Attitudes toward obstetrics training - Europe PMC

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Attitudes toward obstetrics training Residents surveyed at McGill University and University of Montreal Cheryl Levitt, MB, BCH, CCFP, Nazilla Khanlou, RN, MSC, Janusz Kaczorowski, MA, Perle Feldman, MD, CCFP, Remi Guibert, MD, MSC, Francois Goulet, MD, ccFP(M), Apostolo Papageorgiou, MD, FRCPC, Claudette Bardin, MD, Ann Continelli, Eliane Duarte-Franco, MD, MPH, Ron Wilson, MD Michael C. Klein, MD, CCFP OBJECTIVE To determine family medicine residents' attitudes toward family practice training in obstetrics and neonatology before and after implementation of a modified obstetrics curriculum at McGill University (MG). DESIGN Two-group pretest and posttest. Fifty-seven respondents, 31 at MG, 26 at University of Montreal (UM), were case matched as first-year and second-year residents. SETrING Departments of Family Medicine at MG and UM. PARTICIPANTS Family medicine residents at MG and UM. INTERVENTION A modified obstetrics curriculum was introduced at MG (study group); no modifications were introduced at UM (control group). First- and second-year residents' attitudes toward the adequacy of training were assessed through responses to a questionnaire administered in July 1992 and July 1994. MAIN OUTCOME MEASURES Changes in response scores before and after implementation of the modified curriculum. RESULTS Repeated multivariate analysis of variance (MANOVA) showed respondents believed family practice obstetrics training was adequate in general, but that family practitioners were inadequately trained in emergency obstetric skills. Scores for items assessing neonatology skills increased significantly in the MG group after the intervention. CONCLUSIONS Residents' overall confidence in their obstetrics training did not appear to improve, but this might be due to a time lag between curriculum modification and attitudinal change. McGill residents' confidence in neonatology skills improved significantly after curriculum modification.

OBJECTIF Determiner, avant et apres la modification du programme de formation obstetricale a l'Universite McGill, les attitudes des residents de medecine familiale envers la formation dans les domaines de l'obstetrique et de la neonatologie. CONCEPTION Pretest et post-test soumis a deux groupes comportant un total de 57 repondants, dont 31 de l'Universite McGill et 26 de l'Universite de Montreal, qui furent apparies suivant les cas en fonction de leur premiere ou deuxieme annee de residence. CONTEXTE Les departements de medecine familiale de l'Universite McGill et de l'Universite de Montreal. PARTICIPANTS Les residents de medecine familiale de l'Universite McGill et de l'Universite de Montreal. INTERVENTION Mise en application d'un programme modifie de formation obstetricale a McGill (groupe d'etude) ; aucune modification 'a Montreal (groupe temoin). Evaluation des attitudes des residents de premiiere et de deuxieme annees face 'a la pertinence et 'a la qualite de leur formation par l'analyse de leurs reponses a un questionnaire soumis en juillet 1992 et juillet 1994. PRINCIPALES MESURES DES RESULTATS Comparaison des changements notes dans les reponses avant et apres la mise en application du programme modifie de formation. RESULTATS Une analyse multivariee et repetee de la variance (MANOVA) a revele que les repondants etaient d'avis que la formation des residents de medecine familiale etait generalement adequate dans le domaine de l'obst&trique mais que la formation des medecins de famille presentait des carences au niveau des soins obstetricaux d'urgence. Au terme du programme modifie, on a constate dans le groupe McGill une amelioration significative des indices mesurant les habiletes dans le domaine de la neonatologie. CONCLUSIONS Globalement, les residents ne semblent pas davantage confiants dans leur formation obstetricale ; ceci pourrait etre attribuable 'a un decalage chronologique entre la modification du programme de formation et l'apparition de changements dans les attitudes. Apres l'introduction du nouveau programme, la conflance des residents de l'Universite McGill s'est amelioree significativement dans le domaine de la neonatologie. Can Fam Physician 1997;43:239-246. -4-

