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Using Student Interest Groups to Train Medical Students to Lead

Purpose: Medical student interest groups (SIG) serve as students’ introduction to medical specialties. The student leaders of these groups are driven and demonstrate leadership ability early in their careers. Connecting these student leaders with young physicians can improve specialty matriculation, leadership among new residents, and foster mentorship in the organization.

 

Background: The American College of Obstetrics and Gynecology (ACOG) has leadership positions for residents, however, less for medical students, who are encouraged to participate in meetings rather than engage.  SIG leaders have not been a focus of recruitment for ACOG, however, these students are primed to become leaders in ACOG upon completion of medical school. 

 

Methods: Prior to the 2017 ACOG’s Annual Clinical and Scientific Meeting, we contacted medical students registered for the meeting to identify any SIG leaders. A meeting was arranged for student leaders to meet with several national representatives. The group of 17 students was introduced to the structure and benefits of the organization and given training for optimizing SIG function and efficacy. Through our survey, all students appreciated the information about ACOG, ideas on how to improve their SIG, and resources available through ACOG, rating it as just the right of information or stated they would like to hear more.

 

Results: Sixty four percent were planning on establishing a generic SIG email to improve communication with ACOG while 23% already had one. When asked if they felt prepared to take the information back to their SIGs, all students answered positively. Only three of the 17 students had read a leadership book and all students said they would love to participate in a more formal leadership training. 

 

Discussions: Medical student leadership represents a natural group to become future ACOG leaders. Given the barrier of contacting the SIG leaders, we recommended establishing a generic email address for groups (eg OBGYNSIG@***). All students wanted leadership training and to be involved in ACOG. In conclusion, medical SIG leaders are an enthusiastic and untapped resource who will become our colleagues. Connecting with student leaders at organizational meetings secures future leadership and continued engagement after medical student graduation. 

Topics: CREOG & APGO Annual Meeting, 2019, Student, Faculty, Clerkship Director, Clerkship Coordinator, Professionalism, Systems-Based Practice & Improvement, GME, Independent Study,

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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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Transgender Healthy Care: On-line Survey of Physician Knowledge and Comfort

Purpose: To evaluate OB/Gyn provider knowledge and comfort with transgender health care

 

Background: Transgender and gender non-conforming patients (TGNC) are an underserved population that often encounters inadequate or ‘unsafe’ clinical care. Education regarding TGNC patient care has traditionally been minimal, contributing to gaps in Ob/Gyn care for many of these individuals, including transgender men.

 

Methods: An IRB approved, anonymous online non-validated survey was emailed to 130 APGO program coordinators to distribute to their Ob/Gyn faculty and post-graduate learners. Questions addressed included years of practice, experience with TGNC patients, provider comfort, and TGNC education.

 

Results: One hundred and sixty four surveys were completed and an additional ~50 were opened but no information was provided. Of the 164 completed surveys, 76.3% of participants reported less than 5 hours of TGNC specific healthcare education, despite the fact that 75.7% of responders had cared for at least one TGNC patient. Overall most respondents felt comfortable/very comfortable (79.8%) caring for this population. No correlation was found between years in practice and overall provider comfort caring for TGNC patients.  Major obstacles reported by participants included concern for patient comfort, appropriate language, and lack of sufficient clinical education for both providers and support staff

 

Discussions: These data suggest that enhanced TGNC clinical education for the entire health care team is warranted.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Professionalism, GME, Advocacy,

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Training Residents to Place Immediate Postpartum LARC: An Update Among U.S. Residency Programs

Purpose: To survey U.S. Obstetrics and Gynecology (Ob/Gyn) Residency Programs on immediate postpartum (IP) long-acting reversible contraception (LARC) training and challenges.

 

Background: In 2016, the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion supporting IP LARC. Growing evidence describes provider/hospital barriers which hinder IP LARC provision. We hypothesize similar difficulties have prevented programs from implementing training.

