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Wellness Wednesday: Utilization of Strategic Duty-free Hours by OB/GYN Residents

Purpose: To detail the specifics of how OB/GYN residents utilize a monthly duty-free afternoon for wellness activities. 

 

Background: Much attention is paid to burnout and high rates of depression among physicians. Some speculate these difficulties may start in medical school but that they become cemented and sometimes problematic in residency. Studies have made implications that interventions, specifically promotion of self-care and work-family balance, and work hour restrictions, early in residency can decrease burnout and depression levels.  

 

Methods: Starting in 2016, all residents of an OB/GYN program were allowed to have the first Wednesday afternoon of each month free from clinical duties. Faculty members covered all clinical services from noon to 5pm. Residents were then permitted to use the time for whatever they felt promoted their well-being. Two years of data were collected through surveys to determine the specific activities completed by the residents. 

 

Results: The commonly reported activities included health care visits, financial planning activities, leisure time with family/friends, community or church group events, every day errands, home chores, and fitness. Additionally, the residents also used the time away from clinical responsibilities to study and fulfill administrative requirements. 

 

Discussions: By better understanding what residents choose to do to promote their own well-being, programs can then tailor structured wellness activities to those choices.  Alternatively, programs can look at an open-ended wellness day as a possible intervention for fostering excellent overall health and welfare of their residents. More research is needed to validate this approach to wellness promotion.

 

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

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Vaginal Hysterectomy Training in Residency: How Many Cases Is Enough?

Purpose: To evaluate the association of number of total vaginal hysterectomies (TVHs) performed during residency on comfort level and practice habits after residency.

 

Background: TVH is the preferred route of hysterectomy whenever feasible. Evidence is limited about the number of cases needed in residency to produce physicians comfortable with TVH.

 

Methods: We performed a cross-sectional study of 2007-2017 graduates of the MAHEC OBGYN Residency Program. Using an online survey, self-reported feedback was collected on number of TVHs performed in residency, ratings (5-point scales) of adequacy of training and comfort level with the procedure, and the number of TVHs performed in current practice. Spearman correlation (coefficient rho) was used to examine the correlation between the number of TVHs performed in residency and outcomes.

 

Results: Of the 35 graduates meeting inclusion criteria, 31 (88.6%) completed the survey. The range of TVHs performed by graduation varied from 10-59. TVHs performed in residency was significantly correlated with: perceived overall quality of training in TVH (rho=0.565; p=0.001), level of comfort performing TVH within 12 months of graduation (rho=0.384; p=0.43) , level of comfort currently (rho=0.414; p=0.028), and number of TVHs performed over the last year (rho = 0.448; p=0.042).   Graphic representation of TVHs performed in residency against comfort ratings demonstrated substantial, favorable increases in ratings from 10-19 to 20-29 and to 30-39 and leveling off from 30-39 and above.

 

Discussions: The number of TVHs performed in residency is associated with alumni perception of training quality, comfort level and practice habits. Our alumni suggest 30-39 TVHs may be the “sweet spot.”

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Practice-Based Learning & Improvement, GME, Assessment,

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Use of Video Interviews for Selection of Obstetrics and Gynecology Residents

Purpose: To improve the residency selection process using asynchronous video interviews

 

Background: Residency applications have increased, while data available for decision making in ERAS has been static. One-way (asynchronous) video interviews (OWVI) involve the candidate recording answers to pre-selected questions.

 

Methods: Applicants to an OB/GYN residency program with USMLE Step 1 ≥ 220, no USMLE failures and at least 3 months of US clinical experience were scored using five criteria (USMLE 1 score, clinical clerkship grades, letters of recommendation, research achievements and extracurricular/leadership activities) scored 1-5, with 5 as the top score. Applicants with scores from 19 to 22 were invited to complete an OWVI.  The OWVI consisted of 1 open ended question and 2 behavioral questions, scored from 1-5. Applicants were invited for an in person interview based on their video interview scores.

