Training in USA– what could we learn ? Juha Räsänen Department of Obstetrics and Gynecology Kuopio University Hospital Kuopio, Finland

How to be a MD in the US 4 years of undergraduate Whitman College, Walla Walla, WA 4 years of medical school Mayo Clinic, Rochester, MN 3 years of Maternal-Fetal Medicine Fellowship OHSU, Portland, OR 4 years of Ob/Gyn residency University of Utah, Salt Lake City, UT

Residency Training 4 years 4 months “off-service” during 1st year Internal medicine, Intensive care, Family medicine, Emergency medicine Split time between Ob and Gyn Rotations in gyn onc, REI, family planning, MFM, urogynecology

Subspecialty Fellowship Training 3-4 years Maternal-Fetal Medicine Gynecologic Oncology Reproductive Endocrinology and Infertility Urogynecology 2 years Family Planning Adolescent and Pediatric Gynecology 1 year Minimally Invasive Surgery

Residency Work Hour Restrictions Average 80 hours a week Maximum 30 hours per shift Minimum 10 hours off between shifts Average 1 day off per week

Typical Day on L&D Morning Board Sign-out 6:30 am 6:00 am on Fridays for Grand Rounds Evening Board Sign-out at 6:00 pm Night float Sun-Thurs 6 pm – 8 am Off Saturday and Sunday day Day team Mon-Fri 6 am – 7 pm In house call 2 weekends per month Friday night, Sunday day or Saturday 24 hours

Resident Duty Hours 1. Maximum Hours of Work per Week Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house call activities and all moonlighting. a) Duty Hour Exceptions A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale. (1) In preparing a request for an exception the program director must follow the duty hour exception policy from the ACGME Manual on Policies and Procedures. (2) Prior to submitting the request to the Review Committee, the program director must obtain approval of the institution’s GMEC and DIO.

Maximum Duty Period Length Duty periods of PGY-1 residents must not exceed 16 hours in duration. b) Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested. (1) It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours. (2) Residents must not be assigned additional clinical responsibilities after 24 hours of continuous inhouse duty.

Maximum Duty Period Length (3) In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. (a) Under those circumstances, the resident must: (i) appropriately hand over the care of all other patients to the team responsible for their continuing care; and (ii) document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. (b) The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.

Minimum Time Off between Scheduled Duty Periods a) PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. b) Intermediate-level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.

Minimum Time Off between Scheduled Duty Periods c) Residents in the final years of education [as defined by the Review Committee] must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. (1) This preparation must occur within the context of the 80- hour, maximum duty period length, and one-day-off-in seven standards. While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances [as defined by the Review Committee] when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. (a) Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.

Maximum Frequency of In-House Night Float Residents must not be scheduled for more than six consecutive nights of night float. [The maximum number of consecutive weeks of night float, and maximum number of months of night float per year may be further specified by the Review Committee.] Maximum In-House On-Call Frequency PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).

Mandatory Time Free of Duty Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.

OHSU 400 applicants * 7 residents/yr -USMLE -clinical rotation scores -letters of recommendations *start date July 1

OHSU * Intern yr - Williams: Obstetrics * 2nd yr - Gynecology basics * 3rd yr - Reproductive endocrinology * 4th yr - Gynecologic oncology

Examinations During residency * annual CREOG examinations After residency * written examination * case list * oral examination

OHSU Grand grounds * every Friday morning Chart reviews Science project

OHSU 1 yr residents - uncomplicated term deliveries - C. section - minor surgeries 2-3 yr residents - more complicated cases 4 yr residents -chiefs

OHSU Case list Patient charts signed by attending Patient flow in out-patient department

Maternal-Fetal Medicine Fellowship

Curriculum Program Objectives: A Program must be designed to provide advanced training in the care of the pregnant woman and her fetus, and in the use of advanced technical instruments and research skills. The purpose of a Program, therefore, is twofold:  1. The graduate of a Program is expected to function as a subspecialist in MFM; and 2. The graduate of a Program must be trained in advanced clinical and/or basic research and, be capable of expanding the knowledge base of MFM as exemplified by scholarly presentations and peer-reviewed publications generated from work completed during fellowship training.

