Faculty Bibliography

STUDY OBJECTIVE:The purpose of the research was to both develop a vaginal hysterectomy model with surgically pertinent anatomic landmarks and assess its validity for simulation training. DESIGN:A low-cost, reproducible vaginal hysterectomy model with relevant anatomic landmarks for key surgical steps. SETTING:Nine academic and community-based obstetrics and gynecology residency programs. PARTICIPANTS:One hundred sixty-nine obstetrics and gynecology residents. INTERVENTIONS:A vaginal hysterectomy model with surgically pertinent anatomic landmarks was developed and tested for construct validity. MEASUREMENTS AND MAIN RESULTS:Of the 184 available residents, 169 (91%) participated in this study and performed a vaginal hysterectomy procedure on the described model. The validated objective 7-item global rating scale (GRS) and the 13-item task-specific checklist (TSC) were used as tools to assess performance. The median TSC and GRS scores correlated with year of training, prior experience, and trainee confidence. In addition, the TSC scores also correlated with the GRS scores (p <.001) with regard to performance and resident year of training. Receiver Operator Curves for identification of the residents meeting national residency accreditation minimum numbers for vaginal hysterectomy using the GRS and TSC scores had an area under the curve of 0.89 and 0.83, respectively. CONCLUSION:This reduced-cost vaginal hysterectomy model offers high construct validity and pertinence for simulation.

BACKGROUND:Residency applications have increased in the last decade, creating growing challenges for applicants and programs. OBJECTIVE:We evaluated factors associated with application and match into obstetrics and gynecology residency. METHODS:During the annual in-training examination administered to all obstetrics and gynecology residents in the United States, residents were surveyed on the residency application process. RESULTS:< .001). In choosing where to apply, residents identified program location and reputation as the most important factors, while for ranking, location and residency culture were the most important. CONCLUSIONS:Most obstetrics and gynecology residents reported matching into their top 5 choices. Receiving an honors grade in the clerkship was the only factor associated with matching in applicants' top 5 programs. Location was the most important factor for applying to and ranking of programs.

BACKGROUND:This study evaluated treatment patterns among women diagnosed with symptomatic uterine fibroids (UF) in the United States. Data were retrospectively extracted from the IBM Watson Health MarketScan® Commercial Claims and Encounters and Medicaid Multi-State databases. METHODS:Women aged 18-64 years with ≥1 medical claim with a UF diagnosis (primary position, or secondary position plus ≥1 associated symptom) from January 2010 to June 2015 (Commercial) and January 2009 to December 2014 (Medicaid) were eligible; the first UF claim during these time periods was designated the index date. Data collected 12 months pre- and 12 and 60 months post-diagnosis included clinical/demographic characteristics, pharmacologic/surgical treatments, and surgical complications. Prevalence (2015) and cumulative incidence (Commercial, 2010-2015; Medicaid, 2009-2015) of symptomatic UF were estimated. RESULTS:225,737 (Commercial) and 19,062 (Medicaid) women had a minimum of 12 months post-index continuous enrollment and were eligible for study. Symptomatic UF prevalence and cumulative incidence were: 0.57, 1.23% (Commercial) and 0.46, 0.64% (Medicaid). Initial treatments within 12 months post-diagnosis were surgical (Commercial, 36.7%; Medicaid, 28.7%), pharmacologic (31.7%; 53.0%), or none (31.6%; 18.3%). Pharmacologic treatments were most commonly non-steroidal anti-inflammatory drugs and oral contraceptives; hysterectomy was the most common surgical treatment. Of procedures of abdominal hysterectomy, abdominal myomectomy, uterine artery embolization, and ablation in the first 12 months post-index, 14.9% (Commercial) and 24.9% (Medicaid) resulted in a treatment-associated complication. Abdominal hysterectomy had the highest complication rates (Commercial, 18.5%; Medicaid, 31.0%). CONCLUSIONS:Off-label use of pharmacologic therapies and hysterectomy for treatment of symptomatic UF suggests a need for indicated non-invasive treatments for symptomatic UF.

INTRODUCTION/BACKGROUND:Simulation-based training to manage surgical postpartum hemorrhage allows for improved preparation for these rarely needed life-saving procedures. Our objectives were to design a low-tech simulation model for use in training and evaluation of surgical techniques for the management of postpartum hemorrhage and to present evidence of its validity in assessment and training. METHODS:Fifty-two obstetrics and gynecology residents and 25 attending physicians from an academic hospital were video recorded while performing the O'Leary and B-Lynch techniques on the low-tech model. Performance was evaluated using a Technical Skills Checklist, for B-Lynch and O'Leary techniques, and the Reznick's Global Rating Scale. Interrater reliability was computed to assess the consistency of the ratings between 2 raters. Average scores were determined and compared between incoming residents, junior residents, senior residents, and attending physicians to show construct validity. RESULTS:For the B-Lynch, Technical Skills Checklist scores (maximum 17 points) of attendings (15.04) and senior residents (15.12) were higher than those of junior residents (5.63) and new residents (3.38). Global Rating Scale scores (maximum 25 points) on the B-Lynch reflected the same increase (22.38, 19.35 vs. 8.85, 6.75, respectively). For the O'Leary stitch, the scores of attendings, senior, junior, and incoming residents were as follows: 15.20, 13.65, 11.54, and 2.83, respectively (maximum 19 points). This supports the construct validity of the model. The model was considered realistic and useful for improving surgical skills in 71.4% of participants. CONCLUSIONS:This low-cost, easily constructed model is a useful tool for training these surgical skills.

