Faculty Bibliography

Simulation in obstetrics and gynecology (OBGYN) training captures a range of interpersonal, cognitive, and technical skills. However, trainee perspectives on simulation-based assessment remain unexplored. After an observed structured clinical examination (OSCE) simulation hybrid exam, two focus groups of residents were conducted. Analysis grounded in a thematic coding guided the qualitative research process. Responses suggest a valuation of cognitive and technical skills over interpersonal skills. Realism was seen as critical and residents perceived the assessment as more valuable for the educator than the learner. Feedback was highly valued. Resident perspectives on this exam give insight into their perceptions of simulation-based assessment as well as their conceptions of their own learning through simulations.

Objectives: In order to develop effective teaching methods for contraceptive education, researchers require a validated, reliable tool to measure subjects' contraceptive knowledge. However, most widely used indices are outdated and no longer useful. The objective of this study was to create and assess the validity and reliability of a novel assessment tool for measuring contraceptive knowledge. Method: The study tool was validated using both qualitative and quantitative methods. The tool was developed by the research team and then reviewed by a selected group of experts. Participants for testing the tool included English-speaking men and women ages 15- 45 at a single institution. Structured interviews were conducted with a randomly selected group of patients for qualitative feedback regarding the readability and ease of administration and the study tool was adapted accordingly. Quantitative tests included (1) comparison with a gold standard; (2) test-retest reliability; (3) comparison between a group with low contraceptive knowledge and a group with high contraceptive knowledge. Results: Qualitative feedback was obtained on the 25-question knowledge assessment tool from 6 experts and 7 patients. The study tool was administered to a total of 102 patients, with a mean score of 9.0. In comparison with the gold standard, the mean score was significantly higher (new tool 9.1 vs. gold standard 5.8, p<0.001). Test-retest reliability was demonstrated via repeat testing within 2- 4 weeks, demonstrating no difference between test and retest in the same subjects (p=0.667). When compared to medical students, patients' mean scores were significantly lower as expected (patients 9.1 vs. medical students 19.4, p<0.005). Conclusions: We have designed a valid and reliable study tool to measure a person's level of knowledge regarding contraception. This tool will allow the assessment of baseline knowledge, educational gaps, and post-educational knowledge achievements after an intervention

BACKGROUND: Assessment of obstetrics-gynecology residents' ability to integrate clinical judgment, interpersonal skills, and technical ability in a uniform fashion is required to document achievement of benchmarks of competency. An observed structured clinical examination that incorporates simulation and bench models uses direct observation of performance to generate formative feedback and standardized evaluation. METHODS: The Test of Integrated Professional Skills (TIPS) is a 5-station performance-based assessment that uses standardized patients and complex scenarios involving ultrasonography, procedural skills, and evidence-based medicine. Standardized patients and faculty rated residents by using behaviorally anchored checklists. Mean scores reflecting performance in TIPS were compared across competency domains and by developmental level (using analysis of variance) and then compared to standard faculty clinical evaluations (using Spearman rho). Participating faculty and residents were also asked to evaluate the usefulness of the TIPS. RESULTS: Twenty-four residents participated in the TIPS. Checklist items used to assess competency were sufficiently reliable, with Cronbach alpha estimates from 0.69 to 0.82. Performance improved with level of training, with wide variation in performance. Standard faculty evaluations did not correlate with TIPS performance. Several residents who were rated as average or above average by faculty performed poorly on the TIPS (> 1 SD below the mean). Both faculty and residents found the TIPS format useful, providing meaningful evaluation and opportunity for feedback. CONCLUSIONS: A simulation-based observed structured clinical examination facilitates observation of a range of skills, including competencies that are difficult to observe and measure in a standardized way. Debriefing with faculty provides an important interface for identification of performance gaps and individualization of learning plans.

BACKGROUND: Ovarian vein thrombophlebitis is commonly considered to be a postpartum or postoperative disease. We describe an unusual case of ovarian vein thrombophlebitis in a nonpuerperal patient without recent surgery that was associated with venous compression by a large uterine myoma. CASE: A 32-year-old nulligravid woman presented with fever, leukocytosis, and severe abdominal pain. Ultrasound demonstrated an enlarged uterus measuring 16.6x7.9x9.6 cm with a dominant left exophytic myoma; computed tomography scan revealed an intraluminal thrombus in the left ovarian vein. The patient recovered with antibiotics and anticoagulation. Abdominal myomectomy was performed to remove the structural contributor for thrombosis formation. CONCLUSION: Ovarian vein thrombophlebitis should be considered in patients with abdominal pain, fever, and evidence of venous stasis, even if they are lacking typical risk factors of pregnancy or surgery.

