Does Participation in Obstetrics and Gynecology Subspecialties Improve Clerkship Outcomes?

OBJECTIVE: 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) Ob/Gyn clinical science subject exam scores, clinical evaluations, and final clerkship summative grades when compared to students without focused subspecialty time. METHODS: This is a retrospective study of third-year Alpert Medical School of Brown University (AMS) Ob/Gyn core clerkship students at a single institution (Women and Infants Hospital in Providence, RI) from 2012 to 2017. Participation in Maternal Fetal Medicine (MFM) and/or Gynecologic oncology (Gyn Onc) subspecialty track (a one-week focused experience), NBME Ob/Gyn clinical science subject exam raw score, clinical evaluation score, final clerkship summative grade, and decision to pursue Ob/Gyn as a career were analyzed. RESULTS: There was no significant difference in NBME 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). Of the students who pursued an Ob/Gyn residency, 75% participated in a subspecialty track. CONCLUSION: 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.

Feasibility of a Regional Approach to an Obstetrics and Gynecology Transition to Residency Course.

OBJECTIVE: To demonstrate the feasibility of a regional Obstetrics and Gynecology (Ob/Gyn) Transition to Residency Course (TRC) through compliance, satisfaction, and sustainability. METHODS: We implemented a two-week, multi-institutional regional TRC (RTRC) for fourth-year medical students matched in Ob/Gyn or Family Medicine from four New England medical schools. Curriculum was developed to meet Ob/Gyn Milestone One (M1) and Core Entrustable Professional Activity (CEPA) objectives. Compliance, satisfaction, and sustainability were identified as feasibility outcomes. RESULTS: From 2015-2018, a total of 63 fourth-year students have participated. The number of students remained stable each year. All students attended 100% of sessions. There was an average of >9/10 in all satisfaction metrics all four years. The number of faculty members from each institution remained stable over the four years. CONCLUSION: A RTRC is feasible as measured through compliance, satisfaction and sustainability.

Urinary fistula and incontinence.

It is estimated that as many as 3.5 million women worldwide suffer from obstetric urinary fistula. This public health tragedy is a result of obstructed labor and inadequate access to health care, and its eradication lies in prevention and treatment. Efforts at prevention should be made through targeted education and public intervention for improved nutrition, access to health care, and women's social status. Diagnosis and treatment in limited resource settings can occur, and there are specific recommendations regarding nonsurgical and surgical approaches to care. Treatment success may be complicated by social, psychological, and clinical factors, with reintegration a primary concern for this group of women.

Giving Voice to the Experiences of Rwandan Women With Urogenital Fistula.

BACKGROUND: Urogenital fistula is a debilitating condition that women can develop following obstructed labor. The primary objective of this study was to reveal illness narratives of Rwandan women with urogenital fistula to appreciate their unique experiences. The secondary aim was to identify common themes that emerged when women discussed their experiences living with fistula. METHODS: Women presenting for urogenital fistula repair at Kibagabaga Hospital were asked to participate in the study. Eleven participants were asked questions designed to elicit their understanding of their condition and the social and emotional consequences of their fistula. All interviews were anonymous. Transcribed interviews were examined for relative themes to categorize responses into larger domains. FINDINGS: Common themes were identified from the interviews on topics of what barriers existed to having a successful delivery, the socioeconomic and psychosocial consequences of developing a fistula, and each woman's understanding of her fistula. Excerpts from patients' illness narratives illustrated these themes. CONCLUSIONS: These narratives can be used to appreciate the variations in each woman's understanding of her medical condition and the changes that occurred in her life as a result of her fistula. Through patients' narratives, physicians can improve their appreciation of cultural differences to design targeted educational and preventive interventions.

Implementation and evaluation of a novel operating room curriculum for the obstetrics and gynecology clerkship.

