A national survey of procedural skill requirements in family practice residency programs.

BACKGROUND AND OBJECTIVES: Procedural skill training is a controversial but important component of family practice residency programs. This study examines the use and composition of required procedure lists in US family practice residency programs. METHODS: The study used a cross-sectional nine-item questionnaire. This survey was sent to 467 residency program directors listed in the 1999 American Academy of Family Physicians Directory of Family Practice Residency Programs. RESULTS: A total of 326 programs (70%) responded to the survey. Of these, 242 programs (74% of respondents) reported use of a required procedure list. Sixty-six programs provided a list. Of these, 63 lists were interpretable. The number of required procedures on the lists ranged from a minimum of 3 procedures to a maximum of 117, with an average of 42. A total of 265 distinct procedures were identified, with 25 procedures named on more than half of the lists. Thirteen programs (21%) mandated competency in required procedures, but only five programs (8%) gave clear definitions of what constituted competency. There were no significant differences in lists among training program type, university affiliation, number of hospitals used for rotation, size of affiliated hospital, or number of residents. CONCLUSIONS: The expectations of individual programs vary greatly in terms of required procedures. Few programs define how to evaluate the technical competency of their residents.

Ectopic pregnancy.

Ectopic pregnancy occurs at a rate of 19.7 cases per 1,000 pregnancies in North America and is a leading cause of maternal mortality in the first trimester. Greater awareness of risk factors and improved technology (biochemical markers and ultrasonography) allow ectopic pregnancy to be identified before the development of life-threatening events. The evaluation may include a combination of determination of urine and serum human chorionic gonadotropin (hCG) levels, serum progesterone levels, ultrasonography, culdocentesis and laparoscopy. Key to the diagnosis is determination of the presence or absence of an intrauterine gestational sac correlated with quantitative serum beta-subunit hCG (beta-hCG) levels. An ectopic pregnancy should be suspected if transvaginal ultrasonography shows no intrauterine gestational sac when the beta-hCG level is higher than 1,500 mlU per mL (1,500 IU per L). If the beta-hCG level plateaus or fails to double in 48 hours and the ultrasound examination fails to identify an intrauterine gestational sac, uterine curettage may determine the presence or absence of chorionic villi. Although past treatment consisted of an open laparotomy and salpingectomy, current laparoscopic techniques for unruptured ectopic pregnancy emphasize tubal preservation. Other treatment options include the use of methotrexate therapy for small, unruptured ectopic pregnancies in hemodynamically stable patients. Expectant management may have a role when beta-hCG levels are low and declining.