GP-obstetrician: a threatened, undervalued species

A RECENT news article is reflective of a disturbing trend in obstetric models of care in an increasing number of Australia’s regional centres.

Since specialist obstetricians and gynaecologists have been employed and treated as department leaders in regional hospitals, the value of GP-obstetricians (GPOs) has been progressively downplayed, their services underutilised, or their contracts cancelled altogether. This has, at least in part, lead to a range of service delivery complexities, a breakdown in continuity of care and a rising level of dissatisfaction among women accessing maternity services, especially in public hospitals.

The fragmentation of care then occurs by default, without a consistent lead care provider. This has great potential to result in splintered care of reduced quality and sometimes quantity, the opposite to what pregnant women need at this unique time in their lives.

This is not an attack on or criticism of obstetricians and gynaecologists. Regional Australia is serviced by well qualified, specialist obstetricians and gynaecologists who have been through excellent training programs both locally and internationally. They make a massive contribution to regional obstetrics and the general and medical community. Furthermore, those working in the private system establish much the same, albeit shorter term, relationships with their patients when continuity of care is maintained. We cannot do without them any more than we can do without GPOs.

However, their employment in regional centres should not be seen as a replacement for, or even as the supervisor of, the incumbent GPO. Rather, they should be seen as a valuable addition to the staff armamentarium of that local health service.

Medical administrators and various College spokespeople will claim patient safety as being their primary motivation and concern. However, maternity outcomes in regional Australia have not seen any appreciable improvement since staff specialists have been employed in regional centres. In fact, if my patients are any indication, the impact on patient satisfaction is increasingly negative, almost certainly due to the reduction in continuity of care that often results. Moreover, when one takes into consideration the known sequelae of this reduction in continuity, including higher patient morbidity, it is surprising that various aspects of pregnant women’s health care are often overlooked.

The long term relationship established between GPOs and the pregnant women they care for, often begin long before the pregnancy. Can that be matched by the multitude of faces seen by one woman throughout her pregnancy?

As more complications arise in each woman’s pregnancy, the more fragmented the care becomes and the scarcer the opportunity for input from their GPO, who is the one who knows the patient best and is therefore most likely to have a comprehensive and wholistic view, with the ability to individualise the patient’s care. The primary care provider, in my opinion, should be treated just as the dictionary states its meaning to be – “first in rank”, “first in order”, “first in time” – and kept well and truly included in the patient’s health journey.

It seems to me that the term “multidisciplinary care” has become a catchphrase too often used to defend the whittling away of skill sets that have been synonymous with multispecialty medical practitioners, be they traditional GP proceduralists or specialists. These multispecialty doctors have been the backbone of rural and regional health care systems for decades. In my opinion, the fragmentation of care that occurs from their deskilling promotes a culture in which medicine is practised in silos, communication between care providers is reduced or eliminated, and the skill level of individual practitioners is either narrowed or nullified.

We must convince our health administrators of the inherent value of GPOs, both clinical and financial. In InSight+ on 16 April 2018, Dr Wendy Burton wrote the following:

Pre-conception, maternity, neonatal and early childhood care are critical foundation blocks in the health of our country, and having a well informed, well connected and skilled GP workforce is an essential component of the maternity team. Fifty-one per cent of pregnancies are unplanned. Eighty-nine per cent of Australian women visited a GP in the past 12 months. Maternity care falls naturally into the community GP sector; it is very much a core component of what general practice does. Clinical resources and ongoing education need to be a priority for all working in maternity care as well as improving communication pathways and interprofessional relationships.

Regardless of our individual role in the system, those of us that work in health must open our minds to what is most likely to benefit the most people, most often. We must encourage unity, collaboration and consultation and avoid the temptation to design contracts around ever-narrowing scope of practice guidelines that attempt to account for every possible clinical scenario at the expense of care continuity and service delivery. This is just the type of medicine we should avoid practising in the pursuit of quality and sustainable rural and regional maternity services.

GPOs throughout Australia and those who can see value in their service need to sit up and take notice of the insidious whittling away of our role in the medical landscape. I believe that no other profession or medical specialty has made such a unique, wholistic or integral contribution to maternity services in Australia’s history. We must not let bureaucratic nonsense nor the negative medico-political influences affecting various health services interfere with the quality, continuous, pre-conception to post-natal care that only GP-obstetricians can provide.

Carl Henman is a GP-obstetrician (FRACGP DRANZCOG Adv.) and  obstetrician sonologist (DDU OG) from Wagga Wagga, NSW. He is joint owner and director of Riverina Family Medicine, visiting medical officer at Wagga Base Hospital and conjoint lecturer in the Women’s Health faculty at UNSW’s Rural Clinical School.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.