had to be board-certified in obstetrics and gynecology to obtain obstetric privileges. “That was the first any of us had heard.”
The policy had been in place since 2009, and according to Wise Regional’s outside counsel, Kevin Reed, it was part of a strategy to transform the hospital from a small, rural facility into one that resembled hospitals in Dallas and Fort Worth, hospitals that focus on specialty care and where family physicians rarely apply for obstetric privileges. Reed says the change was driven by a shift in the region’s population over the last 15 years.
“The town of Decatur is small, but the catchment area there is actually very large. It’s really that whole area of suburban Fort Worth just growing up into that region and as you have that growth, there’s been a demand for those increased services,” he says.
From left: Brad Faglie, M.D.; Shawn White, M.D.; Lara Pierce,
M.D.; and Jeff Alling, M.D.
The four doctors had about 75 pregnant patients when they found out about the policy. They applied for credentials and began making their case to the hospital board. At first the Medical Staff Ethics and Credentials Committee agreed the doctors should be granted privileges for labor and delivery, but when the matter went before the Medical Executive Committee, the motion died for lack of a second.
At that point, they hired a lawyer and settled in for a fight. They attended board meetings and pled their case; they got help from TAFP and the Texas Medical Association; they collected more than 400 signatures on a petition to the board; they told their story to reporters and garnered media coverage in the Wise County Messenger, the Texas Tribune, and the New York Times. They even filed a Freedom of Information Act request to access the minutes of past hospital board meetings.
To help make their case, they wrote a white paper citing several studies showing that family physicians provide excellent obstetric care. “The results are clear,” they wrote. “Trained and qualified FPs deliver outstanding OB care and now is the time to infuse that message into the medical community and encourage new and existing FPs to adopt OB care if we hope to address the staffing challenges ahead.”
All the while, the doctors were concerned about their maternity patients. Wise Regional had recommended that patients affected by the closure of the Bridgeport maternity ward transfer their care to one of the three obstetricians in Decatur, and several patients did, but the doctors searched for opportunities where they could keep doing OB. White looked to Gainesville, 45 miles northeast of Decatur.
“If I went months without delivering babies, there comes a point where you just stop delivering babies,” he says. “I knew if I stopped, I’d be done. So I reached out to Gainesville, to North Texas Medical Center, and just asked the question.” The last family physician delivering babies there had stopped five years earlier, but White met with the obstetricians on staff and the hospital CEO, and the medical staff voted to give him privileges. “So as soon as we stopped delivering babies here in March, I took my patients up to Gainesville and started delivering babies up there.”
The doctors worked another angle, too, because they were worried about what the closure of the Bridgeport maternity department might mean for communities further west. They approached the CEO of Faith Community Hospital in Jacksboro, 40 miles west of Decatur, about offering maternity care there. Faith Community is a 55-year-old facility, so the infrastructure wasn’t suitable for full-service obstetrics. “They actually brought in a mobile surgical unit from Joplin, Missouri, and put it next to the hospital so we could have 21st century technology,” White says. “We started delivering babies in Jacksboro for the first time on purpose in 33 years.”
In late spring, the doctors entered into legal mediation with Wise Regional, but the effort failed. “The doctors were still making a lot of noise,” Reed says, “and [the board members] were listening.” The board asked the medical staff to reexamine the existing policy and make a recommendation, and they did.
On July 29, 2013, the hospital board adopted a new standard for obstetrics privileging for family physicians. To be eligible, they must have performed 100 vaginal deliveries and 50 cesarean sections. To maintain privileges, they must perform 40 deliveries and 10 C-sections every two years.
Alling, Faglie, and White were awarded privileges, but Pierce didn’t have enough deliveries to be eligible. She still delivers babies in Jacksboro and plans to reapply at Wise Regional once she reaches the mark, but she’s had to rebuild her practice. “If they hadn’t shut everything down and said, ‘No, you can’t practice OB,’ I would have met my numbers already,” she says.
The problem, Alling says, isn’t specific to obstetrics. “This is something we battle on all fronts.”
“All the specialists are worried that we’re going to get ourselves in trouble by getting in over our heads,” Pierce says, “but we are really good as family doctors at knowing when to ask for help. We do it all the time.”
As hospitals and health systems follow the trend toward more specialized care, family physicians find themselves fighting to obtain credentials for many procedures. When they require board certifications for those privileges, as Wise Regional did for obstetrics, they cut family doctors out.
“All the specialists are worried that we’re going to get ourselves in trouble by getting in over our heads, but we are really good as family doctors at knowing when to ask for help. We do it all the time.”
–Lara Pierce, M.D.
“The fundamental problem for family physicians is you have to meet the gastroenterology standards for doing a colonoscopy; you have to meet the OB-GYN standards for delivering a baby,” says Troy Fiesinger, M.D., immediate past president of TAFP. “If you define the ability to do procedures, surgeries, et cetera by training—meaning the type of training—you always will restrict family physicians.”
Rather than requiring fellowships or board certification to gain hospital privileges, credentialing should be based on demonstrated competence, according to the Joint Statement on Cooperative Practice and Hospital Privileges agreed to by AAFP and the American Congress of Obstetricians and Gynecologists.
“The assignment of hospital privileges is a local responsibility and privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to assure the provision of high-quality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies.
“The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice. Provisional privileges in primary care, obstetric care and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented. All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. These principles should apply to all health care systems.”
