Implementation and Evaluation of a Comprehensive Resident Wellness Curriculum During the COVID-19 Pandemic.

OBJECTIVE: To evaluate the effectiveness of resident-led and faculty-led initiatives for physician wellness after implementation of a resident wellness program. DESIGN: We initiated a wellness curriculum with both resident and faculty-led components in a large academic OB/GYN residency program in October 2020. The curriculum was created and evaluated using the Logic model. Residents were surveyed pre and 8 months postintervention with the Maslach Burnout Inventory (MBI) and the Physician Well-Being Index (PWBI), with activity-related questions added to the second survey. Descriptive statistics, Mann-Whitney test, Chi-square test, and theme analysis were performed as appropriate. SETTING: A large academic OB/GYN residency at Baylor College of Medicine in Houston, Texas PARTICIPANTS: All residents (n = 48) were invited to take part in the surveys. Response rate was 31/48 (65%) pre and 28/48 (58%) postintervention. RESULTS: Residents scored moderate for emotional exhaustion and depersonalization and high for personal accomplishment on both pre and post-MBI surveys. All indices of the PWBI improved over time; however, no significant differences were found in pre and postmeasures. Resident-led activities, which were alternated between individualized time off and group resident socialization, were rated significantly higher than faculty-led activities; 93% (52/56) of respondents rated resident-led activities in their top 2 most helpful initiatives compared to 7% (4/56) who rated faculty-led activities in their top 2 most helpful (p < 0.01) initiatives. Open-ended comments revealed that continued focus on wellness, attention to personal health, and systematic change were the most important ways to improve resident wellness. CONCLUSION: Decreases in burnout were not achieved over an 8-month period with program-level resident-led and faculty-led initiatives. Providing scheduled time for residents to use at their discretion and the continuation of events that encourage socialization are tools that are highest rated by residents to facilitate wellness.

Utilizing Structured Worksheets to Strengthen Resident Teaching on the OB/GYN Clerkship.

OBJECTIVE: To determine if structured worksheets can aid resident teaching on the obstetrics and gynecology (OB/GYN) clerkship. DESIGN: We developed structured worksheets to aid residents in teaching medical students. In this pilot study, we measured the impact of the material by conducting end of clerkship focus groups between October 2017 to June 2018 and administering surveys to medical students who had recently completed the clerkship. We performed analyses of the focus group transcriptions for positive and negative themes and analyzed questionnaire data utilizing unpaired t-test and chi-square test to determine whether resident use of structured worksheets influenced student perception of resident teaching quality. SETTING: Medical students rotated at either an academically affiliated public safety-net hospital or tertiary maternity care hospital. PARTICIPANTS: Medical students completing the OB/GYN clerkship volunteered to participate. RESULTS: A total of 37 students participated in focus groups and completed the survey. Focus group comments revealed a generally positive attitude towards the structured worksheets. The survey data revealed that this material helped to facilitate student's clinical reasoning skills and assisted residents in using questions to effectively teach. CONCLUSIONS: Structured worksheets can aid resident teaching on the OB/GYN clerkship. Students perceived the teaching material most favorably when residents utilized the material in a purposeful and timely manner. Effective resident use of structured worksheets on the OB/GYN clerkship can strengthen a culture that promotes student learning. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01318-7.

Enhancing the Teaching Environment: 3-Year Follow-Up of a Resident-Led Residents-as-Teachers Program.

BACKGROUND: Previous faculty-driven residents-as-teachers (RAT) models have had limited efficacy and sustainability. OBJECTIVE: To evaluate the acceptability and effects of a resident-led RAT program on resident teaching. METHODS: In October 2016, obstetrics and gynecology (OB/GYN) residents at a large academic institution implemented a resident-led RAT program, consisting of a steering committee of peer-selected residents with 2 faculty mentors who planned education-focused resident didactics and journal clubs, organized resident involvement in clerkship activities, and recognized residents who excelled in teaching as Distinguished Educators (DEs). From July 2016 through June 2019, using the Kirkpatrick Model, we evaluated the program with annual resident surveys assessing self-perception of 13 teaching skills (5-point Likert scale) and value of RAT program, institutional end-of-clerkship student evaluations of resident teaching, and resident participation in DE award. RESULTS: Annual resident survey response rates ranged from 63% to 88%. Residents' self-reported teaching skills improved significantly in 11 of 13 domains from 2016 to 2018 (improvements ranging from 0.87-1.42; 5-point Likert scale; P < .05). Of the 2018 respondents, 80% agreed that the resident-led RAT program added value to the residency. For 2017-2018 and 2018-2019 academic years, 47% and 48% of medical students (100% response rate) strongly agreed that residents provided effective teaching compared to 30% in 2016-2017 (P < .05). Ten residents have graduated as DEs during this time period. CONCLUSIONS: A resident-led RAT program increased residents' self-reported teaching skills, improved medical student perceptions of teaching quality, and was sustainable and acceptable over a 3-year period.