FOR PRESCRIBING INFORMATION SEE PAGE 3A7

VOL43: FEBRUARY * FtVRIER 1997. Canadian Family Physician . Le Medecin defamille canadien 239

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Attitudes toward obstetrics training

he number of family doctors practising obstetrics in Canada has dropped markedly in the past decade. A 1988 survey, sent randomly to a stratified sample of general practitioners and family physicians in Canada, found a dramatic reduction (from 68.4% in 1983 to 46.1% in 19881) in the proportion of respondents reporting attending births. Health Canada's fee-for-service statistics indicate that the proportion of all deliveries, excluding cesarean sections, performed by physicians in general practice dropped from 52.5% in 1986-1987 to 48.6% in 1989-1990.2 A severe shortage in obstetrics manpower has been forecast, as fewer obstetricians are trained and fewer family physicians practise obstetrics.3 I

I

Dr Levitt was Chiefof the Department of Family Medicine at Sir Mortimer B. Davis (SMBD) -Jewish General Hospital and was an Assistant Professor in the Department ofFamily Medicine at McGill University in Montreal when this article was written. Ms Khanlou was a Research Associate in the Department ofFamily Medicine, SMBD Jewish General Hospital. Mr Kaczorowski was a Research Associate in the Department ofFamily Medicine, SMBD Jewish General Hospital. Dr Feldman was a family physician at the Herzl Family Practice Centre, Department ofFamily Medicine, SMBD Jewish General Hospital, and is an Assistant Professor in the Department ofFamily Medicine at McGill University. Dr Guibert is an Associate Professor and Director ofResearch in the Department ofFamily Medicine at McGill University. Dr Goulet is Program Director in the Department of Family Medicine at the Universite de Montreal. Dr Papageorgiou is Chief ofthe Department of Pediatrics, SMBD Jewish General Hospital, and is a Professor in the Department ofPediatrics at McGill University. Dr Bardin is a neonatologist in the Department of Pediatrics, SMBD Jewish General Hospital. Ms Contineili is an Assistant Education Coordinator at the Herzl Family Practice Centre, Department ofFamily Medicine, SMBD Jewish General Hospital. Dr Duarte-Franco is a Research Associate in the Department of Family Medicine at McGill University. Dr Wilson is an Assistant Professor in the Department ofFamily Medicine at the University of British Columbia in Vancouver Dr Klein, a Fellow ofthe College, is Head of the Department of Family Practice, British Columbia's Women's Hospital and Health Centre Society, and is a Professor ofFamily Practice and Pediatrics at the University of British Columbia. He is also an Adjunct Professor of Family Medicine at McGill University.

This shortage will be particularly acute in rural areas, where many women have to travel long distances and to be separated from their families when they give birth.4'5 Family physicians give up practising obstetrics for reasons such as lifestyle issues, fear of litigation,6'7 and concern that they have insufficient obstetric training.8 Studies of practising family physicians have shown, however, that those who include obstetrics in their practices are on the whole more satisfied with their working lives and less likely to be sued for obstetric cases than nonobstetric ones.9'10 A structured approach to teaching obstetric skills, such as the Advanced Life Support in Obstetrics (ALSO) course,11 appears to increase health professionals' confidence in their ability to provide emergency obstetrics.12 In one Florida study, 13% of graduating family medicine residents cited lack of training in emergency obstetric skills as their reason for not providing obstetric services.13 To improve residents' obstetric skills, we introduced a modified curriculum emphasizing emergency skills at McGill's (MG) Department of Family Medicine in 1992 and undertook a study to measure the effect of the modified curriculum. We did not address lifestyle issues but focused on residents' attitudes toward the adequacy of family practitioners' training in obstetrics and neonatology and their intentions to practise obstetrics upon graduating from the program. Because it was not feasible to measure the change in residents' competency in emergency skills directly, we used changes in their attitudes as a proxy measure for this outcome.

