Collaborative Practice and Teaching in Perinatal Care: Certified Nurse-Midwives as Educators of Medical Residents.

INTRODUCTION: The goal of this study was to update understanding of the current roles and responsibilities of certified nurse-midwives (CNMs) in the education of resident physicians. Three subaims were to (1) examine the involvement of CNMs in the education of residents in obstetrics and gynecology and family medicine, (2) examine the typology of CNMs' collaboration with residents, and (3) describe CNMs' opinions regarding their educational roles and responsibilities. METHODS: This descriptive study used an electronic survey sent to CNMs involved in the education of medical residents. Survey participants were identified using an online directory of CNMs involved in academic midwifery practices in the United States. Survey items included both closed-ended and open-ended questions to generate quantitative and qualitative data, respectively. RESULTS: Of the 146 CNMs invited to participate, surveys were received from 85, a response rate of 58%. Seventy of the respondents fit inclusion criteria of working with family medicine and obstetrics and gynecology resident physician programs. Most of the midwives' educational roles included informal mentorship of residents, supervision and consultation of intrapartum care, and caring for either their own or residents' patients. All respondents agreed that incorporating CNMs into clinical teams and faculty roles improves resident education. The majority of respondents desired a greater degree of involvement in resident education, with 57% preferring a blended interaction model. DISCUSSION: The majority of CNM respondents reported a preference to have greater involvement in the education of residents. Although CNMs desire a blended interaction or fully integrated model of collaboration with resident physicians, the current state of CNM involvement does not fulfill this degree of collaboration. Opportunities exist for further research, including surveys of resident physicians who work with CNMs, leaders in midwifery, residency program directors, and policy makers.

Certified Nurse Midwives as Teachers of Family Medicine Residents.

BACKGROUND AND OBJECTIVES: The high quality of obstetric care provided by certified nurse midwives (CNMs) has led some to hypothesize that collaboration with CNMs may encourage more family medicine (FM) residents to subsequently practice maternity care. Our goal was to understand the current state of CNM involvement in FM resident education. METHODS: We conducted two surveys: one to a random sample of 180 FM program directors, and one to 147 CNMs involved in medical education. The surveys examined the nature, prevalence, and attitudes regarding CNM involvement in FM residency training. RESULTS: The surveys' response rate was 59% from FM program directors and 58% from CNMs. Thirty-six percent of FM directors reported no CNM involvement in their residency programs, 26% reported minimal interaction, and only 6% reported a fully integrated model with CNMs on faculty. Eighty-eight percent of CNMs and 64% of program directors reported a prefence for increased interaction. Programs with highly involved CNMs reported 33% of graduates subsequently practicing prenatal care, with only 13% of graduates practicing in programs with low CNM involvement (P<.003). However, there was no difference in those providing inpatient maternity care. Thirty-one percent of FM program directors and 25% of CNMs felt that physicians and CNMs have different ideas about how to treat patients; 26% of FM program directors who worked with midwives felt that CNMs should not be involved in residency curriculum planning. CONCLUSIONS: CNM participation in FM residency education is very limited. Our study identified a gap between the current state and the preferences of CNMs and FM program directors for greater educational collaboration. Residency program director attitudes may contribute to the low rate of collaboration between the two fields.

Clinical Updates in Women's Health Care Summary: Acute Cough: Primary and Preventive Care Review.

Acute cough is a common presenting symptom in the ambulatory care setting in the United States. It imposes a significant symptom burden on patients and financial burden on the health care system. In most cases, acute cough is caused by a benign viral infection that will resolve without intervention. When needed, there are few evidence-based interventions to hasten the resolution of cough symptoms. Patients may request antibiotics or prescription cough syrups; however, these medications have little evidence of benefit and can be potentially harmful to the patient. It can be challenging for the clinician to provide reassurance while minimizing unnecessary prescriptions. The health care provider also must be alert to signs and symptoms that could signal a high-risk diagnosis that requires urgent evaluation. This monograph provides a review of the differential diagnosis for acute cough, an algorithmic approach to the evaluation of cough, and evidence-based treatment recommendations. Also, it highlights warning signs and symptoms that should trigger an emergent referral and special clinical considerations in more vulnerable patient populations, including pregnant patients and geriatric patients.

Free pregnancy testing increases maternity care volume in family medicine residencies.

BACKGROUND AND OBJECTIVES: Increased prenatal volume in family medicine residencies is associated with a higher proportion of graduates including maternity care in their post-residency practices. However, family medicine residencies struggle just to meet the Residency Review Committee's minimum requirements for maternity care volume. Our objective was to evaluate the effectiveness of free pregnancy testing on increasing maternity care volume in our residency. METHODS: In this before-after intervention study, free pregnancy testing was offered at the residency's Family Health Center (FHC) from May 2011 through November 2012 to established patients and non-patients. Participants with positive tests were provided information on maternity care and an opportunity to schedule an initial prenatal visit. The primary outcome was the percentage of self-referred patients who established prenatal care at FHC. RESULTS: Over 19 months, 241 tests were performed on 224 women with a mean age of 26.2±6.3. Over half were minorities (130 [58%]). Most were under-insured or uninsured (193 [86.1%]). Ninety-nine women (41.1%) had positive tests; 74 of these 99 women (74.7%) established prenatal care at FHC, and 57 of these 74 women (77%) were new patients. The number of obstetric patients increased 13% from 405 to 456 patients. The percentage of self-referred patients increased from 31.9% to 40.8% (P<.001). The total cost of 241 pregnancy tests was $256.24, and maternity care revenue for just one patient was $1,553. CONCLUSIONS: The program's return on investment is favorable. Offering free pregnancy testing is a simple and inexpensive way to increase maternity care volume in a family medicine residency.

Immediate placement of intrauterine devices after first and second trimester pregnancy termination.

BACKGROUND: We reviewed our experience with intrauterine device (IUD) placement after surgical abortion up to 20 weeks' gestation. STUDY DESIGN: Women presenting for elective abortion between January 2004 and March 2009 who requested an IUD were included in this retrospective review. RESULTS: Of 308 women requesting postabortion IUD placement, 221 (72%) planned insertion at the time of abortion (immediate group) and 87 (28%) planned insertion at their postoperative visit (interval group). IUDs were placed in 96% of the immediate group and in 23% of the interval group (212/221 vs. 20/87; p<.0001). Failure to return for placement was the most common reason for noninsertion in the interval group (60/87=69%). Follow-up information was obtained for 56% of patients and was documented a median of 137 days postabortion (range 3-1594 days). There was no difference in complication rates between groups. Expulsion rates were 3% and 0% in the immediate and interval groups, respectively (6/212 vs. 0/20; p=.4). Considering only those with documented follow-up after immediate insertion (119), there was a nonsignificant trend towards increased expulsion with placement after second vs. first trimester abortion (4/54=7% vs. 2/65=2%; p=.3). When analyzing the 172 subjects with documented follow-up, those planning immediate insertion were more likely to have an IUD in situ at the last contact than those planning later insertion (84/124=68% vs. 20/48=42%; p=.002). CONCLUSION: Immediate postabortion IUD insertion is safe and effective. Given the low rate of return for interval insertion, immediate placement may be preferable.