Teaching Competency in Family Medicine Maternity Care… · Teaching Competency in Family Medicine Maternity Care: a National ... assessment in Maternity and Newborn Care in Family

Teaching Competency in Family Medicine Maternity Care: a National Forum. Toronto, June 7th , 2013

"Defining competence for the purposes of assessment in Maternity and Newborn Care in Family

Medicine: Less is More!

Tim Allen, William Ehman For the Working Group on the Assessment of Competence in Maternity and Newborn Care College of Family Physicians of Canada

No conflicts

“Key Features” – What are they?

n  Observable, essential steps in the resolution of clinical situation/problem

n  Where we tend to make mistakes n  Predictors of competence eg.

n  Diagnosis >treatment n  Gathering>interpreting data n  Undifferentiated>differentiated n  Problem specific>routine actions n  Using knowledge>regurgitating knowledge

Evaluation: What we are doing now:

Key Feature Evaluation eg. Induction of Labour

n  Assess and document n  Acceptable indication, priority, EDD,

Cx status, contra-indications, maternal preferences, consent

n  Utilize the appropriate method n  Eg. foley, PGE2, Oxytocin; appropriate

fetal surveillance, documentation n  Manage complications

"Defining competence for the purposes of assessment in Intrapartum and Peripartum care in Family Medicine (core FM): Less is More!”

•  Normal physiologic labour and delivery •  Newborn care , including resuscitation •  Remainder of MNC

elsewhere

•  A pilot project •  A variant on the FM Priority Topics and

Key Features ( Evaluation Objectives) see how it works

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Albert Schweitzer

Intrapartum care as as Assessment priority for FM

•  Complex situations - lots of process Competency is doing the right thing. at the right time, in the right way , for the right reasons

•  “Shoulder to shoulder” experience

•  Higher level cognitive skills for all of FM Generalisable to overall competence

Competence in pragmatic terms: theoretical frameworks vs. workplace tasks

Theoretical Frameworks

Grounded in the workplace

Complex tasks: (building blocks)

Which building blocks (competencies) are most important?

Priority topics n  Problems , situations that must be able to

deal with in a competent fashion

Key Features (what is a competent fashion) n  The key cognitive skills necessary to deal

well with this problem , in this context

How do we find out what these are?

Identifying Priority Topics & Key Features

Modified Delphi n  individual work ( questionnaires , assignments) n  group review and modifications n  multiple iterations ‘til saturation

n  Nominal working group (6 members): practitioners n  Validation group (30-40): practitioners

n  Stratified representativity ( demographics) n  Randomly selected and invited

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1   Gesta&onal  hypertension  /  pre  eclampsia    

2   Post-­‐partum  hemorrhage    3   Team  (  working  with  ,  in)    

4   Fetal  health  surveillance  during  labour    

5   Limits  (knowing  and  applying)    

6   Shoulder  dystocia    

7   Perineal  lacera&ons    (repair)  

8   Assisted  delivery  (  Vacuum  extrac&on)  

9   Labour  dystocia    10   Inducing  labour    

11  BreasDeeding  difficulty    

12   Peripartum  mental  health  

13   PROM    

14  Gesta&onal  Diabetes    

15   3rd  trimester  bleeding  

16   Fever  

17   Pain  in  Labour    

18   TOLAC  (Trial  of  labour  aNer  Caesarian)    

19   Pre-­‐term  labour  

Priority topics ( MNC – core FM): peripartum only

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0

10

20

30

40

50

60

VG #

WG#*4

Correlation WG/VG 0.745

Maternity and Newborn Care: priority topics for assessment of competence( core FM)

Validation study

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Procedure skills( MNC: core FM): peripartum only

Validation and working groups •  manage shoulder dystocia •  repair perineal lacerations •  vacuum extraction

Validation group “only” (=more discussion/optional) •  amniotomy •  place fetal scalp electrode

Excluded from priorities (both groups) •  breech delivery •  perform episiotomy

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1. Anticipate the possibility of shoulder dystocia with any delivery, and when appropriate discuss with the patient as part of anticipatory guidance for delivery

2. For all deliveries, assess the risk factors for shoulder dystocia, develop a plan of management according to the risks, and adjust the preparations according to the evolving risks

3. Look for shoulder dystocia, even when it is not expected, and recognize it promptly when it occurs

4. When shoulder dystocia occurs, use an acceptable standardized sequence of manoeuvres to relieve it.

5. After the shoulder dystocia is resolved, •  debrief with the parents and health care team. •  document the manoeuvres used and the timing of their application. •  examine the newborn for signs of trauma.

(not the procedure skills themselves)

Key Feature example: Topic: Shoulder dystocia (3rd iteration)

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“Example is not the main thing in influencing others. It is the only thing.”

“You don’t have to be an angel to be a saint”

Albert Schweitzer

What next?

n  WG assumes ongoing role n  Complete the Key Features for all priority

topics n  Develop a plan to try out formally n  Start to try them out informally: do they

work? n  Trainee orientation and expectations n  Help with feedback and formative assessment

Back to Family Medicine “curriculum committee”

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1. Whenever a patient presents in labour, assess the risk factors and the overall context of the situation in order to select the appropriate method of fetal surveillance (intermittent auscultation (IA) vs. external (electronic) fetal monitoring (EFM))

•  assessment of risk /context must be current or updated •  generally use IA for low risk situations and EFM when risk

factors are present 2… 3… 4… 5. When abnormal or atypical fetal surveillance is observed

Attempt to correct using basic manoeuvres Interpret within the context of the whole labour and pregnancy

6. When abnormal fetal surveillance is not corrected by basic manoeuvres, institute appropriate intrauterine fetal resuscitation promptly, and develop a backup plan for delivery

Key Feature example: Topic: Fetal  health  surveillance  during  labour    (3rd iteration)

Demographics – Validation Group MNC

26 6

12 20

10 22

7 13

8

10 22

1

26 6

7 22

0 5 10 15 20 25 30

Female Male

Less than 10 More than 10

Rural Urban

West Ontario Quebec

Broad Mixed

Focused

Teaching Non-Teaching

Program Director Not Program Director