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Trends in Off-Service Rotations in Ob/Gyn Residencies Before and After Duty Hour Restrictions

Purpose: To establish trends in off-service rotations in OB/GYN residencies before and after duty hour restrictions.


Background: As co-morbidities in our patient population increases, the skills required of OB/GYNs are changing, we sought to determine the characteristics of off service rotations.


Methods: We searched websites of ACGME accredited OB/GYN residency programs. We collected data on off service rotations: services, number of rotations, and PGY year of rotations. Surveys were emailed to programs regarding off service rotations in 2018 and before duty hour changes in 2003.


Results: 92% (n=259) of programs had information available on off-service rotations, of these, 24% (n=62) had no off-service rotations, 26% (n=67) had 1, 25% (n=66) had 2, 13% (n=34) had 3, 12% (n=30) had 4 or more. The majority (84%) of rotations were in PGY1. The most common rotations were ER (47%, n=122), SICU (24%, n=62), IM (25%, n=66), MICU (9%, n=23). We received 53 responses to the survey (19% response rate). Of those who responded, the most common rotations for 2018 and before 2003 were ER & SICU. The number of programs with SICU rotations remained stable from 2003 to 2018 (43% vs 47%) compared to 1.4 fold decrease in programs with ER rotations. The number of programs with IM rotations decreased 2.5 fold from before 2003 to 2018.


Discussions: Duty hour restrictions have affected off-service rotations. A quarter of all programs have no off-service rotations, with a decrease in ER and IM exposure during residency. This does not reflect the breadth of knowledge required of OB/GYNs today.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Quality & Safety, General Ob-Gyn, CREOG & APGO Annual Meeting, 2019, Student, Resident, Clerkship Director, Residency Director, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, UME, Team-Based Learning,

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Time to Face the Music: Attitudes of Current and Future OB/GYN Residents Regarding the Structure of Residency Training

Purpose: Measure future and current resident perspectives regarding OB/GYN residency training structure and possible future models.


Background: Modifications to the current OB/GYN training paradigm are being considered however the perspective of learner stakeholders on substantial changes has not been measured.


Methods: Medical students invited for OB/GYN residency interviews and residents (PGY1-4) at the University of Colorado, University of Washington, University of California San Francisco, Loyola University, St. Joseph’s Hospital, and Texas A&M in 2017-2018 received a voluntary, electronic survey regarding possible models for restructuring residency training.  Student and resident responses were compared using a chi-square for categorical and two-sample t-test for continuous items. 


Results: Applicants (63%, 280/444) and residents (66%, 101/154) had similar response rates.  Applicants (24%) and residents (29%) reported having concerns about the current structure of residency training.  The ideal residency duration was reported as 4 years by 72% of applicants and 85% of residents.  Lack of gynecologic surgical volume was the most frequently reported concern among applicants (75%) and residents (72%).  Fourth-year tracking (focusing on training aligned with post-graduation career path) was preferred by 90% of applicants and 77% of residents (p=0.002), and 92% among respondents planning fellowship.  Most applicants (68%) and residents (75%) preferred not starting fellowship training after the 3rd year of residency.    


Discussions: The majority of learners surveyed support a 4-year training structure, but likewise support individualizing training in the PGY-4 year. It is imperative that OB/GYN leadership consider this and other feedback from learners when considering modifications to the current OB/GYN training paradigm. 

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, GME, UME, General Ob-Gyn, CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Patient Care, Practice-Based Learning & Improvement, GME, Simulation,

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Targeted Interventions to Improve Resident Well-being

Purpose: To quantify and compare physician well-being and incidence of burnout across residency programs at our institution, emphasizing program-specific and resident-driven interventions


Background: As the national conversation regarding physician well-being evolves, the importance of addressing physician burnout has come to the forefront. Our institution identified moderate levels of burnout across all residency programs, and thus initiated institution-wide efforts. Literature suggests utilizing organization-wide and targeted interventions together has the most significant impact on improving well-being and reducing burnout.


Methods: A Modified Maslach Burnout Inventory (MBI) survey is distributed annually to all residents at our institution. Results from 2015-2018 were analyzed to track changes in burnout scores. All residents participated in institution-wide interventions. Some departments initiated additional resident-determined program-specific interventions.


