Rural Health Advisory Committee
Rural Obstetrics Workgroup Meeting Minutes
Thursday, November 30, 2011, 12-1:30 p.m.
Members Present: Tom Crowley (chair), Ellen Delatorre, Mary Devany, Jen Harvey, Scott Johnson, Frank Lawatsch, Michelle Quale, Suzanne Sudmeier, Nicole Wilson (Manemann), Thomas Witt
MDH Staff: Paul Jansen, Mark Schoenbaum, Kristen Tharaldson
Guests: Macaran Baird, M.D., M.S. and Mary Jo Chippendale (MDH)
Rural Obstetric Provider Training and Residency
ORHPC staff presented workforce information on primary obstetrical care providers. Licensed providers currently participating in deliveries in Minnesota include:
- Family practice physicians (605)
- OB/GYNs (529)
- General surgeons – C-section coverage (511)
- Certified nurse midwives (187).
Additional workforce data was presented by region. The total number of births in Minnesota was 68,157 in 2010. The provider to patient ratio was 25:1000 births. Workforce data show rural obstetric providers are likely to perform few deliveries and provide services other than obstetrics. Rural obstetric providers tend to have a wider variety of roles. Urban obstetric providers tend to do more deliveries.
Information was presented about various obstetric training and residency programs in Minnesota. About 30 percent of family practice graduates from University of Minnesota programs (Twin Cities and Duluth) move into practices that do obstetrics in rural or urban facilities and roughly 70 percent stay in Minnesota. First year students at UMN-Duluth are offered an elective obstetrics longitudinal course. This allows the students to follow obstetric patients during their prenatal care, labor and delivery, and postpartum care. Other electives to gain obstetric experience in rural areas are offered.
There are three general surgery training programs in Minnesota (Mayo, HCMC and UMN) offering 24 residency slots. Currently no programs offer experience in a rural setting. Roughly 33 percent of rural Minnesota’s general surgeons complete medical school and residency in Minnesota.
There is one certified nurse midwife (CNM) program in Minnesota (UMN) and one additional program in the upper Midwest (Marquette in Milwaukee, WI). Several distance learning CNM programs are available. The UMN program has eight-10 graduates each year with approximately 90 percent practicing in Minnesota following graduation. The Accreditation Council for Graduate Medical Education does not allow CNMs to supervise residents. This acts as a deterrent to hiring CNMs in some facilities.
There have been dramatic declines in the number of certified nurse midwife graduates. The CNM program is moving from a master’s level to a doctoral level program. Because longer training requires more money there is less student interest. Most rural graduates are homegrown and intend to return to practice in rural locations.
Dr. Mac Baird, head of the Department of Family Medicine and Community Health at the University of Minnesota Medical School, provided additional information on UMN obstetric provider training and residency programs. The Accreditation Council for Graduate Medical Education has residency review committees that are responsible for setting requirements for post-MD medical training programs. New rules require 80 deliveries (previous requirement was 40) for an MD to be sufficiently trained in obstetrics and skilled in first assisting. C-section training requires a minimum of 50 deliveries.
General surgeon training does not include C-section training. It must be an elective or offered within rural training opportunities. UMN is planning to create a two-year rural track for general surgery with two residency slots at a cost of $130,000/year per slot.
There are 11 family practice residency programs in Minnesota. Of the UMN’s eight programs, three are in greater Minnesota (Duluth, Mankato and St. Cloud). Hennepin County Medical Center, Mayo and United Hospital offer the other residency programs. Family practice residents need to secure a slot with hospital privileges to gain C-section experience. The ease of securing these slots varies.
Dr. Scott Johnson, an OB/GYN and general surgeon, offered additional information on programs in Duluth. OB/GYNs provide the great majority of deliveries in Duluth. Residencies are offered through St. Mary’s and St. Luke’s Hospitals. Due to new work hour restrictions implemented in July 2011, residents have fewer opportunities to do deliveries and are less able to support their own patient base through the course of their pregnancies. Work restrictions have resulted in new graduates not getting the same amount of experience as previous graduates. In some cases, an additional year of residency is needed to meet obstetric training requirements.
