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26 Practical Didactic, Bedside, andOce Teaching Skills
279
In his thematic review of ambulatory teaching, Irby highlighted the following three major challenges in ambulatory
teaching: context, teaching time, and learning [12]. The context of ambulatory teaching is often rapid paced, sometimes
near chaos, with multiple demands and variability in patients
and residents. Although early in their training most rst-year
residents are given from 30 to 60minutes to see one patient,
this time is shortened to 15–20minutes by the time they are
in their last year of training. During the ofce visit not only
does the resident need to see the patient and address a myriad
of issues, but also must develop a management plan to discuss with the preceptor, and then return to the patient to
nalize that plan. Patients coming in that half-day often have
various needs such as acute problems (e.g., skin rash, joint
pain, upper respiratory infection, etc.), chronic diseases (e.g.,
diabetes mellitus, hypertension, coronary artery disease,
etc.), and preventive health care needs (e.g., obesity, tobacco
addiction, need for colon cancer screening, etc.). In addition,
the preceptor will often in a half-day supervise residents of
various skill levels from rst- to third-year residents and
accompanying medical students.
Because of this pressure, time for teaching is often limited
for each patient interaction. Irby found that the average interaction time between preceptors and residents in the ofce
was less than 6minutes, with only 15–30seconds actually
spent in teaching and providing feedback to the resident [12].
Another study of 125 observations of resident-attending physician interactions, the average length of interactions was
4.27minutes, with the resident talking about half the time
[53]. This brief interaction provides little time for collaboration, reection and independent thinking.
To address these challenges, Irby recommended preceptors target the teaching to the needs of the resident using
time-efcient strategies (addressed below) and to develop a
repertoire of teaching methods [12]. For example, a child
presents to the ofce with what is eventually diagnosed as
acute otitis media. Precepting a rst-year resident may focus
on teaching about recognizing and treating ear infections, a
second-year resident may focus on recognized guidelines as
to when to consider referring a child for possible insertion of
a tympanostomy tube, and a third-year resident addressing
impact of an ill child on family dynamics. Having a set of
teaching scripts for the common issues addressed in ambulatory family medicine will enhance teaching effectiveness.
Irby also recommended that preceptors provide residents
opportunities for reection, collaboration, and independent
learning [12]. For example, the preceptor in the scenario of
the child with an otitis media may have the resident search
for recent guidelines for management of this problem and to
set up a later time to discuss questions arising from those
guidelines. If a preceptor does this, it is important that the
preceptor actually follow-up with the resident for that
discussion.
Roles and Expectations of the Family Medicine
Preceptor In the ofce the preceptor has several responsi-
bilities. First and foremost the preceptor is responsible to
ensure that patient care provided by the residents is effective,
safe and of high quality. The preceptor is ultimately responsible for the care of patients seen by the residents. This is
accomplished by providing an appropriate level of resident
supervision as they see patients. The degree of supervision
for all residents is “based on each resident’s level of training
and ability, as well as patient complexity and acuity.” [52]
For the rst 6months all rst-year residents must be directly
supervised, which requires the preceptor to be “physically
present with the resident during the key portions of the
patient interaction.” [52] After these rst 6months, preceptors may provide indirect supervision, but immediately available to see the patient if needed, to those residents who
demonstrate they can be trusted to take a thorough and accurate history, perform an adequate targeted physical examination, assimilate this information in a cogent presentation, and
identify their limitations and ask for help when they need
assistance with the patient. In those circumstances it is
expected that the preceptor sees the patient together with the
resident.
Regardless of supervision level, residents must present
their patients’ issues to the preceptor before the patient
leaves the ofce. It is during this time that the preceptor provides the supervision and teaching, which will be described
below. After the patient leaves the ofce, the preceptor is
responsible for reading the residents’ encounter note for
accuracy, reviewing the results of all returned labs, imaging
studies, other tests, and consultations, ensuring appropriate
billing is attached to the visit, and then closing the encounter.
The preceptor is also responsible for adding a note attesting
to their involvement with the resident in providing care to the
patient. This attestation note should acknowledge if they did
or did not see the patient with the resident followed by a brief
summary of the issues addressed and whether they agree
with the resident’s diagnoses, management plan, and progress note. This attestation note can be as simple as, “I saw
this patient and discussed the care with the resident. We
addressed the following items (which are then listed). I agree
with the medical decision making as described by the resident in their progress note.”
