Birth control, and family physicians’ knowledge of contraception and options counseling, are critical to caring for families. Family doctors need to be competent in providing comprehensive family planning; it is the bread and butter of primary care and preventive medicine.
Let’s get real: birth control is an issue that affects everybody. Unintended pregnancy is one of the major public health issues of our time. Almost half of all pregnancies in the United States are unintended which is one of the highest rates in the industrialized world.
But patients rely on family physicians for more than birth control. Increasingly, many patients in rural and low-income areas look to their family doctors for prenatal care, managing miscarriages, counseling about unintended pregnancies and pregnancy termination. In Oklahoma, the governor recently signed a measure, to go into effect in November 2013, that prohibits specialized family-planning clinics from receiving family-planning funds distributed by the state. The only entities that will continue receiving state funds are public facilities, hospitals, federally qualified health centers, rural health clinics and primary healthcare providers.
And yet training in this key area of clinical care is being threatened by proposed changes to family-medicine standards. The Accreditation Council for Graduate Medical Education (ACGME) suggests eliminating specific language about training in contraception and pregnancy-options counseling in its proposed residency program updates. (ACGME is the organization that sets training standards and confers accreditation for all U.S. residency training programs.)
Its rationale for proposing the changes makes sense. The council wants to cut down, as much as possible, the unwieldy family-medicine training checklist (which currently contains more than 450 items). The council members believe that residency programs should have enough flexibility and autonomy to respond to their particular communities’ health needs.
However, recent U.S. political events demonstrate why the mandated residency training in contraception and options counseling needs to stay in place.
This is best illustrated by the coverage provisions of the Affordable Care Act (ACA). The ACA increased access to contraception by requiring health insurers to offer contraception coverage without charging a co-payment. The contraception mandate is being contested by religiously affiliated companies and organizations that do not want to cover contraception in their healthcare packages.
If the legal challenge brought by these religiously affiliated organizations is successful, then all women working for those organizations will be left without any insurance coverage for contraception.
What does the ACA contraception debate have to do with the ACGME mandates? Nearly 20 percent of U.S. community hospitals are religiously affiliated, and many family-medicine residencies are too.
A number of these hospitals, especially Catholic hospitals, prohibit clinicians from prescribing birth control or providing abortions. (Four of the 10 largest healthcare systems, by hospital count, in the United States are religiously sponsored.)
Without a mandate, many of these programs will likely skip any training related to contraception. Residents could graduate from these programs without having learned anything about prescribing contraception, meaning there could be unintended increases in the numbers of unintended pregnancies and the complications that could arise from them.
This is why family planning is a basic, fundamental component of family medicine, and we cannot risk having programs opt out due to local decision-making or the politics of the day.
To try to improve healthcare access, such as through the ACA, without ensuring that clinicians are well trained and equipped to provide high-quality care would be like building new roads and highways that lead nowhere. In order to provide healthcare for Americans, it remains critical that all clinicians who provide primary care be trained in comprehensive contraceptive management and family planning.
The proposed ACGME changes will go into effect in 2014 unless the council is convinced otherwise. ACGME is currently reviewing comments on these proposed changes. It’s in all of our best interests that the council members make the right choice and maintain the requirement that family-medicine programs train new physicians in contraception and options counseling.