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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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Improved Procedure Performance with Practice of Ultrasound Guidance Targeting Tasks

Purpose: To determine if repetitive practice of ultrasound guidance targeting tasks improves procedural skill in a simulated setting


Background: Due to a decrease in ultrasound guided invasive procedures other training methods are required to insure all MFM fellows graduate with sufficient skill to independently perform these procedures.


Methods: 1st year medical students either practiced the targeting tasks during 4 weekly one hour sessions (training group) or had no training (controls).  Afterward all performed a simulated amniocentesis (AC) and chorionic villus sampling (CVS).  Procedures were timed and the presence of the following recorded: 1) proper angle of entry, 2) excessive (>0.5 cm) needle movement during aspiration, and 3) critical errors (touching the fetus during AC, touching the opposite uterine wall or amniotic cavity during CVS).


Results: There were 22 in the training group and 15 controls.  AC completion time was 140±28 seconds (sec) vs. 211±62 sec in the training and control groups, respectively (p(0.0%) vs. 1/15 (6.7%), 3/22 (13.6%) vs. 7/15 (46.7%), and 6/22 27.3%) and 8/15 (53.3%) had improper angles, excessive needle movement (p(9.1%) vs. 10/15 (66.7%), 1/22 (4.5%) vs. 8/15 (53.3%), and 3/22 (13.6%) vs. 9/15 (60.0%)had improper angles, excessive needle movement, and critical errors, respectively (all p<0.05).


Discussions: Repetitive practice of the targeting tasks improved student performance in simulated AC and CVS.  There appeared to be greater benefit for CVS performance.  Regular practice of the targeting tasks will likely benefit MFM fellow training.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Patient Care, GME, Assessment, Simulation, Maternal-Fetal Medicine,

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Impact of the Indicated Delivery Calculator on Obstetric Residents’ Clinical Decision-Making

Purpose: Evaluating the utility of an indicated delivery calculator (IDC) in assisting residents’ determination of delivery timeline for complex obstetric scenarios.


Background: The American College of Obstetrics and Gynecologists (ACOG) mobile application includes an IDC to provide decision-making support when considering conditions that may necessitate early delivery. The utility of this IDC has not yet been studied. 


Methods: After IRB exemption, obstetric residents at our academic center (n=28) were asked to determine delivery timing for fifteen scenarios, with and without use of the IDC. A mixed effects logistic regression model assessed the change in proportion of test items correct. We conducted semi-structured interviews of the residents’ experience utilizing the calculator. Their responses were subjected to content analysis.


Results: Residents’ ability to identify the gestational age at delivery for the obstetric scenarios significantly improved after use of IDC (47% pre to 86% post; p<0.01). Positive feedback included the calculator being “user-friendly,” “convenient,” and “well-organized”. The ability to enter multiple conditions was thought to be the best feature of the application. Residents expressed desire to incorporate this tool into their practice. Criticism about the calculator included desire for more robust yet streamlined complication list, more evidence-based references and elimination of prompt for estimated due date/gestational age.


Discussions: ACOG’s IDC was effective in improving accuracy of residents’ clinical decisions regarding delivery timelines for complex obstetric scenarios.Users quickly adapted to the tool and successfully navigated the features. Streamlining the input prompts and complication choice list may improve efficiency and increase use.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, GME, Maternal-Fetal Medicine,

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Does Participation in Ob-gyn Subspecialties Improve Clerkship Clinical Scores, NBME Exam Scores, or Final Grades?

Purpose: The primary objective is to determine if participation in subspecialty rotations during Ob/Gyn core clerkships improves student performance as measured by National Board of Medical Examiners (NBME) scores, clinical evaluations and final clerkship summative grade when compared to students without focused subspecialty time.


Background: There is limited research evaluating the effect of subspecialty rotation experience during Ob/Gyn clerkships on student performance, however similar research in general surgery indicates adequate medical student competency and improvements in medical knowledge.

Results: Complete data was identified for 474 students during this study period. There was no significant difference in NMBE scores or final clerkship summative grade when comparing general track students to the subspecialty track. There was a significant difference in the clinical evaluation scores between general track and sub-specialty track students (p<0.002).  45 of the 474 students pursued an Ob/Gyn residency, 75% of whom participated in a subspecialty track.


