bluuebunny/crossref_metadata_2025 huggingface dataset:
Creating a Sustainable ObGyn Residency in a Resource-Limited Country Improves Maternal Health Outcomes
Authors: Evans Lindsey , Derkenne Ruth , Liu James , Larkins-Pettigrew Margaret
Published: September 2017

BACKGROUND:

The 2013 maternal mortality ratio (MMR) in Guyana was 250/100,000 live births according to the WHO, compared to a regional average of 68. Inadequate quality of care, shortage of skilled health care professionals, and systemic limitations are contributing factors.

METHODS:

In 2012 University Hospitals/Case Medical Center (UHCMC), Georgetown Public Hospital Corporation (GPHC) and University of Guyana collaborated to develop a 4-year ObGyn training program using curriculum formalized at UHCMC, modified to suit local needs. A multi-academic institutional partnership allowed international faculty involvement in training Guyana's first ObGyn residents (MDG-8). Maternal morbidity and mortality outcomes (MDG-5) were prospectively maintained, analyzed, and compared to rates prior to program implementation.

RESULTS:

Twenty-three residents were trained and five residents completed the program in 2016. Full-time staff are present in Guyana, and 52 faculty from partnering institutions travelled to Guyana to teach and provide patient care. Development of modified evidence-based clinical guidelines improved quality of care and patient safety outcomes. MMR from direct causes decreased country-wide and at GPHC during the 4-year period. Success was due to shared institutional vision, establishment of partner organizations, resident leadership development, and systems-based improvement. Future challenges include trainee retention and continued sustainability.

DISCUSSION:

Guyana’s first ObGyn residency program can serve as a model for similar endeavors in global health. Creation of sustainable training programs in ObGyn through international partnerships is essential progress toward achieving MDGs 5 and 8.
DREAM: Empowering Preclinical Students With Labor Support Training
Authors: Shakartzi Hannah , Pierre-Joseph Natalie , Marino Rachel , Rodrigues Dona , Omer Roy Nicole St. , Abbott Jodi
Published: September 2017

BACKGROUND:

Preclinical medical education is largely lecture-based with limited patient-experience prior to clinical rotations. Consequently, students begin rotations with low confidence regarding patient communication skills and their utility to the care-team. Minimal clinical exposure, in tandem with intense academic work, likely contributes to student burnout. Furthermore, OB/GYN residencies struggle with recruitment. Concurrently, many pregnant women lack optimal support throughout pregnancy when evidence shows that continuous labor support improves outcomes.

METHODS:

Preclinical medical students are trained by hospital-based doulas and midwives to provide holistic prenatal, labor, and postpartum support. Students are paired with doulas for one labor, and one prenatal, postpartum, and home visit, prior to having independent clients.

RESULTS:

Students gained comprehensive OB/GYN knowledge and developed confidence providing comfort, advocacy, and facilitating patient-care-team communication. Reflections like, “I learned how to be there in a very personal and intimate way for someone I hardly knew,” and “now, on my OB/GYN rotation, I feel much more comfortable jumping in and helping women,” confirm preliminary findings. Patient reflections included, “I can't believe that someone who is going to be a Doctor, took the time to spend so much time with me.”

DISCUSSION:

Student-provided labor support is beneficial for both students and patients.
Education on the Go: Studying the Use of Podcasts in Resident Education
Authors: De Los Reyes Samaqntha , Cholakian Diana , Chau Danielle , Forde Braxton , Johnson Clark , Bienstock Jessica
Published: September 2017

BACKGROUND:

Podcasting has become a mainstream media commodity, although its implementation into medical education has yet to be studied. Podcasting curricula can be readily created and disseminated for educational efficiency.

METHODS:

Four podcasts were created to cover information from American College of Obstetricians and Gynecologists’ Practice Bulletins. All residents in our academic program were randomized to access the bulletins or both podcasts and bulletins. Both groups were offered posteducation quizzes. Outcomes included resident quiz completion as well as overall performance. Analysis was performed using standard statistics in Stata 14, with significance defined as P<.05. This project was IRB-approved.

RESULTS:

Overall, 126 quizzes were administered to 36 residents. Thirty-eight (30.2%) posteducation quizzes were completed, including 16 (27.6%) from residents who received podcasts and 22 (32.4%) from those who did not, a difference that was not statistically significant (P=.56). Similarly there was no significant difference in average quiz scores between podcast and traditional groups (70±22.3% and 80±17.1% respectively, P=.17).

DISCUSSION:

Podcasts have become an efficient and popular way for residents to learn. We noted equivalent participation and comprehension of the curriculum whether or not podcasts were used in conjunction with self-directed reading. The addition of podcasts to a resident curriculum may not significantly improve scores or participation. Future studies may evaluate the efficiency of education through podcasting in the ob/gyn residency given its noninferiority to traditional self-directed learning.
Engaging Residents in Quality Improvement: A Multidisciplinary Collaboration to Decrease the Primary Cesarean Delivery Rate at a New Academic Medical Center
Authors: Williams Liliana Padilla , Harris Roberto Prieto , Hirani Zishan , Ballesteros Carlos , Gonzalez Aida , Hernandez Annabelle
Published: September 2017

BACKGROUND:

Our facility performs more than 9,000 deliveries per year, with a primary cesarean birth rate of 35% and is the primary teaching site for a new Ob/Gyn residency program. An innovative curriculum includes a formal course in quality improvement methods for new faculty, and active participation of all residents in a QI project. In an effort to decrease the primary cesarean birth rate, a multidisciplinary QI project was developed.

