Editorials _eng_ Sep00 DD

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Editorials _eng_ Sep00 DD Powered By Docstoc

Privileging and consultation in
maternity and newborn care
Steven Goluboff, MD, CCFP, FCFP Larry Reynolds, MD, MSC, CCFP, FCFP Michael Klein, MD, CCFP, FCFP, FAAP
Richard Handfield-Jones, MD, CCFP, FCFP Maternity and Newborn Care Committee

C    anada appears to be headed for a crisis in the
     number of providers of maternity and new-
born care. Family physicians are turning away
                                                                          To foster positive roles for family physicians
                                                                       in maternity and newborn care, the College of
                                                                       Family Physicians of Canada’s (CFPC) Maternity
from maternity care for practical reasons, such as                     and Newborn Care Committee (MNCC) propos-
effects on lifestyle, poor and unfair remuneration,                    es the following recommendations.
and rising malpractice fees. But another impor-
tant factor is that they are losing their sense of                     Recommendations
autonomy as maternity care providers.                                  Department organization and responsibilities.
   Family physicians’ perception that modern                           These recommendations apply to hospitals (usually
maternity care is complex and technical and                            larger ones) with separate departments for obstet-
“best left to the exper ts” leads to feelings of                       rics and gynecology, pediatrics, anesthesiology, fam-
powerlessness and being under valued. These                            ily medicine, and midwifery.
feelings discourage family physicians from pro-                        • Responsibility for care provided by department
viding maternity and newborn care. This paper                             members should rest with each depar tment
addresses this growing problem by suggesting                              head. This should include assessing credentials
ways to define the roles and responsibilities of                           and granting privileges, quality assurance, disci-
family physicians (and other providers) accord-                           plining members, and ensuring that policies are
ing to clear privileging policies and consultation                        carried out by members.
relationships.                                                         • No department professional group should be
   We believe structures that foster responsibility,                      responsible for any other.
self-regulation, collegiality, and mutual support                      • Departments should cooperate with each other.
among providers will promote a higher standard                         • Where program management is in effect (ie, a
of care than those that encourage dependence of                           maternity and newborn care program), quality
one group of providers on another. For example,                           assurance will also be carried out on a program
consultations, whether between family physicians                          basis and address the functioning of the full
and specialists or between two family physicians,                         maternity and newborn care team.
are likely to be most useful and appropriate when                      • In departments of family practice where few mem-
both par ties are knowledgeable in their own                              bers provide maternity and newborn care, consid-
domains and are mutually respectful.                                      er establishing a division of maternity and
   The settings in which medical students and                             newborn care for those who do. This division
family medicine residents learn the skills and atti-                      would be responsible for developing maternity and
tudes required for effective maternity care present                       newborn policies for the department as a whole.
a special challenge. Because of the crucial influ-                          Often smaller hospitals (particularly those in
ence of role models, these trainees should experi-                     rural and remote settings) do not have depart-
ence family practice obstetrics where positive and                     mental structures; physicians and midwives are
collegial structures exist. The unintended educa-                      members of a single staff organization. The head
tional message to trainees who see family physi-                       or chief of the medical staff is often a family physi-
cians functioning in dependent roles is that                           cian but could be from another discipline.
obstetric practice is beyond their abilities.                          Normally in such a setting, assessing credentials
Choosing not to incorporate maternity and new-                         and granting privileges is a responsibility of the
born care into future practice is an unacceptable                      hospital-wide staff or, occasionally, of the provin-
consequence.                                                           cial licensing authority.1,2

