PSOTBLOG

2-step PPD -- Clear Guidelines?

STEVEN C BUSSELEN wrote:

Does anyone know of clear PPD guidelines that include a CLEAR/CONCISE explanation of how and why to do the 2-step PPD?
 
Among other questions, a couple of members of our staff are wondering if there is a clear deadline for the 2nd PPD.
 
I reviewed the UpToDate article, which is neither clear nor concise. It suggests waiting 1-3 weeks as a general guideline. I can't see any reason to subject a patient to two more PPDs, just because they waited a month or two after the first PPD. Isn't the goal to deal with the booster phenomenon by having the 2nd PPD reasonably soon after the 1st, so patients getting annual PPD's don't have to face tough questions if the 2nd PPD comes back positive (Did they get exposed in the last year?)
 
 
Steven Busselen, MD
Johnston, RI
 

WMR:

The "booster" phenomenon was studied as means of reducing false negative PPD-TST frequencies in specific populations whose immune system was compromised or WEAK. It was thought to be particularly useful in new admission to nursing homes when the admittee was old and debilitated. These patients were not classical immuno-compromised patients, but the 2 step  principles apply to the entire group of AIDS, metastatic Ca, dementia, etc patients. Generally, the second PPD was given two weeks later, and several gained professorships in the study of this phenomenon.
 
But, I know of no controlled studies indicating that lives were saved. It seemed logical, and hordes "true believers" sought to have the 2 step PPD as a regulatory mandate. Some succeeded. I would prefer that knowledgable physicians be allowed to use their judgement on a case by case basis.
 
One medical school in Tennessee, for a while, required that all entering students submit to a two step test. BayesTheorem would suggest that they had misapplied his basic principles sensitivity and specificity. Nevertheless the student health section did it anyway. Another false step for the American Medical Education system.
 
Similarly there have been no head to head comparisons selecting one "best" interval since the basic test remains untested by randomized outcome studies.
 
But physicians and nurses  have to be very careful in this area, since America is home to the "TB police" with actual incarceration for those who do not follow these arcane regulations in an exact way.
 
With best wishes for your professional success,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
American Board of Family Medicine Obstetrics

Chair, Academic Affairs
Medicos para la Familia
Nashville, Memphis, and International

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a2.htm

Two-step (tuberculin) skin test. A procedure used for baseline skin testing of persons who will periodically receive TSTs (e.g., health-care workers or residents of long-term--care facilities) to reduce the likelihood of mistaking a boosted reaction for a new infection. If an initial TST result is classified as negative, a second test is repeated 1--3 weeks later.

If the reaction to the second TST is positive, it probably represents a boosted reaction, indicating that the infection was most likely in the past and not recent. If the second TST is also negative, the person is classified as not being infected. Two-step skin testing has no place in contact investigations or in other circumstances in which ongoing transmission of M. tuberculosis is suspected.

http://www.cdc.gov/mmwr/preview/mmwrhtml/00038823.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/00038873.htm

Booster Phenomenon and Two-Step Tuberculin Skin Testing

Periodic use of the tuberculin skin test is valuable for the surveillance of tuberculin-negative persons at risk for exposure to M. tuberculosis.
Repeated testing of uninfected persons does not sensitize them to tuberculin. However, delayed-type hypersensitivity resulting from mycobacterial infection or BCG vaccination may gradually wane with years. Although subsequent initial skin testing may be negative, the stimulus of a first test may boost or increase the size of the reaction to a second test administered 1 week to 1 year later and thus may suggest an apparent -- but false -- tuberculin conversion.

Although the booster phenomenon may occur at any age, its frequency increases with age and is highest among persons >55 years of age and/or among those persons who have had prior BCG vaccination (18).

