In 1983 I was honored to be named the editor of the AAFP textbook on Flexible Sigmoidoscopy and Colonoscopy. Among all the books written on the subject, I was the only one to include the techniques of sedation/analgesia. Special thanks to all the family physician pioneers who accepted the challenge of writing and teaching. For twenty years my faculty group held the high ground and shamelessly used the annual scientific assembly as a faculty development session while simultaneously providiing political support for the many family physicians who were summarily refused privileges to perform this life saving procedure.
As family physicians could not easily obtain hospital privilges they were forced to buy and maintain equipment within their own offices. In regions where reimbursement was linked to hospital privileges, colonoscopy in family medicine withered. The AAFP did not successfully defend these issues, and the course demand predictably decreased. The course was downsized and reconstituted under the able leadership of Drs. Pope, Forman, Coleman, and others. But the AAFP scientific assemblly ceased to be a revival meeting for procedural faculty.
My last revision of the colonoscopy book was published in 2004, which was the year I stopped teaching the course. The AAFP took my book and published it, but never sent me a copy for proofreading. Since we had taught over 2,000 physicians from the book for over twenty years. the four revisions seemed to address most issues of accuracy.
But the final edition was changed without review, and the sedation analgesia test was inaccurate through the process of retyping and inattention to detail. Since I was no longer involved with the course and knew that others would be doing their own book, I did not revisit the issue. I assumed the book would die a natural death which it has.
But, it is clear that the topic of office anesthesia needs to be included in our fellowship curriculum. Attaining procedural excellence during the standard three year FM residency curriculum, seems unlikely. Most of the family medicine residencies are owned by hospital administrators and subspecialty oriented academic medical centers whose interests are not aligned with procedural teaching for family physicians. Therefore, I am proposing that these skills be incorporated into the Medicos' Fellowship curriculum book.
Problem based learning uses the multiple choice question as a clinical simulation with the goal of achieving an objective measure of attained skill. CFR 42.12 requires that hospital evaluate physicians by things other than board certification, and these instruments should serve to establish specialty neutral credentialing. I have labeled this process problem based learning and competency based testing.
Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com
Index--Fellowship curriculum, sedation/ analgesia, moderate sedation, surgery in the office
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