Lisa Graves MD CCFP FCFP
Fred Janke MD CCFP FCFP
Kate Miller MD CCFP FCFP
Conflicts of Interest
 All three panelists have no conflicts to
declare
Objectives
 To review the current state of enhanced
skills programs, both surgical and nonsurgical in Canada
 To envision the future of enhanced
skills programs in the Triple C era
en·hance:
intensify, increase, or further
improve the quality, value, or
extent of.
What are enhanced skills in
maternity care?
 Family physicians bring two enhanced skills
sets to maternity care: enhanced maternity
skills (EMS) and enhanced surgical skills
(ESS) including C/S.
 Community need may dictate that an FP has
one, the other or both of these skill sets
Current state of Enhanced
Maternity Skills programs
 What we believe – primarily a vehicle for
added volume, added confidence, required
for privileges/teaching
 What we hope – enhanced skills programs
provide skills that lead to enhanced scope
and are used in practice.
 What we know – limited data available from
the U.S., currently Canadian study in
progress
Will triple C change the need for and
nature of enhanced skills programs?
 Revisit and redefine the core competencies
expected at the start of practice
 If each resident has these competencies how
will enhanced skills programs change?
 What will the transition look like?
What role should Enhanced Skills
Programs fill?
1. Provide a specific, expanded skill set – e.g.
C-section, breech delivery, forceps delivery
2. Prepare for specific practice settings - e.g.
high volume, rural/remote, specific
populations
3. Prepare for the role of maternity care
teacher
4. In some settings, required for privileging
Other jurisdictions and approaches
 American streaming approach
 Three tiers
 Can be completed within 3 year residency
 Has an impact for residency training for those not in the
enhanced skills stream
ESS -Current Landscape
 One single program in Canada that offers a
full R3 program in ESS
 Prince Albert
 Over subscribed and graduates two physicians per year
 Alberta
 Six month surgical obstetrics programs available
 Tentative full R3 program in Grande Prairie
 Other Provinces
 Surgical Obstetrics available on an irregular basis
What should the Enhanced Maternity
Skills curriculum look like? Comments
of Participants
 Need to define core before we can define
enhanced, should we be paying attention to
EMS when if we fail to meet core
competencies?
 Enhancement vs remediation
 Ultrasound in pregnancy – some core, some
enhanced?
 ALARM/ALSO – core or enhanced?
 Special populations/difficult populations
 Able to advise and consult in a pregnancy
 Enhanced skills program should not a place to
train those that do OB only (as EM as done)
 Not an R3 year
 Who will do the teaching? Where will we get
the teachers?
 Research?
 Are there other ways to provide
confidence/volume eg mentoring
 How do you find a place? Do we have the
capacity to meet the need?
 Generalist enhanced skills – respecting an MD
who wants more than one enhanced skill set
 Mandatory FM mentor
 Vacuum – core vs enhanced – independent vs
supervised
 Breech delivery
 Diabetes, gestational HTN – core, spectrum,
enhanced
 If there isn’t enough learning opportunities
– who gets them? Do we ‘force’ the resident
who has their mind made up?
 Newborn skills – core vs enhanced.
Providing volume – ensure paeds not just
OB our supports
 Teaching the future teachers
 Do we have different standards for IMGs?
 Exposed (core) vs expert (enhanced)
 Breastfeeding, tongue tie release – core vs
enhanced.
 Ability to work in environments with less
back-up (eg no surgical service)
 C-section assist
Enhanced Surgical Skills
 FPs with ESS may have a focussed
obstetrical skill set (eg C/S alone) or a
broader skill set including parts of general
surgery, ENT and plastics
 ESS has been approved as a SIFP with the
hopes that one day ESS will be a Certificate
of Added Compentence
Current draft of the national
working group ESS Curriculum
 Modular in format
 Basic Operative Management
 Management of Abdominal Presentation in the Non



Pregnant Patient in Rural and Remote
Management of Pregnancy in Rural and Remote
Management of Non-Abdominal Presentations in Rural
and Remote
Basic Principles
Trauma
Management of Pregnancy in Rural and
Remote
 Complications of Labour & Delivery
 operative vaginal delivery, C-section, obstetrical trauma,
uterine inversion, PPH, retained placenta; ALARM, NRP
 First Trimester Pain and Bleeding
 D&C, ectopic
What should the Enhanced Surgical
Skills Curriculum look like?
 D&C and management of early preg loss
 Broad enough skill set to maintain the OR
and the overall surgical program
How do we ensure the Enhanced Skills
Programs respond to community needs?
 How can we provide volume for our learners if
we have volume caps?
 Accreditation, privileges – what if we give them
skills and then they aren’t allowed to use them?
 What if you can’t get privileges without the
enhanced skills time even if you have the skills
after the core?
 How does return of service influence the skills
that a resident needs and gets?
Thank you