Perceived Impact of a Core Rotation on Hawai'i Island on Future Career Intentions among Obstetrics and Gynecology Residents.

Hawai'i Island faces a growing shortage of obstetric and gynecology providers. Increased exposure of obstetrics and gynecology residents to rural rotations during their core training may increase their interest in rural practice after graduation. In an effort to address the health care needs of women on Hawai'i Island, the University of Hawai'i Obstetrics and Gynecology Residency Program established a 4-week required gynecology rotation in the town of Hilo. Between July 2019 and June 2020, third- and fourth-year obstetrics and gynecology residents provided outpatient gynecologic care and participated in gynecologic surgeries at Hilo-based medical facilities. A total of 9 residents participated in this Hilo-based rotation. This retrospective study extracted data from post-rotation evaluations. Eight out of 9 participating residents (89%) felt that the rotation slightly or far exceeded their expectations. After the rotation, 7 residents (78%) reported an interest in practicing in a rural community, while only 3 residents (33%) reported having this interest prior to the rotation. Underserved rural areas seeking to recruit and retain obstetrics and gynecology physicians may benefit from partnering with residency training programs.

Perceptions Regarding Pediatric and Adolescent Gynecology Training among Obstetrics and Gynecology Residents in Hawai'i.

A pediatric and adolescent gynecology curriculum was implemented for obstetrics/gynecology residents at a single institution in Hawai'i. The primary objective of this study was to evaluate the effectiveness of this pediatric and adolescent gynecology (PAG) formal curriculum in improving knowledge. Twelve residents at the University of Hawai'i completed the curriculum during their second year of training. Of these, 6 residents completed an examination assessing knowledge both before and immediately after the curriculum. Five of these residents completed the examination 1-2 years after completing the curriculum. Average pre-rotation examination scores were 57%, which increased significantly immediately after the curriculum to 87% (P=.003) and remained significantly higher after 1-2 years with average scores of 71% (P=.025). A secondary objective was to assess resident comfort and confidence levels in the subject. All residents who completed the curriculum completed surveys assessing comfort in their pediatric and adolescent gynecology training and both perceived confidence and competence in this area. Despite completing the curriculum, 7 of 12 (58%) did not feel comfortable evaluating pediatric gynecology patients, and 5 of 12 (42%) did not feel prepared nor competent to care for pediatric and adolescent patients. A formal pediatric and adolescent gynecology curriculum increased examination performance, which suggests knowledge retention. However, despite curriculum completion, residents still desired more training in the subject area. Residency programs should consider innovative ways to incorporate inpatient and outpatient educational experiences, periodic testing, and feedback longitudinally throughout residency training to improve long-term retention, confidence, and competence in providing gynecologic care in the pediatric and adolescent gynecology population.

Academic clinical learning environment in obstetrics and gynecology during the COVID-19 pandemic: responses and lessons learned.

COVID-19 pandemic is changing profoundly the obstetrics and gynecology (OB/GYN) academic clinical learning environment in many different ways. Rapid developments affecting our learners, patients, faculty and staff require unprecedented collaboration and quick, deeply consequential readjustments, almost on a daily basis. We summarized here our experiences, opportunities, challenges and lessons learned and outline how to move forward. The COVID-19 pandemic taught us there is a clear need for collaboration in implementing the most current evidence-based medicine, rapidly assess and improve the everchanging healthcare environment by problem solving and "how to" instead of "should we" approach. In addition, as a community with very limited resources we have to rely heavily on internal expertise, ingenuity and innovation. The key points to succeed are efficient and timely communication, transparency in decision making and reengagement. As time continues to pass, it is certain that more lessons will emerge.

The Effect of a Targeted Educational Activity on Obstetrics and Gynecology Resident In-Training Examination Scores.

The objective of this study was to compare the examination scores before and after implementation of a study program based on high yield topics on the Council of Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination. This prospective cohort study compared scores from academic years 2012 to 2014 of University of Hawai'i obstetrics and gynecology residents who participated in a directed study program based on selected high yield topics from the CREOG Test Item Summary Booklet. Topics were considered high yield if more than 75% of the program residents answered the topic questions incorrectly during the immediately preceding CREOG In-Training Examination administration. Residents were assigned topics to research and present at monthly teaching sessions. The presentations were made accessible in a wiki website. The intervention was initiated in 2012 and discontinued in 2013. The primary outcome was the difference among CREOG In-Training Examination scores before the study program, during the study program, and after the study program was discontinued. Only scores of residents who sat for all three exams were included. Eleven residents were present during the duration of the study period and sat for all three CREOG examinations. During the year of the educational activity, paired individual resident CREOG exams scores increased significantly from the 2012 CREOG administration (mean = 194.7) to the 2013 CREOG administration (mean = 208.2). These findings demonstrate that the CREOG Test Item Summary Booklet and the wiki platform can be used to effectively direct educational efforts resulting in improvements in CREOG examination performance.