OBJECTIVE: Primary objective is to estimate the effect of an operating room (OR) curriculum on obstetrics and gynecology (Ob/Gyn) students' clinical knowledge related to the OR. Secondary objective is to estimate the effect of the curriculum on student confidence and satisfaction related to the OR experience. STUDY DESIGN: Prospective cohort study of 6 Ob/Gyn clerkship groups from September 2011 to June 2012. Three control groups received usual teaching and 3 intervention groups received the OR curriculum plus usual teaching. The primary outcome was the measurement of student knowledge using preclerkship and postclerkship questionnaires. Student confidence and satisfaction related to the OR experience were also measured using questionnaires. Standard clerkship evaluations were reviewed to rate the quality of faculty teaching. Between-group scores were compared using Student t test. A total of 26 students per group were needed to detect a 20% difference in between-group change in clinical knowledge (α = 0.05, 80% power). SETTING: Women and Infants' Hospital, Providence, Rhode Island, a tertiary care teaching hospital for the Warren Alpert Medical School of Brown University. PARTICIPANTS: Ob/Gyn clerkship students. RESULTS: Overall, 70 students were enrolled-68 completed evaluation measures immediately after clerkship and 27 at 6 months after clerkship. More intervention subjects were fourth-year students (p = 0.03) and had completed surgery clerkships (p = 0.003). At baseline, groups demonstrated similar clinical knowledge and confidence (p > 0.05). Although there was no difference between groups in knowledge scores immediately after clerkship, at 6 months, the intervention group had greater retention in clinical knowledge scores (1.2 ± 2.6 vs 3.5 ± 1.8; p = 0.02). At clerkship completion, intervention group was more satisfied with student-faculty interaction (mean sum score = 14.7 ± 3.5 vs 16.9 ± 3.0; p = 0.01). On review of standard clerkship evaluations, intervention subjects gave significantly higher scores for quality of faculty teaching (3.82 ± 1.18 vs 4.39 ± 0.67; p = 0.01). CONCLUSIONS: Our OR curriculum improved knowledge retention, increased student satisfaction with student-faculty interactions in the OR, and improved faculty teaching evaluation.

Improving patient knowledge about sacral nerve stimulation using a patient based educational video.

PURPOSE: We developed a patient based educational video to address the information needs of women considering sacral nerve stimulation for overactive bladder. MATERIALS AND METHODS: Five semistructured focus groups were used to identify patient knowledge gaps, information needs, patient acceptable terminology and video content preferences for a patient based sacral nerve stimulation educational video. Each session was transcribed, independently coded by 2 coders and examined using an iterative method. A 16-minute educational video was created to address previously identified knowledge gaps and information needs using patient footage, 3-dimensional animation and peer reviewed literature. We developed a questionnaire to evaluate participant sacral nerve stimulation knowledge and therapy attitudes. We then performed a randomized trial to assess the effect of the educational video vs the manufacturer video on patient knowledge and attitudes using our questionnaire. RESULTS: We identified 10 patient important domains, including 1) anatomy, 2) expectations, 3) sacral nerve stimulation device efficacy, 4) surgical procedure, 5) surgical/device complications, 6) post-procedure recovery, 7) sacral nerve stimulation side effects, 8) postoperative restrictions, 9) device maintenance and 10) general sacral nerve stimulation information. A total of 40 women with overactive bladder were randomized to watch the educational (20) or manufacturer (20) video. Knowledge scores improved in each group but the educational video group had a greater score improvement (76.6 vs 24.2 points, p <0.0001). Women who watched the educational video reported more favorable attitudes and expectations about sacral nerve stimulation therapy. CONCLUSIONS: Women with overactive bladder considering sacral nerve stimulation therapy have specific information needs. The video that we developed to address these needs was associated with improved short-term patient knowledge.

Unrecognized bladder perforation leading to severe progressive cellulitis and candidal infection.

