The ACOG Disconnect: Confessions of an OB/GYN Physician

In May of this year, I attended the Annual Clinical Meeting for ACOG. While there was a wealth of information and innovation shared at the meeting, the conference was missing critical content: collaborative care.

Not one lecture on best practices in collaborative care.

We are facing a physician shortage of great proportions in this country over the next decade and collaborative care is the most patient-centric approach to addressing this crisis. Why aren’t we sharing best practices to overcome that hurdle?

The theme of the conference was “teaming up” for women’s health. I was soooo excited as I thought, “this is it! They are finally going to show us OBGs how important the midwives and NPs are as part of our team!”

But, other than a fairly nasty debate between ACNM president, Ginger Breedlove, and an anti-birthcenter doctor about the benefits of in-hospital vs out-of-hospital birth, Midwifery was nowhere to be found. While some NPs and CNMs showed their faces and attended the scientific lecture series, we never got down and dirty, teasing out the true strengths and weaknesses of our practices. We never had an opportunity to share how a sum of our parts will be the safest way to care for our patients into the future.

Now, I do know we are making progress at the very highest levels. While Ginger was present at the ACOG conference, word on the street is that the ACOG president himself was present at the national ACNM conference.

But why stop there? Shouldn’t we be collaborating more at the conference level?

My midwife director and I debated this issue. She shared with me that physicians had been invited to the recent ACNM conference to discuss collaborative care models (MD-CNM team-based care). We chuckled a bit as we reminisced over the journey we have taken over the past 18 months in our system. We launched midwifery at three hospitals and hired 15 midwives. We created a new compensation model that incentivizes the doctors to support the midwifery model of care and incentivizes the midwives to want to help support the doctors. The current global reimbursement system for professional services in obstetric care does not support teamwork or collaboration and rather pits providers against each other. We decided to work around this reimbursement model and internally created a system that was fair, equitable and supported the desired behaviors of teamwork.

The physicians I work with in our collaborative care practice are extremely productive and highly skilled. The midwives and ARNPs push the docs to their highest levels of licensure. The providers, both CNM and MD, exude confidence in their skills. I am blessed to be part of the team.

But, more than recruitment of midwives and compensation to produce desired behaviors; there is culture change that must occur in order to maximize the benefits of collaborative care in both patient experience and patient safety. Unraveling a culture of very MD-centric maternity care takes education, patience and bravery. But, we keep at it because we believe in the model of care and we believe it is the best thing for our patients.

I’ve worked with midwives for my entire obstetrical career. In fact, my intern year of residency I learned vaginal deliveries with midwives. My first year in my current job, I was thrown into a practice in which I backed-up two midwife call groups. Whenever I was called for a delivery it was either operative, cesarean or a really bad laceration. Never a boring day. A normal, run-of-the-mill routine vaginal delivery was a scarcity for me. But, I learned that midwives were so much better at labor sitting, labor coaching, and labor tinkering than I was. I came to appreciate that our strengths were different. I was raised by midwives and I am a better OB for it.

Patients are becoming more and more connected via social media. Movements such as ICAN, Birth Without Fear, VBAC Support Group and websites such as with millions of followers are SCREAMING for an optimal maternity experience. Are you paying attention to the maternity experience explosion on social media, ACOG? 

Patients are seeking out midwives and out-of-hospital birth experiences. This movement is growing exponentially. Physicians have a responsibility to lead and connect with ALL of our obstetrical community. Only then can we hold each other accountable to the standard of care.

We need to teach physicians how to work and function in collaborative care models. Many of them don’t know how to do it and as a result, groups are pitted against each other in competition. Communication and clinical accountability suffers due to the dysfunction and the ultimately, the patient suffers.

So I challenge ACOG to take the lead. Invite the midwives to the table. Learn from the physicians and health care organizations that have developed successful collaborative care models. Teach our docs to work in this new world of team health. Help us empower our obstetrical communities to work together as a team in providing the safest, patient-centered care for women.

12 thoughts on “The ACOG Disconnect: Confessions of an OB/GYN Physician

  1. You write so well about the strengths each type of provider brings to the care of women. But I encourage you to say “I collaborated with two midwife call groups” rather than “I backed up…” Words are powerful and your statement would shift the discourse more to equality.


    1. Thank you, though I would have to respectfully disagree. I think I learned the term “back-up” from the midwives and this is typically the nomenclature used to describe the relationship we have on our team. While I fully and completely support midwifery, we are different providers with different training and licensure. We must also be cognizant and sensitive to the fact that APC providers are not able to be fully independent licensed practitioners in many states in the US. This places responsibility on the physician for the care provided by an APC for which they “supervise”. I hate to use that term as well, but it is the reality of the situation we live in now. This is a very sensitive and scary issue for many physicians and unraveling that fear and engaging them in a culture of trust will take time and leadership. But, I do see the tide shifting and am hopeful for the future.


  2. Your practice sounds like a great example.
    Beyond speaking at each other’s conferences…
    tune into the archives of the Diane Rehm Show to listed to her interview with GW physicians, Tina Johnson, CNM, Director of Clinical Policy at ACNM, and Mairi Rothman, CNM, co-founder & co-director of MAMAS, a home birth practice in Maryland.
    Also — look for a showing of The Mama Sherpas, a film by Brigid Maher (American University) showcasing 4 collaborative practice models (and many beautiful births).


  3. I love this post! Is there any way an inspired CNM could see this model for reimbursing based on collaborative practice?! We talk about doing this all the time, but no one has had the time or business savvy to make it a reality.


  4. Great blog. I didn’t realize that the OBGYN/CNM battle was as acrimonious as the Anesthesiologist/CRNA one. In both cases, it sounds to me like it is the leaders on both sides that have the objections. At the clinical level many doctor/nurse/CNM/CRNA collaborations work very well. I completely agree – CRNAs (or CNMs) can and want to do the routine cases. They do them well. Doctors should be around to use their training appropriately – for the medically hard stuff.


    1. Thanks for your comment. I think it also depends on the clinical environment. In military and Kaiser-type healthcare settings, collaborative care is a fairly normal occurrence, but it is the fee-for-service world where things tend to change. I have observed a lot of resistance from the anesthesia groups regarding CRNA for financial/competition reasons and for concern over liability. It’s a tough nut to crack. I think the payers and government could do a better job of encouraging these types of relationships.

      I’m not advocating that all healthcare become more like the military or Kaiser either, those orgs have their own set of unique problems as well 🙂


  5. I am reading this (procrastinating working on ERAS for obgyn residency) and while it’s disappointing to hear about the lack of collaboration at the level of ACOG, it’s nice to read about a real world model, especially having recently experienced it myself. I was a patient in a midwife practice for my first, but a frank breech and failed ECV later, ended up getting sectioned by a wonderful MD. The combination of being cared for by a MD and a midwife was so ideal and I hope I can find a similar practice model from the practitioner side in the future.


    1. So glad to hear about your positive birth experience and I wish you the best on your residency match. Be sure to look us up on your job search if you want a strong collaborative practice to work in. WE are always looking for good docs that embrace that model of care!


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