Training the Next Generation of Obstetrics and Gynecology Leaders, A Multi-Institutional Needs Assessment.

OBJECTIVE: To assess resident and faculty interest in, as well as content and preferred format for, a leadership curriculum during obstetrics and gynecology residency DESIGN: From June to July 2019, a needs assessment survey on leadership training was distributed to residents and academic faculty at 3 United States obstetrics and gynecology residency programs. Descriptive and bivariate analyses were performed. Open ended questions were analyzed for themes. SETTING: Three ob/gyn residency programs across the United States: Kaiser Permanente East Bay in Oakland, California, Baylor College of Medicine in Houston, Texas, and Weill Cornell Medicine in New York, New York. PARTICIPANTS: Surveys were distributed to all residents (n = 111) and affiliated academic faculty (n = 124) at each of the 3 participating sites. RESULTS: Resident response rate was 71% (79/111) and faculty rate was 63% (78/124). Postgraduate year (PGY) 1 residents were more likely to believe there was sufficient leadership training during residency (17/23, 74%) compared to PGY 2-4s (16/56, 29%) and faculty (20/76, 26%; p < 0.01). Most residents (66/79, 84%) and faculty (74/78, 82%) expressed that residents would benefit from a leadership curriculum. Both deemed small group exercises and leadership case studies taught by physicians were the preferred format for this curriculum. Residents and faculty agreed on 3 of the top 4 topics for a leadership curriculum - effective communication, team management, and time management - while residents chose self-awareness and faculty chose professionalism as the fourth of their top domains. Open-ended survey questions revealed that leadership demands in obstetrics and gynecology are similar to other specialties but differ in emphasis on crisis management, situational awareness, and advocacy training. CONCLUSIONS: Given unique aspects of leadership within the specialty, obstetrics and gynecology residents and faculty see benefit for specialty-specific formalized leadership training.

A Conceptual Model for Residents as Teachers in Obstetrics and Gynecology.

BACKGROUND: The learning environment in obstetrics and gynecology (OB/GYN) may have intrinsic differences that require modifying existing resident as teacher models for high-quality teaching. OBJECTIVE: To explore medical students' views of resident teaching on the OB/GYN clerkship in order to develop more effective educators. METHODS: Between October 2017 and June 2018, we performed medical student focus groups at the end of the 2-month OB/GYN clerkship. Topics discussed included positive and negative teaching interactions with residents, barriers specific to the OB/GYN clerkship, and best methods for resident teaching. Qualitative analysis utilizing 3 reviewers and N-Vivo software were used to identify themes. RESULTS: A total of 37 students participated in five focus groups. The most common barriers were a learning environment that was less predictable than on other rotations and lack of autonomy due to patient advocacy concerns. The three main contributors to positive learning experiences were team inclusion, clear expectations, and feedback. Negative interactions were passive learning experiences and inconsistent expectations. The best methods for resident teaching were verbalization of cognitive processes, preparation to use common patient encounters as teaching moments, and modeling skills needed for proficient patient care. DISCUSSION: The learning environment on OB/GYN is unpredictable and influenced by four Ps: patient autonomy, passive experiences, procedures, and preconceived notions. The strategy of a resident teacher should focus on medical student inclusion and preparation for teaching role. We thus suggest a TEAM (Thinking Aloud, Expectations, Advanced Preparation, Modeling) approach to improve resident teaching on the OB/GYN clerkship.

Electronic Learning-Spaced Education to Facilitate Resident Knowledge and Guide Program Didactics.

