Transcript Established Technology Tends to Persist in the Face of New

Board Certification in Family Medicine
Obstetrics—An Opportunity for Good
Wm. MacMillan Rodney MD, FAAFP, FACEP
Professor and Chair, Medicos para la Familia
Memphis, Nashville, and International
Editor, American Journal of Clinical Medicine
American Board of Family Medicine Obstetrics
WONCA 2010; Cancun, Mexico; Presenting
The Family Medicine Obstetrics Curriculum and Data
Medicos: A Success in Expanding Services at a Lower
Cost.
Eliminating Barriers to Family Planning: Hysteroscopic
Tubal Occlusion without Anesthesia
Why Certification in Family
Medicine Obstetrics?
The American Model of highly specialized services is untenable wherever
per capita income is less than $25,000 per year. This is most of the planet.
Childbirth has become a treacherous technical adventure with over 30%
of women receiving a Cesarean birth.
A start up OB service in a Florida Hospital requested and received over
$12 million to deliver 300 babies per year.[$40,000 each]
In the USA, OB-Gyn has subspecialized to the point that many OB’s no
longer deliver babies. Unfortunately hospitals and many international
medical schools are following this model
Africa, the UK, and USA are now developing 4 year options with one of
these options to include surgical OB. Australians broke away from
General Practice and created a specialty for rural and frontier medicine
A new model is needed and available. Although , dwarfed by traditional
academic medical centers, there are 30+ viable Family Medicine
Obstetrics programs currently in operation. Africa has several others.
Multiple locations suggest Validity;
See www.aafp.org fellowships
Terminology Varies:
Maternal Child Health is a thesis requiring 2 year program at Brown.
The others are one year programs with most using the title Family Medicine
Obstetrics
Tacoma, Wa. Calls itself a rural fellowship
30 current MCH/OB fellowships programs offering 48
positions
–
–
–
–
3 Maternal Child Health fellowships
15 programs established since 2000
10 programs established 1990-2000
5 programs established in 1980’s
The unifying feature is training in surgical obstetrics. For
example ETSU has a rural fellowship without obstetrics.
Pecci C, Leeman L,Wilkinson J. Family Medicine Obstetrics
Fellowship Graduates: Training and Post-fellowship Experience.
Fam Med 2008;40(5):326-32. A Ten year Sample
32 fellowship programs identified; 26
programs represented
254 fellowship graduates identified
graduating between 1992-2002
166 surveys returned (65.4%)
123 completed OB Fellowships; 43 completed
MCH Fellowships
10 received a Masters of Public Health degree
during fellowship
Cesarean Sections During
Fellowship: A National Survey
Range 0-350
Average 99
Number of C/S
<50
50-75
76-100
101-125
>125
10.8%
23.5%
25.3%
12.0%
9.2%
Other activities in fellowship
Inpt FM
Outpt FM
NBN
Res Ed
Adv US
US Basic
Abortions
PPTL
Bowel/bladder
Hysterectomy
D&C
colpo
0
20
40
60
80
100
Family Medicine Obstetrics-MethodWm. MacMIllan Rodney MD
Career Statistics Fellowship Group
1992-2010; 100% sample response
TOTAL Entered
– Female 30
80
38%
Completed
Obtained Cesarean Privileges
Spent ≥ 2 years Rural
At Least 1 year as Faculty
74
71
47
36
93%
96%
64%
49%
Fellowship Training Goals
– Maintain an identity in and a role for Family Medicine.
– Provide continuing comprehensive health care
unrestricted by age, organ system, and location of service .
– Develop credentialed physicians similar to the African
model of a district hospital physician combining public
health, family medicine obstetrics with the ability to
function in a mission hospital[some ortho, ER, +]
Operative vaginal delivery and Cesarean sections
Newborn resuscitation and stabilization
Obstetrical, gyn, and emergency ultrasound
Colposcopy , gyn, and office surgeries
Care of complicated obstetric patients
Evidence-based, family-centered maternal-child care
Fellowship Certification
Advantages and Disadvantages
Creates clear advantage for family physicians in
communities where some surgical skills are
necessary. The GP is elevated to OB with additional
skills in general Med-Peds-Office Surgery.
Creates an academic credential for hospitals unlikely
to accept generic primary care physicians.
Difficult process of training, written examination,
and oral examination which needs to be expanded
for international physicians. Need USA or Canadian
medical license.