 

Results: For the 2018 residency application season, 495 applications were received, 272 applications were scored and invited to complete a video interview, 234 applicants completed OWVI and 97 OWVI were used for the decision to invite for an in-person interview. Mean OWVI score was 10.4 (range 4-15). For the 2018 season, OWVI scores were weakly correlated with rank list placement (Pearson coefficient = 0.29), in-person interview scores (0.18) and application scores (0.33). The mean in-person interview score increased after implementation of OWVI screening from 59.0 in 2017 to 62.2 in 2018 (P<0.01).

 

Discussions: Use of OWVI led to higher in-person interview scores, suggesting that video interviewing is a useful supplemental tool for selecting competitive residency candidates.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Clerkship Director, Residency Director, Professionalism, Interpersonal & Communication Skills, GME, UME, Assessment,

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Use of POEs( Point of EPA Evaluations) Across All Third Year Clerkships for Year Long EPA ( Entrustable Professional Activity) Monitoring

Purpose: To describe the development of a school wide and longitudinal assessment of the core Entrustable Professional Activity (EPA)s using an easily accessible App.

 

Background: Our insitution is  part of the EPA pilot study sponsored by the AAMC to explore the feasibility of teaching and assessing the core EPAs. This year direct observation and assessment of the EPAs was implemented across clerkships . Each clerkship was allowed to determine which EPAs were applicable to their field.

 

Methods: The OBGYN department determined and assessed that EPA1( History and Physical) , ] EPA2 ( Differential Dx) , EPA3 ( Dx and Screening Tests) and EPA6 ( Oral Presentation)  were core skills to the clerkship with the following scale (1=student observed, 2=assessor had to talk the student through it, 3=assessor had direct them from time to time, and 4=assessor  needed to be available just in case.)

Results:

 

                       OB                    Other Clerkships             p

EPA 1            3.0( 0.5)                     3.5 (0.5)               <0.0001

EPA 2           3.0 (0.9)                       3.4 (0.6)              <0.05

EPA3             3.0 (0.9)                      3.4 (0.7)               n.s

EPA6            3.1( 0.5)                         3.4  (0.5)              < 0.005

 

For the first 3 months there were 2783 EPA assessments. The average score was 3.45. In comparison to other clerkships, students on OBGYN received lower scores in EPA 1,2,6.( p<.0001, P< .05 and P< .005) possibly  indicating more stringent grading by faculty or lower performance of medical students.

 

Discussions: In comparison to all other clerkships combines, student on OBGYN received lower scores in all four EPAs possibly  indicating more stringent grading by faculty or lower performance of medical students. Lower EPA scores may  indicate more stringent grading by faculty or lower performance of medical students. This could also be related to lower numbers of overall EPAs reuired by the OB/GYN clerkship.  Further research is needed to determine the significance of these findings.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Practice-Based Learning & Improvement, GME, UME, Assessment,

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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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Too Many Learners? Do Students Belong in Resident Continuity Clinics?

Purpose: Determine the prevalence of medical students in OBGYN resident continuity clinics and describe effects on the learning environment when students and residents work together in this setting.

 

Background: Patient continuity is an ACGME requirement often fulfilled through a resident run continuity clinic. It’s unknown how frequently students rotate in these clinics, or how multiple levels of learners influence each other.
 

 

Methods: We surveyed OBGYN program managers using a national listserv. Resident and student surveys were based on a Likert scale and sent to all OBGYN residents and students that rotated at our institution from 2016-2018.

 

Results: Program managers responded from 45 programs and 75.6% scheduled students in resident continuity clinics. Our response rates were 79/116(68.1%) for students and 21/24(87.5%) for residents. A one-sample Wilcoxon signed rank test was used to test the hypothesis that the typical response on the five-level Likert scale was \"Agree\" or \"Strongly Agree.\" Of medical students, 88.6% stated that they agreed or strongly agreed they enjoyed working with residents (p<0.001) and 60.8% stated they agreed or strongly agreed residents were effective teachers (p<0.001). Among residents, 52.4% agreed or strongly agreed that they enjoyed working with students (p<0.001). However, 61.9% said they agreed or strongly agreed they were too busy to be effective teachers (p<0.001).

