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Management of Postoperative Issues in Gynecology and Gynecologic Oncology: A New Method for Teaching Residents

Purpose: This project sought to develop and assess a curriculum to improve resident knowledge of and comfort in managing common post operative issues.


Background: Junior obstetrics/gynecology residents enter training with varied experience in post-operative management. They are often the first contact for surgical patients with little formal education on post-operative issues. 


Methods: Eleven common post-operative issues were identified based on literature review, resident experience and gynecology/gynecologic oncology faculty input. Topic based curriculum included: example case, pathophysiology, differential diagnosis, next steps, and useful resources. It was presented at two educational sessions, involving lectures and small-group simulations. Residents completed a pre and post-assessment questionnaire assessing comfort level in managing (10-point Likert scale) and baseline knowledge about (content-specific questions) the topics.


Results: Twenty-three residents participated.Seventeen completed one or both pre-assessment surveys (nine junior residents). Ten completed one or both post-assessment surveys (five junior residents). All post-assessment respondents reported improved knowledge of issues covered. Average self-rated comfort level increased for ten of eleven topics amongst junior residents (average increase 1.6 points (range 0.5 – 3.2; p = 0.02)). Largest increase in score was for hypoxia and low urine output. Average scores maintained or improved for 80% of the content questions (not significant). Residents had no preference for lecture versus small group format.


Discussions: As a result of directed teaching, resident knowledge of post-operative issues showed measurable improvement. Resident comfort level in management increased significantly for 90% of topics covered, most noticeably amongst junior residents. A systematic, resident-led curriculum on post-operative management can improve resident knowledge and patient care.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Medical Knowledge, GME, Simulation, Lecture, Problem-Based Learning, Team-Based Learning, Gynecologic Oncology, Minimally Invasive Surgery, Female Pelvic Medicine & Reconstructive Surgery, General Ob-Gyn,

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Describing Surgical Skills Progression with MyTIPreport - A Multi-center Trial: What Do We See and Is There Construct Validity?

Background: Tracking surgical skill progression through “real-time” feedback could provide valuable information to learners and teachers alike but has proven challenging.  Construct validity testing of such tracking is critically important.


Methods: OBGYN and FPMRS learners and teachers used the myTIPreport program for work-place feedback on surgical skills.  The correlation of learners’ and teachers’ assessments of learners’ procedural abilities was examined by PGY-year. Additionally, senior learner performance, PGY-4s (residents) and PGY-7s (fellows), was compared to junior learner performance, as assesed by both learners and teachers, to begin the process of myTIPreport construct validity testing.


Results: From October, 2014-May, 2016, 12 OBGYN residency and 7 FPMRS fellowship programs participated.  There were 439 unique learners and 442 unique teachers.   Learners and teachers generated/recorded feedback on 4427 surgical procedures. Learner- and teacher-assigned performance curves were generated by PGY-year for all procedures rated in myTIPreport.  Procedural levels assigned ranged from 1 to 5 (5 representing “expert”). Twenty of 26 procedures in the OBGYN myTIPreport had > 10 observations for index and subsequent procedures.  Statistically significant correlations were seen between learner and teacher assessments for these 20 procedures with strong/very strong correlation noted (r > 0.71). As only 3 of 29 procedures in the FPMRS myTIPreport had > 10 observations for index/subsequent procedures, learner- and teacher-reported performance level correlations were not completed.  Construct validity testing of myTIPreport to distinguish amongst PGY level performance was initiated for procedures with > 10 observations.  For all 18 of 26 OBGYN procedures meeting this threshold, PGY-4s performed at a statistically significant higher level than PGY-1s as assessed by both learners and teachers.  Similarly, for the 8 FPMRS procedures meeting this threshold, PGY-7s performed at a significantly higher level than PGY-5s.


Discussions: Strong correlation was found between OBGYN resident and teacher assessments of procedural ability using myTIPreport.  The demonstrated significant effect of PGY level on procedural ratings by both learners and teachers supports emerging construct validity for myTIPreport.


Keywords: Assessment, Communication Skills, Faculty Development, Instructional Materials/Methods, Teaching Skills, Technology

Topics: CREOG & APGO Annual Meeting, 2017, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Assessment, Faculty Development, Female Pelvic Medicine & Reconstructive Surgery, General Ob-Gyn,

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E-learning Is a Satisfactory and Comparable Approach to Teaching Core Urinary Incontinence Objectives

Background: Urinary incontinence (UI) is a prevalent condition inconsistently addressed in medical education. Innovative didactic approaches are needed to increase knowledge on UI and improve care for affected women. An e-learning module was created and validated to teach UI learning objectives.  We hypothesized that the module would be as effective as a Urogynecology rotation in providing satisfactory knowledge on UI.