Fellowships pay $50,000-90,000 per year in US.
Am Board of Family Medicine Obstetrics—
To Apply for Written Exam
http://www.abpsga.org/certification/family_
medicine_obstetric/application.html
Be a graduate of a recognized college of medicine confirmed by a copy of an
allopathic/osteopathic degree or a letter of verification from the institution where
the degree was earned. In the case of foreign medical schools, an English
translation of the document is also required. Graduates of foreign medical
schools must also include a copy of their Education Commission for Foreign
Medical Graduates (ECFMG) Certificate. Canadian medical schools and medical
training programs are considered equivalent to U.S. medical schools and medical
training programs.
Hold a valid and unrestricted license to practice medicine in the United States, or
its territories, or in Canada and submit copies of all licenses. License(s) must
include date of expiration.
Am Board of Family Medicine
Obstetrics-Requirements
Verify staff privileges by means of an original signed letter from the
administrator of each hospital, or facility, at which privileges are held
confirming good standing at that facility. The letter(s) must be current,
dated no more than one year prior to the date the application is received
by ABPS.
Be certified on the "Provider" level in the Advanced Life Support in
Obstetrics (ALSO) program, and Neonatal Resuscitation Provider (NRP)
program. ALSO and NRP do not have to be current at the time of
submitting the application, but must be current and on file 30 days prior
to taking the examination.
Be board certified in Family Medicine by the ABMS, ABPS or AOA or be
eligible to be certified by the Canadian Council of Family Practice (CCFP),
or the Royal College of Physicians and Surgeons (RCPSC). Other Board
Certifications may be considered on an individual basis.
Am Board Family Medicine
Obstetrics-Requirements
Be qualified under one of the following:
– Have completed residency training in a program approved by the
Accreditation Council of Graduate Medical Education or the American
Osteopathic Association, Canadian Council of Family Practice (CCFP), or the
Royal College of Physicians and surgeons (RCPSC) and deemed acceptable to
the American Board of Family Medicine Obstetrics. Such training must
include identifiable training and experience in Family Medicine Obstetrics as
determined by the American Board of Family Medicine Obstetrics and
approved by the ABPS.
The ABPS now accepts all residencies accepted by the Royal College of
Physicians and Surgeons of Canada (RCPSC). ABPS therefore now accepts
all residencies approved by ACGME, AOA, or RCPSC. It should be noted
that the ABPS accepts ALL medical residencies approved by the RCPSC,
including approved residencies outside Canada.
Am Board Family Medicine
Obstetrics--Requirements
Osteopathic physicians who have successfully completed an AOAapproved internship, plus an AOA-approved General Medicine residency
and have a minimum of two (2) years full-time experience in Family
Medicine and 300 hours of CME acceptable to the BCFM.
Submit three (3) letters of recommendation from active Diplomates of an
ABPS, ABMS, or AOA-recognized board of certification. Letters of
recommendation must be current (dated no more than one year prior to
the date the application is received by the ABPS) and on letterhead
stationery. The ABFMO requires original letters; copies are not acceptable.
The ABFMO recommends that the letters be sent to the applicant for
inclusion with other application documents.
Clinical Practice Track - This Track Will Be Available
Until 2018.
The applicant must have been actively engaged in the
practice of Family Medicine with care of obstetric patients on
an ongoing basis for five (5) years. This care should include
the practice of surgical obstetrics. Documentation of training
in obstetrics should include a case log listing all obstetrical
cases completed in the previous two years. Applicants should
demonstrate that their volume of obstetrical medicine is
sufficient to maintain competence ..
Applicants should have performed a minimum of 100 vaginal deliveries
within the last 5 years.
Applicants should have performed a minimum of 50 cesarean sections
within the last 5 years.
Fellowship Track to ABFMOB
Applicants who have satisfactorily completed a 12-month, full-time fellowship
that is recognized by the ABFMO will be considered eligible to sit for the written
exam. The applicant should have completed their fellowship training within the
last five years (8/2002). A list of fellowship programs that are currently
recognized by the ABFMO is attached. Applicants who have completed a
fellowship program that has not been recognized by the ABFMO may ask their
program to submit materials for consideration.
For Fellows who have completed a recognized fellowship, the fellowship
director must submit an original signed letter of verification attesting to
the applicant’s satisfactory completion of the program.
