Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study.

BACKGROUND: Individuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers' role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings. METHODS: We conducted semi-structured qualitative interviews with VA staff using questions derived from the Consolidated Framework for Implementation Research (CFIR). Participants were recruited via a maximum variation strategy across a national sample and interviewed between January 2021-April 2021. The analytic design was a rapid qualitative analysis. Interviews addressed design decisions and potential barriers and facilitators to future implementation. Then, we made adaptations to Whole Health STEPS and catalogued changes using the Framework for Adaptations and Modifications-Enhanced (FRAME). A VA peer conducted the interviews, participated in analyses, assisted with design modifications, and co-wrote this paper. RESULTS: Sixteen staff members from 9 VA primary care peer programs participated (8 peers and 8 supervisors/administrators). Feedback themes included: capitalizing on peer skills (e.g., navigation), ensuring patient-centered and flexible design, and making it easy and efficient (e.g., reducing session length). Understanding the structure of primary care peers' roles and their interactions with other programs helped us identify role conflicts (e.g., overlap with Whole Health Coaches and Health Behavior Coordinators), which led to design modifications to carve out a unique role for Whole Health STEPS. Staff also made recommendations about marketing materials and training tools to support Whole Health STEPS roll out. CONCLUSIONS: Feedback from frontline staff, including peers, in the design process was crucial to identifying essential modifications that would not have been possible after initial trials without re-evaluating efficacy due to the extent of the changes. Whole Health STEPS was adapted to fit within a range of program structures, emphasize peers' unique contributions, and streamline delivery. Lessons learned can be applied to other interventions.

Practical and Emotional Peer Support Tailored for Life's Challenges: Personalized Support for Progress Randomized Clinical Pilot Trial in a Veterans Health Administration Women's Clinic.

INTRODUCTION: Women Veterans experience a broad range of stressors (e.g., family, relationship, and financial) and high rates of mental health and physical health conditions, all of which contribute to high levels of stress. Personalized Support for Progress (PSP), an evidence-based intervention, is well suited to support women Veterans with high stress as it involves a card-sort task to prioritize concerns as well as pragmatic and emotional support to develop and implement a personalized plan addressing those concerns. Our aims were to explore the population and context for delivery and evaluate the feasibility, acceptability, and utility of PSP delivered by a peer specialist to complement existing services in a Veterans Health Administration (VHA) Women's Wellness Center. MATERIALS AND METHODS: This randomized controlled pilot trial compared treatment as usual plus PSP to treatment as usual and used the a priori Go/No-Go criteria to establish success for each outcome. We interviewed staff regarding the population and delivery context at a VHA Women's Wellness Center and analyzed interviews using a rapid qualitative approach. For the rapid qualitative analysis, we created templated summaries of each interview to identify key concepts within each a priori theme, reviewed each theme's content across all interviews, and finally reviewed key concepts across themes. We evaluated feasibility using recruitment and retention rates; acceptability via Veteran satisfaction, working relationship with the peer, and staff satisfaction; and utility based on the proportion of Veterans who experienced a large change in outcomes (e.g., stress, mental health symptoms, and quality of life). The Syracuse VA Human Subjects Institutional Review Board approved all procedures. RESULTS: Staff interviews highlight that women Veterans have numerous unmet social needs and concerns common among women which increase the complexity of their care; call for a supportive, consistent, trusting relationship with someone on their health care team; and require many resources (e.g., staff such as social workers, services such as legal support, and physical items such as diapers) to support their needs (some of which are available within VHA but may need support for staffing or access, and some of which are unavailable). Feasibility outcomes suggest a need to modify PSP and research methods to enhance intervention and assessment retention before the larger trial; the recruitment rate was acceptable by the end of the trial. Veteran acceptability of PSP was high. Veteran outcomes demonstrate promise for utility to improve stress, mental health symptoms, and quality of life for women Veterans. CONCLUSIONS: Given the high acceptability and promising outcomes for utility, changes to the design to enhance the feasibility outcomes which failed to meet the a priori Go/No-Go criteria are warranted. These outcomes support future trials of PSP within VHA Women's Wellness Centers.

Integration of health systems science and women's healthcare.

