Time Differences From Abnormal Cervical Cancer Screening to Colposcopy Between Insurance Statuses.

OBJECTIVE: Screening and diagnostic follow-up to prevent cervical cancer are influenced by socioeconomic and systemic factors. This study sought to characterize intervals from abnormal cervical cancer screening to colposcopy between practices differing by insurance status at a large, urban academic center. MATERIALS AND METHODS: This retrospective cohort study included patients aged 21-65 who presented for colposcopy between January 1, 2021, and January 1, 2022, at the resident and faculty gynecology practices of a single large urban academic medical center. Patient characteristics were compared using t tests or Wilcoxon rank sum tests for continuous measures and χ 2 or Fisher exact tests for categorical measures. Intervals from abnormal cervical cancer screening to colposcopy were compared using the Wilcoxon rank sum test and linear regression analysis with multivariable models adjusted for age, cervical cytology result, human papillomavirus result, and HIV status. RESULTS: Resident practice patients were publicly insured and more likely to be Black or Hispanic ( p < .0001); rates of high-risk human papillomavirus and smoking were similar. Resident practice patients had longer intervals from abnormal cervical cancer screening to colposcopy compared with faculty practice patients (median 79.5 vs 34 d, p < .0001). On adjusted analysis, resident practice patients faced a 95% longer interval ( p < .0001). CONCLUSIONS: Publicly insured patients of a resident-based practice faced significantly longer intervals from abnormal cervical cancer screening to colposcopy than faculty practice patients at a single urban academic center. Effort to address these differences may be an area of focus in improving health disparities.

A Medical Student Obstetric Curriculum Consisting of Online Modules and a Normal Spontaneous Vaginal Delivery Simulation Exercise.

OBJECTIVE: In many medical schools, students are exposed to obstetrics for 2 weeks during the third-year obstetrics and gynecology clerkship. Hence, the purpose of this study was to evaluate the effectiveness of a curriculum combining online obstetric modules and a normal spontaneous vaginal delivery (NSVD) simulation on medical student knowledge and comfort pertaining to obstetrics at the start of the clerkship. METHODS: Students completed the curriculum at the start of the clerkship. They completed questionnaires before and after each module and the simulation. The questionnaires assessed knowledge, management comfort level, and satisfaction with module/simulation. Comfort level and satisfaction scores were based on a 1-5 Likert scale (1 = very uncomfortable/unfavorable, 5 = very comfortable/favorable). Satisfaction scores for online modules were compared with those for a historical cohort of traditional lectures on the same topics. Students also rated satisfaction with the curriculum. RESULTS: Sixty students participated. Mean knowledge and comfort scores significantly increased from 7.2 to 9.2 (P < .001) and from 2.7 to 3.9 (P < .001) before and after the modules, respectively. Although satisfaction scores for traditional lectures were significantly higher than for online modules (4.7 vs. 4.4, P < .001), online modules were still favorably received. Mean satisfaction score for the NSVD simulation was 4.8. Overall, satisfaction score for the curriculum was 4.5. DISCUSSION: An obstetric curriculum consisting of online modules and simulation significantly increases medical student learner knowledge and comfort and is associated with a high level of satisfaction.

Transition From Normative to Criterion-Based Grading in the Obstetrics and Gynecology Clerkship.

