Integrating Medical Abortion Into a Residency Practice - STFM

Vol. 35, No. 7

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Innovations in Family Medicin e Education

Joshua Freeman, MD Feature Editor

Editor’s Note: Send submissions to [email protected]. Articles should be between 500–1,000 words and clearly and concisely present the goal of the program, the design of the intervention and evaluation plan, the description of the program as implemented, results of evaluation, and conclusion. Each submission should be accompanied by a 100-word abstract. Please limit tables or figures to one each. You can also contact me at Department of Family Medicine, KUMC, Room 1130A Delp, 3901 Rainbow Boulevard, Kansas City, KS 66160. 913-588-1944. Fax: 913-588-1910.

Integrating Medical Abortion Into a Residency Practice Linda Prine, MD; Ruth Lesnewski, MD; Rachel Bregman, MD While changing residency services and curricula is difficult under the best of circumstances, adding something as controversial as medical abortion can provoke seemingly insurmountable resistance. This paper describes an innovative approach to adding medical abortion services. We first surveyed staff, faculty, residents, and colleagues to examine their reservations. These concerns were addressed in a structured manner, using a range of educational forums. While residents’ participation in the service was voluntary, all patients were assured access to medical abortion. (Fam Med 2003;35(7):469-71.)

In September 2000, mifepristone was released in the United States for medical abortion. At the Beth Israel Residency Program in Urban Family Practice in New York City, several physicians and residents became interested in incorporating medical abortion into their practice, allowing their patie nts acce ss to early pregnancy termination in a comfortable, familiar setting while avoiding an invasive procedure. In January of 2001, the only family practice residency program that offe re d me dica l a bortion with mifepristone was one of the sites of the mifepristone trials. In mid-2001,

From the Beth Israel Residency Program in Urban Family Practice, NewYork.

the Beth Israel Residency became the second residency program to offer it. By 2003, additional family practice residency programs have added medical abortion, including several in New York City and New England and one in New Mexico. Because of the sensitive nature of abortion, adding this service required extensive preparation. First, research was conducted regarding reservations among staff, residents, and faculty. Second, a formal medical abortion curriculum was developed. Third, administrative issues were addressed. Phase 1: Research A survey was distributed to all faculty, residents, and health center and residency administrators and staff to discover their concerns

about offering medical abortion. From 138 employees, 130 completed surveys were collected. Analysis of these surveys revealed apprehensions about workplace security, the side effects of medical abortion, and inadequate knowledge about the method. The level of support for working in a family practice that offers early abortion was highest among the physicians, lower among administrators, and lowest among cleric al staff and nurses (Table 1). Those who were least supportive of offering medical abortion also reported a low level of knowledge about it. Phase 2: Education To te ach staff a nd collea gues about medical abortion, we and colleagues presented formal work-

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July-August 2003

Family Medicine

Table 1 Level of Comfort for Working in a Family Practice Setting That Incorporated Early Abortion Very Comfortable 47.9%

Somewhat Comfortable 22.2%

Somewhat Uncomfortable 20.5%

Very Uncomfortable 9.4%

Staff position** MDs, nurse practitioners, and social workers

64.3%

19.0%

11.9%

4.7%

Nursing and clerical staff

35.3%

23.5%

25.5%

15.7%

Administrators

45.5%

22.7%

27.3%

4.5%

All respondents

** Due to small sample sizes, analyses were conducted collapsing staff into groups. This was necessary to maintain a reasonable level of power in the study.

shops in collaboration with Planned Parenthood of New York City and the Faculty Development Program of the Institute for Urban Family Health. The practitioners followed an updated, evidence-based protocol that has also been adopted by the Planned Parenthood Federation of America, rather than the Food and Drug Administration (FDA)approved regimen (Table 2). These workshops were accredited for continuing medical education (CME) by the American Academy of Family Physicians. Over the 18-month period, 128 family physicians, pediatricians, residents, nurse practitioners, physician assis-

tants, and students a ttended the c ommunity workshops. Gra nd rounds on mifepristone were given in the residency program’s time slot at Beth Israel Medical Center twice in 18 months, and didactic sessions were presented during the core conference in the family practice residency. Educational meetings with question-and-answer sessions also were held for support staff, allowing workers at all levels to inform themselves and express their concerns. Patient education materials were also developed (www.theaccessproject. org.) The format for the community workshops appears in Table 3. The sign-up sheets from these meetings

