To the Point: Integrating Patient Safety Education Into the Obstetrics and Gynecology Undergraduate Curriculum.

This article is part of the To the Point Series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. Principles and education in patient safety have been well integrated into academic obstetrics and gynecology practices, although progress in safety profiles has been frustratingly slow. Medical students have not been included in the majority of these ambulatory practice or hospital-based initiatives. Both the Association of American Medical Colleges and Accreditation Council for Graduate Medical Education have recommended incorporating students into safe practices. The Accreditation Council for Graduate Medical Education milestone 1 for entering interns includes competencies in patient safety. We present data and initiatives in patient safety, which have been successfully used in undergraduate and graduate medical education. In addition, this article demonstrates how using student feedback to assess sentinel events can enhance safe practice and quality improvement programs. Resources and implementation tools will be discussed to provide a template for incorporation into educational programs and institutions. Medical student involvement in the culture of safety is necessary for the delivery of both high-quality education and high-quality patient care. It is essential to incorporate students into the ongoing development of patient safety curricula in obstetrics and gynecology.

Pelvic and breast examination skills curricula in United States medical schools: a survey of obstetrics and gynecology clerkship directors.

BACKGROUND: Learning to perform pelvic and breast examinations produces anxiety for many medical students. Clerkship directors have long sought strategies to help students become comfortable with the sensitive nature of these examinations. Incorporating standardized patients, simulation and gynecologic teaching associates (GTAs) are approaches gaining widespread use. However, there is a paucity of literature guiding optimal approach and timing. Our primary objective was to survey obstetrics and gynecology (Ob/Gyn) clerkship directors regarding timing and methods for teaching and assessment of pelvic and breast examination skills in United States medical school curricula, and to assess clerkship director satisfaction with current educational strategies at their institutions. METHODS: Ob/Gyn clerkship directors from all 135 Liaison Committee on Medical Education accredited allopathic United States medical schools were invited to complete an anonymous 15-item web-based questionnaire. RESULTS: The response rate was 70%. Pelvic and breast examinations are most commonly taught during the second and third years of medical school. Pelvic examinations are primarily taught during the Ob/Gyn and Family Medicine (FM) clerkships, while breast examinations are taught during the Ob/Gyn, Surgery and FM clerkships. GTAs teach pelvic and breast examinations at 72 and 65% of schools, respectively. Over 60% of schools use some type of simulation to teach examination skills. Direct observation by Ob/Gyn faculty is used to evaluate pelvic exam skills at 87% of schools and breast exam skills at 80% of schools. Only 40% of Ob/Gyn clerkship directors rated pelvic examination training as excellent, while 18% rated breast examination training as excellent. CONCLUSIONS: Pelvic and breast examinations are most commonly taught during the Ob/Gyn clerkship using GTAs, simulation trainers and clinical patients, and are assessed by direct faculty observation during the Ob/Gyn clerkship. While the majority of Ob/Gyn clerkship directors were not highly satisfied with either pelvic or breast examination training programs, they were less likely to describe their breast examination training programs as excellent as compared to pelvic examination training-overall suggesting an opportunity for improvement. The survey results will be useful in identifying future challenges in teaching such skills in a cost-effective manner.

A randomized controlled trial of early versus delayed skin staple removal following caesarean section in the obese patient.

OBJECTIVE: To compare wound complications after Caesarean section in the obese patient, following early versus delayed skin staple removal. METHODS: We conducted a single-centre, non-inferiority, randomized controlled trial. Following Caesarean section, obese women (BMI ≥ 30 kg/m(2)) with subcutaneous wound depth ≥ 2.0 cm and skin staple closure of a transverse incision were randomized to staple removal on postoperative day 3 (early) or between postoperative day 7 and postoperative day 10 (delayed). The primary outcome was superficial wound dehiscence; a rate of 8% or higher in the early group was defined as inferior. Secondary outcomes were seroma/hematoma, surgical site infection, and visual analogue pain score. The planned sample size was 250 patients per group. RESULTS: The study was halted after 295 patients were randomized because of slow enrolment and exhaustion of funding. The rate of superficial wound dehiscence was 15.2% in the early group (n = 145) versus 11.5% in the delayed group (n = 148). The point estimate for this difference (3.7 %; 95% CI -4.4 to 12.4) favours delayed removal. However, because the 95% CI includes zero and the upper CI exceeds the predefined limit for non-inferiority (8%), non-inferiority was not demonstrated. The rates of all secondary outcomes were similar in the early group and the delayed group: seroma/hematoma (6.9% vs. 4.7%; RR 1.4, 95% CI 0.6 to 3.7, P = 0.4); surgical site infection (9.7% vs. 4.8%; RR 2.0, 95% CI 0.8 to 4.9, P = 0.1); and composite (superficial wound dehiscence, seroma/hematoma, and surgical site infection) wound complication (17.2% vs. 12.8%; RR 1.3, 95% CI 0.8 to 2.3, P = 0.3). CONCLUSION: The non-inferiority of early skin staple removal was not demonstrated. Delayed removal of staples should remain the accepted standard in the obese patient following Caesarean section.