When tuberculin skin testing of adults is repeated periodically, as in employee-health or institutional screening programs, an initial two-step approach can reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection. If the first tuberculin test result is negative, a second 5-TU test should be administered 1 week to 3 weeks later. A positive second result probably indicates boosting from a past infection or prior BCG vaccination.
Persons having a boosted reaction should be classified as reactors, not converters. If the second result is negative, the person is probably uninfected, and a positive reaction to subsequent tests indicates a true tuberculin skin-test conversion (see Definition of a Tuberculin Skin-Test Conversion).

Because of problems with continued cross-reactions with other mycobacteria, the specificity of the tuberculin test is less when serial skin testing is performed than when a single test is administered. Thus, serial skin-testing programs tend to overestimate the incidence of new TB infection in the tested population. Because of this potential for overestimation of incidence, serial skin-testing programs should be targeted to populations at high risk for continued exposure to infectious TB.

UK has a nice article on TB testing...

http://www.immunisation.nhs.uk/files/mantouxtest.pdf

http://ajrccm.atsjournals.org/cgi/content/full/159/1/15

Boosting is best distinguished from conversion on clinical grounds. One can attribute an increase in reaction size to boosting when the increase in reaction is seen after an interval of 1 to 5 wk during which there has been no possibility of exposure, such as preemployment testing of a health care worker. Conversion can be confidently stated to have occurred when a previously tuberculin-negative individual becomes tuberculin test positive after receiving BCG vaccination, or following significant exposure such as during an outbreak or as a result of close contact with a highly contagious index case. An increased reaction is more likely because of new mycobacterial infection (i.e., true conversion) if several prior tuberculin tests were negative, particularly if baseline two-step tuberculin testing was performed (12)

http://health.state.ga.us/pdfs/forms/tb/TST_Booster.pdf

This resource says boosting up to 1-year later, but no reference.

http://www.cdc.gov/tb/publications/LTBI/diagnosis.htm#4

Booster Phenomenon

Some people with LTBI may have a negative reaction to the TST if many years have passed since they became infected. They may have a positive reaction to a subsequent TST because the initial test stimulates their ability to react to the test. This is commonly referred to as the “booster effect” and may incorrectly be interpreted as a skin test conversion (going from negative to positive). For this reason, the “two-step method” is recommended at the time of initial testing for individuals who will be tested periodically (e.g., health care workers). If the first test result in the two-step baseline testing is positive, consider that the person has LTBI and evaluate and treat the person accordingly. If the first test result is negative, the second step of the two-step baseline testing should be repeated in 1–3 weeks. If the second test result is positive, consider that the person has LTBI and evaluate and treat the person accordingly; if both steps are negative, consider the person uninfected and classify the TST as a negative baseline (see Figure 1).

Figure 1:  Two-Step Tuberculin Skin Test (TST) Method
1st TST Negative → Repeat TST in 1–3 weeks
2nd TST  Negative → Person probably does not have infection
Positive → Boosted reaction due to infection in the past

Note: A single step approach would be used for serial testing at baseline with QFT because boosting does not occur with QFT.

Kelly Locke, MD

 
Index--TB screening, 2 step PPD, booster pnehnomenon

Against ABFMO

Kate Rowland writes:

And what happens to those of us who do not want C-section privileges but do vaginal deliveries?  I would obviously not qualify for this certification, so if my patients go looking to see if I am certified in Family medicine obstetrics (many of my patients being an engaged population who are likely to do so), they will feel that I am unqualified to attend their normal vaginal deliveries. 

To quote your earlier email: "Without Cesarean skills, FM's go hat in hand seeking "backup" from communities of OB's who may see them as undertrained risks or as competition or both."

Or the OBs see us as collaborators with a more limited scope of obstetric practice (which is a fair descriptor of my practice--limited to non-operative obstetrics).  They can have their 28% c-section rate; I will take my low-risk patients and attend their low-risk vaginal deliveries and keep my 7% c-section rate.  If my patient goes to section, I will be scrubbed and ready to support her, but I have no interest in doing her cesarean delivery.  I'm not competition or a risk to the OBs even though they back me up when my patients are in labor.  I'm trained to do what I do.  I know it and they know it.