METHODS:

The team was led by two community faculty members and included two residents, nursing and hospital administration. Interventions included mandatory completion of a FHR course, provider education on current terminology and recommended interventions, and monthly reporting of cesarean delivery rates. The team used a fishbone analysis of the steps leading to a cesarean delivery to create a data collection checklist. Charts were reviewed by the residents to confirm the indication for cesarean delivery along with other pertinent variables.

RESULTS:

The primary cesarean birth rate decreased from 35% in the first quarter of 2015 to 27% in the first quarter of 2016, a 24% decrease. The project team continues to meet quarterly to discuss ongoing activities necessary to maintain and increase the improvement observed in the initial quarter. Residents and faculty report a strong sense of accomplishment as a result of the project, and an interest in continued participation in QI activities.

DISCUSSION:

Interdisciplinary partnerships between OBGYN residents, faculty and hospital administration/staff to develop and implement quality improvement projects can improve patient care and provide learners with the knowledge and expertise to engage in quality projects in their future practice.
Interdisciplinary Flipped Classroom: Methods and Modules
Authors: Hooks Jared , Brincat Cynthia , Wagner Sarah , Bullough Alexandra
Published: September 2017

BACKGROUND:

To efficiently address the limitations on formal didactic time, we have developed a practical, interprofessional curriculum.

METHODS:

Following IRB exempt status, we piloted a low-fidelity, anesthesia designed module covering Anesthetic Concerns for a Surgical Pneumoperitoneum on OB/GYN residents, prior to their orientation to the robotic surgery system. One component was in lecture format, developed via power point with voice over. The second was an interactive case study. The residency director invited the residents to access the module which was accessible via a link in survey monkey and required 25 minutes to complete. A brief survey followed.

RESULTS:

Forty-seven percent (8/17) of the residents accessed the module. 87.5% of respondents agreed or strongly agreed that the video presentation assisted with learning. Seventy-five percent agreed or strongly agreed that they felt engaged with the educational material. 87.5% agreed or strongly agreed that the case portion of the didactic session allowed for application of the material, and 75% of respondents felt they could apply the knowledge learned clinically. Yet only 50% of the respondents found the self-directed learning: 1) time saving, and 2) more satisfying than traditional learning.

DISCUSSION:

Didactic topics for OB/GYN residents can be developed interprofessionally and addressed efficiently through a flipped-classroom model. While only half of the residents accessed the module, the vast majority found it helpful. But only half found the experience satisfying. Future steps will involve developing topics for anesthesia residents relevant to OB/GYN.
Making Magic With Interprofessional Education: A 3-Year Experience
Authors: Appleton Sarah
Published: September 2017

BACKGROUND:

In the past 5 years, the American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists have urged collaborative practice and the development of interprofessional education (IPE) teams. Many barriers exist in establishing true interdisciplinary teams in training.

METHODS:

Over 3 years, all OB/GYN interns completed a rotation with the faculty CNM practice 1 day per week. The rotation included didactics, simulation, and clinical teaching with an emphasis on normal birth as well as an introduction to midwifery scope of practice and philosophy of care. Interns completed a validated attitude survey before and after the rotation, formative feedback evaluations after each shift, and a clinical reflection.

RESULTS:

Of all participating interns (n=30), 50% had never previously worked with a midwife. Topics rated most helpful included: nonpharmacologic pain control, normal labor and birth, and birth positions. Based on the attitude survey (4-point Likert scale), the most significant changes in perception at completion included: scope of care (Δ 0.5), nonmedical approach to obstetrics (Δ 0.6), and understanding credentials in midwifery (Δ 0.7). Review of the reflections revealed three main qualitative themes learned during the rotation: therapeutic use of self, birth experience, and relationship with midwives.

DISCUSSION:

An interprofessional education with faculty CNMs provided interns with an introduction to midwifery care and an opportunity to establish positive relationships with future collaborators.
Medical Students Can Improve Health Literacy: Training Students to Educate Patients About Obstetric Venous Thromboembolism Prophylaxis
Authors: Siegel Molly , Tukan Natalie , Abbott Jodi
Published: September 2017

BACKGROUND:

Medical schools are increasingly emphasizing patient education in the clerkship year. Effective education is essential to increase patient buy-in when spearheading quality initiatives. This project was designed to train 3rd-year medical students in teach-back education while concurrently enhancing a departmental QI effort to increase obstetric VTE prophylaxis.

METHODS:

Ob-Gyn clerkship students watched a student-created instructional video on teach-back teaching and a case-based presentation on VTE prophylaxis. Students assessed three patients for VTE risk and counseled patients on interventions. Students recorded pre- and postcounseling assessments of patient knowledge and responded to a survey about their experience.

