Obstetrics Fellowship Curriculum 2018-2019
The mission of the Obstetrics Fellowship at Swedish Family Medicine is to provide advanced training in high-risk and operative obstetrics to family physicians who will work in underserved communities.
1. Manage simple and complex labors.
2. Attain competency in operative obstetrics, including cesarean section, instrumented deliveries, and tubal ligation. Provide post-operative care for such patients.
3. Provide competent prenatal care to pregnancies complicated by diabetes, hypertension, thyroid disease, substance abuse, and mental health disorders.
4. Stabilize and treat pregnant patients hospitalized for pre-term labor, pre-eclampsia, diabetes, and placental disorders.
5. Perform biophysical profile and limited obstetric ultrasound.
6. Counsel obstetric patients regarding genetic risk.
7. Maintain family medicine clinical skills.
8. Develop and maintain competency in teaching obstetrics to family practice residents and family practitioners.
1. Evaluate obstetric patients and their fetal monitoring tracings in triage
2. Provide labor management, vaginal delivery and instrumented deliveries to obstetric patients of teaching panel physicians.
3. Perform cesarean sections as primary surgeon with obstetric providers. Surgical skill level at the beginning of the fellowship will determine when the fellow is ready to be the primary surgeon.
4. Augment surgical skills by assisting gynecologic surgeries, including tubal ligations and D&Cs.
5. Perform post-partum tubal ligation on teaching panel patients.
6. Supervise R1 admission and daily management of antepartum service patients.
7. Provide initial consultation and ongoing prenatal care to patients in the perinatal offices of Obstetrix. Focus will be on patients referred from family practice clinics. Visits will be precepted by the obstetrician. Fellows are expected to provide thorough evaluation to 1 to 2 patients each half day.
8. Perform limited obstetric ultrasound at Swedish Family Medicine.
9. Counsel patients regarding Down Syndrome Screening when they are referred to genetics counselors at Obstetrics.
10. Supervise resident care of family practice patients by precepting some clinics each week. Precepting will take place in the First Hill and Downtown Family Medicine clinics.
11. Teach R1s on the obstetric service basic obstetrics, including triage evaluation, cervical exams, labor management, pitocin augmentation, IUPC, FSE, vaginal delivery, and postpartum care.
12. Teach didactics sessions on Tuesday afternoons at First Hill and Cherry Hill didactics.
13. Present a topic in primary care obstetrics at our annual High-Risk Obstetrics for the Family Physician CME.
Fellows will spend one week on each of our five rotations A, B, C, D, and E in sequence until 20 weeks from the end of the fellowship. At that point we will switch to 4 week blocks (one elective block for each fellow) in order to accommodate away experiences. Goals and objectives for each of the experiences that comprise the rotations follow. Specific weekly templates for each rotation are in the following section.
LABOR AND DELIVERY
1. Manage simple and complex labors
2. Supervise R1 simple labors.
3. Attain competency in operative obstetrics, including cesarean section, instrumented deliveries, and tubal ligation.
4. Provide post-operative care for such patients.
5. Develop and maintain competency in teaching obstetrics to family practice residents.
6. Evaluate and supervise triage visits.
7. Stabilize and treat pregnant patients hospitalized for pre-term labor, pre-eclampsia, diabetes, cervical incompetence and placental disorders.
8. Perform ectopic pregnancy evaluations and D&Cs for patients admitted through emergency room
1. Evaluate obstetric patients and their fetal monitoring strips in triage.
2. Provide labor management, vaginal delivery and instrumented deliveries to obstetric patients of teaching panel physicians.
3. Perform cesarean sections as primary surgeon with obstetric members of the Teaching Panel. Surgical skill level at the beginning of the fellowship will determine when the fellow is ready to be the primary surgeon.
