Gynaecological surgical training in the operating room: an exploratory study.

OBJECTIVE: One of the challenging goals of gynaecological education is preparing trainees for independent practice of surgery. Research, however, on how to acquire surgical skills in the operating room safely, effectively and efficiently is scarce. We performed this study to explore trainers' and trainees' mutual expectations concerning operative training, to identify key aspects for improving learning and teaching in the operating theatre. STUDY DESIGN: We conducted a focus group study in different teaching hospitals in The Netherlands. Three focus groups were composed of gynaecology consultants representing over half of the training hospitals in The Netherlands. Four groups were composed of gynaecology trainees at different stages of training, from university and non-university hospitals and of both sexes. The interviews were recorded, transcribed verbatim and entered into qualitative data analysis software and two researchers performed a thematic analysis. RESULTS: Teaching and learning in the operating theatre are complicated by the dynamics of trainer-trainee interaction, which are fraught with potentially conflicting interests. Trainer and trainee have to consider each other's interests, while their primary concern must be patient safety. Trainers want to feel in control and trainees want to be given a free hand within a safe atmosphere. Structuring of the teaching and learning process appears to hold the key to creating positive dynamics between trainer, trainee and their responsibility towards the patient. Structuring can be achieved before, during and after an operation. Before the operation both trainer and trainee can take the initiative to talk about learning objectives, plan of action, and task allocation. During the operation, the trainee can verbalise actions before actually performing them. This makes trainee actions predictable, enhances trainer confidence and thus may increase the trainee's chance of actually performing (a portion of) a procedure. After the operation, both trainer and trainee can initiate an evaluation the trainee's performance. CONCLUSION: Interaction between trainer and trainee is complicated by their shared responsibility towards the patient. Structured interactions before, during and after operations appear to offer opportunities for improving learning and teaching in the operating theatre.

Maternal thyroid hormone concentration during late gestation is associated with foetal position at birth.

OBJECTIVE: To evaluate whether there is an association between maternal thyroid hormone and foetal cephalic head position at term gestation. CONTEXT: Rotation and flexion of the head enables the foetus to negotiate the birth canal. Low-normal range thyroid hormone concentrations in euthyroid pregnant women constitute a risk of infant motor abnormality. We hypothesized that low normal maternal thyroid hormone levels are associated with increased risk of abnormal foetal position at delivery. DESIGN: In 960 healthy Dutch women with term gestation and cephalic foetal presentation, thyroid parameters [foetal T4 (FT4), TSH and thyroid peroxidase antibody] were assessed at 36 weeks of gestation, and related to foetal head position (anterior cephalic vs. abnormal cephalic) and delivery mode (spontaneous vs. assisted delivery). RESULTS: Women presenting in anterior position (n = 891) had significantly higher FT4 levels at 36 weeks of gestation than those with abnormal cephalic presentation (n = 69). There were no between-group differences for TSH. Regression analyses indicated that the risk of abnormal head position decreased as a function of increasing FT4 [single odds ratio (OR) = 0.87, 95% confidence intervals (CI) 0.77-0.98; multivariate OR = 0.88, 95% CI 0.72-0.99)]. A similar inverse relationship between maternal FT4 and risk of assisted delivery was obtained (OR = 0.86, 95% CI 0.79-0.95; OR = 0.91, 95% CI 0.84-0.98). CONCLUSION: The lower the maternal FT4 concentration at 36 weeks of gestation, the higher the risk of abnormal cephalic foetal presentation and assisted delivery.

Long-term effectiveness and costs of a brief self-management intervention in women with pregnancy-related low back pain after delivery.