RESULTS:

During the first clerkship block, 26 students participated in counseling and 75 patients were counseled. Following student counseling, a significantly increased number of patients exhibited understanding of: definition and consequences of VTE (56.25% increase, P<.0001), VTE risk factors (212.5% increase, P<.0001) and prophylactic interventions (169% increase, P<.0001). Students agreed or strongly agreed that their participation improved: understanding of VTE prophylaxis (100%), confidence counseling patients (100%), quality of patient care (64%), and understanding of QI (93%). One hundred percent of students stated that they plan to use teach-back teaching in future patient encounters.

DISCUSSION:

Students felt that the experience was rewarding and contributed to their education, and students' assessment of patient understanding improved following counseling. This intervention demonstrates that medical students can effectively counsel patients and enhance a quality improvement intervention.
Resident Training in Hysterectomy and Patient Morbidity: Interrogating the Association
Authors: Shah Divya , Vitonis Allison , Missmer Stacey
Published: September 2017

BACKGROUND:

Concern regarding resident inexperience as a contributing factor toward unfavorable surgical outcomes is often claimed but has been inadequately explored.

METHODS:

Data were abstracted from American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) on 33,278 benign hysterectomies performed from January 2005–December 2012. Associations between resident participation and morbidity were examined using multivariate-adjusted regression, adjusting for age, BMI, race, ethnicity, year of surgery, smoking, diabetes, hypertension, steroid use, ASA physical classification, uterine size, and postoperative diagnosis. Cases without resident involvement (63.4%) were used as the referent.

RESULTS:

Resident involvement was associated with significantly longer operative times regardless of surgical approach and year of training (all P<.0001). Odds of blood transfusion were increased with resident participation in abdominal (OR 1.74; 95% CI 1.40–2.17) and laparoscopic hysterectomy (OR 1.87; 95% CI 1.33–2.64), while odds of sepsis were increased in abdominal (OR 2.29; 95% CI 1.37–3.83) and vaginal hysterectomy (OR 2.49; 95% CI 1.24–5.00). Odds of urinary tract infections were uniformly higher with resident participation (all P<.001). When stratified by level of training, these associations only remained significant in hysterectomies involving senior residents. All associations were significantly attenuated or absent when operative time was included in the model.

DISCUSSION:

Resident involvement is associated with modest increases in the odds of blood transfusion and infectious morbidity after hysterectomy. These associations are likely driven by prolonged operative times with resident participation.
SUGAR in OB/Gyn: A Multi-Institutional Collaboration to Develop Cases for Simulation Use for Global Away Rotations (SUGAR)
Authors: Rysavy Mary , Butteris Sabrina , Pitt Michael , Anderson Cynthie
Published: September 2017

BACKGROUND:

Simulation Use for Global Away Rotations (SUGAR) is an open source curriculum initially developed by a collaborative of pediatricians to allow residents to experience and debrief common practical and emotional challenges of working in resource-limited settings. The original curriculum included eight pediatric simulation cases with facilitators trained at more than 80 institutions. A multi-disciplinary group was formed to harness the principals of the SUGAR curriculum to provide simulation training for residents in specialties beyond pediatrics.

METHODS:

OB/Gyn collaborators were trained to facilitate SUGAR cases. New OB-Gyn simulation cases were developed, formatted, and piloted with multi-disciplinary groups of residents at our academic institution over a 3-year period.

RESULTS:

Three new OB/Gyn SUGAR cases were developed and piloted with the goal of allowing residents to experience and debrief common medical management and emotional complexities faced in resource-limited settings. The following medical topics are addressed: obstructed labor, postpartum hemorrhage, eclampsia, female genital cutting. The following negative emotional experiences/adaptive characteristics are addressed: frustration/adaptability, floundering/awareness of resources, failure/adjustment and humility. Facilitator and resident feedback is under evaluation. Collaborators agreed that the content would be made available for free for use in global health education on the training website http://sugarprep.org/.

DISCUSSION:

By creating, piloting, and open-sourcing simulation cases in OB/Gyn, the SUGAR curriculum can be expanded to fill a need of global health educators in OB/Gyn. SUGAR simulations hold promise to expand resident preparation for international electives in resource-limited settings.
Enhancing Family Planning Training at a Catholic OBGYN Residency Program
Authors: Fennimore Robin , Guiahi Maryam , Gottesfeld Marshall , Ricciotti Hope
Published: September 2017

OBJECTIVE:

Residents in Catholic hospitals face restrictions in family planning training based on the Ethical and Religious Directives. Our objective was to create a rotation that addresses ACGME competencies in family planning and abortion training for the OBGYN residency program at Saint Joseph Hospital.