Discussions: Exposure to subspecialty fields is not uniform during core clerkships. Our study indicates that using core clerkship time for early subspecialty exposure does not negatively impact student outcomes, and potentially improves clinical evaluations.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Clerkship Director, Clerkship Coordinator, Medical Knowledge, UME, Team-Based Learning, Gynecologic Oncology, Maternal-Fetal Medicine, General Ob-Gyn,

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

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


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


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


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


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

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

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Resident Education in Complex Obstetric Procedures: Are We Adequately Preparing Tomorrow’s Obstetricians?

Purpose: Describe resident experience with surgical obstetrics and comfort in performing those procedures after graduation.


Background: ACGME milestones and CREOG objectives for OB/GYN residents include obstetrical technical skills. Data is limited on how often graduating residents meet these. 


Methods: Anonymous 27-question e-survey sent to all US OB/GYN residents in 3/2018 via CREOG coordinator-listserv. Complex obstetric procedures included: forceps(FAVD), vacuum(VAVD), cerclage, breech second twin(B2T), breech delivery(BVD), perineal repairs, and cesarean hysterectomy. Technical skills questions included experience as primary surgeon(PS), comfort performing procedures independently(CPI), and for 4thyear residents only-comfort performing procedures post-residency(CPPR). Descriptive statistics used to analyze responses. 


Results: 417 residents completed the survey. Respondents were 88% female, 75% from academic programs, and nearly 50% were post-graduate year(PGY) 3&4.

 Among residents of all levels, many had been primary surgeon in operative vaginal deliveries(51%-FAVD,72%-VAVD) and cerclage(62%), fewer for BVD(21%) and B2T(34%), cesarean hysterectomy(21%), and 4th degree repairs(37%). For PGY 3&4, 85% were CPI VAVD, while only 34% were CPI FAVD. 14% and 37% were CPI BVD and 4th degree repairs respectively. Of the 95 PGY4 respondents, all felt CPPR either VAVD or FAVD. Nearly all felt CPPR a 3rd degree repair(97%), but almost 20% did not feel CPPR a 4th degree repair. 33% did not feel CPPR a cesarean hysterectomy, 28% and 74% did not feel CPPR with B2T and BVD respectively.


Discussions: Though ACGME and CREOG recommend that  graduating residents are able to perform complex obstetric procedures, data suggest that for many graduating chief residents, this is not the case.

Topics: CREOG & APGO Annual Meeting, 2019, Resident, Faculty, Residency Director, Patient Care, Medical Knowledge, GME, Assessment, Maternal-Fetal Medicine, General Ob-Gyn,

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A Novel Cervical Cerclage Model for Resident Training

Purpose: This study aimed to assess a novel cervical cerclage model for resident training.


Background: Vaginal suturing can be challenging to teach and to learn due to limited operative field visualization by the surgical assistant, but is a required skill for cervical cerclage placement. There is limited data on resident training and comfort with cerclage placement using models1,2.  


Methods: Residents in Obstetrics and Gynecology (OBGYN) at George Washington University were recruited to participate in a pre and post-test survey during a cerclage simulation training with a novel model. A cervical cerclage model was assembled using a 1 L water bottle, sutures and a “hair bun” maker. Continuous variables were compared using 2 tailed paired t tests.


Results: A total of 20 residents participated with a median of 2 ± 1.6 years of OBGYN residency. 95% of residents reported no prior cerclage simulation training; however, 60% reported previously placing cerclages in practice. Pre and post-test analysis showed a decrease in the perception of need for further training (4.05 ± 1.07 vs. 3.45 ± 0.86; p = 0.024) and resident reported more comfort performing the procedure with decreasing supervision (2.05 ±  1.02 vs. 2.3 ± 1.01; p = 0.021). 90% reported learning to place a cerclage was easy after the simulation, versus 45% beforehand.


Discussions: A novel cervical cerclage model in a training session significantly increased resident knowledge of and comfort regarding cerclage placement.  Future research should replicate this study, focusing on learner achievement of clinical competency and evaluate clinical outcomes.

