A Systematic Review of Development Programs Designed to Address Leadership in Academic Health Center Faculty.

INTRODUCTION: To describe Academic Health Center (AHC) faculty leadership development program characteristics and categorize leadership topics into thematic areas suggesting competency domains to guide programmatic curricular development. METHODS: A systematic literature review was conducted (PubMed/MEDLINE, Scopus, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and Journal Storage [JSTOR databases]). Eligible studies described programs with leadership development intent for faculty in AHCs. Information was extracted using a structured data form and process. RESULTS: Six hundred ninety citations were screened; 25 publications describing 22 unique programs were eligible. The majority (73%) were institutionally based; mean class size was 18.5 (SD ± 10.2, range 4.5-48); and mean in-person time commitment was 110 hours (SD ± 101.2, range 16-416), commonly occurring in regular intervals over months to years (n = 10, 45%). Six programs provided per participant costs (mean $7,400, range $1000-$21,000). Didactic teaching was the primary instructional method (99.5%); a majority (68%) included project work. Fourteen thematic content areas were derived from 264 abstracted topics. The majority or near majority incorporated content regarding leadership skills, organizational strategy and alignment, management, self-assessment, and finance/budget. DISCUSSION: Institutions and faculty invest significantly in leadership development programs, addressing perceived needs and with perceived benefit for both. The prevalence of common curricular content indicates that AHCs deem important faculty development in leadership, business, and self-assessment skills.

Palliative care in women's cancer care: Global challenges and advances.

Women's cancer rates are increasing in low- and middle-income countries, with presentations that are often far advanced requiring intense symptom management, thus advancing the urgent need to address palliative care. Most resource settings have some options available to assist women with advanced gynecologic cancer, and a combination of leveraging these and expanding on emerging models for palliative care could lessen suffering and improve care for women with gynecologic cancers globally. Providing palliative care for women with cancer is constrained by resources (human and physical), lack of equipment, lack of access, and policy absence or barriers. There is important work to be done in advocating for appropriate infrastructure development and legislation to assure that these options are available to women and their families. Access to adequate opioid and other pain relief options for cancer-related pain is a particular concern given that availability, cost, and legislative prohibitions create barriers that cause suffering for patients and grief for their families who are unable to address their suffering. All of these require ongoing advocacy for continual advances to improve access and infrastructure for palliative care.

Meeting the Late-Career Needs of Faculty Transitioning Through Retirement: One Institution's Approach.

PROBLEM: Medical school faculty are aging, but few academic health centers are adequately prepared with policies, programs, and resources (PPR) to assist late-career faculty. The authors sought to examine cultural barriers to successful retirement and create alignment between individual and institutional needs and tasks through PPR that embrace the contributions of senior faculty while enabling retirement transitions at the University of Massachusetts Medical School, 2013-2017. APPROACH: Faculty 50 or older were surveyed, programs at other institutions and from the literature (multiple fields) were reviewed, and senior faculty and leaders, including retired faculty, were engaged to develop and implement PPR. Cultural barriers were found to be significant, and a multipronged, multiyear strategy to address these barriers, which sequentially added PPR to support faculty, was put in place. A comprehensive framework of sequenced PPR was developed to address the needs and tasks of late-career transitions within three distinct phases: pre-retirement, retirement, and post-retirement. OUTCOMES: This sequential introduction approach has led to important outcomes for all three of the retirement phases, including reduction of cultural barriers, a policy that has been useful in assessing viability of proposed phased retirement plans, transparent and realistic discussions about financial issues, and consideration of roles that retired faculty can provide. NEXT STEPS: The authors are tracking the issues mentioned in consultations and efficacy of succession planning, and will be resurveying faculty to further refine their work. This framework approach could serve as a template for other academic health centers to address late-career faculty development.

World Health Organization Guidelines for treatment of cervical intraepithelial neoplasia 2-3 and screen-and-treat strategies to prevent cervical cancer.

BACKGROUND: It is estimated that 1%-2% of women develop cervical intraepithelial neoplasia grade 2-3 (CIN 2-3) annually worldwide. The prevalence among women living with HIV is higher, at 10%. If left untreated, CIN 2-3 can progress to cervical cancer. WHO has previously published guidelines for strategies to screen and treat precancerous cervical lesions and for treatment of histologically confirmed CIN 2-3. METHODS: Guidelines were developed using the WHO Handbook for Guideline Development and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. A multidisciplinary guideline panel was created. Systematic reviews of randomized controlled trials and observational studies were conducted. Evidence tables and Evidence to Recommendations Tables were prepared and presented to the panel. RESULTS: There are nine recommendations for screen-and-treat strategies to prevent cervical cancer, including the HPV test, cytology, and visual inspection with acetic acid. There are seven for treatment of CIN with cryotherapy, loop electrosurgical excision procedure, and cold knife conization. CONCLUSION: Recommendations have been produced on the basis of the best available evidence. However, high-quality evidence was not available. Such evidence is needed, in particular for screen-and-treat strategies that are relevant to low- and middle-income countries.

