QUESTION:
Read your post on some site and would be interested in viewing your list of procedurally competent FP residencies.
Thanks,
Drew Posey
UNT HSC Texas College of Osteopathic Medicine
3rd year
Two issues.
First, academic medical centers, due their dysfunctional design and ownership by physicians who have never actually done any noninstitutional medical practice, have a negative impact on the professional aspirations of physicians who want to provide a broad range of services. Look at the "primary care" leadership panel in the New England Journal 2008. We might as well have a gifted group of librarians from Iowa teaching a mandatory curriculum in trans-oceanic sailing. The innmates have gained control of the asylum.
Medicos is a project using family medicine as its foundation. From there it expands into obstetrics, emergency medicine, office surgery, and international service. Very few programs measure up to this standard but JPS, Ventura, Contra Costa, and Via Christi come to mind as centers of excellence. There are others. Anywhere there is a Family medicine Obstetrics fellowship is worth looking at.
Generally programs in Texas, Alabama, and Oklahoma are worth looking at. Ironically some rural states such as Mississippi have never found a way to get privileges for their FP's, and the academics there actually discourage students from trying.The St Francis Memphis program is regaining its former footing. any program with family medicine faculty doing Cesareans and ultrasound is a step above.
Programs using FQHC's as their FPC are at a major disadvantage. Programs highlighting their alternative medicine and geriatric medicine tracks are usually very toothless with regard to practical skills. Watch out for salemanship and "spin". Get the data. Example on the "lifestyle myth" follows.
Medicos published a study on the amount of hospital time necessary 2300-0600 and # of phones calls received during "sleep time" 2300-0600. consectuive years have been studied since 2000[Y2K] and the data ranges from 72 deliveries/yr to 440 deliveries per year. All fellows are required to answer their cellphones all the time. No answering service. Call averages every 3-4. Thrice a year we have 4-5 deliveries in one 24 hour period. The average physician is up to deliver 2300-0600 once or twice a month. Nurses function as our interns.In 10 years, we have NEVER had a physician up all night. This year Medicos will do about 450 of its own deliveries and another 200 scheduled sections for other physicians. Reprint posted. www.psot.com
Second, while part of the UCLA School of Celebrity Medicine, I created "Rodney's Oscar Nomination Awards[RONA]" for those students seeking residency training where procedures were enthusiastically taught. At the Phoenix Summit for the Society of Teachers,2006-2009 talked about my "Defining Dozen".
In a forward to the annual RONA ceremonies, I point out that the addition or loss of one procedural faculty can be a sea change for over ninety percent of programs. Therefore, the list is a dyanamic set of probabilities. But, there are 6-8 questions which are useful for the students who wish to interrogate in a systematic way. Here is the preamble from the 2008 RONA Awards Ceremony.
The potential for procedural excellence exists in some, but not all residencies. If you guess incorrectly, do not fear. A 12 month post-residency fellowship can usually get you where you want to go. Ironically some rural programs are incredibly weak and some urban programs like Contra Costa seem incredibly strong. [A malignant Dean or hospital administrator can destroy a beautiful program like Maricopa.]
During my highly excellent adventure at UCLA, I developed what came to be known as the Oscar nomination list for students who sought to fulfill their search for the Holy Grail--The universal antidote to procedural helplessness. I told students to search for solar systems where they might encounter enthusiastic effectiveness rather than politically correct, but hollow, promises. This list has been updated annually since 1984.
The Oscar nomination list is distributed to medical students with the disclaimer that the half life of accurate information in the residency reputation world is 18 months. Several programs are listed as a "strong" recommend on the issues which proceduralists[FAMILY MEDICNE-ob-er] view as important. But, when a strong director leaves, programs can change dramatically. Students, residents, fellows, and faculty are asked to update this information and respond to the suggested process. I request that post interview students let me know where additional editing should occur.
The list is not for widespread public dissemination. Undoubtedly there are some good programs that I have not listed accurately and I do not wish to offend those who have struggled to improve their programs. My ignorance of their efforts is not an intentional omission. Although I sat on the RRC for 6-7 years, the list is used internally in my department to help counsel medical students on the process of residency selection through meaningful inquiry.
This document contains generic advice as the central theme, but each year feedback is solicited as students interview and gather information on the most recent status of these programs. The Oscar nominee list" is an adjunct to the process of interview recommended in the preamble.
I. General Guidelines
A.Identify what is likely to be important in the community practice you may have. Since the teaching of procedure-enhanced Family Practice is “the road less traveled,” this report will focus on locating this special subset of programs.
However, there is a list of programs where deliveries and OB are not emphasized. Call me for an up-to-date list.
B.Be tenacious and protect time for this investigational task. There are some exceptional training opportunities, and some are average at best. A motivated individual can always overcome mediocrity.
Do clever things to investigate the quality of support your future patients will receive.
Examples:
1. Pretend you’re a patient who wants an appointment today for a repair of a six inch laceration on your leg.. Tell them you think you might have a fracture. Call and see if you're referred to the ER.
2. Tell them you want to pay cash. Ask how much you should bring.
3. Tell them that Dr. (fill in a real name) resident or faculty member has been recommended to you. Can you be seen today[open access] or do you have to go to the ER? As a resident you want these acute care skills in your family medicine office.
