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The distribution, practice, and attitudes of maternal-fetal medicine specialists
The distribution, practice, and attitudes of maternal-fetal medicine specialists Donald R. Coustan, MD,a Rachel M. Schwartz, MPH,b David E. Gagnon, MA, MPH,b J. Peter VanDorsten, MD,c and the Society for Maternal-Fetal Medicine Providence, RI, Charleston, SC, and Washington, DC 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. (Am J Obstet Gynecol 2001;185:1218-25.)
Key words: Maternal-fetal medicine, work hours, distribution, job satisfaction, practice setting
The subspecialty of maternal-fetal medicine (MFM) was officially recognized in 1972, with the formation of the Division of MFM within the American Board of Obstetrics and Gynecology. The Society for Maternal-Fetal Medicine (SMFM) was founded in 1977 as the Society of Perinatal Obstetricians. The society’s original objectives were “the promotion and expansion of education in obstetrical perinatology and the exchange of new ideas and research in the field of perinatology. The organization shall also be concerned with the promotion of the delivery of improved perinatal care.”1 Lorenz et al2 surveyed the 603 members of the Society in 1986 to assess the job setting, professional activities, and job satisfaction of MFM subspecialists. Seventy percent of all certified MFM subspecialists responded. The authors concluded, “This survey reveals a pattern of busy, satisfied clinicians active in administrative and educational roles while usually continuing both research and From the Department of Obstetrics and Gynecology, Brown Medical School, Women and Infants Hospital of Rhode Island,a National Perinatal Information Center,b Department of Obstetrics and Gynecology, Medical University of South Carolina,c and the Society for Maternal Fetal Medicine. Supported by the Society for Maternal Fetal Medicine. Reprints not available from the authors. Copyright © 2001 by Mosby, Inc. 0002-9378/2001/$35.00 + 0 6/1/119719 doi:10.1067/mob.2001.119719
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gynecologic practice.”2 Since 1986, the climate in which medical care is delivered has continued to evolve. Diminishing reimbursement to health care providers and decreased funding available for medical education have put increasing financial and time restraints on subspecialists within both academic and community settings. In 1993, Lorenz et al3 again surveyed the 1352-person membership of the SMFM, and the response rate was 58%. Among other changes, Lorenz et al3 noted the reporting of an increased number of ultrasound and invasive procedures and a declining involvement in gynecologic care. The authors concluded, “Since 1986, there have been significant changes among MFM subspecialists in job setting, allocation of professional time, and number and types of procedures. Job satisfaction remains high.”3 In 1996, the Society’s Board of Directors drafted a position statement outlining the role of the MFM subspecialist to develop improved approaches to the delivery of perinatal care.4 That statement is included as an appendix to this article. The SMFM is undertaking further efforts to define the role of the MFM subspecialist, to assess community needs for MFM subspecialists, and to document the unique contribution that such providers make to improving the outcome of pregnancy for both mother and offspring. In 1997, the SMFM Board of Directors commissioned the National Perinatal Information Center, a non-profit
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Table I. MFM subspecialist density by census regions Census region Region 1 New England (CT, ME, MA, NH, RI, VT) Region 2 Middle Atlantic (NJ, NY, PA) Region 3 South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) Region 4 East North Central (IL, IN, MI, OH, WI) Region 5 East South Central (AL, KY, MS, TN) Region 6 West North Central (IA, KS, MN, MO, NE, ND, SD) Region 7 West South Central (AR, LA, OK) Region 8 Mountain (AZ, CO, ID, MT, NV, MN, UT, WY) Region 9 Pacific (AK, CA, HI, OR, WA)
Births
MFM subspecialists per 1000 births
170,508 517,843 614,263 597,400 217,449 249,568 450,729 243,297 662,814
0.36 0.52 0.36 0.33 0.22 0.33 0.26 0.32 0.30
MFM subspecialists in census region 61 267 223 196 47 83 116 78 200
Table II. Demographics of survey population Year of survey 1986 (Lorenz et al1) SMFM members (n) Total responses [n (%)] MFM certified [n (% of responses)] Responses excluding fellows in training Mean age in years ± SD Female (%) Department chairs [n (%)] MFM directors [n (%)] Fellowship directors [n (%)] Academic job setting [n (%)]
623 496 (80) 255 (70) 470 41.8 ± 7.4 16
287 (65%)
1993 (Lorenz et al2)
1998
P value
1352 782 (58) 457 (60) 708 43.7 ± 7.3 25 56 (8) 209 (30) 55 (8) 372 (53%)
1461 847 (58) 580 (70) 825 44 ± 8 28 37 (4.5) 235 (28) 52 (6) 567 (69%)
.973 .002 .002 <.001 <.001 .007 .656 .262 NA
Definitions of academic differed among surveys, so comparisons are not appropriate. SMFM, Society for Maternal Fetal Medicine; NA, not applicable.
research organization whose membership includes major perinatal centers across the United States, to gather data regarding the current distribution of MFM subspecialists around the country and to profile MFM subspecialists in terms of their target patient population, the organization of their practices, workloads, and the services provided, as well as their satisfaction working in the subspecialty in the current environment. It is the hope of the Board of Directors that this information will prove useful in benchmarking the most appropriate ratio of MFM subspecialists to patients, the practice patterns of MFM subspecialists, the typical workloads encountered, and trends. Material and methods The membership list of the SMFM, including addresses, was used to determine current manpower and geographic distribution of MFM subspecialists. Fellows in training were excluded. Physicians were mapped according to the 328 metropolitan statistical areas (MSAs) in the United States, defined as any urban market area with a population greater than 50,000.5 In 1997, 83% of all US births occurred in an MSA.6 Birth projections were drawn from the national population file MSABIRTH.DBF, which includes all births for MSAs in the United States by 1-year intervals from 1990 to 2010. We calculated the number of MFM
physicians per 1000 births in the MSAs within each of the nation’s 9 census regions. The population in 1997 was estimated by using inter-censal birth projections by county.6 The survey of MFM subspecialists was designed to profile MFM subspecialists in terms of their target patient population, the organization of their practices, the services provided, and their satisfaction working in the subspecialty in the current environment. The survey was sent, in November of 1998, to all 1461 SMFM members (board-certified and those in fellowship or graduates having not yet completed their board examinations). A follow-up mailing was sent to all non-respondents in February of 1999, and a final mailing was sent to all non-respondents in April of 1999. Confidentiality was maintained through use of a physician code on the respondent survey so that the names on the outside of the outgoing envelope and the code numbers on the inside of the survey were never linked. Current fellows were then excluded from data analysis so as to focus on respondents in active practice. When data for individual items were analyzed, the denominator (“n”) included only those who responded to that question. Tables show univariate analyses; categoric and continuous variables were compared by using chisquare and t tests as appropriate.