The requirements for Fellowship training are outlined in the document
“Guidelines for Recognition of Fellowship Programs by the ABFMO” and
include the following minimum numbers of procedures.
– A minimum of 100 vaginal deliveries.
– A minimum of 50 cesarean sections, with a case log that is externally
validated by one of the following: Medical Records, Medical Staff Office,
Medical Director or Department Chair.
ABFMOB Oral Examination
After successful completion of the written examination,
applicants are also required to submit verification of
competency in operative obstetrics and complete an oral
examination. This portion of the examination will have an
additional fee. The process is as follows:
– The applicant must submit the names of three active Diplomates of an
ABPS, ABMS, or AOA-recognized board of certification who will
observe, or who have observed, the applicant during the care of
Obstetrical patients, including at least 5 cesarean sections, and who
will be willing to attest to the applicant’s surgical skills.
– The Board will ask one or more of these physicians to complete and
sign a notarized Statement of Evaluation regarding the applicant’s
level of independence and surgical skill, to view click here.
– Those applicants who successfully complete the attestation process
will be eligible to sit for the oral examination.
OB FELLOWSHIP OUTCOMES 1992-2010:WHERE DO THEY
GO, WHO STOPS DELIVERING AND WHY?
Wm. MacMillan Rodney MD, Conchita Martinez MD,
Millard Collins MD, Greg Laurence MD, Carl Pean MD, Joe
Stallings MD
– Acknowledgments: Charles E. Couch, M.D., ACOG[deceased], James
Weber MD[deceased]; Eugene Felmar MD[deceased]
Address Correspondence to:
Wm. MacMillan Rodney, M.D.,
6575 Black Thorn Cove
Memphis , Tn. 38119
e-mail: [email protected]
Procedural Skills and Office Technology; www.psot.com
The Fellowship Solved Other
Problems
Regained financial control and ability to self fund a model office with
open access appointments, EMR, all procedural equipment. The university
“dumbs down” family medicine by forcing it to abandon skills.
Retained alliances with ALSO statewide coalition, surgery lab, ultrasound
course, and AAFP.
Established osteopathic and allopathic alliances with Oklahoma State, the
University of Arkansas, Louisiana, and rural locations in .
Funded
Developed alliance with previous faculty who had left academia for
private practice. They provide selectives in GI endoscopy and Derm.
Established 501c3 and began endowment.
Implemented global outreach with fellowship rotations in Kenya, Ghana,
Ecuador, Guatemala, and others.
Trained leadership capable physicians who went on to colonize
previously hostile environments. One hospital system welcomed
fellowship trained family physicians into the department of Obstetrics.
Health Services Research
The electronic medical record and a digital xray system
created efficiencies and improved care.
The OB call group 24/7 365 staffed an open access
appointment system leading to improved service and 63,000
visits in 2009. Gross revenue topped $ 5 Million.
Published over 10 Studies and funded other research. See
bibliography www.psot.com
Developed an internet based and PDA available prenataldelivery database for the management of risk. >4,000 deliver
Developed a curriculum in Office and Obstetrical surgery.
– Cognitive preloading for psychomotor skills:
– The role of the live animal laboratory as simulator for repair of
complex lacerations and inadvertent bladder entry.
– Ultrasound assessment as a means of avoiding Cesarean
Hysterectomy.
Transfer of Technology Projects
Medicos-- A Mission Hospital Simulation in Tennessee
Minor Surgery, Urgent Care, and some ER
reengineered in the office
Diagnostic services: ECG,CXR, and basic lab
reengineered for the Office
Colposcopy 1984- established
– Electrosurgery and cryosurgery came with this procedure
OB-Gyn Ultrasound 1984-established
GI/ENT endoscopy 1979-established
American Board of Family Medicine
Obstetrics
Board Certification in Family Medicine
Obstetrics—An Opportunity for Good
Wm. MacMillan Rodney MD, FAAFP, FACEP
Professor and Chair, Medicos para la Familia
Memphis, Nashville, and International
Editor, American Journal of Clinical Medicine
American Board of Family Medicine Obstetrics
WONCA 2010; Cancun, Mexico; Presenting
The Family Medicine Obstetrics Curriculum and Data
Medicos: A Success in Expanding Services at a Lower
Cost.
