Letters / Correspondance
Can J Rural Med vol 2 (2):118
© 1997 Society of Rural Physicians of Canada
CFPCSRPC: hot-wired at last
For the first time, the College of Family Physicians of Canada (CFPC) has created a body devoted to maternity care issues and to strengthening the role of family physicians providing obstetric care. Rural and urban practitioners are working together to ensure that services are available to pregnant women in communities of all sizes.
The Standing Committee on Family Medicine Maternity Care was developed through the efforts of a number of people who made up what was originally called the Family Medicine Obstetrical Interest Group (see www.cfpc.ca/maternity.htm). The interest group has now developed a Listserv Maternity Care Discussion Group (CFPCMCDG), which serves as a forum for serious discussion among family physicians providing maternity care, and in so doing also provides feedback to the CFPC Standing Committee on Family Medicine Maternity Care. Because a CFCP standing committee is made up of only 5 members from the usual regions, this committee needs to consult widely to be able to do its job. The interest group (now comprising almost 100 family physicians from all settings) and its Listserv perform that consultative function.
For example, in the weeks leading up to the 1997 Society of Rural Physicians of Canada (SRPC) conference on rural medicine in Banff, there were extensive discussions on the problems of providing maternity care in small communities. The discussions served to inform the conference participants about issues that were then discussed in Banff. As a direct result of the partnership that developed in Banff among the SRPC, the CFPC's Standing Committee on Family Medicine Maternity Care and the Society of Obstetricians and Gynaecologists of Canada (SOGC), the lists have been burning up the wires.
The CFPCMCDG and RuralMed lists were essential vehicles for developing the agenda for the Victoria conference "Critical issues in rural maternity care." The specific question under discussion at that meeting was "What are the optimal conditions for the provision of high quality maternity care in small communities without immediate access to cesarean section?" Through passionate discussion, the question was broadened to the following: "Since the literature is unambiguous about the safety of rural obstetric care, how can we support small rural communities so that they continue to provide high quality maternity care?"
Authors from both lists set out to develop a framework that they hope will lead to a flexible guideline, allowing recommendations for the provision of maternity care in such communities. Such a guideline must recognize that rural communities are heterogeneous in geography, climate, distance to transfer site, and technical and procedural capacity, and are subject to staffing uncertainties -- not to mention local political differences, community needs and desires.
It is obvious that, apart from discussions among the providers of health care, a true community consultation needs to take place so that those receiving the care understand all of the benefits and liabilities of their particular situation. That the SRPC, the CFPC, the SOGC and even the Canadian Medical Protective Association committed in Victoria to rapidly producing a joint guideline must be seen as a breakthrough.
Those of us who have been involved in this dialogue are excited not only about the content but about the speed with which information can be exchanged. In fact, the energy has been so great that "email fatigue" has affected some of us, as the perhaps artificial urgency of response and counter-response can create unwelcome pressure. Nevertheless, we will learn to manage this new beast, which we feel certain will lead to an improvement in care for rural women and a sense of accomplishment and genuine mutual support for those family doctors who have been working in the trenches for so long.
Those interested in participating in this dialogue are urged to join the Maternity Care Discussion Group by contacting me, Dr. Michael Klein (mklein@unixg.ubc.ca). We also urge you to participate in the Listserv of the SRPC (RuralMed; send email to jwootton@fox.nstn.ca). Dr. Stuart Iglesias is the SRPC liaison to the Standing Committee on Family Practice Maternity Care and has formed the SRPC Obstetrics Committee to assist with this important work.
In addition, the Standing Committee on Family Medicine Maternity Care has developed a committee to manage Advanced Life Support in Obstetrics (ALSO) in Canada, and members interested in participating in the development of a Canadian version of ALSO should contact Duncan Etches through the CFPCMCDG list.
Future issues for the SRPCCFPCSOGC consortium include special training needs for rural family physicians, induction and augmentation in rural settings with various levels of immediate and not-so-immediate surgical back-up, electronic fetal monitoring by setting, the role of other procedures in various settings and political support for rural physicians in discussions with provincial regulatory bodies and regional boards. It's an exhausting but invigorating time. Join us.
Michael C. Klein, MD, CCFP, FCFP
The SOGC and the SRPC
The Society of Obstetricians and Gynaecologists (SOGC) has cooperated and supported the initiatives of the Society of Rural Physicians of Canada (SRPC) since its inception. The SRPC is a cornerstone for the medical care of hundreds, if not thousands of small- to medium-sized communities throughout Canada. The SOGC is committed to maintaining obstetrical services at the community level as close as possible to the patient's community, while at the same time developing a system of regionalization that will maintain high quality obstetrical services and prevent maternal and neonatal morbidity and mortality.
The SOGC will foster a close relationship with the SRPC and ensure that it is consulted when SOGC policies are developed that could affect rural obstetrical practice. The SOGC is also committed to working with the College of Family Physicians of Canada (CFPC) to further the objectives of the SRPC.