Three third-year residents each year are involved in advanced C-section training. They carry a pager for both hospitals. Issues with this program include work hour restrictions, reduced C-section experience for other residents, no reimbursement for other staff involved in residency training, and the need for ongoing commitment of obstetrical staff.
One fourth-year resident each year is involved in an obstetric procedural fellowship. This provides five months of concentrated high-risk obstetrics and C-section training. The fellow works in a rural setting and is ideally trained to do obstetrics in a rural facility.
Currently, 85 percent of general surgeons subspecialize and only 15 percent remain as generalists. Many choose a sub-specialty for additional training to gain competency and confidence as a surgeon. Twenty years ago, general surgery residences trained in other areas including OB/GYN and emergency medicine. Now they have no OB/GYN training.
Essentia health system is looking to create a rural general surgery residency program. The goal is to offer two residency slots per year starting in 2014. Issues with program development include lack of funding (no GME slots, no ACA funding) and affiliation.
Rural obstetric providers are faced with the challenge of a lower volume of deliveries. Over time, their competency and skill levels may decline. Many choose to stop doing C-sections after two or three years, which is good for safety and quality purposes, but creates a growing gap in rural obstetric services. C-section and advanced neo-natal care skills are especially hard to maintain in a low volume environment. Ongoing refresher courses and/or intensive retraining opportunities (especially for C-section providers) are needed to maintain skills and proper judgment to provide quality obstetric care.
A complicated scenario occurs in rural areas when it is necessary to transport a high-risk patient in labor, but weather or other factors do not allow EMS transfer. In these cases, a great deal is spent on air transport/helicopters. There may be ways to consider the risks/benefits of money spent on air transport versus training a rural physician to provide timely care at a rural location.
Higher education must continually update medical training programs to meet current and future needs. Medical students are immersed in new health information technologies and curriculums must incorporate this new aspect of medical practice. Distance learning technologies may provide ways to increase the number of graduates. Telehealth may provide an alternative to traditional models for adding capacity.
There was discussion about the number of new medical graduates needed to meet future obstetric care needs in Minnesota. With no funding for additional residency slots, Minnesota is going backwards in the percentage of family practice physicians who are ready to practice in rural areas. With falling funding to support current residency slots, it is difficut to maintain family practice residencies because it hits a local facility’s bottom line. The number of GME slots is fixed (12 hospitals in Minnesota) but not sufficient to meet current and projected workforce needs. Dr. Baird believes broader financial support is needed.
With recent cuts to federal Graduate Medical Education (GME) programs, all residency programs are at risk. State programs such as Medical Education and Research Costs (MERC) and Rural Physician Associate Program (RPAP) are also vulnerable. These programs are an essential pipeline for rural medical providers. Potential steps to address this issue include:
- Write letters of concern regarding federal GME funding cuts.
- Make the consequences of these cuts clear to legislators using data and workforce projections; primary care and non-hospital specialties are at greatest risk.
- Write letters to the UMN President, Dean of the Medical School, and the Academic Health Center to keep primary care as a core part of the mission.
Options to increase the number of obstetric providers who are well trained for rural practice environments include:
- Direct fund rural resident slots (state level)
- Refugee physician program (state level)
•This program supports medical graduates from other countries and allows for supervision of medical practice to work up to obtaining their medical license in the United States.
•These providers are often more willing to work in rural areas and some already have advanced surgery experience.
- Older physicians as trainers and mentors (state level) – it may be advantageous to access the collective experience of older physicians to train residents.
•Ireland and Canada may have models in this area.
•Board certification used to be automatic at retirement, but now are time certified. This may complicate arrangements for retired physicians to mentor or train residents.
- Canada provides two-year training for family practice physicians. This may be a model to reconsider time spent in medical school versus a rural practice environment. It would also address medical school debt loads for generalists.
The next workgroup meeting will be via webinar February 6, 2012, from 9-11 a.m. We will look at obstetric issues that impact rural hospitals including the demand for OB services, number of births needed to support a rural OB program, infrastructure requirements, financial/liability issues, availability of support services (i.e., ultrasound) and technology to support access to OB services.
The webinar adjourned at 1:30 p.m.