The Effect of the 2012 ASCCP Consensus Guideline for Abnormal Cervical Cytology on Resident Colposcopy Training.

The primary objective was to determine the theoretical number of colposcopies at a resident clinic if the 2012 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines were applied. The secondary objective was to determine the actual number of colposcopies before and after the ASCCP guidelines. This was a two-part descriptive study. The first part applied the 2012 ASCCP guidelines to all pre-guideline colposcopy cases at a single resident clinic. These theoretical results were then compared to the actual number of colposcopies. The second part compared the actual number of colposcopies during the one-year time period before and after the guidelines. Chi-Square tests and Fisher's Exact tests were used to examine the association of categorical variables. Seventy-three colposcopies were performed during the pre-guideline period. After applying the 2012 ASCCP guidelines, 52.1% would not have been indicated, resulting in 35 colposcopies. The largest reductions would have occurred in patients with low grade cytologic abnormalities. Applying the new guidelines, patients 24 years and younger would have been less likely than patients ages 25 to 64 to require colposcopy (P<.001). Fifty-eight indicated colposcopies were actually performed during the post-guideline period. While there was a decrease in the number of colposcopies performed post-guidelines, the decrease was not as dramatic as expected. From a training standpoint, as indications for colposcopy decrease, fewer training opportunities are available for residents. In particular, residents will have less experience evaluating low grade cytologic abnormalities in younger women.

Improving Human Papillomavirus (HPV) Vaccination in the Postpartum Setting.

Although the HPV vaccine has been shown to be highly effective in preventing cervical dysplasia, vaccination rates remain low. The objective of this study was to assess the effectiveness of an electronic medical record (EMR) prompt on HPV vaccination rates in the postpartum setting. We conducted a pre-post intervention study among postpartum women ages 18-26 seen at an outpatient clinic from 09/01/2012-08/31/2013 (pre-intervention) and from 10/01/2013-03/31/2014 (post-intervention). The intervention was a drop-down menu that was inserted into the EMR postpartum note template inquiring about the patient's HPV vaccination status and whether or not the vaccine was administered at that visit. HPV vaccination uptake was compared pre and post-intervention. Of the 278 postpartum visits during the study period, 241 were eligible for analysis. There was a significant increase of the HPV vaccine uptake, from 1.2 % (2/173) among pre-intervention visits to 26.5 % (18/68) among post-intervention visits (p < 0.001). After adjusting for age, ethnicity, insurance, and religion, HPV vaccination was significantly higher at postpartum visits during the intervention period, with an adjusted OR = 93.49 [95 % CI 15.29-571.52]. Among visits in which the vaccine was not given, HPV vaccination was not discussed in 46 % and patients refused the vaccine in 40 % of visits. An EMR prompt in the postpartum note could be an effective way to promote HPV vaccination in the postpartum setting. It will likely take a combination of strategies to optimize vaccination uptake.

Improving the Utilization of Human Papillomavirus and Cervical Cytology Co-testing for Cervical Cancer Screening in an Obstetrics and Gynecology Resident Clinic.

Human Papillomavirus (HPV) testing in combination with cervical cytology (HPV co-testing) has been recommended for cervical cancer screening for women 30 to 65 years of age. In several studies, HPV co-testing increased sensitivity for detecting high grade dysplasia and resulted in cost-savings. This retrospective cohort study assessed the prevalence of HPV co-testing in an obstetrics and gynecology resident clinic before and after a brief educational intervention which was designed to reinforce current cervical cancer screening recommendations. The intervention consisted of a short presentation that was given to all residents and medical assistants in October 2011. The proportion of women age 30-65 years of age who had cervical cancer screening with HPV co-testing as compared to cervical cytology alone was compared before and after the intervention using chi-square tests. The goal of the intervention was to increase the percentage of patients receiving co-testing from 0.5% to 7.8%. Each arm (pre- and post-intervention) required 130 subjects to achieve 80% power with a significance of P = .05. No significant differences in demographics including age, insurance type, and cytology were noted. HPV co-testing increased from 0% to 55% (P < .001). Of the 72 subjects who had co-testing, 58 (80%) will not need cervical cancer screening for another 5 years. HPV co-testing represents an underutilized cervical cancer screening modality for women 30 years and older. This brief educational intervention, adaptable to any clinical setting, significatnly increased co-testing at the clinical site.