Cervical Cancer Screening in the United States-Affiliated Pacific Islands: Options and Opportunities.

OBJECTIVE: Successful cervical cancer screening in the United States-Affiliated Pacific Islands (USAPI) is limited by geographic, political, economic, and logistic factors. An expert panel convened to examine screening in each of the 6 island jurisdictions and to explore options beyond cytology-based screening. MATERIALS AND METHODS: Forty-one representatives of American Congress of Obstetrics and Gynecology, American Society for Colposcopy and Cervical Pathology, government agencies, the World Health Organization, Pan American Health Organization, health representatives of the 6 Pacific island jurisdictions, Puerto Rico, and several academic institutions met in a 2-day meeting to explore options to improve access and coverage of cervical cancer screening in the USAPI. RESULTS: Cytology-based screening is less widely accessed and less successful in the USAPI than in the United States in general. Barriers include geographic isolation, cultural factors, and lack of resources. Cytology-based screening requires multiple visits to complete the process from screening to treatment. Screen-and-treat regimens based on visual inspection with acetic acid or human papillomavirus requiring 1 or 2 visits have the potential to improve cervical cancer prevention in the USAPI. CONCLUSIONS: The standard US algorithm of cytology screening followed by colposcopy and treatment is less effective in geographically and culturally isolated regions such as the USAPI. Alternate technologies, both high tech, such as primary human papillomavirus screening, and low tech, such as visual inspection with acetic acid, have shown promise in resource-poor countries and may have applicability in these US jurisdictions.

Brief Report on Obstetricians'/Gynecologists' Distribution of Scarce Resources.

On a day-to-day basis, doctors must decide which treatments are most beneficial for their patients, and which make the most sense in terms of costs. In medical decision making, factors such as efficiency and cost-effectiveness can be particularly challenging to navigate because many of the most expensive procedures encountered in medical practice are also high-stake treatments for patients. One-hundred-six obstetricians-gynecologists (Obs/Gyns) completed a survey asking them to allocate the following resources in scenarios in which they are scarce: human papilloma virus (HPV) vaccinations, mammograms, and in vitro fertilization (IVF) treatments. Additional questions focused on how fairness and cost-effectiveness factored into the allocation decisions of each group. Results indicated that Obs/Gyns were more efficient in their distribution of HPV vaccinations and mammograms than in their distribution of IVF treatments. More efficient responding was associated with placing less emphasis on fairness in decision making. This study demonstrates the differences that exist in the emphasis that physicians place on medical evidence, cost, outcomes, and perceptions of fair (equal) allocation when faced with different costs and health impacts.

Comparing physicians personal prevention practices and their recommendations to patients.

BACKGROUND: Hypothetical choice studies suggest that physicians often take more risk for themselves than on their patient's behalf. OBJECTIVE: To examine if physicians recommend more screening tests than they personally undergo in the real-world context of breast cancer screening. DESIGN: Within-subjects survey. PARTICIPANTS: A national sample of female obstetricians and gynecologists (N = 135, response rate 54%) from the United States. In total, they provided breast care to approximately 2,800 patients per week. MEASURES: Personal usage history and patient recommendations regarding mammography screening and breast self-examination, a measure of defensive medicine practices. RESULTS: Across age groups, female physicians were more likely to recommend mammography screening than to have performed the procedure in the past 5 years (86% vs. 81%, p = .10). In respondents aged 40-49 this difference was significant (91% vs. 82%, p < .05), whereas no differences were detected for younger or older physicians. Among respondents in their 40s, 18% had undergone annual screenings in the past 5 years, compared to 48% of their colleagues above 50. Respondents were as likely to practice breast self-examination (98%) as to recommend it (93%), a pattern that was consistent across age groups. A logistic regression model of personal use of mammography significantly predicted recommending the procedure to patients (OR = 15.29, p = .001). Similarly, number of breast self-examinations performed over the past 2 years positively predicted patient recommendations of the procedure (OR = 1.31, p < .001). CONCLUSIONS: Obstetricians and gynecologists tended to recommend early mammography screening to their patients, though their personal practices indicated later start than their own recommendations and lower frequency of screening than peers in recent studies have recommended.

Key concepts in management of vulvar cancer.

