ROTATIONS
DAYS & NIGHTS (FIRST HILL)
You will work with the OB Hospitalist/Nocturnist for all FM patients that require OB consult, work with patients of the KP OB groups, and occasionally work with other OB groups.
Goals
Manage both uncomplicated and complex labors
Attain competency in operative obstetrics, including cesarean section & instrumented deliveries.
Provide post-operative care for patients who have undergone cesarean section.
Develop and maintain competency in teaching obstetrics to family medicine residents (labor deck only).
Evaluate and supervise triage visits
Stabilize and treat pregnant patients hospitalized for pre-term labor, pre-eclampsia, diabetes, cervical incompetence, fetal growth restriction, premature rupture of membranes and placental disorders.
Perform ectopic pregnancy evaluations and D&Cs for patients admitted through emergency room
Objectives
Evaluate obstetric patients and their fetal monitoring strips in triage.
Provide labor management, vaginal delivery and instrumented deliveries to obstetric patients of teaching panel physicians.
Perform cesarean sections as primary surgeon with obstetric members of the Teaching Panel. Surgical skill level at the beginning of the fellowship will determine when the fellow is ready to be the primary surgeon.
Teach Family Medicine Residents on the obstetric service basic obstetrics, including triage evaluation, cervical exams, labor management, pitocin augmentation, IUPC, FSE, vaginal delivery, and postpartum care.
Perform, teach and supervise neonatal circumcisions. Opt out is available for fellows who do not wish to perform neonatal circumcision.
Perform D&Cs.
Evaluate family medicine and no-doc patients in triage.
Manage triage assessment, labor and delivery of no-doc patients
Daily Responsibilities
Pre-round on L+D board and see assigned patients
Scrub in on c-sections; these take precedence over rounds
Maintain presence on L+D to be available for complex labors/ instrumented deliveries, shoulder dystocia, post partum hemorrhage
Be involved in D&Cs and ectopics (per attending preference).
Beginning in January, provide initial evaluation for labor management consultation of family medicine patients when they consult the laborist.
Carry OB fellow pager when on call.
Evaluate teaching panel and perinatal patients in triage. Until January, all patients must be staffed by fellow with their attending or the OB hospitalist (except in the rare case that the OB hospitalist is unavailable due to urgent patient care needs). The hospitalist will see and bill for some of these patients, simple evaluations can be approved over the phone and you will bill for them (triage nurses will ask if you can be the attending). After January, you can see and send home simple triage evaluations. Note: simple rule out labors at 37 weeks or later can be seen and sent home by the nurse after an attending has reviewed the strip.
ISSAQUAH
Goals
Manage both uncomplicated and complex labors in community hospital setting.
Attain competency in operative obstetrics, including cesarean section & instrumented deliveries.
Provide post-operative care for patients who have undergone cesarean section.
Develop and maintain competency in teaching obstetrics to family medicine residents.
Evaluate and supervise triage visits
Stabilize and treat pregnant patients hospitalized for pre-term labor, pre-eclampsia, diabetes, cervical incompetence, fetal growth restriction, premature rupture of membranes and placental disorders.
Perform ectopic pregnancy evaluations and D&Cs for patients admitted through emergency room
Objectives:
Evaluate obstetric patients and their fetal monitoring strips in triage with supervision of OB Hospitalist.
Provide labor management, vaginal delivery and instrumented deliveries to obstetric patients.
Perform cesarean sections with obstetric members of the Teaching Panel. Surgical skill level at the beginning of the fellowship will determine when the fellow is ready to be the primary surgeon.
Perform post-partum tubal ligation on teaching panel patients.
Perform D&Cs when available.
Daily Responsibilities:
You will arrive at 7 AM for signout. We will discuss all the laboring patients as well as any planned cesareans or external cephalic versions.
We will delegate assisting/ surgical roles for the planned cesarean sections.
Plan to follow all OBGYN and Family Medicine patients who are in labor or are being induced.
Be ready to consult with the hospitalists on midwifery patients who may be requiring operative vaginal delivery, cesarean delivery or have developed complex medical conditions.
Be ready to work with Maternal Fetal Medicine on any admitted patients requiring consult.