Placental profiling of UGT1A enzyme expression and activity and interactions with preeclampsia at term.

Placental UDP-glucuronosyltransferase (UGT) enzymes have critical roles in hormone, nutrient, chemical balance and fetal exposure during pregnancy. Placental UGT1A isoforms were profiled and differences between preeclamptic (PE) and non-PE placental UGT expression determined. In third trimester villous placenta, UGT1A1, 1A4, 1A6 and 1A9 were expressed and active in all specimens (n = 10), but UGT1A3, 1A5, 1A7, 1A8 and 1A10 were absent. The UGT1A activities were comparable to human liver microsomes per milligram, but placental microsome yields were only 2 % of liver (1 mg/g of tissue vs. 45 mg/g of tissue). For successful PCR, placental collection and processing within 60 min from delivery, including DNAse and ≥300 ng of RNA in reverse transcription were essential and snap freezing in liquid nitrogen immediately was the best preservation method. Although UGT1A6 mRNA was lower in PE (P < 0.001), there were no other significant effects on UGT mRNA, protein or activities. A more comprehensive tissue sample set is required for confirmation of PE interactions with UGT. Placental UGT1A enzyme expression patterns are similar to the liver and a detoxicative role for placental UGT1A is inferred.

The impact of a longitudinal curriculum on medical student obstetrics and gynecology clinical training.

Clinical training in most medical schools consists of separate rotations, based out of tertiary-care facilities, across the core medical disciplines. In addition to a traditional clinical curriculum, the University of Hawai'i offers a longitudinal clinical curriculum as an option to medical students. The longitudinal curriculum provides students with an innovative, alternative educational track to achieve their educational goals in clinical medicine. The objective of this study was to describe the obstetrics and gynecology procedural experiences of third-year medical students who participated in a longitudinal curriculum versus a traditional block clerkship. The number of procedures reported by third-year medical students who participated in a non-traditional, longitudinal clerkship was compared with the number of procedures reported by students who participated in the traditional block third-year curriculum between July 2007 and June 2009. National Board of Medical Examiners (NBME) subject scores, clerkship grade and chosen residency specialty were also compared. The mean number of pelvic exams (longitudinally-trained 36 [SD 33] versus block-trained 8 [SD 6], [t=4.3, P<.01]) and pap smears (longitudinally-trained 28 [SD 26] versus block-trained 7 [SD 3] [t=4.4, P<.01]) was significantly higher for longitudinally-trained students compared to block-trained students. No significant differences in overall clerkship grades or NBME shelf scores emerged.

Third and fourth degree perineal injury after vaginal delivery: does race make a difference?

Severe perineal injury (third and fourth degree laceration) at the time of vaginal delivery increases the risk of fecal incontinence, chronic perineal pain, and dyspareunia.1-5 Studies suggest the prevalence of severe perineal injury may vary by racial group.6 The purpose of the current study was to examine rates of severe perineal injury in different Asian and Pacific Islander subgroups. A retrospective cohort study was performed among all patients who had a vaginal delivery at Queens Medical Center in Honolulu, Hawai'i between January 1, 2002 and December 31, 2003. Demographic and health related variables were obtained for each participant. Maternal race/ethnicity (Japanese, Filipino, Chinese, other Asian, Part-Hawaiian/Hawaiian, Micronesian, other Pacific Islander, Caucasian, multiracial [non-Hawaiian], and other) was self-reported by the patient at the time admission. The significance of associations between racial/ethnic groups and demographic and health related variables was determined using chi-square tests for categorical variables and analysis of variance for continuous factors. Multiple logistic regression was performed to adjust for potential confounders when examining severe laceration rates. A total of 1842 subjects met inclusion criteria. The proportion of severe perineal lacerations did not differ significantly between racial groups. In the multiple logistic regression analysis, operative vaginal delivery was related to both race and severe perineal laceration. However, despite adjusting for this variable, race was not associated with an increased risk of having a severe laceration (P = .70). The results of this study indicate the risk of severe perineal laceration does not differ based on maternal race/ethnicity.

Effect of robotic surgery on hysterectomy trends: implications for resident education.