Methods: In this prospective cohort study, 3rd year medical students were consecutively approached during OB/GYN clerkship. All were assigned one-week of Gynecologic surgery; a proportion was also assigned a Urogynecology rotation. The e-learning module was administered during the Gynecology week.  A validated knowledge-based questionnaire administered pre- and post-module review was utilized to determine its effectiveness. Twenty-nine students were needed to characterize differences between groups based on validation data.


Results: Seventy students completed the OB/GYN clerkship August 2014–March 2015, 35 (50%) completed pre- and post-questionnaires and were included for analysis.  Fifty-one percent of students were female and 49% were male.  Of 22 possible points, the mean baseline and post-module questionnaire scores were 11.7±3.3 (53% correct) and 15.1±3.2 (69% correct) p>0.05, respectively.  Most participants (57%) had a Urogynecology rotation. Mean changes in questionnaire scores were similar between students with and without Urogynecology exposure [3.65±3.91 vs. 3.07±3.69, p=0.66, respectively]. Student satisfaction was similar between groups,[72% (with Urogynecology) vs 57%(without Urogynecology), p=0.37, respectively].


Discussions: A UI e-learning module may be a comparable and satisfactory replacement for Urogynecology patient exposure.


Keywords: urinary incontinence, teaching

Topics: CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Medical Knowledge, Practice-Based Learning & Improvement, Independent Study, Problem-Based Learning, Female Pelvic Medicine & Reconstructive Surgery,

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An Assessment of Knowledge and Comfort Surrounding Pessary Use Among US Ob/Gyn Residents

Background: There is limited information regarding residents’ attitudes towards and comfort with pessary use.


Methods: A 31-item anonymous electronic survey (Qualtrics 2015, Provo, Utah) regarding attitudes towards, education, and comfort with pessaries was distributed to all U.S. Ob/Gyn residents.  Surveys completed between March 1 and June 15, 2015 were used.  Participants answered questions regarding pessary education and comfort with pessary-use using a 5-point Likert scale.  Descriptive statistical analysis was used with p < 0.05 considered significant.


Results: 478 completed surveys were returned (response rate 40%).  Mean age was 29.5(± 0.12) years.  Participants were evenly distributed among PGY levels (PGY1-25%, PGY2-28%, PGY3-25%, PGY4-22%).  83% reported having a dedicated urogynecology rotation, and 72% had a urogynecology fellowship in the department.  Compared with junior residents (PGY-1/2), senior residents (PGY-3/4) reported significantly more experience in pessary fitting (77 v. 32%), current feelings of adequate preparation (72% v 47%), and comfort with pessary management now (72% v 25%) and anticipated after graduation (70% v 67%).   Having a dedicated urogynecology rotation and outpatient urogynecology experience played a significant role in this comfort, as did having formal didactics specific to pessary fitting and management (p < 0.001).   Having a urogynecology fellowship and receiving didactics only on prolapse and incontinence did not impact comfort and preparation.


Discussions: Formal rotations with outpatient experience specific to urogynecology and pessary-focused didactics may improve resident comfort with incorporating pessary use into their practice.


Keywords: Pessary, urogynecology, preparedness

Topics: CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Practice-Based Learning & Improvement, GME, Simulation, Female Pelvic Medicine & Reconstructive Surgery, General Ob-Gyn,

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Resident Education in Pelvic Organ Prolapse Quantification System (POP-Q): Utility of a Hands-On Model

Background: The POP-Q was created to standardize the evaluation of pelvic organ prolapse (POP). Many residents report being unfamiliar with assessing POP despite it being an established CREOG educational objective and Milestone in ACGME resident evaluation.
Study Objective: To assess the effectiveness of a hands-on vaginal model to aid POPQ teaching

Methods: 35 OB/GYN residents completed a written pre-test to evaluate their baseline knowledge of and comfort performing the POP-Q exam. A lecture on the POP-Q followed. They were then randomized to two groups: Group A documented POP-Q findings of model vaginas simulating various stages of POP without instruction; Group B received a “hands-on” tutorial using model vaginas, and were then tested on the models. Both groups completed a written post-test. Data were analyzed using parametric and nonparametric methods where appropriate.

