Education Columns

by Dana Kirschner, DO, UPMC Family Medicine Residency Program, Williamsport, PA

Background

The UPMC Williamsport Family Medicine Residency is an unopposed community-based residency that has traditionally offered strong obstetrics training.  Our residency delivery numbers decreased by 36% between 2014 and 2020 while the community’s delivery numbers remained stable.  Within that time, the local OB-GYN group began caring for Medicaid patients when previously all of these patients would have received care within the family medicine residency prenatal clinic.  Residents were not able to gain sufficient obstetric experience required for independent practice with the lower patient volumes.

Intervention

With the support of the OB-GYN group and administration, a multi-level plan was developed to start on January 1, 2021:

• Rotation logistics were adjusted to assign a resident on the OB rotation to Labor & Delivery during daytime hours.
• When residents are in labor and delivery, they care for residency clinic patients and midwife patients.  The labor and delivery space was physically changed to allow for a resident workstation directly next to the midwife’s working station.
• Midwives, with OB-GYN attending backup, are now assigned to be the primary supervisor of residents for residency clinic patients when a Family Medicine faculty member is not assigned to labor and delivery.  This has allowed some family medicine residency faculty to transition to outpatient-only prenatal care to focus on other family medicine interests.
• The OB-GYN group offers patients eligible for the Healthy Beginnings program (a government-sponsored program for Medicaid patients to provide access to ancillary services such as nutrition, social work, dentistry) to transfer to the residency clinic for prenatal care to access these services.
• Midwives see patients in the residency prenatal clinic one half day per week to give patients the opportunity to meet them and allow a resident to be present in labor and delivery consistently.

Results

Resident vaginal delivery numbers have more than doubled in our first year since the change.  

Within the first six months of the transition, the family medicine residency prenatal clinic patient volume increased due to Healthy Beginnings referrals from the OB-GYN group with an additional 22 patients having access to this government-sponsored program from the SHOB referrals.  In the first year, 144 patient visits were completed by a midwife in the family medicine residency prenatal clinic.

 Discussion

The goal of this transition was to increase delivery numbers for residents, provide a prenatal-only option to faculty who desired it, and further partner with our local OB-GYN group. We achieved each of these three goals. Resident delivery numbers more than doubled with more time spent on Labor & Delivery and working with midwife patients. The prenatal-only option has proven successful in recruitment as our two newest faculty members have chosen this option and indicated they would likely have not taken the position if inpatient obstetrics was required. The relationship with the OB-GYN group has strengthened. In fact, our residents just awarded the "Inpatient Teacher of the Year" award to one of the midwives!  Additionally, the GYN attendings have started a procedure clinic during the GYN rotation for our residents to have improved access to IUD placement, Nexplanon insertion, colposcopy, and endometrial biopsy. 

Collaboration with other Obstetrics, providers may be a way for Family Medicine Residency Programs to think outside the box to reach the proposed new ACGME delivery number requirement?