4. Supervise R1 admission and daily management of antepartum service patients.
5. Perform amniocentesis for fetal lung maturity to teaching panel patients on the antepartum service.
6. Teach R1s on the obstetric service basic obstetrics, including triage evaluation, cervical exams, labor management, pitocin augmentation, IUPC, FSE, vaginal delivery, and postpartum care.
7. Perform post-partum tubal ligation on teaching panel patients.
8. Perform, teach and supervise neonatal circumcisions.
9. Perform D&Cs.
10. Evaluate perinatal, family medicine and no-doc patients in triage.
11. Manage labors and deliver no-doc patients
12. Supervise R1 triage visits.
1. Pre-round on L+D board and see antepartum patients not seen by other fellows or R1s (R1s are limited to one patient at the start of the year and three by the end).
2. Lead board rounds with R1s at 8 am.
3. Attend teaching rounds 7:30-8. (Teaching schedule: Mon. R1 teaching, Tues. Howard Uman newborn or Camille Fleming OB), Wed. Mary Puttman and Joe teaching, Thurs. OB M+M/path/us/fellows strip review, Friday fellows.
4. Scrub in on c-sections; these take precedence over rounds
5. Maintain presence on L+D to be available for complex labors/ instrumented deliveries
6. Beginning in January, contact attendings when they are on call for the ER and ask to be included in D&Cs and ectopics.
Beginning in January, provide initial evaluation for labor management consultation of family medicine patients when they consult the laborist.
7. Carry OB fellow pager when on call.
8. Evaluate teaching panel and perinatal patients in triage. Until January, all patients must be staffed by fellow with the OB hospitalist. The hospitalist will see and bill for some of these patients, simple evaluations can be approved over the phone and you will bill for them (triage nurses will ask if you can be the attending). After January, you can see and send home simple triage evaluations. Note: simple rule out labors at 37 weeks or later can be seen and sent home by the nurse after an attending has reviewed the strip.
PERINATAL AT OBSTETRIX CLINICS
1. Provide competent prenatal care to pregnancies complicated by diabetes, hypertension, multiple gestation, thyroid disease, substance abuse, and mental health disorders.
2. Counsel obstetric patients regarding genetic risk.
3. Perform biophysical profile and limited obstetric ultrasound.
1. Provide initial consultation, ongoing prenatal care, and post-hospital follow-up visits to patients in the perinatal offices of Obstetrix in the Nordstrom Tower Suite 750. Visits will be precepted by the obstetric hospitalist. Fellows are expected to provide thorough evaluation to 1 to 5 patients each half day. Sessions will be Thursday AM for the Week 2 fellow.
Fellows may choose from 3 options in perinatal clinic: see patients for the perinatologists and laborists in clinic, perform ob ultrasound with the Obstetrix sonographers, or co-counsel patients with the genetics counselors. Try to do some of each initially to get a flavor for what they do.
1. Perform circumcisions using Gomko technique (discuss with Joe if you’d like to incorporate other techniques).
2. Teach residents to perform circumcisions
1. Attend the Tuesday morning circumcision clinic in the First Hill Procedure Pod
2. Skill level will be evaluated at the beginning of the year; fellows that need up to their first ten circumcisions proctored will be precepted by Drs. Fleming, Leininger, Wang or Breuner.
3. After being certified as competent, the fellow will supervise a resident at this weekly clinic.
1. Maintain family medicine clinical skills.
2. Develop and maintain competency in teaching obstetrics to family practice residents and family practitioners.
1. Supervise resident care of family practice patients by precepting one to four clinics per week. Precepting will take place in the First Hill and Downtown Family Medicine clinics. In so far as possible, we will not ask you to precept the geriatric fellows.
Note: Preceptor B means you are the backup preceptor. Need to be available should one of the scheduled preceptors not be able to precept.
DFM acute care clinic
Fellows will see patients for acute medical visits at DFM on Wednesday mornings during week 1. Urgent care visits, hospital follow-ups, medication evaluations and higher risk obstetric visits will comprise the appointment types. Dr Breuner will be available as a preceptor during these mornings should you like supervision.