Objectif : Comparer les effets du retrait précoce des agrafes cutanées aux effets de leur retrait différé, en ce qui concerne les complications de plaie à la suite d'une césarienne chez une patiente obèse. Méthodes : Nous avons mené un essai comparatif randomisé de non-infériorité au sein d'un seul centre. À la suite d'une césarienne, les femmes obèses (IMC ≥ 30 kg/m2) qui présentaient une profondeur de plaie sous-cutanée ≥ 2,0 cm et une incision transversale fermée au moyen d'agrafes cutanées ont été affectées, au hasard, à un groupe devant se faire retirer ces agrafes trois jours à la suite de l'opération (retrait précoce) ou à un groupe devant se faire retirer ces agrafes entre le septième jour et le dixième jour suivant l'opération (retrait différé). La déhiscence superficielle de la plaie constituait le critère d'évaluation principal; un taux de 8 % ou plus au sein du groupe « retrait précoce ¼ a été défini comme étant inférieur. Les critères d'évaluation secondaires étaient le sérome / hématome, l'infection du champ opératoire et le score sur l'échelle visuelle analogue. La taille planifiée de l'échantillon était de 250 patientes par groupe. Résultats : L'étude a été suspendue à la suite de la randomisation de 295 patientes, en raison de la lenteur du processus de sollicitation des patientes et de l'épuisement des fonds. Le taux de déhiscence superficielle de la plaie était de 15,2 % au sein du groupe « retrait précoce ¼ (n = 145) vs 11,5 % au sein du groupe « retrait différé ¼ (n = 148). L'estimation ponctuelle pour cette différence (3,7 %; IC à 95 %, −4,4 - 12,4) favorise le retrait différé. Toutefois, puisque l'IC à 95 % contient zéro et que l'IC supérieur dépasse la limite prédéfinie pour ce qui est de la non-infériorité (8 %), cette dernière n'a pas été démontrée. Les taux de tous les critères d'évaluation secondaires étaient semblables dans les deux groupes : sérome / hématome (6,9 % vs 4,7 %; RR, 1,4, IC à 95 %, 0,6 - 3,7, P = 0,4); infection du champ opératoire (9,7 % vs 4,8 %; RR, 2,0, IC à 95 %, 0,8 - 4,9, P = 0,1); et complication composite de la plaie (déhiscence superficielle de la plaie, sérome / hématome, infection du champ opératoire) (17,2 % vs 12,8 %; RR, 1,3, IC à 95 %, 0,8 - 2,3, P = 0,3). Conclusion : La non-infériorité du retrait précoce des agrafes cutanées n'a pas été démontrée. Le retrait différé des agrafes devrait demeurer la norme acceptée en ce qui concerne les patientes obèses à la suite d'une césarienne.

e-Professionalism: a new frontier in medical education.

BACKGROUND: This article, prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the evolving challenges facing medical educators posed by social media and a new form of professionalism that has been termed e-professionalism. SUMMARY: E-professionalism is defined as the attitudes and behaviors that reflect traditional professionalism paradigms but are manifested through digital media. One of the major functions of medical education is professional identity formation; e-professionalism is an essential and increasingly important element of professional identity formation, because the consequences of violations of e-professionalism have escalated from academic sanctions to revocation of licensure. CONCLUSION: E-professionalism should be included in the definition, teaching, and evaluation of medical professionalism. Curricula should include a positive approach for the proper professional use of social media for learners.

To the point: a primer on medical education research.

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides educators with an introduction to medical educational research by describing the framework of educational scholarship, discussing the similarities and differences between clinical and educational research, reviewing the key steps in educational research, and providing examples of well-designed studies in the field of obstetrics and gynecology.

To the point: medical education reviews-ongoing call for faculty development.

