Wing, Deborah A. MD; Quilligan, Edward J. MD
The subspecialty of maternal–fetal medicine is 35 years old. It was organized by the American Board of Obstetrics and Gynecology in 1972, and the first certification examination was given in 1973. According to the inaugural bulletin, the primary objectives of the subspecialty were to “improve the health care of mother and fetus suffering from diseases peculiar to or related to gestation, by elevating standard of education and training relating to abnormal obstetrics; by enhancing the recruitment of qualified physicians to this field; by improving the organization and distribution of patient care; and by increasing knowledge, thereby improving the treatment of women with pregnancy disorders” (American Board of Obstetrics and Gynecology Bulletin, 1973). Since the inception of maternal–fetal medicine, there have been marked changes in knowledge and advancements in clinical care. There have been concomitant changes in the conduct of fellowship training over time. For example, in 1998, the Division of Maternal–Fetal Medicine increased its fellowship to 3 years (American Board of Obstetrics and Gynecology Bulletin, 1998).
There have been several published reports on surveys of maternal–fetal medicine specialists. The first survey, taken in 1986 and published in 1989 by Lorenz et al,1 showed that the majority of maternal–fetal medicine specialists reported their primary activity was subspecialty care and that they had a high degree of job satisfaction. A survey by the same researchers taken in 1993 and published in 19982 reported the increasing importance of ultrasonography in maternal–fetal medicine practice. In 1998, Coustan et al conducted a survey to evaluate the distribution, practice, and attitudes of maternal–fetal medicine specialists. The response rate of the Coustan survey, published in 2001,3 was 58%, which was the same response reported by Lorenz in 1998 for the 1993 survey.2 Coustan et al found that 94% of 847 respondents delivered babies and that 87% performed targeted ultrasound examinations. The percentage of female practitioners was 25% and 28% in the two most recent surveys, whereas the percentage in academic positions increased from 53% (372/1,352) in the 1993 survey (reported in 1998)2 to 69% (567/1,461) in the 1998 survey (reported in 2001).3 The time spent in clinical care increased for the respondents between the two surveys from 57% to 64%, and the time spent in research decreased from 18% to 10%. The job satisfaction was high in both recent surveys.
An internal review in 2005 of our own training program, in which we questioned our current and prior trainees regarding their satisfaction with our training program, led us to ask several questions regarding the adequacy of training provided and its translation to practice after training. We felt it necessary to have more information from a wider audience and thus developed a questionnaire that was emailed to all members of the Society for Maternal–Fetal Medicine to estimate the current scope of practice and to evaluate the training experience of maternal–fetal medicine specialists in the United States.
MATERIALS AND METHODS
Institutional review board approval for this survey was obtained from the University of California, Irvine. Working in collaboration with the Society for Maternal–Fetal Medicine, 1,764 members of the society were contacted by email to complete a 16- question survey available to them through a hyperlink. A total of 1,636 members were able to be contacted by email. For those without email addresses or whose email addresses were not functional (n=128), surveys were mailed through the United States Postal Service with self-addressed return envelopes included to promote response.
An Internet-based survey administration tool known as Survey Monkey (www.surveymonkey.com) was used to host the anonymous survey. Society members were contacted by email to complete the 16-question survey beginning on July 5, 2007. Weekly reminders were issued for 3 weeks to increase the response rate, and the survey was closed on July 31, 2007. The initial response in the first week was 583 (33.0%), the second week captured an additional 21 responses, totaling 604 (34.2%), and the final week recruited an additional 28. We received 11 mail-in responses; these responses were hand-entered into the Internet-based survey tool and then aggregated with the others.
The survey included 16 questions regarding age, gender, duration of fellowship training, time spent in aspects of fellowship training, satisfaction with aspects of fellowship training, current scope of practice, and number of peer-reviewed and non–peer-reviewed articles published. The survey contained continuous, ordinal, and categorical scale questions. The data were analyzed using analysis of variance, χ2, Wilcoxon rank sum, Kruskall-Wallis tests, and regression analyses where appropriate. We stratified our results based on gender, size of practice (based on number of maternal–fetal medicine practitioners), and type of practice affiliation (designated as university-based, university-affiliated, military, and community-based). For the purposes of presentation, we merged data for university-based and university-affiliated practices, calling this university-associated practice, and compared results with community-based practices. We also evaluated results based on size of practice group, with large groups consisting of eight or more members, small groups consisting of two to seven members, and solo practitioners.
