MAN: Military ALSO Network

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MAN Military ALSO Network

• CPT Joshua Will
• MAJ Jennifer Frank
• I didnt want to create the course I only
  wanted to take it. John Beasley, MD, ALSO
  co-creator

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Learning Objectives

• Understand the life-cycle of an ALSO
  instructor/advisory faculty
• Learn the relevance of ALSO training to residency
  training in obstetrics and the practice of
  obstetrics post-residency
• Identify ways in which the military family
  medicine community can build and sustain an
  ongoing ALSO program

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History of the ALSO course

• Developed in early 1990s by a multidisciplinary
  group of family physicians, obstetricians, one
  perinatologist, and a nurse practitioner
• Modeled on existing life support courses (ACLS,
  ATLS, PALS, NRP)
• Ideal because they are taught locally
• Ideal because their methods and format support
  instruction for the care of emergent patients
• Included extensive feedback to course
  participants
• Modeled on idea that teaching be done by local
  faculty, that new faculty be recruited from
  course attendees, and that all types of maternity
  care providers (FPs, OBs, NPs, nurses) should be
  included.
• Beasley JW et al. The Advanced Life Support in
  Obstetrics course. Arch Fam Med 199431037-1041.

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History of the ALSO course (contd)

• Initially taught through the University of
  Wisconsin Department of Family Medicine
• Curricular content selected to reflect both
  important and/or emergent topics as well as
  psychosocial emergencies.
• Due to practice variations and lack of solid
  evidence to support some practices, management
  strategies were intended to reflect reasonable
  (but not the only or best) strategies.
• Due to overwhelming interest and demand in the
  infancy of the ALSO course, it was transferred to
  the AAFP for further development, operation, and
  dissemination

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Ponder this

• Which of the following will the average military
  family physician be more likely to experience in
  clinical practice?
• Defibrillate a patient in cardiac arrest OR
• Encounter a shoulder dystocia?
• Place an intraosseus canula in a pediatric
  patient OR Manage a postpartum hemorrhage?
• Taylor HA. Providing the Advanced Life Support
  in Obstetrics Course within the military family
  practice training system. Mil Med
  1996161,11696-700.

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Why teach ALSO?

• There is great variability in individual
  residents OB experiences even within the same
  program
• Dependent on
• Resident gender
• Time of day of delivery
• Type of delivery
• Patient parity
• Resident involvement in antenatal care/labor
  management
• Weissman AM, Dawson JD, Fox DL. Variability in
  the learning experiences of family practice
  residents during and obstetrics rotation. Fam
  Med 199931(1)28-33.

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Why teach ALSO? (contd)

• Due to great variability even within the same
  program, ALSO provides an evidence-based medicine
  approach to teaching both knowledge of prenatal
  and labor complications as well as introducing
  and teaching technical skills.
• Assures a basic level of knowledge for
  need-to-know material.

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OB practice of Family Physiciansin the US

• 28.5 of FPs include OB care in their practice
• 30.1 of FP residency grads include OB care
• 21.8 of FPs perform routine OB delivery
• 17.6 perform vacuum deliveries
• 6.4 perform forceps deliveries
• AAFP 2005 Facts about Family Physicians

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OB Practice (contd)

• 19.9 of FPs practice labor augmentation
• 18.7 of FPs practice labor induction
• 7.4 care for high-risk pregnancies
• 9.3 care for high-risk pregnancies in
  consultation
• 6.6 manage VBACs
• 6.1 do so in consultation
• 4.3 perform c-sections

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ALSO course participation and its impact on OB
practice

• Compared with pre-course surveys, ALSO course
  completion was significantly associated with the
  following changes (at 12 months post-course)
• Subjective comfort managing
• -3rd trimester bleeding -PTL/PROM
• -Malpresentation -Dysfunctional labor
• -Breech -Shoulder dystocia
• -Preeclampsia -Postpartum hemorrhage
• -Forceps-assisted delivery -Vacuum delivery
• -US for fetal position, AFI, and placental
  location
• -Neonatal resuscitation

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ALSO course participation and its impact on OB
practice (contd)

• Practice changes included significantly more
  physicians performing
• Amnioinfusion
• Vacuum delivery
• U/S for determining fetal, placental position
• No change noted in physicians performing
• SVD
• Breech vaginal delivery
• Forceps-assisted delivery
• DC for incomplete miscarriage

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ALSO course participation and its impact on OB
practice (contd)

• Survey of residents before and after ALSO course
  participation
• Validated survey of self efficacy (confidence or
  beliefs regarding ones capability to perform a
  given behavior under a variety of circumstances)
• Residents reported increased confidence in their
  ability to manage obstetrical emergencies after
  course completion
• There was no change in the residents reported
  intent to practice maternity care upon completion
  of residency training
• Bower DJ, Wolkomir MS, Schubot DB. The effects
  of the ALSO course as an educational intervention
  for residents. Fam Med 199728(3)187-93.

