The distribution, practice, and attitudes of maternal-fetal medicine specialists.

OBJECTIVES: This study was carried out to determine the distribution of maternal-fetal medicine (MFM) subspecialists and to profile MFM subspecialists' (1) target patient populations, (2) practice organization, (3) workloads, (4) services provided, and (5) job satisfaction. STUDY DESIGN: The membership of the Society for Maternal-Fetal Medicine was compared with birth projections for metropolitan statistical areas. A survey was sent to Society for Maternal-Fetal Medicine members. RESULTS: The national supply of MFM subspecialists was 0.34, with individual census regions ranging from 0.22 to 0.52 per thousand births. MFM subspecialists report spending 64% of their time in clinical pursuits, 9% in research, and 12% in administration. They evaluate an average of 512 patients annually and work a 67-hour week (SD, 15.8 hours). Ninety-four percent perform deliveries and 87% perform targeted ultrasound examinations. Overall job satisfaction averages 7.4 on a 10-point scale. CONCLUSION: The data provide useful bench-marking information for MFM subspecialists exploring options for practice and for health care planners and organizations developing staffing plans. Despite changes in the health care system, MFM subspecialists continue to express a positive attitude toward their work.     

Are obstetrician-gynecologists satisfied with their maternal-fetal medicine consultants? A survey

Objective To survey generalist obstetrician-gynecologists about their satisfaction with and patterns of referral to maternal-fetal medicine (MFM) specialists.Study Design A survey was sent three times to 1030 randomly selected American Congress of Obstetricians and Gynecologists members across the country, and results were tabulated.Results A total of 516 surveys (50%) were returned; 68% of respondents were satisfied (S) with available MFM services and 31% were not satisfied (Not S). S and Not S respondents were similar with respect to age, gender, years in practice, type of practice, hours worked per week, proximity to MFM specialists, number of deliveries per year, and level of nursery in their hospital. Reasons for dissatisfaction included: MFM specialist not readily available (49%), during the day (26%), at night (35%), or on weekends (36%); MFM specialist unwilling to take care of hospitalized patients (26%); or MFM specialist does only ultrasound, chorionic villus sampling, and amniocentesis (32%). Although some generalists do not consult MFM specialists frequently, the majority of both S and Not S respondents would request an MFM consult or comanagement for 26 of 38 specific maternal, fetal, and obstetric diagnoses/complications.Conclusion The majority of obstetrician-gynecologists are satisfied with their MFM support. The dissatisfaction expressed by 31% of generalists might be ameliorated if individual MFM specialists increased their availability and/or broadened their scope of practice.     

Workforce projections for subspecialists in obstetrics and gynecology

OBJECTIVE: To project the future supply of practicing subspecialists in obstetrics and gynecology based on the most recent numbers of physicians entering fellowships. METHODS: A discrete actuarial model was developed, and supply projections were examined using 1999 subspecialty fellowship numbers from the American Board of Obstetrics and Gynecology. RESULTS: The numbers of obstetrician-gynecologists entering subspecialty fellowships in maternal-fetal medicine (MFM) and reproductive endocrinology-infertility (REI) declined sharply between 1994 and 1999. There was a slow increase in gynecologic oncology (GO) fellows. Projections show that the numbers of practicing MFM and GO subspecialists will double by 2020, but they will be serving a 20% larger female population in the United States. Numbers of practicing REI subspecialists will increase slowly. CONCLUSION: The number of fellows in GO continues to enlarge progressively though slightly, whereas those in MFM and REI have fallen sharply in recent years. Among four possible factors affecting growth or decline, the ones that seem most important are existing career opportunities for both generalist and subspecialist obstetrician-gynecologists and the length of subspecialty education.     