OBJECTIVES: To compare grades, National Board of Medical Examiners (NBME) Shelf Exam scores, and student satisfaction with the Obstetrics and Gynecology (OB/GYN) clerkship after transitioning from normative to criterion-based grading. METHODS: Between July 2021 and July 2022, the Icahn School of Medicine at Mount Sinai (ISMMS) adhered to a normative grading scheme in which ∼60% of students achieved a grade of Honors, 30% achieved a grade of High Pass and 10% achieved a grade of Pass for the OB/GYN clerkship. In July 2022, ISMMS transitioned to a criterion-based scheme. In this scheme, 6 competencies were created. Criteria were determined for each competency, delineating achieving a score of "Pass" versus "Honors" for the specific objective. Students needed to meet the criteria for Honors for 4 out of 6 of the competencies in order to ultimately receive a grade of Honors for the clerkship. The number of students achieving Honors, NBME shelf exam scores, and student clerkship satisfaction ratings between the normative and criterion-based schemes were compared. RESULTS: The number of students studying in academic year (AY) 2021-2022 and AY 2022-2023 were 134 and 137, respectively. A significantly lower percentage of students received Honors in AY 2021-2022 than in AY 2022-2023 (66% vs. 96%, P < .01). Mean exam scores were significantly higher for those receiving Honors in AY 2021-2022 than in AY 2022-2023 (P < .05); scores for AY 2021-2022 and AY 2022-2023 were 78.9, 95% CI [77.6, 80.1] and 76.7, 95% CI [75.6, 77.8], respectively. Mean exam scores for all students were not significantly different between the 2 academic cohorts (77.8 vs. 76.2, P = .06). Clerkship satisfaction rating was significantly higher in AY 2022-2023 than in AY 2021-2022 (4.1 vs. 3.7, P < .05). CONCLUSIONS: These findings support a paradigm that compares learner performance to predefined measures as opposed to peer performance.

Call for Action: Undergraduate Medical Education Assessment-Advocating for a Transition From Tiered to Competency-Based Grading.

Traditionally, undergraduate medical education (UME) grading has been based on a tiered system. Tier-based grading can cause anxiety as medical students are compared to their peers. Students then become overly driven by the pursuit of creating favorable impressions by supervisors as well as by high grades. Additionally, the emphasis on normative parameters appears to misalign with the goal of UME which is to not sort learners into different residency programs but to train future doctors to meet the needs of society. This commentary is a call for action to shift from utilizing a normative-based grading paradigm in UME to implementing one in which learners are being assessed on their ability to attain specific competencies. It is important that UME transitions to competency-based assessments as the graduate medical education (GME) realm has already adopted this framework.

Colposcopy and Loop Electrosurgical Excision Procedure: A Simulated Exercise.

Introduction: Cervical intraepithelial neoplasia 3 is associated with a high degree of progression to cervical cancer. Its risk is markedly reduced after excisional treatment. Hence, it is critical that providers accurately diagnose and treat this condition. We present a simulation-based module focused on resident mastery of performance of colposcopy and loop electrosurgical excision procedure (LEEP). Methods: Learners were obstetrics and gynecology residents. Guidelines on performance of colposcopy and LEEP were presented prior to module participation. We used pelvic task trainers, kielbasa sausages, and routine equipment for performance of colposcopy and LEEP. Colposcopy and LEEP sessions each lasted 30 minutes. Learners completed questionnaires before and after regarding comfort level on aspects of colposcopy and LEEP performance and level of agreement with statements on performing procedures independently. Comfort levels and degrees of agreement were based on 5-point Likert scales (1 = very uncomfortable/strongly disagree, 3 = neither comfortable nor uncomfortable/neutral, 5 = very comfortable/strongly agree, respectively). Results: Modules were held in November 2021 and May 2022. Thirty-four residents participated. Mean comfort scores significantly increased from 3.1 to 4.3 (p < .001) before and after the module for all steps. There was an increase in level of agreement with statements on being able to independently perform colposcopy (2.2 to 3.5, p < .01) and LEEP (2.9 to 3.6, p = .06). Discussion: Simulation-based modules on performance of colposcopy and LEEP significantly increased resident learner comfort in the performance of these procedures. Comfort in performing these procedures is important in providing comprehensive gynecologic care.

Improving the Prevention, Detection, and Management of Delirium in Adult Inpatients; an Interprofessional Consultative Team Pilot Project.