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Table III. Distribution of average MFM subspecialist professional time, 1998 survey Academic (n = 558) Clinical research (%) Laboratory research (%) Clinical teaching (students, residents, fellows) (%) Direct clinical care (%) Practice administrative tasks (%) Hospital administrative tasks (%) Teaching (lectures, grand rounds, seminars, etc) (%) Continuing education (conferences) (%) Quality assurance/utilization review (%) Vacation (%) Other (%)
8 2 21 39 6 7 5 3 2 4 2
Non-academic (n = 238) 4 1 11 60 5 4 3 3 2 5 2
All MFM subspecialists (n = 796)
P value
7 2 18 46 6 6 5 3 2 4 2
<.0001 .124 <.0001 <.0001 .164 .0002 <.0001 1.000 1.000 .0099 1.000
Denominators are the number of respondents answering the relevant questions.
Results The SMFM list contained the names and addresses of 1461 obstetricians in the United States as of April 20, 1997, who identified themselves as “perinatal obstetricians.” With the exclusion of fellows in training, there were 1271 members. Of these, 958 were identified as having certification of special competence in MFM. All but 15 of the 1271 self-identified MFM subspecialists practiced in 1 of 328 MSAs. The national supply of MFM subspecialists in 1997 was 0.34 per 1000 births. Census region 2 (New York, New Jersey, and Pennsylvania) had the highest concentration of MFM subspecialists at 0.52 per 1000 births, whereas census region 5 (Alabama, Kentucky, Mississippi, and Tennessee) had the lowest density at 0.22 subspecialists per thousand births (Table I). If the national MFM density were an appropriate standard for the apportionment of MFM subspecialists, then an MSA would require one MFM subspecialist for every 3000 births. Among the 200 MSAs with birth cohorts of at least 3000 per year, there were 33 with no MFM subspecialist as of 1997. There were 19 MSAs with a higher ratio than 1 per 3000 births. Among the 128 MSAs with fewer than 3000 births, 99 had no MFM subspecialists and 29 had one or more. Overall, one fifth of MSAs have no MFM subspecialists. In 1997, more than 500,000 births were in rural areas outside of MSAs, and more than 450,000 births occurred in MSAs with no MFM subspecialist. These two categories include one fourth of all deliveries. The survey of MFM subspecialists was returned by 847 respondents (response rate, 59%), of whom 580 hold Certificates of Special Competence in MFM from the American Board of Obstetrics and Gynecology. Twenty-two of the respondents were fellows in training who were excluded from further analysis, leaving 825 respondents to be considered. Table II provides an overview of those surveyed and compares them with the respondents to previous surveys. The response rates for the present (1998) and the 1993 surveys were similar. The current analysis divides MFMs
into two groups, academic and non-academic, and presents both groups separately and combined. Academics are those who held a medical school rank as either research or clinical faculty and were either university- or hospital-based. This definition differs slightly from that used in previous surveys, so comparisons would be inappropriate. According to this definition, approximately 69% of respondents to the present survey are academic. Among academics, approximately 45% would be considered “junior faculty;” that is, they hold appointments at the level of instructor (3%) or assistant professor (42%). Table III displays results of survey questions intended to assess how MFM subspecialists spend their professional time. These data are somewhat more detailed than those of past surveys. The respondents indicated that the largest proportion of their time is spent in clinical care (60% for academics and 71% for non-academics). Research comprised only 10% of time spent by academics. Although the questions were somewhat more detailed than in previous surveys, overall time spent in clinical care has trended upward (57% in 1986, 62% in 1993, and 64% in 1998; P = .017). More dramatic is the shift in clinical care that does not involve trainees from 31% in 1993 to 46% in 1998 (P < .001). Research time for academics has correspondingly fallen from 19% in 1993 to 10% in 1998, although the somewhat different definition of academic used in this study may confound such a comparison. In its position statement on the role of the MFM subspecialist, the SMFM divided MFM patients into 3 categories: (1) patients with medical and surgical disorders, (2) healthy pregnant women with fetuses at markedly increased risk for adverse outcome, and (3) any antepartum patient admitted for a reason “other than delivery” and patients with postpartum complications. Respondents to the survey were asked to characterize their caseload according to these categories. Table IV shows the results. Because the survey asked for the number of each category of patients, rather than the number of patient
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Table IV. Average annual number of patients and distribution by category Academic (n = 500)
All MFM subspecialists (n = 713)
Non-academic (n = 213)
Avg No. of cases
%
Avg No. of cases
%
Avg No. of cases
%
P value
168 178
38 41
239 351
34 51
189 229
37 45
.328 .016
91 437
21 100
103 693
15 100
94 512
18 100
.08
Patients with med/surg disorders Healthy pregnant women with fetus at markedly increased risk Antepartum or postpartum problems Total
Academic versus non-academic distributions significantly different (P = .03). Note: This question was phrased to elicit the distribution of types of patients, and not numbers of visits.
Table V. Reported hours worked per week No. Academics Non-academics All MFM subspecialists
556 234 790
20th Percentile 60 55 60
Median 65 60 65
80th Percentile 80 80 80
Range 10-140 7-120 7-140
Mean (SD) 68 (15.3) 65 (16.7) 67 (15.8)
Means for academics and non-academics are significantly different (P < .05).
visits, Table IV does not provide data regarding quantity of patient visits. The largest patient category served by both academic and non-academic MFM subspecialsits is healthy pregnant women with fetuses at markedly increased risk for poor outcome. The distribution of the two groups is statistically different: the academic practices are more heavily weighted toward patients with medical and surgical disorders and antepartum or postpartum complications, and the non-academic practices are weighted toward more healthy pregnant women with fetuses at markedly increased risk for adverse outcomes. Table V shows the reported average number of hours worked per week. On average, academic MFM subspecialists reported working slightly longer hours than nonacademic MFM subspecialists. Table VI shows the proportion of MFM subspecialists performing various services and the average number of each procedure or service provided per year by those giving a positive response. Academic and non-academic MFM subspecialists differed with regard to proportion performing genetic amniocenteses (89% of academic vs 94% of non-academic, P = .03), abortion (51% vs 43%, P < .05), targeted sonography (85% vs 91%, P = .02), and consultation (65% vs 74%, P < .02). Among those performing a specific service, non-academic MFM subspecialists reported performing more consultations (mean, 589 vs 307; median, 250 vs 150; P < .001), genetic amniocenteses (mean, 262 vs 191; median, 185 vs 125; P = .001), hysterectomies (11 vs 5, 4 vs 2, P < .001), and laparoscopic procedures (16 vs 9, 9 vs 5, P = .01) per year than did academic MFM subspecialists.
