Interdisciplinary Prenatal Group Visits as a Significant Learning Experience

Editor's Note: The online version of this article contains the interdisciplinary evaluation of resident form and the resident satisfaction survey used in this study.

The New Hampshire Dartmouth Family Medicine Residency received grant funding to transform aspects of patient care and resident education. Using the Accreditation Council for Graduate Medical Education (ACGME) competencies1 and the Future of Family Medicine report2 as the structure, prenatal care was one aspect targeted for educational innovation. The goals were to enhance resident competency-based skills, specifically in facilitative leadership, while providing patient-centered care for pregnant women and their partners.

Group visits for various patient populations are effective for providing high-quality care.3,4 They provide an excellent educational method for competency-based training5 in interdisciplinary team care.6 Although many skills are acquired, the focus is on developing a facilitative teaching style within a patient group setting, specifically through the use of interdisciplinary coaching. The facilitative style, helping patients “run the group,” differs from other models where the leader is the focus. Skills such as effective interprofessional team collaboration, facilitated instruction, patient empowerment, and education are important in competency-based, patient-focused care.

The authors implemented prenatal group visits to provide quality interdisciplinary patient care, innovative experiential learning, and transferable skills to residents.

Efforts to redesign prenatal care education for residents centered on key improvement aims: (1) a “whole-person” orientation to care; (2) relationship building through continuity; (3) facilitating and working within broad interdisciplinary teams; (4) integration of specialists, and institutional and community resources; and (5) addressing quality and safety. Teaching these skills to residents helps prepare them for effective clinical team leadership and membership.

A significant initial step in the redesigned process was promoting understanding and gaining the support of the residency and clinical practice leadership. The champions facilitating this change were a family physician, a prenatal nurse coordinator, and members of the Maternal-Child Health education team. While researching different approaches to educating residents providing group prenatal care, the Centering Pregnancy Model (CPM) was identified. The CPM has been studied, with positive clinical outcomes.7–9 This model correlates well with the climate of transformational practice change suggested by the Institute of Medicine. Our group visit care model was implemented in the residency training at the Concord Hospital Family Health Center clinical practice.

To gain CPM model skills, the project champions attended the 2-day CPM training program through the Centering Healthcare Institute Inc.10 A quality improvement team was initiated, with a family physician, the prenatal nurse, a resident, a medical assistant, a receptionist, and a behavioral health counselor meeting every other week for 6 months. The group worked through issues of scheduling, patient recruitment and retention, educational goals and objectives, collaboration with the multidisciplinary team, and patient confidentiality. Prior to full implementation into resident education, a 6-month pilot series was completed.

From the pilot group, patient suggestions about clinical care and resident suggestions about educational objectives were incorporated.

Prenatal patients were recruited from the residency clinical practice. The practice group consisted of one faculty physician, a prenatal nurse, a behavioral health clinician, patients, and their chosen support staff. Two resident “practice partners” were assigned to each group of 6 to 8 pregnant women with similar estimated delivery dates. Residents received a 2-hour orientation focused on patient-centered care and a “facilitated learning” style of teaching. This included the basics of the CPM, evaluation criteria used to evaluate residents' facilitation skills, and an outline of key skills for group care management. Each resident was the primary care provider for some patients, providing individual care until 20 weeks' gestation. After that, all routine care was provided within the group.

The prenatal group sessions were 2 hours long. Patients were encouraged to bring a support person. Upon arrival, patients weighed themselves and checked their own blood pressure. A resident examined each patient individually on a mat in the group room. The attending physician was present, which facilitated immediate individualized precepting. Once the medical assessments were completed, the group began discussion in a circle. The interactive sessions focused on pregnancy, birth, and parenting issues, with participants guiding the dialogue. Residents facilitated the discussion with support from the family physician, behavioral health counselor, and nurse clinician. After the patients departed, the multidisciplinary team discussed biopsychosocial issues that surfaced and incorporated them into individualized care plans.

Residents received feedback about their facilitation skills. In a final session, a behavioral health clinician provided a summative evaluation of resident skills. One or both of the resident facilitators attended the births of the patients' infants. The group members reconvened with their babies and the team to share birth stories.

