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Curricular Dimensions: Knowledge and Processes
Rationale and Description:
Procedures are a routine part of rural practice and faculty who teach primary care should demonstrate this emphasis. Faculty should actively pursue and teach new techniques. Students who want to practice in rural areas often desire to do procedures, especially obstetrics. Others desire a more surgical practice. Nationwide students have had increasing opportunities to do procedural workshops during family practice rotations. These give students a sense of the broad range of family and rural medicine. A growing number of residency and fellowship programs emphasize procedural training.
Not all rural physicians will need to emphasize procedures. Those who do not plan on hospital practice or those who plan to work with health departments may stay with routine ambulatory care or a limited number of procedures. Community health centers or other public health service sites may not have hospital practice or procedures as part of the practice. Larger rural sites may have specialists performing these on a part or full time basis.
The process of learning procedures begins with instruction in the basic technique. This is followed by a demonstration with further instruction. Later the trainee performs the technique under close supervision. Optimally the trainee repeats the procedure in a relatively compact time sequence with ever declining amounts of supervision. The final step of the learning processes is checkout(s) under the observation of a fully trained professional.
Procedural training must occur in an environment of constant feedback. Learners should communicate with the patients they have treated, the faculty who have supervised, and other personnel involved in the procedure. This provides maximal learning and critical feedback for the procedures as to personal confidence, self-image, and the risk-benefit of doing the procedure.
It is impossible to separate the knowledge of procedures from the process of clinical decision making. One feeds in to the other during the learning process. Faculty, patients, peers, and supervisors all contribute to give the physician a sense of competence which then determines the level of services provided.
The number of procedures needed for competence varies with the complexity of the procedure, the quality of the instruction/supervision, and the previous training and talents of the individual. For fairly complex procedures such as C-Sections, the number of procedures should also be high enough to ensure a likelihood of encountering the common (and some uncommon) complications. These encounters are the true test of the training of the practitioner. Numbers commonly encountered for competence include 50 for OB Ultrasound, 100 C-Sections - references
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Can Obstetrics Survive in FP? http://www.familypractice.com/journal/abfpjournal_frame.htm?main=/journal/2002/v15.n01/1501.13/art-1501.13.htm
Subject Areas:
Orthopedics, Gynecology (Colposcopy), Obstetrics, Minor surgery, Trauma management (ATLS), Cardiac resuscitation (ACLS), Fine needle aspiration, Neonatal resuscitation, Pediatric life support (PALS), Endoscopy, Colonoscopy, Treadmills, Holter interpretation
Caution Regarding Changes in Procedural Training
Procedural Citations and References
Hart LG (1996) Rural and urban differences in physician resource use for low-risk obstetrics. Health Serv Res, 1996 Oct
Norris TE (1996) Are rural family physicians comfortable performing cesarean sections? J Fam Pract, 1996 Nov
Norris TE, Acosta DA. A fellowship in rural family medicine; program development and outcomes. Fam Med 1997;29(6):414-20.
Rodney WM (1998) Enhancing the family medicine curriculum in deliveries and emergency medicine as a way of developing a rural teaching site. Fam Med, 1998 Nov-Dec
Young RA (1999) Practice patterns of rural Texas physicians trained in a full-service family practice residency program. Tex Med, 1999 Feb