DFM COLPOSCOPY CLINIC
1. Perform and supervise colposcopy procedures
1. Thursday morning colposcopy clinic at Downtown Family Medicine supervised by Dr Breuner. The fellow will perform colposcopy and supervise residents performing colposcopy. Dr Breuner will proctor each fellow to assess ability to perform colposcopy, and also to teach to the resident.
FIRST HILL ULTRASOUND
1. Perform limited obstetric ultrasound at Swedish Family Medicine.
1. The first and third Monday morning of each (residency) block the fellow will perform limited obstetric ultrasound with Dr. Garcia in Pod 4 of the First Hill clinic.
OB OUTREACH CLINIC
1. Provide prenatal care to addicted obstetric patients in recovery.
1. Every Tuesday from 12-5 PM the B rotation fellow will join Jim Walsh, MD, of Addiction Recovery Services, Nicole Ingrisano, MD of Swedish OB/GYN, the addiction medicine fellow and one to two Cherry Hill residents in providing prenatal care to prenatal patients in recovery. This takes place at the Cherry Hill clinic. This outpatient experience will include issues of addiction as well as prenatal care for the medically complicated pregnancy. .
This experience may be paired with an elective one to two week inpatient rotation at Addiction and Recovery Services in Ballard. Fellows are encouraged to do this inpatient rotation early in their elective month so they can practice more effectively in the Friday afternoon OB OUTREACH clinic.
1. Obtain training specifically suited to your intended clinical practice setting
1. Attain competence in specific procedural or cognitive skills.
1. 10 weeks prior to your elective, discuss with your fellowship advisor which elective experience you would like to choose. Consider colposcopy/LEEP, ultrasound, family practice clinic, inpatient service, trauma, termination training, or others that you anticipate needing in your intended clinical practice setting.
2. 6 weeks prior to your elective, present your choice and planned rotation schedule to the fellowship director.
3. It is the responsibility of the fellow to let the program director know where he or she is during elective time throughout the year.
Elective One: NEONATOLOGY
1. Resuscitate distressed newborns.
a. Identify distressed newborn
b. Assign Apgars
c. Bag mask ventilate newborns
d. Intubate newborns
e. Assess fluid status of newborn
f. Identify newborns at risk for sepsis
g. Fluid resuscitate newborns
h. Place umbilical venous catheter
2. Provide ongoing care to the hospitalized newborn.
a. Assess nutritional needs of hospitalized newborn
b. Identify and treat newborn infections
c. Treat drug withdrawal
3. Stabilize and prepare newborns for emergency transport
1. Perform newborn resuscitations under the supervision of the special care nursery nurse, neonatal nurse practitioner and/or neonatologist. Resuscitations will include intubations and umbilical vein catheterizations. Consider attending routine sections for easy resuscitations.
2. Admit and manage newborns in step-down unit of the special care nursery. Care will be supervised by attending neonatologist or nurse practitioner.
1. Obtain NRP certification.
2. Carry neonatology pager and respond to resuscitation calls for nurse, nurse practitioner, and neonatologist.
3. Admit compromised newborns to special care nursery.
4. Follow 3-5 feeder/grower babies under supervision of feeder/grower neonatologist
5. Log procedures, including resuscitations, intubations, and umbilical vein catheters, in new innovations.
6. Contact Bryan Fujimoto 386-6051 and ask him to put you on the neonatal resus call calendar. He will also tell you which nurse practitioner and admit nurse are on for your shifts.
7. Introduce yourself to the nurse practitioner and admit nurse each day in the 6S nursery. The nurse practitioners can sometimes be found in the doctor’s lounge in the mornings.