Results: Post-test scores were significantly higher than pre-test scores in both groups (p<0.0001), with no difference between groups. Group B more accurately assessed prolapse findings on the vaginal models compared to Group A (p <0.001). Further, Group B reported an increased understanding of the POP-Q compared to Group A (P=0.039). 68% of participants preferred the models to lecture. 91% thought the models were useful or extremely useful.

Conclusions: The use of a “hands-on” teaching model in POP-Q instruction can improve resident understanding of the POP-Q system and enhance their ability to perform the exam. We believe models can be useful teaching aids in the fulfillment of this CREOG educational objective and ACGME Milestone.

Topics: CREOG & APGO Annual Meeting, 2015, Resident, Residency Director, Patient Care, Medical Knowledge, GME, Assessment, Simulation, Female Pelvic Medicine & Reconstructive Surgery,

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Vaginal Hysterectomy Simulation: Adjunct Training


Topics: CREOG & APGO Annual Meeting, 2015, Resident, Residency Director, Residency Coordinator, Patient Care, GME, Simulation, Female Pelvic Medicine & Reconstructive Surgery,

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Functional Models to Teach and Practice the Pelvic Organ Prolapse Quantification (POP-Q) Exam


Topics: CREOG & APGO Annual Meeting, 2015, Faculty, Patient Care, GME, Simulation, Female Pelvic Medicine & Reconstructive Surgery,

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A Comparison of Residency Program Directors’ Expectations & CREOG Objectives for Surgical Education


Topics: GME, 2015, Residency Director, CREOG & APGO Annual Meeting, Patient Care, Resident, Medical Knowledge, Faculty, Female Pelvic Medicine & Reconstructive Surgery,

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A Colpocleisis Simulation for Resident Education Using Objective Structured Assessment of Technical Skills

Study Objective: Evaluate training of Ob/Gyn residents performing colpocleisis using objective structured assessment of technical skills (OSATS)
Methods: A sock model was developed to simulate and teach the steps of colpocleisis, and an expert surgeon was filmed performing the model. Educational utility was assessed by evaluating residents’ knowledge and confidence in the procedure before and after each step of the simulation using a colpocleisis task specific checklist and an OSATS scale. Each session was recorded and reviewed/scored by an expert surgeon. Step one: residents viewed the video and were then given 30 minutes to work with the model. Step two, 4-6 months later: 30 minutes to complete the colpocleisis simulation without viewing the video.
Results: 24 residents participated, 19 completed each step, and 10 videos were reviewed. All assessment scores significantly improved after the intervention for both Step 1 and Step 2. A total confidence score was calculated given excellent internal validity with Cronbach Alpha=0.97and it was improved after the intervention. Step 1 pre 25.75±14.48 & post 54.25±10.59 (p<.0001) and Step 2 pre 37.7±14.91 & post 53.4±13 57 (p<0.0003). Overall confidence improved, Step 1 pre 2.21±2.06 & post 6.38±1.97 (p<.0001) and Step 2 pre 4.05±2.42 & post 6.25±2.45 (p=0023)

Conclusions: Video instruction plus completion of an inexpensive simulation model proved effective in teaching Ob/Gyn residents a rare surgical procedure.

Topics: Resident, Patient Care, Faculty, Residency Director, Female Pelvic Medicine & Reconstructive Surgery, Simulation, GME, Assessment, 2015, CREOG & APGO Annual Meeting,

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OBGYN Resident Attitudes and Perceptions about Chronic Pelvic Pain: A Targeted Needs Assessment for Future Curriculum Revision

2012 ASL Abstract

Objective(s): Resident education about chronic pelvic pain (CPP) has historically been inconsistent. Pelvic pain accounts for 10% of gynecologic visits and is a common complaint in resident training clinics. Current literature lacks information regarding OBGYN residents’ attitudes regarding CPP. We sought to identify resident attitudes, self-perceived knowledge and potential educational barriers regarding CPP.

Study design: A focus group of 7 OBGYN Residents identified major themes regarding attitudes about CPP. This informed the development of a survey administered to academic and community-based OBGYN Residents.

Results: Survey response rate was 72% (41/57). Resident attitudes were consistent about feeling overwhelmed by CPP patients, lack of time to see them, and their desire to learn more in this area, but varied in chosen learning methods.

Conclusion(s): The majority of OBGYN Residents surveyed felt inadequate to address the needs of women presenting with CPP.