This new Board undermines my practice by making me appeared unqualified.  What's more, at my hospital family physicians who deliver babies are paid more than those who do not-- and this new 'specialty' is certainly going to hurt our chances of continuing to be paid for our obstetric skills.  Without this certification, the hospital administrators can claim that we do not really practice obstetrics, and thus do not need to be paid for doing so.

Kate Rowland
Chicago IL
 
WMR Replys:

I respectfully disagree that this will undermine family physicians who do not wish to do Cesareans. It is more likely to open doors for places where FO's have been excluded.
 
In most communities, Cesarean trained FP's are more likely to support NSVD FP's than not. Further a critical mass of fP-OB is good for the longevity of the community. The problem is that many communities are losing their delivery services for lack of surgical training by FP's. this is even more acute in international situations. This is an opportunity for Family Medicine, and I regret that any would see it as a threat.

Bill:

I can not say anything else to your words. Long time ago I was looking for "3 frases when I got the Academic Excellence award at UIC", and you know well my english and I stole this from yours, I think that it applies well in the case of ABFMO:

Each new and important idea passes through three stages:

First, it is ridiculed

Then, it is violently opposed

Finally, it is accepted as being SELF-EVIDENT
                                    Schopenhauer
In 10 years we will say: "I told you that it makes sense"

Eduardo Scholcoff
Rockford

FrOm Bill Ellert:

I actually agree with both Dr. Rowland and with Dr. Rodney.  Although I have practiced OB my entire career and delivered well over 1000 babies, I personally have never applied for c-section privileges.  Nevertheless, I have used my position(s) within hospital leadership to develop a training program for family physicians to become c-section trained and also fought for the right for appropriately trained famly physicians to obtain c-section privileges in multiple hospitals in metropolitan phoenix.  While obtaining vaginal delivery privileges has never been a problem - even when I was on the East Coast, I must admit that there have been challenging issues in maintaining all the privileges for independent practice for which I am well qualified.  The fight that a family physician has to go through to practice the scope of medicine for which they have been trained is so different from community to community.  Also, the "agenda" that each famliy physician has for their own practice differs from physician to physician within our specialty (this unfortunately has been one of our weakness as a specialty - we tend to not be able to agree among ourselves).
 
I would respectfully submit the following recommendations:

1)  Rather than calling it it the ABFMO, I would suggest that it be called the ABFMSO (American Board of Family Medicine Surgical Obstetrics).  Indeed, the focus is for those who wish to do c-sections - not necessarily high risk OB.  Many of us who do not do surgical obstetrics do high risk obstetrics including diabetes, HIV positive, homeless, etc.).  I assure you that having worked with the homeless for many years - many of which suffer from mental illness - I am much more qualified that most obstricians and other family physicians who do surgical obstetrics and psychiatrists to manage the care of pregnant women on psychotropic medications.  I believe that without the distinction of specifying that these boards are directed towards those who wish to include major surgery in their obstetrical practice, Dr. Rowland's fears may be realized - at least in some parts of the country.

2)  I do agree with Dr. Rodney that the "certification process" will help open the doors for more family physicians to do surgical obstetrics than is currently allowed due to hospital politics as well as the difficulty for medical staff to verify adequate training. It will give a stamp of credibility that will assist Chairmen in advocating for a person's privileges and put the minds of medical staff service personel to rest.  Sadly, some of our colleagues try to do things that they are not well qualified to do.  While Chairman of a department, I had a person apply for privileges to do c-sections who had never done a skin to skin c-section in their life and who had not practiced any OB for over 10 years!  The applicant knew that we had family physicians doing c-sections and figured that if he applied for privileges he could "pick it up along the way."   Most medical staffs do not want to take the time to do that level of screening (unfortunately) or take the risk that somebody like that might slip by.

3)  I believe that we should go to a tiered level of OB training in residency (and fellowship) programs.  Level I - Outpatient Obstetrics;  Level II - Outpatient and Inpatient Obstetrics; and Level III - surgical obstetrics.  Everybody that graduates from a residency program should be required to have achieved TRUE competency in one of these defined levels and should then be "labeled" as such.

