Letters to the Editor

Letters to the Editor

ACOG/AAFP Guidelines for Obstetrics and Gynecology

to the editor: My thanks to Dr. Harr and his colleagues from both the American Academy of Family Physicians (AAFP) and the American College of Obstetricians and Gynecologists (ACOG) for their hard work on the new core educational guidelines for obstetrics and gynecology.1 I support these recommendations wholeheartedly, with one exception.

The guidelines state, in essence, that only residents who plan to go into rural practices where immediate back-up by obstetricians is not available should receive training in advanced procedures such as cesarean section, external cephalic version and management of multiple gestation. I disagree with this restriction. I believe that any physician who has the appropriate training, experience and competency should be privileged to perform a given procedure in any environment, regardless of other available medical services in the community in which he or she practices.

I currently practice in a community of 250,000 persons, with approximately 40 obstetricians-gynecologists on our hospital staff. However, I have earned the privilege to perform cesarean sections and versions, and to deliver twins. I obtained this training as part of my regular three-year residency, using elective time to obtain experience beyond the required period of training in obstetrics and gynecology. I believe that I offer enhanced service and care options to the patients in my group (I perform all of these obstetric procedures for my entire group) without compromising quality of care.

The battle to earn these privileges took almost two years, but it was won, mostly without rancor. Had the current guidelines been in place, I believe it would have been difficult to achieve the training I desired, and I would not have had such a strong position in seeking these privileges in such a community. Furthermore, the current guidelines seem inconsistent with the strong position that the AAFP has taken regarding clinical privileges that are based solely on a physician’s knowledge, training and demonstrated competence.

elizabeth steiner, M.D.

444 N.E. Laurelhurst Pl.

Portland, OR 97232

REFERENCE

1. Joint Task Force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. Maternity and gynecologic care: recommended core educational guidelines for family practice residents [AAFP Core Educational Guidelines reprint 261]. Am Fam Physician 1998;58:275-7.

in reply: We would first like to thank and congratulate Dr. Steiner for seeking and obtaining privileges to serve her patients at an advanced level of maternity care. Dr. Steiner has expressed important concerns regarding the section on advanced skills in “Maternity and Gynecologic Care: Recommended Core Educational Guidelines for Family Practice Residents.”1 Drafted from the original recommendations2 by the Subcommittee on Graduate Curriculum and Review of the American Academy of Family Physicians’ Commission on Education, the new core educational guidelines were developed and finalized by a Joint Task Force of the American Academy of Family Physicians (AAFP) and the American College of Obstetricians and Gynecologists (ACOG). It was important to both groups that the educational guidelines be paired with the “AAFPEACOG Joint Statement on Cooperative Practice and Hospital Privileges.”3

The language in the section on advanced skills in the guidelines states that additional training is recommended for “family practice residents who are planning to practice in communities without readily available obstetricE gynecologic consultation and who need to provide a more complete level of obstetricEgynecologic services for the proper care of patients…”1 This language is nearly identical to that of the original document published in 1980. Moreover, the joint task force agreed that such additional experience “may occur within the three-year family practice residency,” to avoid mandatory fellowship training for family physicians who wish to arm themselves with the skills necessary to provide a more advanced level of maternity care.

The joint task force felt that it was important to couple the educational guidelines with the joint statement on privileges. For this purpose, they are printed as four attached pages rather than as separate documents stapled together. In at least nine sentences of the joint statement on cooperative practice and hospital privileges, both specialties reiterate their common orientation toward privileging, perhaps best summed by the statement, “Privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to ensure the provision of high-quality patient care.” The document goes on to say, “The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice.” It is important to note that the policies of both ACOG and AAFP, as well as the American Medical Association, are virtually identical in support of privileging any physician, regardless of specialty, who is able to document training, experience and demonstrated current competence. For this reason, both organizations felt strongly that the joint statement on privileges be permanently attached to the educational guidelines.

Most family physicians are satisfied with their hospital privileges. Only 4 percent (regional variation: 1.9 to 5.8 percent) of family physicians feel that their hospital privileges are unduly restricted.4 Among those privileges most contested, unfortunately, are surgical and advanced obstetric privileges. While 25.3 percent of family physicians deliver babies (regional variation: 11.8 to 49.3 percent),5 only 7.3 percent of family physicians in the United States perform cesarean sections (regional variation: 0.8 to 15.6 percent).6 Among those who do not perform cesarean sections, the lowest percentage (1.3 percent) is among family physicians whose privileges have been denied. Other reasons that physicians do not perform cesarean sections include issues of liability, the absence of a hospital practice or not desiring the privilege.