Key Words: pelvic pain; attitudes; perceptions; OBGYN Resident

Topics: General Ob-Gyn, Female Pelvic Medicine & Reconstructive Surgery, Independent Study, Assessment, GME, Medical Knowledge, Patient Care, Residency Director, Faculty, 2012,

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An Expert Consensus Approach to Designing Competency Based Curricula for diagnostic cystoscopy

ASL Abstract

Objectives: The primary objective of this project was to create core cystoscopic topics which could assist in teaching cystoscopy and ultimately evaluate competency.

Study Design: An expert panel of 6 local and national urogynecologists and urologists reviewed cystoscopic topics derived from Female Pelvic Medicine and Reconstructive Surgery fellowships and Urology residencies learning objectives. In creating ten essential topics for a cystoscopic curricula, experts were asked to place each topic in one of three categories: “must have”, “not needed” or “maybe”. The topics ranked maybe were also ranked numerically in importance for each reviewer.

Results: A total of twenty five topics were obtained. All of the experts identified six topics as “must have” and two topics as “not needed”. The conjugate score of each maybe topics was used to rank the topics with the four lowest scores determining the additional topics to be included.

Conclusion: A core curricula of ten cystoscopic topics has been agreed upon by experts.

Topics: 2012, Resident, Residency Director, Patient Care, Medical Knowledge, GME, Female Pelvic Medicine & Reconstructive Surgery,

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Committee on Fellowship Training in Obstetrics and Gynecology: A needs assessment

Carrie L. Bell, MD

R Kevin Reynolds, MD, Peggy Engel , Timothy RB Johnson, MD

Background: APGO serves educators focused on women’s health by providing resources and support. Faculty in Obstetrics and Gynecology rely on APGO for this vital role. Currently, no unifying organization or committee exists for fellowships in Obstetrics and Gynecology. In 2010, a group of educators committed to the training of fellows formed a Committee on Fellowship Training in Obstetrics and Gynecology (COFTOG). The group determined that a needs assessment survey would best outline and direct the goals and objectives of the new group.

Objective: Survey the fellowship directors of OB/GYN based fellowships as a basis for the new Committee on Fellowship Training in Obstetrics and Gynecology.

Methods: A survey was designed; 5 demographic questions and 15 survey questions. The survey was entered into Survey Monkey. Contacts were identified gynecology oncology, maternal fetal medicine, reproductive endocrinology and infertility, female pelvic medicine and reproductive surgery, family planning, minimally invasive surgery, breast, pediatric and adolescent gynecology, genetics, and women’s health. The survey was sent to the contact lists. For specific fellowships, the national organization requested the survey for approval and subsequently, the organization sent it out to fellowship directors. The results were collected anonymously by Survey Monkey. The results were compiled and analyzed. The project was determined to be IRB exempt.

Results: There were 85 completed surveys from an estimated 250 possible responses; 34% response rate.. Thirty nine percent were MFM directors and 10-17% of surveys completed by family practice, FPMRS, REI and Gyn Onc. A national committee focused on fellowships was desired by 66% of respondents. 11% had formal training to be a fellowship director with twenty percent having served as a clerkship or residency program directors previously. 37% had participated in a faculty development course to help in their role as fellowship director. Sixty four percent thought a fellowship director school would be helpful. When asked about a central repository for evaluation, curricula, policies and organization, 68-70% responded in the affirmative. Specifically, directors asked for a national group to help with requirements from and reporting for national organizations (ABOG and ACGME), resolution of common problems, mental health, evaluation, training objectives and competencies. Two respondents wrote: "Have been looking to APGO for a long time to pick up the mantel. Have attended these meetings to pick up whatever points I could". "An APGO based organization may be able to provide some benchmarks to judge your program by, such as didactic schedules, curriculum, faculty supervision, etc."

Conclusion: Fellowship directors welcome APGO’s involvement and support in the form of COFTOG to provide support through faculty development and consolidation of resources for general use to improve the education of fellows.

Topics: CREOG & APGO Annual Meeting, 2013, Resident, Faculty, Residency Director, Systems-Based Practice & Improvement, GME, Assessment, Gynecologic Oncology, Contraception or Family Planning, Pediatric & Adolescent Gynecology, Minimally Invasive Surgery, Reproductive Endocrinology & Infertility, Female Pelvic Medicine & Reconstructive Surgery, Maternal-Fetal Medicine, Sexuality, Genetics,

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Success in the Female Pelvic Medicine and Reconstructive Surgery Match: A Survey of the 2012 Applicant Pool

Tyler, M, Muffly, MD

Imran, Iqbal, MD, Pratibha, Sareen, MD, Brenda, Shoup, MD

Objective: To evaluate qualifications of successful applicants to Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellowship programs.