Delirium is a common, often preventable fluctuating state of cognition associated with increased morbidity and mortality. This report describes the implementation of an interprofessional consultative Delirium Team formed to improve the prevention, detection, and management of delirium in a community hospital. Team members consulted refered inpatients with delirium to establish a care plan and provide recommendations for pharmacological and non-pharmacological management. The team also offered delirium-related education to unit staff, patients, and caregivers. Consultations were initially completed by the team Nurse Practitioner or Occupational Therapist, and complex patients were discussed with the team Geriatrician and Psychiatrist at rounds to optimize specialist input. Of the 160 patients managed by the team over the 8-month study period, two-thirds of referred patients did not require specialist consultation for their delirium management. Strategies most often recommended by experts for managing delirium were related to medical management, social/cognitive engagement, and functional mobility. Two-thirds of all recommendations made by the team were implemented. Barriers and facilitators to implementation and improving unit staff adherence are further described. The consultative Delirium Team is a promising model that should be further explored for managing an aging population in a capacity-limited medical system.

A Medical Student Postpartum Telehealth Initiative During the COVID-19 Pandemic.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on our health systems and delivery of care and on the disruption of medical education. It has forced hospitals to move to a telehealth model for prenatal and postpartum visits and expedite discharges for postpartum patients in order to reduce exposure. We describe our medical school and hospital system initiative to employ medical student volunteers for postpartum telehealth calls during the peak of the COVID-19 pandemic in New York City. DESCRIPTION: Ten medical students conducted phone interviews with postpartum patients within 72 h of discharge at three hospitals in a large NYC health system, with faculty preceptors at each site who provided daily call assignments and oversight. Students called patients to screen for risk factors for postpartum complications, including preeclampsia and postpartum depression; provide additional contraception counseling; and address newborn care and health. One week and 2 week post-discharge calls were also made for COVID-19 positive patients for ongoing symptom monitoring and counseling. ASSESSMENT: We found numerous opportunities for intervention in postpartum health via telehealth, including addressing pharmacy-related needs, patient counseling, improving pain management, and identifying patients in need of emergent re-evaluation. CONCLUSION: As this pandemic continues to evolve, our model demonstrates the feasibility of telehealth and medical student involvement in postpartum care and its benefits to patients, medical student learning, and alleviation of burden on obstetric staff.

A Three-Year Analysis of the Impact of a Student-Run Gynecology Clinic on Access to Reproductive Health Care for Uninsured Women in East Harlem.

The East Harlem Health Outreach Partnership (EHHOP) is a medical student-run and attending-supervised clinic that provides primary care to predominantly Spanish-speaking, uninsured patients living in East Harlem, New York. In 2010, the clinic launched a Women's Health Clinic (WHC), to offer comprehensive gynecologic and reproductive healthcare under the guidance of faculty gynecologists. In this cross-sectional study, we analyzed WHC data from January 2018 to March 2021. Over this period, 59 individual patients were seen over 39 clinical sessions through a total of 164 clinical encounters staffed by 43 medical students and 19 faculty preceptors from the Department of Obstetrics and Gynecology at Mount Sinai. The most common reasons for referral to the EHHOP WHC were abnormal uterine bleeding, contraception counseling, and management of abnormal Pap smears; the most common procedures performed were Pap smears, long-acting reversible contraception placements and removals, and colposcopies. We discuss the critical role that student-run, physician-supervised reproductive health clinics play in reducing disparities in gynecologic care for uninsured women.

Successful Implementation of a Medical Student Postpartum Follow-up Phone Call Project.

Introduction: The American College of Obstetricians and Gynecologists recommends prompt postpartum follow-up. However, 40% of women do not attend postpartum visits. These rates are lower in populations with limited resources. In response, the Department of Obstetrics, Gynecology, and Reproductive Science in the Mount Sinai Health System created a postpartum follow-up phone call project that utilized medical students and was conducted at three health system hospitals from April 6 to May 30, 2020. Methods: The number of patients contacted by medical students within 72 hours of hospital discharge was recorded. Students at two of the three sites also recorded the number of patients who needed (1) urgent evaluation and subsequent hospital readmission, (2) medications prescribed, and (3) referral for social work services. Students completed questionnaires at the project beginning and end regarding confidence in rendering of postpartum care. Confidence level was based on a 5-point Likert scale (1 = not confident at all, 5 = very confident). Results: Nine students participated. Overall, confidence on providing postpartum care significantly increased from 2.2 to 3.7 (p < .001). Three hundred eighty-seven patients were contacted. Four patients were advised to return to the hospital emergently; two were readmitted. Forty-seven patients needed medication prescribed. Two patients were referred for social work services. Discussion: Our medical student-driven postpartum follow-up phone call project was associated with a high number of patients called and management of significant postpartum issues. Students' confidence in managing postpartum issues was significantly higher after versus before project participation.