Third-year residents were chosen for the significant learning experience11 because they are generally comfortable with their level of knowledge about pregnancy and prenatal care. This allowed them to focus on facilitation skills and encourage patients to lead the discussion. The facilitated teaching format challenged residents to “let the question circle around” until misconceptions were expressed. Through this process, participant comprehension levels were assessed. As part of a 6-month longitudinal curriculum, the program promotes resident development of transferable skills, which include social and medical risk assessment, facilitative leadership, clinical time management, development of multidisciplinary care plans, and appropriate medical knowledge.12 

The project met the definition of a quality improvement study and was deemed exempt from the Concord Hospital Human Investigation Committee's purview.

During the 18-month study period, 6 distinct groups of 6 to 8 patients each met for a total of 8 to 9 sessions. A family physician, nurse clinician, and behavioral health clinician supervised 2 resident facilitators for each 6-month series. The authors explored the impact on resident skills and satisfaction, on the patients, and on the interdisciplinary team.

Facilitative leadership development was the unique aspect of this innovation and was the focus of the resident evaluation. Initially, residents were oriented to didactic compared with facilitative teaching styles. The behavioral health clinician observed residents and gave formative feedback following each session (Attachment 1). The observed outcome behaviors are described in table 1. At the final session, skills in facilitating and group leadership were independently assessed and recorded. Summative evaluations were reviewed with the resident. These behaviors are the benchmarks used to indicate increasing skill in this area.

Second, the skills needed to conduct group visits were observed and measured within the ACGME competencies (table 2).

In addition, the resident pair often learned medical information about pregnancy, breastfeeding, birth, and parenting from each other. Patient participation guided the educational focus.

Residents observed the behavioral health clinician's skill in dealing with difficult subjects. They also learned about housing, nutrition, and dental care resources available for pregnant women, allowing residents to further assist with these issues.

Residents completed a satisfaction survey (provided as online supplemental material) and answered qualitative open-ended questions about the significant learning experience. One hundred percent expressed satisfaction with the experience and supported its inclusion in the ongoing curriculum. Qualitative observations also confirmed the residents' positive experience. One resident described it as “more comprehensive,” with “more ability to connect and support patients.” Another stated this approach “normalizes” pregnancy, and de-emphasizes the medical aspects without sacrificing quality. Others enjoyed having the time to educate participants about pregnancy-related topics that would not have surfaced in a shorter one-to-one 10-minute office checkup. Residents noted that social situations shared in the group provide important information to the team providing prenatal care. Another observed that groups gave a “more complete picture, more patient oriented.” Education benefits for residents include effective team collaboration using a systems approach, with exposure to physician, nurse, and behavioral health clinician perspectives. Based on the behavioral health clinician's observations, they also clearly demonstrated enhanced skills in facilitative group leadership.

Group visits offer an effective and engaging venue for residents to learn a variety of transferable skills. Residents acquire an enhanced perspective on pregnancy care, facilitative leadership, and team collaboration. The interdisciplinary team gained experience in explicit collaborative teaching for resident physicians. For patients, “normalizing” pregnancy through group interaction and enhanced social support proved to be extremely beneficial. The positive impact on the team, residents, patients, and the system validate this as a strong component of competency-based education and patient-centered care. Other residency programs can easily adapt this model to diverse patient groups in many medical specialty areas.

The initial variation in resident skill level and engagement became more uniform over the duration of the group sessions. Residents commented that consistent guidance from the interdisciplinary team supported both patient care and their education. Factors that may affect generalizability to other institutions include variation in organizational support, availability of multidisciplinary team members, sufficient number of patients, and support for a group approach to prenatal care.

There are implications for further study. These include long-term use of facilitation skills, evidence of effective collaboration, and whether incorporation of group visits continues in postresidency practice. Overall, the intervention can be very practical because it addresses both resident education and patient care simultaneously. Once the infrastructure is generated and incorporated into resident education and clinical workflow, the model can easily be sustained. As outlined, there are multiple benefits for all constituents involved. It creates unique opportunities for residents to teach and learn from patients, the interdisciplinary team, faculty, and each other.