Methods: A 55-point web-based survey was sent to 54 applicants participating in the 2012 FPMRS Match.

Results: The survey achieved a 55% response rate, with a total of 36 respondents. Regarding prematch educational preparations pursued by applicants, 23 of the 26 matched respondents (88%) completed allopathic medical school training. Seventeen successful applicants (17/23, 74%) matched at their number one or two ranked program. None of the unmatched applicants were members of AOA while (2/24, 8%) of matched applicants were members. Over half of applicants applied to over 25 programs and matched applicants attended 10-15 interviews (13/24, 54%) while unmatched visited five or less (5/9, 55%)

Conclusions: If these respondents are representative of all fellowship candidates in FPMRS match, then it would be expected that applicants are highly qualified. This information may be useful to mentor future applicants and lays the foundation for a critical evaluation of the match process.

Topics: CREOG & APGO Annual Meeting, 2013, Resident, Residency Director, Systems-Based Practice & Improvement, GME, Assessment, Female Pelvic Medicine & Reconstructive Surgery,

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Robotic Surgery: The Davinci Uncoded

Soorena Fatehchehr, MD University of Oklahoma Tulsa School of Community Medicine, Tulsa, Oklahoma

Elisa Ramunno, JD , Amber Bledsoe, MD , Michael O. Gardner, MD, MPH , Nora M. Doyle, MD, MPH, MSc

Objectives: Robotic surgery initially designed for battlefield surgery by the U.S. military, became FDA approved for gynecological surgery in 2005. Current uses of robotic surgery include: tubal reversal, myomectomy, hysterectomy, sacrocolpopexy, and oncology procedures. Robotic surgery represents an educational challenge. It is associated with a significant learning curve and a large amount of time and energy is necessary to develop and maintain skills. Currently, robotic training for inexperienced, practicing surgeons is primarily done at sponsored day or weekend courses, with limited proctorship opportunities. Ideally, fellowship training could provide a structured comprehensive program to acquire this skill set. To more fully understand the impact of robotic surgery on fellowship education, we developed a survey to evaluate the current state of robotic training in US fellowship programs.

Methods: A 45 point questionnaire was sent to all Gyn-Onc, REI, UroGyn, MIS fellows and Fellowship directors . OU IRB approval was obtained prior to study onset. We gathered information on demographics, including size of fellowship programs and procedures performed. Univariate and multivariate analysis were performed where appropriate. A p value of less than 0.05 was considered significant.

Results: 546 surveys were sent and 102 responses were collected. Of these, 2/3rd were Fellows and 1/3rd were Fellowship Directors. Our responses were equally distributed from all four fellowships surveyed. Over half of the fellowships reported that they were doing <10% of their surgeries vaginally. 70% responders stated 10 - 40 % of their surgeries done with robot. 80% of fellowship programs are performing at least 10% of their surgeries robotically. 95% reported that conversion to laparotomy occurred < 10% of the time. GYN ONC reports treating 34% of endometrial and 23% of cervical cancers via the robot. Minimal invasive fellowships noted 28% Hysterectomies, 31% Myomectomies, 15% Pelvic Organ Prolapse (POP), and 4% Paravaginal repair were done with the use of the robot. Uro/gyn fellowships stated 40% Sacrocolpopexy, 27% POP were done with the robot. REI fellowships reported robot use in 12% LOA and tubal reanastomosis, 14% hysterectomies, 15% myomectomies, and 5% endometriosis cases. Approx 70% programs report that there is robotic training in the fellowship curriculum. 25% of programs have > 25 hours dedicated specifically to robotic training. 80% report hands-on training, > 50% report that simulator training is available. Finally, 50% of programs report their graduating fellows have > 50 robotic cases at completion of their fellowship.

Conclusions: Robotic surgery has become an accepted modality nationally. Systematic approach for training all GYN fellows appears to offer solutions to how we learn the robot. Incorporation of resident education remains uncultivated.