Health systems science addresses the complex interactions in healthcare delivery. At its core, health systems science describes the intricate details required to provide high-quality care to individual patients by assisting them in navigating the multifaceted and often complicated US healthcare delivery system. With advances in technology, informatics, and communication, the modern physician is required to have a strong working knowledge of health systems science to provide effective, low-cost, high-quality care to patients. Medical educators are poised to introduce health systems science concepts alongside the basic science and clinical science courses already being taught in medical school. Because of the common overlap of women's healthcare subject matter with health systems science topics, such as interprofessional collaboration, ethics, advocacy, and quality improvement, women's health medical educators are at the forefront of incorporating health systems science into the current medical school educational model. Here, the authors have described the concept of health systems science and discussed both why and how it should be integrated into the undergraduate medical education curriculum. Medical educators must develop physicians of the future who can not only provide excellent patient care but also actively participate in the advancement and improvement of the healthcare delivery system.

Expanding access to psychosocial research studies during the COVID-19 pandemic through virtual modalities.

The COVID-19 pandemic has caused psychosocial researchers and clinicians to quickly shift from standard in-person practices to remote modalities. Despite calls to maintain current virtual care modalities due to the potential to improve access to health care, we are not yet aware of any scholarly works which explicitly describe specific modifications made in response to the restrictions to face-to-face care, resulting access, and implications for the field. This commentary describes how modifications to transition both clinical and research processes to fully virtual modalities in 2 ongoing integrated primary care clinical trials during the COVID-19 pandemic increased access. Given the feasibility of implementing these modifications and the success demonstrated by increased enrollment, we advocate for continued use of virtual modalities for both clinical work and research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Does Participation in Obstetrics and Gynecology Subspecialties Improve Clerkship Outcomes?

OBJECTIVE: The primary objective is to determine if participation in subspecialty rotations during Ob/Gyn core clerkships improves student performance as measured by National Board of Medical Examiners (NBME) Ob/Gyn clinical science subject exam scores, clinical evaluations, and final clerkship summative grades when compared to students without focused subspecialty time. METHODS: This is a retrospective study of third-year Alpert Medical School of Brown University (AMS) Ob/Gyn core clerkship students at a single institution (Women and Infants Hospital in Providence, RI) from 2012 to 2017. Participation in Maternal Fetal Medicine (MFM) and/or Gynecologic oncology (Gyn Onc) subspecialty track (a one-week focused experience), NBME Ob/Gyn clinical science subject exam raw score, clinical evaluation score, final clerkship summative grade, and decision to pursue Ob/Gyn as a career were analyzed. RESULTS: There was no significant difference in NBME scores or final clerkship summative grade when comparing general track students to the subspecialty track. There was a significant difference in the clinical evaluation scores between general track and sub-specialty track students (p < 0.002). Of the students who pursued an Ob/Gyn residency, 75% participated in a subspecialty track. CONCLUSION: Exposure to subspecialty fields is not uniform during core clerkships. Our study indicates that using core clerkship time for early subspecialty exposure does not negatively impact student outcomes, and potentially improves clinical evaluations.

Fostering Inclusive Approaches to Lesbian, Gay, Bisexual, and Transgender (LGBT) Healthcare on the Obstetrics and Gynecology Clerkship.

This article from the "To the Point" series prepared by the Association of Professors in Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC) provides educators with strategies for inclusion of Lesbian, Gay, Bisexual, Transgender (LGBT)-related content into the medical school curriculum. With a focus on the Obstetrics and Gynecology (OB/GYN) clerkship, we also address ways to enhance visibility of these curricula within existing clinical and teaching experiences.

Pelvic Organ Prolapse Symptoms in American Samoan Women.

