Faculty Bibliography

OBJECTIVE:Surgical clerkships frequently include oral exams to assess students' ability to critically analyze data and utilize clinical judgment during common scenarios. Limited guidance exists for the interpretation of oral exam score validity, thus making improvements difficult to target. We examined the development, administration, and scoring of a clerkship oral exam from a validity evidence framework. DESIGN/METHODS:This was a retrospective study of a third-year, end-of-clerkship oral exam in obstetrics and gynecology (OBGYN). Content, response process, internal structure, and relationship to other variables validity evidence was collected and evaluated for 5 versions of the oral exam. SETTING/METHODS:Albert Einstein College of Medicine, Bronx, New York City. PARTICIPANTS/METHODS:Participants were 186 third-year medical students who completed the OBGYN clerkship in the academic year 2020 to 2021. RESULTS:The average number of objectives assessed per oral exam version were uniform, but the distribution of questions per Bloom's level of cognition was uneven. Student scores on all questions regardless of Bloom's level of cognition were >87%, and reliability (Cronbach's alpha) of item scores varied from 0.58 to 0.74. There was a moderate, positive correlation (Spearman's rho) between the oral exam scores and national shelf exam scores (0.35). There were low correlations between oral exam scores and (a) clinical performance ratings (0.14) and (b) formal presentation scores (-0.19). CONCLUSIONS:This study provides an example of how to examine the validity of oral exam scores for targeted improvements. Further modifications are needed before using scores for high stakes decisions. The authors provide recommendations for additional sources of validity evidence to collect in order to better meet the goals of any surgical clerkship oral exam.

Background: Excision of multi-compartment deep infiltrating endometriosis with visceral involvement is challenging. We illustrate an interdisciplinary approach to complete minimally invasive excision in a single surgery. Case: We present a case of deep infiltrating endometriosis with visceral involvement in the anterior, middle, and posterior compartments. A collaborative surgical approach was taken with gynecologic, colorectal, and urologic surgeons to perform a robot-assisted total laparoscopic hysterectomy, bilateral salpingectomy, ovarian cystectomy, and unilateral oophorectomy with concurrent segmental resection of rectosigmoid and excision of transmural bladder and vaginal nodules. Conclusion: Thorough preoperative evaluation and an interdisciplinary approach to surgical planning involving radiology, gynecology, colorectal surgery, and urology allowed for complete simultaneous resection of bladder, rectosigmoid, and pelvic deep infiltrating endometriosis without complications via a minimally invasive route.

INTRODUCTION/BACKGROUND:Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. MATERIAL AND METHODS/METHODS:In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. RESULTS:A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route. CONCLUSIONS:Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.

Objectives: The use of power morcellation has been restricted in many centers due to concerns for inadvertent spread of an undiagnosed leiomyosarcoma. Our institution implemented a preoperative protocol to avoid power morcellation in high risk cases. In this retrospective cohort study, we report the impact of this protocol on institutional surgical practice patterns, and the influence of MRI and LDH results on surgical route.
Material(s) and Method(s): An institutional protocol requiring preoperative MRI with diffusion-weighted imaging and serum LDH levels was implemented on 4/23/2014 at a single academic hospital. A retrospective chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. Statistical analyses included univariate comparisons between the cohorts pre- and post-protocol, as well as overall adherence to protocol, trends in surgical patterns, and incidence of uterine pathology.
Result(s): A total of 1085 patients were included, 479 before and 606 after implementation of the MRI/LDH protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p=0.022) and women using tamoxifen (2% vs. 0%, p=0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of minimally invasive surgery (MIS) for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (81% vs. 84% and 90% vs. 91%, respectively). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags when specimens were removed abdominally (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of patients who had abnormal MRI and LDH results, abnormal MRI results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal MRI and LDH tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal LDH results alone did not influence route.
Conclusion(s): Though earlier studies have suggested an overall decrease in minimally invasive hysterectomies in response to the FDA warning on power morcellation, there was no change in rates of minimally invasive hysterectomies and myomectomies at our institution during a similar time period. Changes in surgical techniques, such as decreased use of power morcellation and increased use of contained tissue extraction, were seen. Decreased rates of MIS were seen for patients with abnormal preoperative MRI.
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Objective: Surgery for leiomyomas is common; yet, no reliable test can help distinguish a benign leiomyoma and malignant leiomyosarcoma (LMS).
Material(s) and Method(s): This retrospective observational cohort study evaluated patients before and after implementation of a protocol to identify LMS, which included magnetic resonance imaging (MRI) with diffusion-weighted imaging.
Result(s): This study revealed the incidence of uterine pathology, as well as MRI, lactate dehydrogenase (LDH), and pathology results, in 1085 patients - 479 before and 606 after implementation of the protocol. Two cases of LMS were identified in the postprotocol cohort, and 70% of the patients underwent MRI. Test statistics for MRI to detect LMS in this cohort were: sensitivity of 100%; specificity of 67%; positive predictive value of 1%; negative predictive value of 100%; false-positive rate of 33%; and false-negative rate of 0%. For patients with both MRI and LDH results (358/606, 59%), 56.7% had normal MRI and LDH, 9.8% had negative MRI but high LDH, 6.4% had abnormal MRI and high LDH, and 27.1% had abnormal MRI and normal LDH.
Conclusion(s): Preoperative MRI for detecting LMS had high a sensitivity and a high false-positive rate, which warrants caution in interpreting MRI results, particularly in women of childbearing age.

