1. v v Family Medicine Maternity Care Call to Action: Moving Towards National Standards for Training and Competency Assessment Thomas O. Kim, MD, MPH, Susanna R. Magee, MD, MPH, Mark Loafman, MD, MPH, Suzanne Eidson-Ton, MD, MS, Joseph Breuner, MD, Michael Tuggy, MD, Lawrence Leeman, MD, MPH Introduction Methods Innovations/Recommendations Maternity/newborn care is an integral part of the practice of family medicine (FM) and encouraging more FM graduates to participate in maternity care (MC) could have a lasting national impact on public health needs. Despite a clear need for more obstetrical providers, the percentage of family physicians providing MC services continues to decline, from 29% of providers in 1988 (1) to 10% in 2010 (2). Reasons cited for decrease include privileging issues, lifestyle issues, and malpractice coverage costs (3-6). More newly graduated family physicians decide not to incorporate MC into their practice despite many having achieved a level of competency. Privileging issues may be related to the fact that competency is not immediately apparent to all stakeholders in health systems across specialties CAFM asked for a group of national experts, identified through the Group of Family Centered Maternity Care of STFM, to produce a recommended framework to achieve a system within family medicine training – to clearly define MC competency, systematize a set of tools to assess competency, and develop a national implementation strategy to utilize these tools to decrease barriers to family physicians providing maternity care. 2012: Many residency programs faced challenges in meeting ACGME Family Medicine Review Committee (RC-FM) standards in maternity care 2013: RC-FM standards for maternity care training in FM were changed and accepted -- graduates must demonstrate competence in:  Distinguishing abnormal and normal pregnancies;  Caring for common medical problems arising from pregnancy or coexisting with pregnancy;  Performing a spontaneous vaginal delivery; and  Demonstrating basic skills in managing obstetrical emergencies.” (Lines IV.A.5.a).(1).(c).) 2014: STFM Family Centered Maternity Care Group formed a work group to develop standardized training requirements and assessment tools, culminating in the “Family Medicine Maternity Care Summit” in Chicago. References 1) Nesbitt TS, et al. Am J Public Health 1990; 80:814-818. 2) Tong ST, et al. J Am Board Fam Med 2012;25(3):270-271 3) Pecci CC, et al. Fam Med 2008;40(5):326-32. 4) Magee SR, et al. Fam Med 2015;47(1):48-50. 5) Phillips RL, et al.. J Am Board Fam Pract 2002;15(3):250-4. 6) Sutter MB, et al. Fam Med 2015;47(6):459-465. 6) ACGME Program Requirements for GME in Family Medicine. July 1, 2015. Proposed Minimum Volume (prior to assessment) NOVICE (1)INTERMEDIATE (2)EXPERT (3) Control of delivery Does not control the delivery. Needs assistance of supervisor. Controls the delivery of infant. Obtains cord blood and performs placental delivery w/o assistance. Supervises others in vaginal delivery and manages complications. Time and Motion Many unnecessary moves Efficient time/motion but some unnecessary moves Clear economy of movement and maximum efficiency. Instrument Handling, Laceration Repair Repeatedly makes tentative or awkward moves with instruments Competent use of instruments but occasionally appeared stiff or awkward Fluid moves with instruments and no awkwardness Knowledge of Complications Deficient knowledge. Unable to recognize need for assistance. Ex: Recognizes shoulder dystocia and can perform maneuvers to relieve. Can teach management of shoulder dystocia and PPH. Comments: Example Procedure Competency Assessment Tool (PCAT) Clear delineation of three scopes of practice, allowing for common language and standard understanding of skill set. o Basic: focus on outpatient prenatal/postpartum/inter-conception care o Comprehensive: + routine labor, vaginal delivery management o Advanced: + higher risk cases at scope similar to obstetrician Minimum volume should reflect volume at which exceptional trainees could achieve competence, NOT volume at which competence is achieved Proposed use of PCAT format to standardize competency assessment With common national assessment tool, we build a more learner- centric approach, since volume does not guarantee competency. Volume becomes one part of an equation reflected in training. Lower minimum volume reached by consensus opinion at the Family Medicine Maternity Care Summit, easing a barrier for some programs and trainees (e.g. 40 vaginal deliveries; 70 cesarean deliveries) Online Learning Collaborative proposed – would allow ongoing national discussion and dissemination of best practices around: Learning Collaborative could also facilitate a data platform to validate new educational tools in MC Standardization of curricula and assessment tools could pave the way for formal certification of trainees (e.g. CAQ) who have achieved competencies, and/or training program accreditation/assessment. o PCATs (fine-tuning old, developing new) o Minimum volume standards o Training methods/curricula o Faculty development