Table VII indicates that both academic and non-academic physicians are most likely to be in MFM group practices, but non-academic physicians are more likely than academics to adopt other modes of practice. Academics practice primarily in faculty practice plans, whereas non-academics use other management strategies. About 75% of all respondents reported participation in managed care contracts. Only 16% of non-academics and 34% of academics reported participating in capitated contracts (P < .001). Forty-eight percent of respondents indicated that managed care has restricted patient access to the subspecialty of MFM. Sources of revenue varied for academics and non-academics (Table VIII). Although patient care was the largest source for both groups, it comprised a significantly greater proportion of resources for non-academics. Research, education, and administration were larger revenue sources for academics. Table IX shows the number of respondents reporting various fringe benefits. Blank responses were counted as negative responses. With the exception of profit sharing, academics report a fuller package of fringe benefits than do non-academics. In assessing respondents’ attitudes about the specialty and their satisfaction with it (Table X), the survey asked for a response that indicated the level of agreement (agree, neutral, or disagree) with 4 statements. The first statement asked whether the subspecialty should be predominantly academic. About half of academics and 15% of non-academics agreed. This was the only statement in which the distribution of responses differed between the two groups. Forty-
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Table VI. Services provided, annual case load
High-risk deliveries Genetic amniocentesis Cerclage Normal deliveries Targeted sonography Antenatal testing Screening sonography Consultation Cordocentesis Abortion Fetal diagnostic procedures* Laparoscopy Fetal therapeutic procedures† Hysterectomy Chorionic villus sampling
No. (%) providing service
Mean per year
Median
750 (94) 721 (91) 715 (90) 698 (87) 692 (87) 684 (86) 657 (82) 536 (67) 450 (56) 386 (48) 386 (48) 293 (37) 267 (34) 260 (33) 231 (29)
127 213 15 96 885 713 976 401 7 19 131 11 61 6 52
80 150 10 50 500 400 500 200 5 10 6 5 5 3 30
*Fetal diagnostic procedures include fetal blood sampling, fetal transfusion, fetal muscle/organ biopsy, fetal skin sampling, and fetoscopy/embryoscopy. †Fetal therapeutic procedures include fetal gene therapy and fetal reduction.
Table VII. Practice attributes Academics [n (%)] Practice location* HMO-based Hospital-based Independent/community University-based Total Practice type† Solo practitioner MFM group practice Multi-specialty group Ob/Gyn group practice Other Total Group practice management‡ Faculty practice plan Independent group practice Physician practice management Other Total
Non-academics [n (%)]
All
P value
2 (0) 230 (41) 4 (1) 331 (58) 567 (100)
22 (9) 58 (25) 149 (64) 5 (2) 234 (100)
24 (3) 288 (36) 153 (19) 336 (42) 801 (100)
<.001 <.001 <.001 <.001
23 (4) 332 (59) 50 (9) 73 (13) 80 (14) 558 (100)
49 (20) 115 (47) 27 (11) 32 (13) 20 (8) 243 (100)
72 (9%) 447 (56%) 77 (10%) 105 (13%) 100 (12%) 801 (100%)
<.001 .002 NS NS .02
392 (81) 37 (8) 27 (6) 30 (6) 486 (100)
0 100 (58) 33 (19) 38 (22) 171 (100)
392 (60) 137 (21%) 60 (9) 68 (10) 657 (100)
<.001 <.001 <.001 <.001
NS, Not significant. *Overall P < .001 for location distributions between academic and non-academic MFM subspecialists. †Overall P = .001 for practice type distributions between academic and non-academic MFMs. ‡Overall P < .001 for group practice management between academic and non-academic MFM subspecialists; if faculty practice plans excluded, P = .01.
six percent of respondents believed that MFM subspecialists should only provide consultation and care to high-risk patients, and 57% believed that there is not a need for an increase in the number of MFM subspecialists. Over half the respondents reported that they are satisfied with their jobs, and only 12% were dissatisfied. Comment Although these data do not provide definitive answers regarding the most appropriate number of MFM subspecialists to provide service to the obstetric population of the United States, nor their most appropriate
geographic distribution, they do provide a “snapshot” of the current distribution of MFM subspecialists. The role of MFM subspecialists, like that of other subspecialists, is continually evolving. Fellows in training were not included because, although they deliver services, supervision is required and they are not considered independent MFM practitioners. Inclusion of fellows in training would have confounded manpower distribution estimates toward MSAs including academic medical centers. On the other hand, MFM practitioners who are not yet board certified were included because they provide the full range of MFM ser-
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Table VIII. Sources of revenue Academic (n = 443)
Non-academic (n = 208)
All MFM subspecialists (n = 651)
P value
59 18 10 8 3 3
69 21 5 3 1 2
62 19 8 6 3 2
.015 NS .04 .02 NS NS
Professional fees (%) Technical fees (%) Administration (%) Education (%) Research (%) Other (%)
Overall, P < .01 across all sources of revenue, for academic versus non-academic MFM subspecialists. NS, Not significant.
Table IX. Percentage of respondents reporting receiving fringe benefits Academics (n = 567)
Non-academics (n = 258)
All MFM subspecialists (n = 825)
P value
82* 94* 81* 94* 78* 89* 14* 45 78* 32*
56 79 58 81 50 57 26 39 58 19
74 89 74 90 69 79 18 43 72 28
<.001 <.001 <.001 <.001 <.001 <.001 <.001 NS <.001 <.001
Life insurance (%) Medical insurance (%) Dental insurance (%) Malpractice insurance (%) Long-term disability (%) Retirement plan (%) Profit sharing (%) 401K (%) Travel allowance (%) Dependent education allowance (%)
*P < .001 across all fringe benefits for academics versus non-academics. NS, Not significant.