Of 1,764 potential responses, 36.5% (n=643) were returned. The demographic characteristics of the respondents are listed in Table 1. Of participating respondents with survey completion, 411 were men (64.1%). Of the recent graduates of the 3-year training program, the proportion of men and women was approximately equal, whereas more of the graduates of the 2-year training program were men (298/423 [70.5%] compared with 125/423 [29.6%] P<.001). There were significantly more men in community-based practice compared with university-associated practice (72.3% or 122/155 compared with 61.7% or 294/475, P=.02, χ2 test). The majority of respondents were certified in both obstetrics and gynecology and maternal–fetal medicine, and the majority had been in practice more than 5 years.
Practice-profile data are presented in Table 2. The majority of respondents were in university-based or university-affiliated practices (475/630, 75.3%); this included 306 in university-based practices and 169 in university-affiliated practices. The majority of large-group practices (90.1%) were populated by full-time university appointees or those practitioners with university affiliations. The full-time university group was approximately equally divided between large and small groups (145/304 [47.7%] and 152/304 [50.0%], respectively), whereas the community-based groups were predominately small groups (99/155 or 63.9%). More of the full-time university and university-affiliated respondents had completed a 3-year training program (35.7% or 167/468) compared with community-based practitioners (24.2% or 37/153, P=.009).
The largest block of time in practice for all groups was spent in ultrasonography, with care and consultation on high-risk patients next. The community-based practice group spent less time in full care of high-risk patients and more time in consultation than did the university-associated practice group (11.8±15.1% compared with 16.6±14.2%, P<.001, Wilcoxon rank sum). All groups gave full care to low-risk patients, with the full-time university group spending significantly more time providing low-risk obstetrical care than the other two groups. Genetic counseling constituted 7.6±8.2% of time in practice for the community-based practitioners compared with 4.9±5.9% for the university-based practitioners (P<.001, Wilcoxon rank-sum test). Both groups spent approximately 5% of time in fetal procedures or therapy. As expected, the full-time university group spent more time in teaching and research. The work-week description was split evenly between those who worked 40–60 hours and those working more the 60 hours.
We attempted to evaluate scholarly activity by evaluating the number of published articles, peer-reviewed and non–peer-reviewed (Table 3). We also questioned the type of research being conducted. The number of peer-reviewed publications was small, the majority having five or fewer in 5 years, except for the university-associated group, who had greater production. Of those who reported publishing six or more manuscripts, 160/169 (94.7%) were university-associated compared with 9/169 (5.3%) who were in the community-based practice group (P<.001, χ2 test). The same was true of non–peer-reviewed publications. The type of research being performed was primarily clinical, with very few involved in basic or laboratory research. We evaluated the scholarly activity of those with a 2-year training period compared with those with a 3-year period. There was a significant difference in the numbers of articles written based on duration of training: within the previous 5 years, for the graduates of 2-year training programs, 127/419 (30.3%) wrote no articles, 174/419 (41.5%) wrote one to five articles, 48/419 (11.5%) wrote six to 10 articles, and 70/419 (16.7%) wrote more than 10 articles compared with 30/205 (14.6%), 126/205 (61.5%), 26/205 (12.7%), and 23/205 (11.2%), respectively, for the graduates of 3-year training programs (P<.001, χ2 test).
The majority in all groups were involved in teaching medical students and residents at some level, although teaching was substantially less in community-based practice groups compared with university-associated groups. The university-associated group had statistically greater fellow, resident, and medical student exposure compared with the community-based group overall.
We examined assessments by the respondents of training adequacy and time allocation (Table 4). The vast majority felt satisfied with training in high-risk pregnancy management. The percentage, although high, was not as great in genetic counseling and ultrasonography. It fell somewhat lower in fetal therapy and research tools and lowest in practice management. This mirrored the amount of time spent in training in each of these areas. The highest satisfaction with training was in high-risk pregnancy and the lowest was in practice management. There were statistically significant relationships using logistic regression between satisfaction with various aspects of maternal–fetal medicine training and current time allocation in practice for those same aspects (P<.001) with the exception of total high-risk pregnancy care. Interestingly, the reported amount of time spent in research and its training was less than 50%.
The fundamental question raised by the review of our own program was, “Are we training maternal–fetal medicine specialists for what they will eventually do in practice?” A single survey with a 36% response rate cannot definitively answer that question, but it may point in directions for further consideration.
The subspecialty continues to evolve. Since Coustan et al’s report in 2001, we found that contemporary practice incorporates more ambulatory care than hospital-based care and that fewer maternal–fetal medicine specialists are engaged in total obstetrical care. This conversion to outpatient-based care reflects added and expanded use of ultrasonography for prenatal diagnosis and provision of consultative services.