Job satisfaction among gynecologic oncologists practicing in the United States

OBJECTIVE: We sought to determine whether there have been any significant changes in professional satisfaction among gynecologic oncologists over the past 30 years. METHODS: We mailed surveys to all U.S. gynecologic oncologists belonging to the Society of Gynecologic Oncologists to compile data on demographics, training, motivating factors, overall professional satisfaction, and the effect of managed care. We compared these factors among oncologists who completed training in different years and among different demographic groups. We used calculated confidence intervals to determine statistical significance. RESULTS: We surveyed 767 gynecologic oncologists and received 344 evaluable responses, representing 47% of the total eligible. Results show that neither the factor rated most important in looking for a first job nor the factor rated most important in giving job satisfaction once in a job has changed significantly among gynecologic oncologists over time. In addition, the importance placed on salary has not varied across the fellowship graduate classes, although within each class salary increased in importance from the first job to the current job. Our analysis shows that while male and female gynecologic oncologists are similar in their job satisfaction and practice patterns, men report being sued twice as often as women, and men tend to stay in their first jobs significantly longer than women. We also compare the surveyed academic gynecologic oncologists to the private gynecologic oncologists and show that while overall job satisfaction is similar, their ratings of the factors that provide job satisfaction do differ significantly. Our data show that managed care penetration has increased over time among gynecologic oncology practices and that gynecologic oncologists' job satisfaction ratings tend to decrease with the increase in managed care penetration, although not reaching statistical significance. CONCLUSIONS: Our results show that changes in practice styles since the 1960s have not affected overall job satisfaction among gynecologic oncologists. However, several trends in practice styles can be noted, including differences between sexes, academic versus private physicians, and attitudes about managed care. The survey also suggests that there is interest among gynecologic oncologists in continuing to monitor changes in patterns of practice and satisfaction.     

Maternal-fetal medicine workforce in the United States

Objective?To identify the current supply and locations of maternal-fetal medicine (MFM) subspecialists in active practice in the United States.Study Design?This observational study examined the membership roster of the American Congress of Obstetricians and Gynecologists in 2010 for those whose practice was in either general obstetrics and gynecology or maternal-fetal medicine. Reliable national databases were used to determine the numbers and locations of births annually, reproductive-aged (15 to 44 years old) women, and level III perinatal centers in each state.Results?There were 1355 MFM subspecialists in the United States in 2010 with the highest number being in the most populous states. Nearly all (98.2%) resided in metropolitan counties with level III perinatal center(s). Nationwide, there was one MFM subspecialist for every 24 general obstetrician-gynecologists and for every 3150 births. States with the highest number of MFM subspecialists per 10,000 live births were Vermont (9.5), Connecticut (6.4), Maryland (5.8), New Jersey (5.7), Hawaii (5.7), and Massachusetts (5.6). The lowest densities were in Indiana (1.5), Mississippi (1.3), Idaho (1.2), and Arkansas (1.0), and North Dakota and Wyoming had none.Conclusion?Data from this population-level study will serve as a baseline to follow trends in the workforce of MFM practitioners.     

Survey of female gynecologic oncologists and fellows: balancing professional and personal life

OBJECTIVE: The aim of this study was to determine how female gynecologic oncologists have dealt with the challenge of combining childbearing and a career in gynecologic oncology and to identify other issues which need to be addressed to improve job satisfaction. METHODS: This survey of female members of the Society of Gynecologic Oncologists and fellows addressed demographics, timing of childbearing, type and cost of childcare, satisfaction with childcare choices, and mentorship. Those without children were queried about plans and reservations. Open-ended questions investigated how female gynecologic oncologists felt job satisfaction could be improved. RESULTS: A total of 65/110 (59%) attendings and 18/36 (50%) fellows responded. Three-fourths of respondents felt that the ideal time to have children was postfellowship. Timing of childbearing caused moderate to severe stress in the personal relationships of 23% of respondents. Median maternity leave was 6 weeks (1-120 days). Seventy-eight percent of female gynecologic oncologists with children employed a nanny. Over half of the respondents estimated weekly childcare cost at over $400. A successful balance between family and full-time practice was the most commonly cited quality of an ideal mentor. Sixty-six percent of the respondents replied to open-ended questions with narrative answers, revealing three major areas for improvement: childcare issues, increased flexibility in hours and duties (clinical, surgical, and research), and the need for more female mentoring. CONCLUSIONS: This survey highlighted the concerns of female gynecologic oncologists about achieving a successful balance between family and professional duties. It also revealed the ways in which women have responded and identified other issues that may be targeted to improve job satisfaction.     