Table X. Attitudes and job satisfaction Academics
MFM subspecialty should be predominantly academic MFMs should only provide consultation and ob care to high risk patients There is need for an increase in the present number of MFMs MFMs should practice in groups of two or more Overall job satisfaction
Non-academics
n
Disagree
Neutral Agree
555
29%
23%
47%
244
69%
561
33%
19%
47%
246
558
58%
26%
15%
557
15%
20%
64%
Average (10-point scale) 7.5
vices even before they become certified, 2 1/2 or more years after completion of a fellowship. Currently, there is one MFM subspecialist for every 2942 births in the United States. However, there is a wide range of distribution from one subspecialist for every 4545 births in the east south central states to one subspecialist for every 1923 births in the mid Atlantic region. These data should be useful to MFM subspecialists as they locate their practices and to health care organizations as they bench-mark their staffing plans. A recent American College of Obstetricians and Gynecologists (ACOG) publication7 allows comparison of
n
Disagree Neutral
All MFM subspecialists n
Disagree
16%
15%
799
41%
21%
38%
<.001
37%
20%
43%
807
35%
19%
46%
NS
246
54%
29%
17%
804
57%
27%
16%
NS
245
17%
23%
60%
802
16%
21%
63%
NS
Average (10-point scale) 7.1
Neutral Agree
P value
Agree
Average (10-point scale) 7.4
the demographics of MFM subspecialists with those of 3100 ACOG members, most of whom are generalist obstetrician/gynecologists. Not surprisingly, the distribution of obstetrician/gynecologists follows that of births, with 90% of obstetrician/gynecologists practicing in MSAs. MFM subspecialists tend to be younger than ACOG members in general (44 vs 47 years) and are slightly more likely to be female (28% vs 26%). MFM subspecialists are more likely to be hospital- or university-based than generalist obstetrician/gynecologists (78% vs 25%) and less likely to be in solo practice (9% vs 24%). Both groups report a similar work schedule (67
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vs 66 hours per week), but generalist obstetrician/gynecologists report that 78% of their professional time is devoted to clinical care versus 46% for MFM subspecialists. However, if clinical teaching is included, then 64% of MFM subspecialists’ time is spent in clinical activities. Each reported performing a similar number of deliveries (130 for MFM subspecialists and 141 for generalists). These data regarding distribution of clinical activity, source of income, and fringe benefits should help the MFM subspecialist to bench-mark his or her practice. There has been speculation that modern MFM is more consultative and sonography-oriented, but the survey indicates that more than 90% of MFM subspecialists still deliver babies. Although nearly 90% perform ultrasound examinations, fewer perform fetal diagnostic and therapeutic procedures. Nevertheless, a note of caution should be sounded in that these are all self-reports and no external validation was possible. Less than half of academic MFM subspecialists believe that the subspecialty should be primarily academic, indicating that most have accepted the existence of dual tracks. The manpower requirements remain uncertain among our respondents; more than half of MFM subspecialists believe that there is not a need for an increase in the present number of MFM subspecialists, and there was no difference between academics and non-academics. In the previous surveys, job satisfaction averaged 7.2 on a 10-point scale. In the current survey, the job satisfaction similarly averaged 7.4. It is somewhat surprising that despite all of the changes that have occurred in the specialty and in the health care system as a whole, subspecialists in MFM appear to have maintained the same positive attitude toward their work and their specialty! REFERENCES
1. D’Alton ME, Poole S, Rinehart RD. Society of Perinatal Obstetricians: the first two decades. Washington (DC): Society of Perinatal Obstetricians; 1997. p. 2. 2. Lorenz RP, Sokol RJ, Chik L. Survey of maternal-fetal medicine subsubspecialists: professional activities, job setting, and satisfaction. Obstet Gynecol 1989;74:962-6. 3. Lorenz RP, Sokol RJ, Chik L. Survey of maternal-fetal medicine subsubspecialists: professional activities, job setting, satisfaction, and trends over time. J Matern Fetal Med 1998;7:273-6. 4. SPO Newsletter, November 1996, Volume 14, No. 2. Available from: URL:http://www.smfm.org/Core/Def.html. 5. US Department of Commerce Bureau of the Census. Statistical abstract of the United States—the national data book. Washington (DC): US Government Printing Office; 1998. 6. American Hospital Association. Hospital statistics. 1999 ed. Chicago: Health Forum; 1999. 7. ACOG Division of Fellowship Activities. Profile of ob-gyn practice, 1991-1998. Washington (DC): American College of Obstetricians and Gynecologists; November 2000.
Appendix The Specialty of Maternal Fetal Medicine: Society of Perinatal Obstetricians. Special skills and resources are often required to best enhance the outcome of pregnancy for both mother and fetus. A maternal-fetal medicine spe-
November 2001 Am J Obstet Gynecol
cialist is an obstetrician-gynecologist who has received years of additional education, practical experience, and certification in various obstetrical, medical, and surgical complications of pregnancy. By virtue of this training and technical proficiency, he or she provides care or consultation for both mother and fetus in the complicated pregnancy. Ongoing competency is maintained only by seeing a critical volume of such patients on a regular basis. In addition, he or she provides the obstetrical health care team with an awareness of the most recent approaches to the diagnosis and treatment of obstetric problems along with diagnostic and therapeutic techniques for optimal management of these complicated pregnancies. The discipline of maternal-fetal medicine involves the 4 major subgroups of patients: A. Patients undergoing diagnostic or therapeutic procedures: 1. Abdominal cerclage 2. Chorionic villus sampling 3. Comprehensive sonography 4. Fetal gene therapy 5. Fetal blood sampling 6. Fetal transfusion 7. Fetal muscle/organ biopsy 8. Fetal reduction 9. Fetal skin sampling 10. Fetoscopy/embryoscopy 11. Genetic amniocentesis 12. Other diagnostic/therapeutic procedures B. Patients with medical and surgical disorders: 1. Antiphosphoipid antibodies 2. Cardiac disease (Clark’s Group II, III, any valve replacement) 3. Chronic renal disease 4. Chronic hypertension 5. Central nervous system disease – Seizure disorders – Multiple sclerosis – Arteriovenous malformation – Berry aneurysm – Prolactinoma – Pseudotumor cerebri 6. Systemic lupus erythematosus/other collagen vascular disease 7. Congenital disorders with potential untoward outcomes – Cystic fibrosis – Marfan syndrome – Protein S, C, AT-III deficiency 8. Endocrinologic disorders – Addison’s disease – Diabetes, insulin-requiring/dependent – Thyroid disease – Parathyroid disease – Pheochromocytoma
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9. Gastrointestinal disease – Hepatitis – Acute fatty liver of pregnancy – Portal hypertension – Hyperemesis, unresponsive to conservative therapy – Ulcerative colitis – Crohn’s disease – Cholecystitis/cholelithiasis – Pancreatitis 10. Sickle cell disease/other hemoglobinopathies 11. Thromboembolic disease, past or current 12. Alloimmune and autoimmune thrombocytopenia 13. Infectious diseases – Human immunodeficiency virus – Cytomegalovirus – Toxoplasmosis – Rubella – Parovirus – Varicella – Herpes (primary) – Septicemia – Coccidiomycosis – Any life-threatening infection 14. Maternal malignant disease 15. Myasthenia gravis 16. Paraplegia/quadriplegia 17. Pulmonary hypertension 18. Eating disorders 19. Restrictive lung disease 20. Severe preeclampsia/eclampsia HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome 21. Asthma requiring frequent medications 22. Substance abuse 23. Thrombotic thrombocytopenia purpura/hemolytic uremic syndrome 24. Transplants
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C. Healthy pregnant women with fetuses at markedly increased risk for adverse outcome: 1. Abdominal pregnancy 2. Abnormal maternal serum test results 3. Fetal hydrops: immune, nonimmune 4. Fetal anomaly or cytogenetic abnormality 5. Fetal supraventricular tachycardia or congenital heart block 6. Incompetent cervix 7. Isoimmunization 8. Muellerian anomalies 9. Multifetal pregnancies (twins or greater) 10. Recurrent prior preterm deliveries (≥2) 11. Nonobstetric abdominal surgery in the current pregnancy 12. Oligohydramnios at <37 weeks’ gestation 13. Placenta accreta, increta, percreta 14. Polyhydramnios 15. Premature rupture of membranes (<34 weeks’ gestation) 16. Preterm labor (<34 weeks’ gestation) 17. Prior second-trimester fetal loss 18. Prior intrauterine fetal demise 19. Recurrent pregnancy loss 20. Significant second- or third-trimester bleeding 21. Suspected intrauterine growth retardation 22. Twin-to-twin transfusion syndrome D. Any antepartum patient admitted for a reason “other than delivery” and patients with postpartum complications such as severe hemorrhage, refractory infections, complicated preeclampsia, eclampsia, or difficult complications after cesarean delivery. The maternal-fetal medicine specialist may provide consultation, co-management, or direct care for any of these conditions or any other conditions in obstetrics, including preconceptual counseling. The relationship with the maternal-fetal medicine specialist will depend on acuity of the condition and local circumstances.