 

Methods: We distributed an electronic survey addressing IP LARC training to 273 U.S. Accredited Council for Graduate Medical Education (ACGME) Ob/Gyn Residency Program Directors from the 2017-2018 Academic Year. Data analysis was performed with chi-square and Fisher’s exact test.

 

Results: Of 86 programs that participated, residents were trained in the immediate postpartum period to place implants in 54 programs (63%) and to place intrauterine devices (IUDs) in 52 programs (60%).

Prior to 2015, only 20% of the programs were training their residents to place IP IUDs. Thirty-one percent of eligible programs initiated training in 2017. The majority of programs focused training interns (98%). Patient/provider convenience motivated 46% of programs to offer IP LARC and compliance motivated 27%.

The two barriers most frequently encountered, regardless of program training status, were problems with billing and compensation for services (61%) and the pharmacy (33%).

Programs that reported primarily seeing patients with insurance, either private or Medicaid, were more likely to have IP IUD training compared to programs seeing mostly indigent/uninsured populations (p<0.05).

 

Discussions: IP LARC training has increased since the ACOG Committee Opinion was published, however many programs are still facing challenges with implementation, affecting resident training.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Systems-Based Practice & Improvement, GME, Public Health, Advocacy, Contraception or Family Planning,

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Residents Express Emotional, Social and Physical Stress in the Clinical Learning Environment

 

Purpose: To evaluate OBGYN residents’ perceptions of personal wellness in relation to their clinical learning environment

 

Background: Resident wellbeing is a significant issue affecting our future physicians’ abilities to fulfill their training potential.

 

Methods: The Council on Resident Education in OBGYN (CREOG) administered a voluntary, anonymous, six-item wellness survey.  One question asked about personal experience with mental health problems (burnout, depression, binge drinking, eating disorders or suicide attempt) and then provided a free text response for “other” issues.  The free text responses were reviewed and analyzed.  The ACOG IRB determined this survey exempt from review.  

 

Results: Of 5,061 residents, 4,099 completed the question on personal issues experienced in residency (81% RR), and 200 free text responses were submitted.  1593 residents (32%) endorsed clinical depression.  34 (0.8%) wrote in anxiety, although this was not a formal category.  The free text responses clustered into three categories: physical health (n=56), social concerns (n=34), and mood symptoms (n=115).  Symptoms of clinical depression comprised 5,992 responses, combining structured questions and free text responses.  18 (0.4%) had attempted suicide, and 18 additional residents wrote in suicide ideation or attempt, translating into almost 1% of our residents having contemplated or tried self-harm, likely related to work stress.

 

Discussions: Significant mood disorders and self-harm are under-recognized among OBGYN residents, even as they acknowledge these symptoms.  Programs must consider formal evaluations for depression, anxiety, and suicide risk, conduct thorough culture evaluations to ensure these symptoms are not being normalized, and tailor their interventions to provide accessible, confidential support services within the clinical learning environment.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Osteopathic Faculty, Residency Director, Residency Coordinator, Professionalism, Interpersonal & Communication Skills, GME, CME, Assessment, Team-Based Learning,

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Resident Documentation and Coding Curriculum Can Be Improved Through One-on-one Education

Purpose: Assess impact of one-on-one education of residents in billing and coding. 

 

Background: As billing and coding education was changed from generalized education at didactics to more intensive one-on-one education, the revenue team evaluated the impact for accuracy in billing and monetary impact.

 

Methods: Three groups of residents were analyzed. Group 1 (n=4) were fourth year residents at intervention and had a general meeting with other departments about coding and then one or two one-on-one sessions. Group 2 (n=4) were third year residents at intervention and had two to three one-on-one sessions. Group 3 (n=4) were second year residents at intervention and had three consistent one-on-one sessions every 6 months. A selection of 10 records per resident were randomly selected for review by a certified coder to identify documentation and coding opportunities. 