A family medicine ofce involved in providing graduate
medical education may apply for a Primary Care Exception
for billing E/M services [54]. Under the Primary Care
Exception preceptors may bill for work residents perform in
the ofce for lower and mid-level complexity E/M services
(99202, 99203, 99211, 99212, and 99213) without the preceptor actually seeing the patient (after the rst 6months of
residency training). However, as previously described, the
preceptor must review the care and add an attestation note.
280
W. F. Miser
For higher level E/M services (e.g., 99214 and 99215) the
preceptor must be present with the resident for key portions
of the visit.
In addition to supervising residents in the ofce, the preceptor is also responsible for promoting resident learning,
providing feedback to the resident on what was done right
and what could be improved, and for evaluating the resident
in terms of their various milestones. While performing the
[12]. One such proven strategy to enhance teaching in the
time-limited and often chaotic experience in the ofce is the
One-Minute Preceptor model using ve microskills
(Table 26.6) [55, 56]. Using this learner-centered model
allows preceptors to correctly diagnose patients’ medical
problems, to better assess residents’ skills and abilities, and
to focus the teaching in an effective and efcient manner
[57, 58].
duties of precepting in the ofce, the preceptor should have
no other duties than to supervise and teach the residents during that half-day in the ofce. The ACGME Family Medicine
Residency Review Committee limits the number of residents a preceptor can supervise to no more than four residents at a time [52]. Even with this limit of four residents
the preceptor may supervise up to 40 patient encounters or
more in a half- day depending on resident level and schedule. As Irby pointed out, the preceptor needs a time-efcient
strategy if effective supervision and teaching is to occur
Table 26.6 Five microskills of clinical teaching in the ofce
Microskill What is to be accomplished Examples
Get a
Commitment
Probe for
Supporting
Evidence
Teach General
Rule(s)
Reinforce
What Is Done
Right
Correct
Mistakes
Adapted from Neher etal. [55]
Resident encouraged to make a commitment to a diagnosis,
assessment or management plan.
Forces the resident to process information gathered during
the patient encounter.
Done in a supportive manner.
Preceptor should resist “taking over the case” by asking too
many data questions.
Ask the resident to reect on how they arrived at the
conclusion.
Allows the preceptor to assess the resident’s true knowledge
base and uncover teaching points.
Not a time to “grill” the resident—questions should be asked
in a nonthreatening manner.
This is an opportunity for the preceptor to ll in gaps in the
resident’s knowledge base.
Keep information general (so that it can apply to future cases)
and avoid anecdotes.
If the resident performed well with nothing new to add, skip
this step.
Consider giving the resident a short practical reading
assignment to solidify teaching points.
Positive feedback helps build resident self-esteem and
condence.
Best used when the resident handles the situation in a manner
beneting the patient, colleagues, or ofce.
Focus on specic behaviors that the resident will be able to
repeat consciously.
This is just not “general” praise—be specic.
This is only one part of the teaching encounter and requires
tact to be effective.
First ask the resident to critique their own performance or
limitations.
Discuss what was wrong and potential consequences if not
corrected.
It is not appropriate to provide vague, judgmental
statements—focus on the actual problem.
One-Minute Preceptor Model and Five Microskills In
most situations, the resident rst sees their patient in the
ofce to obtain the history, perform the physical examination,
and develop a management plan. When the FM resident then
discusses the patient encounter with the preceptor, the time
together can be divided into three phases (Fig.26.1). In the
rst phase, the resident reveals what they learned about the
patient (case presentation). At the beginning of training it is
best that residents be taught what is expected of them in this
What do you think is going on with this patient?
Are there any tests you think are appropriate?
What do you hope to accomplish during this visit?
Why do you think this patient has not been adherent to the
treatment regimen?
What were the major ndings that led you to your diagnosis?
Why did you choose that particular medication as opposed to
another?
What factors did you take into account when developing your
plan?
What else did you consider and what kept you from including
them?
If the patient has a skin infection that is not uctuant, incision
and drainage will not be benecial.
Most times a child with otitis media will not need antibiotics.
If you do prescribe antibiotics, typically 3days duration is
sufcient.
Guidelines exist as to the best imaging test for a person with
the headache you are describing. Review these guidelines and
let me know what you learned.