You will see OB triage patients and staff with the OBGYN Hospitalists.
You will postpartum round on any patient you delivered or cared for previously.
5 PM is the official end of your shift. However, if there is a labor patient who is anticipated to deliver or require a CS shortly after your shift ends, you can stay. Please do not feel pressured or obligated to stay.
PRECEPTING
Goals
Maintain family medicine clinical skills, including specific skills in treating substance use disorders and providing gender-affirming care.
Develop and maintain competency in teaching low and high risk prenatal care to family medicine residents.
Objectives
Supervise resident care of family medicine patients by precepting four to eight clinics per week. Precepting will take place in the First Hill, Ballard, Downtown Family Medicine clinics. In so far as possible, we will not ask you to precept the geriatric fellows.
Note: Preceptor B means you are the backup preceptor. Need to be available should one of the scheduled preceptors not be able to precept.
CIRCUMCISION CLINIC
Goals
Perform circumcisions using Gomko technique (discuss with Dr. Breuner if you’d like to incorporate other techniques).
Teach residents to perform circumcisions
Objectives
Attend the Tuesday morning circumcision clinic in the First Hill Procedure Pod
Skill level will be evaluated at the beginning of the year; fellows that need up to their first ten circumcisions proctored will be precepted by Drs. Wang, Diamond or Breuner.
After being certified as competent, the fellow will supervise a resident at this weekly clinic.
Note: Opt out is available for fellows who do not wish to perform neonatal circumcision. Please discuss this with Dr. Thomson as soon as possible for scheduling purposes.
DFM COLPOSCOPY CLINIC
Goals
Perform and supervise colposcopy procedures
Objectives
Thursday morning colposcopy clinic at Downtown Family Medicine supervised by Dr Breuner. The fellow will perform colposcopy and supervise residents performing colposcopy. Dr Breuner will proctor each fellow to assess ability to perform colposcopy, and also to teach the resident.
ELECTIVES
Goals
Obtain training specifically suited to your intended clinical practice setting
Objectives
Attain competence in specific procedural or cognitive skills.
Responsibilities
10 weeks prior to your elective, discuss with your fellowship advisor which elective experience you would like to choose. You may choose from the options below or a different elective experience of your own design (if discussed with and approved by the fellowship director).
6 weeks prior to your elective, present your choice and planned rotation schedule to the fellowship director.
It is the responsibility of the fellow to let the program director know where he or she is during elective time throughout the year.
Labor deck week may be used for PTO, CME or elective time. Labor deck week may also be used for interviews/site visits with the approval of the fellowship director.
Elective One: NEONATOLOGY
Goals
1. Resuscitate distressed newborns.
a. Identify distressed newborn and assign Apgars
b. Bag mask ventilate newborns
c. Intubate newborns (pending case availability and fellow comfort)
d. Assess fluid status of newborn
e. Identify newborns at risk for sepsis
f. Place umbilical venous catheter
2. Provide ongoing care to the hospitalized newborn, including for hypoglycemia,
Methods
1. Perform newborn resuscitations under the supervision of the special care nursery nurse, neonatal nurse practitioner and/or neonatologist. Resuscitations may include intubations and umbilical vein catheterizations.
2. Admit and manage newborns in step-down unit of the special care nursery. Care will be supervised by attending neonatologist.
Responsibilities
1. Have current NRP certification.
2. Carry neonatology pager and respond to resuscitation calls for nurse, nurse practitioner, and neonatologist.
3. Admit compromised newborns to special care nursery.
4. Log procedures, including resuscitations, intubations, and umbilical vein catheters, in new innovations.
5. Rotation will be scheduled through Dr. Thomson and Dr. Robert Mertz (neonatologist)
Elective Two: Malawi Rotation
Swedish Family Medicine sends residents and fellows to Mangochi, Malawi. SFM faculty Anna McDonald is the site preceptor for this experience. Global health skills including infectious disease and collaboration with Malawian family medicine registrars and faculty are the focuses of this experience. 4-5 months lead time is required. Due to the need to change all the fellows’ schedules to accommodate a 4w away rotation, fellows must decide about this elective by Sept 1.