Management of Pre-eclampsia and Eclampsia: A Simulation.

Introduction: Pre-eclampsia is a hypertensive disorder in pregnancy. Maternal sequelae that may occur include impaired liver function, disseminated intravascular coagulation, seizures (eclampsia), stroke, and death. Thus, providers should know how to recognize (diagnose) and treat pre-eclampsia and eclampsia. Methods: A simulator with noninvasive blood pressure monitoring was used. Transducers for fetal heart rate and contraction monitoring were placed on the simulator, which represented the patient. After obtaining a history and performing a physical examination, resident physician (postgraduate years 1-4) and nurse learners had to diagnose pre-eclampsia and treat this condition. They also had to treat severe-range blood pressures and manage eclampsia. Learner performance was assessed with a checklist. Debriefing followed the simulation. Results: Thirty resident learners participated in the study. Nurses did not participate. All resident learners indicated familiarity with the diagnosis and management of pre-eclampsia and emergent hypertension and managed these conditions correctly. All resident learners reported not being confident in managing eclampsia. None of the learners were able to stop the eclamptic seizure. All resident learners were more confident in managing eclampsia after the scenario compared with before (mean confidence level 3.6 ± 0.5 vs. 1.1 ± 0.4, p < .001). Discussion: Resident learners were familiar with the management of pre-eclampsia and emergent hypertension but not with eclampsia. We recommend that eclampsia simulations occur in a laboratory and in situ on the labor and delivery floor with interprofessional team members including obstetricians, nurses, anesthesiologists, emergency and family medicine physicians, nurse practitioners, and physician assistants.

Imperforate Hymen Causing Hematocolpos and Urinary Retention.

BACKGROUND: Acute urinary retention is rare in the pediatric population and is typically caused by an obstructing entity. It may result from hematocolpos caused by imperforate hymen. Imperforate hymen is rare, with an associated incidence of 1 in 2000 people. Nonetheless, in a pediatric age female who presents with urinary retention and who has a history of primary amenorrhea or a history of cyclical pelvic pain an examination of the external genitalia should be performed to rule out this condition. CASE REPORT: A 12-year-old girl presented to the emergency department with urinary retention and was discharged with a diagnosis of urinary tract infection. She returned the following day to the emergency department with worsening abdominal pain. A computed tomography scan revealed a fluid-filled vagina measuring 12.5 cm. Her bladder measured 15.4 cm. The patient was taken to the operating room for further evaluation by the consulting gynecologist. At the time of surgery, 1000 mL of urine were evacuated after catheterization. Three hundred milliliters of chocolate-colored fluid, consistent with menstrual blood, were evacuated at time of hymenotomy. Hymenotomy was performed with a cruciate incision. No complications were encountered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To date, there have been >40 reported cases of imperforate hymen causing hematocolpos and subsequent urinary retention. However, given the rarity of imperforate hymen, hematocolpos leading to acute urinary retention can still be missed. Untreated urinary retention can lead to a compromise in bladder function and subsequent kidney damage.

Third-Trimester Maternal Vaccination Against Pertussis and Pertussis Antibody Concentrations.

