We have developed didactic conferences on options counseling, evidence based contraception, abortion provision and complications, and adoption.

We have developed a series of didactic conferences on pregnancy options counseling, evidence-based contraception, abortion provision and complications, and adoption. They are incorporated into all years of the residency curriculum. Conferences include role-plays to practice use of non-judgmental language and essential information needed to discuss all options with women who have unintended pregnancies.

Residents participate in training at Planned Parenthood Golden Gate where counseling is observed and then performed under supervision.

Third-year residents observe skilled trainers providing options counseling during a four-to-eight-day rotation (over one to two months) at Planned Parenthood Golden Gate, a high volume off-site clinic providing abortion training (Training Early Abortion for Comprehensive Healthcare —TEACH—rotation). They are then observed counseling patients and are given feedback on their skills.

Residents are guided by a TEACH Trainer.

Residents are guided by a TEACH Trainer in an interactive 1:1 discussion about values clarification. This is required of all residents, whether they will undertake training in abortion procedures or not, and provides a valuable framework within which each resident can better understand her/his values and how they inform her/his interactions with patients. We expect that this discussion broadens trainees’ perspectives on unintended pregnancy, balanced counseling, and abortion services. (Curriculum: Counseling, Education and Informed Consent, Training Suggestions for Counseling Exercises, The Abortion Option, Values Clarification Workshop, Pregnancy Options Counseling and Values Clarification Workshop, Basic Counseling Steps)

Residents may learn about procedures— this is an opt-out option.

During training at Planned Parenthood one day per week, residents are given the option to learn to perform early ultrasound, first trimester manual vacuum aspirations (MVA), tissue exams to determine procedure completion, and discussion of differences between abortion services offered at PPGG and those typical of family practice settings. This is an “opt-out” part of the gynecology rotation—specifically, residents choose the extent to which they participate in procedures. (Handout: Pregnancy Dating: Tips and Methods)

All residents have felt comfortable counseling.

While we have had various residents who chose not to learn the abortion procedure, all of our residents to date are required to and have felt comfortable with counseling and referring patients. All have participated in recommended parts of the curriculum including values clarification, contraception, follow-up, and management of complications.

We utilize TEACH Early Abortion Training Workbook as a resource and to complete case-based reviews. (www.ansirh.org/training)

Residents utilize the TEACH Early Abortion Training Workbook as a resource and to complete case-based reviews.

Residents see a diverse population.

The San Francisco General Hospital Family Health Center is a publicly funded health center that provides care to an ethnically diverse population. About 35% of our patients are Latino, about 35% are Asian American, and about 10% are African American. While the predominant languages our patients speak are Spanish, Cantonese, Vietnamese, Tagalog, and English, they represent over 20 languages altogether, including Arabic and Eritrean. We are fortunate to have many languages represented among Family Health Center providers and to have access to trained medical interpreters in person and through video monitors. Fully 50% of our patients are uninsured.

Residents develop skills in interviewing.

Behavioral science and family systems are each a major emphasis of the residency training curriculum. Through seminar sessions and patient/family interviews that are supervised and videotaped, residents have the opportunity to develop skills in family and individual assessments. They are expected to demonstrate competence in eliciting the patient’s priorities and preferences; observing and intervening to improve communication patterns; working with medical interpreters; and examining the ways in which their own culture and beliefs affect their relationships with patients.

Counseling skills are integrated with behavioral science training.

The counseling skills that residents learn through the TEACH program, integrated with their behavioral science training, serve to improve their care of women with unintended pregnancies in their continuity practices and in our urgent care services at Family Health Center.

We have developed and instituted a protocol to ensure that all women with newly diagnosed pregnancy tests at the Family Health Center have consistent and immediate access to options counseling.

To provide systematic support for further improving the care of women with unintended pregnancies, we developed and instituted a protocol in collaboration with Family Health Center leadership, residents, nursing staff and social workers. The protocol ensures that all women with positive pregnancy tests (whether their appointment is an urgent appointment, an appointment with their primary, or for a nurse visit) are offered immediate access to options counseling. The protocol ascribes a role for each level of staff (resident, attending, nursing, social worker), including faculty members who can assist with early ultrasound. The Family Health Center social worker is available on short notice to assist with further counseling if needed, and to provide follow up when necessary.

Ongoing discussions

In the course of instituting this curriculum, faculty members, residents, and Family Health Center staff have engaged in ongoing discussions about the provision of reproductive services in general, and about providing post-coital contraception and medication abortion services in particular. We are a diverse group; we have been willing to express our opinions and beliefs and also to accept that they may differ. Invariably, our discussions have led to further recognition and respect for our diversity. While there are some among us who do not believe that abortion is an ethically acceptable option to offer patients, each of us accepts our responsibility for providing access to abortion and contraceptive services for our patients. We are fortunate to have a working environment that facilitates collaboration, so that our patients may receive the care they need in a timely and respectful manner.

Pre-training baseline skills and knowledge evaluation and post-training comprehensive formal evaluation of clinical knowledge, procedural and patient skills during TEACH rotation

Residents complete a baseline skills inventory before training; this is followed-up with a competency-based evaluation and program evaluation at the end of their rotation. Throughout the rotation, residents maintain a log of procedures. They work one-on-one with a TEACH Trainer who provides formative feedback. At the end of the eight sessions, the Trainer provides the resident with a formal written evaluation of their clinical knowledge, procedural and patient care skills. (Evaluations: Intern Note Review Form, Observed Performance Assessment, Evaluation of Resident, Evaluation of Rotation)

Areas evaluated 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

Electronic evaluation of residents during TEACH rotation, covering procedural, counseling and professional competencies.

Data from these evaluations is entered into a central database where descriptive statistics are generated to monitor performance.

Ongoing evaluation and preceptorship of residents by faculty

• Residents are continuously evaluated and precepted by residency faculty during their experiential learning in the Family Health Center, including their continuity practice, Women’s, Teen, Procedure and Urgent Care Clinics.
• The TEACH rotation is evaluated by residents using the residency program’s web-based electronic evaluation system.

Integrate medication abortion into Family Health Center services summer 2006

Medication abortion will be integrated as an option in summer of 2006. To accomplish this, we have had several sessions with Family Health Center clerical and nursing staff to discuss values clarification. Similar training has been provided to residents and faculty along with training on efficacy, safety, side effects and complications of medication abortion. This training will continue to be offered annually to staff and residents.

Integrate training materials for pregnancy loss

We have recently integrated more complete training materials on management options for early pregnancy loss.

Increase involvement in state and national Family Practice policy and continuing medical education in reproductive health for primary care providers.

Faculty within the residency program are increasingly involved in State and National branches of the American Academy of Family Physicians to advocate for comprehensive reproductive health training.

Train other physicians regionally

UCSF Faculty train other physicians regionally and nationally on options counseling, evidence based contraceptive choices, and provision of early abortion by Family Physicians.

Continue to evaluate training

We will continue to evaluate how our training affects residents' skills and what types of reproductive health care they provide to patients in future settings.