Drug use during pregnancy and lactation.

This article reviews the basic principles of pharmacology and teratogenicity of drugs for the pregnant and lactating woman and summarizes the Food and Drug Administration, American College of Obstetrics and Gynecology, and American Academy of Pediatrics classifications. These categories were devised for caregivers of both women and their babies. The authors propose a two/three letter category system to assist those who, like family physicians, must care for women while pregnant and while lactating. Common problems from everyday practice are reviewed, with an emphasis on the important drugs to use and avoid in a wide variety of everyday clinical settings to help the busy primary care physician in making decisions about medications in pregnancy and lactation.

Keeping normal labor normal.

Labor and delivery have been viewed by physicians as processes that can and must be managed by physicians for their pregnant patients. This article asserts that most births do not need to be interventionally managed and that a birth attendant's highest order skill is knowing when and how not to intervene. Further, the article looks at what birth interventions are likely to keep normal labor normal. The authors propose a new paradigm: The 10 "P's" of keeping normal labor normal.

Postfertilization effects of oral contraceptives and their relationship to informed consent.

The primary mechanism of oral contraceptives is to inhibit ovulation, but this mechanism is not always operative. When breakthrough ovulation occurs, then secondary mechanisms operate to prevent clinically recognized pregnancy. These secondary mechanisms may occur either before or after fertilization. Postfertilization effects would be problematic for some patients, who may desire information about this possibility. This article evaluates the available evidence for the postfertilization effects of oral contraceptives and concludes that good evidence exists to support the hypothesis that the effectiveness of oral contraceptives depends to some degree on postfertilization effects. However, there are insufficient data to quantitate the relative contribution of postfertilization effects. Despite the lack of quantitative data, the principles of informed consent suggest that patients who may object to any postfertilization loss should be made aware of this information so that they can give fully informed consent for the use of oral contraceptives.

SOAP to SNOCAMP: improving the medical record format.

Not since the development of the SOAP note in the problem-oriented medical record has there been a significant need to alter the format of medical record documentation. With the intrusion of third-party audits, malpractice attorney subpoenas, medical guidelines, and reimbursement code criteria into the practice of medicine, there is a need to expand the traditional SOAP note. This article proposes a new acronym, "SNOCAMP," for medical record documentation. SNOCAMP retains the SOAP format, which includes subjective, objective, assessment, and plan of treatment, with the addition of nature of the presenting complaint, counseling, and medical decision-making. It is hoped that this new, more explicit format will prove successful in meeting the divergent needs of practicing physicians, the patients they serve, and the inquiring minds that look over their shoulders.

Relation of infant mortality to the availability of maternity care in rural Florida.

BACKGROUND: This cross-sectional study was designed to explore the impact of the availability of maternity care services on the infant mortality rates in nonmetropolitan (rural) counties in Florida. METHODS: We evaluated the sufficiency of physicians providing maternity care in each rural county. We then constructed a mathematical model to compare physician availability with the infant mortality rates for each county, while controlling for socioeconomic variables. RESULTS: Thirty-one family physicians and 974 obstetrician-gynecologists were delivering babies in Florida in 1991. Forty-seven counties were lacking in maternity care services; 45 of these counties had family physicians who practiced in the county but did not provide maternity care services. There was a negative correlation in rural counties between availability of maternity care services and infant mortality (R = -0.42, R2 = 0.176, P = 0.012), implying that 17.6 percent of the variation in rural Florida's infant mortality was explained by a ranking in physician availability. Multivariate analysis revealed that increasing infant death rates can be predicted by decreasing physician availability (P = 0.003). A multiplicative risk model developed for this study demonstrated that the loss of 1 family physician delivering babies would predict the increase of infant mortality by 2.3 percent, and the loss of 1 obstetrician-gynecologist increased infant mortality by 9.6 percent. CONCLUSIONS: Access to maternity care for women in rural Florida is a problem that could be hampering Florida's ability to reduce its infant mortality rate. Family physicians appear to be the most geographically distributed health care providers in Florida; therefore, strategies should be developed to recruit Florida's rural family physicians into maternity care.

Maternity care in family medicine: economics and malpractice.