BACKGROUND: Retropubic midurethral slings are a minimally invasive surgical procedure used in the treatment of stress urinary incontinence and are typically associated with high cure rates and low complication rates. Bladder perforation is a known intraoperative complication that, if left unrecognized, can have significant morbidity. CASE: A 47-year-old underwent a retropubic midurethral sling, anterior colporrhaphy, and cystoscopy. She developed a suprapubic wound cellulitis that progressed to involve the right trunk and flank as well as persistent fever for more than 48 hours despite broad-spectrum antibiotics. Upon return to the operating room, the patient was found to have an unrecognized bladder perforation with mesh in the bladder. Wound culture was remarkable for Candida parapsilosis and Escherichia coli. CONCLUSION: Unrecognized bladder perforation and nonbacterial causes of infection should be considered in patients with severe progressing cellulitis despite broad-spectrum antibiotic coverage after retropubic midurethral sling placement.

Midurethral sling shortening for persistent stress urinary incontinence.

We describe techniques and objective and subjective outcomes for women who underwent midurethral sling (MUS) shortening for persistent stress urinary incontinence (SUI). This is a case series of women who underwent MUS shortening for SUI within 8 weeks of initial MUS placement. Objective and subjective findings including Urinary Distress Inventory (UDI)-6 and Urinary Impact Questionnaire (UIQ)-7 scores are reported, and shortening techniques are described. Between June 2007 and June 2010, three women underwent MUS shortening for persistent SUI within 8 weeks of initial MUS placement. Shortening was performed with either midline plication or mesh excision and reapproximation. Five months postoperative to shortening, one woman reported subjective improvement in SUI symptoms, and two had subjective and objective resolution of SUI. All showed improvement from baseline in UDI-6 and UIQ-7 scores. There were no erosions. MUS shortening may offer a safe and effective option for management of persistent SUI.

Perceptions of operating room learning experiences during the obstetrics and gynecology clerkship.

BACKGROUND: There is little published describing curriculum development for the medical student in the operating room (OR). PURPOSE: Explore student and faculty perceptions of learning experiences in the OR during the Obstetrics and Gynecology (Ob/Gyn) clerkship as a prelude to defining OR-specific learning objectives and curriculum. METHODS: Fourth year students and Obstetrics and Gynecology faculty participated in structured, audiotaped focus groups aimed at defining OR educational objectives and curriculum content. Review of audiotapes identified emergent themes used to categorize perceived learning experiences. RESULTS: Two focus groups including 13 students and 1 focus group including 5 faculty were conducted. Four dominant categories of OR learning were identified: (1) development of a foundation of clinical knowledge; (2) surgical technique and skill acquisition; (3) personal insight into career choice; and (4) surgical culture and OR functioning. CONCLUSIONS: Students and faculty were aligned regarding general categories of key OR learning experiences, building an experiential framework for developing OR-specific learning objectives and curricular components.

Improving medical student knowledge of female pelvic floor dysfunction and anatomy: a randomized trial.

OBJECTIVE: The objective of the study was to estimate the effect of an interactive computer trainer on improving medical student knowledge and attitudes regarding female pelvic anatomy (PA) and pelvic floor dysfunction (PFD). STUDY DESIGN: Forty-three students were randomized to the trainer and usual teaching vs usual teaching alone. Pre- and postintervention knowledge and attitude questionnaires were completed. Between-group pre- and postintervention scores were analyzed. Multiple linear regression was used to estimate trainer effect on scores, adjusting for confounders. RESULTS: There was no difference in baseline scores between groups (P > .05). The trainer group had significantly higher postintervention knowledge (mean score, 15.6 +/- 1.9 vs 12.6 +/- 2.5; P = .007) and attitude (mean score, 19.2 +/- 2.8 vs 15.8 +/- 3.2; P = .001) scores compared with the usual teaching group. On multiple linear regression, the trainer group had significantly higher postintervention knowledge and attitude scores, after adjusting for year of medical education and prior clerkships. CONCLUSION: An interactive computer trainer to teach female PA and PFD improves medical student knowledge and attitudes.

A randomized trial to estimate the effect of an interactive computer trainer on resident knowledge of female pelvic floor dysfunction and anatomy.