BACKGROUND: Pregnancy-related low back pain is considered an important health problem and potentially leads to long-lasting pain and disability. Investigators draw particular attention to biomedical factors but there is growing evidence that psychosocial and social factors might be important. It prompted us to start a large cohort study (n = 7526) during pregnancy until one year after delivery and a nested randomized controlled intervention study in the Netherlands. METHODS: A randomized controlled trial (n = 126) nested within a cohort study, of brief self-management techniques versus usual care for treatment of women with persisting non-specific pregnancy-related low back pain three weeks after delivery. Women in the intervention group were referred to a participating physiotherapist. Women in the usual care group were free to choose physiotherapy, guidance by a general practitioner or no treatment. Follow up took place at 3 months, 6 months and one year after delivery.Outcomes included change in limitations in activities (RDQ), pain (VAS), severity of main complaints (MC), global feeling of recovery (GPE), impact on participation and autonomy (IPA), pain-related fear (TSK), SF-36, EuroQol and a cost diary. For the outcome measures, series of mixed models were considered. For the outcome variable global perceived effect (GPE) a logistic regression analysis is performed. RESULTS: Intention-to-treat outcomes showed a statistical significant better estimated regression coefficient RDQ -1.6 {-2.9;-0.5} associated with treatment, as well as better IPA subscale autonomy in self-care -1.0 {-1.9;-0.03} and TSK -2.4 {-3.8;-1.1} but were not clinical relevant over time. Average total costs in the intervention group were much lower than in usual care, primarily due to differences in utilization of sick leave but not statistically significant. CONCLUSION: Brief self-management techniques applied in the first 3 months after delivery may be a more viable first-line approach but further research is needed to draw inference on costs and to determine whether no care is a better option in the long term. TRIAL REGISTRATION: [ISRCTN08477490].

The relation between gestational thyroid parameters and depression: a reflection of the downregulation of the immune system during pregnancy?

OBJECTIVE: To assess the relation between thyroid parameters and an episode of major depression at different trimesters during pregnancy, taking into account possible confounders. DESIGN: Prospective follow-up of 1017 pregnant women from the general population with assessment of thyroid parameters and depression using syndromal diagnosis interviews at 12, 24, and 36 weeks' gestation. MAIN OUTCOME: The prevalence of major depression decreased from 5.3% to 2.9%, and that of elevated concentrations of thyroid peroxidase antibody (TPOAb) titers from 8.4% to 6.5% toward the end of term. Subclinical hyperthyroidism not related to TPO-Ab (odds ration [OR] 3.6; 95% confidence interval [CI]: 1.2-0.2) and TPO-Ab (OR 2.1; 95% CI: 1.1-5.8) at 12 weeks' gestation, and TPO-Ab (OR 2.8; 95% CI 1.9-7.1) at 24 weeks' gestation were independently related to major depression. Anxiety and the occurrence of stressful life events were related to depression at all trimesters. CONCLUSIONS: The occurrence of major depression and high titers of TPO-Ab show a similar pattern of decline throughout pregnancy. During early gestation, thyroid autoimmunity seems to be related to depression while at the end of term-when there is maximal downregulation of the immune system-autoimmunity does not seem to play an important role with regard to the occurrence of depression.

A two-day teacher-training programme for medical residents: investigating the impact on teaching ability.

INTRODUCTION: Many of the residents who supervise medical students in clinical practice are unfamiliar with the principles of effective supervision. Training in teaching skills is therefore seen as an effective strategy to improve the quality of clinical supervision. METHOD: Twenty seven medical residents were matched and assigned to an experimental group (n = 14) and a control group (n = 13). The experimental group participated in a two-day workshop on teaching skills. Using standardized questionnaires, the teaching abilities of all participants were assessed anonymously by medical students, before and after the workshop, to determine for any effect of the intervention. RESULTS: A significant improvement in the teaching abilities of the medical residents in the experimental group was observed following the workshop (t=-2.68, p=0.02). The effect size within the experimental group was large (d=1.17), indicating that the workshop led to a measurable positive change in the medical residents' teaching abilities. The effect size estimated from the post intervention scores on teaching ability of the two groups showed a moderate improvement (d=0.57) in the experimental group compared with the control group. DISCUSSION: Medical students rated the teaching abilities of the workshop participants after the training more highly than those of the residents in the control group. The ability to adjust teaching to the needs of the students and teach effective communication and diagnostic clinical skills were among the features that characterized effective teaching. Properly designed, teacher-training workshops could be effective and feasible methods to improve the quality of teaching by medical residents.

Effectiveness of a tailor-made intervention for pregnancy-related pelvic girdle and/or low back pain after delivery: short-term results of a randomized clinical trial [ISRCTN08477490].

