How many deliveries?

[cali-ob]

I am torn about my need/desire to do an OB fellowship. I am unsure about my desire to do sections, though I am leaning towards not. But my concern is about obtaining privileges for OB. I am at an opposed residency program, and although I have already exceeded the minimum number of vaginal deliveries required by the ABFM , my numbers will end up being much lower than someone coming out of an unopposed program.
I am going to do an away OB elective, and I also still have several of my own continuity patients over the next year, but I think I'll be luck if I get to 100 vag deliveries.

Does anyone have experience with obtaining OB privileges that you can share. Most likely, I will be seeking privileges from a community hospital, not an academic facility if that changes things.

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[lowbudget]

I chose not to pursue OB privileges at my hospital because I had plenty of other opportunities to make money by other means. But, for my (community) hospital, vag deliveries are part of regular FM privileges but to get privileges to do vag deliveries you need to maintain X number of deliveries per year & you need X number of proctored deliveries by a member of the OB section. To obtain C-section privileges, you need apply through the FM section but it's the OB section that grants you those privileges, so you have to go through OB. That's my hospital.

My recommendation is that you call the Physician Relations dept of a handful of hospitals in/near/at the place where you likely will practice, identify yourself & ask to get a copy of requirements for privileging. It should be made easily available to you. For me, every hospital (even within the same hospital system) is different. So ask & get concrete answers.

I will add that before you leave your hospital, you should pull charts of all the deliveries you did & get a copy of the delivery note you dictated/wrote. Obviously, the privileging section will be calling your PD to certify that you are "competent" in doing deliveries, but you don't know the language that the PD will use when communicating with the privileging section. So having the actual delivery notes in your possession makes it so much easier when you are asked to turn over evidence of competency.

 

[JackADeli]

...I will add that before you leave your hospital, you should pull charts of all the deliveries you did & get a copy of the delivery note you dictated/wrote. ...So having the actual delivery notes in your possession makes it so much easier when you are asked to turn over evidence of competency.

I think if someone looked at your numbers close enough and noticed a discrepancy such as not being present for delivery/deliveries (i.e. number notes does not match number proclaimed) like previous thread, can make it troubling

 

[drwatson]

100 was the number I was quoted for being "competent" with vaginal deliveries. This is, of course, dependent on how you got those 100 and what types of complications...er...learning opportunities were encountered along the way.

 

[JackADeli]

100 was the number I was quoted for being "competent" with vaginal deliveries. This is, of course, dependent on how you got those 100 and what types of complications...er...learning opportunities were encountered along the way.

And as others noted elsewhere.... "Kudos" to the attending for giving residents credit for a delivery they aren't even present for cause they got stopped for a speeding ticket!

 

[lowbudget]

Lol!

 

[lowbudget]

(Better to respond to the issue of continuity in this thread vs the ID for docs thread.)

The problem I have with the RRC requirement of 40 deliveries & 10 continuity deliveries is the apparent disconnenct in the framer's intent. If it's the technical skill of doing the delivery they are after, then JAD you're right, it should be cut & dry: did you do the delivery? Yes or no, 40 is 40.

But the RRC doesn't say what "kinds" of deliveries they are. 40 can be SVD's, but C-sections, vaccum-assist, & forceps count too. So if RRC's charge is to ensure the minimum standard of competency (& communities' hospitals can define it higher va privileging), and if RRC's going to say the minimum is 40, it has failed in their own mission, because it's possible for a resident to graduate with 40 1st assists in C-sections & no SVD's & the RRC/program states that the resident has completed the "minimum" OB requirements. Clearly a disconnect & on first blush wouldn't meet the standard of "competency".

 

[lowbudget]

The 2nd issue I have is with continuity deliveries. The RRC doesn't define what continuity means! And many programs interpret that word differently. I understand the purpose is to experience a pregancy from beginning to end, but what is beginning? Must a resident follow a patient from pregnancy diagnosis/conception or else it doesn't count? Is starting at 10 weeks ok? 20? What about 32? Or 37-40 or even 41 if they haven't delivered yet?

How many visits is considered continuity? 5? 2? What if I saw a patient in OB triage as an ER drop-in for UTI & referred to my clinic & she only could get 1 visit with me there... does that count as 2 visits?

