Sutter Medical Center of Santa Rosa

Program Description


Background

The Family Medicine Residency Program at Sutter Medical Center of Santa Rosa was created more than 30 years ago by the founders of Family and Community Medicine. We serve an economically and ethnically diverse population, with 80% of patients funded by MediCal or other state funded programs, and are committed to training our residents to deliver quality care in a variety of practice settings.

Half of pregnancies in this country are unintended – and yet many women feel they cannot talk about this issue to their own physician in a balanced, non-judgmental way. This is a barrier to care that affects all women. Even well insured women may lack complete reproductive care because their physicians are not trained or knowledgeable in full spectrum of choices, or may respond with judgmental attitudes, rather than information. Our goal is to train Family Physicians to address the issue of comprehensive reproductive services for diverse patients in diverse communities.

At Sutter Santa Rosa, residents and faculty have been committed to full spectrum reproductive health for many years. When the local clinic, which had been training our residents in out patient reproductive health closed in 2002, our residency was able to translate this setback into an opportunity by initiating services in our own family practice continuity clinic. We have developed an innovative and comprehensive training curriculum for Family Medicine Residents in options counseling and early abortion provision that was the first of its kind on the west coast.

Training

Our training includes independent study, didactic, and experiential components, directed by well-developed goals and objectives.

The didactic component of our training includes 3 interactive conferences, each lasting a full half-day, available to PGY-1, PGY-2, and PGY-3 residents. Topics include the full spectrum of options for unintended pregnancy, values clarification, basic skills in counseling, historical and public health perspectives on reproductive rights, procedures for medication and aspiration abortion, and abortion complications.

Additionally, we have a wonderful case and evidence based training manual for independent and facilitated study that includes a section on values clarification and an entire chapter on counseling, education and informed consent. The curriculum, known as the Early Abortion Training Workbook, was developed collaboratively through TEACH (Training Early Abortion for Comprehensive Healthcare) at UCSF, and some contributing authors are former Sutter residents. The manual provides evaluation tools grounded in the six ACGME-designated competencies, and opportunities for continuing medical education credits. Both Training and Trainer’s versions are available for free download at: http://www.ansirh.org/trainingworkbook/trainingworkbook.html.

Experiential skills in pregnancy options counseling are conducted for PGY2s and PGY3s. . PGY 2s are first introduced to options counseling at Planned Parenthood where they spend four days on their gynecology rotation. There they observe and are then observed doing counseling sessions. They can also be trained in ultrasound, medication abortion, aspiration procedures and options counseling if they want to learn these skills.

In addition, we have a weekly early pregnancy options clinic at our own Family Practice Center, which is staffed by 2 residents a PGY 2, and a PGY 2. In this clinic the residents do all the counseling, ultrasounds, medication abortions, aspiration procedures and follow-up of patients with a wide range of early pregnancy issues such as unintended pregnancy, miscarriage and ectopic pregnancy. Ours is the first on site full spectrum reproductive health clinic in a Family Medicine residency on the west coast. Because the residents are the primary providers at the Family Practice Center, this experience more closely simulates pregnancy diagnosis and options counseling in a private practice. Residents report that the counseling is one of the most challenging and rewarding parts of the visit.

Other important aspects of our training include journal clubs and discussion groups in resident homes, grand rounds, “on-call” experiences, and patient review conferences.

Evaluation

Each resident is evaluated multiple times during training. As PGY2s at Planned Parenthood the resident’s work one-on-one with a Trainer who evaluates their skills and sensitivity and provides feedback in an ongoing way during each day of training. Written formal evaluation of skills is provided at the completion of 4 sessions (See the Observed Performance Assessment attached). During the resident’s third year they work at the early pregnancy options clinic here at the Family Practice Center for 8 sessions. During these sessions, residents do all the options counseling working with a faculty member who is experienced in abortion provision. The faculty member gives feedback to the resident after each session. The residents do a self-assessment of their skills doing options counseling at the end of their third year rotation in women’s health.

To date a total of 37 trainees have attended training sessions at Planned Parenthood, including 7 faculty and 30 residents. Of those who formally completed the program, 84% (n=31) have completed a final evaluation.