C. There are special features that quickly allow the applicant to identify environments where acquisition of clinical skill is more likely.
1. Hospital privileges are currently held by family physicians and active teaching is done by FP faculty in Labor and Delivery. Literally this is a watershed issue for a whole variety of scope of practice issues ranging from the ICU to the ER and beyond.
2. At least four FP faculty are OB-capable and actively help supervise deliveries. Applicant’s question: “Do the FP faculty actually come into the hospital between the hours of 10:00 pm and 6:00am to help you with delivery and/or management?”
3. Ultrasound capable FP faculty with an ultrasound unit, perform these services and teach in the FP office. Applicant question: “Is there an ultrasound machine located in the office and can the residents use it (with or without supervision)?” "Are you allowed to bill?(i.e., Is it for real?)
4. If FP faculty do not even teach colposcopy, office surgery, and short colonoscopy, they are not dedicated to providing a procedural curriculum. Cesarean sections, EGD and/or colonoscopy-capable FP faculty are a bonus.
5. Ask to see an average Letter of Completion (see Appendix A). When you graduate from residency, what will your letter contain?
6. Is there an electronic medical record which works well?
D. Use your contacts at the AAFP/STFM, 1-800-274-2237.
1. Request the STFM Fellowship Directory to locate residencies with fellowships in FAMILY MEDICINE-er-ob. These suggest curricular resources which enrich the residency experience.
2. Are residents encouraged to attend clinically helpful courses (CME) available from the American Academy of Family Physicians (AAFP)?
a) Annual Scientific Assembly (4 days in late Sept/early Oct, call for location). Various procedural courses in endoscopy , office surgery, and more.
b) CME on various topics throughout the year (ask Dr. Rodney for mailing list or check his web page www.psot.com).
3. How to select a practice locale.
a) Hospital Fair Play-on-Privileges List. (community selection)
b) Developing a “critical mass” of like-minded peers. Onesies and twosies are have shorter half lives. Choosing a partner.
c) Selecting limits on your lifestyle, family, and call
E. In the teaching environment, watch out for warning signs and symptoms of “procedural helplessness” (also known as taught helplessness).
1. “Everybody here gave up OB a long time ago because of the malpractice.”
2. “Most of this teaching is done on the subspecialty rotations where the residents learn from an expert.”
3. “Procedures are important, but we are concerned that too many procedures will deflect residents from spending sufficient time on the psychosocial issues.”
4. “We’ve recruited someone (i.e., a single person) to teach procedures.” or “We have one faculty who still does OB.”
5. “Anything that takes you out of the office loses revenue for the practice.” “Procedures are not time efficient!”
6. “Nobody in practice does OB or hospital work anymore.” or “None of our graduates want to do OB once they get into practice.”
7. There are so many underemployed specialists that we’d all be better off referring procedures to them.
8. Others.
Ask to See a Sample Letter of Completion
Appendix A (Revised 7-8-99)
Re: ___________________,M.D.
To Whom It May Concern:
This Family Practice Residency Training Program recommends Dr. ______ for clinical privileges. This letter signifies successful completion of the requirements leading to a qualifying examination by the American Board of Family Practice. This training program is one with special requirements and rigor. By completion of this program, Dr. ______ has demonstrated skill and competence in the diagnosis and treatment of a wide variety of illnesses. Structured hospital rotations are conducted in Internal Medicine, ICU (including ventilator management), Emergency Medicine, Surgery, Obstetrics, Pediatrics, Nursery, and others. During the course of training, the physician performed exceptionally well amidst a variety of critically ill patients. This reflects well upon the judgment and character of Dr. ________.
Special requirements of this program, include Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS), and testing of these skills in a busy emergency room. Pediatric Advanced Life Support (PALS) is encouraged, and Dr. ____ is current in these critical care skills.
The ______ Residency Training Program contains special curriculum for its residents. All residents are required to complete workshops in flexible sigmoidoscopy, endoscopic biopsy, colposcopy, cryosurgery, fetal monitoring, ENT endoscopy, ECG interpretation, chest x-ray interpretation, suturing, and more. These workshops are taught by faculty who are proven clinicians and published scholars.
Please forgive the detail of this letter, but hospital committees and licensing boards face a difficult task without thorough documentation. The Residency Director and/or the Chair are responsible for accurately communicating the accomplishments of each resident. Dr. ______ is entitled to full privileges throughout the spectrum of family practice. This includes, but is not necessarily limited to, routine hospital admissions, ICU, nursery, OB, pediatrics, and the emergency department. Dr. ____ appropriately seeks consultation when needed.
The doctor is entitled to normal obstetrical privileges including diagnostic OB/GYN sonograms-ultrasound, and vacuum assisted delivery.
Optional (depending on resident use of selective time): Dr. ______ has successfully completed additional training in dilatation and curettage, upper GI endoscopy (EGD), colonoscopy, polypectomy, IV conscious sedation. Cesarean section skills are documented.
In summary, Dr. _____ is an exceptionally well-trained family physician who is respected by peers and colleagues. Your community will benefit from patient care provided by this physician. If I can clarify any of the above, please feel free to call me personally.
Respectfully submitted,
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--OB, training design, lifestyle 101, residency selection, RONA's 2009