 

Discussions: Many institutions have students rotate in resident continuity clinics. Residents and students have positive views regarding their interactions. Although students were satisfied, residents expressed concerns about their ability to be effective teachers given clinical demands. Our results highlight the importance of developing resident teaching skills.

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

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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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The Residency Buddy System\': A Better Way to Encourage Laparoscopy Simulation Training?

 

Purpose: To determine if a “buddy-system” compared to independent training increases laparoscopic simulation time amongst residents.

 

Background: Based on prior research, laparoscopic box-trainers improve proficiency on surgical skills, however voluntary simulation time by residents is traditionally low. We propose that a buddy system approach to simulation will increase laparoscopic training time, and further improve skills.

 

Methods: Thirty-two residents at a single obstetric and gynecology residency program were consented for the study.  Each buddy pair was composed of a junior and senior resident. During the first half of the 20-week study, 12 residents were randomly assigned a buddy while 20 remained solo.  During the second half, solo-trainers were assigned buddies and conversely buddies were made solo. Residents recorded check-in and -out times electronically. (Assignments were provided via email at the beginning and mid-way points; no other contact was made.) At the conclusion of the study period a survey link was distributed.

 

Results: Six of the 32 residents (18.8%) attended simulation in the 20-weeks, with an average time of 2 hours 14 minutes. In the solo-trainer group, 1 resident checked in 3 times and 2 residents once. In the buddy group, 1 pair checked in together and 1 person checked in alone.  Fifteen residents (46.9%) completed the survey.  Thirteen (86.7%) agreed they accurately reported times; 1 was neutral and 1 never attended. All communicated with their buddy monthly or less frequently, while 10 of them never communicated.

 

Discussions: Residents’ laparoscopic simulation time was dismal at our program in this study. Dedicated mandatory simulation time may increase participation.

Topics: CREOG & APGO Annual Meeting, 2019, Faculty, Residency Director, Medical Knowledge, CME, Independent Study, Minimally Invasive Surgery,

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The Effect of Dedicated Research Time in an Obstetrics and Gynecology Residency

Purpose: To determine the effect of a second-year research rotation on scholarly output in an academic OB/GYN residency program.

 

Background: Dedicated research time has been shown to have positive impacts on resident outlook and understanding of research, research productivity, and clinical care.  A minority of OB/GYN residencies provide a research rotation due to resource availability and as a result, data on the effect of an OB/GYN specific rotation are sparse.

 

Methods: A retrospective review of resident scholarly activity was performed from academic years 2012-2017, with the rotation implemented 2015-2016.  Data collected from these reports included number of publications, presentations, book chapters, and number of residents who participated in these projects each year. 

 

Results: Following the introduction of research rotation, resident participation in projects doubled to 12/20 (60%).  6 of 19 or 20 residents (31.6% and 30% respectively) had scholarly output each year from 2012-2016, except 2013-2014 when 3/19 residents (15.8%) participated.  Publications nearly doubled and presentations increased by 50% in the first two years of the rotation.  In the second year of implementation alone, there were nearly three times as many publications and more than twice as many presentations than any individual year before the rotation.   

 

Discussions: Scholarly activity output increased following implementation of the research rotation, demonstrating a benefit of dedicated research time and mentorship to our residency.  This study supports the growing consensus that creating a rotation and an associated curriculum are factors associated with successful research education.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Practice-Based Learning & Improvement, GME,

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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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Successful Implementation of an OB/GYN Resident FLS Training Curriculum

Purpose: To describe the implementation of an ob/gyn resident Fundamentals of Laparoscopic Surgery (FLS) training curriculum

 

Background: Beginning in May 2020, all ob/gyn graduating residents will be required to successfully complete the FLS program as a prerequisite for specialty board certification.  

