The cultural and ethnic background of patients in the United States is more diverse than ever before. Physicians must understand and appreciate the various values, family structures, and meaning of life events to effectively care for women and families of different cultural backgrounds.
II. Familiarity with the health care delivery system
The health care delivery system in the United States is becoming increasingly complex. Physicians must understand the social, legal, financial, and ethical system within which they now must practice. Physicians also must understand the mechanisms used to assess the quality and cost of the health care they provide and the procedures used to determine reimbursement for medical care.
1. Describe the common methods of health care financing, such as:
a. Self-payment
b. Preferred provider organization
c. Health maintenance organization
d. Prepaid health care plan
e. Private health insurance
f. Managed care organization
2. Describe the major effects these payment plans may impose on the practitioner, such as:
a. Limitations on resources
b. Limitations on referrals for specialty care
c. Mandatory screening systems
d. Mandatory second opinions for medical and surgical treatments
3. Define the terms used in health care management systems, such as:
a. Utilization
b. Capitation
c. Risk sharing
4. Describe the procedure for, and the professional significance of, maintaining general medical licensure, board certification, recertification, credentialing, hospital staff membership and privileges, and liability insurance.
5. Describe the process of quality assessment and improvement, including the role of clinical indicators, criteria sets, and utilization review.
6. Describe the concept of risk management.
7. Interact in a cooperative, professional manner with risk-management officials.
8. Describe the legal basis of the physician-patient relationship.
9. Describe the concept of standard of care as it applies to physicians and other health care professionals.
10. Describe the physician's legal relationship to other health care professionals, such as
a. Office staff
b. Nurses
c. Nurse practitioners
d. Nurse midwives
e. Physician assistants
11. Demonstrate the basic skills needed to participate in a medical practice:
a. Explain the planning, budgeting, and controlling functions of health care organizations, including medical practices and hospitals.
b. Describe the concepts of partnership and incorporation.
c. Analyze and interpret basic financial statements.
d. Describe the concept of buying into a practice.
12. Describe the leadership skills needed in successful management of a modern health care organization.
13. Describe various concepts and methods of distributing income to physicians in a medical group practice, including:
a. Base salary
b. Productivity bonuses or incentives
c. Use of other factors, such as:
(1) Call schedule
(2) Patient satisfaction
(3) Seniority
(4) Administrative duties
(5) Quality assurance activities
14. Describe the legal and regulatory issues involved in:
a. Integrating multiple medical practices or other health care organizations or both
b. Contracting with managed care organizations
On-line resource: "Managed Care Curriculum, sponsored by the Massachusetts Medical Society"
The classification of disease requires use of a common language. The physician must become familiar with the CPT (Current Procedural Terminology) and ICD-9-CM (Inter-national Classification of Diseases, Ninth Revision, Clinical Modification) coding systems.
1. Describe the current standard terms and definitions used in obstetrics and gynecology.
2. Describe the classification and staging of obstetric and gynecologic diseases and conditions, according to both procedural and diagnostic codes.
3. Apply current procedural and diagnostic codes to reimbursement mechanisms.
4. Describe the concepts of evidence-based medicine and outcomes analysis as they relate to treatment guidelines and reimbursement.
1. Communicate effectively with patients in language that is appropriate to their age and educational, cultural, and socioeconomic background.
2. Foster a trusting and cooperative physician-patient relationship by means of effective communication and interpersonal skills and patient education techniques.
3. Communicate effectively in a cooperative and professional manner with fellow health care providers.
4. Provide instruction and constructive feedback to medical students and other residents.
B. Continuing medical education
The ultimate goal of CME is improvement in health care outcomes. Continuing medical education may take place through individual learning activities (e.g., programmed texts, videotapes, CD-ROM, DVD, the Internet, and audiotapes) or through programs developed by CME providers (e.g., postgraduate courses). An ongoing commitment to CME should enhance a physician's professional competence and improve the effectiveness and efficiency of the health care organization of which he or she is a part. By the end of residency training, physicians should assume primary control for identification of their learning needs and selection of learning modalities. They must acquire attitudes and habits that will help them identify deficiencies in their performance and implement the necessary educational activities to correct those weaknesses.