Topics: CREOG & APGO Annual Meeting, 2012, Resident, Patient Care, GME, Simulation, Gynecologic Oncology, Minimally Invasive Surgery, Reproductive Endocrinology & Infertility, Female Pelvic Medicine & Reconstructive Surgery,

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Using ACGME Competencies and Teamwork to help prepare senior medical students entering surgical specialties . A Pilot Study

Vicky Moy, BA

Nagaraj Gabbur, MD

Objective: To help prepare senior medical students entering surgical specialties using exercises based on AGCME Competencies.

Methods: Eight fourth year medical students who matched into surgical specialties were paired into teams of two to complete five exercises. These covered Professionalism (P); Practice Based Learning and Improvement (PBLI); Communication and Interpersonal Skills (CIS); Systems Based Practice (SBP); and Patient Care (PC). The AGCME core competency that was not covered was Medical Knowledge. Four students matched into Obstetrics and Gynecology and four matched into General Surgery. Each team consisted of one student from each specialty. Each team member had 7 ½ minutes to complete each exercise (15 minutes in total for each team). At the PC station, each team member had to perform a Laparoscopic task completing peg transfers. In the P station, a scenario about an impaired physician was presented and the team had to examine the ethics of the situation. In the CIS station, the teams had to laparoscopically cut a circle and could only accomplish this by team communication. In the PBLI station, teams were given an EBM exercise and in the SBP station, the teams had to work inter-professionally to complete a suturing task. The teams’ performances were recorded. Follow-up surveys were then sent to participants during their internship year.

Results: Each team was able to complete the PC, PBLI, SBP and P stations but failed to complete the CIS station. At each station, the general surgery resident would go first followed by the OB-GYN resident. Three of the four general surgery residents were unable to complete the CIS task. At each station involving surgical skills (PC, CIS, SBP), the OB-GYN residents on the average completed all tasks > 1 minute faster than their general surgery counterparts. In the PBLI Station, the resources most commonly used were Up-to-Date and MD Consult. In the P station, on the average, each team could only describe 2 out of the 5 ethical issues involved. Follow-up surveys revealed that participants did not think that the exercise improved their confidence level in their surgical skills before and after residency started. However the participants did think that it overall was an excellent preamble to skills needed during residency; very relevant in reviewing the ACGME competencies and a good introduction to the value of interdisciplinary teamwork.

Conclusion: ACGME competency-based surgical exercises and a teamwork approach can help senior medical students for residency. The OB-GYN residents were able to learn from the mistakes of their teammates and thus were able to complete their tasks faster. The CIS and P competencies were the weakest and warrant special attention. Further development of these exercises into a more structured elective can benefit future participants.

Topics: CREOG & APGO Annual Meeting, 2012, Resident, Clerkship Director, Residency Director, Patient Care, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Assessment, Simulation, Team-Based Learning, Gynecologic Oncology, Female Pelvic Medicine & Reconstructive Surgery,

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Pursuit of Board-Certified Subspecialties in Obstetrics and Gynecology by Graduating Residents, 2001-2010

William F. Rayburn, MD, MBA

Larry C. Gilstrap, MD, Norman F. Gant, MD

Winner 2012 CREOG & APGO Annual Meeting – 3rd Place Poster Presentation

Objective: A lack of growth in the number of residency positions has been compounded by a perception that more graduates wish to subspecialize rather than to function as general obstetrician-gynecologists. The objective of this study was to determine whether there has been an increase in resident graduates pursuing fellowship training in the current board-certified subspecialties.

Methods: This study examined data published annually in the ABOG (American Board of Obstetrics and Gynecology) Diplomate between 2001 and 2011. Annual comparisons were made between the numbers of graduating residents electing to pursue additional training in any of the three board-certified subspecialties. We examined the numbers who took the written examination first-time, became board-certified, and took the maintenance of certification examination in relation to those in general obstetrics and gynecology.
Results: The numbers of resident graduates who pursued and completed fellowship training increased in all three subspecialties with a progressive overall increase from 8.3% to 12.2% (p < .001). The proportion of all graduates who became board-certified in any of the subspecialties each year did not trend linearly (10.8% overall; 4.8% in maternal-fetal medicine, 3.1% in reproductive endocrinology, and 2.9% in gynecologic oncology). Board-certified subspecialists constituted 13.6% of all ACOG Fellows who took their annual maintenance of certification examination.