Results: Mean MBI scores qualified for moderate burnout for all programs across all years. Most programs utilizing institution-wide interventions demonstrated no change in burnout scores; while some, specifically OB/GYN, saw a statistically significant increase in burnout scores (p<0.001). Departments with program-specific interventions demonstrated decreased scores during the same time period.


Discussions: Residency programs utilizing targeted interventions demonstrated marked improvement in burnout scores.  Amongst those without targeted interventions, OB/GYN demonstrated the largest increase in burnout, suggesting differing etiologies of burnout for individual programs, with OB/GYN being uniquely susceptible. We plan to combat this by utilizing a guided focus group of OB/GYN residents to identify drivers of burnout and specific interventions addressing these factors, using the Mayo Well-Being Index to track anticipated improvement. Continued work in evidence-based strategies addressing the challenge of burnout will ultimately produce more engaged physicians.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Osteopathic Faculty, Residency Director, Residency Coordinator, Professionalism, Systems-Based Practice & Improvement, GME,

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Simulation Training for Operative Vaginal Delivery Among Obstetrics and Gynecology Residents: A Systematic Review

Purpose: To evaluate the impact of simulation training of operative vaginal delivery (OVD) on learner technique, operator comfort, and patient-centered outcomes.


Background: Obstetric simulation affords learners opportunities to acquire and to refine clinical skills in a low-stress environment while potentially improving patient outcomes.  However, the effect of simulation on OVD training is less clear. 


Methods: A systematic research protocol was constructed a priori for the conduct of the literature search, study selection, data abstraction and data synthesis.  Electronic databases were searched for educational randomized trials and observational studies assessing OVD simulation training for OBGYN residents.   The educational domains of knowledge, skills and attitudes were evaluated.  The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality.  The review was prospectively registered with PROSPERO.


Results: The search strategy yielded 30,812 articles, with 7 articles eligible for analysis (2 cohort studies, 1 case-control study, 4 cross-sectional studies).  No randomized trials were identified.  Studies demonstrated simulation to improve learners’ skill with forceps placement and generated force during extraction.  While forceps simulation had no change in procedure failure rates, there were significant decreases in rates of maternal lacerations, neonatal injury, and special-care nursery admission.  Only one study evaluated the effect of simulation on provider comfort, demonstrating increased provider comfort with vacuum-assisted delivery. The median MERSQI score was 9.5 (range 9.0-13.5), indicating low-to-moderate quality.


Discussions: The available evidence suggests improvement in technique, comfort, and patient outcomes with OVD simulation, but additional studies are required to further characterize such benefits for both forceps and vacuum.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Osteopathic Faculty, Residency Director, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Quality & Safety, Maternal-Fetal Medicine, General Ob-Gyn,

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Pain Perception in Cervical Biopsy- Variations by Patient and Provider Characteristics in an Academic Teaching Clinic

Purpose: We aim to identify factors which dependably predict patients’ experience of pain during colposcopy, and to evaluate if providers, stratified by level of training, are capable of anticipating procedural pain.


Background: Cervical biopsy procedures, including colposcopy and loop electrosurgical excision procedure (LEEP), are considered non-invasive office procedures and efforts to codify their use emphasize logistics and ability to detect disease. A significant gap exists for mitigating psychological distress and procedural pain. Previous research suggests that physician assessment of procedural discomfort varies by years of experience.


Methods: Patients presenting to an academic gynecology practice for colposcopy with cervical biopsy or LEEP completed Pre- and Post-Procedure surveys (14- and 3-item surveys, respectively), assessing demographics, past cervical procedures, menstrual pain, and anticipated biopsy pain, among other metrics. Post-Procedure surveys assessed a numerical level of pain experienced during the biopsy. The health care provider (HCP) and procedural assistant were surveyed for perceptions of patient pain. Pain scores were evaluated using a 100mm visual analog scale.  Data analysis was performed using Spearman rank correlation, and coefficients for relevant variables were calculated.