1. Develop a lifelong pattern of independent self-assessment.
2. Develop systematic strategies to improve the efficiency and quality of care for women in one's practice.
3. Identify medical education programs that are appropriately accredited by the Accreditation Council for Continuing Medical Education.
4. Develop a system to track patient outcomes in order to adjust therapies should the resident's chosen approach fall below acceptable standards.
Online Resource: "JAMA's User's Guide to the Medical Literature"
Essential of Clinical Epidemiology
http://www.internal.bmc.org/gme/essentials/html
C. Effective learning and work behaviors
Residents should develop behaviors that foster an attitude of receptiveness to acquiring and imparting information. Such skills are essential to successful learning as well as to patient care and practice management. Examples of such attributes include the following:
1. Develop a lifelong commitment to medical education.
2. Maintain receptiveness to instruction.
3. Maintain a high level of intellectual honesty.
4. Maintain civility, sensitivity, and humility in interacting with instructors, coworkers, and patients.
5. Develop and maintain habits of punctuality and efficiency.
6. Complete medical records and patient care assessments in a timely manner.
7. Maintain a consistently good work ethic (i.e., positive attitude, high level of initiative).
D. Ethics
The physician specializing in obstetrics and gynecology must balance compassion, sensitivity, and pragmatism in interacting with patients and their families and fellow health care providers. The obstetrician-gynecologist must develop a lifelong commitment to continuing medical education (CME) and the highest ethical standards.
1. Demonstrate a high degree of personal responsibility to patients by being available for consultation, protecting the patient's confidentiality, and maintaining respect for the patient's physical and emotional comfort.
2. Describe basic ethical concepts such as:
a. Autonomy
b. Beneficence
c. Justice
d. Nonmalfeasance
e. Positive rights
f. Negative rights
3. Apply ethical concepts appropriately and consistently to the day-to-day practice of medicine in situations, such as:
a. Obtaining informed consent
b. Assisting patients in developing advance directives and durable power of attorney
c. Balancing the interests of the individual patient, the more global patient population, and managed care organizations
Online Resources:
http://griffin.mcphu.edu/
http://eduserv.hscer.washington.edu/
http://www.imc.gsm.com/
http://www.hsc.usc.edu/-mbernste/
http://ohsr.nih.gov/
E. Information management
Physicians are required to process increasingly greater amounts of complex information presented in many different forms. Physicians must be able to collect, report, and interpret statistical data. They must also be able to evaluate the medical literature in a systematic manner and to identify the best evidence-based guidelines and adapt these guidelines to the management of their patients.
1. Use computer-based word processing programs, statistical packages, data management programs, and the Internet.
2. Consult, as appropriate, with other professionals who have unique skills in information management (e.g., business managers, accountants, librarians, statisticians, and epidemiologists).
3. Use appropriate information resources to identify evidence-based literature, evaluate the quality of the data, and apply results to specific patient care issues.
4. Describe the relative scientific value of meta-analyses, systematic reviews, cohort studies, randomized controlled trials, and case reports.
5. Analyze critically and interpret correctly statistical data presented in journal articles.
6. Describe the classification system and mechanism for reporting and analyzing perinatal and maternal morbidity and mortality.
7. Scan the current literature systematically and organize it in an easily retrievable way for future reference.
F. Patient safety
Residents and attending physicians must be aware of the critical need to ensure the patient's safety while she is treated by physicians-in-training. Respect for safety demands that training programs establish clear lines of authority, adopt stringent requirements for graded levels of supervision, delegate responsibility in accordance with a resident's skill and level of experience, and create a work environment that reduces resident stress and fatigue. Programs should evaluate residents on a regular basis to ensure that they are acquiring appropriate cognitive knowledge and technical skills. Individual residents should:
1. Acknowledge that patient safety is always the first concern of the physician (primum non nocere).
2. Demonstrate a consistent willingness to discuss errors in management with the affected patient.
3. Demonstrate the ability to supervise more junior residents until those physicians have convincingly demonstrated competence in performing a given assignment or procedure.