This article in the To the Point series will focus on best practices regarding faculty development in medical education in the field of obstetrics and gynecology. Faculty development is an essential component in achieving teacher and learner satisfaction as well as improving learner outcomes. The Liaison Committee on Medical Education requires medical school faculty to have the capability and longitudinal commitment to be effective teachers. Although many programs have been created to address faculty development, there remains a paucity of literature documenting the impact of these programs on learner outcomes. We reviewed the qualities of an excellent medical educator, expectations regarding medical school teaching faculty, elements of comprehensive faculty development programs, and outcome measures for evaluating the effectiveness of these programs.

The obstetrics and gynaecology resident as teacher.

In this article we discuss the role residents play in the clinical training and evaluation of medical students. A literature search was performed to identify articles dealing with research, curriculum, and the evaluation of residents as teachers. We summarize the importance of resident educators and the need to provide appropriate resources for house staff in this role, and we review evidence-based literature in the area of residents as teachers. Specific attention is given to the unique circumstances of the obstetrics and gynaecology resident, who is often faced with teaching in an emotionally charged and stress-filled environment. We present examples of curricula for residents as teachers and describe barriers to their implementation and evaluation.

To the point: reviews in medical education-taking control of the hidden curriculum.

This article, the ninth in the "To the Point" series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the role of the "hidden curriculum" in shaping the professional identity of doctors in training. The characteristics that distinguish the formal curriculum and hidden curriculum are defined. Specific examples of hidden curricula in clinical environments and the positive and negative impacts that may result are highlighted. Techniques to evaluate clinical training environments and to identify the hidden curriculum are provided and are followed by methods to promote its positive messages and lessen its negative ones.

Complications of central venous catheters during pregnancy and postpartum: a case series.

OBJECTIVE: The objective of the study was to determine the incidence of central venous catheter-related complications during pregnancy and postpartum. STUDY DESIGN: This was a retrospective case series of patients admitted for obstetric care and who had a central venous catheter placed between Jan. 1, 2000, and July 10, 2006. Patient characteristics, catheter indication, and associated complications were identified. RESULTS: Ninety-seven catheter placements in 85 patients were identified. Seventy-six percent of the catheters were placed antepartum at 24.7 +/- 10.7 weeks' gestation. Indications for catheter placement included the following: failed peripheral intravenous access (n = 59; 61%), long-term venous access (n = 33; 34%), and other (n = 5; 5%). The overall incidence of catheter complications was 25% (24/97). Complications included the following: culture-proven line infection 12% (12/97), mechanical failure 4% (4/97), presumed line infection 2% (2/97), superficial and deep venous thrombosis 2% (2/97), hematoma 2% (2/97), ventricular tachycardia 1% (1/97), and discomfort 1% (1/97). CONCLUSION: The overall incidence of catheter complications was 25%, of which 12% were infectious.

To the point: reviews in medical education--the Objective Structured Clinical Examination.

This article, the eighth in the To the Point Series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the effectiveness of the Objective Structured Clinical Examination (OSCE) for assessment of learners' knowledge, skills, and behaviors. The OSCE has also been used for the appraisal of residents and physicians undergoing licensure examinations; herein we focus on its application to undergraduate medical education. We review evidence for best practices and recommendations on effective use of the OSCE and requirements for and challenges to its implementation, including creative ways to design an OSCE program with a limited budget. We discuss its role in providing formative and summative feedback and describe learner performance on the OSCE as the OSCE relates to subsequent testing, including US Medical Licensing Examination step 1. A representative case with assessment used at the authors' medical schools is included.

To the point: medical education review of the role of simulators in surgical training.

Simulation-based training (SBT) is becoming widely used in medical education to help residents and medical students develop good technical skills before they practice on real patients. SBT seems ideal because it provides a nonthreatening controlled environment for practice with immediate feedback and can include objective performance assessment. However, various forms of SBT and assessment often are being used with limited evidence-based data to support their validity and reliability. In addition, although SBT with high-tech simulators is more sophisticated and attractive, this is not necessarily superior to SBT with low-tech (and lower cost) simulators. Therefore, understanding the types of surgical simulators and appropriate applications can help to ensure that this teaching and assessment modality is applied most effectively. This article summarizes the key concepts that are needed to use surgical simulators effectively for teaching and assessment.