 

Methods: Between January 2017 – April 2018, 36 ob/gyn residents participated in the BCM FLS curriculum.  The curriculum consisted of six 3-hour faculty supervised gynecologic simulation sessions, 24/7 individual access to the simulation lab, proctored voluntary one-on-one sessions, and a final mock FLS session.  Participants were followed with attendance sign-in sheets to gauge number and time involved in all sessions.   Residents completed evaluation forms after each simulation session.  Descriptive statistics were utilized to determine the average/range of the number and time involved in the practices sessions, between PGY levels and FLS pass rates.   

 

Results: All 36 ob/gyn residents successfully completed FLS certification on the first attempt.  In addition to the mandatory sessions, residents required an average of 8.64 independent practice sessions (range 3-22) lasting an average 72 minutes/session.  Approximately 688 minutes (range 235 – 1357 minutes) of independent practice were required to pass the FLS exam.  Many residents felt that the curriculum gave them adequate support to succeed on the exam and stated that one of the most valuable components of the curriculum were proctored teaching sessions.  

 

Discussions: With a dedicated curriculum and proctored teaching, residents in obstetrics and gynecology can successfully pass the FLS certification exam with their initial test. 

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Residency Coordinator, Medical Knowledge, GME, Simulation, Minimally Invasive Surgery,

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Students Stuck in a Swamp? Scripting Promotes Medical Student Involvement in Obstetric & Gynecologic Care

Purpose: Characterize the effect of staff scripting on medical student acceptance in outpatient ob-gyn clinic visits.

 

Background: Direct patient care is a major tributary in the river of medical education. When patients refuse medical student involvement in their care, students are stranded in stagnant quagmire. Review of the literature shows that medical student refusal is a national issue not limited solely to obstetrics and gynecology (ob-gyn) clerkships (Chang, et al, 2010; Mavis, et al, 2006; Hartz & Beale, 2000). Written and video messages about medical student training have been effective in furthering medical student acceptance in clinical encounters (Buck & Littleton, 2016). Open the floodgates!

 

Methods: A literature review using search terms “medical student AND refusal” was conducted to guide script composition. Medical assistant and nursing staff implemented the script in an outpatient ob-gyn resident clinic. The script was revised halfway through the clerkship year based on patient and staff feedback. All ob-gyn medical students were surveyed regarding their involvement in patient visits prior to and after script implementation.

 

Results: After script implementation, the percent of medical students refused from at least one patient interaction decreased from 92% to 86%. 66% percent of our students perceived scripting as a supportive measure for medical students, and 61% percent witnessed staff, residents, and faculty utilizing scripting.

 

Discussions: Data from our institution suggest that scripting improves medical student involvement in ob-gyn patient care. Involving staff, students, and patients on scripting revision helped foster a learning environment rich as the Mississippi delta in which medical students can thrive.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Professionalism, Interpersonal & Communication Skills, UME, Team-Based Learning, Advocacy,

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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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Service-learning Wellness Initiative in the Harvard Medical School Clerkship Curriculum

Purpose: The first aim was to assess if incorporation of a service-based initiative into the curriculum results in professional fulfillment, principally: improved medical student feelings of compassion, contribution, wellness, understanding of community need, and team-building of the student class. The second aim is to report the development of this curriculum project.

 

Background: Service-learning increases student awareness of community resources, promotes service to the community, team-building through cooperation rather than competition, broadens cultural awareness, and fosters wellness through hands-on contribution.

 

Methods: The entire class of second year clerkship students volunteered at a local non-profit organization. Students were divided into small groups to work at various team tasks.  Following, the entire group reconvened for teaching reflection. They were asked a value-based qualifier of the experience. They were also asked to provide feedback as an open response. Quantitative data were analyzed using summary statistics, Wilcoxon rank sum and Fischer’s exact test. Content analysis was used to determine themes from the open-ended responses.

 

Results: 47 students participated, 48.9% of whom were male. Average satisfaction with the intervention was high (mean 4.26 on a 5-point Likert scale), with no difference in satisfaction noted by gender. Positive themes included feelings of contribution, wellness, and team-building, with 9 respondents requesting to repeat the event at regular intervals.