OBJECTIVES: American Samoa has one of the highest rates of obesity worldwide, making it a population at high risk for pelvic organ prolapse (POP). The primary objective of this study was to describe the presence of POP symptoms and associated degree of bother in American Samoan women. The secondary objective was to determine which characteristics are associated with POP symptoms in this cohort. METHODS: We performed a cross-sectional survey of women presenting to the waiting room of the emergency department of the Lyndon B. Johnson Tropical Medical Center in Faga'alu, American Samoa from February to March 2017. Questions included self-described characteristics and the Pelvic Organ Prolapse Distress Inventory 6. Univariate distributions were described and comparisons of social and health characteristics were made between women without POP symptoms and those with at least 1 POP symptom. RESULTS: Two hundred eighty-four women were approached and 225 women completed the survey (79% response rate). The mean (SD) age was 40.5 (14.7), the mean (SD) body mass index was 36.4 (8.7), and the median (range) number of vaginal births was 2 (0-14). A total of 44.2% endorsed at least 1 POP symptom, most commonly pelvic pressure (29.9%) and feeling of incomplete bladder emptying (26.7%). The number of vaginal births was associated with lower abdominal pressure (P = 0.04) and hysterectomy was associated with pelvic heaviness (P = 0.05). CONCLUSIONS: This is the first study investigating POP in American Samoa. Almost half of women reported at least 1 pelvic floor symptom, demonstrating the need for further research on pelvic floor disorders within this high-risk population.

To the Point: Integrating Patient Safety Education Into the Obstetrics and Gynecology Undergraduate Curriculum.

This article is part of the To the Point Series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. Principles and education in patient safety have been well integrated into academic obstetrics and gynecology practices, although progress in safety profiles has been frustratingly slow. Medical students have not been included in the majority of these ambulatory practice or hospital-based initiatives. Both the Association of American Medical Colleges and Accreditation Council for Graduate Medical Education have recommended incorporating students into safe practices. The Accreditation Council for Graduate Medical Education milestone 1 for entering interns includes competencies in patient safety. We present data and initiatives in patient safety, which have been successfully used in undergraduate and graduate medical education. In addition, this article demonstrates how using student feedback to assess sentinel events can enhance safe practice and quality improvement programs. Resources and implementation tools will be discussed to provide a template for incorporation into educational programs and institutions. Medical student involvement in the culture of safety is necessary for the delivery of both high-quality education and high-quality patient care. It is essential to incorporate students into the ongoing development of patient safety curricula in obstetrics and gynecology.

Variability in gynecologic case volume of obstetrician-gynecologist residents graduating from 2009 to 2017.

BACKGROUND: Residency training in obstetrics-gynecology has changed significantly over time, with residents expected to master an increasing number of surgical procedures. Residency operative case logs are tracked by the Accreditation Council for Graduate Medical Education, which sets case minimums for all procedures. In 2018, the Accreditation Council for Graduate Medical Education created a combined minimally invasive hysterectomy category and now requires graduating residents to complete a minimum of 70 minimally invasive hysterectomies. OBJECTIVES: The objectiges of the study were to evaluate the range of operative gynecological experience across graduating obstetrician-gynecologist residents in the United States and to estimate the number of residents able to meet new Accreditation Council for Graduate Medical Education minimum hysterectomy cases. STUDY DESIGN: Accreditation Council for Graduate Medical Education surgical case logs of graduating obstetrician-gynecologist residents from 2009 to 2017 were analyzed for case volume trends. RESULTS: The average total number of gynecological cases per resident decreased from 438.2 to 431.5 (P < .0001). Minimally invasive hysterectomy averages increased from 43.6 to 69.3 (P < .0001), a trend driven principally by an increase in total laparoscopic hysterectomies. Mean case log decreases were noted in invasive cancer (70.7 to 54.3), incontinence and pelvic floor (85.6 to 56.7), and total abdominal hysterectomies (74.4 to 42.9); (P < .0001 for all). Mean increases were seen in total laparoscopic (118.8 to 146.3) and operative hysteroscopy (68.6 to 77.1) cases (P < .0001 for all). The ratio of the 90th percentile to the 10th percentile of resident case logs showed substantial variation in surgical volume for all procedures, although this ratio decreased over time. Graduates who logged 70 minimally invasive hysterectomy cases were estimated to fall at the 51st percentile in 2017; this was down from the 91st percentile in 2009. CONCLUSION: Nationwide, graduates of obstetrician-gynecologist residency experience significant variability in their surgical training. Based on our extrapolation of Accreditation Council for Graduate Medical Education data, approximately half of residency graduates fell below the 70 case minimally invasive hysterectomy minimum in 2017. Meeting the new Accreditation Council for Graduate Medical Education hysterectomy minimums may be challenging for a significant proportion of residency programs. Understanding the scope and variability of gynecology training is needed to continue to improve and address gaps in resident education.