METHODS:

In July 2016, a family planning grant was awarded to the OBGYN residency program at Saint Joseph Hospital to create a family planning rotation to improve on-site family planning curricula at Saint Joseph Hospital and provide planned, off-site abortion and contraception training at a family planning clinic affiliated with a nearby academic center. All residents participated in family planning didactic sessions, simulation sessions, and annual values clarification workshop. Residents who participated in the family planning rotation were assigned readings (American College of Obstetricians and Gynecologists publications and journal articles), an e-learning curriculum (LEARN module), and trained in providing contraception and uterine evacuation procedures. Residents who chose to opt-out of performing uterine evacuation procedures were considered partial participators.

EVALUATION:

We will compare pre- and postmean test scores for LEARN modules and median number of family planning procedures before and after the family planning rotation. Participating residents will complete rotation evaluations and comments will be evaluated using thematic codes. Preliminary data suggest residents gain more experience in uterine evacuations and LARC contraception procedures after the rotation.

DISSEMINATION:

Our family planning rotation can serve as a model for other faith-based residency programs to improve training.

REFLECTIVE CRITIQUE:

The family planning rotation provides an opportunity to improve training in our Catholic hospital-based program.
Effect of Time Lapsed on Quality of Surgical Resident Intraoperative Performance Evaluation: A Systematic Review
Authors: Garduno Elizabeth , Swoboda Eva , Kenton Kimberly
Published: September 2017

OBJECTIVE:

Several tools have been developed and validated to assess resident intraoperative performance and to provide formative feedback. The objective of this systematic review is to evaluate the effect of time since the completion of the case on the quality of the feedback gathered by the assessment tool.

DATA SOURCES:

Search English-language studies in PubMed, Cochrane, Science Direct Journals, and Ovid using keywords.

METHODS OF STUDY SELECTION:

Publications selected for review were published in a peer-reviewed journal, described a study involving intraoperative assessment of resident surgical training and reported on the timing of completion. Studies were excluded if they were an abstract or if the subject of study was simulation, medical students or nonsurgical residents. Two reviewers independently appraised the articles to extract relevant data.

RESULTS:

Three hundred sixty-one publications were identified, and three met inclusion criteria addressing the main objective. One study demonstrated that the median time to completion of evaluations was more than 11 days, with a range of 4.5–22 days. Another study demonstrated that elapsed time greater than 6 days threatened the construct validity of the assessment. The final study demonstrated the degree of item-to-item variation and the presence of formative comments were negatively affected when more than 14 days had elapsed.

CONCLUSION:

The amount of time elapsed between the observed operative performance and the performance evaluation can be lengthy and can negatively impact the quality of the data collected. Solutions must be sought to improve the timeliness of feedback to mitigate the impact of the delay.
Using Patient Feedback as a Feedback and Assessment Tool for Medical Students
Authors: Keblawi Hisham A. , Jude David C. , Jude David C. , Ricciotti Hope A.
Published: September 2017

OBJECTIVE:

To improve the quality of feedback and assessment of medical students through a patient satisfaction questionnaire about student performance.

METHODS:

To measure student performance from the patient’s perspective, five items were adopted from the validated Patient Satisfaction Questionnaire from the American Board of Internal Medicine. This was used to assess medical student skills in communication and professionalism, which were rated on a five-point Likert scale. All 3rd-year medical students rotating through the OBGYN clerkship participated in these unsupervised patient feedback encounters. Students then were asked to anonymously respond to a two-item questionnaire on usefulness of the patients’ feedback encounter and whether this process improved feedback that faculty provided to students.

EVALUATION:

This is a survey study; 65% (53 out of 81) of students found the patient feedback encounters helpful and 51% (34 out of 67) thought that the exercise encouraged preceptors to provide useful feedback.

DISSEMINATION:

The goal is to implement this feedback tool locally in the OBGYN Clerkship as well as other clerkships in our institution. The intention is to publish the results in peer-reviewed journal for wider dissemination.

REFLECTIVE CRITIQUE:

Providing feedback and assessment is an essential element of medical education. Feedback to medical students regarding their performance is usually provided by preceptors and standardized patients in simulated encounters. Little attention has been given to feedback provided directly by actual patients. Comments provided by patients have more positive impact compared to numerical rating. Empowering patients to participate in feedback improves the quality of feedback to students.
Cultural Self-Awareness Training in OBGYN Residency
Authors: Lutz Elizabeth , Riley Rachel , Bouldin Sheila , Hueppchen Nancy
Published: September 2017

OBJECTIVE:

Develop and implement a training session for our OBGYN department that expands knowledge of one's own culture and fosters an awareness of the cultures of colleagues.

METHODS:

Needs Assessment including review of the 2014 ACGME Annual Resident Survey, which highlighted need for improved respect in the workplace. This prompted a meeting of the Designated Institutional Officer with the faculty of the OBGYN department regarding improved communication and sensitivity. An extended cultural competency curriculum was suggested from this meeting. Discussions with the institutional Director for Inclusion and Diversity Strategy confirmed that policies of inclusion and diversity are reviewed at new resident orientation; however, there is no further formal training for residents. Focus Group conducted with graduating residents to discuss their experiences during residency regarding issues of respect in the workplace and cultural sensitivity. Developed Framework for curriculum. Workshop conducted to address the specific objectives: Increase knowledge concerning cultural awareness and cultural competency; Identify personal attitudes regarding culturally sensitive issues and biases; Develop skills for addressing culturally sensitive issues.