METHODS Study design We surveyed MG and University of Montreal (UM) family medicine residents at the beginning (pretest) and end (posttest) of residency. Responses of residents at MG were compared with responses from UM. We used a case-matched design in order to control for intrasubject variations. The casematched subjects are part of a larger ongoing cohort study involving 106 respondents (response rate 75.7%) in the first year of family medicine residency in 1992 (Rls) and 76 respondents (response rate 67.8%) completing residency in 1994 (R2s). The R2's responses were matched retrospectively to their responses as Rls. To maintain confidentiality, up to 18 demographic and practice characteristic variables were used in matching.

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Intervention The modified obstetric curriculum, introduced in 1992 at MG, consisted of changes in the structure and process of teaching obstetrics. Obstetrics and neonatology rotations were consolidated into 2 months of obstetrics and 1 month of neonatology, back to back. Obstetrics training included the ALSO course, emphasis on family physicians as role models, and modified educational objectives. These objectives divided learning tasks into three groups: conditions and situations where family physicians are expected to play a definitive role; conditions and situations where family physicians are expected to play a partial role; and conditions and situations where family physicians have a limited role.'4 Neonatal training included the Neonatal Resuscitation Program (NRP)'5 and the mandatory neonatology rotations introduced in 1990. Neonatal curriculum modifications were formalized in 1992.

Table 1. Statements on family residents' training in obstetrics and neonatology: Responses were given on a four-point Likert-type scale (1 - strongly disagree; 4 - strongly agree) GENERAL Family medicine (FM) residency training in obstetrics is adequate for practising obstetrics in regard to prenatal and postnatal care. FM residency training in obstetrics is adequate for practising obstetrics in regard to prenatal, intrapartum, and postpartum low-risk care.

Obstetrics is adequately emphasized in FM training. ..............................................................................................................

Prenatal care training is adequately provided within FM residency. ..............................................................................................................

LOW RISK

Family practitioners (FPs) receive adequate training in the use of forceps in low-risk obstetric patients. ..............................................................................................................

Measurement instrument As no applicable measurement tool for our study existed, we developed our own questionnaire. Face validity of questionnaire items was assessed by a group of medical faculty specializing in family medicine, obstetrics, and neonatology. The questionnaire was translated into French and validated by translating the French version back into English before mailing. It was then pilot tested on English- and French-speaking health sciences students for coherence of terms. In 1994, verb tenses were modified on the questionnaire to reflect respondents' status as graduating R2s. Using the Dillman method,"6 the questionnaire was sent out in four mailings with stamped, addressed, return envelopes. It was mailed to Rls in July 1992 and to R2s in May 1994. To develop and assess the internal reliability of its scales, the questionnaire was also mailed to graduating family medicine residents at MG and UM in October 1992. The self-administered questionnaire had four sections. Two gathered descriptive information on respondents' demographic and training background, a third information on respondents' intention to practise obstetrics (respondents were asked, "Do you plan to practise obstetrics after you finish family medicine residency?" Response choices were 'Yes: pre-, intra-, and postnatal care"; 'Yes: pre- and/or postnatal care"; "No: none of the above"; "Other"; "Don't know"), and a fourth section consisted of 26 items rated on a Likert scale that elicited respondents' VOL 43: FEBRUARY

FPs receive adequate training in the use of vacuum extraction in low-risk obstetric patients. ..............................................................................................................

FPs receive adequate training to deal with shoulder dystocia in low-risk births. ..............................................................................................................

FPs receive adequate training to deal with cord prolapse in low-risk births. ..............................................................................................................

FPs receive adequate training to deal with retained placenta in low-risk births. ..............................................................................................................

WITHOUT BACKUP ..............................................................................................................

FM residency training in obstetrics is adequate for

practising obstetrics without obstetric backup. ..............................................................................................................

FPs receive adequate training in use of forceps to practise without obstetric backup. ........I......................................................................................................

FPs receive adequate training in the use of vacuum extraction to practise without obstetric backup. ..............................................................................................................

FPs receive adequate training to deal with shoulder dystocia without obstetric backup. ..............................................................................................................

FPs receive adequate training to deal with cord prolapse without obstetric backup. ..............................................................................................................

FPs receive adequate training to deal with retained

placenta without obstetric backup. ..............................................................................................................