BACKGROUND: The number of family physicians delivering babies in Florida in 1991 was at an all-time low. Concerns about malpractice risk and insurance costs have resulted in only 2% of Florida's family practice residency graduates choosing to deliver babies. The purpose of this study was to compare the practices of family physicians in Florida who delivered babies in private practice (termed the "OB group") with those who did not (the "non-OB group"). METHODS: A potential study group of 293 family physicians was mailed an extensive survey that explored 132 variables related to medical practice economics and demographics, lifestyle and satisfactions, and malpractice costs and risks. RESULTS: The obstetrical (OB) group was significantly more likely than the non-OB group to perform a variety of procedures and report more patients under age 6 years (15% vs 5%; P = .003) and fewer patients 65 years or older (19% vs 33%; P < .001). Even though the number of patients seen and the number of hours worked were similar, the 1991 incomes were much higher for those practicing maternity care (mean = $164,000 vs $104,000; P = .04). Compared with the non-OB group, the OB group was more likely to report that their financial and psychological compensation was adequate (P < .001), would be more likely to choose medicine as a profession again (94% vs 60%, P < .05), paid more for malpractice insurance (mean = $22,000 vs $11,000; P = .01), and reported 30% fewer nonobstetrical malpractice claims. CONCLUSIONS: Family physicians in Florida who deliver babies, as compared with those who do not, are more likely to report (1) increased financial and psychological satisfaction for the same hours worked; (2) increased satisfaction with medicine and family practice; (3) more frequent performance of a wider range of procedures; (4) younger practices serving a greater number of complete families and fewer Medicare patients; (5) a more diverse and comprehensive hospital and office practice; and, despite paying significantly higher malpractice insurance premiums, (6) few obstetrical malpractice claims and lawsuits, and (7) fewer nonobstetrical malpractice claims and lawsuits.

Family practice maternity care in America: ruminations on reproducing an endangered species--family physicians who deliver babies.

BACKGROUND: The majority of family physicians do not deliver babies. One reason might be the family physician's intrinsic comfort with person- or patient-centered care compared with the common obstetric approach of disease or physician-centered maternity care. Another reason might be the uncritical intrusion of technology into maternity care. In addition, family physicians often are made to feel unwelcome in many maternity care systems. METHODS: The medical literature from 1984 to 1994 was searched for the topics of obstetrics, maternity care, family-centered birthing, and family practice education. Reasons to argue whether family physicians should provide maternity care were selected, and articles were chosen that described the self-reported reasons students, residents, or physicians give whether to provide maternity care. RESULTS AND CONCLUSIONS: There is no scientifically supportable reason for excluding family physicians from maternity care in any setting, and the current maternity care system, in many locations, creates an attitude of taught helplessness among family physicians. In addition, family practice educators must for a variety of reasons be the primary role models and teachers of family-centered birthing for family practice learners. Generally, the groups that should be involved in providing maternity care in the future should include (1) better informed and more independent pregnant patients, (2) maternity care nurses, (3) doulas, (4) midwives, (5) family physicians, and (6) specialized physicians. Specifically, family physicians and midwives have a historic and philosophic similarity that would argue for a much closer working and practicing relationship between these two professionals. Family-centered birthing provides excellent outcomes. Birthing is both foundational and intrinsic to family practice. Conversely, without family physicians maternity care in America might not be able to reach its full potential.

Coding and reimbursement for gastrointestinal endoscopic procedures in primary care.

Endoscopic diagnostic procedures have become part of the comprehensive care provided by many primary care physicians, and when these physicians interact with third-party payers, they must correctly report the endoscopic services they have provided. Included in this review are commonly used upper and lower gastrointestinal endoscopic procedure codes; corresponding reimbursement values from one state's Medicare and Medicaid program; lists of diagnosis codes used in reporting upper and lower endoscopy services; and instructions for reporting visits and intravenous anesthesia associated with endoscopy procedures.

Pregnancy care liability misperceptions among medical students in Florida.

BACKGROUND: Previous studies have demonstrated a professional liability insurance (PLI) fee misperception among medical students that had a direct influence on their subsequent decision making concerning the provision of pregnancy care (PC) in family practice (FP). In Florida, the paucity of family physicians providing PC and prenatal services led to the present study, which was designed to survey those senior medical students in Florida who were interested in FP to determine their opinions regarding pregnancy care-related liability issues. METHODS: All fourth-year medical students in the three allopathic medical schools in Florida who were members of a family practice interest group (FPIG) were mailed a short questionnaire by an independent researcher. The questionnaire asked students about a) whether they planned to deliver babies in practice, b) the cost of first-year liability insurance, and c) the risk of being sued if they provided PC in family practice. RESULTS: Fifty-one medical students (64% of the FPIG members in Florida) provided responses to the mail survey. Of the 51 respondents, 57% plan to enter FP residencies, and 31% were either somewhat likely or very likely to provide PC in FP. Those unlikely to do PC listed PLI cost and risk as their primary concerns. A comparison of medical students planning to provide PC with those not planning to provide PC services revealed average estimates of PLI premiums that were discordant by $5,000 per year. Furthermore, estimates in both groups exceeded the actual first-year rates of PLI insurance by more than $20,000 per year. Ninety percent of the students estimated that the actual risk of being sued for malpractice while providing PC was "high." Students' perceptions of PC PLI cost, and risk of being sued, were learned primarily from sources outside of the medical school. CONCLUSIONS: This study suggests a problem in the medical education of FP-bound students that allows students to develop misperceptions about the liability cost and risk of providing PC in FP.