Topics: CREOG & APGO Annual Meeting, 2019, Faculty, Clerkship Director, Residency Director, Patient Care, Medical Knowledge, GME, Simulation, Maternal-Fetal Medicine, General Ob-Gyn,

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Navigate Stormy Seas with Effective Simulation Training in Delivering Serious News


Purpose: To evaluate the change in obstetrics and gynecology (OB/GYN) resident’s self-confidence in delivering serious news after a communication simulation workshop.


Background: Although OB/GYN residents regularly disclose serious news to patients, formal training on best communication practices is lacking. Using the VitalTalk framework, we developed and evaluated a workshop for delivering serious news in OB/GYN.


Methods: OB/GYN residents attended a 3-hour small group workshop, with didactic and drills (1 hour) followed by practice delivering serious news with simulated patients (2 hours). Change in self-confidence pre- and post-workshop was measured using a 5-point Likert scale (1 is lowest, 5 is highest) and was compared using Wilcoxon signed rank test (alpha = 0.05).


Results: Twenty-five residents completed the training.  Residents agreed that delivering serious news requires a discrete set of skills (89%) and is a procedure all residents should learn (96%). Following the workshop, residents expressed greater confidence explaining medical information (p<0.01), identifying and responding to emotion cues (p<0.01), delivering serious news (p<0.001), and teaching learners about how to facilitate delivering serious news (p<0.001). Residents felt that it taught them skills they plan to use (96%), that simulated practice prepared them better than clinical experience alone (92%), that observing other residents improved their own communication skills (80%) and that they would recommend the workshop (96%).


Discussions: This workshop was well received and associated with improvement in self-confidence in delivering serious news. Longer-term observation is needed to see if this confidence persists and translates into improved patient care.

Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Patient Care, Professionalism, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, CME, UME, Simulation, Standardized Patient, Maternal-Fetal Medicine, General Ob-Gyn,

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

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


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


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


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


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

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

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Development of an Effective Comprehensive Curriculum Regarding the Patient and Provider Experience of Stillbirth

Purpose: To develop and evaluate a comprehensive curriculum about stillbirth focused on both the patient and the provider experience with this difficult topic.


Background: Pilot data from our institution showed that OB/GYN residents felt ill prepared to care for patients with stillbirth, and that training about the patient experience of stillbirth was impactful but emotionally distressing. We sought to develop a comprehensive stillbirth curriculum that included knowledge, communication skills, and emotional domains.


Methods: A four-part curriculum was created including: 1.  Medical management, 2. A stillbirth panel discussion with patients/families, 3. Simulation training in delivering serious news, and 4. Workshop on resiliency. OB/GYN residents completed pre- and post-testing for each session. Five-point Likert scales were compared using the Wilcoxon signed rank test (alpha = 0.05).


Results: All 28 residents participated in parts of the curriculum, with 85% attending two or more sessions.  Following the curriculum, we found statistically significant self-reported improvements in multiple aspects of the stillbirth training: general knowledge (p<0.01), appropriate tests to order (p<0.05), interpretation of placental pathology (p<0.01), genetic evaluation (p<0.01), comfort conveying sympathy (p<0.05), expressing emotion (p<0.01), and confidence in delivering serious news (p<0.001).  In the resiliency workshop, residents shared ideas about how faculty can support them during difficult clinical situations.


Discussions: A comprehensive stillbirth curriculum which addressed the cognitive, emotional, and skills aspects of this topic was well received and effective. Long-term data is needed to evaluate whether these improvements persist and can enhance resident satisfaction with other challenging topics within OB/GYN.


Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, CME, UME, Simulation, Lecture, Standardized Patient, Maternal-Fetal Medicine, General Ob-Gyn,

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Continued Validation for a Task Trainer and Targeting Curriculum for Ultrasound Guided Invasive Procedures

Purpose: To assess the effect of training and the inter- and intra-rater variability of a targeting curriculum for ultrasound guided invasive procedures.


Background: We previously demonstrated the content, face, and construct validity of our curriculum. Here we assess its inter- and intra-rater reliability.