 

Results: The documentation and coding accuracy improved with increased education. Accuracy Group 1: 55%, Group 2: 76%, Group 3: 89%. Revenue lift was also analyzed with these encounters and an average lift of ~$40 was noted between group 1 and group 3. 

 

Discussions: By consistent billing and coding one-on-one education for residents, the accuracy of coding improved as seen in the differences in accuracy rate between graduating 4th years (55%) and second year residents (89%). Residents see 5 patients on average per clinic session in their final 2 years and have approximately 30 clinics per year. This equates to an extra $12,000 in revenue per resident over their final two years. By investing in billing and coding education, accuracy and revenue were increased.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, GME, General Ob-Gyn,

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P&S Partners in Pregnancy: A Longitudinal, Patient-Centered Program for Preclinical Students

Purpose: To develop a longitudinal clinical program pairing first-year medical students with prenatal patients. 

 

Background: Students who participate in early clinical, longitudinal experiences report greater confidence in communication, comfort in clinical settings, and self-esteem during transition to clerkship year. However, few longitudinal experiences exist for preclinical students at Columbia University Vagelos College of Physicians and Surgeons.

 

Methods: A retrospective needs assessment evaluating interest, motivating factors, and perceived barriers to participation was distributed to second-year students. In response, we developed a program pairing ten first-year students with pregnant patients. Students partake in lectures and accompany patients to prenatal visits. Initial perceptions about the patient-physician relationship were assessed in both groups using the Patient-Practitioner Orientation Scale (PPOS), with 1 indicating “doctor-/disease-centered,” and 6 indicating “patient-centered.”

 

Results: 49% of students completed the needs assessment. 90% reported that they would be at least “somewhat interested” in a longitudinal prenatal pairing program. Motivating factors included desiring longitudinal experience (87%), early clinical exposure (82%), and patient advocacy/community engagement (78%). Our program was designed accordingly. All first-year students were invited to apply; ten were accepted. At recruitment, mean student PPOS score was 4.64 compared to 3.95 for patients.

 

Discussions: Students in early medical education are enthusiastic about longitudinal patient experiences and demonstrate patient-centered mindsets. Programs such as ours may help maintain and cultivate patient-centeredness, with the potential to improve patient satisfaction(1) and create positive attitudes towards medical student involvement.

 

1 Krupat E et al. Patient orientations of physicians and patients: the effect of doctor-patient congruence of satisfaction. Patient Educ Couns 2000; 39:49-59.  

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Patient Care, Medical Knowledge, Professionalism, UME, Independent Study, Team-Based Learning, Advocacy, General Ob-Gyn,

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One Size Doesn’t Fit All for Wellness: Residents’ Perception of Wellness Programming

Purpose: To investigate which wellness interventions have the most meaning for a modern cohort of OB/GYN residents.

 

Background: The 2017 CREOG Resident Survey found significant associations between the learning environment and wellness. The primary analysis indicated that PGY-1’s prioritized wellness, and that a sense of wellness decreased with each PGY level. In order to explore whether developmental stage influenced how wellness initiatives were perceived, we performed a secondary analysis of the survey to determine how residents at different PGY levels perceived wellness interventions.

 

Methods: A six-item survey on wellness was administered before the 2017 CREOG exam.  IRB exemption was obtained.  Participation was voluntary and anonymous, linked only to PGY level.  A mixed-methods analysis of the data was performed. Descriptive statistics were analyzed with Microsoft Excel 2010.  Mann-Whitney U tests were used to explore differences between PGY-levels. Thematic analysis of text responses was performed.

 

Results: Among the 5855 residents, 4,753 answered questions regarding wellness programming (81% RR). Significant differences existed between year of training and perceived effectiveness for several initiatives. PGY1 residents valued peer mentorship (p=0.003) and strategic napping (p<0.001) more than senior residents, while PGY3 residents emphasized faculty mentoring (p=.005).  Regardless of training level, residents prioritized the same three activities: wellness days to address personal needs, team-building retreats, and facilitated exercise programs.  

