Universal Cystoscopy After Benign Hysterectomy: Examining the Effects of an Institutional Policy.

OBJECTIVE: To evaluate the association between a universal cystoscopy policy at the time of benign hysterectomy and the detection of urologic injuries. METHODS: This is a retrospective cohort study at a tertiary care academic center where a policy of universal cystoscopy at the time of benign hysterectomy was instituted on October 1, 2008. Benign hysterectomies performed from March 3, 2006, to September 25, 2013, were included and dichotomized into preuniversal and postuniversal cystoscopy groups. Medical records were reviewed for baseline and perioperative characteristics, cystoscopy use, and urologic injuries related to hysterectomy. Urologic injuries were identified by using a search engine and a departmental quality improvement database. RESULTS: Two thousand nine hundred eighteen hysterectomies were identified during the study time period, 96 of which were excluded for indications of abdominopelvic cancers and peripartum indications. Therefore, 973 women were in the preuniversal cystoscopy group and 1,849 were in the postuniversal cystoscopy group. Thirty-six percent (347/973, 95% confidence interval [CI] 32.8-38.8%) and 86.1% (1,592/1,849, 95% CI 84.5-87.7%) of patients underwent cystoscopy prepolicy and postpolicy, respectively. The urologic injury rates were 2.6% (25/973, 95% CI 1.6-3.6%) and 1.8% (34/1,849, 95% CI 1.2-2.5%) in the prepolicy and postpolicy groups, respectively. Delayed urologic injuries decreased significantly (0.7% [7/973], 95% CI 0.3-1.2% compared with 0.1% [2/1,849], 95% CI 0.0-0.3%). Of the nine patients with delayed injuries, four had normal intraoperative cystoscopy findings and five had no cystoscopy performed. CONCLUSION: The practice of universal cystoscopy at the time of hysterectomy for benign indications is associated with decreased delayed postoperative urologic complications.

Evaluation of a precise and measurable model for learning laparoscopic tissue handling.

INTRODUCTION: Laparoscopic tissue handling is quite difficult to measure using virtual-reality laparoscopic simulators and box-trainer exercises, and therefore, completion time is the predominant performance measure for simulation-based laparoscopic training exercises. The purpose of this study was to evaluate the construct validity of a training and assessment model for precise laparoscopic handling of delicate tissue. METHODS: Participants (n = 35) completed 2 progressively challenging laparoscopic tissue translocation exercises using delicate foam pieces and templates. Deidentified performances were scored using objective measures for tissue damage, accuracy, percentage complete, and completion time. Evaluation included multiple analysis of variance with repeated measures among the 3 groups as follows: medical students, residents and faculty who perform laparoscopic surgery less than once per week, and faculty members who perform laparoscopic surgery at least once per week. RESULTS: The model demonstrated significant construct validity by discriminating performances between the types of shapes and templates and across the levels of surgical experience on all dimensions. A significant interaction effect between the level of expertise and the difficulty of the exercise revealed excellent discrimination between experienced laparoscopic surgeons and others. DISCUSSION: This low-cost model provides an alternative or adjunct platform for laparoscopic training and assessment that requires precise and measurable handling of a delicate tissue.

Low-hanging fruit: a clementine as a simulation model for advanced laparoscopy.

INTRODUCTION: Low-cost, high-fidelity models for training in advanced laparoscopic surgery techniques are not currently available. The objective of this study was to evaluate a model and assessment protocol for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making. METHODS: Novice to expert laparoscopists (n = 41) were asked to remove the peel of a clementine in as few pieces as possible, separate and remove all albedo from and between all fruit segments, and return the clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision making included deciding when unacceptable segment damage would result by removing difficult-to-extract albedo, analogous to treating lesions or metastases through other methods, rather than risking damage to vital anatomic structures. Faculty assessed deidentified video-recorded performances. Data analyses included analysis of variance with Bonferroni post hoc. RESULTS: A single-performance construct (operative ability) with 2 scoring dimensions (surgical skills and clinical judgment) was confirmed through factor analysis. There were significant performance differences between all experience levels (F2,41 = 59.175, P < 0.000). There were no statistical time differences between the groups. CONCLUSIONS: Validation of this low-cost, easily facilitated model for developing advanced laparoscopic surgical skills may support the preparation of residents and fellows and provide a platform for skill acquisition, assessment, and basic critical thinking for performing laparoscopic tasks.

Effect of resident evaluations of obstetrics and gynecology faculty on promotion.

BACKGROUND: Promotion for academic faculty depends on a variety of factors, including their research, publications, national leadership, and quality of their teaching. OBJECTIVE: We sought to determine the importance of resident evaluations of faculty for promotion in obstetrics-gynecology programs. METHODS: A 28-item questionnaire was developed and distributed to 185 department chairs of US obstetrics-gynecology residency programs. RESULTS: Fifty percent (93 of 185) responded, with 40% (37 of 93) stating that teaching has become more important for promotion in the past 10 years. When faculty are being considered for promotion, teaching evaluations were deemed "very important" 60% of the time for clinician track faculty but were rated as mainly "not important" or "not applicable" for research faculty. Sixteen respondents (17%) stated a faculty member had failed to achieve promotion in the past 5 years because of poor teaching evaluations. Positive teaching evaluations outweighed low publication numbers for clinical faculty 24% of the time, compared with 5% for research faculty and 8% for tenured faculty being considered for promotion. The most common reason for rejection for promotion in all tracks was the number of publications. Awards for excellence in teaching improved chances of promotion. CONCLUSIONS: Teaching quality is becoming more important in academic obstetrics-gynecology departments, especially for clinical faculty. Although in most institutions promotion is not achieved without adequate research and publications, the importance of teaching excellence is obvious, with 1 of 6 (17%) departments reporting a promotion had been denied due to poor teaching evaluations.

Postinterview Communication between Obstetrics and Gynecology Residency Programs and Candidates.

INTRODUCTION: Residency programs seek to match the best candidates with their positions. To avoid ethical conflicts in this process, the National Residency Matching Program (NRMP or Match) has rules regarding appropriate conduct, including guidelines on contact between candidates and programs. Our study examined communication between obstetrics and gynecology (Ob-Gyn) programs and residency candidates after interviewing and prior to ranking. METHODS: Ob-Gyn program directors in the United States were sent a self-administered survey via e-mail. Data were collected and analyzed using descriptive methods to examine communication practices of these programs. RESULTS: The response rate was 40%. The findings showed that respondents had variable interpretations of the NRMP rules and suggest that programs may be communicating their match intentions especially to favored candidates. Respondents' open text comments highlighted program directors' frustrations with current NRMP rules. DISCUSSION: NRMP communication rules are intended to minimize pressure on residency candidates. Our findings suggest they may be leading to unforeseen stresses on program directors and candidates. CONCLUSIONS: As educational leaders in medicine, we must consider what professional communications are acceptable without increasing the pressure on candidates during the ranking and match process.

Validity: what does it mean for competency-based assessment in obstetrics and gynecology?

Validity refers to an evidence-based claim about the trustworthiness of decisions made from context-specific performance data. Validity requirements for competency-based assessments in obstetrics and gynecology have not been defined in the literature. We explain why validity is intrinsic to any discussion about competency assessment and provide a model for obstetrics and gynecology programs to use in determining the essential validity evidence for various forms of assessments. The implications of decisions made from assessment results influence the requisite level and precision of validity evidence. Although validity evidence is essential, it is also flexibly tied to the implications of decisions made from assessment results and not all assessments require the same degree of validity. We propose a model for considering validity, and build a discussion around specific assessment examples targeting progressive levels of expertise along the training continuum.