Rural residency offers tool to address ob.gyn. shortages
In 2021, the first obstetrician-gynecologist trained on a separate rural residency track will graduate from the University of Wisconsin.
Program leaders are gambling that the investment in specialized training – including a quarter of the training time spent in smaller, community hospitals – will eventually pay off in terms of more ob.gyns. living and practicing in Wisconsin’s underserved rural settings.
“The key premise that we’re working on and that’s been borne out in the literature on rural training in family medicine is that people who are ultimately going to practice in a rural setting are people who are interested in it, who have a rural background, and people who have experience in a clinical environment in the rural setting,” said Ellen Hartenbach, MD, ob.gyn. residency program director at the University of Wisconsin, Madison.
For now, the program is starting slowly. It matched its first and only rural resident – Laura McDowell of the University of Minnesota – in the 2017 National Resident Match. The new rural-track resident joins the six residents in the school’s main ob.gyn. training program. New residents will be added to the rural track based on the availability of funding. The university relied on a development grant from the state, as well as funding from local community hospitals, to help finance the new position.
Dr. Hartenbach said the selection of the rural-track resident centered around finding someone who had both interest and prior experience in a rural setting, as well as someone who wanted to eventually live in a rural community. The university also had to ensure that applicants weren’t trying to game the system, looking for a way to break into the competitive ob.gyn. residency field, which had a 100% fill rate in 2017. More than 100 medical students applied for the single rural track position.
University of Wisconsin’s program is thought to be the country’s first dedicated, sanctioned rural ob.gyn. residency track. The university has been working for the last 2 years to develop the program and get approval from the Accreditation Council for Graduate Medical Education’s Residency Review Committee.
When the first resident starts on July 1, she will receive 75% of her training in the university hospital in Madison and 25% split among four smaller, community hospitals. The rural resident will receive the same clinical and cognitive skills training as the other residents, with the same number of required procedures. The big difference, Dr. Hartenbach said, comes from the experience gained in working in smaller hospitals.
“There’s a pretty big difference with the ob.gyn. unit in a 50-bed hospital, compared to a 500-bed hospital,” she said. “There’s a difference in terms of the types of patients that come in to smaller medical centers.”
Dr. Hartenbach said she hopes having real-world experience in the rural setting will help to dispel common misperceptions, including that rural physicians are always on call.
The Wisconsin program could be a model for other states by giving residents a chance to understand the dynamics of smaller hospitals, said Thomas Gellhaus, MD, president of the American Congress of Obstetricians and Gynecologists (ACOG). But its success would depend on the presence of community hospitals that have an adequate number of physicians to supervise residents and a case mix that matches up with training requirements. “It can’t just be anywhere,” said Dr. Gellhaus, clinical associate professor at the University of Iowa, Iowa City. 
Dr. Hartenbach said the goal behind the new training design is to help bolster the rural OB workforce.
“There’s a lot of rural health disparities in a lot of medical fields, in particular in maternity health services,” she said. “There have been a lot of reports showing that we’re not going to have enough ob.gyns. and a lot of rural hospitals are closing down their maternity services.”
About one out of three Wisconsin counties don’t have an ob.gyn, according to ACOG. In the past, family medicine physicians and nurse midwives have helped to pick up the slack on maternity care in rural settings, but the number of family physicians who offer obstetric services is on the decline. One study showed that the proportion of family physicians providing maternity care dropped from 23% in 2000 to less than 10% in 2010 (J Am Board Fam Med. 2012 May-Jun;25[3]:270-1). That development has contributed to an “acute” crisis in the provision of rural maternity care, Dr. Hartenbach said.
Maldistribution
This trend is national as well. Nearly half of the 3,107 U.S. counties lack ob.gyns. These counties are located in all states but primarily in the Midwest and Mountain West, according to a 2011 workforce report from ACOG.