OBJECTIVE: To compare pertussis antibody concentrations in maternal venous serum (at the time of delivery) and umbilical cord arterial serum among women vaccinated with the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine from either 27-30 6/7 weeks of gestation or from 31-35 6/7 weeks of gestation. METHODS: We conducted a prospective cohort study of pregnant women divided into two groups based on when Tdap was administered: 27-30 6/7 weeks of gestation and 31-35 6/7 weeks of gestation. Paired maternal and umbilical cord samples were obtained at the time of delivery to determine immunoglobulin G (IgG) concentrations to pertussis toxin and pertactin. RESULTS: Eighty-eight pregnant women were enrolled. Cord serum pertussis toxin IgG concentrations were approximately twice maternal serum pertussis toxin IgG concentrations (91.6 vs 48.6 enzyme-linked immunoassay [ELISA] units/mL, P<.01) and were significantly correlated (Pearson correlation coefficient=0.85, P<.01). There was no significant difference in maternal serum pertussis toxin IgG concentrations (48.6 vs 48.6 ELISA units/mL, P=.99), cord serum pertussis toxin IgG concentrations (92.1 vs 90.7 ELISA units/mL, P=.95), and cord serum pertactin IgG concentrations (798 vs 730 international units/mL, P=.73) between the two groups. Furthermore, there was no correlation between time from vaccination to delivery and these three parameters. Cord serum pertussis toxin IgG concentrations were greater than 10 ELISA units/mL (ie, in the protective range) in 87% and 97% of those vaccinated from 27-30 6/7 weeks of gestation and from 31-35 6/7 weeks of gestation, respectively (P=.13). CONCLUSION: Maternal vaccination against pertussis between 27 and 36 weeks of gestation was associated with a high percentage of newborns with antibody concentrations conferring protection and did not vary by gestational age at vaccination.

Bakri balloon placement in the successful management of postpartum hemorrhage in a bicornuate uterus: A case report.

INTRODUCTION: Postpartum hemorrhage is an obstetric emergency that accounts for 25% of maternal deaths worldwide. Initial management consists of uterotonic administration but in cases in which there is a failure of response to medication, uterine cavity tamponade can be effective. This is the first reported case of successful Bakri balloon placement in the management of postpartum hemorrhage at the time of cesarean delivery in a patient with a bicornuate uterus. PRESENTATION OF CASE: The patient was a primigravid female who presented at 40 weeks and 1day gestation with known bicornuate uterus and findings suggestive of placental abruption. Labor was subsequently induced and magnesium was administered after a diagnosis of preeclampsia with severe features was made. Cesarean delivery was then performed for category II fetal heart rate tracing remote from delivery. Intraoperative course was significant for uterine atony unresponsive to oxytocin, carboprost, methylergonovine and misoprostol administration. The right uterine horn was noted to be markedly atonic compared to the left. A Bakri balloon was then placed transvaginally and inflated with 600mL of saline in this location. Atony then resolved. DISCUSSION: Although uterine malformation is not a documented contraindication to Bakri balloon placement, there is no literature on its efficacy in the treatment of hemorrhage in the presence of this anomaly. CONCLUSION: In the management of postpartum hemorrhage, Bakri balloon placement is associated with success in the presence of a bicornuate uterus. Care should be taken to direct insertion of the balloon in the appropriate location.

Nurses in Action: A Response to Cultural Care Challenges in a Pediatric Acute Care Setting.

Culturally congruent care is satisfying, meaningful, fits with people's daily lives, and promotes their health and wellbeing. A group of staff nurses identified specific clinical challenges they faced in providing such care for Hispanic and underserved Caucasian children and families in the pediatric medical-surgical unit of an urban regional children's hospital in the southeastern U.S. To address these challenges, an academic-practice partnership was formed between a group of nurse managers and staff nurses at the children's hospital and nursing faculty and graduate students at a local, research-intensive public university. Using the culture care theory, the partners collaborated on a research study to discover knowledge that would help the nursing staff resolve the identified clinical challenges. Twelve families and 12 healthcare providers participated. Data analysis revealed five care factors that participants identified as most valuable: family, faith, communication, care integration, and meeting basic needs. These themes were used to formulate nursing actions that, when applied in daily practice, could facilitate the provision of culturally congruent care for these children and their families. The knowledge generated by this study also has implications for healthcare organizations, nursing educators, and academic-practice partnerships that seek to ensure the delivery of equitable care for all patients.