Key words: Maternal-fetal medicine, work hours, distribution, job satisfaction, practice setting
The subspecialty of maternal-fetal medicine (MFM) was officially recognized in 1972, with the formation of the Division of MFM within the American Board of Obstetrics and Gynecology. The Society for Maternal-Fetal Medicine (SMFM) was founded in 1977 as the Society of Perinatal Obstetricians. The society’s original objectives were “the promotion and expansion of education in obstetrical perinatology and the exchange of new ideas and research in the field of perinatology. The organization shall also be concerned with the promotion of the delivery of improved perinatal care.”1 Lorenz et al2 surveyed the 603 members of the Society in 1986 to assess the job setting, professional activities, and job satisfaction of MFM subspecialists. Seventy percent of all certified MFM subspecialists responded. The authors concluded, “This survey reveals a pattern of busy, satisfied clinicians active in administrative and educational roles while usually continuing both research and From the Department of Obstetrics and Gynecology, Brown Medical School, Women and Infants Hospital of Rhode Island,a National Perinatal Information Center,b Department of Obstetrics and Gynecology, Medical University of South Carolina,c and the Society for Maternal Fetal Medicine. Supported by the Society for Maternal Fetal Medicine. Reprints not available from the authors. Copyright © 2001 by Mosby, Inc. 0002-9378/2001/$35.00 + 0 6/1/119719 doi:10.1067/mob.2001.119719
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gynecologic practice.”2 Since 1986, the climate in which medical care is delivered has continued to evolve. Diminishing reimbursement to health care providers and decreased funding available for medical education have put increasing financial and time restraints on subspecialists within both academic and community settings. In 1993, Lorenz et al3 again surveyed the 1352-person membership of the SMFM, and the response rate was 58%. Among other changes, Lorenz et al3 noted the reporting of an increased number of ultrasound and invasive procedures and a declining involvement in gynecologic care. The authors concluded, “Since 1986, there have been significant changes among MFM subspecialists in job setting, allocation of professional time, and number and types of procedures. Job satisfaction remains high.”3 In 1996, the Society’s Board of Directors drafted a position statement outlining the role of the MFM subspecialist to develop improved approaches to the delivery of perinatal care.4 That statement is included as an appendix to this article. The SMFM is undertaking further efforts to define the role of the MFM subspecialist, to assess community needs for MFM subspecialists, and to document the unique contribution that such providers make to improving the outcome of pregnancy for both mother and offspring. In 1997, the SMFM Board of Directors commissioned the National Perinatal Information Center, a non-profit
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Table I. MFM subspecialist density by census regions Census region Region 1 New England (CT, ME, MA, NH, RI, VT) Region 2 Middle Atlantic (NJ, NY, PA) Region 3 South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) Region 4 East North Central (IL, IN, MI, OH, WI) Region 5 East South Central (AL, KY, MS, TN) Region 6 West North Central (IA, KS, MN, MO, NE, ND, SD) Region 7 West South Central (AR, LA, OK) Region 8 Mountain (AZ, CO, ID, MT, NV, MN, UT, WY) Region 9 Pacific (AK, CA, HI, OR, WA)
Births
MFM subspecialists per 1000 births
170,508 517,843 614,263 597,400 217,449 249,568 450,729 243,297 662,814
0.36 0.52 0.36 0.33 0.22 0.33 0.26 0.32 0.30
MFM subspecialists in census region 61 267 223 196 47 83 116 78 200
Table II. Demographics of survey population Year of survey 1986 (Lorenz et al1) SMFM members (n) Total responses [n (%)] MFM certified [n (% of responses)] Responses excluding fellows in training Mean age in years ± SD Female (%) Department chairs [n (%)] MFM directors [n (%)] Fellowship directors [n (%)] Academic job setting [n (%)]
623 496 (80) 255 (70) 470 41.8 ± 7.4 16
287 (65%)
1993 (Lorenz et al2)
1998
P value
1352 782 (58) 457 (60) 708 43.7 ± 7.3 25 56 (8) 209 (30) 55 (8) 372 (53%)
1461 847 (58) 580 (70) 825 44 ± 8 28 37 (4.5) 235 (28) 52 (6) 567 (69%)
.973 .002 .002 <.001 <.001 .007 .656 .262 NA
Definitions of academic differed among surveys, so comparisons are not appropriate. SMFM, Society for Maternal Fetal Medicine; NA, not applicable.
research organization whose membership includes major perinatal centers across the United States, to gather data regarding the current distribution of MFM subspecialists around the country and to profile MFM subspecialists in terms of their target patient population, the organization of their practices, workloads, and the services provided, as well as their satisfaction working in the subspecialty in the current environment. It is the hope of the Board of Directors that this information will prove useful in benchmarking the most appropriate ratio of MFM subspecialists to patients, the practice patterns of MFM subspecialists, the typical workloads encountered, and trends. Material and methods The membership list of the SMFM, including addresses, was used to determine current manpower and geographic distribution of MFM subspecialists. Fellows in training were excluded. Physicians were mapped according to the 328 metropolitan statistical areas (MSAs) in the United States, defined as any urban market area with a population greater than 50,000.5 In 1997, 83% of all US births occurred in an MSA.6 Birth projections were drawn from the national population file MSABIRTH.DBF, which includes all births for MSAs in the United States by 1-year intervals from 1990 to 2010. We calculated the number of MFM
physicians per 1000 births in the MSAs within each of the nation’s 9 census regions. The population in 1997 was estimated by using inter-censal birth projections by county.6 The survey of MFM subspecialists was designed to profile MFM subspecialists in terms of their target patient population, the organization of their practices, the services provided, and their satisfaction working in the subspecialty in the current environment. The survey was sent, in November of 1998, to all 1461 SMFM members (board-certified and those in fellowship or graduates having not yet completed their board examinations). A follow-up mailing was sent to all non-respondents in February of 1999, and a final mailing was sent to all non-respondents in April of 1999. Confidentiality was maintained through use of a physician code on the respondent survey so that the names on the outside of the outgoing envelope and the code numbers on the inside of the survey were never linked. Current fellows were then excluded from data analysis so as to focus on respondents in active practice. When data for individual items were analyzed, the denominator (“n”) included only those who responded to that question. Tables show univariate analyses; categoric and continuous variables were compared by using chisquare and t tests as appropriate.
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Table III. Distribution of average MFM subspecialist professional time, 1998 survey Academic (n = 558) Clinical research (%) Laboratory research (%) Clinical teaching (students, residents, fellows) (%) Direct clinical care (%) Practice administrative tasks (%) Hospital administrative tasks (%) Teaching (lectures, grand rounds, seminars, etc) (%) Continuing education (conferences) (%) Quality assurance/utilization review (%) Vacation (%) Other (%)
8 2 21 39 6 7 5 3 2 4 2
Non-academic (n = 238) 4 1 11 60 5 4 3 3 2 5 2
All MFM subspecialists (n = 796)
P value
7 2 18 46 6 6 5 3 2 4 2
<.0001 .124 <.0001 <.0001 .164 .0002 <.0001 1.000 1.000 .0099 1.000
Denominators are the number of respondents answering the relevant questions.