Elective Three: FMS service
Fellows who are interested in future faculty work are strongly encouraged to spend one week as inpatient attending on the family medicine inpatient service. Typically the first week is done while co-attending with a family medicine faculty, with an option for a second week later in the year independently. This service cares for pediatric, obstetric and adult medicine admissions. This elective provides good experience in inpatient medicine and requires 8 to 12 weeks of lead time to schedule. Please decide about this elective by Oct. 1.
Elective Four: Family Medicine Faculty Development
Work on a curricular area or area of scholarship for the fellowship or for fellowship programs nationally, under the supervision of Dr. Thomson
Elective Five: Other Away Rotation
Other away rotations including pregnancy termination, rural rotations, or other rotations of the fellow’s choice are options pending development of goals and objectives of the rotation by the fellow and approval of the fellowship director. Due to the need to change all the fellows’ schedules to accommodate a prolonged away rotation, fellows must decide about any away rotation elective of 2+ w (maximum 4w) by Sept 1. One week away rotations may be scheduled without additional lead time.
Elective Six: Lactation
Combination of self-study and rotation with Lytle Center IBCLCs. Discuss with Dr. Thomson if interested in this elective.
Elective Seven: Ultrasound
Working with ultrasonographers in MFM office for additional obstetric ultrasound experience (fellows get some experience with this during perinatal clinic rotation). Will need to be coordinated for the second half of the year with Dr. Thomson and Dr. Amber Wood.
Elective Eight: MFM
Currently in development; likely will be a combination of outpatient MFM clinic and some inpatient/antepartum experience. For fellows who anticipate managing high risk patients in their future practice setting.
Elective Nine: ARS- Ballard inpatient
Five mornings per week caring for pregnant people admitted to Ballard inpatient ARS service for substance use disorder. Fellows will work with ARS fellows and attendings learning about inpatient detox for pregnant people. Afternoons can be spent at Ballard inpatient unit, Tuesday PMs at ARS ‘OB outreach’ clinic, or paired with another elective experience above.
ADVISING STRUCTURE:
Each fellow will meet with Dr. Thomson individually during orientation for an initial advising meeting. Subsequent meetings throughout the year will be scheduled by Jesse Zayas and include:
October: Discuss evaluations from OBs/MFMs on surgical skills and other clinical skills, in addition to general progress
January: Similar to October, + evaluations from residents re: precepting
April: Review general progress, graduation requirements, career planning
June: Final evaluation review, graduation requirements
July: Exit interviews
Any other meetings as needed by fellow for career advising, troubleshooting, etc.
Fellows are also encouraged to approach one of the members of the Perinatology group Obstetrix to serve as a mentor. Plan to get together every two months or so to review progress and foster development of your skills.
FACULTY:
Dr. Claire Thomson: Fellowship Director
Dr. Luchin Wong: Associate Fellowship Director
Dr. Kelly McCaffrey, OB & Issaquah Site Director
Dr. Meg Kelly, OB Hospitalist
Dr. Minoo D’Cruz, Fellowship Faculty
Dr. Joseph Breuner: Fellowship Faculty
Dr. Kevin Wang: Fellowship Faculty
Attending groups
Issaquah OB/Gyns: 3 groups of OB attendings (Swedish Renton, including Dr. McCaffrey, Swedish Issaquah, and OB Hospitalist group) who provide obstetrical services at Swedish Issaquah.
Obstetric Hospitalists and Nocturnists: 7 obstetricians (including Dr. Kelly), who provide in-house obstetric services for emergencies, back-up, triage evaluation, perform and assist cesarean section, and labor management.
Kaiser Permanente: OB/Gyns and surgical FMOBs who provide obstetric services at KP.
Perinatologists of Obstetrix: a group of 12 perinatologists (including Dr. Wong) who provide maternal-fetal medicine services for Swedish Medical Center and Valley Medical center.
Swedish Family Medicine Faculty First Hill: 10 family physicians (including Drs. Thomson, Breuner, and Wang) that see patients and teach residents at three sites: First Hill Family Medicine, Downtown Family Medicine, and Swedish Community Health at Ballard.