Table 2 Regimen Comparison

Mifepristone dosage

FDA Regimen (Based on Studies up to 1996) 600 mg

Evidence-based Regimen (Based on Studies up to 2002) 200 mg

Misoprostol dosage

400 mcg orally

800 mcg vaginally

Misoprostol location and timing

Office administration on day 3

Home use 24-72 hours after mifepristone

Minimum number of office visits

3

2

Gestational age limit

49 days

63 days

FDA—Food and Drug Administration

indicate that more than 90% of the residents and faculty attended at least one of the educational sessions, with 50% atte nding more than one. Values clarification workshops were held twice at all-staff meetings in each of the practices to promote an attitude of professionalism and patient-centered care in relation to this service. These workshops were attended by 75%–92% of employees overall and by 55% of the residents. Participation in the medical abortion service is voluntary. All residents do options counseling for unplanned pregnancies. For patients who choose to terminate a pregnancy, residents can either offer the medical abortion themselves under attending supervision or refer the patient to others. At this writing, more than 50% of the residents have seen at least one patient through a medical abortion, and four faculty members are supervising this activity. Phase 3: Logistical Barriers Potential logistical barriers included malpractice insurance, billing issues, and back-up for failed medical abortions. The family physicians were relieved to learn that their malpractice insurance covered them for abortion care along with prenatal care and delivery. However, the reimbursement issue was more complicated. Calls to insurers led to a range of answers about coverage; within a single organization, representatives often gave contradictory answers. When Ne w York State Medicaid announced its coverage of medical abortion, many other insurers fell in step. To buy mifepristone from the manufacturer (it is not available in pharmacies— it can be dispensed only from practitioner’s offices), physicians must have “surgical back-up” for a failed or incomplete medical abortion. Since one of the physicians in the residency was a trained surgical abortion provider, she provided

Innovations in Family Medicine Education

Table 3 Workshop Format Time 10 minutes 15 minutes 90 minutes 45 minutes

Activities Introduction Didactic presentation on mifepristone Small-group, case-based discussions Group discussion of logistical barriers to be overcome at the various sites

a “completion” for the one patient whose medical abortion failed. Official back-up was also arranged with the OB-GYN department at Beth Israel. Evaluation Three aspects of the program were evaluated: clinical outcomes, staff attitudes, and the educational workshops. At this writing, four practices affiliated with the residency program have implemented and tracked their medical abortion services. Among the four practices, more than 200 medical abortions have been performed, with a clinical success rate of 99%—comparable to or better than the success rate in many of the published mifepristone studies.2-5 The second round of attitude surveys reflected increased comfort with and support for abortion services. The substantial, though smaller, minority of staff members who still reported lack of knowledge about or support for abortion services reflected some persistent resistance and a high rate of staff turnover. This resistance reinforced the need for ongoing educational

and values work on this sensitive issue. The residents’ responses did not differ significantly from those of the other physician and nurse practitioner providers. The postintegration survey demonstrated an increase in support for this service across all job categories, with the support of the professional group remaining the highest. Written evaluations for the clinicians’ medical abortion workshops were distributed and collected each time, and the workshops were often modified slightly the next time to address participants’ criticisms. The comments were overwhelmingly positive, especially regarding the interactive, case-based discussions. Conclusions Despite its political and emotional volatility, abortion can be successfully integrated into family practice residencies. Success is enhanced by first investigating the reservations of staff, residents, and colleagues and then by addressing their issues. Having a resident involved helped our project enormously. By participating, the resident observed

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firsthand how to identify and address concerns related to implementing change in a structured manner. Her leadership on this issue undoubtedly contributed to her election as chief resident during her third year. This project’s competency checklists and other quality assessment tools have beco me models for other areas of the residency. Feedback through an ongoing evaluation process contributed to improvement in the educational process as well. Acknowledgments: We thank Red Schiller, MD, chair of family medicine at Beth Israel Medical Center, and Neil Calman, MD, president of the Institute for Urban Family Health, for their support for our project. We thank our mentor, Marji Gold, MD. We also thank Jennie Sparandara, Emily Berger, and Sandy Merrill for their help. Corresponding Author: Address correspondence to Dr Prine, Beth Israel Residency Program in Urban Family Practice, 16 East 16th Street, New York, NY10003-3105. 212-366-9320. Fax: 212366-9321. [email protected].

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4. 5.

Prine L, Lesnewski R, Gold M. Medical abortion outcomes in a family practice setting. J Am Board Fam Pract. In press. Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low dose mifepris ton e 200 mg and vagin al misoprostol for abortion. Contraception 1999; 59:1-6. As h ok PW, Pen ney GC, Flett GM M , Templeton A. An effective regimen for early medical abortion: a report of 2,000 consecutive cases. Hum Reprod 1998;13:2962-5. Schaff EA, Fielding SL. A comparison of the abortion rights mobilization and population council trials. JAMA 2000;55(3):137-40. Allen RH, Westhoff C, De Nonno L, Fieldin g SL, Schaff EA. Curettage after mifepristone-induced abortion: frequency, timing, and indications. Obstet Gynecol 2001;98(1):101-6.