 

Discussions: OBGYN residents perceive some wellness activities as valuable throughout training, while the importance of others may vary based on resident year.  Most programs do not yet provide the wellness programs (retreats, facilitated exercise, personal time) that OBGYN residents identify as most effective.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Professionalism, GME, CME, Team-Based Learning,

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Keeping Residents Well: How Important Are Perceptions of Program Support and Psycholocical Safety to Resident Wellness?

Purpose: We aimed to test whether measures of resident well-being correlated with perceptions of program support and psychological safety.

 

Background: Trainee well-being is a crucial component of developing competent and skilled OB/GYN physicians. While there are several measures of well-being collected at the national-level, there is little insight in the role of individual programs to foster trainee well-being. Perceived organizational and psychological safety are two constructs that can help identify cultural aspects of the clinical learning environment that may relate to trainee well-being.

 

Methods: OBGYN residents in a training program were recruited to complete an IRB-approved survey through paper and electronic methods between May-June 2018. Measures included the Survey of Perceived Organizational Support (POS), Psychological Safety Scale (PS), Perceived Stress Scale (PSS), Wayne State Wellness Scale (RWS) and Physician Well-Being Index (PWBI); all demonstrate validity and reliability evidence to assess factors of well-being and cultural aspects of the training program.

 

Results: 20 OBGYN residents completed our survey. Results indicated a strong relationship between perceived organizational support and wellness  (r= .62, P<.01 for RWS, r=.50, P<.05 for PWB)., suggesting greater perceptions of support relate to better wellness. Similarly, psychological safety also had a strong relationship with wellness (r=.56, p<.05 for RWS;  r= -.72, p<.01 for PWB)

Discussions:  
Our findings suggest that there is a strong relationship between trainee wellness and the cultural measures of support and safety, especially between psypschological safety and negative indicators of well-being (e.g,. feeling burnt out from work, feelings of irritation). Further research should include interventions to improve percpetions of suport and safety.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Residency Coordinator, Professionalism, Interpersonal & Communication Skills, GME, Quality & Safety, Advocacy, CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Residency Coordinator, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Lecture, Advocacy,

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Incorporating a Resident-Driven Quality Improvement Process Change Through a Lean Transformation of Post-Partum Hemorrhage (PPH) Care

Purpose: To investigate a resident-driven quality improvement lean event to improve satisfaction in PPH management.

 

Background: Interdisciplinary PPH response strategies are recommended as standard of care. OBGYN resident perceptions regarding PPH management prompted an interprofessional quality improvement lean event to create a systems process change on the post-partum unit.

 

Methods: This was a pre-/post-intervention study evaluating the impact of a lean event that created new hemorrhage protocols (intervention) on postpartum units including: medication safety bundle, assigned/clarified roles for providers, and a streamlined communication process. The survey queried respondents regarding team communication, access to uterotonics and analgesia, and perception of overall patient safety during PPH. It was administered to resident physicians and post-partum nurses prior to the system changes and at 6 and 12-month intervals. These results were compared using nonparametric analyses.

 

Results: Participants included 15 residents and 16 nurses. Pre-intervention, there was a significant difference in the overall perception of safety when comparing resident and nurse response (p=0.0495) with residents perceiving a less safe environment. Post-intervention, overall satisfaction among the 2 groups was improved at the 6 & 12 month intervals (p<0.05) without discrepancy between the groups.  Nurse results demonstrated significantly increased satisfaction with team communication and IV access protocols (p<0.05).

 

Discussions: Resident led quality improvement events can result in improved satisfaction of interprofessional team members in PPH care with improvements maintained over 12 months. Reaching a shared perception and mental model between nursing and residents in the care of PPH can further be studied from the patient’s perspective.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Osteopathic Faculty, Residency Director, Patient Care, Systems-Based Practice & Improvement, GME, General Ob-Gyn,

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Gender in OB-GYN Residency: An Analysis of Factors Impacting Program Diversity

Purpose: To investigate if geographic region, gender mix of previous classes and program leadership impact the gender composition of residency programs.