OBJECTIVE:To assess self-reported readiness of U.S. obstetrics and gynecology residents to perform surgical procedures compared with the perceptions of their program directors. METHODS:The 2019 Council on Resident Education in Obstetrics and Gynecology Survey assessed resident self-confidence and perceived readiness to independently perform common surgical procedures. Concurrently, obstetrics and gynecology residency program directors were surveyed about the readiness of their graduating residents to independently perform the same procedures. RESULTS:The overall response rate was 99.3% for residents (5,473/5,514 examinees attempted to complete the survey) and 83% for program directors (241/292 returned surveys). There were no significant differences in graduating residents and program directors' assessments of graduating residents' surgical confidence in performing cesarean delivery (99.6% [95% CI 98.9-99.9] vs 100% [95% CI 98.2-100.0]), vacuum delivery (96.5% [95% CI 95.2-97.4] vs 98.6% [95% CI 95.9-99.7]), abdominal hysterectomy (95.1% [95% CI 93.6-96.2] vs 96.7% [95% CI 93.3-98.7]) or operative hysteroscopy (99.5% [95% CI 98.9-99.9] vs 100% [95% CI 98.2-100.0]). Ninety percent, 86%, and 69% of graduating residents felt that they could independently perform an abdominal hysterectomy, laparoscopic hysterectomy, and vaginal hysterectomy, respectively, in the event of an emergency. Ninety-seven percent (95% CI 93.3-98.7) of program directors reported their residents could perform a laparoscopic hysterectomy by graduation, as did 93% of graduating resident respondents (95% CI 90.8-94.0). Ninety percent (95% CI 85.3-93.8) of program directors felt their residents could perform vaginal hysterectomies by graduation, compared with 79% (95% CI 76.9-81.8) of fourth-year residents. CONCLUSION:Graduating obstetrics and gynecology residents and their program directors are confident in their abilities to perform the majority of core surgical procedures by graduation. By the second year, more than 90% of residents and their program directors were confident in their ability to perform cesarean deliveries and operative hysteroscopy. Sixty-nine percent and 86% of graduating residents felt comfortable performing vaginal and laparoscopic hysterectomies, respectively.

OBJECTIVE:To establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems. METHODS:A prospective cohort study was IRB approved and conducted at 15 sites in the United States and Canada. The four participant cohorts based on training status were: 1) novice (postgraduate year [PGY]-1) residents, 2) mid-level (PGY-3) residents, 3) proficient (American Board of Obstetrics and Gynecology [ABOG]-certified specialists without subspecialty training); and 4) expert (ABOG-certified obstetrician-gynecologists who had completed a 2-year fellowship in minimally invasive gynecologic surgery). Qualified participants were oriented to both systems, followed by testing with five laparoscopic exercises (L-1, sleeve-peg transfer; L-2, pattern cut; L-3, extracorporeal tie; L-4, intracorporeal tie; L-5, running suture) and two hysteroscopic exercises (H-1, targeting; H-2, polyp removal). Measured outcomes included accuracy and exercise times, including incompletion rates. RESULTS:Of 227 participants, 77 were novice, 70 were mid-level, 33 were proficient, and 47 were experts. Exercise times, in seconds (±SD), for novice compared with mid-level participants for the seven exercises were as follows, and all were significant (P<.05): L-1, 256 (±59) vs 187 (±45); L-2, 274 (±38) vs 232 (±55); L-3, 344 (±101) vs 284 (±107); L-4, 481 (±126) vs 376 (±141); L-5, 494 (±106) vs 420 (±100); H-1, 176 (±56) vs 141 (±48); and H-2, 200 (±96) vs 150 (±37). Incompletion rates were highest in the novice cohort and lowest in the expert group. Exercise errors were significantly less and accuracy was greater in the expert group compared with all other groups. CONCLUSION/CONCLUSIONS:Validity evidence was established for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems by distinguishing PGY-1 from PGY-3 trainees and proficient from expert gynecologic surgeons.

OBJECTIVE:To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs. DESIGN/METHODS:Cross-sectional survey. SETTING/METHODS:Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States. PARTICIPANTS/METHODS:Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents. RESULTS:Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently. CONCLUSIONS:Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.

OBJECTIVE:To characterize trends in self-reported numbers and routes of hysterectomy for obstetrics and gynecology residents using the Accreditation Council for Graduate Medical Education (ACGME) case log database. METHODS:Hysterectomy case log data for obstetrics and gynecology residents completing training between 2002-2003 and 2017-2018 were abstracted from the ACGME database. Total numbers of hysterectomies and modes of approach (abdominal, laparoscopic, and vaginal) were compared using bivariate statistics, and trends over time were analyzed using simple linear regression. RESULTS:Hysterectomy data were collected from 18,982 obstetrics and gynecology residents in a median of 243 (interquartile range 241-246) ACGME-accredited programs. The number of graduating residents increased significantly over time (12.1/year, P<.001), whereas the number of residency programs decreased significantly (0.52 fewer programs per year, P<.001) over the 16-year period. For cases logged as "surgeon," the median number of abdominal hysterectomies decreased by 56.5% from 85 (interquartile range 69-102) to 37 (interquartile range 34-43) (P<.001). The median number of vaginal hysterectomies decreased by 35.5% from 31 (interquartile range 24-39) to 20 (interquartile range 17-25) (P=.002). The median total number of hysterectomies per resident decreased by 6.3% from 112 (interquartile range 97-132) to 105 (interquartile range 92-121) (P=.036). In contrast, the median number of laparoscopic hysterectomies increased by 115% from 20 (interquartile range 13-28) in 2008-2009 to 43 (interquartile range 32-56) in 2017-2018, despite the decrease in overall number of hysterectomies (P<.001). These trends were statistically significant. CONCLUSIONS:The total number of hysterectomies performed by obstetrics and gynecology residents in the United States is decreasing, and the routes are changing with decreases in abdominal and vaginal approaches, and an increase in use of laparoscopic hysterectomy.