Results: 80 patients were enrolled and 62 underwent cervical biopsy. Patients with higher anticipated pain gave higher ratings for post-procedure pain (p=0.024). Women reporting more intense periods predicted and experienced more procedural pain (p<0.001, p=0.058). From the provider perspective, HCPs correctly estimated patients’ pain when compared with the patients’ perceptions (p=0.066). However, only PGY3 and PGY4 OB/GYN residents did so with statistical significance (p=0.014) and PGY1 and PGY2 residents rated lower pain scores (p=0.039).  Male assistants rated pain lower than female assistants (p=0.037). 


Discussions: Providers accurately estimated patients’ pain with variation by years of training. Patient characteristics of age, anxiety, and dysmenorrhea were reliable predictors of pain levels. Our findings suggest that pre-procedure screening of patients may be helpful in directing pain reduction interventions. Additionally, years of experience may provide enhanced pain perception, suggesting future research into pain management training for junior resident physicians and medical students.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Practice-Based Learning & Improvement, GME, CME, Quality & Safety, General Ob-Gyn,

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Evaluating the Rates of Visualized IUD Strings Following Immediate Post-Partum Placement by Ob/Gyn Residents

Purpose: Compare the incidence of visualized IUD strings at follow up by mode of postpartum IUD placement by residents


Background: Immediately postpartum contraception decreases maternal mortality, low birth weight, preterm births and infant mortality.  Missing strings in the setting of a well positioned IUD are more common following postpartum placement as compared to interval placement. This difference may be explained by variation in residents’ techniques for placement in the postpartum setting.


Methods: A retrospective chart review of 306 women receiving immediate postpartum IUD insertion by residents was performed between July 1, 2017-February 15th, 2018.  Variables analyzed included: type of IUD, length of strings prior to placement, method of insertion (applicator, ring-forceps, manual), and delivery type. 


Results: Sixty-two (20%) women attended postpartum follow-up between four to six weeks after delivery.  Eleven of 14 (79%) post-cesarean section and 39 of 48 (81%) post-vaginal delivery had strings visualized.  Insertion via the IUD applicator was associated with significantly more IUD strings visualized at the postpartum visit  when compared to manual insertion (p <0.05) and ring forceps (p <0.05). There was no difference in string visualization between IUD types or after cutting the string to 10 cm. 


Discussions: Mode of placement affects postpartum IUD string visibility. Future research will include developing a protocol for best practices for post-placental IUD placement to improve string visibility at the postpartum visit. Additional research is needed on the low postpartum follow up rate in this subset of the population.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Quality & Safety, Public Health, Contraception or Family Planning, General Ob-Gyn,

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Evaluating Patient Understanding of the “diagnosis of Pregnancy of Unknown Location”

Purpose: To evaluate health literacy in an inner city population among a high risk group of resident-managed patients with a diagnosis of pregnancy of unknown location.


Background: Low health literacy is associated with poor reproductive health outcomes. Previous research on patient compliance with methotrexate protocols as treatment for ectopic pregnancy has shown poor compliance (as low as 10%).  Rates of follow up after diagnosis with pregnancy of unknown location are not well described.


Methods: A chart review was performed to identify of all patients seen in an inner city hospital with the diagnosis of pregnancy of unknown location. Patients meeting inclusion criteria were contacted by phone to survey understanding of the rationale for close follow up. Patients who never followed up after initial contact were excluded.


Results: Eighty seven patients with the diagnosis of pregnancy of unknown location were identified between January – April 2018.  Twenty nine patients met inclusion criteria and twenty agreed to participate. Only 40% of patients correctly explained that there was a concern for ectopic pregnancy. The remaining patients identified their diagnosis as an “abnormal pregnancy” (10%), “miscarriage” (10%); “I don’t know” (15%), and other (25%). 


Discussions: Although the patients surveyed were compliant with follow up, nearly half of the patients showed poor comprehension of their clinical condition. It may be that poor understanding is a major underlying cause for noncompliance for the many patients who never followed up. This should be evaluated in future research.  

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, GME, Quality & Safety, Public Health, General Ob-Gyn,

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Developing a Culture of Continual Process Improvement: A Pilot Kaizen Event in an OB/GYN Resident Clinic

Purpose: To apply Lean Six Sigma concepts and foster a culture of continual process improvement.