OBJECTIVE: To evaluate the use of mobile technology to facilitate resident learning, assess clinical knowledge, and guide curricular development in a busy clinical environment. METHODS: This was a cross-sectional study conducted in a large (N=48) urban obstetrics and gynecology residency program. Question sets were created in the following areas: office gynecology, general obstetrics, gynecologic surgery and urogynecology, maternal-fetal medicine and ultrasonography, reproductive endocrinology and pediatric gynecology, and gynecologic oncology. Using an educational mobile application (app), questions were sent monthly to resident smartphones with immediate feedback on answer accuracy along with answer explanation and references. Outcomes included app use, which was determined by how quickly participants answered questions (very active-active indicates questions answered within 7 days) and proficiency (mean percentage correct) calculated for individuals, resident class level, and by content area. RESULTS: All 48 residents participated and 77.4% were very active or active app users. On average, participants answered correctly 61.0% on the first attempt and improved to 78.3% on repeat attempt (P<.001). Proficiency was lowest for gynecologic surgery and highest for general obstetrics. CONCLUSION: A mobile app to support e-learning was successfully implemented in our program; its use was associated with knowledge retention and identification of low-proficiency topics to guide curriculum development.

Preferences and Outcomes for Chemotherapy Teaching in a Postgraduate Obstetrics and Gynecology Training Program.

PURPOSE: To determine whether chemotherapy teaching is a desired component of postgraduate training programs in obstetrics and gynecology and assess its effect on practicing clinicians. METHOD: After obtaining institutional review board approval, 99 individuals who completed postgraduate training at a single academic medical center between 2005 and 2013 were invited to complete an online survey. Descriptive statistics were used to summarize responses. RESULTS: Of the 99 individuals, 68 (68%) completed the survey. Respondents included physicians currently practicing in both academic medicine (n = 36, 52.9%) and private practice (n = 24, 35.2%). Most respondents (n = 60, 88.2%) indicated that chemotherapy teaching was a desired feature of their training and expressed a preference for both formal didactics and direct clinical involvement (n = 55, 80.2%). Benefits identified by respondents included improved insight into the management of symptoms commonly associated with chemotherapy (n = 55, 82.1%) and an enhanced ability to counsel patients referred for oncology care (n = 48, 70.5%). All respondents who pursued training in gynecologic oncology following residency (n = 6) indicated that chemotherapy teaching favorably affected their fellowship experience. Of the 6 gynecologic oncologists, 3 (50%) who responded also indicated that chemotherapy teaching during residency improved their performance in fellowship interviews. CONCLUSION: Chemotherapy teaching was a desired feature of postgraduate training in general obstetrics and gynecology at the institution studied. Consideration should be given to creating curricula that incorporate the principles and practice of chemotherapy and address the needs of obstetrics and gynecology trainees who intend to pursue both general and subspecialty practice.

Perforated levonorgestrel-releasing intrauterine system resulting in small bowel obstruction: a case report.

BACKGROUND: Complications arising from use of the levonorgestrel-releasing intrauterine system (LNG-IUS) are uncommon. Perforation of the uterus by an LNG-IUS leading to small bowel obstruction (SBO) has not been reported in the literature. CASE: A 29-year-old woman presented to the emergency department with abdominal pain, constipation, nausea, and vomiting. CT scan revealed dilated loops of small bowel suggestive of SBO and an IUD that did not appear within the uterine cavity. Laparoscopy revealed a dense adhesive band of tissue extending from 2 cm caudad to the umbilical port site to 1 arm of the perforated LNG-IUS at the posterior uterine wall. Two bowel loops were twisted around the adhesive band multiple times. The band was taken down at the IUD and the bowel loops were spontaneously freed. The LNG-IUS was removed. CONCLUSION: Use of the LNG-IUS is on the rise in the United States and is a recommended first-line contraceptive agent in the obese patient. Management of perforated IUD in an obese patient should take into account individual patient characteristics. Laparoscopic management of a SBO due to a perforated IUD in an obese patient is possible.

Emotional intelligence and selection to administrative chief residency.

OBJECTIVE: The authors sought to determine whether emotional intelligence, as measured by the BarOn emotional quotient inventory (EQ-i), is associated with selection to administrative chief resident. METHOD: Authors invited senior-year residents at the University of Texas Health Science Center at Houston to participate in an observational cross-sectional study using the BarOn EQ-i. In October 2009 they sent an invitation e-mail to 66 senior residents, with a reminder e-mail 1 month later. The study was designed to detect a 15-point difference in EQ-i scores with 80% power. RESULTS: Of the 66 invited residents, 69.6% participated in the study. Average total EQ-I score was 104.9. Among senior-year residents, there were no statistically significant differences in EQ-i scores between administrative chief residents (at 109) and non-administrative chief residents (at 103.2). CONCLUSION: Administrative chief residents do not demonstrate higher Emotional Intelligence, as measured by the EQ-i, than other senior-year residents.