It is obvious you considered the patient’s social situation when
you selected that therapy. Your sensitivity to this will certainly
contribute to improving adherence to the treatment regimen.
It is good that you discussed the patient’s family history of
this problem as it allows you to better understand their
urgency of wanting that test performed.
You may be right that this patient’s chest pain may be due to
GERD, but it is important to consider cardiac disease,
especially in someone with so many cardiac risk factors. In the
future when you see someone with vague chest aching make
sure you take a more thorough history and think about
potential causes that could be lethal.
You didn’t ask the patient if their cough has resolved, a major
complaint they had last visit. It is important to follow-up
issues form previous visits, and if not resolved, to develop a
management plan for further investigation.
26 Practical Didactic, Bedside, andOce Teaching Skills
Fig. 26.1 Incorporating the
one minute preceptor model
and ve microskills into
teaching in the ofce. (Based
on presentations by David
M.Irby referencing Irby DM
[42], Knudson MP, Lawler
FH, Zwig SC, Moreno CA,
Hosokawa MC, Blake Jr RL
[53], and Neher JO, Gordon
KC, Meyer B, Stevens N [55])
Teach
3. Teach general rule(s)
4. Provide positive feedback
5. Correct error(s)
PHASE 3
Discussion
Diagnose The Resident
1. Ask for a commitment
2. Probe for
PHASE 1
Case
PHASE 2
Inquiry
281
Diagnose
The Patient
evidence
presentation in terms of order, clarity and details. As rst-year
residents typically have more time with each patient, the presentations may be more detailed and lengthy at the beginning
of training. However, as the resident progresses and assures
the faculty that nothing is missed in the history taking and
physical examination, the amount and detail provided may be
shortened to allow more time for the teaching interaction with
the preceptor. During this phase the preceptor usually is able
to identify the patients’ problems and diagnoses.
The second phase, inquiry, consists of two microskills
that allows the preceptor to better diagnose the resident in
terms of their knowledge and patient care skills. The rst
microskill is to get a commitment from the resident as to
diagnosis, evaluation, and/or therapeutic plan. This microskill
reinforces to the resident that this patient is their responsibility and that the preceptor values their opinions. It also permits the preceptor to assess whether the resident is able to
assimilate the information collected during the patient
encounter and to formulate a reasonable diagnosis and management plan. It is best that residents are taught at the beginning of their training to automatically include this as part of
their case presentation, thus saving time and assuring the
preceptor they are able to coherently process the information
they obtained. If the resident fails to offer this information,
the preceptor should ask in a nonthreatening way, “What do
you think is going on?” or “What do you want to do?” [56]
During this phase it may be appropriate for the preceptor to
ask a few questions for clarication, but should resist asking
too many data questions. If the resident is unable to put the
information together, the resident should feel comfortable in
stating they are unable to gure out the diagnosis and needs
help. This shows to the preceptor that the resident understands their limitations. This also opens up opportunities to
discuss potential diagnoses and then to see the patient
together in the exam room, where the preceptor can model
their approach to diagnostic dilemmas.
Once the resident makes the commitment, the second
microskill is for the preceptor to probe for supporting evi-
dence. During this time the preceptor is able to better under-
stand the resident’s thinking process and clinical reasoning,
and to determine what the resident does and does not know.
Open-ended questions such as, “What ndings led you to
that diagnosis?” or “What other conditions did you consider
and why did you eliminate those?” These questions should
be asked in a non-intimidating manner and allow for the preceptor to determine areas that could be taught.
After the preceptor has diagnosed the patient and determined the learning needs of the resident, the nal phase, discussion, consists of three microskills that enhance teaching.
By this time the preceptor should be able to identify a teaching point to discuss any gaps or mistakes the resident may
have revealed. Teach general rule(s) is the next microskill. If
the resident performed well and no gaps are identied, this
microskill may be skipped as not every encounter demands
that the preceptor “teach something.” [55] However, if something is identied, teaching a general rule that can apply to
future similar cases can be quite instructional to the resident.
This is not a time for a lecture, anecdotal stories, or teaching
everything the preceptor may know about the topic. A general rule should be brief. One useful technique is to consider
the question, “What one teaching point do I want the resident
to leave this patient’s encounter with?” [59] The teaching
should be specic and applicable to future cases. This may
also be a time for the preceptor to discuss a recent applicable
guideline or journal article, directing the resident to read for
further learning. If this is done it is important for the preceptor to follow-up with the resident to identify areas that may
be further claried.
