Family Medicine Leader and Tn rural physician for 19 years, David McRay MD is currently director of the Maternity care curriculum at JPS in Ft.Worth.
He writes:
I am concerned.... that we appear to be moving toward a requirement/expectation that family physicians must do an additional year of training to be qualified to perform cesareans. I do not think this should become the norm.
I completed a three-year residency (at JPSH), before fellowships were available. I performed 67 cesareans as a primary surgeon. I then practiced for 19 years in a small community, leading a group practice performing 250 deliveries per year. I have since been granted unrestricted cesarean privileges at JPS, a tertiary care center delivering 7000 babies per year. However, if I understand correctly the decision at Methodist, I would not be eligible for cesarean privileges there. Or, can one read the new requirement (one year in an FM-OB program performing 50 cesareans) to include a traditional 3-year FM residency with a high-volume OB experience? I certainly believe my training and career experience equal or eclipse that of most fellowship-trained family physicians.
What do you see happening around the country? My residents are asking if they will be required to complete a fellowship, if our P4 program will be viewed as equivalent to a fellowship, and how many cesareans they must perform during their training (residency and/or fellowship) in order to be eligible for privileges. What is your take on where we are heading?
REPLY-(WMR):
Completing residency, and adding a fellowship year is the credential most likely to succeed. You should "brand" your fourth year as a fellowship.
Regarding the promise of complete training withing the 3 year FM residency, nobody was more hopeful than I. But maternity care FP's were undercut by the majority of residencies who could not support adequate training. Last year a residency director from Va. wrote my hospitals telling them that he could not recommend his resident for normal delivery privileges!
The logic of this residency director was that, since none of his faculty currently held privileges for normal deliveries, none of his faculty could make a recommendation on delivery privileges for any of their graduates. These residencies have not demanded that the by-laws of their hospitals encourage Family Medicine Obstetrics. Despite the AAFP-ACOG[Harr-Bagley] agreement, specialty neutral credentialing for OB rarely occurs in places where tomorrow's family physicians train.
The fourth year fellowship was a necessary political device which allowed Family Medicine to regain access to privileges. Memphis is recognized as a major urban market and an academic medical center. This precedent was one of my administration's major goals 1989-1999. Rural communities downstream were depending on us hold the fort and wave the flag.
Some university departments have succeeded in this area-- Boston, Portland-Oregon, USC under Ric Hahn[now retired], Colorado, etc. Credit to Tuscaloosa, Tacoma, Rochester, and Spokane who were the original pioneers. Kudos to them.
Family Medicine fellowships have grown, because they reliably produce the desired outcome. The curriculum is more than surgery. The curriculum maintains a Family Medicine identity while addiing skills in ultrasound, neonatal resusciation, office surgery, mission medicine, etc. During the fellowship year, our fellows obtained valid medical licenses in Nigeria and obtained operating room privileges. Residents could never do this.
Because of the credentials barrier, we have created a valid certification examination through the American Board of Family Medicine Obstetrics. I urge you to consider taking the exam and obtaining this credential. You would qualify on the basis of your equivalent training, documented experience, and proven ability.
Family Medicine as a member of the American Board of Medical Specialties(ABMS) cannot create a CAQ in Obstetrics or Emergency Medicine. This is viewed as conflicting with an already established specialty in another area. ACGME bylaws prohibit this.
As I said to Dan Casey, the fellowship credential(not a fourth residency year), is the most likely to succeed. Few are contesting the rural positions where deliveries are low in volume, and doctors take call every other night if not every night.
The problem is that these hospitals are dropping their OB services. Lexington, Huntingdon, Camden, Portland, LaFollett are small town hospitals in Tennessee that have dropped their OB. These job opportunities are shrinking and many of the small town opportunities are not viable. Small town doctors pay big city malpractice premiums.
The residency directors through their organization ARDFM, have not required "fairplay" on OB privileges for their graduates. Most residencies cannot win Cesarean privileges for any graduate at any hospital. Theoretically RRC guidelines required that this training be made available to all residents who requested it, but look at the data. JPS and a few others did provide this training within residency, but very few others did. In my six years, RRC site visitors never once cited this.
Family Medicine leaders will have to convince its own members in the AAFP, STFM and RRC-FM about the importance of this issue. When I served on the RRC, the AAFP did not instruct its delegates to vote for the mandatory OB rule. On the other hand, they were not instructed to vote against it. We won 5-4. Its up for vote again.
The current leadership of the Tennessee AAFP disagrees with me on the need to REQUIRE RRC regulation on this issue. One of my previous fellows dropped OB, and feels it is misguided to make this a priority. He has opposed my efforts in this area. As President of the Tn. AAFP, he has influence.
Therefore, the prevailing political reality REQUIRES graduating from residency before fellowship begins. Graduation from residency means that fellows will have full hospital privileges, a valid medical license, malpractice insurance, and be ABFM eligible before beginning their fellowship. This is not possible if they are still considered "residents". In the university all of my fellows served simultaneously as junior faculty, and we could bill for all of their activities without cosigning their charts. The fellowship is financially self supporting.
I encourage you and your colleagues to engineer your systems accordingly. With best wishes for your professional success,
Wm. MacMillan Rodney MD, FAAFP, FACEP
Chair, Academic Affairs
Medicos para la Familia
Memphis, Nashville and rural
John Gibson MD JPS writes:
It really seems to be that until we can win the battle of COMPETENCY based credentialling vs arbitrary "fellowship" issues, we are all at risk in this fight. Competency should be based on scope and breadth of training AND continuing experience backed up by good record keeping, peer review, and evaluation along with a reasonable process to document current competency (proctoring). I am not sure how a "fellowship" adds more to competency as compared with P4 program with good OB curriculum and experience spread out during the entire training period with a final result of knowledge and procedure experience that meets the same requirements of a fellowship. Perhaps at JPS we will need to adjust terminology for our trainees when they finish, but I am very sure they will have good evidence of competency from their P4 experience.
John Gibson, MD
OB Fellowship Faculty Member
Director of Global Health Education
JPS Dept of Family Medicine
John, this is about the currently brutal reality of American Hospital credentialing. Rightly or wrongly, the fellowship sells the perception of "additional training". Graduating from a 4 year residency does not.
Then there is the issue of trying to bill for a 4th-year resident. You cannot. Keep up the good work. Your graduates will have an easier time of it if they leave with a "fellowship" certificate.
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
www.psot.com
Comments