NEONATOLOGY ..............................................................................................................

Training is adequate for stabilization and transport of sick newborns. ..............................................................................................................

FPs receive adequate training to deal with flat babies (asphyxiated) born to low-risk mothers. ..............................................................................................................

FPs receive adequate training to deal with flat babies without obstetric backup. * FtvRIER 1997 +Canadian Family Physician Le Medecin defamille canadien 241

RESEARCH Attitudes toward obstetrics training

attitudes toward the adequacy of family practitioners' training in obstetrics and neonatology. From 18 of these questions, we developed four attitudinal scales: general, low risk, without backup, and neonatology (Table 1). All items were measured on a four-point scale: 1 (strongly disagree); 2 (somewhat disagree); 3 (somewhat agree); and 4 (strongly agree). Scores above 2.5 indicated agreement; scores below 2.5 indicated disagreement with the item. "Don't know" was also a response choice for each item.

Statistical analyses Statistical significance for categorical data was determined using x2 tests. Applying the repeated measures design, multivariate analysis of variance (MANOVA) was conducted for the Likert scale items. To determine the effect of the new curriculum on residents' attitudes toward their family medicine perinatal training, we looked at variation between subjects at the two locations (MG, UM) and variation within subjects over time (Rls, R2s). Statistical significance was determined using univariate F tests for MANOVA All P values < 0.05 were considered statistically significant. The internal consistency of the Likert scale items was determined using Cronbach's a. All statistical analyses were conducted using the SPSS (Statistical Package for the Social Sciences) software package.17

Handling "don't know" data Because many MG Rls chose "don't know" for the Likert scale items, the number of MG residents responses usable for MANOVA comparisons was lower than that of UM residents. For 16 of the 26 items, more than 50% of MG Rls chose "don't know." Fewer than 25% of UM Rls ever selected this option. To maintain statistical power, we substituted university-specific group means separately for MG Rls and UM Rls. Means were derived from the larger cohort sample of MG Rls (56 respondents) and UM Rls (50 respondents). We did this because university location was the only persistently different characteristic of those selecting "don't know" and those choosing other responses. This decision might have influenced Rl's scores in the case-matched design, but had no effect on their responses as R2s. Ethics All questionnaires were anonymous. Residents' participation in the study was voluntary.

RESULTS Of the 57 subjects successfully case matched as Rls and R2s, 31 (54%) were from MG and 26 (46%) from UM. Demographic and training background characteristics for Rls are summarized in Table 2.

Attitudes General. Residents' attitudes toward the adequacy of family medicine training in obstetrics and prenatal care were assessed using a four-item scale (Table 3). On average, residents believed their training in obstetrics in general was adequate for practising obstetrics. Respondents from UM had significantly higher scores on the General Scale (F = 7.38; df= 1, 51; P = 0.009). The four items constituting the General Scale had poor internal consistency (Cronbach's a = 0.53). This contrasted with the internal consistency on the same scale for the 1992 group of graduating family medicine residents (Cronbach's a = 0.77). Low risk. The five items in this section represent common interventions for family practitioners doing low-risk obstetrics: use of forceps, vacuum extraction, management of shoulder dystocia, management of cord prolapse, and management of retained placenta (Table 3). In general, respondents did not think family practitioners received adequate training in these skills. While UM respondents had higher average scores than MG respondents as Rls and R2s, their scores still fell below 2.5. The internal consistency of the Low-risk Scale (Cronbach's a = 0.65) was comparable to that of the 1992 graduates (Cronbach's a = 0.68).

Without backup. Six items (Table 3) assessed residents' attitudes toward the adequacy of their training in the maneuvers mentioned in the low-risk section but without obstetric backup. As Rls and R2s, MG and UM residents believed their family medicine residency training in obstetrics was inadequate for them to perform these interventions without obstetric backup. On this scale, UM respondents had significantly higher scores (F = 7.01; df = 1, 51; P = 0.011) and, over time, all residents' scores significantly decreased (F = 4.99; df = 1, 51; P = 0.030). The scale items' internal consistency (Cronbach's a = 0.79) was higher than that of the 1992 graduates (Cronbach's a = 0.69).