Results The SMFM list contained the names and addresses of 1461 obstetricians in the United States as of April 20, 1997, who identified themselves as “perinatal obstetricians.” With the exclusion of fellows in training, there were 1271 members. Of these, 958 were identified as having certification of special competence in MFM. All but 15 of the 1271 self-identified MFM subspecialists practiced in 1 of 328 MSAs. The national supply of MFM subspecialists in 1997 was 0.34 per 1000 births. Census region 2 (New York, New Jersey, and Pennsylvania) had the highest concentration of MFM subspecialists at 0.52 per 1000 births, whereas census region 5 (Alabama, Kentucky, Mississippi, and Tennessee) had the lowest density at 0.22 subspecialists per thousand births (Table I). If the national MFM density were an appropriate standard for the apportionment of MFM subspecialists, then an MSA would require one MFM subspecialist for every 3000 births. Among the 200 MSAs with birth cohorts of at least 3000 per year, there were 33 with no MFM subspecialist as of 1997. There were 19 MSAs with a higher ratio than 1 per 3000 births. Among the 128 MSAs with fewer than 3000 births, 99 had no MFM subspecialists and 29 had one or more. Overall, one fifth of MSAs have no MFM subspecialists. In 1997, more than 500,000 births were in rural areas outside of MSAs, and more than 450,000 births occurred in MSAs with no MFM subspecialist. These two categories include one fourth of all deliveries. The survey of MFM subspecialists was returned by 847 respondents (response rate, 59%), of whom 580 hold Certificates of Special Competence in MFM from the American Board of Obstetrics and Gynecology. Twenty-two of the respondents were fellows in training who were excluded from further analysis, leaving 825 respondents to be considered. Table II provides an overview of those surveyed and compares them with the respondents to previous surveys. The response rates for the present (1998) and the 1993 surveys were similar. The current analysis divides MFMs
into two groups, academic and non-academic, and presents both groups separately and combined. Academics are those who held a medical school rank as either research or clinical faculty and were either university- or hospital-based. This definition differs slightly from that used in previous surveys, so comparisons would be inappropriate. According to this definition, approximately 69% of respondents to the present survey are academic. Among academics, approximately 45% would be considered “junior faculty;” that is, they hold appointments at the level of instructor (3%) or assistant professor (42%). Table III displays results of survey questions intended to assess how MFM subspecialists spend their professional time. These data are somewhat more detailed than those of past surveys. The respondents indicated that the largest proportion of their time is spent in clinical care (60% for academics and 71% for non-academics). Research comprised only 10% of time spent by academics. Although the questions were somewhat more detailed than in previous surveys, overall time spent in clinical care has trended upward (57% in 1986, 62% in 1993, and 64% in 1998; P = .017). More dramatic is the shift in clinical care that does not involve trainees from 31% in 1993 to 46% in 1998 (P < .001). Research time for academics has correspondingly fallen from 19% in 1993 to 10% in 1998, although the somewhat different definition of academic used in this study may confound such a comparison. In its position statement on the role of the MFM subspecialist, the SMFM divided MFM patients into 3 categories: (1) patients with medical and surgical disorders, (2) healthy pregnant women with fetuses at markedly increased risk for adverse outcome, and (3) any antepartum patient admitted for a reason “other than delivery” and patients with postpartum complications. Respondents to the survey were asked to characterize their caseload according to these categories. Table IV shows the results. Because the survey asked for the number of each category of patients, rather than the number of patient
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Table IV. Average annual number of patients and distribution by category Academic (n = 500)
All MFM subspecialists (n = 713)
Non-academic (n = 213)
Avg No. of cases
%
Avg No. of cases
%
Avg No. of cases
%
P value
168 178
38 41
239 351
34 51
189 229
37 45
.328 .016
91 437
21 100
103 693
15 100
94 512
18 100
.08
Patients with med/surg disorders Healthy pregnant women with fetus at markedly increased risk Antepartum or postpartum problems Total
Academic versus non-academic distributions significantly different (P = .03). Note: This question was phrased to elicit the distribution of types of patients, and not numbers of visits.
Table V. Reported hours worked per week No. Academics Non-academics All MFM subspecialists
556 234 790
20th Percentile 60 55 60
Median 65 60 65
80th Percentile 80 80 80
Range 10-140 7-120 7-140
Mean (SD) 68 (15.3) 65 (16.7) 67 (15.8)
Means for academics and non-academics are significantly different (P < .05).
visits, Table IV does not provide data regarding quantity of patient visits. The largest patient category served by both academic and non-academic MFM subspecialsits is healthy pregnant women with fetuses at markedly increased risk for poor outcome. The distribution of the two groups is statistically different: the academic practices are more heavily weighted toward patients with medical and surgical disorders and antepartum or postpartum complications, and the non-academic practices are weighted toward more healthy pregnant women with fetuses at markedly increased risk for adverse outcomes. Table V shows the reported average number of hours worked per week. On average, academic MFM subspecialists reported working slightly longer hours than nonacademic MFM subspecialists. Table VI shows the proportion of MFM subspecialists performing various services and the average number of each procedure or service provided per year by those giving a positive response. Academic and non-academic MFM subspecialists differed with regard to proportion performing genetic amniocenteses (89% of academic vs 94% of non-academic, P = .03), abortion (51% vs 43%, P < .05), targeted sonography (85% vs 91%, P = .02), and consultation (65% vs 74%, P < .02). Among those performing a specific service, non-academic MFM subspecialists reported performing more consultations (mean, 589 vs 307; median, 250 vs 150; P < .001), genetic amniocenteses (mean, 262 vs 191; median, 185 vs 125; P = .001), hysterectomies (11 vs 5, 4 vs 2, P < .001), and laparoscopic procedures (16 vs 9, 9 vs 5, P = .01) per year than did academic MFM subspecialists.
