Concordance Rates Between Resident-Performed Ultrasound Measurements and Certified Sonographer Measurements.

OBJECTIVES: To evaluate the accuracy of ultrasound (US) estimated fetal weight (EFW) measurement compared with neonatal birth weight when performed by residents versus certified sonographers. The hypothesis tested was that residents and certified sonographers would not differ significantly in EFW or in EFW compared with neonatal birth weight. METHODS: A retrospective chart review of 142 inpatients from July 2010 to May 2011 was conducted. Ultrasound examinations were performed by a resident physician and a certified sonographer within 7 days after the resident. Standard US measurements obtained were head circumference, biparietal diameter, abdominal circumference, femur length, estimated gestational age, and EFW. Gestational age ranged from 20 to 39 weeks. The time from US to delivery, residency year, and birth weight were collected. Measurements were compared by paired t tests, the Wilcoxon signed rank test, and repeated-measures analysis of variance. RESULTS: The US EFW by residents and sonographers showed excellent concordance with each other regardless of the neonatal birth weight. The resident and sonographer EFW each showed excellent concordance with the neonatal birth weight, and this concordance did not differ significantly between residents and sonographers for neonates weighing less than 1000 g (P = .61) and neonates weighing greater than or equal to 1000 to less than 2000 g (P = .93). The resident EFW (P < .05) and sonographer EFW (P < .01), however, were less than the neonatal birth weight for larger neonates (≥2000 g), but the degree of underestimation was not significantly different between residents and sonographers (P = .51). CONCLUSIONS: Accurate EFW is critical for prenatal management. These data support the value of a dedicated month of US training in residency programs.

Single-Use Energy Sources and Operating Room Time for Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVES: To compare the intraoperative direct costs of a single-use energy device with reusable energy devices during laparoscopic hysterectomy. DESIGN: A randomized controlled trial (Canadian Task Force Classification I). SETTING: An academic hospital. PATIENTS: Forty-six women who underwent laparoscopic hysterectomy from March 2013 to September 2013. INTERVENTIONS: Each patient served as her own control. One side of the uterine attachments was desiccated and transected with the single-use device (Ligasure 5-mm Blunt Tip LF1537 with the Force Triad generator). The other side was desiccated and transected with reusable bipolar forceps (RoBi 5 mm), and transected with monopolar scissors using the same Covidien Force Triad generator. The instrument approach used was randomized to the attending physician who was always on the patient's left side. Resident physicians always operated on the patient's right side and used the converse instruments of the attending physician. MEASUREMENTS AND MAIN RESULTS: Start time was recorded at the utero-ovarian pedicle and end time was recorded after transection of the uterine artery on the same side. Costs included the single-use device; amortized costs of the generator, reusable instruments, and cords; cleaning and packaging of reusable instruments; and disposal of the single-use device. Operating room time was $94.14/min. We estimated that our single use-device cost $630.14 and had a total time savings of 6.7 min per case, or 3.35 min per side, which could justify the expense of the device. The single-use energy device had significant median time savings (-4.7 min per side, p < .001) and total intraoperative direct cost savings ($254.16 per case). CONCLUSIONS: A single-use energy device that both desiccates and cuts significantly reduced operating room time to justify its own cost, and it also reduced total intraoperative direct costs during laparoscopic hysterectomy in our institution. Operating room cost per minute varies between institutions and must be considered before generalizing our results.

A second opinion: response to 100 professors.

Induced abortion is a controversial topic among obstetricians. "100 Professors" extolled the benefits of elective abortion in a Clinical Opinion published in AJOG. However, scientific balance requires the consideration of a second opinion from practitioners who care for both patients, and who recognize the humanity of both. Alternative approaches to the management of a problem pregnancy, as well as short and long term risks to women as published in the peer reviewed medical literature are discussed. Maintaining a position of "pro-choice" requires that practitioners also be given a right to exercise Hippocratic principles in accordance with their conscience.

The third stage of labor: a study of outcomes in the second trimester of pregnancy.