Neonatology. Thbree items dealt with the adequacy of neonatology training (Table 3). On this scale,

242 Canadian Family Physician . Le Medecin defamille canadien * VOL43: FEBRUARY * FVPER 1997

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Table 2. Characteristics of first-year residents CHARACTERISTIC Sex * Male * Female

MCGILL UNIVERSITY (N = 31) 14 (45.2%) 17 (54.8%)

UNIVERSITY OF MONTREL (N = 26) 8 (30.8%) 18 (69.2%)

PVALUE* 0.266

................................................................................................................................................................................................................................

Age (y)t * 23-26 * 27-29 * 3055

18 (58.1%) 6 (19.4%) 7 (22.6%)

10 (38.4%) 7 (26.9%) 9 (34.5%)

0.418

Grew up * Quebec * Other

13 (41.9%) 18 (58.1%)

23 (88.5%) 3 (11.5%)

0.033

Mother tongue * French * English * Other

6 (19.4%) 19 (61.3%) 6 (19.4%)

22 (84.6%)

0.000

0 (0.0%) 4 (15.4%)

................................................................................................................................................................................................................................

Undergraduate medical school * McGill University * University of Montreal * Other

13 (41.9%) 2 (6.5%) 16 (51.6%)

0 (0.0%)

0.000

22 (84.6%) 4 (15.4%)

................................................................................................................................................................................................................................

Undergraduate exposure to family practice obstetrics * Yes * No

18 (58.1%) 13 (41.9%)

15 (57.7%) 11 (42.3%)

0.977

*Based on X? tests; tMcGill - median age 26.0 (SD 13.3); University ofMontreal - median age 28.0 (SD 5.8).

MG respondents had significantly higher scores than UM respondents (F = 6.10; df = 1, 49; P = 0.017). There was also a significant time effect (F = 10.04; df = 1, 49; P = 0.003), with R2s having higher scores, and a significant interaction effect (F = 13.33; df = 1, 49; P = 0.001). To locate specific differences, we did further univariate tests of significance for MG and UM separately and found a significant increase among MG respondents over time (F = 28.86; df = 1, 25; P = 0.000). Neonatology Scale items had a high internal consistency, both among case-matched respondents (Cronbach's a = 0.81) and 1992 graduates (Cronbach's a = 0.88).

Practice intentions The number of residents intending to practise full obstetric care declined from 40% (22 of 55 responses) as Rls to 33% (18 of 55) as R2s. The six residents at MG (60%) and six at UM (50%) intending to practise intrapartum obstetrics as Rls remained committed to this option as R2s. The six residents at MG and five at UM not committed to practising obstetrics as Rls had not changed their minds by the time they were VOL 43: FEBRUARY *

R2s. However, of the seven Rls at MG and one at UM who initially intended to practise prenatal and postnatal care only, two at MG and one at UM anticipated providing full care by the time they were R2s.

DISCUSSION This study was undertaken to determine whether a modified curriculum in obstetrics and an established curriculum in neonatology could improve residents' confidence in the adequacy of family practitioners' training in obstetrics and neonatology. Our overall goal was to train residents to be more competent to manage obstetric emergencies. We expected that the two groups would be very similar when they began their residency in attributes such as sex, age, marital status, and interest in practising obstetrics in the future, but different in language of instruction at the different universities. In fact, MG residents came from many backgrounds and various medical schools across Canada while UM residents were a more homogeneous group. These differences, as well as the FtVRIER 1997* Canadian Family Physician . Le Medecin defamille canadien 243

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Table 3. Mean scores on attitudinal scales: Effect of location and residency year AREA

General (a = 0.53) * First-year residents (Rls) * Second-year residents

MCGILL UNIVERSITY (N = 31)

UNIVERSITY OF MONTREAL (N = 26)

EFFECT*

Locationt 2.67 2.77

3.03 3.04

............................................................................................................................................................................................................................

