Utilizing Complexity Leadership Theory to Promote Faculty Mentorship and Resident Leadership.

OBJECTIVE: To create and evaluate a structured combined faculty mentorship/resident leadership program based on complexity leadership theory. DESIGN: In 2021, a logic model was used to create a 5 part bi-monthly resident leadership series utilizing administrative, adaptive, and enabling components of complexity leadership theory. Each of the 5 sessions had a nationally prominent senior faculty member mentor 3 junior faculty in creation of an interactive workshop that was delivered to resident physicians during scheduled didactics. Validated surveys were used to assess faculty post-mentorship experience and resident self-perception of leadership skills pre-and post-series. Descriptive statistics and 2-way ANOVA were performed; text comments underwent content analysis. SETTING: A large academic OB/GYN department at Baylor College of Medicine in Houston, Texas. PARTICIPANTS: Five faculty mentors, 15 junior faculty, and 48 residents participated in this program. All faculty mentors (5/5) and 87% (13/15) of mentees completed the post-mentorship survey. Resident response rate was 60% (29/48) pre-series and 63% (30/48) post-series. RESULTS: Both mentors and mentees rated the experience favorably (4.62 versus 5.29, p = 0.51). In open-ended comments, enabling components of mentorship process, such as approachability and expertise of the mentors, were most often noted as positive. Both mentees and mentors suggested administrative changes to the experience, such as longitudinal relationships between mentors and mentees. The mean score on the resident leadership questionnaire improved from 3.82 to 3.96 (5-point Likert scale, p = 0.30) with self-reported leadership skills improving in 8/9 domains, although none reaching statistical significance. Open-ended comments revealed that residents also most desired administrative changes in the leadership series, such as increased leadership opportunities and more interactive workshops. CONCLUSIONS: A structured combined faculty mentorship/resident leadership program formed utilizing complexity leadership theory was positively received. Participants most liked the enabling components of the series, with requested administrative changes in the future.

Implementation and Evaluation of a Comprehensive Resident Wellness Curriculum During the COVID-19 Pandemic.

OBJECTIVE: To evaluate the effectiveness of resident-led and faculty-led initiatives for physician wellness after implementation of a resident wellness program. DESIGN: We initiated a wellness curriculum with both resident and faculty-led components in a large academic OB/GYN residency program in October 2020. The curriculum was created and evaluated using the Logic model. Residents were surveyed pre and 8 months postintervention with the Maslach Burnout Inventory (MBI) and the Physician Well-Being Index (PWBI), with activity-related questions added to the second survey. Descriptive statistics, Mann-Whitney test, Chi-square test, and theme analysis were performed as appropriate. SETTING: A large academic OB/GYN residency at Baylor College of Medicine in Houston, Texas PARTICIPANTS: All residents (n = 48) were invited to take part in the surveys. Response rate was 31/48 (65%) pre and 28/48 (58%) postintervention. RESULTS: Residents scored moderate for emotional exhaustion and depersonalization and high for personal accomplishment on both pre and post-MBI surveys. All indices of the PWBI improved over time; however, no significant differences were found in pre and postmeasures. Resident-led activities, which were alternated between individualized time off and group resident socialization, were rated significantly higher than faculty-led activities; 93% (52/56) of respondents rated resident-led activities in their top 2 most helpful initiatives compared to 7% (4/56) who rated faculty-led activities in their top 2 most helpful (p < 0.01) initiatives. Open-ended comments revealed that continued focus on wellness, attention to personal health, and systematic change were the most important ways to improve resident wellness. CONCLUSION: Decreases in burnout were not achieved over an 8-month period with program-level resident-led and faculty-led initiatives. Providing scheduled time for residents to use at their discretion and the continuation of events that encourage socialization are tools that are highest rated by residents to facilitate wellness.

Breastfeeding initiation and duration among people with mild chronic hypertension: a secondary analysis of the Chronic Hypertension and Pregnancy trial.

