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Obstetrics Fellowship Curriculum MISSION The mission of the Obstetrics Fellowship at Swedish Family Medicine is to provide advanced training in high-risk and operative obstetrics to family physicians who will work in underserved communities.
Fellowship Goals 2. Attain competency in operative obstetrics, including cesarean section, instrumented deliveries, tubal ligation, and amniocentesis for assessment of fetal lung maturity. Provide post-operative care for such patients. 3. Provide competent prenatal care to pregnancies complicated by diabetes, hypertension, thyroid disease, substance abuse, and mental health disorders. 4. Stabilize and treat pregnant patients hospitalized for pre-term labor, pre-eclampsia, diabetes, and placental disorders. 5. Perform biophysical profile and limited obstetric ultrasound. 6. Counsel obstetric patients regarding genetic risk. 7. Resuscitate distressed newborns. 8. Provide ongoing care to the hospitalized newborn. 9. Maintain family medicine clinical skills. 10. Develop and maintain competency in teaching obstetrics to family practice residents and family practitioners.
Fellowship Objectives 2. Provide labor management, vaginal delivery and instrumented deliveries to obstetric patients of teaching panel physicians. 3. Perform cesarean sections as primary surgeon with any obstetric providers. Surgical skill level at the beginning of the fellowship will determine when the fellow is ready to be the primary surgeon. 4. Augment surgical skills by assisting gynecologic surgeries, including abdominal hysterectomies. 5. Perform post-partum tubal ligation on teaching panel patients. 6. Supervise R1 admission and daily management of antepartum service patients. 7. Perform amniocentesis for fetal lung maturity to teaching panel patients on the antepartum service. 8. Provide initial consultation and ongoing prenatal care to patients in the First Hill offices of Obstetrics. Focus will be on patients referred from family practice clinics. Visits will be precepted by the perinatologist. Fellows are expected to provide thorough evaluation to 1 to 2 patients each half day. 9. Perform limited obstetric ultrasound at Swedish Family Medicine. 10. Perform biophysical profile and dating ultrasounds. 11. Counsel patients regarding Down Syndrome Screening when they are referred to genetics counselors at Obstetrics. 12. Perform newborn resuscitations under the supervision of the neonatal nurse practitioner and/or neonatologist. Resuscitations will include intubations and umbilical vein catheterizations. 13. Admit and manage newborns in step down unit of the special care nursery. Care will be supervised by attending neonatologist. 14. See family medicine outpatients in one or two clinics per week, at the First Hill site. 15. Supervise resident care of family practice patients by precepting one to two clinics per week. Precepting will take place in the First Hill, Cherry Hill, and Downtown Family Medicine clinics. 16. Teach R1’s on the obstetric service basic obstetrics, including triage evaluation, cervical exams, labor management, pitocin augmentation, IUPC, FSE, vaginal delivery, and postpartum care. 17. Present a topic in primary care obstetrics at our annual Obstetric Advances for the Family Physician CME. Rotations Fellows will spend four weeks on each of our five rotations A, B, C, D, and E in sequence. Rotation D is the elective month. The first elective will be a focused neonatal care and resuscitation elective. Goals and objectives for each of the experiences that comprise the rotations follow. Specific weekly templates for each rotation are in the following section. LABOR AND DELIVERY
Goals 2. Supervise R1 simple labors. 3. Attain competency in operative obstetrics, including cesarean section, instrumented deliveries, and tubal ligation. 4. Provide post-operative care for such patients. 5. Develop and maintain competency in teaching obstetrics to family practice residents. 6. Evaluate and supervise triage visits. 7. Stabilize and treat pregnant patients hospitalized for pre-term labor, pre-eclampsia, diabetes, cervical incompetence and placental disorders. 8. Perform ectopic pregnancy evaluations and D & C’s for patients admitted through emergency room
Objectives 2. Provide labor management, vaginal delivery and instrumented deliveries to obstetric patients of teaching panel physicians. 3. Perform cesarean sections as primary surgeon with obstetric members of the Teaching Panel. Surgical skill level at the beginning of the fellowship will determine when the fellow is ready to be the primary surgeon. 4. Supervise R1 admission and daily management of antepartum service patients. 5. Perform amniocentesis for fetal lung maturity to teaching panel patients on the antepartum service. 6. Teach R1’s on the obstetric service basic obstetrics, including triage evaluation, cervical exams, labor management, pitocin augmentation, IUPC, FSE, vaginal delivery, and postpartum care. 7. Perform post-partum tubal ligation on teaching panel patients. 8. Perform neonatal circumcisions. 9. Perform D & C’s. 10. Evaluate no-doc patients in triage. 11. Manage labors and deliver no-doc patients 12. Supervise R1 triage visits.
