Evidence-based priorities of under-served pregnant and parenting adolescents: addressing inequities through a participatory approach to contextualizing evidence syntheses.

PURPOSE: This study describes an interdiscursive evidence-based priority setting process with pregnant and parenting adolescents and their services providers. METHODS: A mixed methods literature review identified studies reporting on perinatal outcomes and experiences of adolescents during pregnancy to 12 months post-partum published in Canada after 2000. We also calculated relative risks for common perinatal risk factors and outcomes for adolescents compared to adult populations from 2012 to 2017 based on data from a provincial database of maternal and newborn outcomes. Two trained peer researchers identified outcomes most relevant to their peers. We shared syntheses results with four service providers and 13 adolescent mothers accessing services at a community service organization, who identified and prioritized their areas of concern. We repeated the process for the identified priority issue and expanded upon it through semi-structured interviews. RESULTS: Adolescent mothers face higher rates of poverty, abuse, anxiety and depression than do adult mothers. Adolescents prioritized the experience of judgment in perinatal health and social services, particularly as it contributed to them being identified as a child protection risk. Secondary priorities included loss of social support and inaccessibility of community resources. The experience of judgment in adolescent perinatal health literature was summarized around: being invisible, seen as incapable and seen as a risk. Adolescent mothers adapted these categories, emphasizing organizational and social barriers. CONCLUSIONS: Young marginalized women are disproportionately affected by inequities in perinatal outcomes, yet their perspectives are rarely centered in efforts to address these inequities. This research addresses health inequities by presenting a robust, transparent and participatory approach to priority setting as a way to better represent the perspectives of those who carry the greatest burden of health inequities in evidence syntheses. In our work, marginalized adolescent parents adapted published literature around the experience and consequences of social stigma on perinatal outcomes, shifting our understanding of root causes and possible solutions.

Competency-Based Medical Education: Developing a Framework for Obstetrics and Gynaecology.

The development of a Canadian competency-based medical education (CBME) curriculum in obstetrics and gynaecology, slated to begin in 2017, must be rooted in, and aligned with, the principles of CanMEDS 2015 and Competence by Design. It must also reflect the unique realities of the practice of the specialty. The Dutch Society of Obstetrics and Gynaecology has been at the forefront of the movement to design and implement competency-based training for obstetrics and gynaecology. The Dutch curriculum represents a practical example of how such a program could be developed. Several CBME curricular initiatives have now also begun across Canada.

La mise sur pied d'un curriculum canadien de formation médicale fondée sur les compétences (FMFC) en obstétrique-gynécologie (devant débuter en 2017) doit être ancrée dans les principes des programmes « CanMEDS 2015 ¼ et « La compétence par conception ¼. Ce curriculum doit également refléter les réalités particulières de la pratique de la spécialité. La Dutch Society of Obstetrics and Gynaecology est à l'avant-garde du mouvement visant la conception et la mise en œuvre de la formation fondée sur les compétences en obstétrique-gynécologie. Le curriculum hollandais représente un exemple pratique de la façon dont un tel programme pourrait être élaboré. Plusieurs initiatives de FMFC ont maintenant vu le jour au Canada.

Global Women's Health Education in Canadian Obstetrics and Gynaecology Residency Programs: A Survey of Program Directors and Senior Residents.

OBJECTIVE: To become culturally competent practitioners with the ability to care and advocate for vulnerable populations, residents must be educated in global health priorities. In the field of obstetrics and gynaecology, there is minimal information about global women's health (GWH) education and interest within residency programs. We wished to determine within obstetrics and gynaecology residency programs across Canada: (1) current GWH teaching and support, (2) the importance of GWH to residents and program directors, and (3) the level of interest in a national postgraduate GWH curriculum. METHODS: We conducted an online survey across Canada of obstetrics and gynaecology residency program directors and senior obstetrics and gynaecology residents. RESULTS: Of 297 residents, 101 (34.0%) responded to the survey and 76 (26%) completed the full survey. Eleven of 16 program directors (68.8%) responded and 10/16 (62.5%) provided complete responses. Four of 11 programs (36.4%) had a GWH curriculum, 2/11 (18.2%) had a GWH budget, and 4/11 (36.4%) had a GWH chairperson. Nine of 10 program directors (90%) and 68/79 residents (86.1%) felt that an understanding of GWH issues is important for all Canadian obstetrics and gynaecology trainees. Only 1/10 program directors (10%) and 11/79 residents (13.9%) felt that their program offered sufficient education in these issues. Of residents in programs with a GWH curriculum, 12/19 (63.2%) felt that residents in their program who did not undertake an international elective would still learn about GWH, versus only 9/50 residents (18.0%) in programs without a curriculum (P < 0.001). CONCLUSION: Obstetrics and gynaecology residents and program directors feel that GWH education is important for all trainees and is currently insufficient. There is a high level of interest in a national postgraduate GWH educational module.