BACKGROUND: Increased duration of breastfeeding improves maternal cardiovascular health and may be especially beneficial in high-risk populations, such as those with chronic hypertension. Others have shown that individuals with hypertension are less likely to breastfeed, and there has been limited research aimed at supporting breastfeeding goals in this population. The impact of perinatal blood pressure control on breastfeeding outcomes among people with chronic hypertension is unknown. OBJECTIVE: This study aimed to evaluate whether breastfeeding initiation and short-term duration assessed at the postpartum clinic visit differed according to perinatal blood pressure treatment strategy (targeting blood pressure <140/90 mm Hg vs reserving antihypertensive treatment for blood pressure ≥160/105 mm Hg). STUDY DESIGN: We performed a secondary analysis of the Chronic Hypertension and Pregnancy trial. This was an open-label, multicenter, randomized trial where pregnant participants with mild chronic hypertension were randomized to receive antihypertensive medications with goal blood pressure <140/90 mm Hg (active treatment) or deferred treatment until blood pressure ≥160/105 mm Hg (control). The primary outcome was initiation and duration of breastfeeding, assessed at the postpartum clinic visit. We performed bivariate analyses and log-binomial and cumulative logit regression models, adjusting models for variables that were unbalanced in bivariate analyses. We performed additional analyses to explore the relationship between breastfeeding duration and blood pressure measurements at the postpartum visit. RESULTS: Of the 2408 participants from the Chronic Hypertension and Pregnancy trial, 1444 (60%) attended the postpartum study visit and provided breastfeeding information. Participants in the active treatment group had different body mass index class distribution and earlier gestational age at enrollment, and (by design) were more often discharged on antihypertensives. Breastfeeding outcomes did not differ significantly by treatment group. In the active and control treatment groups, 563 (77.5%) and 561 (78.1%) initiated breastfeeding, and mean durations of breastfeeding were 6.5±2.3 and 6.3±2.1 weeks, respectively. The probability of ever breastfeeding (adjusted relative risk, 0.99; 95% confidence interval, 0.93-1.05), current breastfeeding at postpartum visit (adjusted relative risk, 1.01; 95% confidence interval, 0.94-1.10), and weeks of breastfeeding (adjusted odds ratio, 0.87; 95% confidence interval, 0.68-1.12) did not differ by treatment group. Increased duration (≥2 vs <2 weeks) of breastfeeding was associated with slightly lower blood pressure measurements at the postpartum visit, but these differences were not significant in adjusted models. CONCLUSION: In a secondary analysis of the cohort of Chronic Hypertension and Pregnancy trial participants who attended the postpartum study visit and provided breastfeeding information (60% of original trial participants), breastfeeding outcomes did not differ significantly by treatment group. This suggests that maintaining goal blood pressure <140/90 mm Hg throughout the perinatal period is associated with neither harm nor benefit for short-term breastfeeding goals. Further study is needed to understand long-term breastfeeding outcomes among individuals with chronic hypertension and how to support this population in achieving their breastfeeding goals.

Use of a pocket-device point-of-care ultrasound to assess cervical dilation in labor: correlation and patient experience.

OBJECTIVES: To estimate the correlation of cervical dilation between pocket-device point-of-care transperineal ultrasound (TPUS) and digital cervical examination (DCE). METHODS: Laboring pregnant individuals ≥37 weeks of gestation presenting were prospectively evaluated for cervical dilation with a handheld pocket-sized ultrasound (Butterfly iQ+®) applied to the perineum, with a blinded DCE directly following. Subjects completed a survey to rate pain and for any preference from the examinations. To detect a moderate correlation (r=0.5) between TPUS and DCE, with an alpha of 0.05 and power of 80%, a sample size of 30 examinations were needed. RESULTS: From April 2022 to July 2022, 30 pregnant individuals were assessed. The median cervical dilation by TPUS vs. DCE was 5.1 and 5 cm, respectively, with a Pearson's correlation coefficient, r=0.86 (95% CI 0.72 to 0.93), p<0.001. Transperineal ultrasound had a significantly less pain score than DCE, median pain score 0 vs. 2 for TPUS and DCE respectively, p<0.001. All individuals preferred the TPUS over the DCE. CONCLUSIONS: Measurement of cervical dilation using a pocket-device point-of-care TPUS has a strong positive correlation with DCE and offers a non-invasive, convenient alternative to traditional digital exams in term, laboring patients.

YouTube as a source of patient information on external cephalic version.

