MATERNAL-FETAL MEDICINE

INTRODUCTION:A university wishing to have a program in maternal-fetal medicine accredited must also sponsor an accredited program in obstetrics and gynecology.

Maternal-fetal medicine involves the prevention, diagnosis and treatment of those conditions responsible for morbidity and mortality of the mother, fetus and early newborn. The rapidly expanding body of knowledge regarding maternal health and disease, the continuing introduction of new technologic methods for maternal and fetal assessment and increasing societal demands and expectations for mother and child, continue to modify the nature of obstetrical care. A direct result of these evolving processes is a need for specialists in maternal-fetal medicine with educational and research interests, administrative ability and special training in the identification and management of high risk obstetrical problems. Specialists in maternal-fetal medicine are viewed primarily as consultants to the practising obstetrician and other health care providers. For the most part they will limit their practice to referred high risk obstetrical patients in a tertiary health care institution and function as regional consultants in matters of organization, standards and education in the broad field of maternal-fetal medicine.

The purpose of this document is to provide program directors, surveyors and residents with an interpretation of the general standards of accreditation as they relate to the accreditation of programs in maternal-fetal medicine.

Specific Objectives:

At the completion of training, the resident must demonstrate:

1. Knowledge
   1. an understanding of the basic sciences relevant to maternal-fetal medicine: these include knowledge of maternal, placental, fetal and newborn anatomy, embryology, genetics, pharmacology, biochemistry, endocrinology, microbiology, physiology and pathology;
   2. the evaluation and treatment of maternal-fetal and early newborn disorders: an understanding of genetic, teratologic, metabolic, endocrine, immunologic and infectious disorders that relate to pregnancy; diseases of fetal growth and development; abnormal placental and uterine function; diseases of maternal systems and behaviour disorders occurring in pregnancy, and diseases of the neonate;
   3. an understanding of investigative concepts and the development of skills in research methods:
      1. a knowledge of the active research fields related to maternal-fetal medicine currently being published in the major peer reviewed journals;
      2. knowledge of the scientific method as applied to research data and skills that permit a critical analysis of a research presentation and its value as applied to clinical care in maternal-fetal medicine;
      3. involvement of the resident in a perinatal research initiative which should include formulation of an hypothesis, design of the project, implementation, the collection and analysis of original data and the writing of the manuscript. Participation of the resident should be such that she/he is legitimately assigned primary authorship.
   4. an understanding of the organization of and participation in audit of health services in maternal-fetal medicine:
      1. knowledge of the terminology and definitions used in the reporting of maternal, perinatal and abortion statistics by local institutions, provincial and federal departments of health, the World Health Organization, and other major international forums;
      2. knowledge of the organization required for the accurate collection of perinatal statistics at the local, regional and provincial levels and a demonstrated ability to collate, analyze and report perinatal statistics in an accepted format;
      3. knowledge of the composition, terms of reference and function of:
         1. institutional perinatal organizations and their relation to hospital personnel;
         2. regional, provincial and national reproductive care programs.
2. Clinical and Technical Skills

The resident must develop special competence in the assessment and management of acute and chronic maternal and fetal conditions including history, physical examination and other investigative procedures such as lab tests, ultrasound, and invasive technology.

3. Attitudes

The consultant must demonstrate continued empathic, sensitive and ethical attitudes to women and their families during the reproductive process. An ability to communicate with such individuals as well as with other members of the health care team is essential. A recognition of the importance of continuing self education, an awareness of the limitations of current methods of clinical management and the important contribution that research brings to an improvement in the care of the pregnant woman, her fetus, infant and family is necessary.

All residents must demonstrate the knowledge, skills and attitudes relating to age, gender, culture, and ethnicity pertinent to maternal-fetal medicine.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the subspecialty.

The following are the minimum educational requirements in the subspecialty of maternal-fetal medicine. Additional experience may be required by the program director.

1. Pre-requisite:

Five years of obstetrics and gynecology including a basic clinical year which must be completed prior to entry into the maternal-fetal medicine program.

2. Program requirements:

Two years of maternal-fetal medicine in an accredited program including:

1. A six-month block in which the resident is expected to develop proficiency in fetal surveillance including dynamic ultrasound imaging and antepartum/intrapartum assessment of fetal health;
2. A six-month block in which the resident will function in a consultant capacity under supervision of, and directly responsible to, a senior consultant in maternal-fetal medicine. Additional learning objectives may be accomplished during this clinical year including exposure to the principles of obstetrical anesthesia, perinatal follow-up, perinatal organization at the local, provincial and national levels, community outreach and medical complications of pregnancy.

This clinical experience must incorporate increasing professional responsibility, to achieve the level of a junior consultant;

3. Six months devoted to neonatal medicine, diagnostic imaging and reproductive genetics, or elective experiences, sufficient to achieve the objectives outlined above;
4. Six months devoted to an investigative project in maternal-fetal medicine, either of a basic or clinical nature.