EVALUATION:

Pre- and posttests developed with the Office of Diversity and Inclusion to assess knowledge, attitudes, and beliefs. Twenty-one residents and faculty attended the workshop. Nineteen of 21 (90%) of participants felt more open to learning of others' cultures and beliefs after this activity, and 18/21 (86%) felt closer to their colleagues after this activity.

DISSEMINATION:

Present to local “Ed Talks” conference, which promotes Educational Scholarship across the institution. Submit to MedEdPortal.

REFLECTIVE CRITIQUE:

The workshop was very well-received by those in attendance.
“The Electronic Preceptor”—Use of Email to Provide Feedback to Students on Their Suturing Compared to Direct Observation and Direct Feedback in Third-Year Medical Students During Their OB/GYN Clerkship
Authors: Sutton Jill M. , Guyton Lisa M. , Hodson Charles , Nelson Keith H. , Learman Lee A.
Published: September 2017

OBJECTIVE:

To assess medical students' preferred method and timing of feedback on suturing skills.

METHODS:

This study was a quasi-experimental study involving 3rd-year medical students on the OB/GYN Clerkship at East Carolina University (IRB approved exempt). Students were preassigned by the clerkship director based on prior subrotation experience to digital feedback (n=32) or direct feedback (n=35) for each cohort. Upon arrival to the clerkship, students receive instruments, suture, and access to the “Duke Suture Skills Course” video. During Simulation Day (Week 3), students received either “Direct Feedback” immediately by a resident colleague or “Digital/Indirect Feedback” from the Clerkship Director via email shortly after the session. Suturing was performed on contraceptive implant model arms. Feedback preferences were assessed using a questionnaire asking students their level of agreement with six statements regarding the effectiveness of the feedback they received (5-point Likert scale ranging from 1=strongly disagree to 5=strongly agree). Mean responses were compared using the Mann Whitney U Test and a statistical significance threshold of P<.05.

RESULTS:

Direct feedback by a resident colleague was superior to indirect/digital feedback by an expert in perceived skill acquisition (4.53 versus 3.60, P<.001), skill correction (4.50 versus 3.71, P<.001) and value to the learner (4.63 versus 4.29, P<.01). Small mean differences in skill confidence, perceived suturing independence, and the quality of the learning environment were not statistically significant.

CONCLUSION:

Immediate feedback may be valued more by medical students learning suturing skills than indirect feedback, but may not promote more skill confidence or independence.
Implementing Patient Satisfaction Surveys to Assess Resident Professionalism and Communication
Authors: Taché Véronique , Wallach Stacey , Kenton Kim
Published: September 2017

OBJECTIVE:

To develop and implement an outpatient patient feedback measure to assess OBGYN resident professionalism and communication.

METHODS:

After obtaining institutional IRB exemption, we used four questions from inpatient Press Ganey survey assessing communication and professionalism (Did your doctor: 1) treat you with courtesy and respect; 2) listen carefully to you; 3) explain things in a way you could understand; and 4) give you time to ask questions) with the answer scale: Never, Rarely, Sometimes, Always. We administered the same questions to OBGYN residents to determine their baseline perception of their patient–physician communication and professionalism skills.

EVALUATION:

This was a longitudinal study, with collection of outpatient OBGYN patient surveys initially over 3 months. After pilot data (n=22) yielded the same answer (Always) for each question, the answer scale was changed (Yes, No, and Unsure). Data from the new questionnaire (n=34) again yielded the same answer (Yes) to each question. Resident answers showed slightly more variation. All residents (n=17) felt they treated patients with courtesy and respect and gave time for questions. Only 1/17 resident felt s/he sometimes did not listen carefully to patient concerns and 5/17 residents felt they had a hard time explaining things in a manner patients would understand.

DISSEMINATION:

This was initiated to create a template that could be used by other residency programs as part of their evaluation system.

REFLECTIVE CRITIQUE:

This is not useful in its current form. I plan to reassess the survey content, process and administration.
Resident Coaching Sessions: A Clinical Faculty Development Program to Provide Actionable and Formative Resident Feedback
Authors: Werkema Michael , Leach Richard , van de Ridder Monica , Leach Richard , Hueppchen Nancy
Published: September 2017

OBJECTIVE:

To develop a formative evaluation instrument that will facilitate mid-rotation feedback. To educate learners and educators on formative feedback in order to facilitate coaching sessions in timely and actionable ways.

METHODS:

A mid-rotation assessment instrument was created within the New Innovations platform. The instrument focuses on EPAs relevant to the rotation, achievement of resident goals, and resident-directed action plans for improvement. It includes feedback elements that can be completed in 5 minutes. Content validity was confirmed through ACGME Milestones and critical assessment from experts in field. Reliability was confirmed through expert consensus obtained through structured interviews. Faculty and resident development sessions were created and delivered to educate on formative feedback and use of instrument. The sessions included a 15 minute presentation and instrument demonstration. Subspecialty rotations were chosen as pilots due to the limited number of faculty and residents.

