Understanding resident wellness: A path analysis of the clinical learning environment at three institutions.

PURPOSE: The clinical learning environment (CLE) affects resident physician well-being. This study assessed how aspects of the learning environment affected the level of resident job stress and burnout. MATERIALS AND METHODS: Three institutions surveyed residents assessing aspects of the CLE and well-being via anonymous survey in fall of 2020 during COVID. Psychological safety (PS) and perceived organizational support (POS) were used to capture the CLE, and the Mini-Z Scale was used to assess resident job stress and burnout. A total of 2,196 residents received a survey link; 889 responded (40% response rate). Path analysis explored both direct and indirect relationships between PS, POS, resident stress, and resident burnout. RESULTS: Both POS and PS had significant negative relationships with experiencing a great deal of job stress; the relationship between PS and stress was noticeably stronger than POS and stress (POS: B= -0.12, p=.025; PS: B= -0.37, p<.001). The relationship between stress and residents' level of burnout was also significant (B = 0.38, p<.001). The overall model explained 25% of the variance in resident burnout. CONCLUSIONS: Organizational support and psychological safety of the learning environment is associated with resident burnout. It is important for educational leaders to recognize and mitigate these factors.

How We Do It: Student Perspectives on Changes to the Obstetrics and Gynecology Residency Application Process.

OBJECTIVE: To describe the perspectives of obstetrics and gynecology (OBGYN) residency applicants regarding new standards for the 2019 to 2020 application cycle. DESIGN: An anonymous electronic survey was sent to all OBGYN residency applicants to US programs retrospectively evaluating 5 new recommended standards for the application process. This 15-item survey assessed the importance of the proposed standards and their impact on applicants' anxiety. SETTING: The OBGYN residency application process is marked by increasing application numbers and no standardization for managing interview offers. The Association of Professors of Gynecology and Obstetrics (APGO) received a 5-year Reimagining Residency grant from the American Medical Association to improve the transition from undergraduate medical education (UME) to graduate medical education (GME) within OBGYN. The multiphase project, "Transforming the UME to GME Transition for Obstetrics and Gynecology- Right Resident, Right Program, Ready Day One (RRR)," began with Standardizing the OBGYN Application and Interview Process (SOAIP). This group recommended 5 new standards for all US OBGYN residency programs and applicants. PARTICIPANTS: Applicants for US OBGYN residency programs for the 2019 to 2020 application cycle completed the survey, with a 904/2508 (36.0%) response rate, including 762 complete responses (30.4%). RESULTS: Applicants reported that all 5 of the new standards would cause the least self-perceived anxiety (range 76.8% - 96.5%). The impact of the standards on perceived anxiety varied by student group, with International Medical Graduates (IMGs) and students with USMLE Step I scores <200 describing lesser impact compared to others. Despite these differences, all 5 standards were consistently noted to cause the least anxiety for all groups. Despite varying degrees of effects in different groups, the new OBGYN residency application standards caused the least anxiety for all subgroups of applicants. CONCLUSIONS: Implementing universal standards for the OBGYN residency application process was favorably perceived by applicants and caused the least anxiety for applicants.

Stakeholder Perspectives on Limiting Residency Applications and Interviews in Obstetrics and Gynecology.

PURPOSE: Application inflation in the current residency application process leads to congestion, inefficiency, and perceptions of inequity. The authors aimed to assess the interest of key stakeholders on the topic of capping applications and interviews, and their perceptions regarding equity of the process. METHODS: An anonymous survey was electronically distributed in March 2021 to Obstetrics and Gynecology (OBGYN) residency applicants, clerkship directors, program directors, and student affairs deans after the submission of the rank order list for the 2021 application cycle and prior to the release of final Match results. Participants answered questions regarding the perceived equity of the current process (no limits on applications submitted or interviews completed) compared with limiting the number of applications and interviews students could submit or complete. Respondents supporting caps reported the number they considered a reasonable cap for applications and interviews. Associations between the profiles of applicants and program directors and their interest in application and interview caps were explored using chi-squared tests for non-parametric statistics and t-tests for normally distributed interval data. The University of Michigan determined the study exempt from IRB review. RESULTS: The overall response rate was 36.0% (1167/3243), including 34.0% of applicants (879/2579), 50.3% of program directors (143/284), 41.8% of clerkship directors (94/225) and 32.9% of student affairs deans (51/155). All groups reported application caps for either all applicants or the most competitive applicants to be more equitable than the current process, and suggested a median application cap ranging from 25 (clerkship directors and program directors) to 40 (applicants). All groups also believed interview caps to be more equitable than the current process, and suggested a median interview cap ranging from 12 (clerkship directors) to 15 (applicants, program directors, and student affairs deans). CONCLUSIONS: Stakeholders in the OBGYN application process consider caps to applications and interviews a promising means to improve equity in the Match.