The next microskill is for the preceptor to reinforce what
the resident did right. Highlighting what the resident did correctly reinforces future behaviors that may be repeated in a
similar situation. The preceptor should identity those actions
that have a positive impact on the patient, on colleagues, or
the ofce. Doing so promotes resident self-esteem. It is not
general praise such as “You did a great job!” but should
focus on specic behaviors that can be repeated in the future.
This is an important microskill as residents often feel that
their mistakes are always pointed out but what they did right
receives little attention.
282
W. F. Miser
The last microskill is to correct mistakes that the preceptor notices during the encounter. Mistakes left unattended
have a good chance of being repeated in the future, so it is
important for the preceptor to identify those mistakes and
provide advice as to what to do in the future. Follow the
guidance about feedback given earlier in this chapter. Focus
on the issue and not the resident. Be specic and provide
advice on what to do in the future. Feedback should provide
an opportunity for the resident to self-reect and independent study [60].
Sometimes asking the residents what they would do better
next time allows the preceptor to assess both the residents’
knowledge and personal performance standards. Residents
who are aware of their mistakes and know what to do differently in the future need only to be reinforced. Residents who
are aware of their mistake but are unsure of how to avoid the
situation in the future are likely to be in a “teachable moment”
and appreciative of tips that will help them next time. Those
residents who are unaware that they made a mistake should
be told the potential negative impact of their mistake as well
as any corrective action.
Other Tips While Precepting It is important to keep an eye
on patient ow in the ofce. If one resident has a particularly
difcult patient encounter that has resulted in them getting
behind in their schedule, the preceptor may ask another resident to help out, especially if that resident has a no-show or
opening in their schedule.
Almost all learners appreciate preceptors who are enthusiastic in their approach to patient care and teaching, who
provide feedback, and who are willing to discuss their reasoning processes [61]. At the beginning of training residents
typically want to be told what to do, but as they mature,
desire more autonomy in making decisions. Senior residents
tend to more value patient care management teaching.
Seeing a patient together in the exam room with the resident can be a powerful learning experience. It allows the preceptor to model their approach to patient care, display
interpersonal and communication skills, and demonstrate
physical examination skills. The preceptor should ensure
they do not take over the care of the patient, but work in a
collaborative manner with the resident, emphasizing to the
patient that they are there only as an assistant to the resident,
who is the patient’s primary physician. Emphasize to the
patient that they are in good hands with the resident who is
taking good care of them. This helps build up the esteem of
the resident during that visit.
After the visit, the preceptor needs to ensure the resident’s
progress note and orders are accurate before adding the attestation note and closing the encounter. The preceptor then
needs to monitor the results of any subsequent labs, imaging,
and other tests ordered by the resident to ensure they are
properly addressed. If unanswered questions arise during the
patient encounter, it is important for the preceptor to follow
up with the resident to encourage further learning.
The Resident asTeacher
Family medicine residents are another important teacher in a
family medicine residency program. First-year residents
teach medical students, second-year residents teach both
rst-year residents and medical students. Senior residents
teach junior residents. Medical students recognize residents
as being major contributors to their education [62, 63].
Most of this teaching is informal through role modeling
and occurs on the wards, in the emergency room, and in the
ofce. It is estimated that 40–50% of a resident’s teaching is
received from fellow residents [64, 65]. This is not surprising
given the amount of time residents spend together in the
wards and in the ofce.
As adult learners, residents are actively engaged in their
own learning by teaching. Residents who teach have better
knowledge acquisition than do self-study or lecture attendance [63, 66]. In a randomized trial of pediatric residents,
those who presented a brief lecture on oral rehydration
retained nearly two times more information about the topic
than those assigned to read the same material [67]. In another
study of pediatric residents, those who taught parents about
oral rehydration tested better than did residents who merely
attended a lecture on the subject [66]. Active engagement in
teaching by residents benets their learning, whether the
teaching is informal (i.e., at the bedside) or formal (i.e., lecture) [66].