Crisis in Canada
At the present time, Canadians are faced with an obstetrical crisis. There is a temptation by governments to substitute the excellent care provided by physicians with nonphysician personnel. Through the help and dedication of thousands of physicians -- family physicians and gynecologists -- we are now the envy of the world in terms of maternal and perinatal morbidity and mortality. However, closure of hospitals, especially community hospitals in semi-urban and urban areas, is a policy for disaster. For example, cities such as Ottawa and Quebec City have reduced community obstetrical services so that access to personalized care and community involvement will soon be greatly reduced or nonexistent.
Reimbursement in Canada does not address the time, expertise and risks involved in delivering high-quality obstetrical services. Provincial governments and provincial medical associations will have to be lobbied and pressured to address these issues in an urgent manner. There are no specialty services in Canada with lower reimbursement schemes than obstetrical services. Midwifery reimbursement is being established in various provinces for normal obstetrical delivery at double or triple the reimbursement allocated to physicians. There is great difficulty in convincing provincial medical associations to allow consultation fees for cases referred by midwives.
The medicolegal crisis in Canada, with its high insurance rates for obstetrical services, presents a unique problem to both specialists and rural physicians. There is no provision for start-up costs, therefore, a rural physician with a low number of patients pays the same price as an urban physician with a large practice. This is also a problem with those on maternity leave or those who are participating in on-call services only. Physicians who provide on-call services in obstetrics for a rural physician group should have the same coverage as a physician with a busy practice, even though, in a rural setting, only a few patients may be cared for. The fact that this is not the case discriminates among physicians and practice patterns and makes obstetrical practice in rural Canada unappealing. This has led directly to the current medical manpower crisis in Canada.
Manpower crisis
The obstetrical workload for specialists has increased 50% during the last 10 years, with no increase in the number of gynecologists. Furthermore, the average age of gynecologists is 52 years. One-third of our work force will be retiring in the next 10 years, leaving Canada in short supply of obstetricians/gynecologists by the year 2010. The difficulties of obstetrical practice in rural communities, coupled with crippling medicolegal costs, have led family physicians to abandon obstetrical practice across Canada. This has had disastrous results, including an increased workload for gynecologists, decreased recruitment of family physicians in obstetrics, decreased access to community and rural obstetrical care and decreased opportunity for family medicine resident training in obstetrics by community physicians.
SOCG guidelines
The SOGC has a strong mandate to develop clinical practice guidelines in obstetrics and gynecology. We are fulfilling this mandate and have merited, throughout the years, a high reputation. Our guidelines are prepared by specialists in collaboration with family physicians, patients and other interest groups. The future model, proposed at the SRPC's annual conference in April 1997, is a closer association with the CFPC and the SRPC in the development of particular guidelines. The CFPC and the SRPC would form committees that could respond effectively in a very short period of time in this consultation process. When issues are of particular interest to rural physicians, the SOGC would include representatives from the CFPC and the SRPC as regular committee members. The CFPC has also formed a committee on a permanent basis. This should lead to better understanding and increase cooperation among the 3 organizations. Dr. Guy-Paul Gagné of the LaSalle Hospital (Quebec) will represent the SOGC on the CFPC maternity care committee.
SOGC policy
The SOGC Council (the governing body of the Society) has a family physician as a voting member. This family physician is elected by family physicians from the Associate Membership of the SOGC. This, in itself, provides for input from family physicians. Our guidelines are developed from evidence-based medicine, by thorough research of the literature and the Cochrane Database. All our guidelines, which are policy statements of the SOGC, are sent to our Council prior to their approval.
SOGCnet
The SOGC Network can be "hot-linked" with any other network, and we would be pleased to offer our Internet link to the SRPC Web site. This way, SRPC members could access SOGC guidelines rapidly and without cost. The guidelines and patient education material can also be downloaded, utilized, reprinted and photocopied at no cost. The objective is not to make money with our guidelines, but to have them widely distributed and available to physicians and communities.
The SOGC guidelines are living documents. When a guideline is published, the rural community group should bring it up at its next regular meeting, discuss the guideline, and adopt or modify it according to local needs and circumstances. This should be documented and kept in the obstetrical unit. Feedback on all guidelines should be sent to the National Office, which will transmit the comments when updating a particular guideline. Guidelines are not there to limit practice, but to provide a scope of practice for physicians to access the best possible advice in Canada. SOGC guidelines are not set at a minimum standard as seen in other countries, but are "best practice models," in order to provide the best possible care to Canadian women.
Conclusions
The SOGC has never spoken nor intends to speak for family physicians or rural physicians. We intend to work with physicians and Canadian women in order to come up with the best possible options for the best and most appropriate care. The SOGC supports the SRPC and would be pleased to help it in any way to develop its expertise in obstetrical care. The SOGC will look at current issues in rural obstetrics, such as delivery of obstetrical care in hospitals without cesarean section capability, induction with oxytocin and prostaglandins, training in cesarean section capability for physicians in remote areas and other issues of concern to family and rural physicians. In the end, whether we agree or disagree, informed consent and evidence-based medicine will bring us together to offer the best possible options or alternatives available to Canadian women so they may make informed choices for their personal health.
André B. Lalonde, MD, MSc, FSOGC
Executive Vice President
Society of Obstetricians and Gynaecologists of Canada