By and large, training programs rate highly in satisfaction with training for high-risk pregnancy management and ultrasonography but lower for research, genetic counseling, invasive procedures, and fetal therapy. The lowest rated aspect of fellowship education was practice management and administration. Despite the increasing role of human genetics in maternal–fetal medicine, we were surprised to find that only 67% (430/643) of all respondents felt they had been adequately trained in genetics.
Another area in which the satisfaction was somewhat lower was ultrasonography. Although our questionnaire did not delve into the specifics for the dissatisfaction, we can speculate somewhat. In our opinion, the perfect situation is of one-on-one instruction so that the initial stage of fellow ultrasound training would be constant, direct supervision and then eventual independence with frequent consultation with faculty members and ultrasonographers. The first stage of intense, immediate, and direct faculty involvement is a difficult paradigm to obtain in today’s work environment, where concerns for clinical productivity are also paramount. Awareness of this pressure and other reasons may make some fellows reluctant to interrupt their instructors with questions or to ask for feedback, whereas others may be less reticent. This may account for some of the disparity in the satisfaction of the respondents with their ultrasound training.
Fewer individuals are remaining in traditional academic medicine settings after completion of their fellowships than in times past. Our survey revealed that 306/630 (49%) respondents were in full-time academic positions; this differs from the 53% in Lorenz’ 1993 survey (published in 1998)2 and the 69% reported in Coustan’s 1998 survey (published in 2001).3 Undoubtedly this reflects increasing market demand in the community sector for maternal–fetal medicine specialists, but it brings to light the question about the protected time for research set forth in fellowship training programs. The reports of percentage of time spent in research is less than the 50% required by the American Board of Obstetrics and Gynecology; responses may reflect varying interpretations of the survey question, such that some respondents perceived this to apply only to didactic time spent on research tools and techniques rather than total time dedicated to all research endeavors. We can only wonder whether the extension of maternal–fetal medicine fellowships to 3 years in duration has improved the understanding and appreciation for research of our trainees.4 Our survey could not measure the effect of added time for research on improvements in ability to read and interpret the literature or to incorporate new discoveries in genetics, epigenetics, genetic epidemiology, genomics, proteomics, and related advances into practice. The argument could be made that, without a strong background in research methodology, community-based practitioners would be hard-pressed to keep up with such advances in medical care.
We noted a statistically significant increase in the number of individuals publishing peer-reviewed articles based on duration of training (P<.001, χ2 test). This observation is in accord with that made by Sciscione in 2004.5 Whether or not this metric of peer-reviewed publications of respondents who underwent a 2-year training program in maternal–fetal medicine compared with those who underwent 3-year training can be used as a measure of value of the extension of training is debatable.
We acknowledge the limitations of this investigation. Our survey was not designed in such a way as to capture information regarding time spent on administrative duties. Clearly, as subspecialists, many maternal–fetal medicine practitioners have assumed administrative roles within their hospitals, departments, universities, or communities; this was an oversight that should be considered in any future survey of maternal–fetal medicine practitioners. We acknowledge as well that the possibility exists for nonresponse bias, and we speculate that, despite repeated reminders to complete the survey, many of our colleagues may simply have been too busy to respond in a timely fashion. We acknowledge that the element of time since graduation of fellowship could have confounded the results regarding number of peer-reviewed articles because we questioned the number published specifically within the previous 5 years. We unfortunately did not inquire as to other measures of scholarly productivity such as grant applications and awards and academic rank. Also, although other surveyors have queried their participants regarding job satisfaction, this was not a measure evaluated in our survey.
A key question stems from this survey: How should training programs be structured in the future? There is consensus regarding a core of experience and knowledge that every maternal–fetal medicine specialist should possess, including care of the high-risk mother, maternal and fetal physiology, ultrasonography, basic perinatal genetics, research methodology, biostatistics, and practice management. Further, there is agreement that the provision of a broad base of clinical and research experience is paramount to successful subspecialty training and that lifelong learning is an integral part of any practitioner’s experience, and certainly no training program can be regarded as “complete” because of this. Increased concentration in areas such as genetics, critical care medicine, basic science, and perinatal epidemiology may require additional years of training depending on the program. Recent approval by the American Board of Obstetrics and Gynecology and the American Board of Medical Genetics for combined training in maternal–fetal medicine and medical genetics spanning 4 to 5 years reflects such evolution. Extramural funding mechanisms, such as the Women’s Reproductive Health Research Career Development Program and Reproductive Developmental Scientist Programs, can aid in specialized research career pursuits. Flexibility and tailoring training programs to fit the needs of the candidates is the key to continuing excellence in maternal–fetal medicine.