For satisfactory completion of the College requirements in maternal-fetal medicine a resident must:

1. have successfully completed a two-year program in maternal-fetal medicine in an accredited program in which the resident has been enrolled for the full two years;
2. have attained certification in obstetrics and gynecology;
3. produce a report based on an investigative hypothesis that contains original data from a protocol designed and implemented by the candidate and approved by the residency program.

Residents must be provided with increasing individual professional responsibility, under appropriate supervision, according to their level of training, ability, and experience.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents to complete the program and achieve the educational objectives in maternal-fetal medicine.

In those cases where a university has sufficient resources to provide most of the training in maternal-fetal medicine but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training. When an accredited program is unavailable, residents may be sent to another learning environment for a period of time deemed appropriate by the residency program committee. The educational objectives for this period of training must be clearly defined and evaluation of the resident and of the experience by the resident must be adequately documented.

1. Teaching Faculty

There must be a sufficient number of qualified teaching staff to supervise residents and provide teaching in the basic and clinical sciences related to maternal-fetal medicine.

2. Number and Variety of Patients

The number and variety of patients available to the program on a consistent basis must be sufficient to meet the educational needs of the residents.

3. Clinical Services Specific to Maternal-Fetal Medicine
   1. In-Patient

The program must be located in a tertiary care institution in order to provide a sufficient number and variety of patients and clinical services to allow residents in the program to meet the following specific objectives:

• to assume major responsibility, under appropriate supervision, for complicated patient management and to take an active part in providing consultative services;
• to become skilled in the procedures necessary for identification and assessment of high risk obstetrical problems and subsequent management;
• to become skilled in all aspects of the intensive care of the mother and fetus and relevant aspects of the newborn in the perinatal intensive care unit.
1. Ambulatory Services

Residents in maternal-fetal medicine must be assigned responsibilities for outpatients in relevant clinics on a regularly scheduled basis. Such assignments must constitute a learning experience supervised by the teaching staff.

3. Consultation

The maternal-fetal medicine program must provide opportunities for the resident to develop comprehensive consultation skills, both oral and written, on the breadth of maternal and fetal conditions encountered in the practice of the specialty in the inpatient and outpatient settings. Such consultations would be directed toward family doctors, other obstetricians and gynecologists and allied health personnel. These opportunities should elicit an appreciation of the medico-legal responsibilities of a consultative relationship.

4. Community Learning Experiences

Community-based learning experiences should be acquired with emphasis on maternal-fetal health promotion, education, audit of perinatal services and/or maternal-fetal or neonatal transfer.

4. Supporting Services — Clinical, Diagnostic, Technical
   1. Liaison with Other Specialties and Subspecialties

There must be appropriate liaison with teaching services in internal medicine, neonatology and anesthesia.

2. Diagnostic Services

There must be:

                                                         i.            Close association with a pathology teaching service, preferably with expertise in perinatal pathology.

                                                       ii.            A full range of diagnostic facilities, including those for genetics, imaging, invasive fetal testing, biochemistry and microbiology.

                                                      iii.            A specialized staff and facilities necessary for laboratory assessment.

3. Intensive Care

There must be access to collaborative involvement with comprehensive intensive care facilities for the mother as well as a level III neonatal intensive care unit under the direction of neonatologist.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities such as journal clubs, research conferences and seminars must be a regular part of the program.

2. Basic and Clinical and Epidemiological Sciences Relevant to Maternal-Fetal Medicine

The educational program must include organized teaching in the relevant basic sciences and in the advanced clinical, epidemiological and scientific knowledge essential to the understanding of those areas.

3. Biomedical Ethics

The academic program must ensure that residents gain an understanding of the basic principles and practice of biomedical ethics as it relates to maternal-fetal medicine.

4. Communication Skills

The program must ensure that residents will continue to develop effective communication skills for interacting with patients and their families, colleagues, co-workers from other disciplines, and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team.

6. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, patient education, and/or formal courses in medical pedagogy.

7. Management Skills

Residents must be given opportunities to develop skills in management as applied to maternal-fetal medicine such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

8. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

9. Research Opportunities for Residents

There must be a faculty member with the responsibility to facilitate the involvement of residents in research and other scholarly work. The milieu of scholarship should be enhanced by close association with and mentoring by active investigators on the staff. All residents must demonstrate an ability to incorporate age, gender, cultural and ethnic perspectives in research methodology, data presentation and analysis. There must be opportunities to participate in research projects under the supervision of such investigators. There must be adequate space for research and, if appropriate, it should be situated close to the patient care facilities. Residents must become familiar with current literature in the field and develop and formulate a research plan for the required investigative activities that the resident will pursue for successful completion of the program.

10. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

11. Life-Long Learning

All programs must promote development of skills in self-assessment and self-directed life-long learning. To promote this end, the program should provide opportunities for residents to attend conferences outside their own university. Presentations of original work at these conferences should be encouraged. 

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.