The 1980 core educational guidelines on obstetrics and gynecology have anecdotally resulted in family practice residency programs that have obtained training in obstetrics and graduates who have obtained obstetric privileges. Indeed, again anecdotally, no other set of core educational guidelines published by the AAFP has had the impact on training and privileges than has the original AAFP Reprint No. 261. We hope that the 1998 version will be as useful to the discipline, its trainees and graduates as was the original document. We also hope that more graduates will choose to serve their communities with a full scope of family practice, including maternity and gynecologic care, and will be as successful in their local application for privileges as has Dr. Steiner.

deborah i. allen, M.D.

Chair, Commission on Education

norman b. kahn, jr., M.D.

Director, Division of Education

American Academy of Family Physicians

8880 Ward Parkway

Kansas City, MO 64114

REFERENCES

1. Joint Task Force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. Maternity and gynecologic care: recommended core educational guidelines for family practice residents [AAFP Core Educational Guidelines Reprint No. 261]. Am Fam Physician 1998;58:275-7.

2. American Academy of Family Physicians, American College of Obstetricians and Gynecologists, Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics. ACOG-AAFP recommended core curriculum and hospital practice privileges in obstetrics-gynecology for family physicians. Kansas City, Mo.: AAFP, 1980. AAFP Reprint No. 261.

3. Joint Task Force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges [AAFP Core Educational Guidelines Reprint No. 261]. Am Fam Physician 1998;58:277-8.

4. American Academy of Family Physicians. Facts about family practice, 1998. Kansas City, Mo.: American Academy of Family Physicians, 1998:102.

5. American Academy of Family Physicians. Facts about family practice, 1998. Kansas City, Mo.: American Academy of Family Physicians, 1998:103.

6. American Academy of Family Physicians. Facts about family practice, 1998. Kansas City, Mo.: American Academy of Family Physicians, 1998:106.

Screening for Inborn Errors of Metabolism in Children

to the editor: I found the article by Drs. Legler and Rose1 on the assessment of abnormal growth curves to be quite interesting. One of the most common abnormalities we see in our practice is poor weight gain in children. Legler and Rose recommend that children who have poor weight and height gain and decreased growth of head size undergo laboratory evaluation, including evaluation for inborn errors of metabolism.

I would like to know specifically which tests should be ordered to screen for inborn errors of metabolism and which diseases are common causes of decreased growth.

Is there a reference containing this information that the author could suggest?

audrey spencer, M.D.

Maysville Family Medical Clinic

910 Kenton Station Dr.

Maysville, KY 41056

REFERENCE

1. Legler JD, Rose LC. Assessment of abnormal growth curves. Am Fam Physician 1998;58:153-8.

in reply: I wish to thank Dr. Spencer for her inquiry concerning the role of inborn errors of metabolism as etiologies of growth failure in children. I would refer Dr. Spencer to a general pediatric reference such as the 20th edition of Rudolph’s Pediatrics.1 In particular, Chapter 6 contains lists and descriptions of the multitude of metabolic disorders that have been described in the literature. Growth retardation (that is, “failure to thrive”) is listed as a potential component in a number of these metabolic disorders. Figure 6-12 outlines a sequence of laboratory studies that may be used to approach this large group of diseases. On the basis of this diagram, the family physician can begin the initial work-up with a complete blood count, serum chemistry profile (to include serum bicarbonate, glucose, liver function tests and bilirubin), serum ketones, serum ammonium and urine reducing substances. Abnormalities in these initial findings lead to further testing with serum and urine metabolic screens. Further specialized testing at referral centers may be required.

james d. legler, M.D.

Department of Family Practice

University of Texas Health Science Center at San Antonio

7703 Floyd Curl Dr.

San Antonio, TX 78284

REFERENCE

1. Rudolph AM, Hoffman JI, Rudolph CD, eds. Rudolph’s pediatrics. 20th ed. Stamford, Conn.: Appleton & Lange, 1996.

Freezer Burn to the Sacral Area Using a Plastic Cooler Insert

to the editor: I read with interest the “Diary from a Week in Practice” column in the September 1, 1998, issue of American Family Physician.

The Wednesday entry described a patient who used a plastic insert from his cooler as an icepack to relieve wrist pain caused by carpal tunnel syndrome. I recently saw a patient with a large area of second-degree “freezer burn” of the sacral area, caused by placing an insert from a cooler directly on the skin to relieve backache. The patient had experienced this complication before, but she thought she could control the burn effect by using the cooling insert for a shorter period of time.

Patients must be cautioned that these cooler inserts may cause severe burns.

maria d. rodriguez, M.D., f.a.a.f.p.

Wyckoff Heights Medical Center Residency Training Program

84-20 112th St.

Richmond Hill, NY 11418

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