To Enhance or Not to Enhance

1. To Enhance or Not to Enhance Lisa Graves MD CCFP FCFP Fred Janke MD CCFP FCFP Kate Miller MD CCFP FCFP

2. Conflicts of Interest • All three panelists have no conflicts to declare

3. Objectives • To review the current state of enhanced skills programs, both surgical and non-surgical in Canada • To envision the future of enhanced skills programs in the Triple C era

4. en·hance:intensify, increase, or further improve the quality, value, or extent of.

5. What are enhanced skills in maternity care? • Family physicians bring two enhanced skills sets to maternity care: enhanced maternity skills (EMS) and enhanced surgical skills (ESS) including C/S. • Community need may dictate that an FP has one, the other or both of these skill sets

6. Current state of Enhanced Maternity Skills programs • What we believe – primarily a vehicle for added volume, added confidence, required for privileges/teaching • What we hope – enhanced skills programs provide skills that lead to enhanced scope and are used in practice. • What we know – limited data available from the U.S., currently Canadian study in progress

7. Will triple C change the need for and nature of enhanced skills programs? • Revisit and redefine the core competencies expected at the start of practice • If each resident has these competencies how will enhanced skills programs change? • What will the transition look like?

8. What role should Enhanced Skills Programs fill? • Provide a specific, expanded skill set – e.g. C-section, breech delivery, forceps delivery • Prepare for specific practice settings - e.g. high volume, rural/remote, specific populations • Prepare for the role of maternity care teacher • In some settings, required for privileging

9. Other jurisdictions and approaches • American streaming approach • Three tiers • Can be completed within 3 year residency • Has an impact for residency training for those not in the enhanced skills stream

10. ESS -Current Landscape • One single program in Canada that offers a full R3 program in ESS • Prince Albert • Over subscribed and graduates two physicians per year • Alberta • Six month surgical obstetrics programs available • Tentative full R3 program in Grande Prairie • Other Provinces • Surgical Obstetrics available on an irregular basis

11. What should the Enhanced Maternity Skills curriculum look like? Comments of Participants • Need to define core before we can define enhanced, should we be paying attention to EMS when if we fail to meet core competencies? • Enhancement vs remediation • Ultrasound in pregnancy – some core, some enhanced?

12. ALARM/ALSO – core or enhanced? • Special populations/difficult populations • Able to advise and consult in a pregnancy • Enhanced skills program should not a place to train those that do OB only (as EM as done) • Not an R3 year • Who will do the teaching? Where will we get the teachers? • Research? • Are there other ways to provide confidence/volume eg mentoring

13. How do you find a place? Do we have the capacity to meet the need? • Generalist enhanced skills – respecting an MD who wants more than one enhanced skill set • Mandatory FM mentor • Vacuum – core vs enhanced – independent vs supervised • Breech delivery • Diabetes, gestational HTN – core, spectrum, enhanced

14. If there isn’t enough learning opportunities – who gets them? Do we ‘force’ the resident who has their mind made up? • Newborn skills – core vs enhanced. Providing volume – ensure paeds not just OB our supports • Teaching the future teachers • Do we have different standards for IMGs?

15. Exposed (core) vs expert (enhanced) • Breastfeeding, tongue tie release – core vs enhanced. • Ability to work in environments with less back-up (eg no surgical service) • C-section assist

16. Enhanced Surgical Skills • FPs with ESS may have a focussed obstetrical skill set (eg C/S alone) or a broader skill set including parts of general surgery, ENT and plastics • ESS has been approved as a SIFP with the hopes that one day ESS will be a Certificate of Added Compentence

17. Current draft of the national working group ESS Curriculum • Modular in format • Basic Operative Management • Management of Abdominal Presentation in the Non-Pregnant Patient in Rural and Remote • Management of Pregnancy in Rural and Remote • Management of Non-Abdominal Presentations in Rural and Remote • Basic Principles • Trauma

18. Management of Pregnancy in Rural and Remote • Complications of Labour & Delivery • operative vaginal delivery, C-section, obstetrical trauma, uterine inversion, PPH, retained placenta; ALARM, NRP • First Trimester Pain and Bleeding • D&C, ectopic

19. What should the Enhanced Surgical Skills Curriculum look like? • D&C and management of early preg loss • Broad enough skill set to maintain the OR and the overall surgical program

20. How do we ensure the Enhanced Skills Programs respond to community needs? • How can we provide volume for our learners if we have volume caps? • Accreditation, privileges – what if we give them skills and then they aren’t allowed to use them? • What if you can’t get privileges without the enhanced skills time even if you have the skills after the core? • How does return of service influence the skills that a resident needs and gets?

21. Thank you