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Ideas for implementation

• Full 2 day course
• No consensus on best time during residency to
  provide training.
• Longitudinal curriculum
• 1 hour classes/stations given over months
• Generally not considered as beneficial
• 4 Half-days spread over a week
• Minimizes impact on clinic access
• Involve OB staff as instructors
• Invite nursing staff to take course
• More ideas Taylor HA. Providing the Advanced
  Life Support in Obstetrics Course within the
  military family practice training system. Mil
  Med 1996161,11696-700.

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Requirements to host an ALSO course

• Identify need for training in your area
• Have appropriate faculty to conduct course
• Course director should be knowledgable about
  the ALSO course and plan to remain on-site for
  entirety of course
• Faculty one Advisory Faculty and at least 50
  ALSO Instructors or Instructor Candidates
• Ratio of 15 or 16 FacultyStudents
• Obtain approval through AAFP (complete
  application)

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The Life-cycle of an ALSO Faculty
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Who may act as an ALSO Instructor?

• Any licensed physician, registered nurse, or
  certified nurse midwife
• Complete ALSO Instructor Course and be designated
  an ALSO Instructor Candidate
• Participate as faculty within one year of
  Instructor Course completion and be evaluated by
  an Advisory Faculty

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ALSO Advisory Faculty

• Need to be present to assure accuracy and quality
  of teaching during the entire course
• Few ALSO Advisory Faculty (for example, only 3 in
  the state of Georgia) this may be the rate
  limiting step in hosting ALSO courses
• Average honorarium for an ALSO Advisory Faculty
  is 750-1000
• To be approved as an ALSO Advisory Faculty need
  to have completed the provider course, instructor
  course, be certified as an instructor, act as
  course director, be recommended by an existing
  ALSO advisory faculty, and be approved by the AAFP

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What is MAN?

• An idea for a Military ALSO Network.
• It is also a cute mnemonic that emphasizes the
  irony of naming something after one gender that
  is designed to treat a condition of the other
  gender.

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MAN

• Purpose is to provide ALSO training to all
  military Family Physicians by
• Developing ALSO instructors and Advisory Faculty
• Providing a list of instructors/advisory faculty
  available to teach courses
• Consolidating ALSO equipment in central areas
  where it can be borrowed/shared by MTFs in close
  geographical proximity
• Minimize cost to any department/MTF by having
  military ALSO instructors and advisory faculty,
  as well as the equipment and materials to conduct
  the course

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Developing ALSO faculty

• Goal to train all FM residents by the end of 2nd
  year of residency.
• Identify 1-2 per program that would be good
  instructors, train over summer before entering
  3rd year.
• These resident instructor-candidates will teach
  in their program prior to graduation which allows
  them to become certified ALSO instructors.
• In teaching programs, develop junior faculty to
  become ALSO instructors and select 1 per teaching
  program per 3-5 year cycle to become ALSO
  Advisory Faculty.

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Provide ALSO faculty

• If a department/MTF would like to sponsor an ALSO
  course, there would be a central repository (at
  USAFP) of current ALSO providers/instructors/advis
  ory faculty.
• Allows for courses to be conducted more easily
  and allows for the necessary faculty members to
  be contacted quickly.
• Allows quick location of deployed ALSO faculty
  who could provide training in forward deployed
  areas.

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Consolidate ALSO equipment

• Manikins, slides, and other equipment are
  expensive
• Not practical for each MTF to have its own supply
  of ALSO equipment
• Allow for regional location of ALSO equipment
  that is available to all 3 services in
  geographical proximity

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Minimize cost

• By providing military ALSO instructors and
  advisory faculty, no cost of honoraria
• By having regionally located and available course
  equipment and materials, minimize cost of rental
  equipment or need to purchase equipment
• By providing courses at MTFs, eliminate need to
  send military FPs to civilian courses (cost of
  300 and up). Only cost will be of the course
  syllabus.

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Potential benefits

• Requires coordination with local maternity care
  providers. This collaborative relationship
  (among other factors) has been shown to increase
  the percentage of residents who intend to
  incorporate prenatal care or deliveries in their
  practices after residency training.
• Helton M, Skinner B, Denniston C. A maternal
  and child health curriculum for family practice
  residents Results of an intervention at the
  University of North Carolina. Fam Med
  200335(3)174-80.

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Potential benefits

• Military family physicians have the opportunity
  to interact with physicians from other nations in
  unique settings. Bring the ALSO curriculum (as
  has been done in Iraq) to these health care
  provides both a key element to nation-building as
  well as having the potential to impact medical
  care in these developing countries.

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QUESTIONS?