4)  I believe that in the past, many programs were able to train residents to do all three levels of obstetrics along with all the other things that are included in "full-spectrum" family medicine.  That having been said, with the current work hour restrictions, the lack of practical training from many medical schools upon graduation, and the proposed additional work-hour restrictions, I am not really sure how practical it is to adequately train beyond level II obstetrics in most residency programs.  While there wlll always be a few exceptional programs and a few exceptional residents, I believe that these will be the exception rather than the rule and if we hope to have credibility as a specialty (rather than just the few exceptions having credibility) then we have to start making structures that make our medical institutions comfortable with "the norms" within our specialty. 

5) As much as most of us hate tests, and hoops to jump through, that is unfortunately what is going to ultimately give us credibility across multiple hospital systems and communities.  Our "board certification" as a specialty may need to have special sections for family medicine obstetrics (level II) and family medicine hospitalists - and require passage of those sections to be board certified for that scope of practice.  I believe that "special boards" for surgical obstetrics (as is being proposed) may be benefical as well.  At this point, CMOs, chiefs of staff, and the very nice - but overworked - ladies and gentlemen  in medical staff services have absolutely nothing to determine a family physician's level of training other than the physician's word that they can do a given procedure and the very flimsy letters of recommendation - most of which come back with "excellent" checked in all of the boxes.  Many are now requesting numbers from previous hospitals - which is a nightmare for people who come from a County Hospital like the one I just left which has no accurate documentation of numbers.....hence, they have to trust my own personal logs.
 
In summary, I do believe that from what I just read, there are kinks to be worked out still with the ABFMO (or as I propose ABFMSO), but there are some definite benefits to the direction that is being proposed.  I also believe that unless our regular boards start making some distinctions for those of us who are hospitalists and who practice non-surgical OB, it is going to become more and more difficult for us to maintain credibility (and privileges) in all but rural settings.  This would be sad because all research and at least the quality indicators in the hospitals with which I have been associated have shown that family physicians match or exceed the standards of their colleagues in other specialties.  Even with that data staring the medical executive committee in the face, it still remains an uphill battle sustaining our broad spectrum of privileging.
 
We need to work together folks to protect the broad scope of family medicine and to protect its credibility across multiple communities going into the future.  This is going to require some very carefully written policies and very careful word-crafting and "labeling."
 
Bill
 

 
"A pessismist sees flowers and looks around for a funeral".
Mary MacMillan Rodney MD 1882-1986 ; member AAGP
 

Index--against ABFMO

ABFMO Part 2

From Bill Ellert MD founder of the Maricopa Fellowship:

Although I have practiced OB my entire career and delivered well over 1000 babies, I personally have never applied for c-section privileges.  Nevertheless, I have used my position(s) within hospital leadership to develop a training program for family physicians to become c-section trained and also fought for the right for appropriately trained famly physicians to obtain c-section privileges in multiple hospitals in metropolitan phoenix.  While obtaining vaginal delivery privileges has never been a problem - even when I was on the East Coast, I must admit that there have been challenging issues in maintaining all the privileges for independent practice for which I am well qualified.  The fight that a family physician has to go through to practice the scope of medicine for which they have been trained is so different from community to community.  Also, the "agenda" that each famliy physician has for their own practice differs from physician to physician within our specialty (this unfortunately has been one of our weakness as a specialty - we tend to not be able to agree among ourselves).
 
I would respectfully submit the following recommendations:

1)  Rather than calling it it the ABFMO, I would suggest that it be called the ABFMSO (American Board of Family Medicine Surgical Obstetrics).  Indeed, the focus is for those who wish to do c-sections - not necessarily high risk OB.  Many of us who do not do surgical obstetrics do high risk obstetrics including diabetes, HIV positive, homeless, etc.).  I assure you that having worked with the homeless for many years - many of which suffer from mental illness - I am much more qualified that most obstricians and other family physicians who do surgical obstetrics and psychiatrists to manage the care of pregnant women on psychotropic medications.  I believe that without the distinction of specifying that these boards are directed towards those who wish to include major surgery in their obstetrical practice, Dr. Rowland's fears may be realized - at least in some parts of the country.