 

Background: Women comprised only 7.1% of all Obstetrics and Gynecology (OB-GYN) providers in 1970, and held 58.7% of OB-GYN positions in 2017.

 

Methods: 56 of the top OB-GYN residencies as ranked by Doximity.com and US News & World Report were identified and grouped by geographic region. Demographic information for residents (n = 1732) and program/departmental leadership (n = 112) were compiled. Individuals’ gender was identified using online photos and biographical descriptors. The male-to-female ratio (MFR) of the 2018 intern class, of existing residency classes, program directors and departmental chairs were calculated and compared. Two-way ANOVA and Tukey’s multiple comparison tests were used (significance = p<0.05).

 

Results: A majority of trainees in OB-GYN programs are women (62.5-94%.) The MFR varied significantly based on geographic region; southern programs had the highest MFR (Figure 1). Programs with male chairs compared to those with female chairs recruited more male interns (14.2% vs. 8.9%, p < 0.001). Programs with > 20% male residents (PGY 2,3,4) had a higher MFR in the incoming intern class compared to programs with < 20% (15.4% vs. 11.4%, p = 0.020).

 

Discussions: Men are a minority in OB-GYN training. Gender composition of residency programs is influenced by the gender of leadership, geographic region, and of prior classes.  Programs must balance empowerment of women with a culture of inclusion and support of qualified male candidates to ensure strength gained through diversity.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Professionalism, GME, UME, Advocacy, Sexuality,

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Family Planning Training at Catholic and Other Faith-based Obstetrics and Gynecology Programs

Purpose: The objective of this study was to determine the current paradigm of forceps assisted vaginal delivery (FAVD) training across the United States (U.S.) amongst OBGYN residents. 

 

Background: As national FAVD rates decline and primary cesarean rates continue to be high, we must be aware of resident interest, training, and skill acquisition in FAVD.  There is a current paucity of literature on FAVD training practices. 

 

Methods: A survey was created and disseminated on the internet and to OBGYN residency program directors for distribution to current OBGYN residents from March to June 2018. Geographic regions were determined using Census Bureau-designated regions.

 

Results: The survey was completed by 434 OBGYN residents (8.5% of 5,061 ACGME residency positions) with representation from all U.S. regions. Of postgraduate year (PGY)-4 respondents, 71% participated in ≤10 FAVDs, with only 20.2% with >20 FAVDs. Of all residents, 40% expressed a desire to learn FAVD, with 54.6% completing FAVD simulation training. While 46% of resident stated that they would like to perform both FAVD and VAVD once in practice, only 13% expressed confidence in performing FAVD independently. Residents from the Midwest are most likely to have completed >20 FAVD at 18%, compared to 0%, 5.7% and 11.3% of residents from the Northeast, West and South, respectively (p=0.11).

 

Discussions: Residents are motivated to learn FAVD and would like to have the skill to perform them independently. Our study demonstrates that current trainees are not obtaining adequate experience, irrespective of geographical region. Current OBGYN residency training programs should implement simulation and real-time training of FAVD. 

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Systems-Based Practice & Improvement, GME, Assessment, Public Health, Contraception or Family Planning,

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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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Ethical Issues Identified by Third Year OB-GYN Medical Students Vary According to Rotational Site

Purpose: To categorize ethical concerns identified by OB-GYN medical students and compare across rotational sites.

 

Background: APGO recognizes that students should understand the basis of ethical issues in OB-GYN in order to promote quality patient care and patient safety.  Little, however, is known about how OB-GYN medical students experience ethical issues and if rotational site plays a role.  At the University of Colorado School of Medicine, third year OB-GYN students complete an ethics assignment based on their experience rotating at either a university hospital (UH), a safety-net hospital (SH), or a Catholic hospital (CH).