And what's the end of pregnancy? If I care for a patient from conception to 9 months, did everything for her , but have a last minute complication where she needed to be transferred to OB or MFM in another hospital for higher level of care, do I get to count this patient towards my continuity? What if after I deliver baby & because now they get emergency Medicaid & goes elsewhere for mom's postpartum visit & baby's newborn check up, do I get to count that patient towards my 10? What if mom has twins? Does that count as 1 or 2 continuity deliveries?

You see, FM issues are different from yours in surgery where you do 100 appendectomies bam bam and then you're done. And, no, logistics do matter because the RRC sets up an ideal world, holds programs to it, gives no guidance on how to achieve it, & sets a standard that doesn't jive with reality of residency education.

I would rather RRC say, look, you need 10 continuity "patients" (not deliveries per se) because the INTENT is to experience cognitively & procedurally longitudinal care and define continuity for us.

That's where my kudos comes from.

And, hospital privileging doesn't care how many deliveries were done for "continuity experience". They want to know your technical know-how. That's why I say have delivery notes with you, because programs all define these terms differently.

 

[JackADeli]

Point taken about logging procedures. It's 40+10 and no, not every program can source those 10 no matter how proactive the residents are. It does put the program in jeopardy...

Which brings us back to the basics of ethics. The resident/s are lying cause the program might not pass muster. Either the program provides for the minimum standards as required or it does not. The attendings/PD "allowing" resident/s to lie is a problem. We are talking about lying for personal gain on the part of the resident and program gain on the part of the program. It is not a slippery slope when you choose to down hill ski on these issues.

...The problem I have with the RRC requirement of 40 deliveries & 10 continuity deliveries is the apparent disconnenct in the framer's intent...

But the RRC doesn't...

So here is where the disconnect is on the matter. The RRC did not in isolated fashion generate these requirements. They just review and enforce. I suspect the FP/FM board had/has a big amount of say in what they feel is a minimum requirement. I do not think it appropriate for a trainee or attending to decide on what is really important.... By trying to take it away from the FM/FP board and point at the RRC as if independent and lacking understanding is simple rationalization made easy.

...The RRC doesn't define what continuity means!...

But, they clearly state a fundamental requirement is that the resident actually perform the delivery. In the case described, that requirement is not met. Game over, no credit, doesn't count. The definition the RRC has likely comes in part from the FM/FP board.

...You see, FM issues are different from yours in surgery where you do 100 appendectomies bam bam and then you're done...

The more they differ, the more they are the same! We were discussing very similar issue in surgery forums. For full surgical procedure credit, we call this logging as "surgeon", there is an expectation of continuity. It is NOT go to OR, remove appendix, "bam and then you're done...". That is why surgery residents get into trouble with false/double logging. Read through the thread to get an idea of what I am talking about.
http://forums.studentdoctor.net/showthread.php?t=719430
Needless to say, surgery PDs try to rationalize as well and encourage double logging.... because their program may get in trouble for shortages too!

...I would rather RRC say, look, you need 10 continuity "patients" (not deliveries per se) because the INTENT is to experience cognitively & procedurally longitudinal care and define continuity for us...

Then your program and other programs should appeal to the board to discuss with the RRC and make changes. Surgery actually did this a few years ago and continues to do so. Surgery actually increased required number of endoscopies, etc... Many programs scrambled around for fear they lack the volume of experience, etc... the increase was not a arbitrary RRC generation. It was a result of the ABS.

...And, hospital privileging doesn't care how many deliveries were done for "continuity experience". They want to know your technical know-how. That's why I say have delivery notes with you, because programs all define these terms differently.

I understand that. Which is what the problem is if you are logging procedures you didn't perform to obtain board certification and it doesn't match actual procedural notes for hospital credentialing.

It is not for trainees or attendings to determine RRC (thus board) requirements are not really important. If a program comes up short in one set of numbers but over-all program quality is felt to be more then adequate, a good & ethical PD will make their case to the RRC and the FP/FM board. They will NOT doctor the books or support residents doctoring the books..

...Prior approval of the RRC is required for major changes in the curriculum...of the program...
...Each program must document the availability of a stable patient population of sufficient number and variety to ensure comprehensiveness and continuity of experience for the residents in the FMC...