Daily responsibilities 2. Lead board rounds with R1s at 7:45. 3. Attend teaching/perinatal rounds 8-9 am. 4. Scrub in on c-sections; these take precedence over rounds 5. Maintain presence on L+D to be available for complex labors/ instrumented deliveries 6. Beginning in January, contact HCFW attendings when they are on call for the ER and ask to be included in D & C’s and ectopics. 7. Carry senior OB pager when on call. PERINATAL CLINIC
Goals 2. Counsel obstetric patients regarding genetic risk. 3. Perform biophysical profile and limited obstetric ultrasound.
Objectives 2. Counsel patients regarding Down syndrome screening with genetics counselors at Obstetrics. 3. Perform and read ultrasounds with the perinatologist and technician. CIRCUMCISION CLINIC
Goals 2. Teach residents to perform circumcisions
Objectives 2. Skill level will be evaluated at the beginning of the year; fellows that need up to their first ten circumcisions proctored will be precepted by Drs Tuggy or Breuner. 3. After performing 10 circumcisions, the fellow will supervise a resident at this weekly clinic. PRECEPTING
Goals 2. Develop and maintain competency in teaching obstetrics to family practice residents and family practitioners.
Objectives CLINIC
Goals
Objectives COLPOSCOPY CLINIC
Goals
Objectives FIRST HILL ULTRASOUND
Goals
Objectives NEXT STEPS CLINIC
Goals
Objectives ELECTIVE
Goals
Objectives
Responsibilities 2. 6 weeks prior to your elective present your choice and planned rotation schedule to the fellowship director. Elective One: Neonatology, blocks 3-7
Goals
Methods
Responsibilities Block rotation and yearly schedule Antepartum rounds: A, C and E Vacations possible on B or D. Elective fellow (D) has to be available to cover Saturday call for B in order for B to take vacation. FH - First Hill DFM – Downtown Family Medicine
5 fellow Rotation template
Advisor Assignments Joe Breuner will serve as fellowship advisor for all fellows. He will meet with each of you every three months to review practice plans, evaluations, and progression of your skills. The final ‘quarterly’ meeting will also serve as a feedback session for making changes in the fellowship. Consider, in addition, approaching one of the members of Health Care for Women or the Perinatology group Obstetrics to serve as a mentor. Plan to get together every two months or so to review progress and foster development of your skills. Clinic Each fellow will have zero to three clinics a week depending on rotation. Some are scheduled at the First Hill Clinic. Clinics will be cancelled for vacations. Attending groups Perinatologists of Obstetrix: a group of 9 perinatologists who provide maternal-fetal medicine services for Swedish Medical Center and Valley Medical center. And until July 2009 were primary backup for obstetric emergencies in the hospital. David Gorenberg, MD serves as our liaison to the fellowship and attends one Friday meeting per month.
Health Care for Women: a group of 6 obstetricians who provide primary obstetric care at Swedish Medical Center, back up all the Family Medicine groups at Swedish, and play a primary teaching role in the fellowship.
Obstetric Hospitalists: 5 obstetricians, who provide in-house obstetric services for emergencies, back-up, triage evaluation, perform and assist cesarean section, and labor management. New to Swedish in July 2009.
Swedish Family Medicine Faculty First Hill: 10 family physicians that see patients and teach residents at three sites: First Hill Family Medicine, Downtown Family Medicine, and Swedish Community Health at Ballard. Swedish Family Medicine Faculty Cherry Hill: 7 family physicians who see patients and teach residents at Cherry Hill family medicine. Residency satellites at Seattle Indian Health Board and Seamar Community Health. Precepting Fellows will precept every first and third Monday morning and every Monday and Friday afternoon at the First Hill clinic, and Tuesday morning and Thursday afternoon at the Downtown Family Medicine clinic. They will precept family medicine residents in clinic visits and procedures. A separate faculty preceptor need not be present for Medicare billing because the fellows are licensed and privileged family physicians and the fellowship is not subject to Medicare supervisory requirements. Meeting Attendance All fellows will attend a supervised reading session and team meeting with the fellowship director every Friday from 12:30 to 1:30 in the Mt. Rainier room of the First Hill Clinic. Absences will be excused if fellows are post-call, scrubbed into a procedure, or on vacation. Attendance at regular First Hill residency meetings every Tuesday from 12:30 to 1:30 is encouraged but not required. Lunch is provided. E-mail and Pager Response Times Fellows will check and respond to e-mail no less than twice a week except when on vacation. Numeric pages and text pages, which require a response, should be answered within 10 minutes. Voice mails on your pager will be left for informational purposes only and won’t require a response. Vacations
Medical/Family/Sick Leave For acute illness or family emergency please use the following template for backup. If you are ill please call the person you are supposed to relieve so they can contact the correct person to cover call. The fellow coming off call should remain until the sick leave fellow arrives. If no relief can be found, please alert the charge nurse, on call perinatologist, and HCFW attending prior to leaving.