STUDY OBJECTIVE: To compare the surgical approach used for hysterectomy at 2 teaching hospitals before and after introduction of the robotic surgical system. DESIGN: Retrospective cohort study (Canadian Task Force classification II-3). SETTING: Two gynecologic training sites at the University of Hawaii. PATIENTS: Women who underwent hysterectomy between January 1, 2005, and December 31, 2011. MEASUREMENTS AND MAIN RESULTS: ICD-9 procedural codes were used to identify hysterectomies performed between January 1, 2005, and December 31, 2011. Hysterectomies were categorized according to surgical approach: abdominal, vaginal, laparoscopic-assisted vaginal/total laparoscopic, and robotic. Each hysterectomy was also categorized according to primary preoperative diagnosis as general gynecology, gynecologic oncology, and urogynecology. The rates and numbers of hysterectomies performed during 2005-2006 (2 years before acquisition of the robot), 2007-2008 (first 2 years with the robot), and 2009-2011 (3-5 years after acquiring the robot) were compared using χ(2) tests and analysis of variance. The numbers of hysterectomies reported in resident case logs were also collected and compared. A total of 5894 hysterectomies were performed between 2005 and 2011. The total number of hysterectomies performed at Hospital A, which acquired the robotic surgical system, increased over time (p = .04) but remained stable at Hospital B, which did not acquire the robotic surgical system. At Hospital A, the number of robotic hysterectomies increased as the number of abdominal hysterectomies decreased (p < .001), a trend consistent across all diagnostic categories. The number of vaginal and laparoscopic hysterectomies remained stable. Resident case logs also reflected a decrease in the number of abdominal hysterectomies (p = .002) and an increase in the number of combined laparoscopic/robotic hysterectomies (p < .001) performed. The total number of hysterectomies performed by residents was unchanged. CONCLUSION: Introduction of the robotic surgical system was associated with significant changes in the numbers and types of hysterectomies performed in both general and subspecialty gynecology. Although abdominal hysterectomies decreased as robotic hysterectomies increased, other hysterectomies did not. These trends mirror reported resident surgical experience and have implications for resident education.

Improved abnormal Pap smear triage using cervical cancer biomarkers.

OBJECTIVE: The current system of Pap smear screening and management of abnormal cytology has resulted in a marked reduction in invasive cervical cancer. Many women, however, are not found to have significant precursor lesions. This is due to the poor specificity of high-risk human papillomavirus (HPV) triage. More specific cervical cancer biomarkers may be more effective triage tools than hr-HPV. We evaluated whether a dual stain for p16 and Ki-67 might improve the triage of abnormal Pap smears. MATERIALS AND METHODS: p16/Ki-67 immunostaining was performed on additional slides prepared from 515 women with abnormal Pap smears (301 atypical squamous cells of undetermined significance [ASCUS], 169 low-grade squamous intraepithelial lesion [LSIL], 29 atypical squamous cells-cannot exclude high-grade lesion [ASC-H], 16 high-grade squamous intraepithelial lesion [HSIL]). High-risk HPV typing was performed on all cases. Immunostaining and hr-HPV were compared in relation to their diagnostic accuracy for the detection of biopsy-proven cervical intraepithelial neoplasia (CIN) 2/3. A cost analysis comparing hr-HPV versus immunostaining as the initial triage tool used for abnormal Pap smears was also performed. RESULTS: High-risk HPV was positive in 127 (42.2%) ASCUS, 129 (76.3%) LSIL, 20 (69.0%) ASC-H, and 15 (93.8%) HSIL. p16/Ki-67 was positive in 54 (17.9%) ASCUS, 73 (43.2%) LSIL, 19 (65.5%) ASC-H, and 15 (93.8%) HSIL. For detection of CIN 2/3, sensitivity/specificity of hr-HPV and p16/Ki-67 was 89.29%/14.94% and 96.43%/60.92%, respectively. Overall, diagnostic accuracy was statistically significantly higher for p16/Ki-67 compared with hr-HPV. Compared to HPV, immunostain triage could have generated approximately $46,000 savings in the study population. CONCLUSIONS: The triage of abnormal Pap smears by p16/Ki-67 immunostaining shows comparable sensitivity, improved specificity, and significantly improved diagnostic performance when compared to hr-HPV. Immunostaining is of value in triaging LSIL and ASC-H Pap smears in addition to ASCUS. The widespread utilization of biomarker triage could result in significant health care cost savings without compromising the detection of significant cervical cancer precursors.

A pilot structured resident orientation curriculum improves the confidence of incoming first-year obstetrics and gynecology residents.