Background: Quality improvement is an ACGME Obstetrics and Gynecology Milestones sub-competency. However, the 2016 CLER National Report demonstrated that most residents have little working knowledge of basic quality improvement concepts. In 2017, Lean Six Sigma certification was incorporated into Summa Health’s resident education. To apply these concepts, a resident-designed pilot Kaizen event was executed in the resident clinic.


Methods: Three-day Lean Six Sigma training began in 2017; the pilot Kaizen event was planned for June 2018. Preparation included a brainstorming session and the creation of interprofessional teams and project area assignments. During the half-day event, house staff (residents and attendings) and office staff identified workplace process inefficiencies and implemented solutions within five assigned project areas: scheduling, patient flow, room setup, patient consent and instrument stocking.  Teams then presented their improvements to the larger group and 22 participants completed a post-event survey.


Results: Six (46%) house staff completed Yellow Belt certification prior to the event and all rated the training “very helpful” in identifying and improving processes during the event. Eight (72%) house and 6 (75%) office staff reported the improvements “very positively” impacted the clinic. Seven (54%) house and 8 (100%) office staff responded that the event should be repeated at least biannually.


Discussions: Residents found Yellow Belt training and the Kaizen event to be beneficial and have a positive impact on daily workflow.  These activities will be repeated in the future to foster a culture of continual process improvement.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Osteopathic Faculty, Residency Director, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, GME, Quality & Safety,

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Can I Get a Suggestion? Improv Training to Teach Empathy in Ob/Gyn Residents

Purpose: To examine improvisation training on Ob/Gyn resident empathy


Background: Physician empathy is associated with improved patient outcomes. Empathy training is effective in physicians, and many models exist. However, no studies have examined whether the improvements are sustained over time. Our primary aim is to determine whether an improv workshop is an effective tool to deliver empathy training. Our secondary aim is to determine whether that effect is sustained over time.


Methods: This is a prospective study of Ob/Gyn residents. Validated empathy surveys were administered 1 week prior to empathy training, immediately after training and 1 month later. Improv games were used in conjunction with empathy training during the intervention. Paired t-tests and McNemar’s were used to compare statistical differences at each post-intervention assessment compared to pre-intervention.


Results: 22 residents participated. Empathy scores increased immediately after training (mean=113 vs 120, p=0.03), but were not sustained 1 month later  (mean=113 vs 117, p=0.11).  Residents reported that the workshop positively impacted their delivery of care both immediately (mean=3.5 vs 4.6, p <0.001) and 1 month later (mean=3.5 vs 4.1, p=0.04).


Discussions: Using improv comedy to delivery empathy training is associated with improved empathy scores in Ob/Gyn residents, but this improvement gravitates back to baseline over time. Residents report that the improv workshop was effective at improving empathy, even up to one month later.   

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Interpersonal & Communication Skills, GME, Simulation, Team-Based Learning, CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Assessment, Lecture, Maternal-Fetal Medicine, General Ob-Gyn,

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Assessment of Knowledge Gain and Retention with Multidisciplinary Simulation of Maternal Cardiac Arrest

Purpose: Our objective was to assess the improvement and retention of learner knowledge in managing cardiac arrest in the pregnant patient using multidisciplinary simulation training.


Background: Simulation can address challenges facing education, including patient safety, work hours, and decreased patient volume. Simulation is invaluable for rehearsing rare emergencies. There is data showing that simulation improves knowledge; however, there is limited data on the retention of this knowledge, especially for rare events unlikely to be encountered in practice.


Methods: We developed a simulation curriculum for the resuscitation of a pregnant patient who experiences cardiac arrest.  We created a 10-question test that emphasized the points of the didactics. Participants, including residents and nurses, took the test before and after the training and received electronic notification 3 months after their training to take the test again.


Results: Over 9 months in 16 sessions, we trained 90 learners: 31 OB/GYN residents, 5 anesthesiology residents, and 54 labor and delivery nurses. For the OB/GYN residents, the mean scores (out of 10) were 5.4 for the pre-test, 8.8 for the post-test, and 7.9 for the 3-month test. Post-test scores were significantly increased from the baseline (p < 0.0001). The decrease by < 1 point at 3 months was significant (p = 0.006) but still a passing score.


