Feature

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.

Dr. Ellen Hartenbach Courtesy John Maniaci/UW Health
Dr. Ellen Hartenbach


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. Thomas Gellhaus
Dr. Thomas Gellhaus


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.

As of 2010, the national ratio of ob.gyns. per 10,000 women was 2.1, but that ratio decreases from 2.9 in metropolitan counties to 0.7 in rural counties.

William F. Rayburn, MD, distinguished professor and emeritus chair of obstetrics and gynecology at the University of New Mexico, Albuquerque, is working on an update to the workforce report, expected to be released in May 2017 at ACOG’s annual scientific meeting in San Diego.

Dr. William F. Rayburn
Dr. William F. Rayburn


The maldistribution trend is likely to continue over the next decade for several reasons, said Dr. Rayburn, associate dean for continuing medical education and professional development at the university.

At the top of the list is the stagnant number of residency training slots across the country. While medical schools in the United States and abroad are graduating more students, the number of first-year ob.gyn. residency positions has remained at about 1,200 since 1980. In 2017, there were 1,288 positions offered in the Main Residency Match.

Gender is another factor. Ob.gyn. is now a majority female specialty and by 2025 women will make up about two-thirds of the workforce, Dr. Rayburn said. While women are just as productive as men, they don’t work as many hours and they tend to drop obstetrics from their practices earlier, he added.

In addition, research indicates that women ob.gyns. are more likely to stay in urban areas after training.

“The movement, generally speaking, when people relocate is often to urban areas, from one urban area to another or from a rural area to a more urban area,” Dr. Rayburn said.

There is growing demand for health care from a population of adult women that is increasing at a greater rate than the number of ob.gyn. residents, he said.

The rural residency option being explored in Wisconsin is a great idea, Dr. Rayburn said, provided the trainees receive enough experience in the rural environment to prepare them for the change in practice. “The more you can get people to train in more rural areas, the more likely they are to eventually go there. But that’s far from a guarantee,” he said.

Going forward Dr. Rayburn said he expects to see loan repayment used to draw physicians to underserved areas.

“The problem is that the rural areas tend to have less of a good payer mix,” he said. “In other words, there are more poor people in rural areas. And the health care delivery is more limited in terms of resources, types of surgical equipment, and being able to take care of complicated pregnancies.”
 

GME funding cap

The Association of American Medical Colleges is focused on easing physician shortages by getting lawmakers to lift the cap on federal funding for graduate medical education (GME) positions that was put in place as part of the Balanced Budget Act of 1997.

“The population is getting larger and aging, which increases the need for more physicians and thus we have to work with Congress to lift the cap,” said Janis Orlowski, MD, Chief Health Care Officer at the Association of American Medical Colleges.

Dr. Janis Orlowski
Dr. Janis Orlowski


Specifically, the association is calling for funding to train at least 3,000 more physicians each year. In the last Congress, lawmakers introduced bills that would have provided those positions, with one of those bills directing that a portion of those new positions be dedicated to specialties with physician shortages.

Dr. Orlowski said bipartisan support still exists for lifting the cap, though new legislation probably won’t be introduced until after the summer recess when Congress won’t be bogged down with efforts to repeal and replace the Affordable Care Act.

Getting the GME cap lifted is mostly about coming up with the funding, she said. But some lawmakers have expressed concerns about how to ensure that increases go to the specialties with the greatest needs or that physicians trained in these spots will ultimately practice in the areas where care is needed, such as rural America.

“Those are issues that we need to continue to work on and address,” she said.

ACOG supports efforts to lift the GME funding cap and is pushing federal legislation that would establish maternity care health professionals shortage areas, allowing the National Health Service Corps to offer scholarships and loan repayment benefits to providers who work in those areas. Similar programs are already in place for primary care, and dental and mental health. Like the GME funding bill, legislation on this topic was introduced in the last session of Congress but will need to be reintroduced in the current Congress.

“We have to work on the workforce,” Dr. Gellhaus said. “It’s going to be a concern.”
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