Preparing medical students for obstetrics and gynecology milestone level one: a description of a pilot curriculum.

BACKGROUND: The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident. PURPOSE: We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies. METHODS: The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks. RESULTS: Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey. CONCLUSIONS: This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGME's Next Accreditation System.

Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse.

OBJECTIVE: We sought to compare bony pelvis dimensions at the level of pelvic support in women with and without pelvic organ prolapse (POP). STUDY DESIGN: Pelvic floor dimensions of 42 white women with POP > 1 cm beyond the hymen were compared with 42 age- and parity-matched women with normal support. Bony landmarks relevant to connective tissue and levator attachments were identified on magnetic resonance imaging. Dimensions were independently measured by 2 examiners and averaged for each subject. RESULTS: Measurements (in centimeters) for patients and control subjects were as follows: interspinous diameter, 11.2 +/- 0.8 versus 11.1 +/- 0.7, P = .19; anterior-posterior outlet diameter, 11.7 +/- 0.7 versus 11.7 +/- 0.8, P = .71; pubic symphysis to ischial spine left, 9.5 +/- 0.5 versus 9.5 +/- 0.4, P = .91; pubic symphysis to ischial spine right, 9.5 +/- 0.4 versus 9.5 +/- 0.5, P = .81; sacrococcygeal junction to ischial spine left, 7.0 +/- 0.6 versus 7.0 +/- 0.5, P = .54; and sacrococcygeal junction to ischial spine right, 7.0 +/- 0.6 versus 6.9 +/- 0.4, P = .32. CONCLUSION: Bony pelvis dimensions are similar at the level of the muscular pelvic floor in white women with and without POP.

Structure of the perineal membrane in females: gross and microscopic anatomy.

OBJECTIVE: To re-examine the anatomy of the perineal membrane and its anatomical relationships in whole-pelvis and histologic serial section as well as gross anatomical dissection. METHODS: Serial trichrome-stained histologic sections of five female pelvic specimens (0-37 years old) were examined. Specimens included the urethra, perineal membrane, vagina, and surrounding structures. Macroscopic whole-pelvis sections of three adults, 28-56 years of age, in axial, sagittal, and coronal sections were also studied. Dissections of six female cadavers, 48-90 years of age, were also performed. RESULTS: The perineal membrane is composed of two regions, one dorsal and one ventral. The dorsal portion consists of bilateral transverse fibrous sheets that attach the lateral wall of the vagina and perineal body to the ischiopubic ramus. This portion is devoid of striated muscle. The ventral portion is part of a solid three-dimensional tissue mass in which several structures are embedded. It is intimately associated with the compressor urethrae and the urethrovaginal sphincter muscle of the distal urethra with the urethra and its surrounding connective. In this region the perineal membrane is continuous with the insertion of the arcus tendineus fascia pelvis. The levator ani muscles are connected with the cranial surface of the perineal membrane. The vestibular bulb and clitoral crus are fused with the membrane's caudal surface. CONCLUSION: The structure of the perineal membrane is a complex three-dimensional structure with two distinctly different dorsal and ventral regions; not a simple trilaminar sheet with perforating viscera.

Interrater reliability of assessing levator ani muscle defects with magnetic resonance images.

The objective of this study is to determine interrater reliability of assessing pubovisceral levator ani muscle defects with magnetic resonance images. Normal pubovisceral muscle was assigned a grade of 0; PVM defects were graded as mild=1 (less than half missing), moderate=2 (more than half missing), and severe=3 (total or near total loss). Among six pairs of examiners, percent agreement and weighted kappa coefficients were calculated to determine agreement between pairs of examiners and among all examiners (i.e., "overall"). For unilateral scoring, exact agreement was found in 83.7%, and differences of one, two, and three grades were found in 14.7, 1.5, and 0.1%, respectively. For bilateral scoring, exact agreement and differences of one, two and three grades were found in 75.4, 15.9, 6.9, and 1.6%, respectively. Thus, exact agreement or a one-point difference was reached in 91.3% of cases. When defect status was categorized as none/normal, minor, and major, the overall weighted kappa coefficient was 0.86 (95% CI 0.83, 0.89). There was variation among examiner pairs with unilateral (p=0.002) and bilateral (p=0.02) scoring, but not when defect status was categorized as none/normal, minor, and major (p=0.59). There was agreement to within one point in 91% of cases when six examiner pairs scored levator ani defects on a seven-point scale. Examiner pairs discriminated injury similarly when defect status was categorized as normal/none, minor, or major.

Appearance of the levator ani muscle subdivisions in magnetic resonance images.

OBJECTIVE: Identify and describe the separate appearance of 5 levator ani muscle subdivisions seen in axial, coronal, and sagittal magnetic resonance imaging (MRI) scan planes. METHODS: Magnetic resonance scans of 80 nulliparous women with normal pelvic support were evaluated. Characteristic features of each Terminologia Anatomica-listed levator ani component were determined for each scan plane. Muscle component visibility was based on pre-established criteria in axial, coronal, and sagittal scan planes: 1) clear and consistently visible separation or 2) different origin or insertion. Visibility of each of the levator ani subdivisions in each scan plane was assessed in 25 nulliparous women. RESULTS: In the axial plane, the puborectal muscle can be seen lateral to the pubovisceral muscle and decussating dorsal to the rectum. The course of the puboperineal muscle near the perineal body is visualized in the axial plane. The coronal view is perpendicular to the fiber direction of the puborectal and pubovisceral muscles and shows them as "clusters" of muscle on either side of the vagina. The sagittal plane consistently demonstrates the puborectal muscle passing dorsal to the rectum to form a sling that can consistently be seen as a "bump." This plane is also parallel to the pubovisceral muscle fiber direction and shows the puboperineal muscle. CONCLUSION: The subdivisions of the levator ani muscle are visible in MRI scans, each with distinct morphology and characteristic features.

An interdisciplinary course in women's health integrating basic and clinical sciences: clinical anatomy and women's health.

Traditionally, undergraduate medical education is divided into preclinical and clinical years, with basic sciences taught during the first years and clinical sciences taught during the latter years. In an effort to better integrate the basic and clinical sciences in undergraduate medical education, and focus on women's health, we have developed a new interdisciplinary fourth-year elective at the University of Michigan Medical School. The elective, titled "Clinical Anatomy and Women's Health," is a joint effort between the Division of Anatomical Sciences and the Department of Obstetrics and Gynecology at the University of Michigan Health System. During the course students participate in didactic, laboratory, cadaveric dissection, and clinical-correlate sessions that focus on gynecologic anatomy and clinical issues in women's health. Educational goals and learning objectives were used to assess the effectiveness of the curriculum; revisions, based on outcomes of the educational assessment, will be implemented in the next offering of the course. Preliminary data from the first offering of the course in February 2002 are provided. The goals of this course include integrating basic science and clinical concepts while reducing the division between preclinical and clinical medical education, addressing issues of women's health, and encouraging lifelong learning by using basic science concepts and techniques of discovery in clinical practice.