Methods: Echogenic targets (wooden dowels, plastic straws, and wooden balls) were placed in water filled buckets covered with simulated skin (ballistic gelatin). We assessed 23 1st year medical students performing two targeting tasks (guiding the needle to multiple targets in a random sequence), held 4 weekly one hour training sessions, and reassessed their performance. Completion time in seconds, errors (as recorded by multiple assessors), and error adjusted time (5 sec penalty/error) were recorded. These measures were compared before and after training using a repeated measures t-test. Inter- and intra-rater inter-class correlation coefficients (ICC) were calculated.


Results: Completion time, errors, and error adjusted time on the dowel tasks were 176±70, 7.4±, 213±95, respectively before training,  and 95±61, 2.7±3.4, and 109±74, respectively after training (all p<0.0001).  The completion time, errors, and error adjusted time on the straw task were 319±98, 9.4±4.6, and 366±114, respectively before training, and 179±57, 3.1±3.2, and 195±67, respectively after training(all p<0.0001).  The inter-rater ICC for the dowel and straw tasks were 0.83 and 0.91, respectively.  The intra-rater ICCs were 0.93 and 0.90, respectively.


Discussions: Conclusions: Student performance on the targeting tasks improved markedly after 4 weekly training sessions. The inter- and intra-rater reliability was excellent. This provides additional validity evidence for our novel ultrasound guided invasive procedure task targeting curriculum.


Topics: CREOG & APGO Annual Meeting, 2018, Resident, Faculty, Residency Director, Patient Care, GME, CME, Assessment, Simulation, Maternal-Fetal Medicine,

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Continued Development and Validation of a Novel Task Trainer and Targeting Curriculum for Ultrasound Guided Invasive Procedures

Background: We previously completed a single center study using 3 targeting tasks demonstrating that a subject’s performance correlated well with their level of experience.  Here we report two additional tasks and the results of a multi-center study investigating the correlation between level of experience and performance on all 5 targeting tasks.


Methods: Echogenic targets made from wooden dowels, plastic straws, and wooden balls were placed in a water filled bucket covered with simulated skin made from ballistic gelatin.  The five targeting tasks involved serial needle touches of the targets and required participants to use the core guidance skills outlined by the American Institute of Ultrasound in Medicine including in-plane and out-of-plane guidance; and probe translation, rotation, and oblique standoff techniques.  Completion time, targeting errors, and error adjusted completion time (5 second penalty/error) were compared between 30 inexperienced (residents and junior MFM fellows) and 26 experienced providers (MFM faculty and senior fellows) from 3 different centers using a Mann-Whitney test.


Results: The raw completion time was similar for all tasks.  The number of errors and error-adjusted completion time were not different in the out-of-plane task but were lower in the experienced providers for the remaining 4 tasks by an average of 11 errors and 151 seconds.


Discussions: Except for the out-of-plane task, performance correlated well with level of experience.  Although further validation is necessary, these findings suggest our curriculum may be useful in teaching trainees to perform ultrasound guided invasive procedures.


Keywords: Assessment, Curriculum Development/Evaluation, Simulation

Topics: CREOG & APGO Annual Meeting, 2017, Resident, Faculty, Patient Care, GME, Assessment, Simulation, Maternal-Fetal Medicine,

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Cesarean Section Surgical Competency Operating Room Evaluation (CS-SCORE) Use as Assessment Tool Has a Learning Curve

Background: We had faculty all agree to a standarad procedure of performing a cesarean delivery (CD)  based on latest literature review. A CD was then video taped and recorded. Also, we adopted the Cesarean section surgical competency operating room evaluation (CS-SCORE) from the O-SCORE described in literature. The control group was those interns who learnt theCD procedure by traditional methods which included memorizing the steps & using simulation models. The video group watched a video of CD being performed along with the traditional methods. Our objective was to determine whether using a video of CD as an alternative teaching method and the CS-SCORE as an evaluation tool will help intern performance.


Methods: An evidenced based video of a primary CD was made. The 2013-14 interns comprised the controls. The interns starting July, 2014 and then July, 2015, were shown the CD video along with the traditional methods (video group). The CS-SCORE was completed by the faculty present at surgery. The video group was compared to the control. The CS-SCORE included preop preparation of patient, each step of the surgery and immediate post op care. Each of these was compared using Man Whitney test and student t test. P value


Results: Eight interns from UTMB and 6 from UCSD were included each year. 112 CS-SCORE were completed for control group and 167 for video group.  Intern survey indicated that video improved understanding and learning in a low stress environment. Comparing CS-SCORE forms revealed better performance of the controls for most of the CD steps than the video group in 2014-15 group, but equally good performance in 2015-16 video group.