Given this amount of teaching responsibility, it is important that we train residents in the principles of learning and
teaching, particularly on the topics of small group teaching
and providing feedback. Residents should understand their
role as teachers, receive formal education on teaching, and
receive feedback on their teaching skills, often given condentially, by the rst- and second-year residents. Teacher-asresident courses have been shown to improve residents’
condence in their teaching and improve self- and peer evaluations of teaching effectiveness [63–65, 68–72]. Teaching
Table 26.7 Potential topics for a resident-as-teacher workshop
Expectations of residents as teachers
Characteristics of the adult learner
Traits and behaviors of outstanding clinical teachers
What makes a good leader—skills to be emulated
How to provide optimal feedback
How to prepare and deliver a dynamic presentation
How to lead a resident team on the inpatient service
Goal setting
26 Practical Didactic, Bedside, andOce Teaching Skills
283
residents the One-Minute Preceptor model has been shown
to improve their overall teaching effectiveness [73].
Although various methods exist, one proven implementation of a Resident-as-Teacher workshop has been successfully implemented by the Ohio State University Family and
Community Medicine Residency Program. At the beginning
of each academic year, residents actively participate in a
four-hour workshop that covers a range of topics, with the
focus of the resident being the teacher (Table26.7). The purposes of this workshop are to introduce rst-year residents to
important concepts of teaching and their role in teaching
medical students, to emphasize to junior and senior residents
their roles as teachers, team leaders, running work rounds
efciently, managing and teaching interns and medical students, interacting with attending physicians, and ensuring
quality patient care. At the end of the rst year of training,
rst-year residents undergo an Objective Structured
Examination (OSCE) to determine whether they are ready to
assume the role of junior resident. Two scenarios involve
supervision of a rst-year resident as they review the orders
of a complicated patient admission and to review discharge
instructions and medications. Second-year residents undergo
an OSCE scenario in which they are counseling a rst-year
resident who appears lazy and detached but is really overwhelmed and stressed. To assess their effectiveness as teachers, rst-year and junior residents condentially rate senior
residents on their teaching and leadership skills; this information is reviewed by the program director and collated for
the end-of-the-year evaluation.
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Teaching Maternal Health Care
MadieD.Hartman, SarahI.Ramírez, KathleenWoods,
andKarlT.Clebak
27
Key Points
• The ACGME requires a combination of both obstetric and
gynecologic care in family medicine residency training.
• Family medicine residents should provide preconception
care and evidence-based patient information throughout
the pregnancy and postpartum periods.
• Social determinants of health (nancial concerns, food, or
shelter insecurity) can profoundly impact health care.
Residents should learn how to recognize and address
these concerns in the obstetric patient.
• Residents should learn how to recognize and manage
common obstetric emergencies and when a specialist consult is required.
• All obstetric patients should receive mental health screening and treatment if clinically indicated.
ACGME Requirements
To meet the 2024 ACGME program requirements, family
medicine residency training must include evidence-based
women’s health care including obstetrical medicine, see Box
27.1. The ACGME requires programs to provide at least
1month of training in obstetric issues to ensure that residents
deliver high-quality, patient-centered care to women across
their lifespan [1]. Further, residents must have at least
200hours of pregnancy-related care, including a structured
curriculum in prenatal, intrapartum, and postpartum care,
and experience with a minimum of 20 vaginal deliveries [1].
Residents who plan to continue comprehensive pregnancyrelated care and vaginal deliveries into independent practice
“must complete at least 400hours (or 4months) dedicated to
M. D. Hartman (*) · S. I. Ramírez · K. Woods · K. T. Clebak
Penn State Health Milton S.Hershey Medical Center,
Hershey, PA, USA
e-mail: mhartman5@pennstatehealth.psu.edu
training on labor and delivery and perform or directly supervise at least 80 deliveries” [1]. Typically, maternity care education offers the opportunity to highlight the impact of a
family-centered approach, interdisciplinary collaboration,
and continuity of care on the overall health of an individual
and family during the course of a health-changing event [2].
Furthermore, robust medical knowledge, effective communication skills, and ethical and professional behavior are
required for residents to successfully master maternity care.
Box 27.1
Section IV.C.3.i) including subsections IV.C.3.i). (1)
and IV.C.3.i).(1).(a) of the 2024 ACGME requirements
state that FM residents must have at least 200hours (or
2 months) dedicated to participating in pregnancyrelated care. (Core). This time must include prenatal,
intrapartum, and postpartum care including the care of
medical issues that arise during the pregnancy. (Core)
Family medicine residency programs can improve prenatal education by extending rotations in obstetrics and gynecology, increasing time in labor and delivery units, and
providing exposure to high-risk clinics and prenatal ultrasound departments. Educational sessions and simulation
training can enhance hands-on experience. This investment
can better prepare residents to provide top-quality prenatal
care. Furthermore, fellowships for family physicians in
obstetrical care and management provide extra training in
obstetrics, particularly to increase experience in handling
complex cases, high-risk pregnancies, and surgical
obstetrics.