BACKGROUND: For the moment, scientific evaluation of programs on treatment of pregnancy-related pelvic girdle and/or low back pain after delivery is hardly available with only one study with a positive result, suggesting uncertainty about the optimal approach. Investigators draw particular attention to biomedical factors but there is growing evidence that biopsychosocial factors appear to be even more important as a basis of an intervention program. METHODS: We studied the effectiveness of a tailor-made program with respect to biopsychosocial factors (intervention group) in women with pregnancy-related pelvic girdle and/ or low back pain versus usual care based on a pain contingent basis (control group) shortly after delivery in a randomized controlled trial. Women with severe complaints shortly after delivery were selected from a longitudinal prospective cohort study (n = 7526), aimed at pregnancy-related pelvic girdle and/or low back pain in the Netherlands. A concealed block randomization was performed after collecting baseline data. Researchers were blinded to treatment assignment. Outcomes were evaluated within the domains of the biopsychosocial approach. Primary outcome concerned limitations in activities (RDQ). Follow-up measurements were performed 12 weeks after delivery. RESULTS: Since May 2001 until July 2003, 869 women out of the cohort made a request for treatment by a physiotherapist, 10 days after delivery. Because of a quick recovery in two weeks time, we included only 126 women three weeks after delivery. There was a statistically significant and clinically relevant difference in improvement on the primary outcome (RDQ) between the two groups in favor of the experimental intervention. CONCLUSION: The results favored the hypotheses. Women's worries about their condition were major targets in the experimental intervention. The prognosis after delivery, especially in de first weeks, turned out to be favorable.

A Description of a Validated Effective Teacher-Training Workshop for Medical Residents.

A teacher-training program for residents was designed and piloted in the St. Elisabeth Hospital in Curaçao, Netherlands Antilles. The program comprised of six modules namely: effective teaching, self-knowledge and teaching ability, feedback, assessing prior knowledge, trouble shooting and time management. METHOD: Instruction was provided during a two-day workshop with eight hours instruction time per day. Residents in the first three years of training participated, and the instructors were experienced clinicians. Lectures, group discussions, case simulations, video presentations and role-plays were the forms of instruction. RESULTS: Using standardized questionnaires, the participants rated the quality of the workshop highly. They considered it to be a feasible and appropriate educational intervention and that it had a positive impact on their teaching skills. CONCLUSION: This workshop was developed based on careful analysis of medical residents' perceived educational needs and systematically implemented and evaluated. The results show that it is a suitable and effective educational intervention.

A historical perspective on pregnancy-related low back and/or pelvic girdle pain.

The growing interest in pregnancy-related low back and/or pelvic girdle pain has invoked research projects to this subject. Although it seems a modern syndrome, historical articles show that pregnancy-related pelvic girdle pain (PPGP) was already known centuries ago. The purpose of the present article is to provide a summary review of performed studies on pregnancy-related pelvic girdle pain. Remarkably, these studies show large differences in results with regard to, for example, incidence rates and relevant etiologic factors of pregnancy-related pelvic girdle pain. These differences can be explained by the use of different definitions and descriptions of pregnancy-related pelvic girdle pain between studies. In conclusion, it is necessary to search for an evidence-based overall definition of pregnancy-related pelvic girdle pain in order to provide more knowledge about incidence rates, etiologic factors and other related subjects.

Etiology and prognosis of pregnancy-related pelvic girdle pain; design of a longitudinal study.

BACKGROUND: Absence of knowledge of pregnancy-related pelvic girdle pain (PPGP) has prompted the start of a large cohort study in the Netherlands. The objective of this study was to investigate the prevalence and incidence of PPGP, to identify risk factors involved in the onset and to determine the prognosis of pregnancy-related pelvic girdle pain. METHODS/DESIGN: 7,526 pregnant women of the southeast of the Netherlands participated in a prospective cohort study. During a 2-year period, they were recruited by midwives and gynecologists at 14 weeks of pregnancy. Participants completed a questionnaire at baseline, at 30 weeks of pregnancy, at 2 weeks after delivery, at 6 months after delivery and at 1 year after delivery. The study uses extensive questionnaires with questions ranging from physical complaints, limitations in activities, restriction in participation, work situation, demographics, lifestyle, pregnancy-related factors and psychosocial factors. DISCUSSION: This large-scale prospective cohort study will provide reliable insights in incidence, prevalence and factors related to etiology and prognosis of pregnancy-related pelvic girdle pain.

Treatment of pregnancy-related pelvic girdle and/or low back pain after delivery design of a randomized clinical trial within a comprehensive prognostic cohort study [ISRCTN08477490].