Leave for chronic medical reasons per Swedish personnel policies, see residency curriculum manual available on-line at: http://www.fammed.washington.edu/network/sfm/vacations_leave.htm
Orientation The fellowship year begins with a two day orientation covering ALSO workshops on vacuum/forceps and shoulder dystocia, c-section technique by outgoing fellows, billing and incentive compensation, schedule review, clinic and L+D orientation, precepting, directed reading text review, and the year’s first OB/GYN dept meeting. Remuneration: Salary and Incentives Salary will be $60,000. In addition, $1500 and 5 workdays off are available for CME. These should be scheduled during your elective time. INCENTIVES Goal That our team of fellows and visiting licensed providers will submit billings for as many c-section assists and triage evaluations as possible each 4-week block. Each block every fellow will receive $10 for each completed triage evaluation or c-section assist billing that they submit In addition, individual fellows are eligible to receive incentive pay for managing no-doc patients. If the fellow performs and bills for a vaginal delivery, they may submit a request for $250. If the fellow performs and bills for labor management and/or c-section assist, they may submit a request for $150. Only one fellow may bill for each no-doc patient, and it should be the fellow that attends the delivery. The fellows will be responsible to submit the payroll request to the fellowship coordinator. Graduation Requirements Directed reading Fellows will read and present chapters to their peers, residents in the obstetric area of concentration, and the fellowship director as scheduled from Gabbe’s Obstetrics, Williams’ Textbook of Obstetrics, ACOG compendium, Up-to-date monographs, and Green Journal articles. Readings are organized by topic and each fellow will be assigned a reading from the above sources pertinent to that topic. Procedure numbers Fellows will complete 60 c-sections as primary surgeon. This is a minimal requirement for graduation. Fellows will also participate in the resuscitation of 20 newborns. Vaginal deliveries, instrumented deliveries, amniocenteses, ultrasounds, D & C’s, tubal ligations, circumcisions, neonatal intubations and umbilical vein catheterizations should be logged by the fellows on New Innovations in order to obtain hospital privileges, but minimum numbers are not required for graduation. Please also see the competencies table below for a sense of which procedures to focus on. Clinic numbers Fellows will see a minimum of 300 patient care visits in their continuity clinic. Billing The hospital receives no outside funding to support the fellowship and its costs are covered by the billings submitted by the fellows. Fellows are expected to fill out billing slips for c-section assists, triage evaluations, vaginal deliveries where they act as attending, circumcisions, and D & C’s. To cover our costs, each fellow needs to bill for 15 c-section assists and 15 triage evaluations each month, incentives are provided as described above. Presentation Each fellow will give a 40-minute presentation at our annual Advances in Obstetrics for the Family Physician conference. The 2010 conference will be on April 9. Choose a topic with your fellowship advisor. The presentation should include slides, current evidence, cases, and time for questions. Three months of Friday meeting times will be reserved to prepare these presentations. Evaluations and Due Process For performance evaluations and progressive discipline, please see the First Hill residency curriculum manual section on advisor system and due process. It is available online at: http://www.fammed.washington.edu/network/sfm/advisorandevals.htm OB fellowship Competencies Three objectives for this list: 1) to give new fellows a framework for their learning, 2) to set a basic standard for training, much like we have in residency, 3) to credit and help define the level of training for fellowship grads looking for jobs or seeking privileges. Obviously, as is the case with core competencies in residency, graduates will find themselves in communities with varying needs, comfort levels, and acceptance. Therefore, the lists below are hopefully organized to set goals and limits, as well as some room for flexibility.
A) You should feel
comfortable with this by the end of fellowship. Privileging for each of these
skills may still be hospital/geographically dependent. With letters of
recommendation and procedure log support, however, you may be able to claim
"competency" in these skills.
# = ability to proceed with this skill depends on your experience and procedure log numbers NICU = ability to proceed with this skill is determined by the NICU and hospital where you practice ! = ability to proceed with this skill is determined by the ability of your hospital team to do a crash section * = ability to proceed with this skill is determined by hospital ethics
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