The Case for Capping Residency Interviews.

OBJECTIVE: To determine 2020 residency cycle application practices and to model potential consequences in the 2021 cycle if (1) applicants scheduled an uncapped number of interviews; (2) applicants were capped to schedule 12 interviews; (3) residency programs kept their number of interview offers unchanged; and (4) programs increased their interview offers by 20%. DESIGN AND SETTING: The authors sent an anonymous survey to all obstetrics and gynecology applicants registered through the Electronic Residency Application Service in February 2020 asking respondents to share demographics and number of interview offers received and completed. Based on prior estimates that 12 interviews are needed to match in obstetrics and gynecology, respondents were divided into Group 12+ (those receiving ≥12 interview offers) and Group <12 (those receiving <12 offers). Model assumptions were (1) applicants can complete all interviews they are offered because they are virtual; (2) interview offers that applicants in Group 12+ decline are subsequently offered to applicants in Group <12; (3) the proportions of interviews offered to Group 12+ and Group <12 will remain the same if programs chose to increase their total number of interview spots. PARTICIPANTS: Among 2508 applicants, 750 (30%) provided the number of interview offers received and completed: 417 (56%) in Group 12+ and 333 (44%) in Group <12. RESULTS: In models where applicants are uncapped in the number of interviews, Group <12 applicants receive <1 interview offer, even if programs increase the number of interviews offered and performed. If applicants are capped at 12 interviews, Group <12 applicants will receive 9 interview offers on average and will reach 12 if programs increase the number of interviews offered by 20%. CONCLUSIONS: This work highlights how current inefficiencies may lead to negative consequences with virtual interviews. Interview caps and preference signaling systems need to be urgently considered.

Can Standardized Dates for Interview Offers Mitigate Excessive Interviewing?

OBJECTIVE: To determine the impact of specialty-specific guidelines for standardized interview offers on residency applicant behavior towards excessive interviewing. DESIGN: In 2019 to 2020, the Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology (OBGYN) outlined standard dates for residency interview offers. A cross-sectional survey of applicants queried adherence to standardized interview offers, the number of interviews offers received, interviews completed, and application characteristics. Based on data that applicants in OBGYN with a mean number of 12 contiguous ranks are highly likely to match, factors associated with accepting an excessive percentage of interview offers were investigated in applicants with at least 12 interviews, using multiple logistic regression. SETTING: All OBGYN applicants were sent an anonymous electronic survey distributed through the Electronic Residency Application Service in February 2020, with the subset of US MD senior respondents selected for this analysis. PARTICIPANTS: There were a total of 1292 US MD senior applicants into OBGYN in 2020, with 505 (39%) providing their interview information through the survey. Three hundred and sixty (71%) of US MD senior respondents received at least 12 interviews. RESULTS: Applicants receiving at least 12 interview offers completed a median of 83% of their interviews, and excessive interviewing was defined as completing greater than this median percentage. Receiving most interview offers on standardized interview offer dates resulted in less excessive interviewing despite controlling for number of programs applied to, applying as a couple, and United States Medical Licensing Exams Step 1 score. CONCLUSIONS: The standardization of interview offer dates may mitigate interview inflation by altering applicant behavior. This promising pilot data suggests that applicants may be able to make more informed decisions about which interview offers to accept when all offers are received on predetermined dates.

Stakeholder Perspectives on Standardizing the Residency Application and Interview Processes.

OBJECTIVE: The purpose of this study was to examine stakeholder perspectives on recommended standards for the obstetrics and gynecology (OBGYN) residency application and interview processes proposed for the 2019 to 2020 application cycle. The authors aimed to assess the acceptance and perception of key stakeholders on the feasibility of implementing the standards as well as the effect of these changes on applicant anxiety. DESIGN AND SETTING: The authors electronically distributed an anonymous survey in February 2020 to OBGYN residency applicants, clerkship directors, student affairs deans, program directors, and program managers. Participants received a 15-item survey, with questions assessing the importance and adoption of the guidelines, as well as their effect on perceived applicants' anxiety. Responses were measured on a 5-item Likert scale. Multiple regression analysis was used to explore which residency factors were associated with compliance with the standards. IRB exemption was granted by the University of Michigan. PARTICIPANTS: A total of 1358 participants completed the survey for an overall response rate of 39.26%. Response rates were 36.04% for applicants (904/2508), 46.67% for CDs (105/225), 34.84% for members of GSAs (34/155), 59.43% for program directors (167/281), and 51.03% for program managers (148/290). RESULTS: The overall response rate was 39.26% (1358/3459) with 36.04% of applicants (904/2508), 46.67% of clerkship directors (105/225), 34.84% of student affairs deans (34/155), 59.43% of program directors (167/281), and 51.03% of program managers (148/290). The recommendations were perceived as important by all stakeholders. More than 90% of program directors reported compliance with some or all of the recommendations and more than 90% of all applicants, clerkship directors and student affairs deans reported that the standards reduced applicant anxiety. All stakeholders rated each guideline to be important to extremely important. CONCLUSIONS: This study demonstrates the feasibility and acceptance of universal standards for the residency application process in the field of OBGYN. The vast majority of stakeholders surveyed supported the initiative and participated in the guidelines. Applicant respondents perceived the guidelines to be important and to decrease anxiety surrounding the application and interview timelines. These findings are important for other specialties when considering similar interventions.