Transcervical Foley catheter with and without extraamniotic saline infusion for labor induction: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of transcervical Foley catheter alone (Foley) to transcervical Foley catheter with extraamniotic saline infusion for labor induction and cervical ripening in women with an unfavorable cervix. METHODS: This was a multicenter, randomized, controlled trial of women presenting for labor induction with a singleton, cephalic fetus, intact membranes, and unfavorable cervix (Bishop score 6 or less). Eligible women were randomly assigned to receive either Foley catheter alone or Foley catheter with extraamniotic saline infusion. All women received concurrent oxytocin administration. The primary study outcome was the induction-to-delivery interval. Secondary outcomes included cesarean delivery, maternal infectious outcomes, and immediate neonatal outcomes. Analysis was by intent to treat. RESULTS: One hundred eighty-eight women met eligibility criteria and were randomly assigned (Foley plus extraamniotic saline infusion, n=97; Foley, n=91). Baseline demographic characteristics, including parity, gestational age, and Bishop score were similar between the study groups. The median induction-to-delivery interval in the extraamniotic saline infusion arm (12.6 hours, interquartile range 9.3-18.8 hours) was similar to that in the Foley arm (13.4 hours, interquartile range 9.6-17.5 hours) (P=. 70). The proportion of women delivered by 24 hours was comparable between groups (delivery 24 hours, extraamniotic saline infusion 89.7%, Foley 87.9%, P=.70), as was the rate of cesarean delivery (Foley 18.7%, extraamniotic saline infusion 27.8%, P=.14). No significant differences were noted between the study groups with respect to rate of chorioamnionitis, endometritis, or immediate birth outcomes. CONCLUSION: In women with an unfavorable cervix, the addition of extraamniotic saline infusion to a transcervical Foley catheter does not improve efficacy for labor induction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00442663 LEVEL OF EVIDENCE: I.

The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors.

OBJECTIVE: The purpose of this study was to characterize residency program director baseline perceptions regarding the effect of resident duty hour limitations on key components of the graduate medical education environment. STUDY DESIGN: This was a survey of directors of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) between June 21st and July 16th, 2004. Participants were queried on views regarding the need for duty hour limitations, and the perceived effect of these changes on various issues related to the residency environment. RESULTS: Fifty-eight percent (123/211) of the study population completed the questionnaire. Seventy-one percent of respondents supported duty hour restrictions, 19% opposed restrictions, and 10% were undecided. Forty-one percent of respondents preferred a maximum duty hour limitation of 80 hrs/wk or less, 55% preferred one at least 90 hrs/wk, and 4% preferred no upper limit. A significantly greater proportion of female program directors supported limits > 80 hrs/wk than males (73% vs 53%, P = .04). A majority of participants believed resident education, surgical skills, and work ethic have been negatively impacted by the limitations, while patient safety and the overall quality of patient care have remained unchanged or declined, and resident well-being has improved. Opposition to duty hour regulations and a preference for higher limits was associated with a higher prevalence of negative impressions regarding the impact of duty hour regulations on the residency environment. CONCLUSION: Variations in current opinions regarding the impact of residency duty hour restrictions reflect ongoing bias in those most influential to resident education.

The scope of duty hour-associated residency structure modifications.

OBJECTIVE: The purpose of this study was to characterize the duty hours-associated modifications made to the educational and patient care structure of obstetrics and gynecology residency programs, and the relationship of these modifications to residency program setting and size. STUDY DESIGN: A survey of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) was performed between June 21st and July 16th, 2004. Program representatives were queried on the difficulty encountered in complying with each of the 6 components of the ACGME common duty hour requirements and the prevalence of residency modifications affecting the educational and patient care structure. RESULTS: Fifty-eight percent (123/211) of the study population completed the questionnaire. Ensuring a minimum 10-hour rest period between shifts was rated the most difficult requirement. Ninety-eight percent of respondents reported various types of modifications to program structure, including modification of on-call structure (94%), redistribution of responsibilities among resident levels (85%), modification of resident participation in patient care processes (80%), and modification of resident assignments to clinical services (75%). A minimum of 38% of programs reported reductions in resident participation in patient care, regardless of clinical service type or care setting. The prevalence of hiring attending physicians was significantly higher among non-university-based programs (18%), compared to university-based programs (3%, P = .007). CONCLUSION: Duty hour-related changes have resulted in near universal program modifications. One third of programs have made modifications that have resulted in a decrease in the available clinical experiences for residents.

Do factors that are important during obstetrics and gynecology residency program selection differ by applicant gender?