Curriculum Maternal-Fetal-Neonatal Physiology A Fellow must have a thorough understanding of the physiology and pathophysiology of diseases occurring in pregnancy. A knowledge of both normal and abnormal newborn physiology also is expected so that there is a continuum of understanding which leads to improved care from the fetal through neonatal periods. Education in maternal-fetal physiology and in pathophysiology may be attained through lectures and laboratory experiences.

Curriculum Genetics / Genomics / Teratology Knowledge of genetics, genomics, teratology, and dysmorphology should be attained by a variety of venues, including practical experiences with reproductive/medical geneticists and genetic counselors (such as formal rotations and/or clinics), as well as lectures and courses. A Fellow must be able to obtain and interpret pedigrees, provide genetic counseling to women and families, and discuss the risks and benefits of different strategies for prenatal screening and invasive prenatal diagnosis. They should understand both Mendelian and non-Mendelian patterns of inheritance, principles of cytogenetics, chromosomal abnormalities, single gene genetic disorders, and emerging genetic technologies including free fetal DNA and microarray technologies. They also should be able to provide a differential diagnosis, management options, and prognosis for a fetus with abnormalities detected on ultrasound or with abnormal genetic testing.

Curriculum Infectious Diseases Knowledge and practical experience in infectious diseases as it relates to pregnancy and the puerperiumis essential. This must include the effects of maternal infection on the fetus and newborn.

Curriculum Obstetrical Critical Care A Fellow must have knowledge and experience in obstetrical critical care. This must include the training in the management of acute peripartum medical and surgical complications.

Allocation of Fellowship Training Time (In effect through June 30, 2013) Within a Program, the length of training must be the same for each Fellow unless the Fellow has entered a combined MFM/Genetics Program. The Program must include a minimum of: *18 months of block time for research/didactics *12 months of clinical MFM *6 months of for electives to focused on a specific clinical or research area at the discretion of the Program Director

Allocation of Fellowship Training Time (In effect starting July 1, 2013) *12 months of block time for research/didactics *1 month assigned to a medical or surgical intensive care unit as a participant in patient care, not simply as an observer *2 months as supervisor of a Labor and Delivery unit *12 months in clinical MFM *9 months of electives focused on a specific clinical or research area at the discretion of the Program Director

Leave Policy Three-Year Program: *8 weeks in the first year *8 weeks in the second year *6 weeks in the third and final year Total of 15 weeks over the entire three years

Evaluations and Reviews 1. Fellow Evaluations a. Semi-Annual Evaluations The Program Director must evaluate each Fellow at least every six months. b. Final Evaluation The Program Director must perform a final evaluation on each Fellow who completes the Program (separate from the semi- annual evaluation). It must verify that the Fellow has demonstrated sufficient ability to practice competently and independently. c. Thesis Defense Each Fellow must defend their thesis to the Program Director, research mentor, and other members of the Division prior to graduation. Written documentation of the defense must be available to the ABOG Fellowship Reviewer at the time of each onsite program review.

Annual Report – Research and Clinical a. Research Summary Statement A summary of each Fellow’s accomplishments in research must be submitted each year with the Annual Report. This summary must be brief, but must explain what the Fellow’s activities were during the academic year. This will be submitted every year as part of the Program’s Annual Report. b. Clinical Experience Logs (Starting with the first-year Fellow for the academic year 2012-2013) Beginning in July 2013, the Fellows will be required to submit a log of the number of procedures performed in certain categories, such as cerclages, peripartum hysterectomy, genetic amniocentesis, etc. These procedures will be submitted every year as part of the Program’s Annual Report.

Evaluations and Reviews 2. Faculty Evaluations The performance of the faculty must be evaluated formally in writing by the: *Fellows on an annual basis *Program Director no less frequently than at the midpoint of the accreditation cycle and again prior to the next onsite program review These evaluations should include a review of each faculty member’s teaching abilities, commitment to the educational program, clinical knowledge, research mentoring, and scholarly activities. These evaluations must be available to the ABOG fellowship reviewer at the time of each onsite program review.

Thesis By the end of the first year of fellowship training, a Fellow should have: *A thesis topic *An assigned thesis mentor(s) By the end of the fellowship training program, a Fellow should have: *Completed the work for their thesis *Completed and submitted a written manuscript of the thesis to their Program Director *Verified with the Program Director that the thesis meets the requirements for eligibility for the ABOG’s subspecialty oral examination *Defended their thesis to their Program Director, research mentor, and other members of the Division *At least one publication or presentation at regional, national, or international meeting

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