2)  I do agree with Dr. Rodney that the "certification process" will help open the doors for more family physicians to do surgical obstetrics than is currently allowed due to hospital politics as well as the difficulty for medical staff to verify adequate training. It will give a stamp of credibility that will assist Chairmen in advocating for a person's privileges and put the minds of medical staff service personel to rest.  Sadly, some of our colleagues try to do things that they are not well qualified to do.  While Chairman of a department, I had a person apply for privileges to do c-sections who had never done a skin to skin c-section in their life and who had not practiced any OB for over 10 years!  The applicant knew that we had family physicians doing c-sections and figured that if he applied for privileges he could "pick it up along the way."   Most medical staffs do not want to take the time to do that level of screening (unfortunately) or take the risk that somebody like that might slip by.

3)  I believe that we should go to a tiered level of OB training in residency (and fellowship) programs.  Level I - Outpatient Obstetrics;  Level II - Outpatient and Inpatient Obstetrics; and Level III - surgical obstetrics.  Everybody that graduates from a residency program should be required to have achieved TRUE competency in one of these defined levels and should then be "labeled" as such.

4)  I believe that in the past, many programs were able to train residents to do all three levels of obstetrics along with all the other things that are included in "full-spectrum" family medicine.  That having been said, with the current work hour restrictions, the lack of practical training from many medical schools upon graduation, and the proposed additional work-hour restrictions, I am not really sure how practical it is to adequately train beyond level II obstetrics in most residency programs.  While there wlll always be a few exceptional programs and a few exceptional residents, I believe that these will be the exception rather than the rule and if we hope to have credibility as a specialty (rather than just the few exceptions having credibility) then we have to start making structures that make our medical institutions comfortable with "the norms" within our specialty. 
5) As much as most of us hate tests, and hoops to jump through, that is unfortunately what is going to ultimately give us credibility across multiple hospital systems and communities.  Our "board certification" as a specialty may need to have special sections for family medicine obstetrics (level II) and family medicine hospitalists - and require passage of those sections to be board certified for that scope of practice.  I believe that "special boards" for surgical obstetrics (as is being proposed) may be benefical as well.  At this point, CMOs, chiefs of staff, and the very nice - but overworked - ladies and gentlemen  in medical staff services have absolutely nothing to determine a family physician's level of training other than the physician's word that they can do a given procedure and the very flimsy letters of recommendation - most of which come back with "excellent" checked in all of the boxes.  Many are now requesting numbers from previous hospitals - which is a nightmare for people who come from a County Hospital like the one I just left which has no accurate documentation of numbers..... hence, they have to trust my own personal logs.
 
In summary, I do believe that from what I just read, there are kinks to be worked out still with the ABFMO (or as I propose ABFMSO), but there are some definite benefits to the direction that is being proposed.  I also believe that unless our regular boards start making some distinctions for those of us who are hospitalists and who practice non-surgical OB, it is going to become more and more difficult for us to maintain credibility (and privileges) in all but rural settings.  This would be sad because all research and at least the quality indicators in the hospitals with which I have been associated have shown that family physicians match or exceed the standards of their colleagues in other specialties.  Even with that data staring the medical executive committee in the face, it still remains an uphill battle sustaining our broad spectrum of privileging.
 
We need to work together folks to protect the broad scope of family medicine and to protect its credibility across multiple communities going into the future.  This is going to require some very carefully written policies and very careful word-crafting and "labeling."
 
