University of California San Francisco

Program Information


Background

The UCSF Family Practice Residency Program at San Francisco General Hospital (SFGH) was established in 1972 with a mission to prepare family physicians for practice in urban underserved areas. We train 39 residents annually (13 in each of three resident years), and our curriculum is tailored to provide residents with the skills, knowledge, and attitudes necessary for working effectively with individuals and families of diverse racial, ethnic, cultural, and socioeconomic backgrounds. Most direct teaching and observation occurs at our Family Health Center (FHC) which is part of the SFGH campus. While the majority of our residents’ training is concentrated in urban, underserved settings, graduates also successfully practice in rural and suburban settings.

The UCSF Family Practice Residency Program (FPRP) has always provided broad reproductive health training with a focus on the culturally diverse population at FHC. Beginning in January 2004, the FPRP expanded our reproductive health curriculum and patient care opportunities immensely through collaboration with the UCSF TEACH Project (Training Early Abortion for Comprehensive Healthcare). TEACH is an academic-community partnership with Planned Parenthood Golden Gate (PPGG) where over 90% of the trainers are family physicians. The goal of TEACH is to expand reproductive health access by helping residencies integrate evidence based and patient centered contraception provision, options counseling for unintended pregnancy, and early abortion training into their curricula. This innovative training program, offers residents experience in all aspects of reproductive care whether or not they choose to perform abortion procedures.

The integration of this training has been strongly supported and met with great enthusiasm by the Chair of Family and Community Medicine, as well as the Residency Director, faculty, and residents.

Didactic and Experiential Skills in Option Counseling for Unintended Pregnancy

Prior to the integration of the TEACH program there was ad hoc didactic training in options counseling for unintended pregnancy, and training in abortion provision was via elective rotations. Currently, our training in options counseling for unintended pregnancy has 4 components ­ didactic conferences, problem-based review, off-site higher volume training, and on-site options counseling and service provision. TEACH offers interactive didactic conferences including one on options counseling for unintended pregnancy that occurs annually. The didactic session on abortion complications also increases resident’s skills in options counseling.

The TEACH Early Abortion Training Workbook includes an entire chapter on options counseling, education and informed consent (see attachment #--- Chapter). The workbook has case-based exercises at the end of each chapter, and key evidence-based teaching points in the Trainer’s version. It also has many useful tables, ultrasound images, available CME credit, as well as ACGME-aligned evaluation instruments. During the first training session, the TEACH trainer reviews exercises on values clarification and options counseling with the resident before procedural training. Entire Training and Trainer’s versions are available for free download at http://www.ansirh.org/trainingworkbook/trainingworkbook.html.

In all FHC clinics, residents have the opportunity to interact with women who have not yet decided between the options of parenting, abortion or adoption. During their 8 days training at PPGG residents in their 3rd year now receive extensive experiential skills in options counseling for unintended pregnancy observing skilled trainers, and then being observed providing options counseling to patients. This rotation improves resident skills in providing sensitive and accurate options counseling for unintended pregnancy to the diverse patient population in our FHC Clinics: Urgent Care Clinic where women frequently drop in for pregnancy tests, resident continuity clinics, Women’s and Teen clinics.

We are starting to offer early ultrasound dating to women who choose to terminate their pregnancy in an effort to increase resident skills, clarify dating and aide the choice of medication or aspiration procedure.

Evaluation Methodology and Summary Results to Date

Residents are evaluated and precepted by faculty during their experiential learning in continuity clinics, Women’s, Teen, Procedure and Urgent Care clinics. In addition to the verbal interaction and feedback given by UCSF Faculty, interns have written evaluation of every note (see attachment #2- intern review note). We also use an electronic evaluation system for senior residents (E-value).

The resident’s competency is evaluated multiple times during their TEACH training. Residents participate in baseline skills inventory, procedure logs, competency-based evaluation, and program evaluation at the end of their rotation. All data are entered into a secure central database, and descriptive statistics are generated using Filemaker and Excel software. The Human Subjects Institutional Review Board at UCSF has reviewed and approved TEACH’s evaluation research.

The residents work one-on-one with a TEACH Trainer who evaluates their skills and sensitivity and provides feedback. At the end of the 8 sessions, the resident gets a written formal evaluation of their clinical knowledge, procedural, and patient care skills by the Trainer. (See Attachment #- the Observed Performance Assessment).

Areas of evaluation pertinent to pregnancy options counseling include:

  • Consistently introduces him/herself to patients
  • Consistently uses open-ended questions when counseling patients
  • Establishes rapport with the patient
  • Provides options counseling in a “patient-centered manner” (one that is free of personal judgments and is focused on meeting the patient’s expressed needs)
  • Confirms appropriately signed patient consent
  • Answers patients’ questions clearly, correctly, and comprehensively

Since UCSF began with TEACH, 5 faculty and 13 residents have been trained. Of those who formally completed the training program at UCSF, 80% completed a final evaluation. Evaluation pertinent to pregnancy options counseling includes:

  • 100% felt adequately prepared to both counsel patients of pregnancy options and to counsel patients choosing abortion.
  • The most highly rated aspects of the abortion training rotation were interaction with clinic staff, the program orientation, and the opportunity for open discussion with trainers.

Programmatic evaluation of our on-site training has been less formal. However, a survey of residency abortion training programs done by UCSF and presented at STFM, showed very strong support from the residents about our options counseling for unintended pregnancy training. Organizers and trainers received outstanding evaluations and feedback after our recent provider training on Options Counseling for Unintended Pregnancy.

Plans for Residency Program to Enhance its Teaching Methodologies this Year

In addition to recent expansions in contraceptive and pregnancy options counseling training, we plan to integrate medication abortion into the FPRP and FHC in spring of 2006. This involved a values clarification workshop for FHC nursing and clerical staff. We will be providing similar training for the residents and faculty along with extensive training on the efficacy, safety, and differences between side effects and complications of medication abortions. As of July 2006, we plan to expand our Nurse Practitioner run Contraception Follow-Up clinic to be a resident training site with a dedicated attending physician who is well versed with current and evidence based contraception technologies.

Through collaborative regional networking of the TEACH Program, we will continue to share our experience with other Residency Programs in the region. At the policy level, faculty in the Department played a key leadership role in the successful passage of a 2005 resolution recommending evidence based contraception provision and abortion training with opt-out provisions through the California Branch of the AAFP. We are becoming increasingly involved through State and National branches of the AAFP to advocate for comprehensive reproductive health training, and inclusion of evidence based contraception provision within the scope of practice of Family Physicians.