Stewardship

The Oxford Dictionary defines stewardship as “the job of supervising or taking care of something, such as an organization or property.”1 The term is most often used in conjunction with religious institutions where stewardship committees are responsible for the financial health of churches. It is not a word often used when referring to the work of family physicians, but perhaps it should be. Are we not stewards of the health care and health education of our communities? Isn’t community stewardship a role we embraced when we chose to be a family physician?

In this issue of Family Medicine, Barreto and colleagues report the results of a survey of 2,098 residency graduates who took the American Board of Family Medicine certification exam between 2014 and 2016 and who stated they intended to include maternity care in their future practices.2 Forty-eight percent (1,016) responded to the survey and 68.9% of those responding reported they had entered practices that included maternity care after residency. The study then focused on the 316 graduates who did not enter practices with maternity care in spite of having indicated their intention to do so. The most common reason cited for this was that they “found a job without OB,” followed by “lifestyle concerns.” The graduates surveyed in this study account for only 22% of those taking the exam during this 3-year period. These data paint a bleak picture of a process of maternity care attrition among graduating residents. Of the 9,549 graduates taking the test, 7,451 indicated no intent to do obstetrics. Of the 2,098 who indicated an intention to deliver babies, only 1,016 completed the survey and only two-thirds of those completing the survey were doing maternity care in practice. This study supports previous work by these same investigators indicating that the major barrier to young family physicians providing maternity care is finding a practice that supports them in this goal.3 As a result, some have suggested that it is time for us to admit that obstetric care is no longer a core activity in our discipline.4

The current study is limited by a relatively low response rate (48.4%) and a response bias that probably underestimates the attrition rate. Nevertheless, the results offer a disturbing look at the sad condition of family-oriented maternity care. As educators, we tend to view these results through the lens of the residency curriculum. Problems abound in trying to produce a family medicine maternity care workforce. Some residents enter residency with little interest in this type of work. Some residencies struggle to provide a comprehensive experience in maternity care and many openly admit that they cannot do so. Now we learn that about a third of graduates who are interested in maternity care—and presumably trained to deliver babies—cannot find a practice that supports this interest. So maybe Young and Sundermeyer are right. Maybe it is time to make maternity care a fellowship to be completed after residency.4 After all, we don’t need every family physician to provide maternity care, so why does it matter if we have large numbers of residency programs who cannot provide this training?

In fact, it matters a lot for reasons that are both philosophical and symbolic. There is clear evidence that communities in the United States are facing a crisis in access to maternity care and this crisis disproportionately affects rural communities.5,6 Family medicine has always claimed a special role in assuring access to care in rural America and recent public health data suggests we are failing young rural families if we no longer provide maternity services. The maternal mortality rate in America is increasing for the first time in two generations and this increase is occurring disproportionately in rural communities and communities of color, populations we claim to serve. So maybe it is time to ask ourselves how we should go about making decisions about the scope of our discipline. Is this about what we are interested in or what we want to do, or is it about what the people we serve need from us? Should we accept reality as it is, or should we build our discipline based on what our country needs?

So this brings us back to the notion of stewardship—stewardship for our nation, for the young people who choose to enter our residencies, and for the discipline of family medicine. Increasing maternal mortality and decreasing access to services in rural and underserved communities are problems we should be responsible for fixing. There is no historical reason to expect obstetricians to meet this need. They have never done so and are poorly equipped to start now. There is also no reason to expect corporate hospital systems to care about communities outside of their own backyards. There is simply no escaping the fact that responsibility for this problem lies with our discipline.

To be successful, young family physicians need to master the comprehensive scope of practice that will allow them to practice anywhere they choose. They need to see that this is possible while they are medical students and to master the necessary skills while they are residents. They also need to enter practices where they are supported by senior partners who can role model and mentor their transition from residency to practice. Once upon a time, senior and midcareer family physicians were there to play this role. The study by Barreto and colleagues suggests that collectively, we are failing to support even the small number of young family physicians that make it through medical school and residency with their goals for comprehensive practice intact. This is not just a problem for rural residencies; it is a problem for family medicine as a discipline. Medical students are very smart people; they recognize hypocrisy when they see it. We claim to care for rural America. We claim to be comprehensive physicians. Whether or not we use the word, we claim to be stewards of the nation’s health. It may or may not be time to admit that obstetrics is no longer a core service we provide, but it is definitely time to stop claiming we care about a problem we so woefully ignore. Our discipline has set a goal of recruiting 25% of graduating American medical students into family medicine by 2030.7 Matching our rhetoric with our actions seems like a good way to start.