OBJECTIVES: : To estimate the effect of a computer trainer on improving knowledge and attitudes of Obstetrics and Gynecology residents regarding female pelvic anatomy (PA) and pelvic floor dysfunction (PFD) compared to usual teaching. METHODS: : A randomized trial was conducted between April and June 2008. Obstetrics and Gynecology residents randomized by year of training participated in a 1-hour session with a computer trainer for individual-based learning of female PA and PFD or usual teaching. Questionnaires assessing (1) knowledge of and (2) attitude regarding, or comfort with, female PA and PFD were completed at baseline and 1 month following recruitment. Residents randomized to the trainer answered trainer-specific questions on the post-intervention questionnaire. Higher scores indicated higher knowledge and comfort level. Between-group differences in pre-intervention and post-intervention questionnaire knowledge and attitude scores were analyzed. Eleven residents randomized to each group would provide a power of 0.8 at α = 0.05. RESULTS: : Twenty-two residents completed the study. There were no significant differences between residents randomized to trainer versus usual teaching in knowledge or attitude scores on the pre-intervention questionnaire (p > 0.50). There was no significant difference in median post-intervention knowledge (14 [range 13-17] vs 13 [range 10-18], P = 0.10) or attitude scores (30 [range 14-41] vs 22 [range 11-42], P = 0.49) for the residents randomized to the trainer compared to the controls. CONCLUSIONS: : In this single-center study, the trainer was not associated with significant improvements in resident knowledge or attitude scores regarding female PA and PFD.

Epidemiology of pelvic floor dysfunction.

The epidemiology of female pelvic floor disorders, including urinary incontinence, pelvic organ prolapse, anal incontinence, and interstitial cystitis/painful bladder syndrome is reviewed. The natural history, prevalence, incidence, remission, risk factors, and potential areas for prevention are considered.

Magnetic resonance imaging of pelvic organ prolapse: comparing pubococcygeal and midpubic lines with clinical staging.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to determine which magnetic resonance imaging (MRI) reference line for staging pelvic organ prolapse, the pubococcygeal line (PCL) vs. the midpubic line (MPL), has the highest agreement with clinical staging. METHODS: A retrospective study of women with pelvic floor complaints who underwent dynamic pelvic MRI from January 2004 to April 2007 was conducted. Two radiologists staged descent on MRI for each pelvic compartment (anterior, apical, posterior) by consensus, using PCL and MPL reference lines. Agreement between MRI and clinical staging was estimated using weighted kappas. RESULTS: Twenty women were included. Agreement between clinical and PCL staging was fair in the anterior (kappa = 0.29) and poor in the apical (kappa = 0.03) and posterior (kappa = 0.08) compartments. Agreement between clinical and MPL staging was fair in the anterior (kappa = 0.37), apical (kappa = 0.31), and posterior (kappa = 0.25) compartments. CONCLUSIONS: The MPL has higher agreement with clinical staging than the PCL. However, neither reference line has good agreement with clinical staging.

Pelvic organ prolapse.

Pelvic organ prolapse can encompass a range of disorders, from asymptomatic, altered anatomy to complete eversion of the vagina and may present with associated urinary, defecatory, and sexual dysfunction. Patient symptoms are important to elicit, because many patients with prolapse are asymptomatic. Ascertaining patient treatment goals is necessary when discussing options for management, and patients can choose from conservative, noninvasive treatment and prevention to surgical reconstruction. As comparable data for prolapse operations are poor, surgical route is determined based on the type and severity of prolapse, surgeon preference, and desired outcome.

The impact of multichannel urodynamics upon treatment recommendations for female urinary incontinence.