Do maternal-fetal medicine practice characteristics influence high-risk referral decisions by general obstetrician-gynecologists?

OBJECTIVE: To determine whether the decision of the general obstetrician-gynecologist to refer high-risk obstetric patients depends on the type of practice of the maternal-fetal medicine (MFM) specialist. METHODS: A questionnaire was mailed to 935 general obstetrician-gynecologists who were asked whether the MFM specialist's practice characteristics would influence their decision to refer their high-risk obstetric patients. Potential MFM practice components presented in the survey included: MFM, high-risk obstetrics, low-risk obstetrics or general obstetrics and gynecology. RESULTS: A total of 140 (15%) general obstetrician-gynecologists responded, 110 of whom were practicing obstetrics. Of the practicing responders, 77% stated that they were more likely to refer their high-risk obstetric patients if the MFM specialist practiced only MFM and high-risk obstetrics; 69% were less likely to refer their patients when the MFM specialist, in addition to MFM, practiced general obstetrics; and 75% were less likely to refer their patients when the MFM specialist also practiced general obstetrics and gynecology. The MFM practice setting (university vs. community hospital vs. private practice), as well as the geographic location and years of practice of the respondents, did not influence the general obstetrician-gynecologists' decision to refer their high-risk obstetric patients. CONCLUSION: General obstetrician-gynecologists are more likely to refer high-risk obstetric patients if the MFM specialist practiced only MFM and high-risk obstetrics.     

Heat shock protein 70 expression in neonatal rats after hypoxic stress

Objective : To determine whether the decision of the general obstetrician-gynecologist to refer high-risk obstetric patients depends on the type of practice of the maternal-fetal medicine (MFM) specialist. Methods : A questionnaire was mailed to 935 general obstetrician-gynecologists who were asked whether the MFM specialist's practice characteristics would influence their decision to refer their high-risk obstetric patients. Potential MFM practice components presented in the survey included: MFM, high-risk obstetrics, low-risk obstetrics or general obstetrics and gynecology. Results : A total of 140 (15%) general obstetrician-gynecologists responded, 110 of whom were practicing obstetrics. Of the practicing responders, 77% stated that they were more likely to refer their high-risk obstetric patients if the MFM specialist practiced only MFM and high-risk obstetrics; 69% were less likely to refer their patients when the MFM specialist, in addition to MFM, practiced general obstetrics; and 75% were less likely to refer their patients when the MFM specialist also practiced general obstetrics and gynecology. The MFM practice setting (university vs. community hospital vs. private practice), as well as the geographic location and years of practice of the respondents, did not influence the general obstetrician-gynecologists' decision to refer their high-risk obstetric patients. Conclusion : General obstetrician-gynecologists are more likely to refer high-risk obstetric patients if the MFM specialist practiced only MFM and high-risk obstetrics.     

Is there a preferred gestational age threshold of viability?: a survey of maternal-fetal medicine providers.

OBJECTIVE: To characterize variation and factors associated with the perceived gestational age for the threshold of viability among maternal-fetal medicine (MFM) providers. METHODS: We performed a web-based online survey of 1375 MFM providers. For this secondary analysis, a subset of survey questions targeted toward perceptions of the limit of viability was analyzed to identify how the respondents viewed the optimal threshold of viability gestational age. Comparative statistics were performed to assess various characteristics that influence the perceived threshold of viability. RESULTS: Five hundred and eight providers (37%), representing all 50 states and 13 countries, responded to the survey. The reported threshold of viability varied among survey respondents: 22 weeks, 2.0%; 23 weeks, 37.2%; 24 weeks, 55.3%; 25 weeks, 3.4%; and 26 weeks, 2.2%. No significant differences were noted in the reported threshold of viability with respect to practitioner age (<50 years old vs. > or =50 years old, p = 0.42), nursery availability (level III vs. other, p = 0.46), and years in practice (<10 years vs. > or =10 years, p = 0.86). Significant differences in the reported threshold of viability were noted with respect to practitioner gender with males tending to have a lower gestational age threshold than females (p = 0.005). Significant differences were also noted among practitioners from academic vs. community/private practice settings (p = 0.008). A logisitic regression model, adusting for both gender and practice setting, revealed that male gender was independently associated with selection of a threshold of viability less than 24 weeks of gestation: male gender OR 1.8 (95% CI 1.3-2.7, p = 0.002); academic practice setting OR 1.1 (95% CI 0.8-1.6, p = 0.50). CONCLUSIONS: Perceived threshold of viability among MFM providers varies with the majority of practitioners identifying 23-24 weeks of gestation. Significant difference, however, exists between practitioner genders.     