Discussions: Introducing CS-SCORE form may be a useful tool for feedback provided discussion of the completed form is done with resident .• There may be a learning curve to use of CS-SCORE forms for those providing the assessment. Video of CD may be a useful tool for teaching CD to resident interns


Keywords: Assessment, Communication Skills, Evaluation of Clinical Performance, Evidence Based Practice, Faculty Development, Feedback Evaluation, Milestones, Teaching Skills, Video Creation

Topics: CREOG & APGO Annual Meeting, 2017, Faculty, Osteopathic Faculty, Residency Director, Patient Care, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, CME, Assessment, Simulation, Quality & Safety, Standardized Patient, Faculty Development, Maternal-Fetal Medicine, General Ob-Gyn,

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Bringing Basic Science to the Women\'s Health Bedside: A Proof of Concept

Background: The University of Michigan’s new curriculum emphasizes an early introduction to clinical training. This presents a challenge as it condenses two years of traditional classroom basic sciences into just one. Therefore, an elective was developed to integrate reproductive sciences into clinical training.


Methods: The elective was developed by OBGYN departmental medical education experts and faculty from the pathology department. The goal was for students to engage in patient care, and relate these experiences to underlying pathophysiology. The topic of placental pathology was chosen as a pilot, and faculty from MFM, pathology and the basic sciences were recruited.


Results: The pilot course was designed so students initially review normal placental histopathology and placental abnormalities. After following patients with interesting clinical findings, students examine specific patients’ placental histopathology with the expertise of pathologists. The latter half of the course focused on a literature search of a basic sciences topic of interest, which was presented to the department.


Discussions: We were successful in developing and offering an elective that revisits basic science education in the context of clinical activities. We identified areas for improvement, including narrowing a topic of interest earlier to allow students to expand their scientific inquiry, and realize the vast amount of resources required to optimize learning. We envision that this pilot can be broadened to include concepts such as fetal malformations, genito-urinary dysplasia, and gynecological cancers.


Keywords: Curriculum Development/Evaluation, Interdisciplinary, Research Methods, Other

Topics: CREOG & APGO Annual Meeting, 2017, Student, Faculty, Clerkship Director, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, UME, Independent Study, Maternal-Fetal Medicine,

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Quality in Your Pocket: Using Pocket Cards to Integrate Large Scale Quality Improvement into the Clerkship Year

Jan 2017 Fac Dev Workshop
Précis: Knowledge of quality improvement principles is rapidly becoming a core educational
requirement. In this workshop you will learn how one medical school integrated a year of learners into
large scale QI projects, along with the tools to create one.
Workshop Text: Objective/Background: Incorporating quality improvement (QI) into medical education
is increasingly common and has been shown to improve both patient care and learners comfort with QI,
but integrating QI into undergraduate medical education is a novel pursuit. In line with the APGO core
value of system improvement, we incorporated a large-scale QI project into the clerkship year. The
project includes didactic and experiential elements, and follows core quality measures. In this workshop
participants will engage to: incorporate QI into the clerkship year, identify measures for improved
patient care and educational outcomes, and develop accompanying student pocket cards to implement
their own projects at home institutions. Workshop Agenda: 1.Review of educational principles for QI
and educational project development. 2.Brief demonstration of how we incorporated QI into the
clerkship and measured outcomes in patient understanding, student satisfaction, knowledge and
behaviors. 3.Small group breakouts will brainstorm strategies to incorporate medical students in QI
projects and outcome measure development. 4.Following a suggested template, small groups will design
pocket cards for students to guide their participation and record outcomes. Interactive: Participants will
discuss how to creatively incorporate a QI project into your Ob-Gyn clerkship. Using guidelines, you will
design your own pocket cards for medical students to use during the clerkship. Take-home: Participants
will have designed a pocket card guide that can be used to incorporate QI into their own clerkship
curriculums, and will have developed a framework for quantifying both QI and educational outcome