Evaluation of a precise and measurable model for learning laparoscopic tissue handling.

INTRODUCTION: Laparoscopic tissue handling is quite difficult to measure using virtual-reality laparoscopic simulators and box-trainer exercises, and therefore, completion time is the predominant performance measure for simulation-based laparoscopic training exercises. The purpose of this study was to evaluate the construct validity of a training and assessment model for precise laparoscopic handling of delicate tissue. METHODS: Participants (n = 35) completed 2 progressively challenging laparoscopic tissue translocation exercises using delicate foam pieces and templates. Deidentified performances were scored using objective measures for tissue damage, accuracy, percentage complete, and completion time. Evaluation included multiple analysis of variance with repeated measures among the 3 groups as follows: medical students, residents and faculty who perform laparoscopic surgery less than once per week, and faculty members who perform laparoscopic surgery at least once per week. RESULTS: The model demonstrated significant construct validity by discriminating performances between the types of shapes and templates and across the levels of surgical experience on all dimensions. A significant interaction effect between the level of expertise and the difficulty of the exercise revealed excellent discrimination between experienced laparoscopic surgeons and others. DISCUSSION: This low-cost model provides an alternative or adjunct platform for laparoscopic training and assessment that requires precise and measurable handling of a delicate tissue.

Low-hanging fruit: a clementine as a simulation model for advanced laparoscopy.

INTRODUCTION: Low-cost, high-fidelity models for training in advanced laparoscopic surgery techniques are not currently available. The objective of this study was to evaluate a model and assessment protocol for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making. METHODS: Novice to expert laparoscopists (n = 41) were asked to remove the peel of a clementine in as few pieces as possible, separate and remove all albedo from and between all fruit segments, and return the clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision making included deciding when unacceptable segment damage would result by removing difficult-to-extract albedo, analogous to treating lesions or metastases through other methods, rather than risking damage to vital anatomic structures. Faculty assessed deidentified video-recorded performances. Data analyses included analysis of variance with Bonferroni post hoc. RESULTS: A single-performance construct (operative ability) with 2 scoring dimensions (surgical skills and clinical judgment) was confirmed through factor analysis. There were significant performance differences between all experience levels (F2,41 = 59.175, P < 0.000). There were no statistical time differences between the groups. CONCLUSIONS: Validation of this low-cost, easily facilitated model for developing advanced laparoscopic surgical skills may support the preparation of residents and fellows and provide a platform for skill acquisition, assessment, and basic critical thinking for performing laparoscopic tasks.

Validity: what does it mean for competency-based assessment in obstetrics and gynecology?

Validity refers to an evidence-based claim about the trustworthiness of decisions made from context-specific performance data. Validity requirements for competency-based assessments in obstetrics and gynecology have not been defined in the literature. We explain why validity is intrinsic to any discussion about competency assessment and provide a model for obstetrics and gynecology programs to use in determining the essential validity evidence for various forms of assessments. The implications of decisions made from assessment results influence the requisite level and precision of validity evidence. Although validity evidence is essential, it is also flexibly tied to the implications of decisions made from assessment results and not all assessments require the same degree of validity. We propose a model for considering validity, and build a discussion around specific assessment examples targeting progressive levels of expertise along the training continuum.

The bartholin gland cyst: past, present, and future.

Bartholin gland cysts account for 2% of all gynecologic visits per year. The treatment of Bartholin gland cysts has evolved from a complicated, bloody procedure requiring general anesthesia to, most recently, a simple puncture of the cyst and placement of a drain performed in the office. Although treatments for Bartholin gland cysts seem simple on the surface, recurrent cysts as well as diagnosing simple cysts versus abscesses versus malignant tumors can complicate treatment for this common problem. This article exams a history of the treatment of Bartholin gland cysts, including the use of the traditional treatments of excision, fistulization, marsupialization, as well as cauterization with carbon dioxide laser and silver nitrate. Modern variations are discussed, including the use of hydrodissection for excision, as well as the application of magnetic resonance imaging use in devising treatment for recurrent cysts.