EVALUATION:

Nineteen residents and six faculty were surveyed prior to implementation on quality of feedback skills. Upon completion of feedback cycles residents and faculty will be resurveyed for comparison.

DISSEMINATION:

The optimized feedback tool will be expanded to every rotation facilitating structured feedback and timely consistent reporting.

REFLECTIVE CRITIQUE:

The implementation of structured feedback training and an assessment tool that formalizes the process can optimize meaningful feedback for learners. Education on formative feedback and instrument use improves efficiency and increases timely and actionable feedback.
Gender Differences in Medical Students' Experience of Burnout, Perceived Stress, and Empathic Concern
Authors: Worly Brett , Verbeck Nicole , Walker Curt , Clinchot Dan , Keder Lisa , Steinauer Jodi
Published: September 2017

OBJECTIVE:

To evaluate the differences in burnout, empathy, and perceived stress between genders in 3rd-year medical students.

METHODS:

This is an IRB-approved, cross-sectional study of 657 3rd-year medical students who attended medical school from 2008 to 2014. Students responded to a Learning Environment Student Survey which included the Maslach Burnout Inventory- Student Scale (MBI-SS), Interpersonal Reactivity Index (IRI), and Perceived Stress Scale (PSS) items. These primary outcomes were compared between gender with independent sample t tests. Secondary outcomes, including the MBI-SS subscales of emotional exhaustion, professional efficacy, and cynicism; IRI subscales of fantasy, perspective taking, and empathic concern; and personal distress were evaluated with equal variances using Levene's Test for Equality of Variances. Multivariate analysis with two-way ANOVA was also performed.

RESULTS:

Females were more likely to have higher (IRI) empathic concern (21.0±3.9 versus 19.1±4.1, P<.001), but reported more (IRI) personal distress (8.9±4.3 versus 7.6±3.8, P<.001), (MBI-SS) emotional exhaustion (15.3±5.8 versus 14.4±5.9, P<.05), and (PSS) perceived stress (17.1±6.2 versus 15.2±6.6, P<.001). Males were more likely to have (MBI-SS) cynicism (8.6±4.9 versus 7.7±4.4, P=.03) and lower (MBI-SS) professional efficacy (11.5±4.9 versus 12.4±4.9, P=.03). No interactions between age, ethnicity, or gender were found on multivariate analysis.

CONCLUSION:

Although male and female 3rd-year medical students experience burnout, empathy, and perceived stress in a statistically different fashion, the measures between the groups were similar. Medical student support program design does not need to be redesigned based on gender.
Teaching the Unteachable: Educating Obstetrics and Gynecology Residents About the Patient Experience of Stillbirth
Authors: Fay Emily , Gravett Michael , Alexander Sarah , Stephenson-Famy Alyssa
Published: September 2017

BACKGROUND:

Annually, approximately 24,000 fetuses in the United States are stillborn, and parents often feel alone in their grief. Obstetric providers may not be adequately trained to manage the medical and emotional aspects of stillbirth; therefore, we implemented a didactic for OB/GYN residents to address this need.

METHODS:

A 2-hour resident didactic including an overview of medical management and a panel of patients and families who had experienced stillbirth was offered in 2013 and 2015. Prior to each session, OB/GYN residents received an electronic 26-question survey about previous training and comfort with caring for patients with stillbirth. Following the didactic, residents were sent a follow-up survey to evaluate and reflect on the content.

RESULTS:

Of 47 residents, 41 responded to the pre-didactic survey (85%). Residents disagreed that the management of stillbirth was adequately covered in medical school (100%) or residency (90%). Forty-one percent agreed that they were unsure of how much personal emotion to express to patients. In qualitative comments following the session, residents felt more comfortable and confident caring for these patients throughout their experience. Residents felt that the session was “incredibly important,” “powerful and memorable,” “hard to attend…so much emotion, so many memories of so many patients.”

DISCUSSION:

Our experience suggests that residents feel unprepared to medically and emotionally care for families with stillbirth. Incorporating a didactic on stillbirth that includes a patient panel can improve resident knowledge and comfort.
Medical Student Attitudes on Abortion Reflect Professionalism: A Qualitative Exploration
Authors: Bartz Deborah , Janiak Elizabeth , Jackson Courtney , Berkowitz Lori , Steinauer Jody , Berkowitz Lori , Steinauer Jody
Published: September 2017

OBJECTIVE:

In medical education we must train learners to be competent in aspects of professionalism. It is challenging to assess an individual’s professionalism. The goal of this study was to examine the extent that medical students' attitudes toward abortion, as captured through vignettes and interviews, reflect their overall general professionalism attitudes.

METHODS:

We conducted qualitative interviews with 4th-year medical students who had applied for ob/gyn residency programs between 2012 and 2014. Semi-structured interviews explored factors that influenced their attitudes toward abortion before medical school, any transition in attitudes that occurred during medical school, and how they perceive abortion to be relevant to their future training and medical practices. Narratives were analyzed for meaningful patterns regarding professionalism tenants as outlined in the Charter for Medical Professionalism based on an analytical approach.