Family medicine’s shrinking scope
Despite their success, the four FPs in Decatur are not the norm. The days when most family physicians delivered babies are long gone. A recent study in the Journal of the American Board of Family Medicine reports the proportion of family physicians practicing maternity care declined from 23.3 percent in 2000 to 9.7 percent in 2010.
A study in the Annals of Family Medicine shows that from 1995 to 2004, the percentage of prenatal visits provided by family physicians dropped from 11.6 percent to 6.1 percent. In rural areas where people depend more heavily on family doctors to deliver babies, the decrease was even greater, from 38.6 percent to 12.9 percent. These results led researchers to question whether residency training programs may soon have difficulty supporting the family medicine curriculum because there simply aren’t enough family doctors practicing obstetrics to recruit as faculty, to host rotations, or even to serve as community role models for residents.
About 20 percent of AAFP members report they have hospital privileges for routine deliveries, but only 10 percent say they delivered one or more babies in 2009. Whether it’s because of liability costs, lifestyle concerns, or lack of institutional support, family doctors aren’t delivering many babies. When Wise Regional representatives defended their policy requiring a residency in obstetrics and gynecology for obstetric privileges, they said they were emulating Baylor University Medical Center at Dallas and other hospitals around the Metroplex. But those hospitals don’t bar family physicians from gaining obstetric privileges. Family physicians just aren’t requesting those privileges.
Ten years ago, AAFP published the Future of Family Medicine report, setting the course for the Academy and the specialty for years to come. The authors called for the adoption of a “new model” of family medicine, in which all family physicians would commit to providing a “full basket of services” that all patients could expect. That basket included maternity care, but the authors hedged somewhat on whether obstetrics was absolutely required.
“The flexibility and adaptability of the New Model will accommodate variation from practice to practice in the specific services provided, depending on the geographic location of the practice, the unique needs of the community being served, the physicians’ interests and training, and the availability of staff. For example, practices will vary in the range of diagnostic and therapeutic procedures performed, in the amount and intensity of hospital care provided, and in the extent to which they provide intrapartum maternity care. All family physicians, however, will share a common commitment to provide or coordinate all care specified in the family physician’s basket of services, thereby serving as effective personal medical homes for their patients.”
This year AAFP announced that it will revisit the project to examine the current state of family medicine and to define the role of the family physician in the 21st century. Jerry Kruse, M.D., M.S.P.H., is one of the core team members on the new project, Family Medicine for America’s Health: Future of Family Medicine 2.0. He is the Executive Associate Dean of the SIU School of Medicine and the CEO of Southern Illinois University HealthCare. He’s also the immediate past president of the Society of Teachers of Family Medicine.
“There’s a significant body of literature in the world that shows that the type of prenatal care, the type of total maternity care that is delivered by family physicians is highly effective and I don’t think you can find one study that shows that maternity patients that book with a family physician have worse outcomes of any kind than those that book with anyone else, whether it be an obstetrician or a midwife or any other kind of practitioner,” Kruse says. “Speaking personally and for a large group of family physicians, I think it’s very important that maternity care remain a big part of family medicine. There is some debate among those in leadership levels in the discipline of family medicine, but that’s my thought.”
Kruse traces the start of the long downward trend to the 1980’s when spiking malpractice premiums caused many family physicians to give up obstetrics. Once the family physicians in a community stop delivering babies, it’s hard to start up again.
The trend toward physician employment plays a role as well. AAFP survey results show that more than 60 percent of members are employed. More than 80 percent of physicians who have practiced seven years or less are employed. Physicians in employed settings often have defined roles in a system, which means employers determine the scope of practice for their family physician employees.
Rising demand for primary care services in the midst of a physician shortage causes many family physicians to narrow their own scope. “More and more, family physicians can fill their days completely with patients with chronic medical problems and spend their whole day in the office. And there’s pressure for them to do that,” Kruse says. “So things like procedures and maternity care and nursing home care and general hospital care sometimes tend to slip just because of that sheer volume pressure that comes with a shortage of family physicians and an aging population.”
“More and more, family physicians can fill their days completely with patients with chronic medical problems and spend their whole day in the office. And there’s pressure for them to do that. So things like procedures and maternity care and nursing home care and general hospital care sometimes tend to slip just because of that sheer volume pressure that comes with a shortage of family physicians and an aging population.”
–Jerry Kruse, M.D., M.S.P.H.
That problem will only get worse. The Association of American Medical Colleges predicts that by 2015, the nation will have a shortage of about 21,000 primary care physicians. The American Congress of Obstetricians and Gynecologists predicts a 25 percent shortage of OB-GYNs by 2030, and 35 percent by 2050.
When the Wise County physicians wrote their white paper to the Wise Regional Health System board of directors, they titled it, “Who’s Going to Catch All the Babies?” Given these predicted shortages, it appears to be a fair question. Thanks to their tenacity and determination, pregnant patients in north Texas have a few more options.
White says even though the fight was difficult, the ordeal had a “strange outcome.” Before it began, family physicians were delivering babies in one hospital in the area – Bridgeport. Now family physicians are delivering babies in three hospitals – Wise Regional in Decatur, North Texas Medical Center in Gainesville, and Faith Community Hospital in Jacksboro.
“I think after education and perseverance,” he says, “it’s very gratifying that even though this is a partial victory in some ways, when it’s all said and done, they voted unanimously to grant privileges. Their hospital board voted unanimously to give us privileges.”