Eliminating Barriers to Family Planning: Hysteroscopic
Tubal Occlusion without Anesthesia
References Supporting Cesarean
Training in Family Medicine
Nothnagle, M; Sicilia, J; Forman, S, et al, Rodney WM. Required Procedural Training in
Fammily Medicine Residency: A Consensus Statement. Fam Med 2008;40(4):248-52.
24)Kelly B, Sicilia J, Forman S. Advanced Procedural Training in Family Medicine: A
Consensus Statement Fam Med 2009;41(6):398-404.
25)Norris T, Reese, J, Pirani M, et al. Are Rural Family Physicians Comfortable Performing
Cesarean Sections? J Fam Pract 1996;43:455-460.
26)Deutchman M, Connor P, Gobbo R, FitzSimmons R. Outcomes Of Cesarean Sections
Performed By Family Physicians And The Training They Received: A 15-Year Retrospective
Study. J Am Board Fam Pract 1995; 8:81-90.
27)Eidson-Ton WS, Nuovo J, Solis B, et al; An Enhanced Obstetrics Track for a Family
Practice Residency Program: Results from the First 6 Years. J Am Board Fam Pract
2005;18:223-8.
28)Pecci C, Leeman L,Wilkinson J, Family Medicine obstyetrics Fellowship Graduates:
Training and Post-fellowship Experience. Fam Med 2008;40(5):326-32.
29)Heider A, Neely B, Bell L. Cesarean Delivery Results in a Family Medicine Resedency
Using a Specific Training Model. Fam Med 2006;38(2):103-9.
Bibliography
1. Morgan WC, Rodney WM, Hahn RG, Garr DA, O'Brien J. Echografie bij Verloskunden en
gynaecologie in de praktijruiute: Een ondersteuning voor Luisartsenverloskunde (Office-based
ultrasound as a support for family centered obstetrics), Huissarts Nu (HANU) 1987; 16:277-280.
2. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician:
Applications in family-centered obstetrics. Postgrad Med 1988; 83(2):103-107
3. Hahn R, Ornstein S, Davies TC, Rodney WM, et al. Obstetric ultrasound training for family
physicians: results from a multi-site study. J Fam Pract 1988; 26:553-558.
4. Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract--An
International Journal 1988; 5(2):129-135.
5. Rodney WM, Prislin MD, Hahn RG. Family practice obstetrical ultrasound in an urban
community health center: Birth outcomes and examination accuracy of the initial 227 cases. J
Fam Pract 1990; 30:163-168.
6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME. Obstetric ultrasound by family
physicians. J Fam Pract 1992; 34:186-200.
7. Deutchman ME, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetric
ultrasound: results and technique. J Fam Pract 1994; 39:33-37.
8. Euans DW, Hahn RG, Rodney WM. A comparison of manual and ultrasound measurements of
fundal height. J Fam Pract 1995; 40:233-236.
9. Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in
FP. J Am Board Fam Pract 2002;15:255-56.
10. Dresang LT. Rodney WM, Dees J. Teaching OB ultrasound to family practice residents. Fam
Med 2004; 36: 98-107.
11.Dresang LT, Rodney WM, Leeman L, Dees J, Koch, P, Palencio M. ALSO in Ecuador:
Teaching the Teachers. J Am Board Fam Practice. 2004;17(4): 276-282.
http://www.jabfp.org/cgi/content/full/17/4/276
12. Dresang LT, Rodney WM, Rodney KMM. Prenatal Ultrasound: A tale of two cities. J Nat Med
Association Feb 2006; 98: 167-171.
Challenges—Civil Rights
Political stability and the threat of mandatory
consultation for things like labor at 36 weeks
The threat of a “bad case”.
Medicos para la Familia example:
– No maternal deaths or morbidity, n=3000 + deliveries
– 14 newborn deaths, shoulder dystocias, brachial plexus
injury; retained placentas, over 1000 Cesareans,
abruptio; HELLP; American nursing politics,staff squabbles
– One lawsuit, and medical malpractice insurance has
doubled to $30,000/year since 1999. Year one cost is
$12,000.
International Medicine vs. USA
Twice the service at a tenth of the cost
50 bed hospital Destin Fla
Comprehensive women’s health program to
cost $ 12 million for start up.
Currently 500 women in the county deliver
each year.
Start up $24,000 per delivery. Hospital
charges $4-5 k/delivery “We’re not-forprofit.”
Reference The Destin Log. May 7, 2005. pA14