Credentialing residents for intraoperative cystoscopy.

OBJECTIVE: To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. METHODS: We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. RESULTS: Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. CONCLUSION: Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation. (Obstet Gynecol 2000;96:1014-7.)

Myomectomy during early pregnancy.

Abdominal pain during early pregnancy may be caused by leiomyoma of the uterus. Inconsistency of uterine size and gestational dates in a pregnant patient with acute abdominal pain may be the first sign of leiomyoma. This 31-year-old primigravida presented with progressively worsening lower abdominal pain at 12 weeks gestational age. Ultrasonography and magnetic resonance imaging demonstrated a large fundal heterogeneous mass and an intrauterine gestation compatible with her menstrual dates. Exploratory surgery and myomectomy confirmed a large leiomyoma showing benign degenerative changes. The operative procedure was successful, and the pregnancy progressed normally. An elective cesarean section was performed at 37 weeks gestation after confirming fetal maturity by amniocentesis and serial ultrasonography. Abdominal pain in a pregnant patient with leiomyoma uteri may be attributable to degenerative changes in the myoma. Surgical intervention during pregnancy is occasionally necessary in uncommon cases of intractable pain.

Development of a core curriculum in professional growth: practice management military model.

Military medicine has faced some big challenges in recent years. Military treatment facilities have not been exempt from these alterations, as the American public has sought to reinvent government practices with regard to medicine. Until recently, professional education consisted almost entirely of emphasis in the particular content of the chosen field. Obstetrics and gynecology was one of the first medical specialties to recognize the importance of practice management, professional growth and development, and to require exposure to it as part of the residency process. The Department of Obstetrics and Gynecology's instructional objectives dealing with professional growth and development originated as part of the military-unique curriculum for physicians implemented at Tripler Army Medical Center in Hawaii. Later, these objectives were used at Madigan Army Medical Center in Tacoma, Washington. Recent changes in the health care environment, coupled with an increasing awareness of professional liability and the newer specter of managed care, force physicians to learn the cost of each health encounter and to be more familiar with the business aspects of health care. As medicine in general is changing, the curricula have been revised and tailored to the needs of our physicians with the addition of ethics, managed care, utilization, and practice management.

Genital mutilation of young girls traditionally practiced in militarily significant regions of the world.

Very few physicians practicing in the United States have experience in treating female patients who have undergone mutilation of the external genitalia, incorrectly termed female circumcision. This procedure, known as infibulation, consists of removing the clitoris, prepuce, and portions of the labia of young girls, usually younger than 7 years of age. Infibulation has been practiced by lay midwives for centuries in the Horn of Africa and in other African and Middle Eastern countries. This paper discusses infibulation, the techniques, and the recommended medical and obstetric management of patients subjected to genital mutilation. With increased immigration to the United States by Africans and Middle Easterners, and with readily increasing military medical deployments, primary care physicians and specialists can expect to be confronted with patients who have undergone this disfiguring procedure during their youth.

Fine needle aspiration of palpable breast masses performed in a military obstetrics/gynecology clinic: a follow-up report.

Evaluation of breast disease has increasingly become more integrated into the routine gynecology care of women seen in the obstetrics/gynecology (OB/GYN) clinic. Patients expect their obstetrician-gynecologist to have expertise in evaluation and diagnosis of breast problems that arise from self examination, routine mammography, unusual breast symptoms, or clinical findings during annual gynecology examinations. In 1993, Tripler Army Medical Center Department of Obstetrics and Gynecology initiated a Breast Evaluation Clinic to better serve its patients with breast problems and to train military OB/GYN resident physicians in evaluation and diagnosis of breast disease. A preliminary report of the first 40 patients evaluated in this Breast Evaluation Clinic was previously published in Military Medicine. The patient evaluation, the technique of performing fine needle aspiration (FNA) of breast masses, and the cytologic slide preparation was described in the preliminary report. This follow-up report presents a total of 245 patients who underwent FNA of palpable breast masses in the Tripler Army Medical Center OB/GYN Department Breast Evaluation Clinic between December 1, 1993, and December 8, 1995. Patients found to have suspicious breast masses or abnormal mammography reports at the time of evaluation were immediately referred to the Department of General Surgery for evaluation rather than be subjected to FNA in the OB/GYN Department Breast Evaluation Clinic. Of the 245 patients who underwent FNA, 26 (11%) were referred to the Department of General Surgery for treatment or open biopsy based on cytologic diagnosis and evaluation in the OB/GYN Breast Evaluation Clinic. No major complications from the FNA procedures occurred during this 2-year study period.

