Who Will Deliver My Baby Who Will Deliver My Baby? Prenatal Care for Low-Risk Obstetric Patients An 18-month Interactive Learning Curriculum for Family Medicine Residents Patricia L. Goodemote MD Lt Col, US Air Force Belleville/Scott AFB Family Medicine Residency

Imagine as pregnant. - yourself - your wife - your daughter - your niece as pregnant.

Who Will Deliver My Baby Who Will Deliver My Baby? 23 Red Alert States (ACOG) - 1 in 7 OB/GYNs not providing obstetric care - 35% OB/GYN PGY-1 slots - not filled 2004 - Family medicine providing OB care declining; 43%(1986) - 22%(2000) Medicaid and uninsured have difficulty finding OB care

Location – Belleville, Illinois Combined military/civilian Family Medicine 14 residents per year group Purpose - train residents in full-spectrum care Required to follow 15 OB continuity patients

Local Need Local Assessment Residency Assessment Illinois and Missouri - Red Alert States Our hospital lost 6 of 11 OBs in last 2 years Residency Assessment Focus Groups/Surveys/In-training-exams Primary obstetric area needing improvement Prenatal curriculum Wednesday didactics – interactive learning

Interactive Learning Curriculum for Family Medicine Residents Proposed Curriculum Prenatal Care for Low-Risk Obstetric Patients An 18-month Interactive Learning Curriculum for Family Medicine Residents

Curriculum Development 1. Received expedited IRB Approval 2. Derived course goal/structure 3. Specified unit goals and general content of each 4. Developed draft of sample unit to be tested: Goals and Objectives Content and Instructional Strategies Learner Evaluation 5. Created materials for tested unit 6. Pilot test 7. Expert reviewers

Curricular Goals As family medicine physicians working in the community, when seeing obstetric patients in each trimester will be able to : 1. Elicit and document history 2. Perform and document physical 3. Identify and document appropriate labs 4. Develop problem list and determine risk 5. Manage low risk obstetric patients 6. Counsel prevention and follow-up

Curriculum Overview Didactics - 6 sessions of 4 hours each Unit I. First Trimester 2 sessions Unit II. Second Trimester 1 session Unit III. Third Trimester 3 sessions

Identify, counsel, and document labs Curriculum Overview Low-risk prenatal care 1st Trimester 2nd Trimester 3rd Trimester Elicit and document history Perform and document physical Identify, counsel, and document labs Develop problem list and determine if low risk Manage low risk obstetric patients Counsel on prevention/follow-up

Unit Pilot Test – 1st Trimester Provides a solid foundation March/April 2005 Intervention - 2 sessions (4 hours each) Pre and post tests conducted 1 week prior and 2 weeks after Selection criteria Written test – all residents available during testing Videotape – 1st years (advisors not involved in study)

Unit Objectives When presented with a first trimester obstetric patient a family medicine resident will be able to: 3. Identify/document appropriate laboratory tests a) order routine labs and labs based on H&P b) counsel patient on MSA* and CF** screen c) document labs in obstetric chart correctly *MSA – Maternal Serum Analyte **Cystic Fibrosis

Unit Instructional Strategies Explanation and Demonstration: 1. Order a) Reviewed CPG* for appropriate lab tests to order b) Ordered lab tests based on a simulated chart 2. Counsel a) Reviewed samples of MSA and CF consent forms b) Videotape shown of counseling a patient 3. Document a) Reviewed where and how to document labs b) Sample documentation of labs for simulated chart *DOD/VA Clinical Practice Guideline for Management of Uncomplicated Pregnancy

Unit Instructional Strategies Practice: 1. Order a) Residents given 3 sample charts and practiced ordering appropriate lab tests b) Residents given 8 practice True/False questions on specific lab tests 2. Counsel a) Residents broke into groups of 3 and practiced counseling each other on MSA and CF screen 3. Document – not specifically practiced

Practice Makes Perfect Working on simulated charts Practicing counseling skills

Unit Evaluation Strategies 1. Order – residents given written tests a) 2 sample charts provided - ordered appropriate labs b) 8 True/False questions on specific lab tests 2. Counsel – residents videotaped and scored a) Simulated obstetric patient b) Counseled patient on MSA and CF screen 3. Document – not tested as this is evaluated on every obstetric chart

Pilot Study Written test Videotape Counseling Evaluation 18 residents took both Pre and Post 16 residents had attended one or both sessions Videotape Counseling Evaluation 3 first year residents pre and post video

Pilot Test – Written Results Residents pre and post tested Number tested Written Pre-test % Correct Post-test Total 18 63.7 72.8 Attended one or both sessions 16 63.2 73.7 Attended neither session 2 67.5 66.0 Paired differences in pre and posttest result percentages of the 16 residents who attended one or both sessions Mean improvement of 10.5 % (CI 6.9-14.1) P value <0.001

Pilot Test – Video Results Counseling subject Pretest Ave (%) Post-test Ave (%) CF and MSA 63.3 74.2 Prevention/Follow-up 58.3 80.0 Overall 60.8 77.1

Pilot Unit – Resident Rating 41 evaluations received 40 of 41 rated session good or excellent Most useful Practice with simulated charts Least useful Practice history taking with other residents

Reviewers Educational Design Expert (PhD) Content Experts (MDs) Kent Sheets “faculty development…to help with didactic sessions….assist in reinforcing new behaviors” Content Experts (MDs) Margaret Helton, Dave Harnisch, Deborah Bostock “exceptionally organized and clear” “more emphasis on prenatal counseling” (Harnisch) Pre and post tests of equal difficulty

Future Endeavors Revise 1st Trimester Unit Eliminate history taking exercise Decrease didactic lecture style Increase activities with practice simulated chart Retest revised 1st Trimester Unit at Eglin AFB Include faculty development prior to testing Develop Other Units 2nd Trimester Unit - Spring 07 3rd Trimester Unit – Fall 07

Conclusion Family physicians can help fill the gap in obstetric care even in this litigious environment but they need a solid foundation. This curriculum could start building that foundation.

Who Will Deliver My Baby Who Will Deliver My Baby? Prenatal Care for Low-Risk Obstetric Patients: An 18-month Interactive Learning Curriculum for Family Medicine Residents Patricia L. Goodemote MD Belleville/Scott AFB Family Medicine Residency