 

Discussions: It is crucial to investigate different types of wellness interventions throughout UME. Service-based interventions are not adequately studied and may be an important addition to the wellness program as they are a way for students to feel connected to the community they are serving.  

Topics: CREOG & APGO Annual Meeting, 2019, Faculty, Clerkship Director, Residency Director, Professionalism, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, UME, Team-Based Learning, Public Health, General Ob-Gyn,

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Saving Lives: Students Enhancing Patient Health Literacy Regarding Hypertension in Pregnancy and Prenatal Aspirin

Purpose: To increase medical student’s knowledge, behavior and belief systems regarding hypertension (HTN) in pregnancy and prenatal aspirin (PNA). To increase patient\'s understanding regarding the complications of HTN in pregnancy and the benefits of PNA.

 

Background: Prenatal aspirin (81 mg) has been recommended by ACOG for high-risk women and women with >1 moderate risk factor. Its use reduces the rate of preeclampsia, preterm birth, intrauterine growth restriction and fetal death in at-risk patients. In a survey conducted at Boston Medical Center, the incidence of hypertension in pregnancy is 30%, with only 15% of patient having heard of PNA, demonstrating high prevalence and low patient literacy regarding the topic.

 

Methods: Ob/Gyn clerkship students are instructed to educate patients regarding: knowledge of HTN in pregnancy, warning signs of preeclampsia, and efficacy of PNA in pregnancy. The student educational intervention was evaluated regarding: satisfaction, knowledge, confidence, and belief systems by surveys at the beginning and end of the clerkship. Patient education was evaluated by pre and post intervention metrics.

 

Results: Student knowledge of PNA and HTN increased 35%, confidence 45% and belief systems 14%. They gave the project a 72% satisfaction rating. Patient’s knowledge about HTN increased 48%, warning signs 80%, and understanding of efficacy of PNA 65%.

 

Discussions: Medical student health counseling increased patient knowledge regarding HTN and PNA. By educating patients, students also increased their knowledge and confidence in the subject. We plan to continue implementing this QI project throughout the year to augment a departmental QI initiative and evaluate its benefit to patients and students.

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, Interpersonal & Communication Skills, UME, Quality & Safety, Advocacy,

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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 Wellness: Barriers to Seeking Mental Health Services Among OB GYN Residents

Purpose: Residency predisposes residents to the development of burnout and mental health complications. The culture of residency inevitably places barriers to wellness through expectations of perfectionism, increasing stress levels, and long hours. This study aims to highlight the main reasons why OB GYN residents may not seek help for depression in residency.

 

Background: Residency is a period of extreme stress, lack of sleep and long work hours. Factors such as embarrassment and confidentiality play key roles into why physicians don’t seek help. Some additional barriers cited in the literature include lack of time, fear of documentation on academic record, cost and lack of confidentiality. 

 

Methods: This was a qualitative study to assess the barriers that may keep OB GYN residents from seeking access to mental health resources.  The surveys were electronically distributed via Survey Monkey to OB GYN resident programs

There were a total of 18 questions that assessed demographics and the main barriers that may keep OB GYN residency from seeking mental health services.•A 5 point Likert scale was used to assess the following; ranging from strongly disagree to strongly agree •I can manage my problems on my own •I don’t have enough time •I am worried my privacy would be violated •I don’t know if my program offers mental health services •I don’t have money or health insurance to seek help •I don’t think treatment would be of any help •I am worried about the stigma of mental health 

 

Results: There were 275 respondents to the 18 question survey. Lack of time was the most highly reported barrier, followed by a lack of protected time for appointments. Not knowing if their programs offered services or how to access those services and not thinking treatment would not be of help were the least popular responses.

Discussions: In summary, our data outlines that lack of time and protected time in OB-GYN residencies are prevalent barriers to seeking help among OB GYN residents that must be addressed. Understanding the barriers to seeking help will help us to enact programs that will maintain the wellness of our residents.

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

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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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