Conclusion: The previously reported decline in residents entering fellowships in reproductive endocrinology and maternal-fetal medicine has reversed, and the proportion of all graduating residents pursuing fellowship training in the subspecialties increased during the past 10 years. Unless there is a change in fellowship slots, we anticipate that this trend will continue for residents to fill those fellowship positions in those subspecialties. We also anticipate that board-certification in female pelvic medicine and reconstructive surgery will add another 3% into the subspecialty workforce.

Topics: General Ob-Gyn, Maternal-Fetal Medicine, Female Pelvic Medicine & Reconstructive Surgery, Reproductive Endocrinology & Infertility, Gynecologic Oncology, GME, Residency Director, Resident, 2012, CREOG & APGO Annual Meeting,

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Can Residents. Assess Themselves? - The relationship between simulation scoring and resident confidence when learning obstetrical skills

Loralei L. Thornburg University of Rochester, Rochester, NY
Erin Duecy, Eva K. Pressman
Objective: To describe how obstetrical residents view simulation for training in rarely observed and used obstetrical skills (OBS) including forceps, pudendal blocks, cerclage, amniocentesis, 3rd/4th degree repairs, and vaginal breech deliveries.

Methods: In July 2012, residents at the University of Rochester participated in a skills assessment simulation day. Residents rotated through multiple skills stations where they performed OBS on simulators, question/identification stations to evaluate knowledge of complications, indications, instruments and anatomy related to skills. Residents were observed and scored by Maternal Fetal Medicine attendings for all stations except 3/4th degree repair scored by a Urogynecologist. Skills were scored in multiple domains on a 4 point scale (1=inadequate, 2 adequate, 3 advanced, and 4 exceptional/ready to perform independently). Scores are reported as means. Residents scored their confidence and knowledge in each area using a 10-point Likert scale before and after simulation. Scores in each area were compared using a Student’s t-test between those rating themselves “high” (5-10) and those rating them “low” (0-4).

Results: Of the 32 residents in the program, 21 participated in the 7/2012 simulation day and all completed the survey. Overall, average skill performance was adequate for all OBS. Resident pre-assessment confidence in cerclage skills was associated with improved performance, as was post-assessment confidence for forceps. Confidence in other OBS skills appeared unrelated to performance. For knowledge testing, resident confidence before and after simulation for amniocentesis and forceps was associated with more correct answers, as was pre-assessment for cerclage. The majority (20/21) felt simulation was a valuable learning experience and 18/21 wanted to participate again. Most (19/21) felt it helped focus their studying and was a good assessment of knowledge and skills. Both groups identified weakness afterwards; with 13/21 residents planning to focus studying on pelvic anatomy.

Conclusions: Although some areas of confidence in knowledge were associated with improved performance on systemic assessment, the ability of pre-test confidence to predict performance was limited for most domains. This illustrates the need for objective systematic assessment to focus residents on areas of needed improvement.

Topics: CREOG & APGO Annual Meeting, 2013, Resident, Residency Director, Medical Knowledge, Professionalism, Interpersonal & Communication Skills, GME, Assessment, Simulation, Female Pelvic Medicine & Reconstructive Surgery, Maternal-Fetal Medicine, General Ob-Gyn,

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Assessing Intraoperative Judgment through the Obstetrics and Gynecology Continuum of Practice