RESULTS:

The final sample included 74 students enrolled in 39 medical schools in 25 states and the District of Columbia. Within-transcript content related to abortion attitudes, three themes emerged. First, students reflected on abortion care as a primacy of patient welfare. Second, students recognized patient autonomy was preserved when abortion was offered as a pregnancy option. Lastly, students advocated that availability of abortion services fell within the preview of social justice to be afforded to their future patients.

CONCLUSION:

The investigation of attitudes toward abortion through a qualitative approached provides an assessment of professionalism tenants in medical students. This finding may inform professionalism curricula that utilize pregnancy options and abortion case-based scenarios to facilitate medical student learning and assessment.
A Communication Curriculum for Obstetrics and Gynecology Residents: Applying the Principles of a “Goals of Care” Conversation
Authors: Bevis Kerri S. , Covarrubias Julie , Barnett Michael , Barnett Michael , Ricciotti Hope
Published: September 2017

OBJECTIVE:

To develop an evidence-based communication training curriculum for obstetrics and gynecology residents using a “goals of care” framework and to develop the tools necessary to evaluate its effectiveness.

METHODS:

Following IRB approval, the baseline assessment examined: experience, comfort, concerns, and perceived barriers with conversations around serious illness; knowledge of communication skills; and a needs assessment. The existing and well-researched Vitaltalk curriculum for communicating in the setting of serious illness was adapted into a series of three 1-hour sessions including case scenarios relevant to Ob/Gyn practice. A postcourse evaluation assessed: self-reported comfort (retrospective) pre- and postintervention, knowledge of specific communication skills, and concerns and barriers regarding serious conversations. The curriculum and assessment tools were piloted in PGY-4 Ob/Gyn residents.

EVALUATION:

Eight PGY-4 residents participated in the pilot curriculum. All participants reported didactic training on delivering difficult news during medical school (1–10 hours). Thirty-eight percent of respondents reported ANY communication skills training in residency. Residents had poor baseline knowledge of communication skills (45% correct). Responding to patient emotion, addressing patient requests for unindicated treatment, and eliciting patient concerns about death and dying were the areas of greatest discomfort. Most (80%) participants found the training to be important to their development as an obstetrician/gynecologist.

DISSEMINATION:

Curricular materials and results of the pilot data will be submitted for publication on MedEdPORTAL.

REFLECTIVE CRITIQUE:

The value of a pilot study cannot be overstated. Moving forward, I will re-structure the didactic sessions, will not organize sessions by PGY class, and will streamline the assessment tools.
Multimodality Neuromonitoring in Adult Traumatic Brain Injury
Authors: Smith Martin
Published: September 2017

Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
Anesthesia with Dexmedetomidine and Low-dose Isoflurane Increases Solute Transport via the Glymphatic Pathway in Rat Brain When Compared with High-dose Isoflurane
Authors: Benveniste Helene , Lee Hedok , Ding Fengfei , Sun Qian , Al-Bizri Ehab , Makaryus Rany , Probst Stephen , Nedergaard Maiken , Stein Elliot A. , Lu Hanbing
Published: September 2017

Background

The glymphatic pathway transports cerebrospinal fluid through the brain, thereby facilitating waste removal. A unique aspect of this pathway is that its function depends on the state of consciousness of the brain and is associated with norepinephrine activity. A current view is that all anesthetics will increase glymphatic transport by inducing unconsciousness. This view implies that the effect of anesthetics on glymphatic transport should be independent of their mechanism of action, as long as they induce unconsciousness. We tested this hypothesis by comparing the supplementary effect of dexmedetomidine, which lowers norepinephrine, with isoflurane only, which does not.

Methods

Female rats were anesthetized with either isoflurane (N = 8) or dexmedetomidine plus low-dose isoflurane (N = 8). Physiologic parameters were recorded continuously. Glymphatic transport was quantified by contrast-enhanced magnetic resonance imaging. Cerebrospinal fluid and gray and white matter volumes were quantified from T1 maps, and blood vessel diameters were extracted from time-of-flight magnetic resonance angiograms. Electroencephalograms were recorded in separate groups of rats.

Results

Glymphatic transport was enhanced by 32% in rats anesthetized with dexmedetomidine plus low-dose isoflurane when compared with isoflurane. In the hippocampus, glymphatic clearance was sixfold more efficient during dexmedetomidine plus low-dose isoflurane anesthesia when compared with isoflurane. The respiratory and blood gas status was comparable in rats anesthetized with the two different anesthesia regimens. In the dexmedetomidine plus low-dose isoflurane rats, spindle oscillations (9 to 15 Hz) could be observed but not in isoflurane anesthetized rats.