Table VII indicates that both academic and non-academic physicians are most likely to be in MFM group practices, but non-academic physicians are more likely than academics to adopt other modes of practice. Academics practice primarily in faculty practice plans, whereas non-academics use other management strategies. About 75% of all respondents reported participation in managed care contracts. Only 16% of non-academics and 34% of academics reported participating in capitated contracts (P < .001). Forty-eight percent of respondents indicated that managed care has restricted patient access to the subspecialty of MFM. Sources of revenue varied for academics and non-academics (Table VIII). Although patient care was the largest source for both groups, it comprised a significantly greater proportion of resources for non-academics. Research, education, and administration were larger revenue sources for academics. Table IX shows the number of respondents reporting various fringe benefits. Blank responses were counted as negative responses. With the exception of profit sharing, academics report a fuller package of fringe benefits than do non-academics. In assessing respondents’ attitudes about the specialty and their satisfaction with it (Table X), the survey asked for a response that indicated the level of agreement (agree, neutral, or disagree) with 4 statements. The first statement asked whether the subspecialty should be predominantly academic. About half of academics and 15% of non-academics agreed. This was the only statement in which the distribution of responses differed between the two groups. Forty-
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Table VI. Services provided, annual case load
High-risk deliveries Genetic amniocentesis Cerclage Normal deliveries Targeted sonography Antenatal testing Screening sonography Consultation Cordocentesis Abortion Fetal diagnostic procedures* Laparoscopy Fetal therapeutic procedures† Hysterectomy Chorionic villus sampling
No. (%) providing service
Mean per year
Median
750 (94) 721 (91) 715 (90) 698 (87) 692 (87) 684 (86) 657 (82) 536 (67) 450 (56) 386 (48) 386 (48) 293 (37) 267 (34) 260 (33) 231 (29)
127 213 15 96 885 713 976 401 7 19 131 11 61 6 52
80 150 10 50 500 400 500 200 5 10 6 5 5 3 30
*Fetal diagnostic procedures include fetal blood sampling, fetal transfusion, fetal muscle/organ biopsy, fetal skin sampling, and fetoscopy/embryoscopy. †Fetal therapeutic procedures include fetal gene therapy and fetal reduction.
Table VII. Practice attributes Academics [n (%)] Practice location* HMO-based Hospital-based Independent/community University-based Total Practice type† Solo practitioner MFM group practice Multi-specialty group Ob/Gyn group practice Other Total Group practice management‡ Faculty practice plan Independent group practice Physician practice management Other Total
Non-academics [n (%)]
All
P value
2 (0) 230 (41) 4 (1) 331 (58) 567 (100)
22 (9) 58 (25) 149 (64) 5 (2) 234 (100)
24 (3) 288 (36) 153 (19) 336 (42) 801 (100)
<.001 <.001 <.001 <.001
23 (4) 332 (59) 50 (9) 73 (13) 80 (14) 558 (100)
49 (20) 115 (47) 27 (11) 32 (13) 20 (8) 243 (100)
72 (9%) 447 (56%) 77 (10%) 105 (13%) 100 (12%) 801 (100%)
<.001 .002 NS NS .02
392 (81) 37 (8) 27 (6) 30 (6) 486 (100)
0 100 (58) 33 (19) 38 (22) 171 (100)
392 (60) 137 (21%) 60 (9) 68 (10) 657 (100)
<.001 <.001 <.001 <.001
NS, Not significant. *Overall P < .001 for location distributions between academic and non-academic MFM subspecialists. †Overall P = .001 for practice type distributions between academic and non-academic MFMs. ‡Overall P < .001 for group practice management between academic and non-academic MFM subspecialists; if faculty practice plans excluded, P = .01.
six percent of respondents believed that MFM subspecialists should only provide consultation and care to high-risk patients, and 57% believed that there is not a need for an increase in the number of MFM subspecialists. Over half the respondents reported that they are satisfied with their jobs, and only 12% were dissatisfied. Comment Although these data do not provide definitive answers regarding the most appropriate number of MFM subspecialists to provide service to the obstetric population of the United States, nor their most appropriate
geographic distribution, they do provide a “snapshot” of the current distribution of MFM subspecialists. The role of MFM subspecialists, like that of other subspecialists, is continually evolving. Fellows in training were not included because, although they deliver services, supervision is required and they are not considered independent MFM practitioners. Inclusion of fellows in training would have confounded manpower distribution estimates toward MSAs including academic medical centers. On the other hand, MFM practitioners who are not yet board certified were included because they provide the full range of MFM ser-
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Table VIII. Sources of revenue Academic (n = 443)
Non-academic (n = 208)
All MFM subspecialists (n = 651)
P value
59 18 10 8 3 3
69 21 5 3 1 2
62 19 8 6 3 2
.015 NS .04 .02 NS NS
Professional fees (%) Technical fees (%) Administration (%) Education (%) Research (%) Other (%)
Overall, P < .01 across all sources of revenue, for academic versus non-academic MFM subspecialists. NS, Not significant.
Table IX. Percentage of respondents reporting receiving fringe benefits Academics (n = 567)
Non-academics (n = 258)
All MFM subspecialists (n = 825)
P value
82* 94* 81* 94* 78* 89* 14* 45 78* 32*
56 79 58 81 50 57 26 39 58 19
74 89 74 90 69 79 18 43 72 28
<.001 <.001 <.001 <.001 <.001 <.001 <.001 NS <.001 <.001
Life insurance (%) Medical insurance (%) Dental insurance (%) Malpractice insurance (%) Long-term disability (%) Retirement plan (%) Profit sharing (%) 401K (%) Travel allowance (%) Dependent education allowance (%)
*P < .001 across all fringe benefits for academics versus non-academics. NS, Not significant.
Table X. Attitudes and job satisfaction Academics
MFM subspecialty should be predominantly academic MFMs should only provide consultation and ob care to high risk patients There is need for an increase in the present number of MFMs MFMs should practice in groups of two or more Overall job satisfaction
Non-academics
n
Disagree
Neutral Agree
555
29%
23%
47%
244
69%
561
33%
19%
47%
246
558
58%
26%
15%
557
15%
20%
64%
Average (10-point scale) 7.5
vices even before they become certified, 2 1/2 or more years after completion of a fellowship. Currently, there is one MFM subspecialist for every 2942 births in the United States. However, there is a wide range of distribution from one subspecialist for every 4545 births in the east south central states to one subspecialist for every 1923 births in the mid Atlantic region. These data should be useful to MFM subspecialists as they locate their practices and to health care organizations as they bench-mark their staffing plans. A recent American College of Obstetricians and Gynecologists (ACOG) publication7 allows comparison of
n
Disagree Neutral
All MFM subspecialists n
Disagree
16%
15%
799
41%
21%
38%
<.001
37%
20%
43%
807
35%
19%
46%
NS
246
54%
29%
17%
804
57%
27%
16%
NS
245
17%
23%
60%
802
16%
21%
63%
NS
Average (10-point scale) 7.1
Neutral Agree
P value
Agree
Average (10-point scale) 7.4
the demographics of MFM subspecialists with those of 3100 ACOG members, most of whom are generalist obstetrician/gynecologists. Not surprisingly, the distribution of obstetrician/gynecologists follows that of births, with 90% of obstetrician/gynecologists practicing in MSAs. MFM subspecialists tend to be younger than ACOG members in general (44 vs 47 years) and are slightly more likely to be female (28% vs 26%). MFM subspecialists are more likely to be hospital- or university-based than generalist obstetrician/gynecologists (78% vs 25%) and less likely to be in solo practice (9% vs 24%). Both groups report a similar work schedule (67