Objective: Pour devenir des praticiens compétents sur le plan culturel étant en mesure de prodiguer des soins aux populations vulnérables et de défendre leur cause, les résidents doivent recevoir une formation abordant les priorités de la santé à l'échelle mondiale. Dans le domaine de l'obstétrique-gynécologie, nous ne disposons que de peu de renseignements au sujet de la formation en santé des femmes à l'échelle mondiale (SFEM) qu'offrent les programmes de résidence et de l'intérêt envers ce type de formation que l'on y constate. Nous souhaitions déterminer ce qui suit en ce qui concerne les programmes canadiens de résidence en obstétrique-gynécologie : (1) la situation actuelle pour ce qui est de l'enseignement de la SFEM et du soutien disponible à cet égard; (2) l'importance de la SFEM pour les résidents et les directeurs de programme; et (3) le degré d'intérêt envers un curriculum national de cycle supérieur dans le domaine de la SFEM. Méthodes : Nous avons mené, à l'échelle du Canada, un sondage en ligne auprès des directeurs des programmes de résidence en obstétrique-gynécologie et des résidents de dernière année du domaine. Résultats : Parmi les 297 résidents sollicités, 101 (34,0 %) ont répondu au sondage et 76 (26 %) ont rempli le sondage en entier. Onze des 16 directeurs de programme sollicités (68,8 %) ont répondu et 10/16 (62,5 %) nous ont fourni des réponses complètes. Quatre des 11 programmes (36,4 %) comptaient un curriculum de SFEM, 2/11 (18,2 %) comptaient un budget de SFEM et 4/11 (36,4 %) comptaient un président de la SFEM. Neuf directeurs de programme sur 10 (90 %) et 68 résidents sur 79 (86,1 %) étaient d'avis qu'une compréhension des questions de SFEM est importante pour tous les stagiaires canadiens en obstétrique-gynécologie. Seulement un directeur de programme sur 10 (10 %) et 11 résidents sur 79 (13,9 %) étaient d'avis que leur programme offrait une formation suffisante sur ces questions. Parmi les résidents des programmes comptant un curriculum de SFEM, 12/19 (63,2 %) étaient d'avis que les résidents de leur programme qui n'entreprenaient pas un stage au choix international auraient tout de même l'occasion de se sensibiliser à la SFEM, par comparaison avec seulement neuf des 50 résidents (18,0 %) des programmes ne comptant pas un tel curriculum (P < 0,001). Conclusion : Les résidents et les directeurs de programme du domaine de l'obstétrique-gynécologie estiment que la formation au sujet de la SFEM est importante pour tous les stagiaires et qu'elle est actuellement insuffisante. La mise sur pied d'un module pédagogique national de cycle supérieur en SFEM suscite un vif intérêt.

Competency-based medical education: the wave of the future.

Competency-based medical education (CBME) is a new educational paradigm that will enable the medical education community to meet societal, patient, and learner needs of the 21st century. CBME offers a renewed commitment to both clinical and educational outcomes, a new focus on assessment and developmental milestones, a mechanism to promote a true continuum of medical education, and a method to promote learner-centred curricula in the context of accountability. Accountability is central to CBME, ensuring that graduating practitioners are well-rounded and competent to provide safe and effective patient care. The structure of CBME in obstetrics and gynaecology must be rooted in, and reflect, Canadian practice. Its development and implementation require an understanding of the principles that are the foundation of CBME, along with the involvement of the entire community of obstetricians and gynaecologists and other maternity care providers. We provide here an overview of the basic principles of teaching and learning and the theories underpinning CBME.

La formation médicale axée sur les compétences (FMAC) est un nouveau paradigme pédagogique qui permettra à la communauté de la formation médicale de répondre aux besoins de la société, des patients et des apprenants du 21e siècle. La FMAC offre un engagement renouvelé envers les issues tant cliniques que pédagogiques, un nouvel accent sur l'évaluation et les jalons du développement, un mécanisme visant à promouvoir un réel continuum de formation médicale, ainsi qu'une méthode permettant de promouvoir un curriculum axé sur l'apprenant dans le contexte de la responsabilité. La responsabilité est au cœur de la FMAC, ce qui permet d'assurer l'obtention de diplômés épanouis et compétents qui seront en mesure d'offrir des soins sûrs et efficaces aux patients. Dans le domaine de l'obstétrique-gynécologie, la structure de la FMAC doit être fondée sur la pratique canadienne et la refléter. Son élaboration et sa mise en œuvre nécessitent une compréhension des principes qui étayent la FMAC, en plus de solliciter la participation de l'ensemble de la communauté des obstétriciens-gynécologues et celle d'autres fournisseurs de soins de maternité. Nous offrons ici un aperçu des principes de base de l'enseignement et de l'apprentissage, et des théories qui sous-tendent la FMAC.

"GIOSAT": a tool to assess CanMEDS competencies during simulated crises.