 

Methods: All ethics assignments completed during the 2016-2018 academic years were deidentified of student names and rotational sites.  Two investigators independently performed thematic analysis using a previously published OB-GYN ethics framework to categorize assignments and reached consensus.  We performed descriptive frequencies and compared ethical categorizations across sites using Pearson’s chi-square.

 

Results: 252 assignments were analyzed (46.0% UH, 29.8% SH, 24.2% CH).  The most common ethical category identified was treatment decisions (80.2%). UH students were more likely to encounter code status (p=0.03), surrogate decision-maker (p=0.03), and fetal viability (p=0.03) issues.  SH students were more likely to encounter disagreement in treatment plans between patients and providers (p=0.03) and consent issues (p=0.02). CH students were more likely to encounter issues of institutional policy restricting care (p<0.001) and competing responsibilities of mother versus fetus (p= 0.02).

 

Discussions: OB-GYN medical students encounter ethical concerns that vary by rotation site. Our findings can inform site-specific educational interventions to address ethical concerns encountered during OB-GYN rotations.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Patient Care, Professionalism, GME, UME,

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Decreasing the incidence of hospital-acquired venous thromboembolism (VTE) through inter-disciplinary educational methods

Purpose: This study explored the knowledge of a venous thromboembolism (VTE) prevention protocol among residents, fellows and nurses and the impact of an educational module in an effort to improve adherence to this protocol and subsequently decrease the incidence of hospital-acquired VTE.

 

Background: VTE significantly contributes to morbidity and mortality in hospitalized patients. Patients with gynecologic cancers are at high risk primarily due to malignancy, increased age, and recent surgery and immobility. Several evidence-based interventions are used to decrease the risk of hospital-acquired VTE commonly leading to institutional policies. The division of Gynecologic Oncology at University Hospitals Cleveland Medical Center  standardized VTE prevention guidelines in 2015.

 

Methods: Participants included OB-GYN residents, Gynecologic Oncology fellows and nurses on the Gynecologic Oncology floor. Participants received a fifteen question pre-test immediately followed by an educational presentation describing the venous thromboembolism prevention guidelines. They then received the same fifteen question post-test. The participants were re-tested in six months to gauge knowledge retention. The scores were compared using an unpaired T test.

 

Results: There were seventy-five eligible participants. The survey response rates were: pretest 68%, post-test 35%, follow up pretest 28% and follow up posttest 21%.Of the participants who identified their role, 62% were nurses, 33% were residents and 5% were fellows. There was a statistically significant difference between the test scores before and after the educational intervention during the initial intervention and the six month follow up (p= 0.0001). During the initial survey, the mean pre-test and post-test scores were 54.5% (95% CI 49.7-59.3) and 80.2% (95% CI 73.4-87.1) respectively. At the six month follow up, the mean pre-test and post-test scores were 62.2% (95% CI 56.5-67.9) and 82.1% (95% CI 75.3-88.9) respectively. There was no significant difference between the post-test scores at zero and six months (p= 0.7).

 

Discussions: These findings suggest that knowledge of the VTE prevention guidelines improved following an educational module. Further studies can elucidate the impact of this knowledge on compliance with the VTE protocol and incidence of hospital-acquired VTE.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, GME, Quality & Safety, Gynecologic Oncology,

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Attitudes Around Interprofessional Team-Based Learning on L&D

Purpose: To investigate the impact of integrating student nurse-midwives (SNMs) into an academic center’s labor and delivery (L&D).

 

Background: The American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM) encourage team-based maternity care. CNM and OB-GYN resident learners rarely work together clinically.

 

Methods: SNMs were integrated into the obstetric team at University of California, San Francisco.  Pre- and post-integration, a validated interprofessional survey was administered.