Discussions: We demonstrated a significant knowledge improvement for managing maternal cardiac arrest among OB/GYN residents using simulation. The knowledge was largely maintained 3 months later. Future research including longer intervals for reassessment will aid educators in optimizing training intervals for similar uncommon emergencies.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Osteopathic Faculty, Residency Director, Patient Care, Medical Knowledge, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, CME, UME, Assessment, Simulation, Team-Based Learning,

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RWJBarnabas Health System: System-wide Obstetrics Collaborative. the Clinical, Research and Teaching Implications and Benefits

Purpose: The eight perinatal hospitals in the RWJBarnabas health care system, with ~25,000 deliveries annually, utilize bi-monthly interdisciplinary meetings to update all sites on quality outcomes, evidence-based best practice, research initiatives and education. This model trains Ob/Gyn residents, as well as the entire health care team on an overall approach to maternity care.


Background: In 2015, the perinatal practices at each of the hospitals were functioning  independently, which resulted in variation in clinical practice and outcomes, scant research and different approaches to patient care models for resident education. The RWJBarnabas Health leadership recognized the benefit of a systematic approach to optimize this service and to best utilize the strengths and experience of all its health care obstetrical providers. This would also translate into a stronger model to enhance resident education. This approach was promoted by Dr. Asch who stated in the September 23, 2009 JAMA that the best function Ob-Gyn attendings in NY and FL came from residency programs that emphasized the best-practice of evidence-based medicine in a culture of patient safety. Thus, creating a win-win scenario for quality patient care and resident education.


Methods: Supported by corporate leadership the RWJBarnabas Health Ob Collaborative was initiated. The obstetrical department chairs and the Ob nursing administrators from each site met bi-monthly to review pooled data, develop clinical bundles and institute standards of practice at each medical site based on a common EMR. From the pooled data, clinical practice changes and research ideas were also introduced that the health care team and the learners could initiate/participate in.


Results: This model has been very effective in improving patient satisfaction, quality and patient safety. This is especially notable in Pain Management, the reduction of SSI and C/Section rates and increased TOLAC/VBAC rates. In addition, medical education for residents includes utilization of standardized evidenced based practices developed by the collaborative across all the sites. The specifics of the data collection will be discussed.


Discussions: Not only have there been benefits in the core missions of clinical care, teaching and research, but this model has inspired a joint effort by others within the health care system to further improve outcomes through collaborative educational venues.


Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Systems-Based Practice & Improvement, GME, CME, Quality & Safety, General Ob-Gyn,

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Multidisciplinary Severe Maternal Morbidity Reviews Can Teach the Clinical Learning Environment Review Focus Areas of Patient Safety and Quality

Purpose: To describe a resident focused multidisciplinary severe maternal morbidity (SMM) review program.


Background: The Joint Commission defined SMM as peri-partum blood transfusion of 4 units or admission to ICU and recommends multidisciplinary reviews to determine opportunities for improvement in care


Methods: An ongoing process detects cases of SMM with root-cause-analysis performed if case qualifies as a sentinel event. Data is extract and presented quarterly to, a multidisciplinary committee to determine contributory factors, opportunities to alter outcome, best practices and recommendations.


Results: Forty-five SMM cases were reviewed from 1/15 to 6/17 by residents 67%, fellows 9%, nurses 7%, and MFM faculty 17%. Opportunities to alter care were determined to be strong in 9% and possible in 62%. System/provider   could alter outcome in 53% while the patient could have altered outcome in 33% of cases.  Outcomes could have been altered by contraception/sterilization in 13%, patient compliance 11%, early prenatal care 20%, referral/consultations 9%, improved documentation 7%, early recognition 33%, team communication 4% and management 31%. Good practices recognized included multidisciplinary teamwork/communication 60%, evidence-based response 36%, timely recognition 24%, documentation 20%, quality obstetric care 22%, timely referral 13%, expertise care 9%, and patient-centered-care 7%. Strong opportunity to alter outcome was present with hypertensive crisis (p=0.026). Significant opportunities to alter outcomes were: preterm SMM cases by contraception/sterilization (p=0.036); patient compliance in Medicaid insured (p=0.01) and younger women (p=0.04). Transfusions were recognized for the good practice of timely recognition (p=0.045).


Discussions: Residents’ involvement in SMM reviews can determine care improvement opportunities and provide training on safety and quality.

Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Quality & Safety, Public Health, Maternal-Fetal Medicine,

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Do Entering Ob Gyn Interns Understand How to Navigate Today\'s Complex Health Care Systems?


Purpose: We sought to determine the baseline QI/PS and population health knowledge for new obgyn interns in comparison to new interns from other specialties.


Background: The ACGME requires residents to be trained in practice-based learning and improvement(PBLI) as well as systems-based practice(SBP). In an effort to establish a formal curriculum for graduate medical education, several residencies at our institution are piloting a novel QI/PS/population health curriculum that will ensure residents are educated in SBP and PBLI.


Methods: Baseline knowledge of all new interns was assessed with the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R), a self assessment questionnaire and a Population Health Knowledge Application tool (POPKAT). Mean score differences for each intern group were measured with ANOVA.  Interrater relability was assessed using cohen’s k.  P


Results: Preliminary assessments of incoming obgyn interns compared to all new interns at our institution suggests they are equally familiar with the principles of QI (PBL1, PBL2 level 2) and PS (SBP level 2) but have a slightly higher baseline knowledge of population health (SBP2 level 3).  Interrater reliability for total scores and individual categories on the QIKATR and POPKAT was consistent.


Discussions: Understanding baseline knowledge of new interns can help PDs obtain a baseline assessment of entering residents; SBP and PBLI. After implementation of a QI/PS/population health directed curricula, resident acquisition of knowledge for SBP and PBLI can be quantitated. A quantitative holistic assessment of knowledge utilizing validated knowledge tools will give programs an opportunity to evaluate the impact of their QI/PS/population health focused curricula.

Topics: CREOG & APGO Annual Meeting, 2018, Resident, Faculty, Residency Director, Medical Knowledge, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Quality & Safety, General Ob-Gyn,

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An Analysis of the Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate Among Practice Groups in a High-Volume Community Teaching Hospital

Purpose: Data regarding factors that influence the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate is limited. This study’s purpose was to compare the NTSV cesarean rate across practice groups at Virginia Hospital Center (VHC).


Background: VHC is a high-volume community teaching hospital in Arlington, Virginia. Labor and Delivery is managed by different practice groups: hospitalists with resident coverage, hospitalists without resident coverage, and private attendings. Hospitalists are attending physicians who provide 24-hour in-house management of laboring patients, whereas private attendings are only expected to be in-house for patients in active labor.


Methods: This was a retrospective cohort study of all NTSV pregnant women who delivered at VHC from 2014 to 2016. Chi-square tests were used to determine whether NTSV cesarean rates were significantly different over time and across different practice groups.


Results: There were 2,339, 2,090, and 1,673 NTSV pregnancies in 2014, 2015, and 2016, respectively. The NTSV cesarean rate decreased significantly by 30.8% (31.8% in 2014, 27.7% in 2015, and 22.0% in 2016,  0.01). The NTSV cesarean rate was significantly lower with hospitalists, with the lowest rate in the hospitalists with resident coverage (NTSV rate of 19.8% for hospitalists plus residents, 25.7% for hospitalists without residents, 30.3% for private attendings,  0.01). All groups decreased their NTSV cesarean birth rate over time, with significant decreases in the hospitalists without residents and private attending groups ( 0.01).


Discussions: Having 24-hour in-house attending coverage is associated with lower NTSV cesarean rates. Resident involvement may also be a factor in lowering this rate.


Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Residency Director, Patient Care, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Quality & Safety, Team-Based Learning, General Ob-Gyn,

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Growing the Next Generation of Professionals: Utilizing Obstetric Simulation in the Women\'s Health Course as a Foundation for Inter-Professional Education and Collaboration

Objective/background: Inter-professional teamwork and communication are

essential for optimal patient care. A collaborative and creative OBGYN inter-professional event

involving both Liberty University’s College of Osteopathic Medicine and School of Nursing has

been uniquely crafted and tested. During the second year women’s health course, medical

students engage in obstetrics simulation alongside nursing students. This interaction facilitates

a safe level of uncertainty in the learner concerning simulation, clinical scenarios, and

professionally interfacing. The facilitated panel discussion concluding the event incorporates

self-assessment and team debriefing. The goal is to encourage superb communication, to

address the development of a student’s emotional quotient, and to provide the early

foundation for healthy interactions with nurses.