Swedish Family Medicine Faculty Cherry Hill: 7 family physicians who see patients and teach residents at Cherry Hill Family Medicine. Residency satellites at Seattle Indian Health Board and Seamar Community Health.
FELLOWSHIP EXPECTATIONS/POLICIES
E-mail and Pager Response Times
Fellows will check and respond to e-mail no less than twice a week except when on vacation. Numeric pages and text pages, which require a response, should be answered within 10 minutes.
Vacations
Vacation may be taken during labor deck manager time and should be scheduled out at least 8 weeks ahead of time.
Medical/Family/Sick Leave
Policies per Swedish contract. For acute illness or family emergency, please contact the fellow not on day or night call [2nd choice is fellow on labor deck manager or clinic/preceptor week] for backup. If you are ill, please call the person you are supposed to relieve so they can contact the correct person to cover call. The fellow coming off call should remain until the sick leave fellow arrives. If no relief can be found, please alert the charge nurse, on-call perinatologist, and OB Hospitalist attending prior to leaving.
Leave for chronic medical reasons per Swedish personnel policies/contract.
Remuneration: Salary and Incentives
Salary is per your contract. In addition, $1500 and 5 workdays off are available for CME. These should be scheduled during your elective time.
Fellows should bill for c-section assists, triage evaluations, and vaginal deliveries as is commensurate with their work. As an incentive, $10 will be added to your subsequent paycheck each month for triage evaluations and c-section assists billed that month. $250 will be added for no-doc vaginal deliveries that the fellow bills. It is expected that in the first half of the fellowship year (until 1/1) , the vast majority of triage visits and vaginal deliveries will still be supervised by the MFM or OB Hospitalist attending who will bill for these services. In rare circumstances the fellow may perform these services independently (if the attending is unavailable due to acute patient care needs) and in these instances the fellow should bill for the procedure they perform independently.
Procedure numbers
Fellows will complete 100 c-sections as primary surgeon. This is a minimal requirement for graduation. Vaginal deliveries, instrumented deliveries, ultrasounds, D&Cs, tubal ligations, circumcisions should be logged by the fellows on New Innovations in order to obtain hospital privileges, but minimum numbers are not required for graduation.
Didactics:
Tuesday mornings (7:30-8:30am): ‘Fellow time’ with all 5 fellows + Dr. Thomson. Each week one fellow will prepare and present on a topic using the high-yield article list at the end of this document. Additional topics will be presented by Dr. Thomson, Dr. Kelly, as well as other FMOB and neonatology attendings. This time also serves as our ‘fellowship business meeting’ to discuss any fellow concerns/issues.
Thursday mornings (7:30-8:30am): OB Grand Rounds (2nd Thursday) and OB M&M (4th Thursday). Thursday morning half-day OB residency didactics are open to fellows pending availability of the fellow and relevance of topic.
Scholarly Work
Minimum expectation is that each fellow will participate in didactics as above and will give a 25-minute presentation at our annual High-Risk Obstetrics for the Family Physician conference. The 2022 conference will be in March . Fellows will be assigned a topic based on a needs assessment sent out in September. The presentation should include slides, current evidence, cases, and time for questions. Dr. Thomson is available to help fellows prepare their topics and presentations. Three Tuesday meeting times will be reserved to practice these presentations.
All fellows are expected to teach the residents on the Birth & Family service. The fellow should coordinate with the Birth & Family senior if able to do teaching on Mondays and Fridays; ad hoc teaching overnight is encouraged (particularly practicing suturing, lac repair, and other procedural skills).
Additional scholarly work is encouraged, in particular for fellows considering faculty positions. This can take the form of additional teaching at resident tuesday afternoon didactics, submission of a scholarly poster or presentation at a conference (STFM, FCPC, etc.), submission of an perinatal-related peer-reviewed paper or other piece of writing, serving as an expert reviewer for perinatal-care related articles, or other scholarly endeavors of the fellows’ choice. You will discuss scholarly aspirations for your fellowship year with Dr. Thomson at your initial advisor meetings.
Evaluations and Due Process
For performance evaluations and progressive discipline, please see the First Hill residency curriculum manual section on advisor system and due process. It is available online at: https://swedish-fh.squarespace.com/policies/