A prospective, observational study was performed to evaluate a pilot orientation curriculum which involved all 7 incoming obstetrics and gynecology residents in June 2012. The objective of this study was to assess how a structured orientation curriculum, which employs an evaluation of baseline competency, affects the confidence of incoming first-year obstetrics and gynecology residents. The curriculum included didactic lectures, online modules, simulation, and mock clinical scenarios. Pre- and post-course surveys were conducted online via SurveyMonkey™ and were sent to all incoming obstetrics and gynecology residents. All seven incoming obstetrics and gynecology residents completed the orientation curriculum which included evaluations at the end of the orientation to assess baseline competency prior to taking part in clinical care. Confidence levels improved in all 27 elements assessed. Statistically significant improvement in confidence levels occurred in cognitive skills such as obstetric emergency management (2.9 vs 3.9, P< .05) and technical skills such as knot tying (3.9 vs. 4.6, P< .05). Certain teaching skills also demonstrated statistically significant improvements. A structured orientation program which improves resident self-confidence levels and demonstrates baseline competencies in certain clinical areas can be valuable for many residency training programs.

Perineal body length among different racial groups in the first stage of labor.

OBJECTIVE: Anatomic differences among racial groups may contribute to observed differences in the occurrence of severe perineal lacerations at the time of vaginal delivery. The purpose of this study was to identify differences in perineal body length between racial groups. METHODS: Perineal body length was measured in primigravid women aged 18 to 45 years who were admitted in labor. Women were classified into 1 of 6 racial groups: White, Filipino, Japanese, Chinese, Native Hawaiian, or Micronesian. The primary outcome, perineal body length, was compared using analysis of variance. RESULTS: A total of 200 women were recruited. There were no significant differences in perineal body length (P = 0.42) and severe perineal lacerations (P = 0.82) between the different racial groups. The mean (SD) perineal body length of women who had a severe laceration was 3.9 (0.5) versus 3.9 (0.6) cm in women who did not have a severe laceration (P= 0.98). CONCLUSION: Perineal body length does not seem to differ among the different racial groups studied and therefore an unlikely cause of racial variation in rates of severe perineal lacerations.

Faculty and resident perceptions regarding overnight student call during the third year OB/GYN clerkship.

OBJECTIVES: The objective of this study is to identify university faculty, community physician, and resident perceptions of how a schedule that employs overnight call in addition to a traditional weekday schedule affects medical student education, well being, and patient care during the third year obstetrics and gynecology clerkship. METHODS: In July 2007, a descriptive study was performed by distributing surveys to community teaching physicians, current residents, and faculty in the University of Hawai'i Department of Obstetrics and Gynecology. A total of 114 surveys were distributed to all current residents, clinical faculty and full-time faculty in the University of Hawai'i Department of Obstetrics and Gynecology. The survey included questions regarding the effect of the student call/work hour restrictions. RESULTS: A response rate of 45.6% was obtained (52/114). Results demonstrate that 84.6% (44/52) of residents, faculty, and community attendings agree that third year medical students should take call during their obstetrics and gynecology clerkship. Data was analyzed utilizing Spearman correlation and Cochran-Mantel-Haenszel statistics. No statistical difference was detected in terms of age or physician type (resident vs faculty vs community attending). CONCLUSION: Most physician-educators believe that medical students benefit from taking overnight call during their obstetrics and gynecology clerkship. Careful consideration should be given prior to elimination of overnight call in the obstetrics and gynecology clerkship.

A polymorphism in the retinol binding protein 4 gene is not associated with gestational diabetes mellitus in several different ethnic groups.

OBJECTIVE: Various Asian and Pacifific Islander groups have higher prevalence rates of type 2 diabetes and gestational diabetes. This increased incidence is likely to include genetic factors. Single nucleotide polymorphisms in the retinol binding protein 4 gene have been linked to the occurrence of type 2 diabetes. Hypothesizing a link between retinol binding protein 4 and gestational diabetes, we performed a candidate gene study to look for an association between an important retinol binding protein gene polymorphism (rs3758539) and gestational diabetes. STUDY DESIGN: Blood was collected from Caucasian, Asian, and Pacific Islander women diagnosed with gestational diabetes and from ethnically matched non-diabetic controls. DNA was extracted and real time PCR technology (TaqMan, Applied Biosystems) used to screen for the rs3758539 single nucleotide polymorphism located 5' of exon 1 of the retinol binding protein 4 gene. RESULTS: Genotype and allele frequencies in the controls and gestational diabetes cases were tested using chi-square contingency tests. Genotype frequencies were in Hardy-Weinberg equilibrium. There was no association between the rs3758539 retinol binding protein 4 single nucleotide polymorphism and gestational diabetes in the Caucasian, Filipino, or Pacific Islander groups. CONCLUSION: Interestingly, the rs3758539 retinol binding protein 4 single nucleotide polymorphism was not found to be associated with gestational diabetes. The absence of association suggests that gestational and type 2 diabetes may have more divergent molecular pathophysiology than previously suspected.