Bill Ellert

Index--ABFMO, new suggestion for American Board of Family Medicine Surgical Obstetrics

The requirements for ABFMO

As you can see residency only people will not be excluded. Dr. Scholcoff, despite his excellent training at Rockford, has personally told me that he cannot get his residents credentialed at the place where he trains them. Further his Chair does not support the idea.
 
For every success story such as the letter from Chicago(she is not excluded) we have thirty stories like this one, "I am not sure if you remember me however I work under your work study program as a medical student.  I am currently a PGY III at AHEC-NE  in Jonesboro, AR.  I am very interested in doing obstetrics in my practice when I complete the program.
 
I am from Blytheville, AR and I really would like to go back there to practice.  At the end of my PGY I year, I contacted the CEO/Administrator there for information concerning their thoughts on FP and obstestrics.  He stated that they did not require a fellowship and that the c/s requirements would be the same as those recommended by ACOG. Since that time, the hospital has turned over and there is a new CEO.  Upon talking with him I was given the impression that they would love to have me come there as a family physician however not so sure about the obstetrical part.
 
He stated that he would like to continue to talk with me about this but he first wants to talk to the only delivering obstetrician there.  The concern he gave me was that they were trying to build up their OBGYN staff with 2-3 additional OBGYN's and with the number of deliveries "may not be enough to go around".  Another concern was insurance issues concerning an OBGYN checking out to an FP.
 
Another bait and switch CEO shenanigan undermining the excellent training she received in residency. It will be a difficult issue for any FP resident to practice OB in these towns. The CEO's are obsessed with the notion that only a board certified Ob-Gyn can do this job. they are continuing to squeeze out FP's rather than having one Ob and a supporting team of Cesarean capable FP's.
 
Same thing happened to the Contra Costa people in the NHSC story I shared. Why? Because nobody ever put the rights of FP-OB into writing. The residencies are not doing it in the teaching hospitals. The fellowship has allowed us to do that. If you can do it without  the fellowship, you are amazing. But there are very few of you.  I would welcome any evidence to the contrary.
 
Effective November 1, 2008 ABFMO REQUIREMENTS

The process of certification for Family Medicine Obstetrics involves satisfactory completion of a written examination, and oral examination, and demonstration of surgical competency to peer observers.

To begin the initial process of board certification in Family Medicine Obstetrics through the American Board of Family Medicine/Obstetrics (ABFMO), the applicant must:

Submit a completed Family Medicine Obstetrics (ABFMO) application with required processing fee, two (2) passport-size photographs taken within the last 90 days, and a notarized signature.

Be in conformity with the Code of Ethics of the American Board of Physician Specialties (ABPS); be known in his/her community as an ethical member of the profession, and be active in Family Practice/Medicine.

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.

Submit a current curriculum vitae which includes medical school experiences and degrees earned in chronological order.
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.

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 .

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. An ABPS CME form must be used, to view click here. (Form is included with the application materials)

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. Letters submitted on plain paper, without an address or telephone number of the signatory, are not acceptable. 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.

In order to sit for the written exam, applicants must also be qualified under one (10A or 10B) of the following:

A. 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.

B. Fellowship Track

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.

Applicants who have completed a fellowship program that has NOT been recognized by the ABFMO will be required to follow the Medicine track for eligibility.
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.

Successful completion of the oral examination satisfies all the requirements for initial board certification.

All physicians must do a self-query of the National Practitioner Data Bank and submit a sealed (unopened envelope) copy of the report as part of the application process. The report need not be submitted with the application but must be provided in order for the applicant to be approved to take the written examination. For information on performing a self-query of the Bank, go the National Practitioner Data Bank at http://npdb-hipdb.hrsa.gov for information.
All Canadian physicians must request and submit a testament statement form each Province in which a license is held, verifying that there have been no disciplinary actions against the applicant.

All physicians must allow AAPS to perform a background check, attested by initialing the appropriate line on the application form.

All physicians must submit the signed candidate appeal form.

Payment of appropriate fees.  To view the fee schedule, click here.

The ABFMOB recommends that the applicant keep a copy of all applications documents submitted to the ABPS.