Exploring factors influencing patient request for epidural analgesia on admission to labor and delivery in a predominantly Latino population.

Ethnic disparities in labor pain management exist. Our purpose is to identify patients' attitudes and beliefs about epidural analgesia in order to develop a culturally competent educational intervention. A prospective observational study was conducted in patients admitted for vaginal delivery between July 1st-31st, 2009. Inclusion criteria were: singleton, term, cephalic, normal fetal heart tracing and no contraindications for epidural. Patients were surveyed regarding their wishes for analgesia, and their reasons for declining epidural. The obstetrics physician performed pain management counseling as is usually done. Patients were asked again about their choice for analgesia. Likert scale questionnaires were used. Wilcoxon signed ranked test was used for categorical variables. Logistic regression was performed to look for predictors of epidural request. Fifty patients were interviewed. Average age was (27.9 ± 6.7), gestational age (39.3 ± 1.3), and a median parity of 2 (range 0-6). 72% declined epidural upon admission, and 61% after counseling (P = 0.14). Most common reasons for declined epidural were 'women should cope with labor pain' (57%), 'fear of back pain' (54%) and 'family/friends advise against epidural' (36%). Acculturation was assessed by years living in the US (10 ± 6.3), preferred language (Spanish 80%) and ethnic self-identification (Hispanic 98%). 38% were high school graduates. In multivariate logistic regression, graduation from high school was the only variable associated to request for epidural in labor (OR 4.94, 95% CI 1.6-15.1). Educational level is associated to requesting an epidural in labor. Knowledge of patients' fears and expectations is essential to develop adequate counseling interventions.

Laparoscopy in the morbidly obese pregnant patient using a modified foley lap-lift technique: case report.

Obesity in women of reproductive age is increasing. Gynecologic laparoscopy in the morbidly obese pregnant patient presents challenges, and is not often attempted. Herein is reported a successful case using a modified Foley lap-lift technique, which improved visualization and facilitated mechanical ventilation.

Cervical and prolapsed submucosal leiomyomas complicating pregnancy.

UNLABELLED: Cervical and prolapsed submucosal leiomyomas are rarely seen in pregnancy. Depending on the size threshold used to diagnose a leiomyoma, the prevalence of uterine leiomyomas in pregnancy is approximately 3% to 10%. The prevalence of clinically evident cervical leiomyomas in pregnancy is less than 1%. Contrary to prior thought, the majority of uterine leiomyomas in pregnancy do not usually lead to complications. Indications for surgical intervention in pregnancy for cervical leiomyomas include bleeding, infection, degeneration, pain, and urinary stasis. Preoperative imaging with ultrasound and magnetic resonance imaging may help to delineate the location and nature (e.g., pedunculated) of the cervical leiomyoma when clinical examination is inconclusive. We reviewed the current literature in regard to cervical leiomyomas in pregnancy and summarize the major findings. After completing this CME activity, readers should be better able to evaluate the prevalence and natural history of uterine and cervical leiomyomas in pregnancy, assess indications for surgical intervention in pregnant patients, manage surgical complications, and select imaging modalities that may determine their origin. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the reader should be better able to evaluate the prevalence and natural history of uterine leiomyomas in pregnancy; assess indications for surgical intervention in pregnant patients; manage surgical complications; and select imaging modalities that may determine their origin.

Chronic nonpuerperal uterine inversion and necrosis: a case report.

INTRODUCTION: Inversion of the non-pregnant uterus is rare. CASE PRESENTATION: A 56-year-old African American woman presented to our emergency center with complaints of a mass protruding from her vagina. She subsequently underwent vaginal myomectomy, abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathologic examination revealed a necrotic fibroid and endometrium. At the time of laparotomy an inverted uterus was diagnosed when a 3 cm dimple containing bilateral round ligaments, infundibulopelvic ligaments and bladder was observed. CONCLUSION: Chronic nonpuerperal inversion of the uterus is rare. Infection should be suspected and appropriate broad spectrum antibiotics begun while planning surgery. An attempt at vaginal restoration and removal is difficult. Abdominal hysterectomy may be necessary taking care to locate the distal urinary collecting system.

Vaginal myomectomy in pregnancy: a report of two cases.

Prolapsed fibroids presenting in pregnancy are rare. Two cases of bleeding prolapsed fibroids, one cervical and the other submucosal, are presented to demonstrate the clinical features and outcomes following surgical treatment during pregnancy. While vaginal myomectomy of a prolapsed cervical fibroid in pregnancy appears safe, prolapse of a submucosal fibroid in pregnancy necessitating excision may be associated with rupture of the membranes.