OBJECTIVE: The purpose of this study was to examine the relationship between applicant gender and factors that influence obstetrics and gynecology residency program selection. STUDY DESIGN: A national survey was conducted of graduates of US allopathic medical schools who were registered with the Electronic Residency Application Service for the year 2003 and who indicated that obstetrics and gynecology was their primary specialty choice. The selection prevalence of 20 possible influential factors was analyzed by gender. RESULTS: Our study cohort consisted of 450 eligible respondents, 80.4% of whom were female. There were no significant differences by gender in regards to applicant age, race, marital status, number of dependents, or geographic region of medical school. Overall, the 4 factors with the highest selection prevalence in both gender groups were all related to workplace environment. Compared with male respondents, female respondents were more likely to consider how well the current residents seemed to work together (99.2% vs 94.3%; P = .002) and the amount of conference/didactic teaching (80.4% vs 68.2%; P = .01). Male respondents were more likely to consider the quality of the hospital facility (92% vs 82%; P = .02), salary (28.4% vs 17.1%; P = .02), and supplemental income (moonlighting) opportunities (18.2% vs 8.6%; P = .008), as compared with female respondents. CONCLUSION: Significant differences in gender-associated preferences that are related to obstetrics and gynecology residency program selection exist and include both curricular and financial factors.

Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis.

OBJECTIVE: To systematically review published data evaluating the comparative use of misoprostol with placebo/expectant management or oxytocin for labor induction in women with term (> or = 36 weeks of gestation) premature rupture of membranes. DATA SOURCES: PubMed (1966-2005), Ovid (1966-2005), CINAHL, The Cochrane Library, ACP Journal Club, OCLC, abstracts from scientific forums, and bibliographies of published articles were searched using the following keywords: premature rupture of membranes, misoprostol, labor induction, and cervical ripening. Primary authors were contacted directly if the data sought were unavailable or only published in abstract form. METHODS OF STUDY SELECTION: Only randomized controlled trials evaluating the efficacy and safety of misoprostol in comparison with placebo or expectant management (n = 6) and oxytocin (n = 9) published in either article or abstract form were analyzed and included in the meta-analysis. TABULATION, INTEGRATION, AND RESULTS: Studies were reviewed independently by all authors. Meta-analysis was performed, and the relative risks (RRs) were calculated and pooled for each study outcome. Misoprostol, compared with placebo, significantly increased vaginal delivery less than 12 hours (RR 2.71, 95% confidence interval [CI] 1.87-3.92, P < .001). Misoprostol was similar to oxytocin with respect to vaginal delivery less than 24 hours (RR 1.07, 95% CI 0.88-1.31, P = .50) and less than 12 hours (RR 0.98, 95% CI 0.71-1.35, P = .90). Misoprostol was not associated with an increased risk of tachysystole, hypertonus, or hyperstimulation syndrome when compared with oxytocin and had similar risks for adverse neonatal and maternal outcomes. CONCLUSION: Misoprostol is an effective and safe agent for induction of labor in women with term premature rupture of membranes. When compared with oxytocin, the risk of contraction abnormalities and the rate of maternal and neonatal complications were similar among the 2 groups.

High-dose vaginal misoprostol versus concentrated oxytocin plus low-dose vaginal misoprostol for midtrimester labor induction: a randomized trial.

OBJECTIVE: This study was undertaken to compare the efficacy and side effects of a high-dose vaginal misoprostol regimen to concentrated intravenous oxytocin plus low-dose vaginal misoprostol for midtrimester labor induction. STUDY DESIGN: Women at 14 to 24 weeks, with obstetric or fetal indications for delivery and no prior cesarean, were randomly assigned to receive either vaginal misoprostol 600 microg x 1, then 400 microg every 4 hours x 5 (group 1) or escalating dose-concentrated oxytocin infusions (277-1667 mU/min) plus vaginal misoprostol 400 microg x 1, then 200 microg every 6 hours x 2, then 100 microg x 1 (group 2). Analysis was by intent to treat. Primary outcomes were live birth rate and induction-to-delivery interval. RESULTS: The intended sample size was 70 women per group; however, the trial was terminated at the initial interim analysis because of a highly significant difference in 1 of the primary study outcomes. Twenty women were assigned to group 1 and 18 were assigned to group 2. Median induction-to-delivery interval was significantly shorter in group 1 (12 hours, range 4-44 hours) versus group 2 (18 hours, range 7-36 hours; P = .01). Induction success rate at 12 hours was significantly higher in group 1 (60%) compared with group 2 (22%, P = .02). No significant difference was noted in the live birth rate between groups 1 and 2 (13%, 0%, P = .16). The incidence of retained placenta requiring curettage, chorioamnionitis, intrapartum fever, nausea, emesis, and diarrhea were similar between both groups. CONCLUSION: Compared with concentrated oxytocin plus low-dose vaginal misoprostol, high-dose vaginal misoprostol significantly shortens midtrimester labor inductions.