Vulvar carcinoma is an uncommon tumor that is seen most often in older women. Subtle symptoms such as pruritus should prompt examination and targeted biopsy in all women as this disease can be successfully treated even in elderly, frail individuals. Vulvar cancer has a bimodal age distribution and is seen in both young and older women with risk factors including human papillomavirus (HPV) infection, smoking, and vulvar skin diseases (i.e., lichen sclerosus). This cancer is staged surgically, with an update in 2009 incorporating prognostic factors. The treatment of vulvar carcinoma has evolved to include more conservative surgical techniques that provide improved cure rates with emphasis on minimizing morbidity. Advanced and metastatic lesions are now treated with chemoradiation which produces substantial cure rates with decreased morbidity. Promising areas of research in vulvar cancer include refinement of sentinel lymph node biopsy, prevention of lymphedema, and preservation of sexual function following treatment.

Body enhancement through female genital cosmetic surgery creates ethical and rights dilemmas.

Female genital cosmetic surgery is surgery performed on a woman within a normal range of variation of human anatomy. The issues are heightened by a lack of long-term and substantive evidence-based literature, conflict of interest from personal financial gain through performing these procedures, and confusion around macroethical and microethical domains. It is a source of conflict and controversy globally because the benefit and harm of offering these procedures raise concerns about harmful cultural views, education, and social vulnerability of women with regard to both ethics and human rights. The rights issues of who is defining normal female anatomy and function, as well as the economic vulnerability of women globally, bequeath the profession a greater responsibility to ensure that there is adequate health and general education-not just among patients but broadly in society-that there is neither limitation nor interference in the decision being made, and that there are no psychological disorders that could be influencing such choices.

Surgery in elderly people: preoperative, operative and postoperative care to assist healing.

Surgery for elderly women is likely to increase steadily as the population of elderly people increases globally. Although increasing age increases perioperative morbidity and mortality, the functional age and physiologic reserve rather than chronological age is more important in preventing complications. Preparation for surgery, with special attention to functional capacity and activity, mental status, and existing comorbid conditions, can improve outcomes. Perioperative management must be tailored to physiologic changes of ageing, which affect respiratory, cardiac and renal function, as well as guidelines for preventing infection and thrombotic events. Of particular note is the enhanced effect of narcotic medications in elderly people, which affects intraoperative and postoperative management of pain. Prevention of postoperative delirium is accomplished through preoperative and postoperative planning. Discharge planning, particularly for frail elderly people, must start before surgery.

Building a better safety net: taking the safety agenda to office-based women's health.

The recent focus on health care safety is a response to the central ethical tenet of medicine--to do no harm. The delivery of safe hospital care has led to demonstrable reductions in medical errors, adverse events, and patient injuries. These improvements have led to a commensurate reduction of legal risk and the emotional toll on caregivers as well as families. It also has reinvigorated the reason many physicians went into medicine--to make a difference for women's health. The new, voluntary Safety Certification in Outpatient Practice Excellence (SCOPE) for Women's Health program of the American Congress of Obstetricians and Gynecologists is a means to both evaluate and recognize work in a critical but often neglected arena--the outpatient setting. It builds on infrastructure created for safety programs in hospital settings. Strong physician leadership, the development of an office culture committed to safety, communication and teamwork skills, safety programs for office-based surgery, medication safety, and tracking systems are all important for safe treatment of our patients in the office setting. The SCOPE Program defines the necessary safety goals for ambulatory women's health care and provides an educational pathway to reach those goals. SCOPE certification is an achievement recognizing the commitment of physicians and their staff to the health and safety of their patients.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from six working groups, and a recent symposium co-sponsored by the ACS, American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP), which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (e.g., management of screen positives and screening interval for screen negatives) of women after screening, age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16/18 infections.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

The evolution of cervical screening and the specialty of obstetrics and gynecology.

The American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society of Clinical Pathologists have released revised consensus recommendations for cervical cancer screening. These new recommendations integrate molecular testing and include significant changes in screening, particularly in women from 30 to 65 years of age without complications who now may be screened every 5 years by co-testing with cervical cytology and high-risk human papillomavirus testing and women 21-29 years who may be screened with cervical cytology alone every 3 years. The revised recommendations include clarification on when to start and stop screening and management of women who have undergone hysterectomy. They also clarify the management of results of co-testing. The new recommendations achieve the same degree of protection against cervical cancer as previous recommendations. They require less screening and will be much more convenient for our patients. They are a further step away from the days of annual Pap tests, and the decreased requirements for cervical cancer screening pose an exciting opportunity for focusing on many other important health issues during the well woman visit.