Index--ABFMO eligibility requirements

American Board of Family Medicine Obstetrics.

I am not sure that the ABFMO is going to require a fellowship but will have standards for minimum OB experience and C-section numbers for competency.  This is a response to the ABS's inability to create a certification for operative obstetrics fellowships so we have responded with our own board.  If in the end, the certification process will be only for fellowship trained FM docs, it still is important.  Most, if not all, fellowships are much more rigorous than any residency experience. In the end our speciality will be better served formalizing our fellowship programs and ensuring they are teaching to an appropriate standard. 

Mike Tuggy

Hello:
 
I just received a letter and booklet delineating the NEW American Board of Family Medicine Obstetrics as a member of the American Board of Physician Specialties formed by FP's and OB docs recently.

Appear poised to provide board certification to FM docs who get fellowship training in approved programs (to be determined) so they can perform operative OB,  advanced OB practice with full certification. They are developing a board exam, process of grandfathering, etc.
 
Did anyone see this coming?  Hadn't heard it was in the works and then, blam, here it is.  Remarkable.
 
As with most things likely some good will come of it,  yet will graduates of programs training FM residents in operative OB now face discrimination based on not having the ABFMO certification?  I don't know how many FM programs are out there graduating folks with comfort in providing C/S---so we need to figure out how many they are and be sure the needs of our graduates are taken into consideration BEFORE we grandfather in everyone and cut off future folks.
 
Any guesses as to how many FM programs right now train graduates of 3 year programs to perform C/S as first assist and/or primary surgeon by graduation (at least some portion of their graduates (say at least one per year)?
 
Jeremy

I am proud to have been part of the original group for the American Board of Family Medicine Obstetrics. I will be at the Kansas City meeting to explain my advocacy for BCEM and ABFMO.
 
With a few exceptions, most residencies are owned by corporate interests whose political and economic incentives are not aligned with the training of full service family physicians. Few residencies have successfully obtained privileges for their own graduates on the benchmark issues of Cesarean section and other office surgeries. The fellowships have become a political necessity.
 
This is not about science or merit. The American medical education system has become a heavily subsidized research institute producing mainly subspecialized physicians with little accountability to the American public. Most of community medicine is being handed to nurses, PA's and other "providers" who are seen as interchangeable with office physicians. Fractures, pregnancy complications, and abcesses are routinely being triaged to the ER. Six years out of high school is what it takes to produce a Guatemalan GP and an American NP.
 
In Australia, the rural physicians broke away from GP family medicine and started their own specialty. Read J Rural Health 2009;25:231-232. Simmons PD. Rural Health: Its Own specialty? Published this month.
 
I have been corresponding with 2 recent graduates nobly fulfilling their NHSC commitment after outstanding training at Contra Costa(including Cesarean section). They will probably need  a fellowship credential to break into the marketplace of metropolitan/suburban America,  or teaching. Without Cesarean skills, FM's go hat in hand seeking "backup" from communities of OB's who may see them as undertrained risks or as competition or both.
 
The Contra Costa grads were placed in a small town where they have done 3 cesareans a year. The town is actively recruiting another OB. Their own town does not perceive their identity as a useful solution to the shortage of delivery committed physicians. This is doubly true for Central America, South America, and other parts of the developing world who perceive FP's as ambulatory triage officers. ABFMO built on a foundation of FM residency has a huge international opportunity if we can establish this credential.
 
The STFM group has the intellectual and political ambition to establish FP's as a specialty worthy of hospital privileges. But, when it comes to OB, many in family medicine are leading the retreat. The tree of family medicine may become lost in the forest of generic primary care.  The professional DNA of FM is constructed in places opposed to full training. The RRC has held the fort, but it is widely known that some are manipulating the rules when it comes to fulfillment of OB training. Were family physicians in residencies pushed or did they jump?
 