Topics: General Ob-Gyn, Maternal-Fetal Medicine, Quality & Safety, UME, Practice-Based Learning & Improvement, Interpersonal & Communication Skills, Systems-Based Practice & Improvement, Professionalism, Medical Knowledge, Patient Care, Clerkship Director, Faculty, Student, 2017, Faculty Development Seminar,

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Empowering Students for Improved Patient Outcome: Prevention of Venous Thrombotic Events in Pregnant Patients

Background: Pregnancy significantly increases the risk of VTEs in women. In the US, pregnancy-related mortality has been increasing with deaths due to VTEs representing a leading cause. To address this issue, a quality improvement study was designed to increase rates of VTE risk assessment and appropriate prophylaxis. By engaging medical students, they gain exposure to quality improvement processes in the healthcare setting and improve their clinical skills by counseling patients.


Methods: This study is part of a curriculum-wide integration of all third-year medical students into departmental quality improvement projects across the required clerkships. In the obstetrics and gynecology clerkship, students calculated obstetric patients\' risk of VTEs. Students worked with their teams to put in place appropriate prophylactic measures and then provided patient counseling regarding the recommended interventions. Medical students completed pre- and post-tests about their VTE knowledge and a survey regarding their experience with the study.


Results: 94% of third-year medical students who had completed their obstetrics and gynecology clerkship participated in this study. 76% of these students responded to a survey about their participation. Of these respondents, 92% reported participation had improved their understanding of obstetric VTE prophylaxis, 77% reported they had gained confidence counseling patients, and 69% reported having a better understanding of quality improvement in the healthcare setting.


Discussions: This study demonstrates that medical students can be engaged in a large-scale quality improvement initiative with the goal of improving patient outcomes. In addition to advancing the success of a departmental patient safety initiative, students reported increased medical knowledge and clinical skills.


Keywords: QI student engagement

Topics: CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Patient Care, Medical Knowledge, GME, Quality & Safety, Maternal-Fetal Medicine, General Ob-Gyn,

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Improving Communication Among Faculty, Residents and Nursing on Labor and Delivery Through Multidisciplinary Fetal Heart Tracing Rounds

Background: ACGME milestones for resident education in obstetrics and gynecology include resident participation in departmental or institutional quality improvement and safety initiatives. Given the current multidisciplinary model of health care delivery, it is especially important that residents learn to work well and effectively with other members of the collective team. On Labor and Delivery this is especially important as effective communication is essential to achieving the best outcome for mothers and their unborn infants.  


Methods: The Safety Attitudes Questionnaire® was given to all members of Labor and Delivery. Team members then participated in Fetal Heart Tracing Rounds during Ob/Gyn Resident Education time. After 4 sessions, the questionnaire was redistributed and answers were compared using the Cochran-Armitage Trend Test. The patient responses were measured through a Press Ganey® satisfaction survey.


Results: Communication improved between nurse to nurse (p = 0.005) and nurse to OB Resident (p = 0.0256). Communication improvement between Family Medicine and OB Resident nearly achieved statistical significance (p = 0.074). Patient survey responses indicate a perceived improvement in communication among physician and nursing teams.


Discussions: Communication failure is identified in a high proportion of sentinel events. Data gained from this study indicate that communication among providers in intrapartum care can be improved with implementation of multidisciplinary fetal heart tracing rounds. Long-term goal of this initiative will be to correlate improvement in communication among Labor and Delivery care providers with a decrease in adverse maternal and fetal events.


Keywords: Communication, Safety, Obstetrics

Topics: CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Residency Director, Patient Care, GME, Problem-Based Learning, Team-Based Learning, Maternal-Fetal Medicine,

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Effect of a Warm-up on Cervical Examination Accuracy in Medical Students

Background: The impact of immediate pre-procedure practice, or “warm up”, on labor cervical exam accuracy has not been assessed.  As an alternative to performing such an experiment on patients, we have investigated whether warm up with a low fidelity task trainer improves accuracy on a high fidelity model.