Current Practice of Maternal–Fetal Medicine Specialists Regarding the Prevention and Management of Preterm Birth in Twin Gestations

ObjectiveTo investigate the current practices of maternal–fetal medicine (MFM) specialists regarding the prevention and management of preterm birth (PTB) in twin pregnancies.MethodsThis was a cross-sectional study of Canadian MFM specialists. Participants responded to an anonymous survey regarding the prevention and management of PTB in twins, including lifestyle and gestational weight gain recommendations, cervical length screening, PTB prevention, and labour and delivery practices.ResultsOf 137 MFM specialists surveyed, 95 (69%) responded. Most MFM specialists recommend against activity restriction (77.9%), avoidance of sexual activity (96.7%), routine progesterone (97.8%), routine prophylactic cerclage (98.9%), and routine administration of antenatal corticosteroids (95.6%). There were considerable inconsistencies with respect to gestational weight gain management. Despite lack of support by guidelines, most MFM specialists reported using routine cervical length screening (97.8%) and progesterone for short cervix (92.3%). Over half (52.7%) of MFM specialists recommend cervical cerclage when the cervix is <15mm. In cases of PTB, most MFM specialists recommend vaginal delivery when twins are in vertex presentation (63%–75%). MFM specialists are less likely to recommend vaginal delivery when twin B is non-vertex (35%–41%).ConclusionThere is a considerable variation among MFM specialists regarding the prevention and management of PTB in twins, and the practice of many MFM specialists differs from that recommended by professional societies’ guidelines. These findings underscore the necessity for high-quality studies and up-to-date recommendations.     

A Quality Improvement Initiative: Using Lean Methodology to Improve Efficiency of the Morning Cycle Monitoring at an Ambulatory Academic Fertility Clinic

ObjectivePatients receiving fertility treatments require near-daily blood work and ultrasound for cycle monitoring. Patient volumes at an academic hospital-based ambulatory clinic were expected to increase with expanded provincial funding. The aim of this quality improvement project was for 85% of cycle monitoring patients to have a turnaround time (TAT) of 20 minutes or less from arrival until checkout.MethodsThis is a time series study analyzed with statistical process control methodology. A baseline survey was conducted to understand patient priorities. Multiple site-specific change ideas were developed by front-line staff using lean methodology including standard processes, standard work, supportive tools, visual management, and staffing and scheduling to meet Takt time. Patient and staff satisfaction surveys were conducted after implementation (Canadian Task Force Classification II-2).ResultsWith the start of funding in December 2015 the clinic accommodated a 17% increase in daily patient volumes and increased the proportion of patients receiving education at each visit from 50% to 100%. Despite increased patient volumes and added education time, the control chart showed special cause variation with decreased TATs from 38.2 to 34.7 minutes. Patient surveys showed that their priorities were being met or exceeded, and all staff reported increased satisfaction with the new process.ConclusionBy using lean methodology in an ambulatory fertility setting, the clinic was able to improve efficiency in the morning monitoring process to decrease patient TATs while accommodating increased patient volumes and improving the quality of patient care.     

Training in chorionic villus sampling: limited experience for US fellows

OBJECTIVE: This study was undertaken to assess training availability, methods, and plans for future practice of invasive procedures for maternal fetal medicine (MFM) fellows. STUDY DESIGN: A survey was sent to all MFM fellows registered with the American Board of Obstetrics and Gynecology in March of 2001. RESULTS: Of 91 surveys, 55 (60.4%) were returned. All respondents were trained in second-trimester amniocentesis and planned on performing the procedure after fellowship. Of the 55 respondents, 53 (96.4%) were trained on continuing pregnancies. Despite 82% of training institutions performing chorionic villus sampling (CVS), only 24 of 45 (53%) fellows had availability for training. Of those 24, 14 (58%) initiated training on pregnancies that were undergoing termination. Median number of procedures performed by fellows (continuing pregnancies and before termination) was 3 (range 0-120), with 40 procedures (range 0-140) expected to be performed before completing fellowship. Twenty-eight fellows planned on performing CVS after training. CONCLUSION: The number of centers training MFM fellows in CVS and the number of procedures performed in the United States is limited.     

