There are a defining dozen issues that lead to reimbursement privileges. Almost all relate to hospitals' stranglehold on the boundaries of Family Medicine. Colonoscopy, EGD, Deliveries, Cesarean Sections, D&C, IV sedation/analgesia, and the hospitalist/ER tool chest(central line insertion, chest tubes, pacemaker placement, etc.).
Other skills require a standardized set of clinical simulations. After drills with performance-based learning, the material logically leads to competency-based testing. This was the model for ACLS which begat ATLS which begat NALS which begat PALS which begat NRP which begat ALSO and CALS.
Medicosmundial has defined similar competency-based testing for ECG interpretation, chest xray interpretation, fractures in the office, offfice anesthesia, Ob ultrasound, Gyn ultrasound, Abdominal ultrasound, colposcopy. This is defining our concept of Surgical Family Medicine Obstetrics.
Other skills are more difficult to study, but I think Medicos is on the right track in defending our graduates as having proven training, experience, and ability---Gyn Surgeries in theoffice(Bartholin's, EMB, D&C, IUD, cervical cryosurgery,...); Derm surgeries in the office(includes lacerations, cryo, electrosurgery, circmumcision).
Yes, I believe circumcision is mainly a derm surgery for cosmetic reasons. However, we have expanded our curriculum to include some phimosis cases ages 6-64. Can you say, "Bulldog Gomco"? The holy grail of this quest is a curriculum defining all the variations on the the theme of cesarean section. This door opens others.
This is the physician who can regain the high ground once held by family physicians who cared for children, deliveried babies, managed fractures, counseled single parents, and went from the nursery to the nursing home. When all else failed, they comforted the dying. How many cases should the physician have to be declared competent for that?
The definition of competency is an appropriate intellectual pursuit, but the word itself is contaminated by inappropriate usage and false expectations. Shave biopsy is not on my top two hundred things to worry about. It is a see one, do one, teach one. No graduate has ever been challenged for the right to do a shave biopsy.
For example, if you were writing a residency completion letter for one of your graduates, would you specifically mention shave biopsy? Hasta la Bamba!
With best wishes for your professional success,
Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor and Chair
Medicos para la Familia
Hi Dr. Rodney :
In spite of my reluctance, I have actually become rather good at circumcisions during the course of residency. I think I prefer the mogan technique. Can you comment?
Keep an eye out for my ob fellowship application!
C Gray
Bill:
I sure enjoyed the "bobsled ride" down through your last email reply . . . and I couldn't agree with you more on many of these points or have stated them any better. Nonetheless, after all this time and despite the noble and valiant efforts of this STFM procedures/hospitalist group, our FM training programs are still struggling in their efforts to define and recognize "competency".
Certainly, there is still a long list of procedures like Shave Biopsy that fall into the category of "See One-Do One-Teach One", but there are plenty of more procedures that require a minimum set of numbers - both to provide a "flower bed" of experience in which competency (proficiency?) can germinate, grow and blossom - as well as to provide the fodder for those pesky hospital credentials committees that have such a vested "turf-based" exclusionary interest in specific high-profile profitable procedures. This is where we as family docs and our graduating residents and fellows as new family docs are being thwarted by "emminence-based" and "arrogance-based" medicine. In addition, the RRC is raising the stakes for our residency programs by requiring all of these hoops to be jumped through for all procedures for which we say we train our residents to competency, no matter how simple.
I, for one, am strongly opposed on principle to setting a specific number as a threshold for determining competency/proficiency for any procedure. Credentials committees, professional societies, and training programs universally take such numbers and wind up setting this number as the default determination of competency; it becomes both the goal and a wall simultaneously. As Jeremy iterated well, we all really prefer to keep the focus on the high road of expert faculty observing and recognizing when a resident is competent, "I can't define it, or ascribe a # to it, but I know it when I see it!"
And therein lies the rub: most of our training programs are too large and have too few procedurally proficient faculty to get that part of the job done. In the end, we quibble about numbers for procedures when in reality, Bill, you are correct. It takes a quantum leap in training and experience as well as a much more profound embracing of our role as family physicians and healers to comfort the dying patient and gently guide grieving family members and loved ones through the process of "letting go".
-pwd
Agree with both.
We are moving toward "prepared" as the term to explain where we want residents to be on graduation. We are using that term when surveying residents and getting some interesting results that are helping guide our ever-evolving curriculum (procedural and non-procedural).
When asking about faculty, we use the term "comfort" in teaching others. Tried to use that term with residents but residents tend to under-estimate comfort---which connotes feeling at ease rather than prepared---yet it seems to be right for those who teach.
Anyway, size and the enormous numbers of procedures being done---hundreds per month in New-Innovations at our program---make initial number thresholds important to identify "readiness to be signed off" for more complex and higher risk procedures, while we've fallen into the number alone for most others.
Not perfect, yet the best we have been able to muster at this point.
Jeremy
Index--What is the number?
Comments