Methods: Druing the 6 weeks OB/GYN clerkship, 3rd year medical students were required to complete 130 simulated cervical exams using high fidelity silicone training models.  Prior to an end of clerkship assessment a group of students performed a warm-up of 10 exams with a low-fidelity PVC pipe trainer and were given the correct dilation and effacement of each model.  The control group did not have the opportunity to practice.  As a final assessment, all students then performed 10 cervical exams on the high fidelity trainers, and accuracy was compared between groups.


Results: For dilation, the accuracy for warm up students (n=15) and controls (n=12) was 69 ± 22% & 66 ± 19%, respectively.  For effacement, the accuracy for warm up students and controls was 93± 7% & 88 ± 10%, respectively.  There were no statistical differences in either comparison.


Discussions: Although we hypothesized that pre-procedure simulation would lead to improved exam accuracy, we did not see any increase in accuracy with warm-up.  Larger studies should be performed to better assess the effects of warm-up on this crucial obstetrical skill.


Keywords: Cervical exam Simulation

Topics: CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Clerkship Director, Residency Director, Patient Care, Interpersonal & Communication Skills, GME, UME, Assessment, Simulation, Maternal-Fetal Medicine,

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Delivering Bad News in Obstetrics and Gynecology Residency: A Pilot Curriculum to Address Identified Training Gaps

Background: A recent literature review identified no publications on resident training in diagnosing and counseling patients on fetal demise. A previous needs assessment identified resident training gaps in the following areas: 1) communication skills in delivering bad news, 2) bereavement support and 3) counseling and consenting for the postmortem evaluation of the stillborn.


Methods: A 3-pronged curriculum, created and implemented to address the identified needs, included: directed readings, didactic lectures, and standardized patient simulation.  Residents were surveyed pre and post-intervention to assess impact of the curriculum.  Results were compared using McNemar’s Test.


Results: Fourteen of 21 residents completed the curriculum.  Resident self-assessed confidence significantly increased in: initiating proper workup after stillbirth (85.7% post vs  50% pre-intervention, p=0.025), addressing patient anxiety and grief (100% post vs 71.43% pre, p = 0.045), and consenting for autopsy (100% post vs 50% pre, p = 0.008).  The curriculum successfully addressed the gaps in training identified in grief management and autopsy counseling. A post-intervention objective measure demonstrated significant improvement in resident knowledge.


Discussions: This novel curriculum significantly improved residents’ confidence and competence in diagnosing and counseling a fetal demise. Our department has integrated this successful training program into the residents’ formal curriculum. We are sharing it as a model with neighboring institutions to further evaluate and expand this project.


Keywords: Curriculum, Obstetrics/education, Communication

Topics: CREOG & APGO Annual Meeting, 2016, Resident, Faculty, Residency Director, Patient Care, Medical Knowledge, Professionalism, Interpersonal & Communication Skills, GME, Assessment, Simulation, Standardized Patient, Maternal-Fetal Medicine,

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Cesarean Section BOX Simulator – Utilizing CREOG Resources to Develop Surgical Skills

Background: Development of surgical skills is a necessary step for all surgeons. Learning environments such as hospital-based training institutions often train interns with limited or no surgical experience. Simulation models remove patient factors and allow for a safe learning environment. The CREOG modules are available for all ACOG members but have not been universally adopted by residency programs.


Methods: We constructed the Cesarean section BOX simulator using the published CREOG instructions. Each of six interns of the 2014-2015 academic year of the LSU HSC Obstetrics and Gynecology received their own model. Senior level residents led the workshop on the BOX simulators with the interns.


Results: All six interns participated in the Cesarean section BOX simulators.  After their experience as learners, the interns then transitioned to teachers, with the rotating medical students.


Discussions: Utilizing the Cesarean section BOX simulator introduced and supplemented the surgical skills of new interns. Additionally, the BOX simulators served as “repeat Cesarean sections” with repetition of the simulation. Introduction of this CREOG simulation for Cesarean section has prompted the program to explore other modules for future simulations.


Keywords: Simulation, CREOG, C-section

Topics: CREOG & APGO Annual Meeting, 2016, Student, Resident, Faculty, Clerkship Director, Clerkship Coordinator, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Practice-Based Learning & Improvement, GME, Simulation, Maternal-Fetal Medicine,

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