1224 Coustan et al
vs 66 hours per week), but generalist obstetrician/gynecologists report that 78% of their professional time is devoted to clinical care versus 46% for MFM subspecialists. However, if clinical teaching is included, then 64% of MFM subspecialists’ time is spent in clinical activities. Each reported performing a similar number of deliveries (130 for MFM subspecialists and 141 for generalists). These data regarding distribution of clinical activity, source of income, and fringe benefits should help the MFM subspecialist to bench-mark his or her practice. There has been speculation that modern MFM is more consultative and sonography-oriented, but the survey indicates that more than 90% of MFM subspecialists still deliver babies. Although nearly 90% perform ultrasound examinations, fewer perform fetal diagnostic and therapeutic procedures. Nevertheless, a note of caution should be sounded in that these are all self-reports and no external validation was possible. Less than half of academic MFM subspecialists believe that the subspecialty should be primarily academic, indicating that most have accepted the existence of dual tracks. The manpower requirements remain uncertain among our respondents; more than half of MFM subspecialists believe that there is not a need for an increase in the present number of MFM subspecialists, and there was no difference between academics and non-academics. In the previous surveys, job satisfaction averaged 7.2 on a 10-point scale. In the current survey, the job satisfaction similarly averaged 7.4. It is somewhat surprising that despite all of the changes that have occurred in the specialty and in the health care system as a whole, subspecialists in MFM appear to have maintained the same positive attitude toward their work and their specialty! REFERENCES
1. D’Alton ME, Poole S, Rinehart RD. Society of Perinatal Obstetricians: the first two decades. Washington (DC): Society of Perinatal Obstetricians; 1997. p. 2. 2. Lorenz RP, Sokol RJ, Chik L. Survey of maternal-fetal medicine subsubspecialists: professional activities, job setting, and satisfaction. Obstet Gynecol 1989;74:962-6. 3. Lorenz RP, Sokol RJ, Chik L. Survey of maternal-fetal medicine subsubspecialists: professional activities, job setting, satisfaction, and trends over time. J Matern Fetal Med 1998;7:273-6. 4. SPO Newsletter, November 1996, Volume 14, No. 2. Available from: URL:http://www.smfm.org/Core/Def.html. 5. US Department of Commerce Bureau of the Census. Statistical abstract of the United States—the national data book. Washington (DC): US Government Printing Office; 1998. 6. American Hospital Association. Hospital statistics. 1999 ed. Chicago: Health Forum; 1999. 7. ACOG Division of Fellowship Activities. Profile of ob-gyn practice, 1991-1998. Washington (DC): American College of Obstetricians and Gynecologists; November 2000.
Appendix The Specialty of Maternal Fetal Medicine: Society of Perinatal Obstetricians. Special skills and resources are often required to best enhance the outcome of pregnancy for both mother and fetus. A maternal-fetal medicine spe-
November 2001 Am J Obstet Gynecol
cialist is an obstetrician-gynecologist who has received years of additional education, practical experience, and certification in various obstetrical, medical, and surgical complications of pregnancy. By virtue of this training and technical proficiency, he or she provides care or consultation for both mother and fetus in the complicated pregnancy. Ongoing competency is maintained only by seeing a critical volume of such patients on a regular basis. In addition, he or she provides the obstetrical health care team with an awareness of the most recent approaches to the diagnosis and treatment of obstetric problems along with diagnostic and therapeutic techniques for optimal management of these complicated pregnancies. The discipline of maternal-fetal medicine involves the 4 major subgroups of patients: A. Patients undergoing diagnostic or therapeutic procedures: 1. Abdominal cerclage 2. Chorionic villus sampling 3. Comprehensive sonography 4. Fetal gene therapy 5. Fetal blood sampling 6. Fetal transfusion 7. Fetal muscle/organ biopsy 8. Fetal reduction 9. Fetal skin sampling 10. Fetoscopy/embryoscopy 11. Genetic amniocentesis 12. Other diagnostic/therapeutic procedures B. Patients with medical and surgical disorders: 1. Antiphosphoipid antibodies 2. Cardiac disease (Clark’s Group II, III, any valve replacement) 3. Chronic renal disease 4. Chronic hypertension 5. Central nervous system disease – Seizure disorders – Multiple sclerosis – Arteriovenous malformation – Berry aneurysm – Prolactinoma – Pseudotumor cerebri 6. Systemic lupus erythematosus/other collagen vascular disease 7. Congenital disorders with potential untoward outcomes – Cystic fibrosis – Marfan syndrome – Protein S, C, AT-III deficiency 8. Endocrinologic disorders – Addison’s disease – Diabetes, insulin-requiring/dependent – Thyroid disease – Parathyroid disease – Pheochromocytoma
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9. Gastrointestinal disease – Hepatitis – Acute fatty liver of pregnancy – Portal hypertension – Hyperemesis, unresponsive to conservative therapy – Ulcerative colitis – Crohn’s disease – Cholecystitis/cholelithiasis – Pancreatitis 10. Sickle cell disease/other hemoglobinopathies 11. Thromboembolic disease, past or current 12. Alloimmune and autoimmune thrombocytopenia 13. Infectious diseases – Human immunodeficiency virus – Cytomegalovirus – Toxoplasmosis – Rubella – Parovirus – Varicella – Herpes (primary) – Septicemia – Coccidiomycosis – Any life-threatening infection 14. Maternal malignant disease 15. Myasthenia gravis 16. Paraplegia/quadriplegia 17. Pulmonary hypertension 18. Eating disorders 19. Restrictive lung disease 20. Severe preeclampsia/eclampsia HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome 21. Asthma requiring frequent medications 22. Substance abuse 23. Thrombotic thrombocytopenia purpura/hemolytic uremic syndrome 24. Transplants
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C. Healthy pregnant women with fetuses at markedly increased risk for adverse outcome: 1. Abdominal pregnancy 2. Abnormal maternal serum test results 3. Fetal hydrops: immune, nonimmune 4. Fetal anomaly or cytogenetic abnormality 5. Fetal supraventricular tachycardia or congenital heart block 6. Incompetent cervix 7. Isoimmunization 8. Muellerian anomalies 9. Multifetal pregnancies (twins or greater) 10. Recurrent prior preterm deliveries (≥2) 11. Nonobstetric abdominal surgery in the current pregnancy 12. Oligohydramnios at <37 weeks’ gestation 13. Placenta accreta, increta, percreta 14. Polyhydramnios 15. Premature rupture of membranes (<34 weeks’ gestation) 16. Preterm labor (<34 weeks’ gestation) 17. Prior second-trimester fetal loss 18. Prior intrauterine fetal demise 19. Recurrent pregnancy loss 20. Significant second- or third-trimester bleeding 21. Suspected intrauterine growth retardation 22. Twin-to-twin transfusion syndrome D. Any antepartum patient admitted for a reason “other than delivery” and patients with postpartum complications such as severe hemorrhage, refractory infections, complicated preeclampsia, eclampsia, or difficult complications after cesarean delivery. The maternal-fetal medicine specialist may provide consultation, co-management, or direct care for any of these conditions or any other conditions in obstetrics, including preconceptual counseling. The relationship with the maternal-fetal medicine specialist will depend on acuity of the condition and local circumstances.