Worskshop Agenda:

1. (25 min) Review: event background, importance of medical simulation, effective

communication tools like TEAMSTEPPS, faculty and student learning objectives.

2. (10 min) Orient all learners to the patient (Lucina simulator), the “delivery room” and

the different team member roles. A subgroup of volunteers is given lanyards with assigned


3. (10 min) Run a delivery simulation with role playing volunteers.

4. (5 min) Observers complete a self-reflection handout.

5. (20 min) Panel discussion involving a facilitator, the volunteer learners, and our audience.

Our “Lucina patient voice” will also provide feedback to the volunteers on patient

communication skills.

Interactive Component: 3 - 5

Take Home Product: A toolkit including everything needed to reproduce the event: learning objectives, “roles” of learners, standardized simulation scenarios (2), observer reflection

handout, and questions to facilitate an effective panel discussion

Keywords: Inter-professional, simulation, collaboration

Topics: Faculty Development Seminar, 2019, Clerkship Director, Osteopathic Faculty, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, UME, Simulation, Team-Based Learning,

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Reflecting on wipeouts: a M&M Healthcare matrix to teach health systems thinking


Morbidity and mortality (M&M) conferences are an opportunity to identify systems issues important in

patient care and to train our learners to analyze care using this lens. In 2016, to better teach health

systems analysis, our program adopted the Healthcare Matrix (Bingham, 2005) into our M&M


The Matrix asks the learner to assess the patient care (considering medical, patient, and health systems

factors), to determine whether care met the IOM Health Care Quality Domains (i.e. Safe, Timely,

Effective, Efficient, Equitable, Patient-Centered) and then to suggest improvements. This Matrix is an an

evidence-based educational intervention and represents a unique way to introduce learners to health

systems thinking while fulfilling APGO Medical Student Objective I.6 and allowing evaluation for the

ACGME Quality Improvement milestone.

Our objective is to teach attendees to use the Matrix and to share our experience since implementation.


We will present the Matrix and several demonstration cases and how the analysis generates

opportunities for institutional improvement <30 min>. Audience members will then be given an

opportunity to analyze two cases <30 min>. We will conclude with a review of our experience in both

learner education and evaluation <15 min>.


We have created two demonstration cases. We will ask the audience to work in groups to review these

and complete the matrix themselves to identify where systems issues might have occurred.


We will share the matrix both in print and as a Powerpoint for participants to incorporate into their



Health Systems Science, Systems-Based Practice, Practice-Based Learning and Improvement

Topics: Faculty Development Seminar, 2019, Clerkship Director, Systems-Based Practice & Improvement, GME, UME, Quality & Safety,

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Mind over Bricks: Finding Your Team’s Inner Sunshine with LEGO® Elements

Objective/Background: In the realm of business, whose mantra has been “all

work and no play,” the LEGO® SERIOUS PLAY® (LSP) tool has been used to enhance innovation and

performance, which may have similar effects in the worlds of medicine and academia. The LSP

methodology deepens the reflection process. This tool encourages the culture of participation by

flattening the hierarchy through narrative play. By creating the cultural identity of an organization,

involved participants have a shared understanding of their work or their goal. Cultural constructs, such

as sports and the arts, can create a positive social environment that impacts not only the morale of the

population, but their work ethic. Play, normally the antithesis of work, has been suggested to have

emotional, social, and cognitive benefits.

• Workshop Agenda: The workshop will introduce the concept of LSP, as evidenced in multiple

disciplines. Simultaneously, the participants will have a hands-on experience with the process itself. The

workshop will have multiple LEGO building challenges that follow this basic format, with each challenge

addressing a more advanced or abstract question to extract deeper personal meaning and values:

Question, Building, Sharing, and Reflection.

• Interactive Component: Participants will partake in the actual process of LSP, learning and

experiencing first-hand how narrative play encourages teambuilding and leadership development.

• Take Home Product: Participants will receive a toolkit that will include an open-source manual

to the LSP methodology via hyperlink, an illustrated example of a teambuilding workshop design, and a

handout with additional resources.