BACKGROUND: Pregnancy-related pelvic girdle and/or low back pain is a controversial syndrome because insight in etiology and prognosis is lacking. The controversy relates to factors eliciting pain and some prognostic factors such as the interpretation of pain at the symphysis. Recent research about treatment strategies also reflects those various opinions, in fact suggesting there is professional uncertainty about the optimal approach. Currently, physiotherapists often prescribe a pain-contingent treatment regime of relative rest and avoiding several day-to-day activities. Additionally, treatment more often includes an exercise program to guide rectification of the muscle imbalance and alignment of the pelvic girdle. Effectiveness of those interventions is not proven and the majority of the studies are methodologically flawed. Investigators draw particular attention to biomedical factors but there is growing evidence that important prognostic issues such as biopsychosocial factors appear to be even more important as point of action in a treatment program. METHODS/DESIGN: This pragmatic randomized controlled trial is designed to evaluate the effectiveness of a tailor-made treatment program with respect to biopsychosocial factors in primary care. The effect of the experimental intervention and usual care are evaluated as they are applied in primary health care. The trial is embedded in a cohort study that is designed as a longitudinal, prospective study, which studies prevalence, etiology, severity and prognosis during pregnancy until one year after delivery. The present paper focuses on choices regarding recruitment procedures, in-/exclusion criteria and the development of a well-timed intervention. DISCUSSION: This section briefly discusses the actions taken to minimize bias in the design, the proper time-window for the experimental intervention and the contrast between the experimental intervention and usual care.

Low concentrations of maternal thyroxin during early gestation: a risk factor of breech presentation?

OBJECTIVE: To evaluate the relation between breech position at term (>37 weeks of gestation) and low maternal fT4 levels during gestation in women not suffering from overt thyroid dysfunction. DESIGN: A prospective cohort study of pregnant women. SETTING: Community-based study. POPULATION/SAMPLE: At random selected pregnant women of the general population. METHODS: At antenatal booking, based on thyroid function assessed at 12 weeks of gestation in a large cohort of pregnant women, two groups of participants were defined: women with low fT4 levels-below the 10th centile (n= 135) and women with fT4-between the 50th and 90th centiles at 12 weeks of gestation (n= 135). Women with clinical thyroid dysfunction (fT4 and TSH outside reference range) at 12 weeks of gestation were excluded. Maternal thyroid function (fT4 and TSH) was subsequently assessed at 24 and 32 weeks of gestation. Analysis refers to 204 women who met the inclusion and exclusion criteria and in whom all thyroid parameters were assessed. MAIN OUTCOME MEASURES: Fetal presentation (cephalic-breech) at delivery in women with term gestation (>37 weeks of gestation) in relation to maternal thyroid function at 12, 24 and 34 weeks of gestation. RESULTS: Breech presentation at term delivery was independently related to fT4 levels <10th centile at 12 weeks of gestation (OR = 4.7, 95% CI 1.1-19 [but not to an fT4 level below the 10th centile at 24 and 32 weeks of gestation]) as well as primiparity (OR = 4.7, 95% CI 1.3-15). CONCLUSIONS: Women with hypothyroxinaemia (fT4 level at the lowest 10th centile) during early gestation but without overt thyroid function are at risk for fetal breech presentation at term (>37 weeks of gestation).

The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students.

INTRODUCTION: Much of undergraduate clinical teaching is provided by residents. An earlier study showed the attitude of residents towards teaching to be generally positive. Little is known, however, about attending doctors' views on their own and residents' roles as teachers of medical students. OBJECTIVES: To examine attending doctors' perceptions of the (dis)advantages of resident teaching, their own teaching abilities and the need for a teacher training programme for residents. METHOD: A questionnaire survey of 76 attending doctors was carried out in the Departments of Obstetrics & Gynaecology and Paediatrics at the teaching hospitals of the Universities of Maastricht and Amsterdam, the Netherlands. RESULTS: Attending doctors perceive teaching by residents to be beneficial for students and residents alike. Although they consider themselves to be better suited than residents to teach medical students, they see teaching as an integral part of residency training and feel it should be recognised as such by departments and medical schools. Attending doctors are in favour of a teacher training programme for residents, which should include communication, clinical and teaching skills as well as skills such as time management and (self-) assessment. DISCUSSION: Despite the uneven distribution of participants between the departments, no significant differences were found between departments. It is interesting that attending doctors perceive teacher training as beneficial to residents' teaching skills, but provide more feedback on residents' attitudes than on their teaching. The results show that, in general, attending doctors share residents' views that teaching is an important component of residency and that a teacher training programme for residents is to be recommended.

The effects of oral carbohydrate administration on fetal acid base balance.