Risk for developing gestational diabetes in women with twin pregnancies

Objective. To characterize variation and factors associated with the perceived gestational age for the threshold of viability among maternal-fetal medicine (MFM) providers.

Methods. We performed a web-based online survey of 1375 MFM providers. For this secondary analysis, a subset of survey questions targeted toward perceptions of the limit of viability was analyzed to identify how the respondents viewed the optimal threshold of viability gestational age. Comparative statistics were performed to assess various characteristics that influence the perceived threshold of viability.

Results. Five hundred and eight providers (37%), representing all 50 states and 13 countries, responded to the survey. The reported threshold of viability varied among survey respondents: 22 weeks, 2.0%; 23 weeks, 37.2%; 24 weeks, 55.3%; 25 weeks, 3.4%; and 26 weeks, 2.2%. No significant differences were noted in the reported threshold of viability with respect to practitioner age (<50 years old vs. ≥50 years old, p = 0.42), nursery availability (level III vs. other, p = 0.46), and years in practice (<10 years vs. ≥10 years, p = 0.86). Significant differences in the reported threshold of viability were noted with respect to practitioner gender with males tending to have a lower gestational age threshold than females (p = 0.005). Significant differences were also noted among practitioners from academic vs. community/private practice settings (p = 0.008). A logisitic regression model, adusting for both gender and practice setting, revealed that male gender was independently associated with selection of a threshold of viability less than 24 weeks of gestation: male gender OR 1.8 (95% CI 1.3–2.7, p = 0.002); academic practice setting OR 1.1 (95% CI 0.8–1.6, p = 0.50).

Conclusions. Perceived threshold of viability among MFM providers varies with the majority of practitioners identifying 23–24 weeks of gestation. Significant difference, however, exists between practitioner genders.     

Re-evaluating the role of the MFM specialist: lead, follow, or get out of the way.

OBJECTIVE: To assess the effect of sub-specialty prenatal care provided to high-risk obstetrical patients in a community perinatal center as a function of whether consultation and referral to a Maternal-Fetal Medicine (MFM) sub-specialist was at the discretion of the generalist, required by the insurance carrier, or by patient choice. METHODS: Demographics, management, and perinatal outcomes for high-risk patients managed exclusively by MFM were compared with those managed by generalists who were later referred to MFM after problems arose. RESULTS: Despite similar demographics, high-risk patients managed exclusively by a single MFM had less prematurity, lower cesarean section rates, fewer low 5-minute Apgar scores (1.3% vs. 5.5%, p < 0.001), and lower perinatal mortality rates (8.0/1000 vs. 47.6/1000, p < 0.001) than those referred at a later date. CONCLUSIONS: In this setting, earlier MFM care resulted in better outcomes. These data suggest that the 'gatekeeper' model of generalist to MFM might be better the other way around.     

Obstetrics and gynecology residents' attitudes toward maternal-fetal medicine fellowship training.

OBJECTIVE: To assess factors associated with residents' decisions to pursue or forego fellowship training in maternal-fetal medicine (MFM). METHODS: A survey utilizing multiple-choice, Likert, ordinal and categorical scale questions was distributed to all (n = 2337) postgraduate year (PGY) 3 and 4 obstetrics and gynecology residents in accredited US training programs during the 2001-02 academic year. The 18-question survey sought demographic and residency training details, quality of interactions with the MFM faculty and fellows, and information about 13 specific factors that might influence a resident's decision to pursue MFM training. RESULTS: Surveys were returned by 642 (27%) residents, equally divided between PGY 3 and 4. Only 90 (14%) residents reported either ongoing consideration of, or having already applied for, MFM training (MFM group), while 278 (43%) had considered MFM training, but chose to either stay in general practice or pursue another fellowship (neutral group). The remaining 274 (43%) reported never having considered MFM (never group). The three groups were similar with regard to demographic characteristics and residency training; however, the MFM group ranked the quality of teaching by the MFM faculty significantly higher than the neutral and never groups. Encouragement by the MFM faculty, salary during fellowship and the 3-year (as opposed to 2-year) duration were reported to be the strongest influencing factors and were significantly different from ten other factors considered in the survey (p < 0.05). CONCLUSION: Major positive factors influencing the pursuit of MFM training are the quality of educational experiences and encouragement from the MFM faculty. Conversely, the duration and the perceived financial burden of the 3-year training program appear to be significant deterrents.     