• Keywords: interprofessional, teambuilding, communication

Topics: Faculty Development Seminar, 2019, Student, Resident, Faculty, Clerkship Director, Residency Director, Professionalism, Interpersonal & Communication Skills, GME, UME, Quality & Safety, Team-Based Learning,

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Ring the Alarm-Interdisciplinary Obstetrical Emergency Drills

Participants will learn how to involve medical students as leaders in

obstetrical emergency drills on Labor and Delivery. We will discuss identifying obstetrical

emergencies to be used as drills for interdisciplinary educational training involving physicians,

nurses and medical students. We will review how to increase medical student involvement with

planning and leading emergency drills. Interdisciplinary drills can be used to identify areas of

improvement in patient safety and quality and enhance medical students’ understanding of

systems based practice.

Topics: Faculty Development Seminar, 2019, Clerkship Director, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, UME, Simulation, Quality & Safety, Team-Based Learning,

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Avoiding Lava and Volcanic Ash: Protecting Students from Disruptive Behavior and Mistreatment

Objectives/Background: The Joint Commission has defined unprofessional/disruptive

behavior as behaviors that undermine the culture of safety in healthcare settings. Specifically, these

behaviors create environments that can lead to decreased quality of care and patient safety, poor

communication, and increased medical errors. As educators, we are often the first to be notified about

incidents of disruptive physician behavior and/or student mistreatment and should have a framework to

mitigate the effects of unprofessional conduct and break the cycle of learned disruptive behavior in


Workshop Agenda: We will review

- how disruptive behavior violates Interpersonal/Communication Skills and Professionalism core


- how to identify other contributing factors that can produce unprofessional behavior

- the impact that disruptive behavior has on the healthcare environment and on the learner

Participants will then work on cases in small groups before reporting management strategies to the

larger group

Interactive Component: Participants will work in small groups on cases highlighting disruptive physician

behavior and/or medical student mistreatment perpetrated by either an attending, resident or another

medical student. Small group members will together to identify the disruptive behavior, contributing

factors, and formulate a strategy for addressing disruptive behavior with both physician and student.

Each group will then report to the large group on their findings and management strategies.

Take Home Product: Participants will be confident in identifying disruptive behavior and/or student

mistreatment. They will return to their institutions with a strategic framework for addressing disruptive

behavior to protect the learner from mistreatment.

Keywords: mistreatment, disruptive behavior, professionalism

Topics: Faculty Development Seminar, 2019, Faculty, Clerkship Director, Professionalism, Interpersonal & Communication Skills, UME, Quality & Safety,

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It’s right in front of you: Using Interprofessional Education to enrich your current learning environment.

Objective/ background: This workshop will empower the participants with information
and tools to create, implement, and evaluate Interprofessional Collaboration (IPC)/ Interprofessional
Education (IPE) experiences in their respective learning environments using current clinical
collaborations. We will encourage learners to “look through a different lens,” using existing clinical
experiences that are not being recognized or structured as IPC/IPE. This workshop will breakdown the
curricular components and send participants home with the foundation to engage students and
colleagues in IPC/IPE thereby enriching the learning environment, improving communication and overall
patient safety.
Workshop Agenda: In this interactive workshop, we will define and discuss the importance of a
deliberate IPC/ IPE curriculum, as well as take participants through the steps of planning, developing,
and evaluating an IPC/IPE curriculum via small group exercise and large group discussion. We will also
communicate and discuss potential barriers to development and implementation.
Interactive Component: Participants will: 1. Work in small groups to develop a basic IPC/IPE planned
experience and present to large group for discussion. 2. Work in small groups to develop goals/
objectives for IPC/IPE. 3. Discuss in large groups development of an evaluation tool for IPC/IPE
curriculum and clarifying the intended evaluation target(s).
Take Home Product: Participants will receive a toolkit for creating, implementing and assessing an
IPC/IPE curriculum. The IPC/IPE curriculum will serve as a model for engaging, understanding roles, and
communicating with interprofessional students and colleagues promoting a combined teamwork
approach to patient-centered healthcare.

Topics: Team-Based Learning, Quality & Safety, UME, Interpersonal & Communication Skills, Systems-Based Practice & Improvement, Professionalism, Patient Care, Clerkship Director, Faculty, Resident, Student, 2018, Faculty Development Seminar,

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