AIMS: Little evidence-based data are available on the effects of eating and drinking during labor. Intravenous glucose administration has been related to fetal metabolic acidosis. The question is, whether oral intake of carbohydrates effects the fetal acid-base balance. METHODS: In a double blind, prospective placebo controlled study 100 nulliparous women were randomized at 8-10 cm of cervical dilatation. All women were asked to drink 200 cc of either a carbohydrate solution (containing 25 grams carbohydrates) or placebo. In all women, both arterial and venous umbilical cord pH, pCO2, pO2, HCO3- and base excess/deficit were assessed. In a subgroup of women, whose deliveries were complicated by mild signs of fetal distress, clinical outcome and acid-base status was described separately. RESULTS: Fetal arterial umbilical cord pH were identical: 7.20 +/- 0.07 in the placebo group and 7.20 +/- 0.08 in the carbohydrate group and the base excess -6.6 +/- 2.8 versus 6.6 +/- 3.7. In the women with mild signs of fetal distress, no differences were observed as well. CONCLUSIONS: Oral carbohydrate intake during labor seems to be safe regarding the fetal acid-base balance. Further study on the maternal and fetal metabolic parameters is essential to give a more complete picture.

How residents perceive their teaching role in the clinical setting: a qualitative study.

Residents play an important role in teaching and they consider teaching medical students as one of their primary responsibilities. Teaching is, however, limited due to lack of teaching skills and the time constraints involved in preparing and conducting teaching. Eighteen residents involved in teaching medical students and who took part in an initial study on teaching were interviewed on the perceived benefits of teaching and the role of residents in the teaching process. They also provided recommendations on how a training programme for residents could be created. The findings showed that enthusiasm and enjoying teaching were qualities of good teachers. Lack of time and support from attending staff were factors that contributed considerably to poor quality of teaching. There was a need for basic teaching skills and the recommendations provided included literature on teaching, training workshops, constructive evaluation and feedback and interactive sessions with experts.

The impacts of supervision, patient mix, and numbers of students on the effectiveness of clinical rotations.

PURPOSE: This study investigated whether supervision, patient mix, and numbers of students influence the effectiveness of clinical rotations. METHOD: The authors administered a questionnaire to 1,208 medical students in 1999 to evaluate the rotations' quality. They computed four variables--overall effectiveness, supervision, patient mix, and number of students contemporaneously involved--and analyzed the data using analysis of variance. RESULTS: Supervision and patient mix positively influenced a rotation's effectiveness. A higher level of supervision and a higher level of patient mix led to higher overall effectiveness scores. The number of students did not significantly influence the effectiveness score, although a low number led to a higher score as compared with a high number. Furthermore, the two-way interaction between supervision and patient mix was significant. Supervision more strongly influenced the rotation's effectiveness when patient mix was limited than when it was high. Also, when the patient mix was limited and supervision was high, the average effectiveness score was still 7.7 (scale 1-10). CONCLUSIONS: The effectiveness of clinical rotations depends on the supervision provided and patient mix, but not the number of students. Furthermore, supervision more strongly influences effectiveness when patient mix is limited than when it is high. Finally, high-quality supervision guarantees at least a sufficient score for the rotation's effectiveness, irrespective of the level of patient mix.

A double-blind, randomised, placebo controlled study on the influence of carbohydrate solution intake during labour.

OBJECTIVE: Although there has been much debate on whether women should be allowed to eat and drink during labour, little scientific data are available on the effects of caloric intake on the course of labour. DESIGN: Double-blind, randomised, placebo controlled. SETTING: Leyenburg Hospital, The Hague, The Netherlands. POPULATION: Two hundred and one consecutive nulliparous women, pregnant of a single fetus in cephalic presentation. METHODS: All women were included in early labour (2cm-4cm of cervical dilatation) and were allowed to drink at will. MAIN OUTCOME MEASURES: The duration of labour, the need for augmentation and pain medication and the incidence of abdominal and vaginal instrumental deliveries. RESULTS: Drinking of carbohydrate solutions was well tolerated, but did not show any beneficial effects regarding labour outcome when compared with the control group. In the carbohydrate group, a higher caesarean section rate was observed (RR 2.9, 95% CI 1.29-6.54). CONCLUSIONS: Women in the carbohydrate group had worse labour outcome. It is unclear whether a statistical coincidence, a negative effect of the carbohydrate intake or an incorrect carbohydrate intake strategy is responsible for these results. Further studies are necessary before any definite conclusion can be drawn.