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For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.
Cradle to grave
Dr. Hartline’s rural training classmate Rebecca Pfaff, MD, now lives and works in Vernon County, Wisc. The clinic and the small community hospital that are her practice home are in the small town of LaFarge. A native of Washington State, Dr. Pfaff thought she’d end up there after her undergraduate years at Wellesley College and her time at Meharry Medical College, a historically black medical school with a social justice focus in Nashville, Tenn.
She realized that in the right practice setting, she could find the scope she was seeking. “I became a family medicine doctor to do obstetrics, and to do family medicine,” she said.
Dr. Pfaff chose the Baraboo rural training track, still with the intention of eventually returning to practice in her home town of Port Angeles, Wash. There, the family practice group had already hired two Baraboo graduates, so they knew the strength of the program and recommended it to Dr. Pfaff.
Seeing patients living with the challenges of rural poverty, she said, helped her learn to care for women with substance use disorder and to gain experience caring for infants with neonatal abstinence syndrome. “That is the perfect setting for where family medicine thrives,” said Dr. Pfaff. Having established relationships with the mothers, she felt able to treat the mother-infant dyad as a unit, without judgment, and with natural opportunities for frequent follow-up.
Dr. Pfaff had a busy obstetrics practice in Baraboo and had the opportunity to perform cesarean sections. To feed her interest in low-intervention obstetrics, though, she sought and was able to secure a rotation in LaFarge, her eventual practice home.
Knowing she would return to LaFarge, Dr. Pfaff went on to complete a 1-year obstetrics fellowship at Swedish Hospital in Seattle. The obstetricians and family physicians there cared for high-risk patients from as far away as Alaska; her fellowship training, she said, was in many ways “the polar opposite” of the low-intervention, community-based work she’d done in Baraboo.
Still, she said, the fellowship gave her procedural expertise and boosted her confidence that she could handle many high-risk situations. She appreciated the perspective of some of her obstetrician instructors, who themselves had been solo practitioners in rural areas.
Her practice now, she says, is everything she’d hoped it would be. She sees patients in the clinic in a cradle-to-grave practice that includes many members of Vernon County, Wisconsin’s Amish community. Dr. Pfaff and her colleagues at the small clinic in LaFarge embrace the special challenges and rewards of obstetric care of a population that has traditionally had their babies at home.
The Amish community
Using low-intervention techniques is a priority, even when many Amish women have grand multiparity or present with other risk factors. “It’s not uncommon for us to see women on their twelfth or thirteenth pregnancy,” she said. Gestation dating is usually no more than a best guess, since women become pregnant while still amenorrheic from breastfeeding their last child.
Because the area’s Amish population has grown from a small group of founders who came to the hills of Vernon County in the late 1700s, there is an elevated rate of genetic disorders in the population, including metabolic disorders and congenital heart disease. Most Amish women return home within a few hours of delivery, and use no analgesia, even for breech and twin vaginal deliveries.
Though she’s comfortable with low-intervention care, Dr. Pfaff also performs cesarean sections at the community hospital when it’s indicated, sharing call duties with the community’s general surgeons. There’s no obstetrician in Vernon County.
The hospital is not equipped to care for preterm infants, so deliveries earlier than 36 weeks’ are referred, as are patients with abnormal placentation or fetal anomalies detected on ultrasound.
She loves the continuity that her practice now lets her have, said Dr. Pfaff. “When you’re seeing a woman in family medicine, instead of seeing her at 6 weeks, setting her up with contraception, and then seeing her again in a year, you’re seeing her every 2 weeks with that baby of hers,” she said. The care of mother and infant is so intertwined that sometimes it gives Dr. Pfaff pause, as when she tries to decide in whose chart she should be documenting. “They’re a unit at this time of their lives.”
When asked if she plans to stay put, Dr. Pfaff doesn’t hesitate. “Oh yes,” she said. “I’m so lucky.”
Dr. Hartline agreed. When asked what advice she’d give a trainee considering a rural, full-spectrum career path, she said, “This is a good life. Come and join us!”
Dr. Knight is an employee of AAFP. None of the physicians interviewed had financial conflicts of interest.
Correction, 9/22/17: An earlier version of this article misstated Dr. Munneke's title.
This article was updated 9/25/17.
[email protected]
On Twitter @karioakes
For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.
