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Tuesday Jun 16, 2020

Lessons in Negotiation: Saving OB Training During Pandemic

In mid-March, when Washington was under a stay-at-home order and our county had more than half of the state's 2,469 confirmed COVID-19 cases, the Department of Obstetrics and Gynecology's leadership wrote to directors of the OB curriculum at our three family medicine residencies. Effective immediately, our residents would not be allowed on the labor and delivery floor due to concerns regarding COVID-19 transmission and the impending surge.

[newborn wearing id bracelet in hospital]

The logic: In a single continuous shift, family medicine residents care for hospitalized in-patients as well as obstetrical patients, and they might spread COVID-19 between these groups. Residents may also see patients who are COVID-19-positive in clinic and then come to the hospital. Moreover, personal protective equipment was at a premium.

Our hospital in Seattle is a major center for obstetrical care, with more than 7,000 deliveries per year. It is home to 87 residents from three family medicine residencies with track records of producing full-spectrum family physicians, including many who provide prenatal and obstetrical care.

Withholding resident obstetrical training during COVID-19 would be catastrophic. Residents would lose a month or more of dedicated time to learn obstetrical care. Patients would lose resident doctors, who support attendings by navigating the important intricacies of the inpatient system, including EHRs and clinical workflows. Residents are also able to provide timely, culturally sensitive care. Some patients would lose their continuity resident doctor at the time of delivery.

"Getting to Yes," the celebrated study of negotiation, presents four fundamentals of principled negotiation:

  • separate people from the problems;
  • focus on interests, not inflexible positions;
  • generate options for mutual benefit; and
  • use objective criteria.

In their attempt to respond quickly to COVID-19, OB/Gyn department leaders made decisions based on the important interests of reducing patient and personnel exposure and preserving PPE, but they did not include other critical interests to generate options of mutual benefit.

Perhaps the fifth and most important aspect of negotiation is institutional power. One of our residency program directors, who is also the department chief of family medicine, communicated clearly: Any stakeholder meeting about obstetrical care that does not include family medicine is not a complete stakeholder meeting.

Before residents could be taken off L&D, faculty and program directors from the three residencies communicated using the principles of negotiation. Less than 24 hours after sending out their initial e-mail, OB/Gyn department leadership readily agreed to a more complete stakeholder meeting that included family medicine.

We identified the following common interests:

  • support social distancing on the labor deck,
  • consolidate care to prevent disease transmission,
  • conserve PPE and
  • move patients through triage quickly to reduce exposure time.

Our residencies also emphasized an interest in providing irreplaceable resident education.

This multidisciplinary group then generated a series of options for the mutual benefit of all involved, including patients. The outcome was that family medicine residents would remain on L&D, with numerous changes for the duration of the COVID-19 surge.

We separated the services for obstetrical patients and other hospitalized patients. The attending call groups from the two largest family medicine residencies were combined, residents no longer came for continuity deliveries and nonsurgically trained family medicine physicians stopped scrubbing in for operating room deliveries. During day shifts, there were two (instead of three) obstetrical residents. One resident was a PGY-1 caring for up to six laboring patients at a time, and another was a PGY-2 resident based in triage. In the event that the service was too busy, these residents had a back-up resident available at home.

Our immediate transformation received significant acknowledgement from OB/Gyn department leadership as an example of rapid adaptation and compromise for patient safety and resident education.

For residents, the weeks that followed these changes were intense. COVID-19 brought a pervasive anxiety and the new challenge of supporting our patients who could not receive care from their continuity doctors.

During this time, we saw a patient who we will call Teresa -- a 30-year-old presenting with nonspecific back pain. She had experienced extensive emotional trauma during her first pregnancy. A month before we saw her, Teresa's sister had died from cancer. A number of months before that, another sister of hers was killed by gangs in Central America.

Teresa was not in labor, but something still seemed off. After a careful assessment by a doula and a resident who spoke Spanish, we found that Teresa had a symptomatic kidney stone. She was dehydrated, and we admitted her for IV fluids and connected her with extensive social support resources. Our team eventually cared for her again when she returned to the hospital with preeclampsia with severe features.

At every step, residents made culturally sensitive clinical decisions, actively learned obstetrical management and served as advocates to reduce the barriers that non-English-speaking immigrants often face.

With Seattle's tentative success in responding to the pandemic, our hospital is returning to its pre-COVID family medicine resident structure. During this negotiated arrangement, we preserved resident education while partnering with our Ob/Gyn colleagues to address their concerns and maintained patient safety.

The education preserved during this stretch will influence the scope of practice of the residents affected, allowing them to provide obstetrical services for patients like Teresa. This is a future we are grateful to have preserved.

Devesh Vashishtha, M.D., M.S., is a second-year family medicine resident at Swedish Family Medicine Residency at Cherry Hill in Seattle and a former resident member of the AAFP Commission on Quality and Practice. You can follow him on Twitter @dmvashishtha(twitter.com) and visit his website.(www.deveshvashishtha.com)

Mary Puttmann-Kostecka, M.D., M.Sc., is the maternal child health director at Swedish Family Medicine Residency at Cherry Hill and a clinical assistant professor at the University of Washington School of Medicine.

Posted at 09:10AM Jun 16, 2020 by Devesh Vashishtha, M.D., M.S., and Mary Puttmann-Kostecka, M.D., M.Sc.

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