OBJECTIVES:The use of simulation-based education to train surgeons is widely accepted. Although many authors describe the use of an Objective Skills Assessment Test (OSAT) to assess performance of various surgical procedures, there is a paucity of research on use of this modality to evaluate vaginal surgery skills. We created a vaginal hysterectomy procedure-specific checklist (PSC) to complete the OSAT (which is composed of a PSC and a global rating scale [GRS]). The primary objective of this study is to evaluate the performance of a novel evaluation strategy for vaginal hysterectomy using an OSAT combining PSC and GRS. METHODS:This is a descriptive prospective study from a single institution. After orientation to the model, participants were filmed performing vaginal hysterectomy. A blinded grader scored each subject using the PSC and GRS. RESULTS:Medical students, residents, fellows, and attendings performed vaginal hysterectomy on a simulated model. Mean PSC and GRS scores increased significantly with surgeon level of experience (P < 0.001). Procedure-specific checklist scores significantly correlated with GRS scores (P < 0.001). CONCLUSIONS:The vaginal hysterectomy model and PSC have been studied across different surgeon levels using OSATs. Training programs should consider using this low-cost task trainer as a teaching tool.

OBJECTIVE:To evaluate the impact of a simulation-based elective on medical student preparedness for obstetrics and gynecology (OB/GYN) residency. METHODS:A two-week, simulation-based elective course for post-clerkship medical students was developed, and 10 students participated at a single academic institution in 2016 and 2017. Using standardized patients and team-based training, students practiced procedural and surgical skills, as well as the diagnosis, management, and work-up of commonly seen problems. Close coaching with a low student-faculty ratio was employed for each session, allowing for individualized feedback in real time. Prior to and after completing the elective, student knowledge was evaluated using the Preparation for Residency Knowledge Assessment tool (PrepForRes). Written course evaluations were also completed by students at the end of the course. RESULTS:Mean scores on the PrepForRes exam increased from 63.6% to 75.3% (p=0.0136). Notably, the average post-course score improved to a passing level, and all but one student achieved a passing score on the post-course test. Course evaluations and student feedback showed high satisfaction rates with the course. CONCLUSIONS:This study demonstrates that a simulation-based elective course is an effective tool for helping medical students transition to OB/GYN residency. As medical schools work to facilitate the transition from undergraduate to graduate medical education, simulation can bridge gaps during this transition in order for students to meet entry-level residency requirements.

Resident physicians' scores on the REI section of the CREOG exam are traditionally low, and nearly 40% of house staff nation-wide perceive their REI knowledge to be poor. We aimed to assess whether an interactive case-based group-learning curriculum would narrow the REI knowledge gap by improving understanding and retention of core REI concepts under the time constraints affecting residents. A three-hour case-based workshop was developed to address four primary CREOG objectives. A multiple-choice test was administered immediately before and after the intervention and 7 weeks post-workshop, to evaluate both knowledge and confidence. Following the intervention, residents self-reported increased confidence with counseling and treatment of PCOS, ovulation induction cycle monitoring, counseling and treatment of POI, and breaking bad news related to infertility (p < 0.05). The multiple-choice exam was re-administered 7 weeks post-intervention, and scores remained significantly improved compared to pre-workshop scores (p < 0.05). At that time, all residents either strongly agreed (91.7%) or agreed (8.3%) that the case-based interactive format was preferable to traditional lecture-based teaching. In conclusion, a nontraditional curriculum aimed at teaching core REI concepts to residents through interactive case-based learning can be successfully integrated into a residency curriculum, and significantly improves knowledge and confidence of critical concepts in REI.

Objectives: There is general consensus in the surgical community that task and virtual reality trainers, as well as surgical skills labs should be utilized before trainees embark on live surgery (1-4). The objective skills assessment test (OSAT) for assessing resident skills is used as a modality to objectively assess residents' performance, and more recently has been used as a way to troubleshoot skill deficits.[5-9]While a vaginal hysterectomymodel has been developed by Greer and colleagues (10), validation for construct validity using OSATs has not yet been established. Our primary aim was to use OSATs and GRS checklists to assess the construct validity of the vaginal hysterectomy task trainer as a teaching tool. We sought to assess learners of all levels to comprehensively analyze the validity of the task trainer. Methods: All 3rd and 4th year medical students, OB/GYN residents, Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows, FPMRS attendings and OB/GYN attendings at our institution received an email invitation to participate in the study. Subjects first took a non-validated pre-test assessing overall general knowledge of performing vaginal hysterectomy. They were then oriented to the model and watched a video demonstrating how to complete a vaginal hysterectomy on the task trainer before performing the task. This assessment was videotaped and a blinded grader graded each subject using OSATS and GRS checklists. Total time to accomplish the task was also recorded. The primary outcome of our study was GRS/OSAT scores for each participant. We also looked at surgical performance time and pre-test scores as secondary outcomes. Results: We recruited 14 medical students, 15 residents, 3 FPMRS fellows, 11 generalist gynecology attendings and 3 FPMRS attendings. Mean GRS and OSAT scores did significantly improve with surgeon level (p<0.001) (Table 1). When comparing students versus residents versus all others the scores improved significantly according to surgical experience (p<0.001) (Table 1). In general, mean time to completion was not significantly different between the groups, however when comparing students and residents versus all others there was a significant improvement in mean time to complete the task (33.7 versus 27.5 minutes respectively) (Table 1). Lastly, mean pre-test scores did improve with level of experience (p=0.05). Conclusions: The vaginal hysterectomymodel can be validated across surgeon level using both general (GRS) and surgery specific (OSAT skills) assessment tools. Using this low cost task trainer as an educational intervention should be considered by training programs for teaching vaginal hysterectomy