Cradle to grave
Dr. Hartline’s rural training classmate Rebecca Pfaff, MD, now lives and works in Vernon County, Wisc. The clinic and the small community hospital that are her practice home are in the small town of LaFarge. A native of Washington State, Dr. Pfaff thought she’d end up there after her undergraduate years at Wellesley College and her time at Meharry Medical College, a historically black medical school with a social justice focus in Nashville, Tenn.
She realized that in the right practice setting, she could find the scope she was seeking. “I became a family medicine doctor to do obstetrics, and to do family medicine,” she said.
Dr. Pfaff chose the Baraboo rural training track, still with the intention of eventually returning to practice in her home town of Port Angeles, Wash. There, the family practice group had already hired two Baraboo graduates, so they knew the strength of the program and recommended it to Dr. Pfaff.
Seeing patients living with the challenges of rural poverty, she said, helped her learn to care for women with substance use disorder and to gain experience caring for infants with neonatal abstinence syndrome. “That is the perfect setting for where family medicine thrives,” said Dr. Pfaff. Having established relationships with the mothers, she felt able to treat the mother-infant dyad as a unit, without judgment, and with natural opportunities for frequent follow-up.
Dr. Pfaff had a busy obstetrics practice in Baraboo and had the opportunity to perform cesarean sections. To feed her interest in low-intervention obstetrics, though, she sought and was able to secure a rotation in LaFarge, her eventual practice home.
Knowing she would return to LaFarge, Dr. Pfaff went on to complete a 1-year obstetrics fellowship at Swedish Hospital in Seattle. The obstetricians and family physicians there cared for high-risk patients from as far away as Alaska; her fellowship training, she said, was in many ways “the polar opposite” of the low-intervention, community-based work she’d done in Baraboo.
Still, she said, the fellowship gave her procedural expertise and boosted her confidence that she could handle many high-risk situations. She appreciated the perspective of some of her obstetrician instructors, who themselves had been solo practitioners in rural areas.
Her practice now, she says, is everything she’d hoped it would be. She sees patients in the clinic in a cradle-to-grave practice that includes many members of Vernon County, Wisconsin’s Amish community. Dr. Pfaff and her colleagues at the small clinic in LaFarge embrace the special challenges and rewards of obstetric care of a population that has traditionally had their babies at home.
The Amish community
Using low-intervention techniques is a priority, even when many Amish women have grand multiparity or present with other risk factors. “It’s not uncommon for us to see women on their twelfth or thirteenth pregnancy,” she said. Gestation dating is usually no more than a best guess, since women become pregnant while still amenorrheic from breastfeeding their last child.
Because the area’s Amish population has grown from a small group of founders who came to the hills of Vernon County in the late 1700s, there is an elevated rate of genetic disorders in the population, including metabolic disorders and congenital heart disease. Most Amish women return home within a few hours of delivery, and use no analgesia, even for breech and twin vaginal deliveries.
Though she’s comfortable with low-intervention care, Dr. Pfaff also performs cesarean sections at the community hospital when it’s indicated, sharing call duties with the community’s general surgeons. There’s no obstetrician in Vernon County.
The hospital is not equipped to care for preterm infants, so deliveries earlier than 36 weeks’ are referred, as are patients with abnormal placentation or fetal anomalies detected on ultrasound.
She loves the continuity that her practice now lets her have, said Dr. Pfaff. “When you’re seeing a woman in family medicine, instead of seeing her at 6 weeks, setting her up with contraception, and then seeing her again in a year, you’re seeing her every 2 weeks with that baby of hers,” she said. The care of mother and infant is so intertwined that sometimes it gives Dr. Pfaff pause, as when she tries to decide in whose chart she should be documenting. “They’re a unit at this time of their lives.”
When asked if she plans to stay put, Dr. Pfaff doesn’t hesitate. “Oh yes,” she said. “I’m so lucky.”
Dr. Hartline agreed. When asked what advice she’d give a trainee considering a rural, full-spectrum career path, she said, “This is a good life. Come and join us!”
Dr. Knight is an employee of AAFP. None of the physicians interviewed had financial conflicts of interest.
Correction, 9/22/17: An earlier version of this article misstated Dr. Munneke's title.
This article was updated 9/25/17.