OBJECTIVE: To evaluate the length of the third stage of labor in second trimester pregnancies, to determine the rate of complications such as hemorrhage or infection, and to determine the ideal timing for delivery of the placenta in these pregnancies. STUDY DESIGN: A review of 121 consecutive vaginal deliveries between 16 and 27 gestational weeks was performed. Length of the third stage of labor was determined, as well as the composite endpoint of need for manual or instrumented removal of the placenta, or development of chorioamnionitis or endometritis. RESULTS: Women who delivered at < 23 weeks' gestational age had a significantly longer length of the third stage of labor than did women who delivered at > or = 23 weeks' gestational age (47 minutes vs. 11 minutes, p < 0.01) and were more likely to have chorioamnionitis (30.6% vs. 12.5%, p < 0.05). A third stage of labor > 30 minutes was associated with an increase in manual or instrumented delivery of the placenta (49.0% vs. 14.9%, p < 0.002), a greater decrease in hemoglobin (-1.6 g/dL vs. -0.8% g/dL, p < 0.01), and a higher rate of chorioamnionitis (35.8% vs. 13.6%, p < 0.01). Receiver operating characteristic curve analysis showed optimal timing for delivery of the placenta is < 60 minutes. CONCLUSION: Midtrimester deliveries are at increased risk of retained placenta and chorioamnionitis. The optimal timing for placenta delivery is < 60 minutes.

Stiff person syndrome and pregnancy.

BACKGROUND: Stiff person syndrome, also known as Moersche-Woltman syndrome, is a debilitating disorder that is rarely seen in the pregnant patient. It is characterized by muscle spasms triggered by startle, voluntary movement, or tactile or emotional stimuli, occurring predominantly in the axial musculature. CASE: A woman diagnosed with stiff person syndrome became pregnant 2 months after her diagnosis. Her medication regimen was adjusted because of pregnancy, and anesthesia was initiated early in labor to control her pain. She was able to have a full-term pregnancy with few complications. CONCLUSION: Stiff person syndrome may be successfully managed in pregnancy. Patients can deliver vaginally with adequate pain control to avoid muscle spasms.

Are medical students agreeable? An exploration of personality in relation to clinical skills training.

BACKGROUND: Clinical competencies like trust, empathy, and cooperation are emphasized in medical school curricula. Agreeableness, a personality domain, reflects these competencies. It is unclear, however, whether medical student personality is intrinsically agreeable. AIM: We explored whether medical student personality reflects Agreeableness, and compared student Agreeableness with that of police officer recruits, a group in which high Agreeableness is not preferred. METHODS: Students and recruits completed the Revised NEO Personality Inventory, which measures domains of the five-factor model: Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness. RESULTS: Medical student Agreeableness was at average levels. Students were high in Extraversion and Openness, reflecting personal growth, leadership, problem solving, and influencing. Relative to recruits, students had higher Neuroticism and Openness and lower Conscientiousness. Agreeableness and Extraversion did not differ. Using discriminant analysis, Neuroticism, Openness, and Conscientiousness accurately classified 77% of students and recruits. CONCLUSION: Medical students were not inordinately agreeable. They were ambitious, intellectually-creative problem solvers with a preference to direct/influence. Clinical skills training that acknowledges this style may enhance clinical education processes. Model-based methods for clinical skills--including agenda-setting, conflict resolution, and alliance making - that require mastery of techniques and have evidence-based relevance to patient care may be useful adjuncts to conventional clinical training.

Do clinical evaluations in a psychiatry clerkship favor students with positive personality characteristics?