Nathan Kow, MD
Mark D. Walters, MD, Benjamin Nutter, J. Eric Jelovsek, MD
Objectives: High-stakes decision methods that are currently used to assess intraoperative decision-making and surgical judgment of obstetrician gynecologists include a review of the candidate’s surgical case list with oral examination. Emerging alternatives to assess judgment include using a novel multiple-choice tool based on Script Concordance Theory (SCT). This method compares an examinee’s responses to a series of “ill-defined” scenarios in which correct decisions are weighted and compared to a reference panel of experts. The objectives of this study were to design, validate and establish normal passing values for an instrument to assess intraoperative judgment using SCT in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) using the spectrum of clinicians practicing Obstetrics and Gynecology.
Methods: A test consisting of 20 cases (2-3 items/case) was designed and administered to practicing OBGYN’s and designated FPMRS experts using previously valid and reliable SCT methods. Scoring was calculated for each case using a modified aggregate method. Individual expert scores were calculated based on a scoring key that excluded their own responses. Experts with scores ≥2 SD below the mean were excluded from the final panel as outliers. Participants’ tests were then scored using the final expert-scoring key. Internal consistency was measured by Cronbach alpha. Correlations between indicators of surgical experience and test scores were measured using Pearson’s correlation.
Results: Eleven experts and 134 practicing OBGYN’s completed the test. Median (range) age of practicing OBGYN’s was 46 (41-51), years in practice = 12 (10-19), annual vaginal hysterectomies = 75 (43-105), robotic hysterectomies = 0 (0-9), stress incontinence procedures = 105 (95-133) and pelvic organ prolapse procedures = 120 (85-160). Eleven expert scores were included in the final scoring key. Practicing OBGYN’s scores were significantly lower than expert’s (mean difference -4.1 (95%CI -4.9 to -3.3, P<.001). Internal consistency was good (Cronbach alpha = 0.72). There were significant correlations between indicators of surgical experience and test scores with number of vaginal hysterectomies (R=0.2, P=.016), robotic hysterectomies (R=0.17, P=.036), stress incontinence procedures (0.28, P<.001) and pelvic organ prolapse procedures (0.30, P<.001). Practicing OBGYN’s scores were standardized relative to the mean and standard deviation of the expert scores and are available to provide easy to interpret passing values for the examination.
Conclusions: The FPMRS-SCT is a reliable and valid instrument to assess intraoperative judgment of FPMRS cases, appears to have comparable psychometric qualities of oral examination methods, and is feasible to design and implement. Future studies should investigate the use of SCT methods compared to the current oral examination process or as a method of assessing judgment in maintenance of certification.

Topics: CREOG & APGO Annual Meeting, 2013, Faculty, Residency Director, Medical Knowledge, Practice-Based Learning & Improvement, GME, Assessment, Female Pelvic Medicine & Reconstructive Surgery,

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To Determine the Effect of Identifying Total Vaginal Hysterectomy (TVH) as the Default Route of Hysterectomy on Resident Surgical Experience

Alison B. Vogel, MD
Sandra D. Dayaratna, MD
Methods: We conducted an IRB approved review of all hysterectomies performed at Thomas Jefferson University Hospital between January 1, 2007 and April 30, 2010. A cohort of 353 patients who had undergone a TVH, robotic hysterectomy, or laparoscopic hysterectomy (either total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy) for benign indications was identified. Potential candidates for vaginal hysterectomy were then identified based on the assumption that a patient with at least one prior vaginal delivery, absence of prior laparotomy and uterine size less than 14 weeks would be reasonable candidates for TVH. We then obtained Accreditation Council for Graduate Medical Education (ACGME) data concerning the average reported number and types of hysterectomies performed nationally and at our institution; and looked at the impact of making vaginal hysterectomy the default route on resident numbers.
Results: Of the total number of patients who underwent minimally invasive hysterectomy, 253 (72%) were performed via laparoscopic or robotic assisted approach. Using the assumptions outlined above, 58% of the patients who underwent LAVH, 67% of those who had TLH, and 43% of those who had robotic hysterectomy could have had a TVH. According to ACGME data during the same time frame, the abdominal approach was chosen 54.65 % (64.7), laparoscopic 28.55% (3.8) and vaginal 16.81% (19.9) of the time. At TJUH abdominal cases were done 73.27 % (66.6) of the time, laparoscopic 14.74% (13.4) and vaginal 11.99% (10.9) of the time. If based on the assumption above, candidates eligible for vaginal hysterectomy had undergone TVH and the cases were divided among the chief residents during that time period, each graduating residents would have performed an additional 12 vaginal hysterectomies. This would have increased the average total number of TVH from 10.9 to 22.9 per resident, a more than 100 % increase and above the current national average of 19.9 per graduating resident.
Conclusion: Governing bodies including ACOG and the AAGL recommend hysterectomies be preferentially performed through minimally invasive surgical approaches. Trends among accredited residency programs do not currently comply with these recommendations. In addition, even though there is a move to count all minimally invasive hysterectomy as one group when it comes to residency program evaluation, TVH has a lower incidence of complications and less frequent use of expensive devices and for many reasons is the optimal route. It has become a dying art with the bulk of minimally invasive hysterectomies being performed laparoscopically. We hope that these guidelines about appropriate candidates for TVH, which should identify technically easy TVH cases, and the impact demonstrated on residency training will encourage gynecologists in academic centers to reconsider TVH and thereby train our next generation of gynecologic surgeons this important technique.

Topics: CREOG & APGO Annual Meeting, 2013, Resident, Faculty, Residency Director, Patient Care, Medical Knowledge, GME, Female Pelvic Medicine & Reconstructive Surgery,

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