Elective Two: CLINIC
1. Maintain family medicine clinical skills.
1. See family medicine outpatients in one or two clinics per week, at the Downtown Family Medicine site.
Elective Three: AFRICA ROTATION
Swedish Family Medicine sends residents and fellows to Mangochi Malawi. SFM faculty and UW Global Medicine fellowship grad (and DFM alum) Anna McDonald is the site preceptors for this experience. Care for underserved and infectious disease experience are the focuses of this experience, additional surgical experience may be available depending on how this site develops. . 4-5 months lead time is required.
Elective Four: INPATIENT SERVICE WEEKS
Fellows are strongly encouraged to spend one week as inpatient attending on the family medicine inpatient service. Depending on experience level when the fellowship begins, this could be co-attending with a family medicine faculty or it could be attending independently. A second week later in the year is also an option. This service cares for pediatric, obstetric and adult medicine admissions. This elective provides good experience in inpatient medicine and requires 8 to 12 weeks of lead time to schedule. Please decide about this elective by Sept 1.
Elective Five: NEIGHBORCARE OB
Take family medicine call on Tuesdays x 24 hrs, Thursdays x 24 hrs or weekend days for 45th St./Greenwood/Swedish Family Medicine First Hill. Arrange these call shifts through Dr Putter Scott, MD. Bill for these deliveries in the same way you would for no-doc deliveries.
Elective Six: Perinatal ultrasound and clinic
5 days a week perform ultrasounds with the ultrasonographers working in the perinatal clinic.
Contact is with Shayna Worley, ultrasonographer, 386-2101.
Elective 7: FAMILY MEDICINE FACULTY DEVELOPMENT
Work on a curricular area for the fellowship or for fellowship programs nationally, under the
supervision of Drs. Wang or Breuner.
Joe Breuner and Kevin Wang will serve as fellowship advisor for all fellows. Drs. Breuner or Wang will meet with each of you every three months to review practice plans, evaluations, and progression of your skills. The final ‘quarterly’ meeting will also serve as a feedback session for making changes in the fellowship.
Consider, in addition, approaching one of the members of the Perinatology group Obstetrix to serve as a mentor. Plan to get together every two months or so to review progress and foster development of your skills.
Perinatologists of Obstetrix: a group of 9 perinatologists who provide maternal-fetal medicine services for Swedish Medical Center and Valley Medical center. And until July 2009 were primary backup for obstetric emergencies in the hospital. David Gorenberg, MD, serves as our liaison to the fellowship and attends one Friday meeting per month.
Obstetric Hospitalists: 5 obstetricians, who provide in-house obstetric services for emergencies, back-up, triage evaluation, perform and assist cesarean section, and labor management. New to Swedish in July 2009.
Swedish Family Medicine Faculty First Hill: 10 family physicians that see patients and teach residents at three sites: First Hill Family Medicine, Downtown Family Medicine, and Swedish Community Health at Ballard.
Swedish Family Medicine Faculty Cherry Hill: 7 family physicians who see patients and teach residents at Cherry Hill Family Medicine. Residency satellites at Seattle Indian Health Board and Seamar Community Health.
Fellows will precept frequently at the First Hill clinic and the Downtown Family Medicine clinic. They will precept family medicine residents in clinic visits and procedures. A separate faculty preceptor need not be present for Medicare billing because the fellows are licensed and privileged family physicians and the fellowship is not subject to Medicare supervisory requirements.
All fellows will attend a supervised reading session and team meeting with the fellowship director every Tuesday from 730-830 in the 5-North Classroom in the hospital. Absences will be excused if fellows are post-call, scrubbed into a procedure, or on vacation.
Attendance at regular First Hill residency meetings every Tuesday from 12:30 to 1:30 is encouraged but not required.
E-mail and Pager Response Times
Fellows will check and respond to e-mail no less than twice a week except when on vacation. Numeric pages and text pages, which require a response, should be answered within 10 minutes.
Vacation may be taken during elective time.
Vacation should be scheduled out at least 8 weeks ahead of time.