The Job Satisfaction of Female Sex Workers Working in Licensed Brothels in Victoria,Australia

IntroductionPrevious studies have examined sex workers' attitudes to work but not their levels of job satisfaction compared with other occupations.AimThe job satisfaction levels and standards of living of sex workers in licensed brothels in Victoria were compared with Australian women.Main Outcome MeasuresResponses to a questionnaire that included questions about sex work and their “most likely alternative job.” Survey data was compared with identical questions from the Households, Income and Labour Dynamics in Australia Survey.MethodsA structured survey was undertaken with sex workers in Victoria attending a a sexual health service.ResultsOf the 112 sex workers who agreed to participate in the study, 85 (76%) completed the survey. The median years women had been working as sex workers was three (range 0.1–18). The main reasons women started sex work was because “they needed the money” (69%), were attracted to the flexible hours (44%) or had a particular goal in mind (43%). The two biggest concerns women had about sex work were their safety (65%) and the risk of sexually transmitted infections (65%). When compared with the median job satisfaction scores of Australian women working in sex workers' “most likely alternative jobs,” 50% of sex workers reported a higher median satisfaction score for sex work in relation to hours worked, 47% in relation to flexibility, 43% in relation to total pay, 26% in relation to job security, 19% in relation to the work itself, and 25% in relation to overall job satisfaction.ConclusionsWomen reported that they primarily do sex work for financial gain although a significant minority prefer it to other work they would be likely to do. These results should be interpreted in the context that the presence of personality disorders that are common among sex workers were not measured in this study. Bilardi JE, Miller A, Hocking JS, Keogh L, Cummings R, Chen MY, Bradshaw CS, and Fairley CK. The job satisfaction of female sex workers working in licensed brothels in Victoria, Australia.     

Operative Hysteroscopy in an Office-Based Surgical Setting: Review of Patient Safety and Satisfaction in 414 Cases

Study ObjectiveTo determine the safety and satisfaction among patients undergoing operative hysteroscopy in an office-based setting.DesignRetrospective analysis (Canadian Task Force classification II-2).SettingPhysician's private office.PatientsWomen undergoing operative hysteroscopy in an office setting.InterventionsThree hundred eighty-seven women underwent a total of 414 operative hysteroscopic procedures, with use of parenterally administered moderate sedation, a 9-mm operative resectoscope, and sonographic guidance. All patients were American Society of Anesthesiologists class I–III.Measurements and Main ResultsA total of 305 primary operative hysteroscopic procedures were performed including endomyometrial resection, myomectomy, polypectomy, removal of a uterine septum, and adhesiolysis. One hundred nine (26.3%) repeat operative procedures were performed in women in whom previous endometrial ablation and resection had failed. The average procedure required a mean (SD) of 37.6 (13.5) minutes to complete, and produced 14.1 (10.2) g of tissue. Ninety-nine percent of all procedures were completed. Only 1 patient required a hospital transfer for evaluation of a uterine perforation necessitating diagnostic laparoscopy. There were 8 (1.9%) postoperative infections, and no complications attributable to use of conscious sedation. Two hundred fifty-five women (65.6%) responded to our telephone survey. Two hundred fifty-two (98.8%) respondents were either “very satisfied” or “satisfied.” Two hundred forty-nine women (97.6%) preferred the office to a hospital setting, whereas 6 (2.4%) would have preferred a hospital setting. All but 5 respondents would recommend this procedure to a friend.ConclusionMajor operative hysteroscopic surgery can be performed in an office-based setting with a high degree of safety and patient satisfaction.