Electronic fetal monitoring: family medicine obstetrics.

Electronic fetal monitoring assesses fetal health during the prenatal and intrapartum process. Intermittent auscultation does not detect key elements of fetal risk, such as beat-to-beat variability. Family medicine obstetric fellowships have contributed new knowledge to this process by articulating a method of analysis that builds on evidence-based recommendations from the American College of Obstetrics and Gynecology as well as the National Institute of Child Health and Development. This article summarizes the development, interpretation, and management of electronic fetal heart rate patterns and tracings.

Required procedural training in family medicine residency: a consensus statement.

BACKGROUND AND OBJECTIVES: Specific procedural training standards for US family medicine residencies do not exist. As a result, family physicians graduate with highly variable procedural skills, and the scope of procedural practice for family physicians remains poorly defined. Our objective was to develop a standard list of required procedures for family medicine residencies. METHODS: The Society of Teachers of Family Medicine Group on Hospital and Procedural Training convened a working group of 17 family physician educators. A multi-voting process was used to define categories and propose a list of required procedures for US family medicine residency programs. RESULTS: The group defined five categories of procedures within the scope of family medicine. Consensus was reached for a core list of procedures that all family medicine residents should be able to perform by the time of graduation. CONCLUSIONS: Defining standards for procedural training in family medicine will help clarify family medicine's scope of practice and should benefit both patients and family physicians. We propose that with input from national family medicine organizations, the procedure list presented in this report be used to develop a national standard for required procedural training.

The University of Tennessee's accelerated family medicine residency program 1992-2002: an 11-year report.

BACKGROUND AND OBJECTIVES: In 1992, with the approval of the American Board of Family Medicine (ABFM) (formerly known as the American Board of Family Practice), we established an accelerated residency program (ARP) involving five residency programs at the University of Tennessee (UT). An accredited resident can complete medical school and residency in a combined total of 6 years. This paper is a report of our experience with the ARP. Our objective was to determine if accelerated residents performed as well as or better than non-accelerated residents. METHODS: Students are selected for the ARP on the basis of academic achievement, life experience, interviews, and commitment to family medicine. For the accelerated residents, we tracked outcomes measures, including medical school grade point average (GPA), US Medical Licensing Examination (USMLE) scores, ABFM In-training Examination scores, and board certification status. RESULTS: From 1992 to 2002, 47 students entered the ARP at five UT residency programs. Five students did not complete the program. The average entering GPA was 3.17, and the average USMLE Step I score was 207. The accelerated residents, on average, performed better on ABFM In-training Examinations in the first and third years of residency than the non-accelerated residents did. Accelerated residents have a 100% ABFM certification rate. A total of 76% practice in Tennessee, and 65% began practice in a rural county. CONCLUSIONS: The UT ARP has been an effective means for allowing medical students to complete their family medicine training in 6 years. Accelerated residents have performed as well as or better than non-accelerated residents on standardized testing.

Advanced life support in obstetrics in Ecuador: teaching the teachers.

The advanced life support in obstetrics (ALSO) course is designed to help maternity care providers prepare for obstetrical emergencies. A team of 12 US physicians and a medical interpreter recently taught the ALSO course in Ecuador, with the goal of addressing Ecuador's high maternal and infant mortality rates. To have a greater impact, a teach-the-teacher model was used so that Ecuadorian physicians can now hold their own ALSO courses. In the process of implementing the courses, valuable lessons were learned which can be applied to future ALSO courses in developing countries and in the United States.

Impact of the limited generalist (no hospital, no procedures) model on the viability of family practice training.

BACKGROUND: Some doubt the desirability and cost-effectiveness of continuing to provide an expanded scope of primary care practice. Additionally, there has been concern about declining reimbursement from Medicaid and Medicare. Although an expanded scope of patient care services are required for training, we wanted to determine whether these services drain resources and time from other primary care activities. METHODS: To determine the financial impact of deleting services other than office visits from an urban primary care practice, we tabulated charges, economic case mix, and actual collections during 12 consecutive months. Using regional and national norms, the practice set charges for hospital services, office visits, and procedures at approximately 50th percentile as a maximum. Common diagnostic and therapeutic procedures were tabulated, and gross charges per item per year were tabulated. To validate net collection predictions for a predominately TennCare (Medicaid) practice and compare these with projected net collections from private practice, charges were compared with projected collections using two expectations (40% net and 80% net). Overall collections were projected and then compared with actual collection. For hospital services and office procedures, costs were attributed to equipment, training, liability insurance, and lost opportunity for office visits. The setting was an urban family practice teaching program providing hospital services, hospital deliveries, newborn care, office visits, and a variety of office procedures. There were 30,262 office visits, 510 non-pregnant hospitalizations, 252 deliveries, 1,352 office radiographs, and a variety of common office-based diagnostic and therapeutic procedures, such as electrocardiograms (408), skin surgeries (265), gastrointestinal endoscopies (306), diagnostic obstetric sonograms (525), non-stress tests (95), and colposcopy (161). The main outcome measures were the financial values calculated after subtracting costs for hospitalist services, office visits, and procedures. RESULTS: After lost opportunities for office visits are deducted, hospital services created positive revenue ranging from $167,306 to $340,612, depending on the net collection scenario chosen (ie, worst case versus best case). CONCLUSIONS: Revenue was adequate for reimbursement of equipment, staff, and physician time in either case. For procedural activities in the office, there was a net gain of $372,974 in charges once opportunities for lost office visits were deducted. Even within the 40% net collection scenario, revenue was more than adequate to pay for overhead and equipment. For this practice with 84% Medicaid-Medicare accounts, projected collections of 40% underestimated slightly the actual net revenue.