The Family Medicine ACGME requirement regarding
resident experience with obstetrical care has several implications for family medicine residency programs, residents, and
patient care:
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_27
285
286
M. D. Hartman et al.
• Resident Training and Competency: By completing at
least 20 vaginal deliveries, residents develop their obstetrical skills including prenatal care, labor management,
delivery techniques, and postpartum care. By establishing
a set minimum for the number of deliveries, the requirement helps ensure that there is a consistent baseline experience across programs.
• Preparation for Independent Practice: For residents
who seek to incorporate comprehensive pregnancyrelated care following graduation into their independent
practice, the ACGME requirement sets a higher standard
to meet (see Box 27.2). These residents are required to
complete at least 400 hours (or 4 months) dedicated to
training on labor and delivery, along with directly
supervising or performing at least 80 deliveries. This
more stringent requirement ensures that residents gain the
advanced skills and experience necessary for providing
autonomous obstetrical care.
• Patient Safety and Quality of Care: These obstetric-
focused ACGME requirements contribute to ensuring
patient safety and the provision of high-quality maternity
care. By requiring that residents have an established minimum experience and training with vaginal deliveries, the
ACGME helps mitigate risks associated with complications
and adverse outcomes. Competent residents are trained to
recognize and manage emergencies, reduce the likelihood
of medical errors, and improve patient outcomes.
• Program Compliance and Accreditation: Meeting the
minimum requirements for resident experience with vaginal
deliveries and comprehensive pregnancy-related care demonstrates the program’s commitment to training competent
and procient obstetrical providers. Maintaining ACGME
accreditation enhances the program’s reputation within the
medical community and among prospective residents.
• Career Opportunities and Scope of Practice: Residents
who fulll the ACGME requirements for maternity care
training may pursue various career opportunities.
Comprehensive training prepares residents for roles in primary care settings, community health centers, academic
institutions, and obstetrical practices. Graduates who choose
to incorporate maternity care into their practice can provide
continuity of care to pregnant individuals and their families,
addressing the ongoing need for access to comprehensive
maternity care services in diverse communities.
Box 27.2
Subsection IV.C.3.i).(2) of the 2024 ACGME requirements state that FM residents interested in incorporating prenatal care that includes intrapartum obstetrical
management and deliveries into independent practice,
complete 400hours (or 4months) of dedicated to training on labor and delivery and perform or directly supervise at least 80 deliveries.
Overall, the ACGME requirement regarding resident
experience with vaginal deliveries plays a signicant role
in shaping obstetrical training, ensuring resident competency, improving patient care, and preparing future family
medicine physicians for the challenges and responsibilities
of managing labor and delivery. While the ACGME
requirement regarding resident experience with vaginal
deliveries aims to enhance residency training and ensure
competency in obstetrical care, there are potential unintended consequences that programs and stakeholders
should consider:
• Focus on Quantity over Quality: Programs may pri-
oritize meeting the minimum number of vaginal deliv-
eries required by the ACGME, potentially leading to a
focus on quantity rather than the quality of resident
training. Residents may feel pressure to meet numerical
targets, which could compromise the emphasis on com-
prehensive and patient-centered care. Programs may
also need to make space for new or expand current
obstetric rotations requiring the removal of other exist-
ing rotations.
• Shift Away from Individualized Learning: The rigid
numerical requirements may limit opportunities for indi-
vidualized learning and tailored experiences based on
residents’ unique interests, skills, and career goals.
Residents may feel compelled to focus solely on meeting
the minimum requirements rather than exploring addi-
tional opportunities for professional growth and develop-
ment. By requiring the obstetrical experience for all
residents, residents who are not interested in obstetrics
may have less time to focus on their intended career
interests.
• Potential for Burnout: Residents may experience
increased stress and burnout as they strive to meet the
increased requirements set by the ACGME.Long hours
spent in labor and delivery settings, coupled with the
pressure to perform and supervise deliveries, can contrib-
ute to physical and emotional exhaustion among
residents.