Low risk (a = 0.65) * Rls * R2s

1.97 1.90

2.17 2.04

................................................................................. I...............................................................................................................................................

Without backup * Rls * R2s

Location,t timel 1.64 1.58

2.0 1.73

............................................................................................................................................................................................................................

Neonatology * Rls * R2s

2.18 2.90

2.18 2.13

Location,t time,t location * timet

*Location - McGill vs University ofMontreal; time (Rls vs R2s); location . time - interaction between location and time.

tp< O.0o.

tP < 0.05.

different universities for residency training, might have led to the initially higher opinion scores among UM Rls. Yet, in general, both groups had low confidence and expectations regarding family physicians' emergency obstetric skills. Our definition of an effective curriculum is one where residents begin with an open mind about a rotation and end with increased confidence in their skills. We predicted that mean scores for the Likert items on the questionnaire would be around 2.5 for incoming residents and above 2.5 for graduating residents. In general, residents appeared to be satisfied with the training program. Scores on the General Scale's attitudinal items indicated that most residents started their programs with high scores for positive expectations and completed them with slightly higher scores. However, respondents reported a low level of confidence in the adequacy of training in common emergency skills for low-risk obstetrics and in settings without obstetric backup. This could indicate that the modified curriculum we implemented was inadequate, either because it did not address the problem of insufficient training adequately or because it is too early to evaluate the program's effectiveness (based on only one cohort of residents). In our definition of a successful rotation, the neonatology curriculum is succeeding at MG and could be a model for other universities. Residents at MG had more confidence in family physicians' training in neonatal skills at the end of the program. The

MG faculty have made extensive efforts to ensure that the neonatology rotation is relevant to residents' needs. The different curriculums at MG and UM likely are responsible for the difference in reported confidence in neonatology training found in our study. Because neonatology curriculum changes were implemented 2 years before obstetric changes, the more favourable results in neonatology might indicate more time is required to demonstrate the effects of a modified curriculum. We have found a decline over the course of family medicine residency in the number of residents intending to practise obstetrics. While this trend might reflect concern about lifestyle or malpractice issues, it could be associated with lack of confidence to manage obstetric problems. Residents not intending to practise obstetrics did not change their minds over time. These findings are similar to those in a study conducted at the University of Toronto where none of the family medicine residents who initially said they were "unlikely" to do obstetrics changed their minds at the end of their training.18 We have considered the concept of streaming residents so that all obstetrics teaching and training is directed at those most likely to practise obstetrics. However, until all efforts to promote and support obstetrics at undergraduate and postgraduate levels are exhausted, it would be premature to adopt this policy. The results of this study reassured us about how we are teaching neonatology at MG and led us to

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serc Attdstwr aii*ir Attitudes toward obstetrics training

reexamine how we are teaching obstetrics. We must consider changes in three areas. It might be important to reinforce what is taught in the ALSO course in the clinical setting; obstetricians and family physicians must clearly understand and support family medicine residents' curriculum objectives and encourage them to practise their skills (often family medicine residents are overlooked in favour of more experienced obstetric residents when obstetric intervention is required); and more time might need to elapse before changes in attitude and confidence are noted. A recent University of Toronto study found that residents with more positive attitudes to obstetrics tended to have more deliveries; more full prenatal, intrapartum, and postpartum care; and strong family medicine teacher role models.7 We acknowledge some limitations to our study. First, a disproportionate number of MG residents responded "don't know" as Rls. We applied the method of mean substitution to the "don't know" responses that we believe best uses the group-specific information of the larger cohort. Second, the study was carried out in Montreal only. Given interprovincial variations in the proportion of family physicians incorporating obstetrics into their practices,3 the generalizability of our results to family medicine residents in other provinces cannot be determined. In provinces such as Quebec and Ontario, where proportions are low, it might be that the background attitudes and beliefs of the entire system, including patient expectations and physicians' lifestyle expectations, limit the effect of any curricular intervention aimed at retaining or increasing obstetrics in family practice. Finally, caution is required when interpreting the statistically significant differences for the attitudinal items. To reduce the likelihood of finding a statistical difference by chance alone and to determine clinical differences, we did not report findings from individual items but focused on the findings from the scales. We recognize that, by measuring confidence as a proxy for competence in obstetric skills, we have used a surrogate measurement instrument that does not directly measure the acquisition of competence.