4. Demonstrate a consistent willingness to seek consultation when confronted by unfamiliar clinical situations.
5. Demonstrate a consistent willingness to acknowledge when stress or fatigue has compromised decision-making or technical proficiency.
6. Make clear, legible entries in the patient's medical record, including prescription orders.
7. Demonstrate a willingness to seek remediation when deficits in cognitive knowledge or technical skill may have compromised patient care.
8. Develop a personal system for preventing oversights in review of laboratory studies.
9. Participate consistently in organized peer review activities and use the outcomes of such reviews to improve their practice patterns.
10. Demonstrate an ability to cooperate with other specialists (e.g., pharmacists, nurses, risk managers) to correct system problems and improve patient care.
G. Stress management
The practice of obstetrics and gynecology is an inherently stressful profession. Significant stress experienced by a resident can arise from career-related factors, such as concerns about professional liability, negligence, or potential litigation; the handling of complex clinical problems without close supportive supervision; the management and counseling of angry, demanding, or hostile patients; and financial pressures. Personal problems-such as lack of understanding from family concerning the demands and responsibilities of clinical practice, lack of time with spouse and family, child care responsibilities, time pressures, and sleep deprivation-can add to stress and predispose to depression. Residents must develop strategies to recognize and manage unacceptably high stress levels and signs of depression. These strategies should be adaptive, healthy, and effective for the individual.
1. Describe the value of preventive stress-reduction activities, such as:
a. Regular exercise program
b. Regular program of recreation and diversion with family members and friends
c. Personal leave
2. Identify the warning signs of excessive stress within one's self and in others, such as:
a. Excessive fatigue
b. Poor concentration
c. Sleep disturbance
d. Mood disturbance
e. Withdrawal from relationships with family members and friends
f. Increased irritability
g. Poor appetite
h. Carelessness
i. Drug use
j. Self-destructive behavior
3. Recognize the need for professional counseling for one's self, family members, and fellow residents when stress causes dysfunction.
4. Intervene promptly when family members or peers exhibit evidence of excessive stress. Intervention usually will take the form of a referral for professional counseling.
V. Risk management and professional liability
Residency education programs in all fields of medicine are now being challenged to develop innovative methods for confirming that trainees acquire both the requisite cognitive knowledge and technical skills appropriate for their discipline and the important personal attributes that will enable them to function effectively in a competitive, stressful, highly technical, and rapidly changing environment. The goal of the residency training process is to produce a technically and intellectually competent physician who acts in a professional and ethical manner and consistently manifests compassion, sensitivity, and integrity. The specialty-specific competencies required of the obstetrician-gynecologist are summarized below in the form of performance-based learning objectives.
A. Insurance
1. Describe the rationale for malpractice insurance.
2. Describe the major types of insurance providers, e.g.:
a. Commercial insurance companies
b. Underwriting associations such as the state, medical society, or physician group.
