Board Certification in Family Medicine Obstetrics

1
Board Certification in Family Medicine
ObstetricsAn 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

2
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 OBs 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.

3
Multiple locations suggest ValiditySee
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 1980s
• The unifying feature is training in surgical
  obstetrics. For example ETSU has a rural
  fellowship without obstetrics.

4
Pecci C, Leeman L,Wilkinson J. Family Medicine
Obstetrics Fellowship Graduates Training and
Post-fellowship Experience. Fam Med
200840(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

5
Cesarean Sections During Fellowship A National
Survey

• Range 0-350
• Average 99

Number of C/S
lt50 10.8
50-75 23.5
76-100 25.3
101-125 12.0
gt125 9.2
6
Other activities in fellowship
7
Family Medicine Obstetrics-Method-Wm. MacMIllan
Rodney MD

• Career Statistics Fellowship Group 1992-2010
  100 sample response
•  TOTAL Entered 80
• Female 30 38
• Completed 74 93
• Obtained Cesarean Privileges 71 96
• Spent 2 years Rural 47 64
• At Least 1 year as Faculty 36 49

8
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 hospitalsome 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

9
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.

10
Am Board of Family Medicine ObstetricsTo Apply
for Written Exam

• http//www.abpsga.org/certification/family_medicin
  e_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.

11
Am Board of Family Medicine Obstetrics-Requirement
s

• 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.

12
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.

13
Am Board Family Medicine Obstetrics--Requirements

• Osteopathic physicians who have successfully
  completed an AOA-approved 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.

14
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.

15
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 applicants 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.

16
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 applicants
  surgical skills.
• The Board will ask one or more of these
  physicians to complete and sign a notarized
  Statement of Evaluation regarding the applicants
  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.

17
OB FELLOWSHIP OUTCOMES 1992-2010WHERE 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.,
  ACOGdeceased, James Weber MDdeceased Eugene
  Felmar MDdeceased
•  Address Correspondence to
• Wm. MacMillan Rodney, M.D.,
• 6575 Black Thorn Cove
• Memphis , Tn. 38119
• e-mail Wmrodney_at_aol.com
• Procedural Skills and Office Technology
  www.psot.com

18
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.

19
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
  prenatal-delivery database for the management of
  risk. gt4,000 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.

20
Transfer of Technology ProjectsMedicos-- 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

21
Board Certification in Family Medicine
ObstetricsAn 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

22
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 200840(4)248-52.
• 24)Kelly B, Sicilia J, Forman S. Advanced
  Procedural Training in Family Medicine A
  Consensus Statement Fam Med 200941(6)398-404.
• 25)Norris T, Reese, J, Pirani M, et al. Are Rural
  Family Physicians Comfortable Performing Cesarean
  Sections? J Fam Pract 199643455-460.
• 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 881-90.
• 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 200518223-8.
• 28)Pecci C, Leeman L,Wilkinson J, Family Medicine
  obstyetrics Fellowship Graduates Training and
  Post-fellowship Experience. Fam Med
  200840(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
  200638(2)103-9.

23
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
  16277-280.
• 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 26553-558.
• 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 30163-168.
• 6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME.
  Obstetric ultrasound by family physicians. J Fam
  Pract 1992 34186-200.
• 7. Deutchman ME, Hahn RG, Rodney WM. Maternal
  gallbladder assessment during obstetric
  ultrasound results and technique. J Fam Pract
  1994 3933-37.
• 8. Euans DW, Hahn RG, Rodney WM. A comparison of
  manual and ultrasound measurements of fundal
  height. J Fam Pract 1995 40233-236.
• 9. Rodney WM. Historical observations from the
  RRC 1994-2000 Maternity careOB training in FP.
  J Am Board Fam Pract 200215255-56.
• 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.
  200417(4) 276-282. http//www.jabfp.org/cgi/cont
  ent/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.

24
ChallengesCivil 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, n3000
  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.

25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
International Medicine vs. USATwice the service
at a tenth of the cost

• 50 bed hospital Destin Fla
• Comprehensive womens 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 Were not-for-profit.
• Reference The Destin Log. May 7, 2005. pA14