OBJECTIVES: To assess the quality and content of information regarding external cephalic version on YouTube. METHODS: YouTube was searched using the phrase "external cephalic version" (ECV) to identify informative videos by two independent reviewers. Videos were included if: (1) in English; (2) available November 20, 2021; (3) related to ECV. Videos were excluded if: (1) duration exceeded 15 min; (2) target audience was not patients or the general public; (3) not in English; (4) were advertisements or news clips; (5) did not relate to ECV. The Global Quality Scale was used to assess overall quality of selected videos. A content score was developed based on guidelines from the American College of Obstetricians and Gynecologists. Video quality was also categorized as "slightly useful", "useful" and "very useful". The Patient Education Materials Assessment Tool (PEMAT) for audiovisual materials was used to score understandability and actionability. RESULTS: Of 60 videos screened, 31 met inclusion criteria. They were classified as People or Blogs (n=19, 61%) or Education (n=12, 39%). Videos were calculated to be "slightly useful" (n=10, 32%), "useful" (n=18, 58%), or "very useful" (n = 3, 10%). The PEMAT - understandability was less in the "slightly useful" compared to the combined "useful" and "very useful" groups, p<0.01. No differences existed between total usefulness score and category, p=0.6. CONCLUSIONS: Most videos were useful, but few were very useful. These results highlight the importance of thorough counseling regarding this procedure.

Cost-effectiveness analysis of rubella screening strategies using electronic medical records.

OBJECTIVE: The redundancy of routine laboratory tests in medicine has become increasingly more apparent in the age of electronic medical records (EMRs). The purpose of this study was to determine whether targeted screening strategies are more cost-effective than the current standard of universal screening of pregnant women for immunity to rubella. STUDY DESIGN: A decision analysis model was used to evaluate three strategies: universal screening, screening if a previous titer was not available, and use of an "alert" in the EMR to prompt screening. Cost, probability, and utility values were derived from the literature and institutional data from Lyndon B. Johnson General Hospital. One-way sensitivity analyses were performed on all cost and probability values. RESULTS: The strategy of an EMR alert was most cost-effective, with a cost of $0.27 per quality-adjusted life years (QALY). The model was robust to all costs and probability values over their respective ranges. CONCLUSIONS: Although all strategies were cost-effective compared with traditional industry benchmarks of $50,000/QALY, the EMR alert strategy is most cost-effective. Implementing an EMR alert may lead to a more cost-effective approach to prenatal evaluation of rubella immunity.

Assessment of the concordance among 2-tier, 3-tier, and 5-tier fetal heart rate classification systems.

OBJECTIVE: In 2008, a National Institute of Child Health and Human Development/Society for Maternal-Fetal Medicine-sponsored workshop on electronic fetal monitoring recommended a new fetal heart tracing interpretation system. Comparison of this 3-tier system with other systems is lacking. Our purpose was to determine the relationships between fetal heart rate categories for the 3 existing systems. METHODS: Three Maternal-Fetal Medicine specialists reviewed 120 fetal heart rates. All tracings were from term, singleton pregnancies with known umbilical artery pH. The fetal heart rates were classified by a 2-tier, 3-tier, and 5-tier system. RESULTS: Each Maternal-Fetal Medicine examiner reviewed 120 fetal heart rate segments. When compared with the 2-tier system, 0%, 54%, and 100% tracings in categories 1, 2, and 3 were "nonreassuring." There was strong concordance between category 1 and "green" as well as category 3 and "red" tracings. CONCLUSION: The 3-tier and 5-tier systems were similar in fetal heart rate interpretations for tracings that were either very normal or very abnormal. Whether one system is superior to the others in predicting fetal acidemia remains unknown.

Interobserver and intraobserver reliability of the NICHD 3-Tier Fetal Heart Rate Interpretation System.

OBJECTIVE: Our purpose was to test the reliability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) 3-Tier Fetal Heart Rate (FHR) classification system. STUDY DESIGN: Individual 15- to 20-minute FHR segments (n = 154) were independently reviewed without clinical data by 3 maternal-fetal medicine examiners and classified by NICHD category (I, II, III). RESULTS: Interobserver reliability was moderate (kappa 0.45) and varied by NICHD category (category I moderate [kappa 0.48], category II moderate [kappa 0.44], and category III poor [kappa 0.0]). The intraobserver agreement ranged from substantial to perfect (kappa 0.74-1.0). CONCLUSION: Interobserver agreement of 3-Tier FHR classification System was moderate for NICHD categories I and II. Agreement for category III tracings was poor mainly due to lack of agreement regarding absent vs minimal variability.