Family medicine residents need to learn reproductive healthcare

Jennifer was one of my first patients as a new doctor, and she came to see me about an unintended pregnancy. A single mom to a rambunctious 5-year-old girl, Jennifer was struggling economically and battling depression. We talked about the options available to her: continuing the pregnancy and preparing to parent another child, offering the baby for adoption or having an abortion. She chose to continue with the pregnancy, and I worked with her over the following months as she struggled with the discomforts of pregnancy, excessive weight gain and the anxiety of having to raise two small children on her own.

Seven months later, I delivered Jennifer’s beautiful baby boy. Six weeks after that, I saw Jennifer, her new baby and her 5-year-old for a joint checkup. We discussed colic, diet and exercise, her daughter’s ADHD and birth control. During Jennifer’s visit, I placed an IUD, a long-acting intrauterine contraceptive device, so that her next pregnancy could be by choice and not by chance.

These are the types of relationships that inspired me to become a family doctor: intergenerational, continuous care for patients of all ages, inclusive of all healthcare needs.

New policies proposed in April by the Residency Review Committee for Family Medicine, or RRC, the group that outlines requirements for physician training programs nationwide, threaten to interfere with that comprehensive care and to decrease reproductive health access for women like Jennifer.

The proposed RRC changes would eliminate the current requirement that family medicine residents learn full-scope reproductive healthcare. Instead, the decision to teach these skills would be up to the discretion of individual residency programs. Family doctors would no longer be required to learn how to prescribe birth control, place intrauterine devices or contraceptive implants, provide options counseling for women with unintended pregnancies or diagnose and manage miscarriages.

The RRC, composed of 11 men and three women, finds the current guidelines too onerous. The committee’s proposal aims for more flexibility and creativity by making the requirements more general and less restrictive.

Although the RRC has the right idea (the requirements for family medicine training are notoriously cumbersome), its choices are misguided. Family medicine residents, for example, are required to complete two months of surgical training. It could eliminate that requirement instead, given that the number of family doctors practicing general surgery is infinitesimal.

Unintended pregnancies account for nearly 50% of U.S. pregnancies and lead to healthcare costs of more than $12 billion annually. If we stop training family physicians in reproductive health skills, the result will be many more unintended pregnancies, particularly in the medically underserved poor urban and rural communities where family physicians tend to work. These communities often lack access to specialty care. If we place these medical services solely in the domain of costly specialists, reproductive healthcare will become even more unobtainable.

As a general practitioner, I have tremendous respect for my specialist colleagues. I refer patients to them often to help with cases that are out of my scope of practice. Comprehensive contraceptive care, however, is relevant to about 75 million women in this country and should fall within the scope of primary care.

The Affordable Care Act intends to expand women’s access to reproductive healthcare by requiring health insurance programs to cover the cost of birth control. The law also addresses the enormous primary-care shortage by offering incentives to physicians to enter primary-care fields. To expand our primary-care resources but opt out of training these new doctors in the most current and effective reproductive health skills would be like investing in a sailboat, hiring an inexperienced crew and refusing to teach them how to sail.

Physicians should be allowed to choose what type of medicine they practice and what procedures they perform. Residents currently can opt out of reproductive health training on moral or religious grounds, just as they can opt out of abortion training.

But if the proposed changes go through, a substantial number of residency programs, particularly those affiliated with religious institutions, are likely to stop teaching these skills altogether. Residency program directors who have personal objections to contraception and abortion could decide not to train any of their residents in these essential tools of reproductive healthcare. Many family doctors interested in learning full-spectrum women’s healthcare would have difficulty finding the programs invested in teaching the necessary skills.

Almost weekly, another state or institution attempts to restrict women’s rights to reproductive freedom. I am deeply disturbed that my own profession, the one I chose for its emphasis on continuity of patient care and its foundation of social justice, seems to have joined the fray.

Alison Block is a family medicine resident.

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  • LaurieMann

    It read to me like the doctor was discussing all kinds of reproductive health care, but, in particular, birth control.

  • Original_Cait

    It seems like a lot of American women prefer to have most of their “woman’s business” taken care of by OB/GYNs rather than by primary care physicians, even demanding to see specialists for simple things like Pap smears and straightforward prenatal care & childbirth.

    I certainly think that these are things family doctors (GPs in Australia) can and should handle, but in a “customer-driven” system like America’s where many women have the “freedom to choose” to bypass family medicine practitioners/GPs, perhaps it is “the market” as much as anything that is seeing the shifting of reproductive medicine from GPs/PCPs to specialists, not any grand religious-political-ideological master plan.

    It’s a shame though, because once this training and these skills are lost to a cohort of family doctor residents, it will be tough to ever reclaim it, if America does ever come to her senses and start recognising the value once again of having a family doctor be the primary caregiver for *all* of a family’s basic healthcare needs.

    • Dr. Drake Ramoray

      It’s not just customer choice. I know several family practice docs who don’t practice OB because of the increase in malpractice insurance premiums if they provide obstetrical care. You didn’t account for how litigious American medicine is.

      It’s also a more expensive way to provide bare because in my practice at least, I’m more likely to get consults for things like new onset uncomplicated diabetes that the OBs either don’t want to or can’t handle that would otherwise be managed by family practice

    • Mengles

      In America, when it comes to delivering babies, OB-Gyns have always done straightforward prenatal care & childbirth. It wouldn’t make sense to further fragment your care between an FP and an OB-Gyn.

    • Patricia

      Why don’t you try to discern why women prefer to take care of their “woman business” with an OB/GYN? You are dismissive of it, but why not apply some critical thinking here?

  • Guest

    Why are you so fixated on abortion when the author barely mentioned it? The point to me was where the author wrote, “Family doctors would no longer be required to learn how to prescribe
    birth control, place intrauterine devices or contraceptive implants,
    provide options counseling for women with unintended pregnancies or diagnose and manage miscarriages.” These are all so vital! What is “Family Medicine”, if it does not cover all aspects of family planning and reproductive health?

  • buzzkillerjsmith

    Prescribing OCPs, inserting IUDs, and inserting contraceptive implants can be taught in about a day and half, two days max, in either residency or in your first week in practice.

    If you want to learn how to diagnose and manage miscarriages, go to UpToDate and spend half an hour.

    Talking to pts about “options” requires a half-day seminar.

    Spend your time on learning how to manage heart failure, young doc.

    • Patricia rude. Your attitude is why medicine in America suffers so much; the arrogance. There is more to an IUD than just “inserting” it; as if a woman’s uterus is some kind of bag you can stick something in. Why not take the Doc’s thoughts think about them? You know rather than knee jerk “old doc” response?

      • buzzkillerjsmith

        Rude?! Rude?! I resemble that remark. Notice the name. ;)

        • Patricia

          You should use your power of humor for good!

  • lauramitchellrn

    As and L&D nurse who has worked in two teaching hospitals and a California district hospital with ED residents, I think the problem starts in the residency programs. At one of the teaching hospitals I worked at FP had a low-risk OB practice and delivered their own patients. If the patient required a c-section, the FP physician (even attendings) got “demoted” to first assistant to an OB resident. FP and ED physicians are fighting for the skills and are effectively shut out by the OB residents.

    FP, Emergency Medicine and OB-Gyn need to sit down and actually talk (a novel concept, I know) about the necessary skills that ED physicians (a lot of our residents were Navy and would sometimes end up being the ONLY physician at their duty station) and FPs need. For example, both should know how to deliver babies but the ED physician needs experience with ectopic pregnancy as well. Maybe the answer is to add a year to ED and FP programs focused exclusively on obstetrics.

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