3. Describe the major types of professional liability insurance, such as:
a. Occurrence policy
b. Claims made policy
c. "Tail" coverage policy
B. Malpractice claims
1. List the agencies to which malpractice claims may be reported:
a. National Practitioner Data Bank
b. State licensing board
c. Medical Boards
2. Describe the most common reasons for malpractice claims, for example:
a. Inadequate rapport or communication with the patient or the patient's family
b. Failure to diagnose a specific disorder
c. Delay in diagnosis of a specific disorder
d. Failure to obtain timely consultation
e. Failure to obtain informed consent
f. Negligent performance of a procedure
g. Negligent treatment with drugs
h. Poor documentation of medical care
3. List the legal basis for most malpractice cases:
a. Breach of contract
b. Tort - intentional negligence
4. Explain the following medical concepts:
a. Applicable standard of care
b. Breach of the standard of care
c. Proximate course of injury
5. Describe a systematic plan for minimizing the risk of malpractice claims in clinical practice:
a. Maintain a lifelong commitment to learning and professional development
b. Provide thorough documentation of all patient encounters
c. Communicate effectively with patients and their families
d. Ensure that all members of the office staff are well trained in both technical and communication skills
e. Ensure that office procedures are in place that facilitate (1) timely review of all laboratory and radiographic test results and consultation reports, and (2) communication of these test results to the patient
6. Describe the steps in the processing of a malpractice claim:
a. Request for medical records
b. Notice of intent to file a claim
c. Filing of the claim
d. Naming of expert witnesses for the plaintiff and the defense
e. Submission of affidavits by the expert witnesses
f. Obtaining of depositions from expert witnesses
g. Mediation/settlement conference
h. Trial
i. Verdict
j. Appeal
7. Describe sources of support and advice for a physician and his or her family when a malpractice suit is in process:
a. Attorney
b. Insurance provider
c. Accountant
d. Financial adviser
e. Colleagues
C. Litigation
Regrettably, the threat of a malpractice claim is an ever-present concern confronting the clinician, particularly on engaged in a surgical specialty. Current estimates indicate that at least 70% of all obstetrician-gynecologists will be sued at some point in their career. Such suits can be markedly disruptive of the physician's personal and professional life. Accordingly, residents-in-training must become aware of the clinical events that most commonly precipitate malpractice claims and develop strategies to minimize the risk of such claims. They also must understand the sequence of events associated with a malpractice suit and adopt coping mechanisms to lessen the impact of such a suit on their practice and family.
VI. General Competencies
The American Council for Graduate Medical Education (ACGME) has increased its emphasis on educational outcomes. They have identified six general competencies which have been designed to adequately prepare physicians to practice medicine in a changing health care environment. The six competencies are:
A. Patient care
1. Perform a complete and accurate medical history and physical examination.
2. Make an informal diagnosis.
3. Make evidence-based treatment decisions.
4. Prescribe medications in a rational, thoughtful, and safe manner.
5. Safely and correctly perform the diagnostic and surgical procedures unique to the discipline of obstetrics and gynecology.
B. Medical knowledge
1. Demonstrate a sound understanding of the basic science background of reproductive medicine and apply this knowledge to the clinical care of patients.
2. Demonstrate the ability to use the scientific method and the deductive reasoning process.
C. Practice-based learning and improvement
1. Describe the clinical and economic significance of outcomes research.
2. Describe methods for analyzing practice-based outcomes research.
3. Describe a systematic plan for reviewing practice patterns and insuring continuous improvement in patient care.
4. Demonstrate the ability to use information technology to improve the practitioner's fund of knowledge and technical skills and, ultimately, provide better care to patients.
D. Interpersonal skills and professional communication
1. Communicate effectively with other healthcare professionals.
2. Communicate with patients and their families in easily understood and culture-sensitive language.
3. Work effectively as both a member of a professional group and as a group leader.
4. Demonstrate the ability to serve as a consultant to other physicians and healthcare professionals.
5. Consistently demonstrate sensitivity to patients from different cultures.
6. Maintain comprehensive, timely, and legible medical records.
E. Professionalism
1. Demonstrate ability to serve as patient advocate
2. Demonstrate willingness to provide needed are regardless of ability to pay
3. Understand how physician power may be abused in interactions with patients, students, colleagues
4. Demonstrate knowledge of resources and options for care if they or a colleague are identified as impaired.
On-line resources: BMC Wellness Committee
Massachusetts Medical Society
F. Systems-based practice
1. Describe the responsibility of the individual physician to the patient, the practice and the overall health care system.
2. Describe the concepts of limitation of resources and rationing of care.
3. Describe the concepts of cost-containment and cost-effectiveness.
4. Describe methods for ensuring that the practitioner and the practice group use scarce resources in a sound, thoughtful, and cost-effective manner.
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