...Total Deliveries​

Each resident must perform a minimum of 40 deliveries over the 3- year program, of which a minimum of ten must be continuity deliveries. At least 30 of the total deliveries must be vaginal deliveries. Two residents may be given credit for the same delivery if one of those residents is supervising. The experience of each resident must be documented as to the role played in the delivery...

It just troubles me to find so many residents on these forums trying to rationalize and justify fraud. All the end-points on these efforts to rationalize are "to protect the program" and/or allow the resident to get boarded. It can be used to justify lying on work hours/etc... In the end, it is lying/cheating/fraud... for individuals' gain. Take it a step further, I have seen people try to rationalize how they bill....

"because the insurance companies do not understand the reality of medical practice..."
or
"do not reimburse fairly..."

Start your career straight and narrow. Do NOT allow yourself to suddenly start bending and rationalizing....

 

[lowbudget]

The straight & narrow is to follow these RRC rules without question & to interpret them en face as you (JAD)'ve done. Yea, of course I can read the requirements & make it black & white. You defend the requirement, I question the requirement & say the requirement is stupid & unrealistic.

To miss a continuity delivery due to a traffic ticket is a non-educational technicality. If you were a bean-counting auditor, you're right, no delivery, no credit. But big picture, this resident's educational burden has been met, at least in the spirit of "continuity".

RRC is an arm of ACGME & so I don't know what their relationship is with the ABFM, but I will say that this "required" "continuity deliveries" makes no damn sense in modern FM residency education in the era of 80-30 hour work restrictions, OB hospitalists, and block rotations. The ONLY way this resident could have made the delivery is if s/he actually resided in the hospital during 36-40th & maybe 41-42nd week of this patient's pregnancy, awaiting this lady to pop. This models harkens back to the pre-work hours era & is outdated. And that's even assuming he's on site in the hospital. What if he was in clinic/hospital elsewhere like he was supposed to? You can't effectively design a block curriculum & then hope to interlace a longitudinal curriculum over it. None of this makes any sense, so why are we trying so hard to defend this stupid rule?

You can't arbitrarily create a stupid rule, brow beat the residents, when you in fact know that there is no way this resident can achieve it because of constraints. It's very much a glass-ceiling & has nothing to do with the resident not "trying hard enough". Damned if you miss the delivery, damned if you break the law & get a ticket. Gimme a break.

 

[lowbudget]

These stupid rules are indefensible. They definitely need to be changed to meet current day realities so that sympathetic educators who "get it" don't have to per se "lie" or "commit fraud" or be forced to defend a stupid letter of an irrational rule.

It's not just my opinion. Rumor has it that the OB requirement is being revamped as we speak & will be changed in the next 1-2 years.

 

[cali-ob]

wow, quite a bit of discussion over my question.

LB: I appreciate your advise. At my hospital, we use an EMR so it would be easy for me to look up patients and print delivery notes. However, we also rotate at a private hospital where the private attendings do deliveries and if they are "nice" you can get in on it. They don't let you write in the chart though, so I wouldn't have much "proof" of those deliveries. I know many of my classmates counted deliveries at that hospital where they simply observed and never laid hands on the patient. I only included those deliveries where I was touching baby as it came out. But I still doubt I was included in the delivery note, and at this point, it would be quite difficult to go back and obtain the records. But I do have every patient's name and MR number and the date of the delivery, type of delivery,etc logged. So I suppose it's traceable.

So it seems 100 may be the minimum "magic number". I was told that at my program too for a community hospital.

I will work on that goal.

Re: continuity deliveries. I agree, quite a pain. I have followed quite a few more pregnant ladies from conception to term, than I have actually delivered. Last year, one of our graduating residents had to come back 1 month later to do a delivery so that they could effectively meet the requirement.

 

[JackADeli]

The straight & narrow is to follow these RRC rules without question & to interpret them en face as you (JAD)'ve done. Yea, of course I can read the requirements & make it black & white. You defend the requirement...

Wow! That is creative. Let's actually clear it up a little without the inflamation. The requirements as far as deliveries is clear. That is not a grey area with interpretation. You (FP/FM) resident "...must perform ...deliveries ... of which a minimum of ten must be continuity deliveries". Ten of those forty must IN ADDITION to the basic requirement of performing the delivery must have the continuity component on top. How can you take credit for this special/specific "type" of delivery if you didn't do the delivery. You are trying to turn it backwards with your interpretation. I am not making it black and white. The most specific component is the minimum baseline requirement of performing the delivery in order to take credit for performing the delivery. I have NOT defended the rule. I am not going to declare what is necessary training for an FP/FM as you seem to do. I have not said these rules are good or bad. I am merely opposing fraudulent conduct endorsed or not by attendings.