[email protected]
On Twitter @karioakes
For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.
Cradle to grave
Dr. Hartline’s rural training classmate Rebecca Pfaff, MD, now lives and works in Vernon County, Wisc. The clinic and the small community hospital that are her practice home are in the small town of LaFarge. A native of Washington State, Dr. Pfaff thought she’d end up there after her undergraduate years at Wellesley College and her time at Meharry Medical College, a historically black medical school with a social justice focus in Nashville, Tenn.
She realized that in the right practice setting, she could find the scope she was seeking. “I became a family medicine doctor to do obstetrics, and to do family medicine,” she said.
Dr. Pfaff chose the Baraboo rural training track, still with the intention of eventually returning to practice in her home town of Port Angeles, Wash. There, the family practice group had already hired two Baraboo graduates, so they knew the strength of the program and recommended it to Dr. Pfaff.
Seeing patients living with the challenges of rural poverty, she said, helped her learn to care for women with substance use disorder and to gain experience caring for infants with neonatal abstinence syndrome. “That is the perfect setting for where family medicine thrives,” said Dr. Pfaff. Having established relationships with the mothers, she felt able to treat the mother-infant dyad as a unit, without judgment, and with natural opportunities for frequent follow-up.
Dr. Pfaff had a busy obstetrics practice in Baraboo and had the opportunity to perform cesarean sections. To feed her interest in low-intervention obstetrics, though, she sought and was able to secure a rotation in LaFarge, her eventual practice home.
Knowing she would return to LaFarge, Dr. Pfaff went on to complete a 1-year obstetrics fellowship at Swedish Hospital in Seattle. The obstetricians and family physicians there cared for high-risk patients from as far away as Alaska; her fellowship training, she said, was in many ways “the polar opposite” of the low-intervention, community-based work she’d done in Baraboo.
Still, she said, the fellowship gave her procedural expertise and boosted her confidence that she could handle many high-risk situations. She appreciated the perspective of some of her obstetrician instructors, who themselves had been solo practitioners in rural areas.
Her practice now, she says, is everything she’d hoped it would be. She sees patients in the clinic in a cradle-to-grave practice that includes many members of Vernon County, Wisconsin’s Amish community. Dr. Pfaff and her colleagues at the small clinic in LaFarge embrace the special challenges and rewards of obstetric care of a population that has traditionally had their babies at home.
The Amish community
Using low-intervention techniques is a priority, even when many Amish women have grand multiparity or present with other risk factors. “It’s not uncommon for us to see women on their twelfth or thirteenth pregnancy,” she said. Gestation dating is usually no more than a best guess, since women become pregnant while still amenorrheic from breastfeeding their last child.
Because the area’s Amish population has grown from a small group of founders who came to the hills of Vernon County in the late 1700s, there is an elevated rate of genetic disorders in the population, including metabolic disorders and congenital heart disease. Most Amish women return home within a few hours of delivery, and use no analgesia, even for breech and twin vaginal deliveries.
Though she’s comfortable with low-intervention care, Dr. Pfaff also performs cesarean sections at the community hospital when it’s indicated, sharing call duties with the community’s general surgeons. There’s no obstetrician in Vernon County.
The hospital is not equipped to care for preterm infants, so deliveries earlier than 36 weeks’ are referred, as are patients with abnormal placentation or fetal anomalies detected on ultrasound.
She loves the continuity that her practice now lets her have, said Dr. Pfaff. “When you’re seeing a woman in family medicine, instead of seeing her at 6 weeks, setting her up with contraception, and then seeing her again in a year, you’re seeing her every 2 weeks with that baby of hers,” she said. The care of mother and infant is so intertwined that sometimes it gives Dr. Pfaff pause, as when she tries to decide in whose chart she should be documenting. “They’re a unit at this time of their lives.”
When asked if she plans to stay put, Dr. Pfaff doesn’t hesitate. “Oh yes,” she said. “I’m so lucky.”
Dr. Hartline agreed. When asked what advice she’d give a trainee considering a rural, full-spectrum career path, she said, “This is a good life. Come and join us!”
Dr. Knight is an employee of AAFP. None of the physicians interviewed had financial conflicts of interest.
Correction, 9/22/17: An earlier version of this article misstated Dr. Munneke's title.
This article was updated 9/25/17.
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