For acute illness or family emergency, please contact the fellow not on day or night call [2nd choice is fellow on elective] for backup. If you are ill, please call the person you are supposed to relieve so they can contact the correct person to cover call. The fellow coming off call should remain until the sick leave fellow arrives. If no relief can be found, please alert the charge nurse, on-call perinatologist, and HCFW attending prior to leaving.
Leave for chronic medical reasons per Swedish personnel policies, see residency curriculum manual available on-line at: https://swedish-fh.squarespace.com/policies/
Remuneration: Salary and Incentives
Salary is per your contract. In addition, $1500 and 5 workdays off are available for CME. These should be scheduled during your elective time.
That our team of fellows and visiting licensed providers will submit billings for as many c-section assists and triage evaluations as possible each 4-week block. $10 will be added to your subsequent paycheck each month for triage evaluations and c-section assists billed that month. $250 will be added for no-doc vaginal deliveries that the fellow bills.
Fellows will read and present chapters to their peers, residents in the obstetric area of concentration, and the fellowship director as scheduled from the reading list of essential articles included at the end of this curriculum manual. Readings are organized by topic and each fellow will be assigned a reading from the above sources pertinent to that topic.
Fellows will complete 60 c-sections as primary surgeon. This is a minimal requirement for graduation. Fellows will also participate in the resuscitation of 20 newborns. Vaginal deliveries, instrumented deliveries, amniocenteses, ultrasounds, D&Cs, tubal ligations, circumcisions, neonatal intubations and umbilical vein catheterizations should be logged by the fellows on New Innovations in order to obtain hospital privileges, but minimum numbers are not required for graduation.
Please also see the competencies table below for a sense of which procedures to focus on.
The hospital receives no outside funding to support the fellowship and its costs are covered by the billings submitted by the fellows. Fellows are expected to bill electronically for c-section assists, triage evaluations, vaginal deliveries where they act as attending, circumcisions, and D&Cs. To cover our costs, each fellow needs to bill for 15 c-section assists and 15 triage evaluations each month, incentives are provided as described above. Note: context in epic must be ‘family practice’ for billing modality to be enabled. ‘hospital problems’ on problem list can be updated prior to billing in order not to have to go back and do this.
Each fellow will give a 25-minute presentation at our annual High Risk Obstetrics for the Family Physician conference. The 2019 conference will be on March . You will be assigned a topic based on a needs assessment we send out in September. The presentation should include slides, current evidence, cases, and time for questions. Three months of every other Tuesday meeting times will be reserved to prepare these presentations.
Evaluations and Due Process
For performance evaluations and progressive discipline, please see the First Hill residency curriculum manual section on advisor system and due process. It is available online at: https://swedish-fh.squarespace.com/policies/
OB fellowship Competencies
Three objectives for this list: 1) to give new fellows a framework for their learning, 2) to set a basic standard for training, much like we have in residency, 3) to credit and help define the level of training for fellowship grads looking for jobs or seeking privileges. Obviously, as is the case with core competencies in residency, graduates will find themselves in communities with varying needs, comfort levels, and acceptance. Therefore, the lists below are hopefully organized to set goals and limits, as well as some room for flexibility.
Skill sets and situations are broke down into these three categories.
A) You should feel comfortable with this by the end of fellowship. Privileging for each of these skills may still be hospital/geographically dependent. With letters of recommendation and procedure log support, however, you may be able to claim "competency" in these skills.
B) These are skills that you may feel comfortable with by the end of fellowship, but may or may not be "competent" in. Many graduates AFTER fellowship are NOT comfortable doing them due to lack of numbers (i.e. D&C), or because they are not able to get privileges (tubals) or due to hospital location and assets (NICU, blood bank, etc...). If you will manage some of these cases, you may want OB or perinatal consultation.
C) These are skills or situations that you may witness while in fellowship, however are not goals and by most opinions you should not be doing or managing with your level of training. You would definitely want perinatal or OB consult, and you would likely transfer care.