Program Information
Background
The University of New Mexico Family Practice Residency has 44 residents at five family practice centers throughout Albuquerque. Prior to 2002 resident training in pregnancy options counseling and abortion care was limited and quite variable. As the University of New Mexico did not offer abortion care, women contemplating pregnancy termination usually self referred to one of the local abortion care practices. In 2002 UNM Family Medicine began training residents in pregnancy options counseling, medical abortion, surgical abortion, and first trimester dating ultrasound during a required third year rotation in Ambulatory Women’s Health. Although residents may opt out of the provision of abortion services, all residents are required to receive training in options counseling and the management of abortion complications.
Training
Options counseling and abortion care occur throughout the Ambulatory Women’s Health rotation as four to five half-days per week of the rotation occur in clinical settings which offer pregnancy options counseling and abortion care. One half-day is spent in the Family Practice Center Options Clinic; one half-day is spent in the 1209 Family Health Women’s Health Clinic; one half-day is spent at the private office of Dr. Bruce Ferguson; two half-days are spent at the local Planned Parenthood clinic.
The Family Practice Center Options Clinic was designed specifically to train Family Medicine residents in a model that has integrated pregnancy options counseling, abortion, and first trimester ultrasound into primary care. The clinic occurs for one half-day every week, serving a diverse, multicultural population of women from the greater UNM Family Practice network, which provides care for urban and rural areas across New Mexico. Four UNM faculty members who are trained and credentialed by the university to offer abortion care and first trimester ultrasound precept UNM Family Medicine residents in running the clinic. Women seeking pregnancy options counseling and/or abortion care are referred from many affiliated practices. Women choosing medical abortion with mifepristone can receive mifepristone immediately following their options counseling. Women choosing surgical abortion were initially referred to one of the local abortion practices, however we have recently added a pilot surgical abortion clinic that is held at the Family Practice Center in the early evening the day of the Options Clinic.
We chose to offer first trimester obstetrical ultrasound during the Options Clinic session for several reasons. Although medical abortion can be offered without a dating ultrasound, many women are unsure of their menstrual dating and the presence of on-site ultrasound greatly facilitates options counseling. The inclusion of many women who will continue prenatal care with Family Practice maternity care providers in the same clinical setting with women who are seeking options counseling for undesired pregnancy presents the full spectrum of reproductive decisions made by pregnant women. Residents who have been uneasy getting training in options counseling with local abortion providers have been comfortable receiving the training here. We have found that attaining competency in first trimester ultrasound requires seeing many more patients than is required to achieve competency in the other skills of medical abortion provision and, for some faculty and residents, requires a larger number of clinical encounters than competency on manual vacuum aspiration.
Pregnancy options counseling is provided to an average of two women per session by UNM Family Medicine faculty and residents. The residents typically observe or participate in counseling for the first few patients and then perform the counseling themselves with the faculty serving as teachers. All patients are presented the options of parenthood, adoption, and abortion. If a patient chooses abortion, she is counseled further about her options of surgical versus medical abortion, depending on her gestational age. Surgical and medical abortion services are both offered on-site. Patients choosing medical abortion are given the number of a 24-hour pager, carried by the Ambulatory Women’s Health resident, to call if they have questions or potential complications.
If a patient chooses parenthood, we are also able to offer continued prenatal care at the same site, often with the same resident. Our ability to offer both abortion and prenatal care through one Options Clinic attracts a patient base that truly represents the whole spectrum of women and their pregnancy decisions, rather than primarily attracting patients seeking one service or the other, and provides a “one-stop-shop” for women in their first trimester of pregnancy.
Residents receive additional training and experience in pregnancy options counseling at three other local clinics. They spend one half-day per week in the Women’s Health Clinic at 1209 Family Health, one of the other five clinics within the Family Practice Department. This clinic, precepted by Dr. Toby Palley, provides pregnancy options counseling, first trimester dating ultrasound, medical abortion, and colposcopy. Much like the Options Clinic, residents are able to establish relationships for prenatal care through this clinic as well.
One half-day per week is also spent at the private practice of Dr. Bruce Ferguson, a Family Practice physician who provides pregnancy options counseling and abortion services. Two half-days per week are spent being precepted by Dr. Diana Koster at Planned Parenthood, where abortion services are offered, including pregnancy options counseling. Consequently, Family Practice residents become familiar with a wide variety of counseling styles and settings, including options counseling in primary care, in private practice, and in high-volume abortion clinics.
Residents also receive didactic training in options counseling and abortion care. At the beginning of the rotation they go through a values clarification to help them identify their own feelings which may influence their counseling style. During the Ambulatory Women’s Health rotation residents attend a series of small group seminars on reproductive health topics, including pregnancy options counseling, medical and surgical abortion, and first trimester ultrasound. Lectures and values clarification exercises are also periodically given to the resident population as a whole during weekly Grand Rounds teaching sessions, and to smaller groups of residents during weekly MCH seminars. Residents also independently review a series of videos, PowerPoint presentations, textbooks, and articles about pregnancy options counseling, which are provided to them during their Ambulatory Women’s Health rotation. Although we have developed a concentrated training experience during a third-year rotation, we are also providing training early in residency as each intern has the option to spend 2-4 half days of their monthlong Maternal and Child Health rotation participating in options counseling and observing abortion care.
Evaluation
Resident competency in pregnancy options counseling is evaluated in two ways: through surveys completed by the residents at the end of the rotation and by evaluation of the residents by preceptors. Each resident is given a survey to complete at the end of the Ambulatory Women’s Health rotation, which asks them to evaluate the abortion training program and what they have learned. There is a question on the survey asking for self-evaluation of their options counseling skills, rating competence on a scale of one to five. Since the inception of the program three years ago, the average rating for options counseling is 4.6.
Additionally, residents are evaluated by each preceptor who trained them in options counseling, ultrasound, and abortion. The form used asks for evaluation regarding the resident’s demonstration of respect for patients, ability to explain things to patients, and ability to answer patients’ questions clearly and comprehensively. Residents are also evaluated on whether or not they can identify contraindications to medical and surgical abortion and accurately date a pregnancy based on pelvic examination and sonography. Preceptors indicate whether the resident’s performance in each area is satisfactory for the level of a third-year resident or needs improvement, or whether they are unable to evaluate the resident in this area. Very rarely have our residents received unsatisfactory scores in areas related to pregnancy options counseling.
Evaluation of the program is done in two ways. We routinely look at evaluations of residents in aggregate to assess the success of the training program. Additionally, residents are asked to evaluate the program on the post-rotation survey. They rate the effectiveness of several areas of training, including counseling experience, as needing improvement, satisfactory, or excellent.