PURPOSE: Our objective was to develop and evaluate a Generic Integrated Objective Structured Assessment Tool (GIOSAT) to integrate Medical Expert and intrinsic (non-medical expert) CanMEDS competencies with non-technical skills for crisis simulation. METHODS: An assessment tool was designed and piloted using two pediatric anesthesia scenarios (laryngospasm and hyperkalemia). Following revision of the tool, we used previously recorded videos of anesthesia residents (n = 50) who managed one of two intraoperative advanced cardiac life support (ACLS) scenarios (ventricular tachycardia or ventricular fibrillation). Four independent trained raters, blinded to the residents' level of training, analyzed the video recordings using the GIOSAT scale. Inter-rater reliability was calculated using intraclass correlations (ICCs) for single raters (single measure) and the average of the four raters (average measure), and construct validity was investigated by correlating GIOSAT scores with postgraduate year of residency (PGY). RESULTS: Total GIOSAT scores for the ACLS scenarios had single measure ICCs of 0.62 and average measure ICCs of 0.85. Inter-rater reliability was substantial for both Medical Expert and intrinsic competencies (single measure ICCs 0.69 and 0.62, respectively; average measure ICCs 0.90 and 0.82, respectively). We found significant correlations between PGY level and total GIOSAT score (r = 0.36; P = 0.011) and between PGY level and Medical Expert competencies (r = 0.42; P = 0.003); however, correlations were not found between PGY level and intrinsic CanMEDS competencies (r = 0.24; P = 0.09). CONCLUSION: Inter-rater reliability of the total GIOSAT scores using four trained raters was substantial. Significant correlation between PGY and (i) total GIOSAT score and (ii) Medical Expert competencies supports construct validity. Evidence of validity was not obtained for intrinsic CanMEDS competencies.

Assessing residents' disclosure of adverse events: traditional objective structured clinical examinations versus mixed reality.

OBJECTIVE: The skill of disclosing adverse events is difficult to assess. Assessment of this competency in medical trainees is commonly achieved via the objective structured clinical examination (OSCE) using a standardized patient (SP). We hypothesized that the addition of a simulated clinical adverse event prior to the SP encounter could increase trainees' engagement and empathy, thereby improving performance. The objective of this study was to explore whether experiencing a simulated adverse event prior to an SP encounter alters resident performance on a disclosure OSCE. METHODS: Sixteen obstetrics and gynaecology residents participated in this mixed methods study. Prior to disclosing the complication in an SP encounter, residents were randomized either to receive a written description of an adverse event, or to experience a mannequin simulation of an adverse event. Mean OSCE scores from blinded examiners were compared in each group. Focus group discussions elicited residents' reflections on the experience of disclosing the adverse event. RESULTS: The mean score was 16.6/23 ± 2.9 (range 10 to 20) for the traditional OSCE group and 16.9/23 ± 1.7 (range 15 to 20) for the simulation group. Analysis of the focus group data revealed several themes, such as the type of context the residents desired, the emotional involvement they felt, and their insights about their experience of the simulation scenario or with the SP. CONCLUSION: The assessment of adverse event disclosure was not enhanced by the addition of a simulated experience. Study participants reported that the simulation did not provide the contextual information required to elicit empathy and a sense of being emotionally invested in the adverse event.

Assessing residents' communication skills: disclosure of an adverse event to a standardized patient.

INTRODUCTION: Disclosing adverse events to patients after a poor outcome is an essential task involving both communication skills and professionalism, but one that is difficult to teach and assess during clinical rotations. Beyond ensuring clinical competency, these skills are essential in minimizing medico-legal risk. An objective structured clinical examination (OSCE) station with a standardized patient allows an opportunity to evaluate these skills. Our objective was to assess residents' communication skills involving the disclosure of a poor outcome to a standardized patient using a standardized patient encounter, and to compare their performance before and after formal teaching on disclosure. METHODS: Fourteen obstetrics and gynaecology residents (PGY-2 to PGY-5) were evaluated in a two-station OSCE. In the first station, they obtained a history and counselled an obstetrical patient, and in the second station they met with the same patient to discuss an adverse outcome that had occurred. The residents were evaluated using guidelines for the disclosure of adverse events developed by the Canadian Patient Safety Institute and published by the Canadian Medical Protective Association. The residents then participated in a workshop on disclosure and were retested. RESULTS: The mean score in the pre-workshop disclosure OSCE was 59.1% (12.4/21, SD 2.7), while the mean score in the post-workshop OSCE was 80.1% (16.9/21, SD 2.1). Using the paired Student t test, the scores differed significantly with P < 0.01. CONCLUSION: Residents' performance in disclosure improves after formal teaching and the OSCE is an effective technique for testing communication skills.

An unusual complication after vaginal hysterectomy.

BACKGROUND: uterovaginal prolapse is a common problem in older women, with significant economic and health implications. For the patient no longer desiring fertility or unwilling to undergo conservative management, the definitive treatment is a vaginal hysterectomy with simultaneous repair of anterior or posterior compartment defects if present. CASE: A 66-year-old postmenopausal woman with procidentia, cystocele, rectocele, and latent stress incontinence underwent vaginal hysterectomy, anterior and posterior colporrhaphy, and placement of a modified mid-urethral sling. Perioperatively she sustained a fracture of the pubic ramus that was not explained by perioperative events or her medical history. CONCLUSION: unusual and unexpected complications can occur after routine vaginal surgery in the older, postmenopausal population.