Factors complicating surgical management of the vulvar abscess.

OBJECTIVE: To delineate risk factors and demographics in those patients with vulvar abscess that required surgical intervention, identify the most common bacterial isolate present at the time of surgery and comment on the progression to necrotizing fasciitis and the need for reoperation. STUDY DESIGN: Retrospective chart review. RESULTS: A total of 47 vulvar abscesses with cellulitis were managed surgically. The most common isolate was methicillin-resistant Staphylococcus aureus (MRSA), which comprised 43% of the total. The median length of stay was 4 days (1-66), and 17% had stays >7 days. Diabetes was significantly related to hospitalization >7 days (38% vs. 6%, p<0.01), reoperation (25% vs. 3%, p=0.02) and progression to necrotizing fasciitis (19% vs. 0%, p=0.01). CONCLUSION: When treating abscess of the vulva with cellulitis, antibiotic coverage of MRSA should be undertaken. Inpatient management with aggressive treatment for abscess of the vulva in those patients with concomitant diabetes is recommended.

Intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy: a practice survey.

OBJECTIVE: To assess practice patterns concerning intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy among members of the Association of Professors of Gynecology and Obstetrics (APGO). STUDY DESIGN: A 16-question survey regarding intraoperative fetal heart rate monitoring during nonobstetric surgery was delivered to the 1300 APGO members via email. Descriptive statistics were used to determine the reasons for fetal monitoring during nonobstetric surgery in pregnancy. RESULTS: Concerning intraoperative monitoring during nonobstetric surgery, 98% of respondents recorded the fetal heart rate pre-and post-surgery, and 43% of respondents reported they usually monitor intraoperatively. Of the 1151 physicians surveyed, 16% completed the survey. CONCLUSION: The majority of APGO members surveyed do not employ intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy.

Laparoscopy in pregnancy: a literature review.

The first laparoscopic surgery in pregnancy was a cholecystectomy in 1991. Since that time, a number of articles and case series have been published addressing laparoscopy in pregnancy. Current recommendations are on the basis of these findings, such as operating during any trimester in pregnancy can be safely performed, fetal heart monitoring should be made preoperatively and postoperatively, prophylactic tocolytics should not be used, and multiple entry techniques (Veress needle, Hasson trocar, or optical trocar) can be safely performed. This article will review anesthesia, fetal effects, obesity, complications, adnexal masses, and gastrointestinal issues.

Management of the acute abdomen in pregnancy: a review.

PURPOSE OF REVIEW: The acute abdomen remains a challenge for all physicians who take part in the care of women in pregnancy. Obstetricians must be abreast of current topics, especially critical when having to consult other specialties for assistance in managing these conditions. RECENT FINDINGS: We will highlight recent observations in the literature concerning the ability to perform laparoscopy safely in pregnancy, the accuracy of diagnosing appendicitis, and new methods to accurately diagnose urolithiasis with less ionizing radiation effect on the fetus. Finally, with the proficiency of laparoscopy and choledochoscopy improving, we will review several articles underlining their safety. SUMMARY: Laparoscopy appears to be well tolerated in pregnancy, but larger multicenter prospective studies are required to make better recommendations concerning its use, with a registry needed to facilitate this endeavor. Conservative management of gallstone pancreatitis may fall out of favor, and choledochoscopy for symptomatic gallstones in the biliary tree may become the treatment of choice. Most cases of urolithiasis resolve with conservative management, but the possibility of preterm labor in these patients must be recognized and newer imaging techniques for diagnosis containing less radiation be used. Adnexal torsion in pregnancy may be another condition that is managed through the laparoscope as the gynecologic community's laparoscopic skills improve.

Approach to the acute abdomen in pregnancy.

Numerous physiologic changes in pregnancy may affect the presentation of abdominal pain in pregnancy. A high index of suspicion must be used when evaluating a pregnant patient with abdominal pain. General anesthesia is considered safe in pregnancy. Intraoperative monitoring and tocolytics should be individualized. Laparoscopic surgery should be performed in the second trimester when possible and appears as safe as laparotomy. If indicated, diagnostic imaging should not be withheld from the pregnant patient. Appendectomy and cholecystectomy appear to be safe in pregnancy. The reported incidence of adnexal masses and fibroids in pregnancy may increase with increasing use of first-trimester ultrasound. Conservative management, with surgical management postpartum, appears reasonable in most cases.