• Impact on Patient Safety: While the ACGME require-
ment is intended to enhance patient safety by ensuring
resident competency in obstetrical care, residents may be
involved in deliveries beyond their level of prociency.
Inexperienced residents may inadvertently contribute to
adverse outcomes or medical errors, particularly in high-
risk or complex obstetrical cases.
• Disparities in Training Opportunities: Residency pro-
grams in underserved or rural areas may face challenges
in providing sufcient training opportunities to meet the
ACGME requirements. Limited access to obstetrical
facilities, low patient volumes, and stafng shortages may
hinder residents’ ability to attain the requisite experience
with vaginal deliveries, further exacerbating disparities in
training and access to quality care.
27 Teaching Maternal Health Care
287
• Impact on Program Resources: Meeting the ACGME
requirements for obstetrical training may require substantial nancial and human resources from residency programs. Investing in faculty development, simulation
equipment, and clinical support staff to ensure adequate
supervision and training infrastructure can strain program
resources and budgets.
• Potential for Unintended Consequences on Workforce
Distribution: Stringent ACGME requirements may discourage residents from pursuing careers in family medicine or obstetrics, particularly in regions with challenging
practice environments or limited resources. This could
exacerbate workforce shortages in underserved areas and
contribute to disparities in access to obstetrical care.
Overall, while the ACGME requirements for resident
experience with vaginal deliveries aim to uphold standards
of training and patient care, programs and stakeholders need
to remain mindful of potential unintended consequences and
proactively address challenges to optimize resident education and patient outcomes.
Competency Versus Number ofDeliveries
ment, critical thinking, communication skills, and professionalism alongside hands-on procedural experience.
Programs should incorporate structured assessments, faculty
mentorship, simulation training, and opportunities for reective practice to ensure that residents are competent and prepared to provide high-quality obstetrical care. Further
research is needed to explore the relationship between
numerical benchmarks, resident competence, and patient
outcomes in obstetrical care.
Continuity inObstetric Training
Continuity is one of the hallmarks of family medicine and a
crucial part of obstetrical care in family medicine. Residency
training should allow learners to manage their patient’s pregnancies throughout all four trimesters. Both patients and providers report higher satisfaction levels when continuity of
care is provided [3]. Moreover, studies have shown that
patients receiving continuous care throughout their pregnancies have better outcomes, including improved birth weights
and healthy weight gain. Having a regular obstetric provider
also increases the likelihood that patients will comply with
their scheduled appointments [3].
The controversy surrounding the ACGME requirement for a
minimum number of deliveries revolves around the balance
between competency and a system anchored on obtaining a
certain number of deliveries performed by residents. While
the requirement sets numerical benchmarks aimed at ensuring residents gain sufcient experience in obstetrical care,
critics argue that the focus on numerical targets may not necessarily equate to enhanced competence or prociency.
Competence in obstetrical care includes demonstrating
success across a range of skills beyond the number of deliveries performed. It involves the ability to effectively manage
prenatal care, recognize and manage obstetrical emergencies, provide patient-centered care, and demonstrate prociency in communication and teamwork. Critics of numerical
requirements argue that competence in obstetrical care cannot be solely determined by the number of deliveries performed, but rather by the quality of training, supervision, and
overall clinical experience. The controversy surrounding the
ACGME requirement for 80 deliveries stems from a lack of
empirical evidence linking this specic numerical threshold
to improved resident competence or patient outcomes. While
the requirement aims to ensure that residents have a sufcient volume of hands-on experience in managing deliveries,
there is limited data to support that performing 80 deliveries
is a denitive marker of resident competence or readiness for
independent practice.
While the ACGME requirement serves as a minimum
standard for obstetrical training, it is essential for residency
programs to prioritize a comprehensive approach to resident
education that emphasizes the development of clinical judg-
Addressing Resident Continuity While
onNon-Obstetric Rotations
Continuity of care is a requirement set forth by the ACGME
(see Box 27.3). Handling a continuity obstetrical patient
when a resident is on another rotation can be a challenging
scenario. In such situations, determining priority requires
careful consideration of patient care needs, resident education, and program resources. Here are several factors to
consider:
• Patient Care Needs: The primary consideration should
always be ensuring the continuity maternity care patient
receives timely and appropriate care. If the patient
requires urgent medical attention or obstetrical management, priority should be given to addressing their needs,
regardless of the resident’s scheduled rotation. Patient
safety and well-being must always be the highest
concern.