1716   Canadian Family Physician • Le Médecin de famille canadien ❖ VOL 46:   SEPTEMBER • SEPTEMBRE 2000

Policy development. Regardless of the hospital                  experience. This could assist providers in gaining
organizational structure (departmental, program                 confidence or incorporating new or advanced skills
management, or a combination), coherent and                     into their practice. Providers should have input into
consistent policy development for all maternity                 the choice of probation supervisor, who could be
and newborn care is needed.                                     anyone qualified for that task.
• Policies should be developed by a multidiscipli-
  nary committee consisting of obstetricians, pedi-          Scope of privileges. A distinction is made here
  atricians, anesthesiologists, family physicians,           between basic skills for which any family physi-
  nurses, midwives, and administrative represen-             cian providing mater nity and newbor n care
  tatives. Each department should be represented.            should be granted privileges and more advanced
  This would be consistent with the national                 skills that should be treated on an individual
  guidelines for Family-Centred Maternity and                basis. The following are the basic skills:
  Newborn Care.3                                             • spontaneous term singleton vertex labour and
• Policies should apply equally to all disciplines.            birth;
• The chair of the committee could be a member               • induction of labour for postdates pregnancy or
  of any of the constituent disciplines.                       ruptured membranes at term with no evidence
                                                               of fetal compromise6,7;
Granting privileges. Decisions on privileges                 • basic fetal surveillance;
should be based on evidence and best practice                • assessment of placental function by ordering
standards. The CFPC’s MNCC supports the CMA                    and interpreting appropriate clinical and labora-
policy summary “The Physician Appointment and                  tory investigations;
Reappointment Process.”4 Key principles in this              • management of dystocia in the first and second
policy are as follows.                                         stages of labour by nonpharmacologic and phar-
• All processes should be fair, equitable, docu-               macologic means, including oxytocin8;
  mented, transparent, and just.                             • management of shoulder dystocia;
• Regular evaluation of appointed physicians should          • outlet and low vacuum extractor or forceps-
  be conducted by the appropriate department head.             assisted births;
• The quality of a physician’s care is the most              • repair of laceration or episiotomy;
  important criterion to consider at time of appoint-        • management of postpartum hemorrhage;
  ment, reappointment, and granting of privileges.           • vaginal birth after cesarean section (VBAC);
• A physician’s credentials, skills, expertise, and          • examination and care of newborns; and
  quality of care, as judged by peer assessment,             • basic neonatal resuscitation, including intuba-
  should be considered during the process.                     tion and management of meconium.
                                                                Where any of these skills, par ticularly the
   In particular, the following guidelines should            more complex ones, are underdeveloped or where
be considered for maternity and newborn care.                experience is limited, family physicians are
• Maternity and newborn care privileges should               encouraged to seek mentoring from other family
  be granted according to skill and expertise. No            physicians or consultants or take ALSO or
  evidence shows that any particular training or             ALARM courses. Further specific privileges for
  clinical experience produces ideal maternity               more advanced skills can be granted to individual
  care providers.                                            family physicians following appropriate review of
• No evidence supports having stated lower or                previous training and experience.
  upper limits of births attended or procedures
  performed to maintain privileges.5                         Consultations. Consultation plays an integral
• Privileging should always take place in the                role in all health care settings. Principles of con-
  context of departmental and institutional qual-            sultation have been well described, both generally
  ity assurance and risk management programs.                and in obstetrics.9,10 Key principles for maternity
• Risk management courses, such as Advanced                  and newborn care include the following.
  Life Suppor t in Obstetrics (ALSO) and                     • Mandatory consultation should not be part of
  Advances in Labour and Risk Management                       departmental policy because family physicians
  (ALARM) are encouraged and desirable but                     vary greatly in skill and expertise and because a
  should not be mandatory.                                     policy of mandator y consultation has never
• A probationary period could be used when providers           been shown to improve care. It should be
  are unable to document adequate previous                     assumed that responsible physicians will seek

                         VOL 46: SEPTEMBER • SEPTEMBRE 2000 ❖ Canadian   Family Physician • Le Médecin de famille canadien   1717