The aim of this study was to evaluate whether multichannel urodynamic testing changes a physician's treatment recommendations when managing women with urinary incontinence. In this prospective reader study, four fellowship-trained urogynecologists reviewed 39 abstracted cases of urinary incontinence on two occasions: first without and subsequently with urodynamic data. Treatment recommendations were made for each case after each review. The probability of urodynamic data modifying treatment recommendations was estimated for each reader and for the population of readers using a random effects logistic regression to account for reader variability. The overall probability that urodynamic data would change treatment was 26.9% (95% confidence interval (CI), 18.6%, 37.2%) for medical treatments and 45.5% (95% CI, 37.8%, 53.4%) for surgical treatments. Reader-to-reader differences accounted for 3% and <1% of the total variance for medical and surgical treatments, respectively. Multichannel urodynamic evaluations are significantly associated with changes in medical and surgical treatment recommendations in a referral population.

Long-term follow-up of a transvaginal Burch urethropexy for stress urinary incontinence.

OBJECTIVE: The objective of the study was to describe long-term objective and subjective success rates and complications following transvaginal Burch urethropexy for stress urinary incontinence. STUDY DESIGN: A case series of 66 women who underwent vaginal Burch urethropexy for urodynamic stress urinary incontinence with urethral hypermobility using a suture carrier device is presented. Concurrent prolapse repairs were performed as indicated. RESULTS: Sixty-six women (mean age 49.4 +/- 12.1 years) underwent vaginal Burch urethropexy. Mean follow-up time was 20.9 +/- 18.9 months. Objective failure was observed in 16 patients (24.2%). Subjective failure was reported by 21.2% of patients, with 50% and 28.8% reporting success and improvement, respectively. Six patients (9%) experienced febrile illness, 4 (6%) experienced intraoperative hemorrhage, 1 (1.5%) received transfusion, and 1 (1.5%) experienced pelvic abscess. Twelve patients (18.2%) experienced suture erosion; half required surgical revision or excision. CONCLUSION: Vaginal Burch urethropexy is generally well tolerated but is associated with poor long-term success and high suture erosion rates.

Pyometra necessitating hysterectomy after colpocleisis in an extremely elderly patient.

As the number of women more than the age 65 increases, so will the need for treatment of pelvic organ prolapse and the comorbidities that come with surgical treatment of an aging population gain significance. Colpocleisis is an option for women failing or refusing conservative prolapse management and not desiring sexual function. The advantages of colpocleisis are decreased operative time, low complication rate, and ability to use local or regional anesthesia. We report a case of a 95-year-old woman whose procidentia was treated with colpocleisis. Endometrial evaluation with dilation and curettage was performed at the time of colpocleisis. Postoperative course was complicated by pyometra necessitating total abdominal hysterectomy and bilateral salpingoopherectomy, leading to further complications including deep vein thrombosis, anemia, atrial fibrillation, and pleural effusions. Preoperative versus intraoperative endometrial evaluation may decrease the risk of developing pyometra after colpocleisis and, therefore, diminish the possibility of multiple complications.

Pelvic arterial embolization in the setting of acute hemorrhage as a result of the anterior Prolift procedure.

Acute hemorrhage following pelvic reconstructive surgery is a complication requiring immediate evaluation and treatment. Therapeutic options include fluid resuscitation, tamponade techniques, exploratory surgical intervention, and, more recently, pelvic vessel embolization. New approaches to pelvic organ prolapse have been evolving rapidly with little reported on safety and efficacy. We present a 77-year-old female who had a life-threatening acute pelvic hemorrhage from an anterior Prolift procedure successfully treated with pelvic artery embolization.

Vesicouterine fistula presenting with urinary incontinence after primary cesarean section: a case report.

BACKGROUND: Vesicouterine fistula is a rare complication most commonly associated with cesarean section. Though conservative management has been reported, surgical intervention is usually required to treat the condition. CASE: A 32-year-old woman presented with urinary incontinence following a primary cesarean section; it was initially thought to be a vesicovaginal fistula. Careful evaluation and a high index of suspicion resulted in the correct diagnosis of a vesicouterine fistula. The patient was successfully treated with uterus-sparing surgery. CONCLUSION: This case illustrates the importance of a comprehensive evaluation of all patients suspected of having a urogenital fistula. A thorough workup led to the correct diagnosis of vesicouterine fistula and allowed the surgeons to plan the appropriate operative strategy in managing the patient.