Conclusions

We propose that anesthetics affect the glymphatic pathway transport not simply by inducing unconsciousness but also by additional mechanisms, one of which is the repression of norepinephrine release.
Mindfulness-Based Cognitive Therapy for Chronic Tinnitus: Evaluation of Benefits in a Large Sample of Patients Attending a Tinnitus Clinic
Authors: McKenna Laurence , Marks Elizabeth M. , Vogt Florian
Published: September 2017

Objectives:

Mindfulness-based approaches may benefit patients with chronic tinnitus, but most evidence is from small studies of nonstandardized interventions, and there is little exploration of the processes of change. This study describes the impact of mindfulness-based cognitive therapy (MBCT) in a “real world” tinnitus clinic, using standardized MBCT on the largest sample of patients with chronic tinnitus to date while exploring predictors of change.

Design:

Participants were 182 adults with chronic and distressing tinnitus who completed an 8-week MBCT group. Measures of tinnitus-related distress, psychological distress, tinnitus acceptance, and mindfulness were taken preintervention, postintervention, and at 6-week follow-up.

Results:

MBCT was associated with significant improvements on all outcome measures. Postintervention, reliable improvements were detected in tinnitus-related distress in 50% and in psychological distress in 41.2% of patients. Changes in mindfulness and tinnitus acceptance explained unique variance in tinnitus-related and psychological distress postintervention.

Conclusions:

MBCT was associated with significant and reliable improvements in patients with chronic, distressing tinnitus. Changes were associated with increases in tinnitus acceptance and dispositional mindfulness. This study doubles the combined sample size of all previously published studies. Randomized controlled trials of standardized MBCT protocols are now required to test whether MBCT might offer a new and effective treatment for chronic tinnitus.
Binaural Pitch Fusion in Bilateral Cochlear Implant Users
Authors: Reiss Lina A. J. , Fowler Jennifer R. , Hartling Curtis L. , Oh Yonghee
Published: September 2017

Objectives:

Binaural pitch fusion is the fusion of stimuli that evoke different pitches between the ears into a single auditory image. Individuals who use hearing aids or bimodal cochlear implants (CIs) experience abnormally broad binaural pitch fusion, such that sounds differing in pitch by as much as 3–4 octaves are fused across ears, leading to spectral averaging and speech perception interference. The goal of this study was to determine if adult bilateral CI users also experience broad binaural pitch fusion.

Design:

Stimuli were pulse trains delivered to individual electrodes. Fusion ranges were measured using simultaneous, dichotic presentation of reference and comparison stimuli in opposite ears, and varying the comparison stimulus to find the range that fused with the reference stimulus.

Results:

Bilateral CI listeners had binaural pitch fusion ranges varying from 0 to 12 mm (average 6.1 ± 3.9 mm), where 12 mm indicates fusion over all electrodes in the array. No significant correlations of fusion range were observed with any subject factors related to age, hearing loss history, or hearing device history, or with any electrode factors including interaural electrode pitch mismatch, pitch match bandwidth, or within-ear electrode discrimination abilities.

Conclusions:

Bilateral CI listeners have abnormally broad fusion, similar to hearing aid and bimodal CI listeners. This broad fusion may explain the variability of binaural benefits for speech perception in quiet and in noise in bilateral CI users.
Rheumatoid arthritis and citrullination
Authors: Darrah Erika , Andrade Felipe
Published: September 2017

Purpose of review

Dysregulated citrullination is a key element that drives the production and maintenance of antibodies to citrullinated proteins, a hallmark in rheumatoid arthritis (RA). This article reviews recent literature on the origin of citrullinated antigens in RA.

Recent findings

The study of synovial fluid from patients with RA has provided important insights into the identity of citrullinated proteins that accumulate in the RA joint (the RA citrullinome) and mechanisms that control their generation.

Citrullinating enzymes (peptidylarginine deiminases, PADs) are tightly controlled to limit their hyperactivation. Calcium and redox conditions are important regulators of PAD activity. Studies suggest that citrullination is dysregulated both intra- and extracellularly in RA. In neutrophils, host (i.e., perforin and the membrane attack complex) and bacterial (i.e., toxins) pore-forming proteins induce prominent calcium influx, cytolysis, and hyperactivation of PADs. These factors likely drive hypercitrullination in the RA joint and at extraarticular sites of disease initiation, respectively. As oxidizing conditions present in the extracellular environment are known to inactivate PADs, extracellular citrullination in RA probably requires the constant release of active enzymes from dying cells and may be accelerated by autoantibodies that activate PADs.
Is “Early Total Care” a Safe and Effective Alternative to “Staged Protocol” for the Treatment of Schatzker IV–VI Tibial Plateau Fractures in Patients Older Than 50 Years?
Authors: Borade Amrut , Kempegowda Harish , Richard Raveesh , Graham Jove , Suk Michael , Horwitz Daniel S.
Published: September 2017

Objectives:

To compare “Early Total Care” (ETC) with “Staged Protocol” (SP) for the treatment of Schatzker IV–VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness.

Design:

Retrospective cohort study.

Setting:

An academic level 1 US trauma center.

Patients/Participants:

Eighty-one patients older than 50 years with Schatzker grade IV–VI tibial plateau fractures were included.

Intervention:

Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation.

Main Outcome Measurements:

Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures.

Results:

The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures.

Conclusion:

ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV–VI fractures in patients older than 50 years.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.