Influence of Psychological Safety and Organizational Support on the Impact of Humiliation on Trainee Well-Being.

OBJECTIVES: To develop physicians who can practice safely, we need better understanding of how the clinical learning environment affects trainee well-being. Two psychosocial constructs may help us understand the context: psychological safety (belief one can speak up without concerns) and perceived organizational support (degree to which members feel that their organization cares for them and values their contributions). The objective of this study is to test a moderated mediation model to determine how humiliation (X) impacts trainees' well-being (Y) while taking into account psychological safety (mediator) and organizational support (moderator). METHODS: Between May and June 2018, a single health system recruited resident physicians across 19 programs to complete an anonymous electronic survey to assess facets of the clinical learning environment, well-being, and experiences of humiliation. In a moderated mediation analysis, mediation helps explain how a predictor variable (X) impacts an outcome variable (Y) through a mediating variable, whereas moderation helps explain under what conditions such a relationship exists. RESULTS: Of 428 residents, 303 responded (71%) to the survey across 19 training programs. The effects of humiliation on well-being were mitigated by psychological safety, which varied depending on the levels of perceived organizational support. Environments rated 1 SD below the mean on perceived organization support by residents had a stronger negative impact of public humiliation on psychological safety. CONCLUSIONS: The findings suggest that humiliation is associated with well-being through the effects of psychological safety and influenced by organizational support. Further work might explore the relationship by investing resources (e.g., faculty development, mentorship) to increase psychological safety and reduce humiliation during training, especially within environments prone to be perceived as unsupportive of trainees.

Adherence to the American Society for Colposcopy and Cervical Pathology guidelines: an observational study.

OBJECTIVE: The 2012 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines were developed to provide guidance regarding cervical pathology and to minimize overtreatment of lesions that may resolve spontaneously. We aimed to evaluate the adherence to these guidelines with referrals for colposcopy at a large academic center and to understand the factors associated with incorrect referrals. METHODS: This retrospective observational study involved women referred to the Virginia Commonwealth University for colposcopy or loop electrosurgical excision procedure from January 2015 to December 2016. RESULTS: Referral requests from 430 women were reviewed. Among these, 17.4% were discordant with the ASCCP guidelines. The most common discordant colposcopy referrals were low-grade squamous intraepithelial lesions (48%) and atypical squamous cells of undetermined significance (29%). The possibility of incorrect referrals was decreased among highgrade lesions (odds ratio [OR], 0.03), while it was increased in women aged <25 years (OR, 31.6) and in those referred by family medicine (OR, 3.6) or internal medicine (OR, 4.4). Ten patients were referred for cervical cytology results of samples collected from the vaginal cuffs despite hysterectomies performed for benign lesions. CONCLUSION: Patients referred outside of the guidelines were most often women aged <25 years with low-grade lesions. Referrals outside evidence-based guidelines may lead to unnecessary procedures and additional healthcare expenses. Our results help identify the areas for provider education and potential areas of concern regarding the implementation of the 2019 ASCCP guideline updates.

Case Report: Recurrent Pyometra in an Adolescent.

BACKGROUND: Pyometra is an uncommon but serious condition that is generally diagnosed in postmenopausal women. It rarely occurs in premenopausal patients, particularly adolescents. CASE: A 16-year-old girl with multiple comorbidities including severe intellectual disability, neurogenic bladder, and recurrent urinary tract infection presented with fever, abdominal pain, and vaginal discharge after prolonged treatment with depot medroxyprogesterone acetate. Ultrasound imaging showed an intrauterine fluid collection consistent with hematometra; however, hysteroscopic evaluation confirmed pyometra, which was evacuated using a suction curette. Despite postoperative antibiotic therapy, she re-presented with similar findings requiring additional hysteroscopic evaluation and evacuation. After a third evacuation, an intrauterine catheter was placed to aid in drainage. This was not tolerated by the patient, and she ultimately required total laparoscopic hysterectomy for definitive management, which was performed without incident. SUMMARY AND CONCLUSION: Pyometra is a rare occurrence that typically presents after menopause; however, it should be considered in patients with poor genitourinary hygiene and medically induced endometrial atrophy. In severe cases, hysterectomy might be required for definitive management.

Cold Compress for Intrauterine Device Insertional Pain: A Randomized Control Trial.

Background: Pain with intrauterine device (IUD) insertion is identified as a barrier to uptake of this highly effective long-acting reversible contraceptive. Several studies have assessed the efficacy of interventions to alleviate patient discomfort associated with IUD insertion, but no interventions have been clearly shown to improve procedural pain. The aim of this study was to determine whether use of a cold compress on the abdomen during IUD insertion reduces pain. Materials and Methods: This was a prospective randomized control trial of women presenting to Virginia Commonwealth University for insertion of IUD from September 2016 to October 2017. A power analysis determined that 69 subjects were needed in each arm to detect a 30% reduction in pain with a power of 80%, significance value of p < 0.05. One hundred forty-two participants were consented for the study, 69 were randomized to the control group, which received the usual management, and 73 were randomized to the study group, which received a cold compress to the abdomen before the procedure. In addition to data on the difference from pre- to postprocedure pain scales, we collected information regarding inserting provider type, gravidity/parity, body mass index, demographic information (age, race, insurance type, and level of education), history of IUD placement or cervical procedure, history of chronic pain, and the use of regular pain medications (defined as more than once per week). Statistical analysis was accomplished using t-test and chi square tests. Results: There was no difference in pre and postinsertional pain in those who received a cold compress versus the control during insertion of an IUD (3.4 vs. 3.5). The insertional pain was rated at 4.3 and 4.6 for patients who received the cold compress and the control group, respectively (p = 0.805). Conclusion: Although a cold compress is a simple, inexpensive, and safe method of pain control, this study shows no reduction in insertional pain for IUD placement.