• Resident Education: While patient care is paramount,
resident education is also a critical component of family
medicine residency programs. Residency programs
should strive to provide residents with diverse clinical
experiences and opportunities for learning. However,
continuity of care should not be compromised solely for
the sake of resident education.
• Program Resources: Consideration should be given to
the availability of resources, including stafng, supervision, and support services, to ensure adequate coverage
288
M. D. Hartman et al.
and support for both patient care and resident education.
Residency programs may need to allocate additional
resources or adjust schedules to accommodate the needs
of continuity maternity care patients while maintaining
educational objectives and clinical coverage needs.
• Communication and Collaboration: Effective communication and collaboration among residents, attending
physicians, nursing staff, and other healthcare team members are essential for coordinating care and addressing
continuity maternity care patient needs. Clear communication channels should be established to facilitate timely
decision-making and ensure seamless transitions of care
between rotations.
• Balancing Competing Priorities: Family medicine resi-
dency programs must strike a balance between the priorities of patient care and resident education. While resident
education in obstetrics is a required component of training,
it should be integrated to prioritize patient safety and continuity of care. Programs may need to develop protocols,
guidelines, and contingency plans to address continuity
maternity care patient needs during resident rotations.
Box 27.3
Subsection II.B.1.d).(2) of the 2024 ACGME requirements state that FM programs providing maternity
care competency training to the level of independent
practice must have family medicine physician faculty
members teaching and providing family-centered,
pregnancy-related care, including prenatal, intrapartum, vaginal delivery, and post-partum care. (Core)
Structuring obstetrical rotations within family medicine
residency programs requires careful consideration of patient
care needs, resident education, program resources, and effective communication and collaboration among healthcare team
members. This task becomes more nuanced when there is an
obstetrics residency program within the same hospital and is
also important when obstetrical residents are not present. In
addition, promoting patient continuity enhances both educational and patient care purposes. Handling a continuity maternity care patient when a resident is on another rotation requires
careful consideration While patient care should always be the
top priority, residency programs must also ensure that residents receive valuable educational experiences while maintaining continuity of care for maternity care patients. As such
this may be achieved by block scheduling the maternity care
experience or scheduling obstetrical patients within the resident’s clinic schedule. The decision is based on the exibility
of the curriculum at each residency program.
Contributors toDiscontinuation
ofObstetrical Care inPractice
While the ACGME requires that family medicine residents
seeking training for independent practice of maternity
care, be trained by family medicine faculty, see Box 27.3,
the reality is that this number is declining. Family physicians are known to care for socially complex prenatal
patients without compromising the quality of care they
receive yet less are doing so; 44% in 1982 to 27% in 2022
and 12% included deliveries [3]. While 84% of family
medicine graduates in 2022 reported feeling that their residency training prepared them to include maternity care in
their practice, barriers to doing so included a lack of interest (62%), lifestyle considerations (58%), and lack of
opportunities with their current employer (40%) [4].
Awareness of these barriers can help family medicine residency programs frame the ways their training programs
are structured.
Obstetric Family Medicine Faculty Shortage
Family medicine residency programs facing a shortage of
faculty can employ several strategies to mitigate the impact
on resident training and ensure the delivery of high-quality
obstetrical care:
• Utilize Telemedicine and Teleconsultation Services:
Implementing telemedicine and teleconsultation services allows residents to access obstetrical expertise and
guidance remotely. Collaborating with obstetrical
experts from other institutions or leveraging telehealth
platforms enables residents to consult on complex cases,
receive real-time feedback, and access educational
resources despite the shortage of local faculty.
• Engage in Collaborative Partnerships: Forge partner-
ships with nearby obstetrical practices, community hospitals, academic medical centers, and obstetrical
residency programs to expand access to obstetrical
expertise and resources. Collaborative arrangements can
involve sharing faculty, preceptorship opportunities,
educational materials, and simulation training facilities
to enhance resident education and exposure to
obstetrics.
• Develop Faculty Development Programs: Invest in fac-
ulty development initiatives aimed at equipping existing
family medicine faculty with obstetrical expertise and
teaching skills. Providing faculty with opportunities for
continuing education, workshops, conferences, and online
resources can enhance their ability to teach obstetrical
topics effectively and mentor residents in clinical
practice.