AN electronic bulletin board for instruction in reproductive endocrinology in a residency in obstetrics and gynecology.

OBJECTIVE: To explore the role of an electronic bulletin board as a means of computer-based learning in reproductive endocrinology for residents in obstetrics and gynecology. DESIGN: An electronic bulletin board was networked to all residents to present a formal lecture series in reproductive endocrinology and an informal question, answer, and discussion session after each lecture. Ten lectures were presented, one each month, throughout the academic year followed by question, answer, and discussion sessions. All lectures could be stored in an electronic file folder or printed as hard copy for review. A questionnaire was distributed at the conclusion of the project to assess previous resident experience with computers, resident response to, and utilization of the bulletin board. SETTING: A residency program in obstetrics and gynecology in a major medical center. PARTICIPANTS: Twenty-four residents in a 4-year program. MAIN OUTCOME MEASURES: Previous computer experience, ease of use, resident participation, and satisfaction with the bulletin board. RESULTS: Sixty-five percent of the residents considered themselves computer literate and 33 percent previously had taken a course in computer technology. Computer experience in word processing, spreadsheet, and database management was related by 55 percent, 40 percent, and 25 percent of the residents, respectively. Ninety-five percent of the residents accessed the bulletin board for the lectures and found this system a convenient means of review. Sixty percent reviewed the lectures and stored them in an electronic file folder for later review. Forty percent printed the lecture on hard copy. On a scale of 1 to 5 (1 = lowest; 5 = highest), overall resident satisfaction was high at 4.5. CONCLUSION: Our data suggest a potential role for electronic bulletin boards as a complement to standard teaching protocols in resident education. The relative ease of use and satisfaction suggest that these techniques are feasible and offer an effective method of on-line instruction.

Uterine packing in the combined management of obstetrical hemorrhage.

Uterine packing to control obstetrical hemorrhage has been generally discouraged over the past several decades. Intractable uterine hemorrhage postpartum or following an abortion is an extremely vexing management problem for the physician and continues to be a leading cause of maternal mortality. Uterine packing should be considered as a presurgical management tool after lacerations of the lower genital tract, uterine rupture, or retained products have been ruled out and when conventional therapy fails to control uterine hemorrhage. We describe two obstetrical patients with intractable uterine hemorrhage who were managed with uterine packing in combination with other methods of therapy. Causes of obstetrical hemorrhage and techniques of packing the uterus are discussed.

Fine needle aspiration of palpable breast masses with immediate cytologic interpretation in an OB/GYN residency training program: a preliminary report.

Increasing emphasis has been placed on the training of obstetrics and gynecology residents in the evaluation of patients with breast disease. In the past, one had to refer to the surgery, radiology, or pathology literature to obtain current information on fine needle aspiration. With the present mandate to include breast disease in the academic curricula of obstetrics and gynecology residency training, the Department of Obstetrics and Gynecology, Tripler Army Medical Center, initiated training in breast evaluation. This preliminary report describes the Tripler Obstetrics and Gynecology Department Breast Evaluation Clinic and presents the findings of the first 40 patients.

Laparoscopic management of fallopian tube prolapse.

Sporadic cases of fallopian tube prolapse and various methods of management have been reported since the initial case described in 1902. Two cases were managed recently by a combined vaginal and laparoscopic approach. Total salpingectomy was accomplished with minimal difficulty and limited invasiveness. A brief summary of each case and detailed description of the operative technique are presented.