Conclusion Family medicine residents at MG and UM believe that their general obstetrics training is adequate but that family practitioners are inadequately trained in specific obstetric skills. Residents at MG are more confident in neonatology skills. This might be related to having a mandatory and well established VOL 43: FEBRUARY * F

neonatology program and indicative of a time lag between curriculum modification and attitudinal change. The findings of our study have led us to consider further changes to our obstetric curriculum. Further studies are necessary to determine the most effective approach and to establish whether the effects of such interventions are retained or increased in the long term.

Acknowledgment This study was conducted by the McGill University Universite de Montreal Perinatal Research Group, undertaken at the Department ofFamily Medicine at the SMBD Jewish General Hospital, and funded by an FMOQ seed funding grant and the Department of Family Medicine, SMBD Jewish General Hospital.

Correspondence to: Dr C. Levitt, Department of Medicine, McMaster University, 1200 Main St W, Hamilton, ON L8N3Z5

References 1. Woodward CA, Rosser W. Effect of medicolegal liability on patterns of general and family practice in Canada. Can Med Assoc J 1989;141:291-9. 2. Health Canada. Medical care data base (fee-for-service statistics). Ottawa: Health Information Division, 1995. 3. Cohen L. Looming manpower shortage has Canada's obstetricians worried. Can Med Assoc J 1991;144:478-9, 482. 4. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA Access to obstetric care in rural areas: effect on birth outcomes. Am J Public Health 1990;80(7):814-8. 5. NesbittTS, Baldwin LM. Access to obstetric care. Obstetrics 1993;20(3):509-22. 6. Bain ST, Grava-Gubins I, Edney R. The family doctor in obstetrics: who's looking after the shop? Can Fam Physician 1987;33:2693-701. 7. Reid AJ, Carroll JC. Choosing to practise obstetrics. What factors influence family practice residents? Can Fam Physician 1991;37:1859-67. 8. Buckle D. Obstetrical practice after a family medicine residency. Can Fam Physician 1994;40:261-8. 9. Thorn L. To do or not to do - obstetrics. N YState MedJ

1992;44(Fall):14-5. 10. Larimore WL, Sapolsky BS. Maternity care in family medicine: economics and malpractice.JFam Pract 1995; 40:153-60. 11. Beasley JW, Byrd JE, Damos JR, Roberts RG, Koller WS. Advanced Life Support in Obstetrics course. Am Fam

Physician 1993;47:578-80. 12. Beasley JW, Damos JR, Roberts RG, Nesbitt TS. The

Advanced Life Support in Obstetrics course. Arch Fam Med 1994;3:1037-41.

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13. Larimore WL. Attitudes of Florida family practice residents concerning obstetrics. J Fam Pract 1993;36:534-8. 14. Department of Family Medicine, McGill University. Educational objectives in preconception, prenatal, intrapartum, postpartum, neonatal, and well baby care. Montreal, Que: Department of Family Medicine, McGill University, 1992. 15. Bloom R, Cropley C. Textbook ofneonatal resuscitation. Washington: American Heart Association, American Academy of Pediatrics, 1987. 16. Dillman DA. Mail and telephone surveys: the total design method. New York: John Wiley and Sons, 1978. 17. SPSS by PC Plus 4.0 for the IBM. Chicago: SPSS, 1990. 18. Balfour G. Obstetrics of little interest to many residents. Med Post 1995;March 28:26.

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246 Canadian Family Physician . Le MIdecin defamille canadieni*nV0L43:UFEBRUARY F

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Signature..de.poste.et.seront.factures.des.qu Veuillez retouner votre demande dabonnement par la poste ou par t(lcopieur, accompagn6e dun cheque ou mandart lhell au eric deIbnee

*RER1997FOR PRESCRIBING INFORMATION SEE PAGE 365

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