 

Results: Prior to integration, all stakeholders were positive about the new team composition. Residents were more comfortable initiating care discussions and assuming different roles including leadership. Residents and CNM faculty were concerned about an increase in workload and MD faculty were concerned about decreasing resident experience and decreased teaching of residents by CNMs. After integration, SNMs level of comfort with assuming different roles increased. All learners and CNM faculty thought that hierarchy was a problem and SNMs were more likely to comment on a power dynamic. All respondents thought that midwives provide more holistic care and that residents had more competing demands. Post integration, MD faculty were less concerned about a diminution of resident experience and CNM faculty and residents were more mixed about the impact on their workload. 

 

Discussions: Integration of midwifery students into a L&D team is feasible and acceptable. CMS regulations on SNM charting impact resident and CNM workload.  While all respondents reflected positively on the integration and noted more holistic care provided by midwives, there is still a marked difference in perception of hierarchy by both midwifery students and faculty. 

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Residency Director, Professionalism, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME,

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An Interprofessional Fais Do-Do: Medical Student Field Notes on a New Integrated Practice Unit

Purpose: - To gauge medical students’ perspectives on integrated care using an experiential learning approach

 - To provide a clinical application of interprofessional learning

 - To inform continuous quality improvement

 

Background: Dell Medical School students attain the Basic Certificate in Quality & Safety through the IHI Open School online course in year two of our interprofessional integration curriculum. Recently, our institution opened a Complex Gynecology Integrated Practice Unit (CGIPU), which also serves as an interprofessional clinical site for students on the Women’s Health (OB/GYN) clerkship.

 

Methods: Students followed CGIPU team members and composed field notes on the provision of high-quality, patient-centric care.  They used a truncated list of the IOM Six Aims for Healthcare on which to base their notes: Timeliness, Efficiency, Equity, and Patient-centeredness.  At the end of each clerkship block, they submitted a group report based on individual experiences.  Reports were qualitatively analyzed to identify key questions and recommendations emerging from their observations.   

 

Results: 100% of students completed individual field notes (N=50).  Six group reports were evaluated.  Results revealed positive Patient-centered observations, specifically the desire to attain patients’ goals, time allotted for visits, and interprofessional coordination of care. Under Equity, psychosocial determinants of health and access to care were routinely addressed. Appointments were lengthy due to the delivery of personalized care. Recommendations included a better balance of time (Timeliness). Efficiency focused on technical operations including improved integration of the EHR and facilitation of online language interpretation.

 

Discussions: Reports were submitted to leadership to consider recommendations for quality improvement.  The assignment achieved its purposes.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Residency Director, Patient Care, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, UME, Assessment, Quality & Safety, Problem-Based Learning,

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A Triple Aim Curriculum That Addresses Health Care Inequity: A Resident Driven Patient Centered QI Project That Improves Postpartum Care Utilization for a High Risk Population

Purpose: To describe the design and implementation of a resident driven QI initiative which addresses the low percentage of patients returning for a 6-week postpartum visit in a resident obstetrics clinic.

 

Background: The postpartum period or the “fourth trimester of pregnancy” is a critical period for women’s health and well-being.  At our resident clinic (2014-2016), only 21% of patients presented to their 6-week postpartum visits compared to 80-93% in other practices.  As part of a new, mentored experiential approach to QI education, our residents completed a QI project based on an identified clinically relevant patient care issue.

 

Methods: 12 Ob/Gyn residents (single institution) completed the IHI QI Online modules as part of a GME supported Health Systems Science initiative focused on operationalizing a Triple Aim targeted curriculum.  Applying the Model for Improvement, the residents designed and implemented a QI project with the aim of 100% of postpartum patients discharged from the resident service during a 6-month period to receive a 2-week post-discharge check-in call.   The % of discharged patients attending their 6-week postpartum visit was calculated and compared to the % attendance 2014-16. Data analysis: independent t test, P<0.05

 

Results: 6 months after implementation, 97%(37/38) of patients received a 2-week check-in call.   Of those contacted, there was a 45% increase in patients who returned for a 6-week postpartum visit (p<0.01).

 

Discussions: An educational intervention can directly improve patient care.  An experiential approach to QI can facilitate knowledge application and result in improved postpartum care utilization for high risk patients.  