OBJECTIVE: The authors examine associations of personality characteristics, National Board of Medical Examiners subject examination performance, and Objective Structured Clinical Examination performance with clinical evaluations of third-year medical students in a psychiatry clerkship. METHODS: Students completed the Revised NEO Personality Inventory, which measures personality domains of neuroticism, extraversion, openness, agreeableness, and conscientiousness and associated personality traits. At clerkship completion, students completed the National Board of Medical Examiners subject examination and a psychiatry Objective Structured Clinical Examination, and were evaluated by attending physicians (using a standardized evaluation form) regarding their clinical "knowledge and skill" and "interpersonal behavior." Data were analyzed using Pearson correlation and canonical correlation. RESULTS: National Board of Medical Examiners subject examination and Objective Structured Clinical Examination scores were uncorrelated with clinical evaluations of "knowledge and skill" and "interpersonal behavior." Personality variables explained a moderate amount of variance in clinical evaluations. "Knowledge and skill" was positively associated with the domain of conscientiousness, the extraversion trait of warmth, and the conscientiousness traits of competence and achievement striving. "Interpersonal behavior" was negatively associated with the neuroticism trait of angry hostility and positively associated with the domain of agreeableness; the extraversion traits of warmth, gregariousness, and positive emotions; and the agreeableness traits of trust, altruism, compliance, and tender-mindedness. CONCLUSION: Clinical evaluations of medical students may favor personality styles that reflect positive elements of extraversion, agreeableness, and conscientiousness. The present findings raise questions regarding the validity of clinical evaluation elements in clerkship performance appraisal.

Medical student identification of domestic violence as measured on an objective, standardized clinical examination.

OBJECTIVE: This study examined the incidence and predictors of domestic violence screening by third-year medical students at an end of clerkship Objective Standardized Clinical Examination. STUDY DESIGN: Two hundred and seventy-five third-year medical students completed an 8-station end of clerkship Objective Standardized Clinical Examination as part of this retrospective observational study, one with nonspecific abdominal pain and possible domestic violence. Checklists on history, physical, communication, and interpersonal skills were collected. Domestic violence screening was analyzed by logistic regression and analysis of variance. RESULTS: The incidence of domestic violence screening by history alone was 34% before the physical. Interpersonal scores on the overall exam and domestic violence station, but not gender or rotation sequence, predicted domestic violence questioning. CONCLUSION: In this standardized patient study there was a low rate of domestic violence screening by history.

Construct validity of an objective structured clinical examination (OSCE) in psychiatry: associations with the clinical skills examination and other indicators.

OBJECTIVE: The construct validity of checklist and global process scores for an objective structured clinical examination (OSCE) in psychiatry was assessed. Multiple regression analysis was used to predict psychiatry OSCE scores from the clinical skills examination, an obstetrics/gynecology (OB/GYN) OSCE, and the National Board of Medical Examiners (NBME) psychiatry subject examination. METHODS: Archival data from two successive classes of third-year medical students (1999-2000, N=142; 2000-2001, N=144) were aggregated and analyzed. RESULTS: The pattern and magnitude of convergence and discrimination were indicative of adequate construct validity for both the psychiatry checklist scores and the global process score. Clinical skills examination scores for history taking, interpersonal skills, and physical examination were related to psychiatry OSCE scores that reflected the same skill set. Construct validity was fairly higher for the global process rating. CONCLUSION: Evidence of construct validity of a psychiatry OSCE was obtained from multiple measures of performance, including the clinical skills examination. Findings lend support to the continued use of checklist and global process evaluations as part of OSCEs in psychiatry.

The influence of testing context and clinical rotation order on students' OSCE performance.

PURPOSE: To investigate the influence of testing context and rotation order on third-year medical student performance on a common objective structured clinical examination (OSCE) station in both obstetrics-gynecology (ob-gyn) and psychiatry rotations. METHOD: Archival OSCE performance data (in the form of a 25-item binary content checklist) from one class of third-year medical students (n = 141) at Saint Louis University (2002-03) were aggregated and analyzed. RESULTS: Despite the fact that the station was identical in both OSCEs, students were, in general, less likely to inquire about ob-gyn issues on the psychiatry OSCE and less likely to inquire about psychiatric issues on the ob-gyn OSCE, regardless of order of rotation. Order did have a positive effect on some results, such that students were more likely to mention menopause and vaginal dryness on the psychiatry OSCE if they had already had the ob-gyn rotation. CONCLUSION: The testing context may influence student approaches to patients in ways that bias their collection and interpretation of information. OSCE evaluations may better approximate true clinical context and complexity by presenting case scenarios that reflect a broader range of diagnostic possibilities than those limited to the recently completed rotation.