Objectives: To evaluate the effect of a pelvic model simulation on performance of sacrospinous ligament fixation (SSLF) and to develop and validate a reliable Objective Structured Assessment of Technical Skills (OSATS) to measure the necessary surgical skills to perform SSLF. Methods: After developing a pelvic model for SSLF, we enrolled OB/GYN residents as well as experts who routinely perform the procedure. Baseline resident knowledge on SSLF was evaluated using a written test. All residents underwent a didactic session pertinent to SSLF and were then randomized to simulation training vs. no training. During the simulation, participants were taught to perform the procedure in a systematic fashion on a pelvic model that permitted the trainees to visualize spatial relationships and understand the procedure in a 3-dimensional space. All residents were then evaluated using a modified OSATS which consisted of a global rating scale (GRS) to examine performance during the entire testing process and a task-specific checklist (TSC). The GRS was comprised of 5 domains related to surgical performance graded on a 5-point scale from 1 to 5 (poor to excellent performance). The TSC consisted of an 8 item surgical check list and was graded on a 3-point scale from 0-2. Two blinded experienced independent raters used the OSATS scale for SSLF to evaluate each individual performance. After completion, knowledge was reassessed using a written post-test and participants were asked to evaluate the training session. Construct validity was measured by comparing OSATS scores between experts and trainees. Data collected included year of residency and self-reported number of prior procedures. Written test scores (paired t- test) and OSATS scores (Wilcoxon signed rank test) between the groups were compared. A p-value < 0.05 was considered significant. Results: The trainee group consisted of 20 residents, 11 of whom underwent simulation training and 9 who did not. 4 subjects were included in the expert group (3 urologists and 1 gynecologist). After simulation, OSATS mean total GRS scores (18.4+/-0.9 vs. 11.1+/-0.5, p=0.0005) and mean total TSC scores (12.6+/-1.4 vs. 6.1+/-0.6, p=0.0003) were significantly better for the simulation group vs. the traditional learning group. Mean time required to complete the procedure was also significantly different between the two resident groups (p=.0006). Results were still significant when adjusting for year of residency and number of prior procedures. There was improvement in mean written post-test scores in all the trainees (p=0.0005); however, there was no difference in scores between the two randomized groups. Experts had higher total GRS scores (25+/-0.7 vs. 15.1+/-0.8, p=0.006) and TSC scores (13.7+/-0.6 vs. 9.7+/-1.2, p=0.02) as well as higher scores in each subscale. Experts also required less time to complete the procedure than trainees (p=0.02). All participants agreed that the pelvic model was useful for learning SSLF and felt it would improve their ability to perform the procedure in vivo. Conclusions: Simulation for urogynecologic procedures like our SSLF model can be useful in improving skills and confidence in trainees. Additionally, the OSATS scale demonstrated validity in differentiating novices from experts

Background: Complete separation of the vaginal vault from the uterus is a rare complication of cesarean delivery, requiring assistance with a vaginal hand. Case: A 24-year-old nulliparous woman at 40 weeks plus 3 days of gestation experienced arrest of the second stage of labor, and a vaginal hand was required during cesarean delivery to disimpact a deeply engaged fetal head. Results: Following delivery, complete detachment of the vaginal vault from the cervix was noted without disruption of the uterine vessels. Normal anatomy was surgically restored without complications. The neonate was treated for respiratory distress, and examined for sepsis and hyperbilirubinemia, requiring phototherapy. He was discharged 6 days and was healthy at a 2-week follow-up. Conclusions: Complete separation of the uterus and vaginal vault is a previously unknown complication resulting from elevation of an impacted fetal head vaginally. Simple reattachment of the uterus to the vaginal cuff represents a reasonable alternative to peripartum hysterectomy. 2013, Mary Ann Liebert, Inc

OBJECTIVES: Educators of trainees in procedure-based specialties need focused assessment tools that are valid, objective, and assess technical skills in a realistic context. A framework for hybrid assessment using standardized patient scenarios and bench skills testing might facilitate evaluation of competency. METHODS: Seven PGY-1 obstetrics and gynecology residents participated in a hybrid assessment that used observed structured clinical examination (OSCE) by a standardized patient who had sustained a vaginal laceration during vaginal delivery. The residents elicited a history and counseled the patient, and then completed a laceration repair on a pelvic model. The residents were rated on their performance in the scenario, which included issues of cultural competency, rapport-building, patient counseling. The technical skills were videotaped and rated using a modified global assessment form by 2 faculty members on a 3-point scale from "not done" to "partly done" to "well-done." Residents also completed a subjective assessment of the station. RESULTS: Mean technical performance of the residents on the technical skills was 55% "well-done," with a range of 20%-90%. The assessment identified 3 residents as below the mean, and 1 resident with areas of deficiency. Subjective assessment by the residents was that juggling the technical, cognitive, and affective components of the examination was challenging. CONCLUSIONS: Technical skills can be included in a case-based assessment using scenarios that address a range of cognitive and affective skills required of physicians. Results may help training programs assess individuals' abilities as well as identify program needs for curricular improvement. This framework might be useful in setting standards for competency and identifying poor performers.

BACKGROUND: Reflective practice may help physicians identify and connect with what they value and find meaningful in their work. There are many practical obstacles in teaching narrative skills and reflection to residents in surgical subspecialties. We aimed to assess the feasibility of designing and implementing a writing workshop series within an obstetrics and gynecology curriculum. MATERIALS AND METHODS: Between 2008 and 2009, a reflective writing workshop series was introduced into the didactic curriculum of an obstetrics and gynecology residency program. The course included reading fiction and creative writing. Workshops focused on topics residents identified. Residents answered a subjective questionnaire and also completed the Maslach Burnout Inventory and Interpersonal Reactivity Index to assess burnout and empathy. RESULTS: Six 1-hour reflective writing workshops took place within the dedicated didactic time for residents. Of the 20 residents in the program, 10 junior residents and 8 senior residents evaluated the workshops. Ten residents participated in more than one workshop, an average of 3.6 workshops. Residents felt that the workshops were enjoyable, and some felt that they influenced their experience of residency, but few felt that it affected their work with patients. Trends in Maslach Burnout Inventory and Interpersonal Reactivity Index scores did not show statistical significance. CONCLUSION: A practical curriculum for introducing reflective practice to obstetrics and gynecology residents is described. This model may be useful to educators looking to incorporate reflective practice into residency curricula and lead to collaborative work that may assess the impact of this work on the experience of residents and their patients.