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Residency Director, Residency Coordinator, Systems-Based Practice & Improvement, GME, CME, UME, Quality & Safety, Problem-Based Learning,

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Increasing Access to Emergency Contraception, Non-emergent Contraception, and LARC Referrals in the Emergency Room: A Resident-based Educational Intervention

 

Purpose: The aim of this study is to determine whether an educational intervention improves emergency medicine residents\' knowledge of and personal comfort with prescribing EC, offering non-emergent contraception, and referring patients for LARCs.

 

Background: Approximately 50% of pregnancies in the United States are unintended. Increasing access to emergency contraception (EC), non-emergent contraception, and long-acting reversible contraception methods (LARCs) is one way of decreasing unintended pregnancies. Emergency rooms enable physicians to assess a woman\'s risk of unintended pregnancy and afford an opportunity to intervene, if appropriate. Previous studies have found that emergency medicine physicians do not always offer EC, even in cases of sexual assault. Barriers to prescribing EC have been identified and include time constraints, lack of clinical resources, concern about discouraging regular birth control, and concern about birth defects.

 

Methods: Emergency medicine residents were given an interactive lecture on contraception with emphasis on EC. They were also given a pocketbook on contraception to keep. Pre- and post-lecture surveys were given in person, along with another 6 months later. The surveys assessed knowledge, comfort level, and prescribing/referring practices with both quantitative data and qualitative data. Data will also be extracted from the electronic medical record to assess if there was an increase in prescriptions for contraception and/or referrals to family planning.

 

Results: The preliminary data analysis is currently being conducted. Twenty-three emergency medicine residents completed the pre- and post-test surveys. Additional information from prescriptions and referrals will provide objective data to assess whether the educational intervention changed behavior.

 

Discussions: There are two hypotheses for this study. First, it is hypothesized that an educational intervention will increase emergency medicine residents\' knowledge of and comfort with EC, non-emergent contraception, and LARCs. Second, there will be a significant increase in prescriptions for EC, non-emergent contraception, and referrals for LARCs one year after the educational intervention takes place. If the hypotheses are correct, residency programs and hospitals should consider developing educational strategies and policies to improve access to contraception in the emergency room and prevent unintended pregnancy.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, GME, CME, Assessment, Lecture, Quality & Safety, Contraception or Family Planning,

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Family Planning Training at Catholic and Other Faith-based Obstetrics and Gynecology Programs

Purpose: To evaluate family planning training at obstetrics and gynecology (OB-GYN) residency programs that primarily train at restrictive religious hospitals.

 

Background: Catholic and other religious hospitals face institutional family planning care restrictions, which are in conflict with the training requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME).

 

Methods: We identified 30 ACGME accredited OB-GYN residency programs in which at least 70% of resident time is in restrictive, faith-based hospitals.   We queried program representatives about training using an online survey and follow-up telephone interview. 

 

Results: We had an 80% survey response rate.  The majorities were program directors (83%), represented Catholic hospitals (75%), and completed telephone interviews (71%). Programs often relied on other sites to accomplish contraceptive (33%), sterilization (71%), and abortion (88%) training. All programs reported adequate training in reversible contraception.  58% reported inadequate sterilization training, most commonly in postpartum and hysteroscopic sterilizations.  67% reported inadequate abortion training, most commonly in D&E.  Approximately half (54%) offered ‘routine’ and 13% did not offer any abortion training.  Eight programs (33%) received a total of ten Residency Review Committee citations due to insufficient family planning training, and most of these programs (71%) reported using these citations to gain institutional support for off-site training. 

 

Discussions: While Catholic and other faith-based OB-GYN residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies and half remain noncompliant with abortion training requirements. Residency Review Committee citations, however, provided an opportunity for programs to leverage support for comprehensive training. 

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Residency Director, Patient Care, Systems-Based Practice & Improvement, GME, Contraception or Family Planning,

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