  • 90%(28) felt adequately prepared to both counsel patients of pregnancy options and to counsel patients choosing abortion.
  • 87.1% (27) felt that the reproductive health training they received had adequately prepared them to provide 1st trimester vacuum aspiration abortion procedures with confidence.
  • 70.9%(22) anticipate providing aspiration abortions and the same number also anticipate providing medical abortion.
  • Over 64%(20) felt that the training has increased their interest in providing abortion services; none reported decreased interest.

A survey of residency abortion training programs done by UCSF and presented at SFTM, showed very strong support from our residents about our training. The quotes below about the experience at our early pregnancy options clinic are representative:

Resident #1: “I feel much better about it [on-site training] because I feel like I have a lot more contact with the patients, it’s much more comfortable… I’ve seen a lot more gratitude from the patients and a lot more smiles and comfort…I think the way we’re doing it in our clinic has been pretty neat to watch.…but certainly we don’t do the volume that you would see at like a Planned Parenthood ... But I think it’s – I feel much better about it because I feel like I have a lot more contact with the patients, it’s much more comfortable. I end up spending a huge chunk of my day with each patient that goes through this. And I think there’s more of a connection there. There’s an expectation. They understand who their doctor is, whereas my experience when I was training ..the Planned Parenthood, you walk into the room, we do the aspiration procedure, I walk out and never see the patient again and had never really talked to the patient beforehand and understand any complexities of that patient’s life. And so I think, being a family physician, I think it follows much more along my understanding of a family physician. So I think that would be the part that pleases me the most, is the relational part of that, feeling comfortable knowing that if they have questions about what’s going to happen afterwards or questions about their birth control or questions about any sort of other healthcare needs, that they’re going to be free to come back and ask me and feel comfortable about it.”

Resident #2: “I've been very lucky to work in places where people have been very nice and helpful and … the full spectrum of getting to do everything from the ultrasound to the procedure to all the counseling stuff. I think it’s very good to get to do all that stuff…”

Resident #3:“I really liked the values clarification and the opportunity to follow a patient through the clinic from start to finish. I loved the teaching. It's hard stuff, abortion training; but I think the program helps every provider, whether they plan to do abortions or not.” (Opt Out Trainee)

Opt-Out Curriculum

We have routine training with opt-out provisions, and find that the program may be tailored to focus on the core material and meet the needs of each resident. Our program and the Training Workbook outline an Alternative Curriculum Pathway for residents opting out, including values clarification, options counseling, contraception, complication management & follow-up. Residents are also offered a gradation of training at Planned Parenthood and can to choose from a palate of related skills, which can include:

  • Pregnancy Options and Contraceptive Counseling
  • Dating Ultrasounds and Exams
  • Gynecologic skills such as cervical anesthesia, miscarriage management, and IUD insertion.
  • Discharge Teaching and Complication Management

A written policy is helpful to inform prospective residents and positively message training and opt out provisions (see attached Opt Out Letter). Respect for varying opinions has helped defuse polarity around reproductive health care in our Residency.

Future Plans

In the coming year, our residency plans to continue its reproductive health training at both our off-site training in PGY2 at Planned Parenthood and our own on-site early pregnancy options clinic. The integration of the training program and on-site reproductive health clinic has helped to change institutional culture and attitudes, as well as to transfer skills out of the OR into to ambulatory settings more appropriate for Family Practice residents and future service provision. In the next year we hope to make it easier for residents to offer options counseling and medication abortion in their routine continuity clinics.

We are in the process of collaboratively submitting an article to Family Medicine on “Integrated Abortion Training in Three Family Medicine Programs” The TEACH curriculum is also being expanded to include a chapter on Miscarriage Management, which should be available online by early 2006.

Through collaborative regional networking of the TEACH Program, we will continue to share our experience with other Residencies in the region, and we are becoming increasingly involved through state and national Family Practice Associations to advocate for comprehensive reproductive health training, and inclusion of early pregnancy options within the scope of practice of Family Physicians.