Program Information
Background
The mission of the Beth Israel Residency in Urban Family Practice is to prepare family physicians to serve as leaders in urban health care, with an emphasis on the particular needs of medically underserved communities. The program is run collaboratively by Beth Israel Medical Center's Alfred and Gail Engelberg Department of Family Medicine and the Institute for Urban Family Health, a non-profit organization established in 1983 that makes family medicine services available to medically underserved populations. The Beth Israel Residency in Urban Family Practice opened in 1993, and it is now a 24-resident family medicine residency program.
Contraception Education
Our residents attain competency in provision of contraceptive care through a curriculum integrated into our three-year residency. During a one-month orientation to family medicine rotation (“family medicine month”) in October of the first year, all interns participate in a three-hour interactive didactic curriculum on contraception, emergency contraception, health maintenance, and women’s health care (see attachment). The sessions include case-based scenarios with evidence-based back-up to encourage interns to think creatively and critically about the delivery of contraceptive care.
Interns and residents gain practical experience in contraceptive care during clinic sessions, where each resident often counsels patients about contraception choices. Faculty preceptors reinforce the didactic information provided in the orientation curriculum, including providing prescriptions for emergency contraception to all appropriate patients, providing appropriate evidence-based pregnancy prevention care with both hormonal and non-hormonal contraceptive products, and patient-centered initiation of hormonal contraceptives (e.g., “quick start”).
A one-month Gynecology rotation in the PGY-2 year develops resident knowledge and skills in contraceptive care. Required readings highlight evidence-based knowledge in contraceptive care (see attachment 2). In addition, the residency program provides each resident with the Managing Contraception pocket book for further self-directed study and quick reference. During this rotation, residents gain competency in placement of intra-uterine devices, diaphragm fitting, and post-abortion contraceptive counseling during a weekly procedure session at the clinic site. Additional weekly procedure clinic experience is gained in a longitudinal fashion during three selected months during the PGY-3 year. Interested residents use this opportunity to achieve mastery in IUD placement and care.
Additional didactic education is provided in the context of the longitudinal core curriculum, for which all residents are pulled from clinical activities for one half-session per week, and in weekly Grand Rounds presentations. Recent curricula have included a procedural session on insertion of IUDs and Grand Rounds presentations on vasectomy and emergency contraception.
Evaluation of Residents
The Gynecology rotation evaluation provides an in-depth opportunity for key faculty with a special interest in contraceptive care to work with and evaluate residents, both informally during clinic precepting and formally through a course evaluation (see attachment 3). Additional clinical observation is achieved through precepting during the PGY-1 year, when all patients must be precepted to a faculty supervisor before the visit can be completed.
Evaluation of Curriculum
Feedback from the residents is provided through anonymous evaluations of the Gynecology Curriculum (see attachment). Average evaluation scores have exceeded 3.5 on a 4-point scale. Curricular success can also be seen in board scores: gynecology scores have steadily risen until, in 2004, BI residents performed better in this area than in any other. In addition, graduation statistics show that many Beth Israel graduates continue to practice full-spectrum reproductive health care, and several have pursued reproductive health fellowships. Finally, an Observed Structured Clinical Encounter (OSCE) module on contraception was developed for the residency program (see attachment).
Teaching the Competencies: Practice-Based Learning
While medical knowledge and patient care are taught through the didactic curriculum and clinical experiences described above (see attachment for competency-based evaluation), residency program faculty have been instrumental in using evidence-based research on contraceptive care to demonstrate practice-based learning in the clinical environment. For example, residents learn the concept of “quick start” and are taught to implement this concept through active precepting and frequent reminders in the clinic. Faculty have also promoted a policy by which nursing staff may fill standing prescriptions for emergency contraception for patients who meet appropriate clinical criteria, without an office visit. These changes were possible only through the review of evidence-based guidelines for emergency contraception and leadership of the clinic management team.
Teaching the Competencies: Systems-Based Practice
Our model of evidence-based contraception management specifically addresses professionalism by creating accessible care for diverse patients. Our clinic serves an economically disadvantaged, ethnically diverse patient population. Residents learn a nonjudgmental, patient-centered approach to contraception, emphasizing the need to identify and honor patients’ preferences and to partner with patients to enhance adherence. Preceptors discuss the importance of removing barriers to contraception. In the initial didactic sessions on contraceptive care, faculty members address the consequences of delaying access to contraception – that is, the impact of unintended pregnancy on patients, families, and society. This patient-centered approach is reinforced through precepting during the three years of residency. When residents care for patients with unintended pregnancy in our options counseling clinic sessions, they see the results of failed contraception first hand. This approach is reinforced through a variety of reflective discussion activities that allow residents to discuss their experiences in providing contraception.
Replicability of the program
Stand-alone didactic modules that we present in the PGY-1 year can be incorporated into many different residency education modules and can be adapted to small-group learning or even on-line self-learning modules. Provision of procedural skills can similarly be incorporated into existing procedural curricula, though faculty will need to ensure that patient panels provide sufficient experience for residents to learn IUD placement, care, and removal. Finally, faculty development will be necessary to replicate our program, because longitudinal precepting in the resident clinic plays a large role in reinforcing evidence-based behaviors and creating the appropriate resident attitudes and practices to carry through into residents’ future practices