Jessica Burchett was several months pregnant when she learned she was expecting twins. That news was a bit of a shock, but what terrified her was hearing that they suffered from a rare, dangerous condition called twin-twin transfusion syndrome. Suddenly, Burchett needed highly specialized care that wasn’t available in her small town of Barling, Arkansas, 160 miles from Little Rock.
But Burchett got the help she needed through an innovative telemedicine program called ANGELS (the Antenatal and Neonatal Guidelines, Education and Learning System) that provides long-distance maternal-fetal medicine consultations to family doctors, obstetricians, neonatologists, and pediatricians in remote areas.
Burchett is grateful that ANGELS, run in part by the University of Arkansas for Medical Sciences College of Medicine, enabled her to visit a local family doctor’s office for virtual appointments with her specialist. “It made me so much more comfortable to be able to talk directly to my doctor by video-conferencing,” she says.
Burchett is among the high — and rising — numbers of women who live in regions with little or no obstetrical care. In fact, the American College of Obstetricians and Gynecologists (ACOG) reported in 2017 that half of U.S. counties lack a single obstetrician-gynecologist (OB-GYN). Those areas are home to more than 10 million women, many of whom may need OB-GYNs for primary care.
And the problem is only going to worsen. By 2020, there will be up to 8,000 fewer OB-GYNs than needed, according to ACOG, and the number may rise to 22,000 by mid-century.
The shortage hits rural women hardest, with over half living more than 30 minutes away from a hospital with perinatal services, a trek that can be life-threatening in an emergency. Yet the shortage is a nationwide problem. Cities like Detroit, St. Louis, Dallas, Miami, and Los Angeles also face severe shortfalls.
Several factors fuel this worrisome trend, including too few residency slots. To help keep the pipeline filled, some states are funding additional residency positions, and the AAMC continues to lobby Congress to increase federal investment in graduate medical education.
Meanwhile, medical schools and teaching hospitals are devising creative ways to use and retain the existing workforce. From programs designed to encourage OB-GYNs to work in underserved communities to efforts to alleviate stress, they are working to support physicians and protect the health of women.
By 2020, there will be up to 8,000 fewer OB-GYNs than needed, and the number may rise to 22,000 by mid-century.
“The growing OB-GYN shortage represents a serious threat to women, many of whom are low-income and in remote rural areas, and who need quality prenatal care, cancer screening, and other vital services,” says Janis Orlowski, MD, AAMC chief health care officer. “We need to work to solve this problem with all the tools at our disposal.”
Understanding the shortage
The growing OB-GYN shortage is mostly a matter of demand exceeding supply. In recent decades, the number of U.S. women over age 18 has increased by 33 million — yet OB-GYN first-year residency positions grew by less than 200 between 1992 and 2016.
In addition, many OB-GYNs are nearing retirement: their average age is 51, and they tend to retire beginning at 59. Some may consider leaving in part because of their specialty’s high likelihood of being sued. In fact, nearly two out of three OB-GYNs face legal action at some point, the highest rate of all specialties, according to a 2018 report.
Compounding the shortage is the growing number of OB-GYN residents who pursue subspecialty training. In 2000, only 7% sought subspecialty training, but by 2012 it had risen to 20%.
“Because OB-GYNs are among the least compensated of all surgical specialties, an increasing proportion of residents pursue fellowship training in highly specialized areas where reimbursement is higher,” says William Rayburn, MD, associate dean of obstetrics and gynecology at the University of New Mexico Health Sciences Center and author of the 2017 ACOG report. Rayburn adds that trainees also believe subspecialties bring better working hours.
And, Rayburn notes, many OB-GYNs choose to live in urban areas. “These highly trained professionals want to live in urban areas,” he says, “with more cultural activities, better services and more medical specialists, and highly rated schools for their kids.”
Serving the underserved
Some academic medicine efforts focus on attracting future OB-GYNs to communities most in need.
For example, the University of Wisconsin School of Medicine and Public Health department of obstetrics and gynecology opened the nation's first rural OB-GYN residency track in 2017. The program, which currently sends its two residents to three rural sites, plans to add several more learners over the next few years.
The program strives in part to boost residents’ comfort working in remote settings, explains Jody Silva, rural residency coordinator. “You don't have all the specialists around you, so you have to be more confident in your abilities,” she says. “By having part of your training at a rural hospital you’ll be more comfortable taking a job at a rural hospital.”
Miles away in the inland Southern California region, the University of California, Riverside, (UCR) School of Medicine is working to improve health among a rapidly growing, ethnically diverse population. The school is focused on providing learners with opportunities to connect with local underserved populations.
“This is a very different model. We train residents in community clinics and in a community hospital,” says Kimberly Tustison, MD, an assistant clinical professor of obstetrics and gynecology at the UCR School of Medicine. What’s more, she explains, the school aims to produce physicians who will remain in the area.
Trina Mansour, MD, is one recent grad who plans to stay. The daughter of immigrants from Afghanistan, Mansour was inspired to become an OB-GYN by descriptions of limited care in her parents’ homeland. Mansour appreciates the opportunity to work with uninsured and underserved populations. “Many of these women have never seen a doctor, they have chronic medical conditions that are not being treated, and we don’t know if their baby is okay,” she says. “It’s very gratifying to help them and follow them post-partum to make sure that they and their babies are healthy.”
Long hours, midnight dashes to the hospital, and stressful emergencies all contribute to the burnout that can lead OB-GYNs to cut back on — or leave — their practices. OB-GYNs tend to experience higher rates of burnout than their peers according to a 2018 report, ranking fourth out of 29 specialties.
Saint Louis University (SLU) School of Medicine has been working to address such concerns for years. In the school’s affiliated hospitals and OB-GYN practices, faculty benefit from part-time schedules as well as nurse practitioners and midwives hired to lighten the load.
“The growing OB-GYN shortage represents a serious threat to women, many of whom are low-income and in remote rural areas, and who need quality prenatal care, cancer screening, and other vital services.”
Janis Orlowski, MD
AAMC Chief Health Care Officer
Mary McLennan, MD, SLU chair of the department of obstetrics, gynecology, and women’s health, notes that flexible schedules often are particularly helpful to female OB-GYNs, who may want to work part-time while raising young children.
“We do have more females in the OB-GYN workforce and a lot of them will work part time because they are raising families,” McLellan says. “But once their kids are older, they often transition back to working full time.” And, she notes, SLU faculty who work part-time report feeling fulfilled in balancing their professional and home lives.
Filling treatment gaps
As some efforts focus on training and retaining physicians, innovative telemedicine programs work to share the expertise of existing OB-GYNs.
For example, the Medical University of South Carolina (MUSC) Center for Telehealth operates a Maternal Fetal Telemedicine program that allows local providers and remote specialists to co-manage high-risk pregnancies. The program, available at six locations throughout the state, has been credited with helping reduce premature birth rates as well as neonatal and maternal mortality rates.
In Arkansas, where 73 of 75 counties are designated medically-underserved areas, the ANGELS call center offers 24-hour expert advice, weekly videoconferencing consults on complex cases, and neonatal bedside live video feed.
Telemedicine certainly helped Jessica Burchett, whose ultrasounds were performed at a local doctor’s office and then transmitted to her specialist. When one scan at 32 weeks revealed that the fetuses had run out of room to grow, Burchett headed to Little Rock where she delivered two healthy babies by C-section. “They just had their shots,” says Burchett of her twins, now 16 months old. “They’re doing wonderfully.”