Question:
A Cesarean trained family physician, asks about having additional surgical backup as a prerequisite for accepting responsibility for surgical OB night call. He cites the need for someone to manage ectopics, ruptured cysts, and bleeding fibroids.
WMR Replies:
This is a variation on the C hyst dilemma, but double coverage of this type is nearly impossible for most rural, frontier, and mission hospitals.
Is there data describing the epidemiology of these events?
Is the event frequency 1 per 1,000, 10,000, 100,000 female patients 15-44 per year?
Needs assessment is the foundation of curriculum planning.
Early and frequent office ultrasound at the point of serivce has totally changed the game with the majority of our ectopic pregnancies(which are rare to begin with) now being managed nonsurgically(methotrexate).
If desirable, why not just learn to remove an ectopic surgically? It's only a few clamps and a few more sutures.
As to the ruptured cysts, this is a pain and observation issue with chemical peritonitis or life threatening hemorrhage being rare to the point of invisibility. Bleeding fibroids as a cause for urgent surgical intervention? Everybody has an anecdote, but what are the data to justify all of this extra commotion and double coverage?
During 12 years of gathering data for the Medicos Project which now stands at overe 500,000 office vists and over 5,000 deliveries--We have not seen any need for these last two skills as prerequisites to allowing Cesarean section trained family physicians to take night call.
As Dr Mary used to say, "Age is a wonderful teacher, but a lousy beautician"
aka "Risk and fecal debris occur spontaneously".
----wmr
PREVIOUS EMAIL INQUIRY AND RESPONSE:
Good morning everyone:
I know this is a colonoscopy list but I know many of you still do operative OB.
I recently finished my OB fellowship in Seattle at Swedish First Hill. It was a great experience. I want to thank many of you who helped me in deciding where to go and what programs to look at.
I am now working as faculty in a residency program in Canton, Michigan. We are working on getting our OB numbers up but in the meantime I wanted to continue to operate by moonlighting here. I have C/S privileges and the OB department has been very helpful.
The problem with moonlighting on OB is that occasionally you have a ruptured ectopic, ruptured cyst or bleeding fibroid which I am not credentialed to do.
Do any of you have something worked out with your hospital so that when you are on call covering OB there is a "second call" gyn who can come in on the rare event one of these cases presents itself? Do any of you have ideas about how I can approach this when asking to moonlight and this comes up?
Thank you for your help.
I have worked in two communities and in both instances I made certain that I did have coverage for those circumstances before signing a contract. Yes, I am employed as are the obstetricians, which really helps with leverage. I also moonlight as a hospitalist there and bring a lot of patients to the hospital... which again, helps a lot with leverage. In other words, I think it is key to have the hospital supporting your 'type of practice' and to gain their support, you need to bring something in return.
xxxxx MD
Index--Surgical OB, privileges, fellowship curriculum needs
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