...To miss a continuity delivery due to a traffic ticket is a non-educational technicality. If you were a bean-counting auditor, you're right, no delivery, no credit. But big picture, this resident's educational burden has been met, at least in the spirit of "continuity"...

Wow, again. The logging is for a delivery with additional experience on-top. It is what the requirement is. You are are declaring the requirement to be relatively not important for taking credit. But, in taking credit, you are declaring you performed the procedure! The composition of the continuity component is the component that is up for some interpretation.

...RRC is an arm of ACGME & so I don't know what their relationship is with the ABFM, but I will say that this "required" "continuity deliveries" makes no damn sense in modern FM residency education in the era of 80-30 hour work restrictions, OB hospitalists, and block rotations...

You can't arbitrarily create a stupid rule...

Again, you are suggesting this was an arbitrary creation in a vacuum by RRC/ACGME. The current requirements are a matter for your board leadership to address and or change if they so desire. RRC/ACGME simply post and enforce criteria that has been created with the guidance/leadership of the different specialty boards. If your FM/FP board feels these are unrealistic training requirements it is really up to them to change it. I will add, as an other reason opposing fraudulant logging, false logs send the message the requirement is achievable. It is the same with work hours and other factors. As long as residents and/or attendings lie, shortcomings will not be identified and corrected. It is also sad to lie and then tell applicants, "yes, we have plenty of deliveries and meet all our continuity DELIVERY requirements...".

These stupid rules are indefensible. They definitely need to be changed to meet current day realities so that sympathetic educators who "get it" don't have to per se "lie" or "commit fraud" or be forced to defend a stupid letter of an irrational rule...

Man, that is rich. It is NOT "per se lie". It is outright lying. If you take credit for a procedure you did NOT perform because YOU think the pre & post procedure component is more important... you have lied. That is black and white. I could never turn and tell some one,
"yeh, I delivered that baby. I wasn't in the room at the time. But, I provided the mother with prenatal & postpartum care...".
Ask the mother who actually delivered her baby! It doesn't even pass the laugh test. From a surgery standpoint, one could argue the pre-op care/management and post-op care/management is the most important part of say pyloromyotomy in a child with pyloric stenosis. The operation itself is fairly straightforward and simple. But, to say you did the case when you didn't because you did the pre & post care is ridiculous.

...It's not just my opinion. Rumor has it that the OB requirement is being revamped as we speak & will be changed in the next 1-2 years.

I suspect others do share your opinion, but citing rumors does not change it nor does lying now because you think later the guidelines will change show solid character or ethics. Again, you are arguing based on what you feel/believe is more important... Thus, as the pre and post care seems more important to you, one should take credit for the procedure they never performed? I don't care about this or any other requirement in any specialty. I do not support or oppose it. That is to say, I am NOT defending the rule/s. I am saying acting fraudulently for personal gain... be it graduation eligibility or reimbursement or program accreditation is wrong. Further, fraud hides the problem. So, surgical residents double logging or FP/FM residents logging procedures they did not perform perpetuate the problem.

...Re: continuity deliveries. I agree, quite a pain. I have followed quite a few more pregnant ladies from conception to term, than I have actually delivered. Last year, one of our graduating residents had to come back 1 month later to do a delivery so that they could effectively meet the requirement.

It seems like it can be a pain. I am glad to hear your colleague did the honest and ethical thing and actually performed the procedure instead of fraudulantly logging it.

 

[EdibleEgg]

I'm not doing any more OB. I miss it, but I have enough other battles to fight. I am doing endoscopy however, and I think some of the credentialing issues are applicable. As far as number of procedures, it's going to vary from institution to institution. Do you know where you want to eventually work? Are there other FP's doing OB there? Have you thought about call coverage? Are you expecting the OB's to cover call for you? Regardless, keep an accurate and detailed record of your procedures. Go ahead and grab a copy of the delivery record while you are there and start a file. I'm not sure if that's kosher with HIPPA, but it will save you some grief later.