From the lips of a faculty this weekend--The Dean at UT Knoxville told faculty they would have to pay the differential for their OB insurance($5000), but, if they continued to deliver, the money for these services would not go to them; ie the faculty doing the work and paying their own insurance would not get paid anything extra. The Dean is a PhD. Flagrantly discriminatory but representative of the challenges of those who would dare to teach deliveries and procedures in an academic medical center.
 
At a state level the Tenn AAFP has never lifted a finger on this issue. Special kudos to the Bagwell-Harr AAFP-ACOG agreement, but it needs to be supported at the state level.  I believe that most of the membership will eventually understand that, even those with a deep seated aversion to OB, have something at stake here. Ask not for whom the bell tolls...........
 
The ABMS cannot allow the ABFM to establish training pathways or CAQ's in an area already claimed by another specialty. Ergo--BCEM and ABFMO. We expect to win the legal challenge which is sure to follow.
 
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
American Board of Family Medicine Obstetrics

Chair, Academic Affairs
Medicos para la Familia
Nashville, Memphis, and International

Index--American board of Family Medicine Obstetrics.

Pelvic Exams 2

Jack:

I am honored by your work and to be in your company. On the pelvic exam, my advice is  to demand universal pelvic ultrasound training for family medicine and/or any specialty seeking early and accurate diagnosis of pelvic pathology. Even using q 6 m screening schedules and a physician with arachnodactyly, the pelvic exam does no better than chance in the prevention of death from pelvic cancers.
 
As usual I am still learning, but I find significant pelvic pathology every week. Yesterday, I documented an 8x7 cm ovarian mass whose presence was not reported by two physicians who performed pelvic exams in the last week. One of them was a gynecologist.  She reported persistent pelvic pain which seemed different from her usual PMS. She was successfully having sexual relations 4-5 times a week. "Mild discomfort, but...." 
 
In our first flex sig study, JFP 1984, the biggest percentage of patients in that study were patients whose symptoms had been overlooked or underemphasized. The line between screening and case finding is very fuzzy. We have agreed that these equipment advances could be the antidote to diagnostic helplessness IF the RRC demanded educational accountability.
 
The medical home would be more likely to make a difference if it was well equipped, and there was a requirement that some of its physicians do more than generic primary care.
 
As one of my patients told me, "Without the cow, you can't put the cheese on your chili dog".  Yes, we speak redneck here in Tennessee. Meanwhile, Viva el NPI!
 
With best wishes for your professional success,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics

Chair, AcademicAffairs
Medicos para la Familia
Nashville, Memphis, and International

Index--pelvic exam, ultrasound, educational reform

Cesarean Refresher Plan

Dear Dr. Rodney:

I have question for you.  I am at a larger small hospital in rural Iowa about 100 beds with 400 + deliveries a year.  We have a group of three general surgeons who will do c sections and an ob in town.  There  is also a family doc who does c sections( he does the best job).  We have a colleague who did a residency and a fellowship and was trained to do c sections.  This person has not done one since residency (seven years ago)  and is now requesting privileges.  We want to be fair to this person but in my estimation the physician should have some amount of retraining.  This person works part time ( 2 days a week) and does no operative ob or procedures not even a circ. What is reasonable for retraining and then proctoring?  Thanks D. Dickman M.D.  P.S. This is a very good physician in question.
 
REPLY (WMR):

Easiest answer would be to scrub ten sections with your current surgeons and FP surgeon(3-4 each). Then there would be a candid evaluation of limits and continued professional development. Easier said than done in a small community.
 
The AAFP offers an instensive OB course each year and the next one is in March. There is another course called Advanced Life support in Obstetrics(ALSO) which should be taken and passed(2 days).
 
We are giving one in Chattanooga July 9-10 and I could get the doctor a spot if you want. I would personally give that physician a  refresher on basic surgery issues if you wanted. We do cover Cesarean basics in that course. Therer would be an evaluation.
 
Finally we will be giving a day long surgery lab this Fall.
 
With best wishes for your professional success,
 
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

Index--Cesarean refresher plan