  consultation when required, according to indi-                       Director of Continuing Medical Education of the College of
  vidual clinical situations.                                          Family Physicians of Canada.
• There are circumstances when consultation
  might be seriously considered, either from a                         Correspondence to: Dr Richard Handfield-Jones,
  specialist or a family practice colleague.                           The College of Family Physicians of Canada, 2630
  Consultation should be obtained when physi-                          Skymark Ave, Mississauga, ON L4W 5A4
  cians lack the requisite skill or experience, when
  diagnosis is in doubt, or when the problem is                        References
  serious or life threatening.                                         1. Iglesias S, Grzybowski S, Klein MC, Gagné GP, Lalonde A.
• A quality assurance process should be in place;                        Rural obstetrics. Joint position paper on rural maternity
  risk management protocols should be developed.                         care. Can Fam Physician 1998;44:831-7 (Eng), 837-43 (Fr).
• All consultations should be formally requested                       2. Hutten-Czapski P, Iglesias S, Baskett T. Joint position
  with clarification of who is to assume the team                         paper on training for rural family practitioners in
  leadership for ongoing care. Informal and often                        advanced maternity skills and caesarean section. SOGC
  incomplete “corridor consultation” pertaining to                       Joint Position Paper No. 80. J SOGC 1999;21(10):985-94.
  particular patients should be discouraged for                        3. Health Canada. Family-centred maternity and newborn
  the medical and legal protection of all those                          care; national guidelines. Ottawa, Ont: Minister of Public
  involved. This is not meant to discourage colle-                       Works and Government Services; 2000.
  gial discussions about patient care principles                       4. CMA Policy Summary. Sommaire de politique de L’AMC.
  and general management issues but rather to                            The physician appointment and reappointment process.
  ensure consultants have the benefit of a com-                           Le processus de nomination des médecins et de renou-
  plete picture before offering an opinion.                              vellement de leur mandat. Can Med Assoc J
• Family physicians should remain part of the care                       1998;158(2):249-54.
  team both during and after consultation even in                      5. Society of Obstetricians and Gynaecologists of Canada.
  situations where care has been transferred.                            Number of deliveries to maintain competence. Policy statement
                                                                         No. 58; 1996 Nov. Available from: Society of Obstetricians and
Conclusion                                                               Gynaecologists of Canada via
One of the goals of institutional maternity and new-                     sogc_docs/common/guide/index_e.shtml. Accessed 2000 Jun 2.
born care should be to create a mutual sense of                        6. Society of Obstetricians and Gynaecologists of Canada.
respect and collegiality among all those providing                       Induction of labour. Policy Statement No. 57; 1996 Oct.
care. An important element in reaching this goal is                      Available from: Society of Obstetricians and Gynaecologists
to establish an appropriate system of privileging                        of Canada via
and consultation that recognizes the complemen-                          common/guide/index_e.shtml. Accessed 2000 Jun 2.
tar y expertise and responsibilities of individual                     7. Society of Obstetricians and Gynaecologists of Canada. Maternal-
care providers and disciplines. The functioning of                       Fetal Medicine Committee. Post-term pregnancy. Committee
such a system should be evaluated as part of ongo-                       Opinion No. 15; 1997 Mar. Available from: Society of
ing quality assurance and risk management pro-                           Obstetricians and Gynaecologists of Canada via
grams. Within this context, family physicians and              
all other members of the team can provide excel-                         Accessed 2000 Jun 2.
lent care well within their capabilities.                              8. Society of Obstetricians and Gynaecologists of Canada.
                                                                         Dystocia. Policy Statement No. 40; 1995 Oct. Available
Dr Goluboff practises family medicine and is an Associate                from: Society of Obstetricians and Gynaecologists of
Clinical Professor in the Department of Family Medicine at               Canada via
the University of Saskatchewan in Saskatoon. Dr Reynolds                 mon/guide/index_e.shtml. Accessed 2000 Jun 2.
is a Professor in the Department of Family Medicine at the             9. Ross LG, College of Family Physicians of Canada, Task
University of Western Ontario and is Chief of the                        Force on the Relationship between Family Physicians and
Department of Family Medicine at St Joseph’s Health Care                 Consultants, Royal College of Physicians and Surgeons of
in London, Ont. Dr Klein is a Professor of Family Practice               Canada. The relationship between family physicians and
and Pediatrics at the Department of Family Practice at the               specialist/consultants in the provision of patient care.
University of British Columbia, is Head of the Division of               Mississauga, Ont: The College of Family Physicians of
Maternity and Newborn Care at the Children’s and Women’s                 Canada; 1993.
Hospital of British Columbia in Vancouver, and is Chair of             10. Reid AJ, Carroll JC, Ruderman J, Murray M.
the Maternity and Newborn Care Committee of the College                  Consultation in family practice obstetrics. Can Fam
of Family Physicians of Canada. Dr Handfield-Jones is                     Physician 1995;41:591-8.

1718   Canadian Family Physician • Le Médecin de famille canadien ❖ VOL 46:   SEPTEMBER • SEPTEMBRE 2000

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