A National Survey of Profiles of Clerkship Directors in Obstetrics and Gynecology.

OBJECTIVE: To monitor demographics and factors associated with quality of life among obstetrics and gynecology clerkship directors. A secondary goal was to compare current demographics and survey responses to a 1994 survey of clerkship directors. METHODS: A 36-item electronic survey was developed and distributed to the 182 U.S. clerkship directors with active memberships with the Association of Professors of Gynecology and Obstetrics. Items queried respondents on demographics, attitudes about being a clerkship director, quality of life, and burnout. RESULTS: A total of 113 of the 182 (62%) clerkship directors responded to the survey. The mean full-time time equivalent allocated for clerkship director responsibilities was 25%. When compared with clerkship directors from 1994, current clerkship directors are younger, work fewer total hours per week, spend more time on patient care, and less time on research. Notably, 78% (87) of respondents were female compared with 21% (31) of respondents in 1994. Overall, most current clerkship directors responded optimistically to quality of life and burnout measures, with 25% (28) reporting symptoms of high emotional exhaustion and 17% (19) reporting symptoms of depersonalization. Clerkship directors' perception of support from their medical school was significantly correlated with increased personal fulfilment and positive quality of life, as well as decreased burnout and emotional exhaustion measures. CONCLUSION: The gender demographics of obstetrics and gynecology undergraduate medical education leadership have dramatically shifted over the past 25 years; however, many of the changes are not correlated with quality of life and burnout. The association between perceived support from the medical school and multiple quality of life measures point to the vital importance of support for our medical educators.

Feasibility of a Regional Approach to an Obstetrics and Gynecology Transition to Residency Course.

OBJECTIVE: To demonstrate the feasibility of a regional Obstetrics and Gynecology (Ob/Gyn) Transition to Residency Course (TRC) through compliance, satisfaction, and sustainability. METHODS: We implemented a two-week, multi-institutional regional TRC (RTRC) for fourth-year medical students matched in Ob/Gyn or Family Medicine from four New England medical schools. Curriculum was developed to meet Ob/Gyn Milestone One (M1) and Core Entrustable Professional Activity (CEPA) objectives. Compliance, satisfaction, and sustainability were identified as feasibility outcomes. RESULTS: From 2015-2018, a total of 63 fourth-year students have participated. The number of students remained stable each year. All students attended 100% of sessions. There was an average of >9/10 in all satisfaction metrics all four years. The number of faculty members from each institution remained stable over the four years. CONCLUSION: A RTRC is feasible as measured through compliance, satisfaction and sustainability.

Developing as an Academic Medical Educator in Obstetrics and Gynecology.

The lack of a defined framework for advancement and development of professional identity as a medical educator may discourage faculty from pursuing or progressing through a career in academic medical education. Although career advancement has historically been linked to clinical work and research, promotion for teaching has not been supported at the same level. Despite potential challenges, a career in academic medicine has its share of rewards. This article by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee will describe how to develop as an academic medical educator in obstetrics and gynecology, providing tips on how to start, advance, and succeed in an academic career, and provide an overview of available resources and opportunities.

To the Point: a prescription for well-being in medical education.

This article is from the "To The Point" series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. The purpose of this review was to provide an overview of the importance of well-being in medical education. A literature search was performed by a Reference Librarian who used Ovid/MEDLINE to identify scholarly articles published in English on learner well-being, using the search terms "burnout," "resilience," "wellness," and "physicians" between 1946 and January 11, 2019. The accreditation expectations and standards, available assessment tools for learner well-being, existing programs to teach well-being, and some key elements for curriculum development are presented. This is a resource for medical educators, learners, and practicing clinicians from any field of medicine.

To the point: undergraduate medical education learner mistreatment issues on the learning environment in the United States.

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is an overview of issues to consider regarding learner mistreatment and its effects on the undergraduate medical education learning environment in the United States. National data from the American Association of Medical Colleges Graduate Questionnaire and local data regarding learner mistreatment provide evidence that the learning environment at most medical schools needs to be improved. The American Association of Medical Colleges' definition of learner mistreatment focuses on active mistreatment, but data on passive mistreatment also contribute to a negative learning environment. The lack of tolerance for active mistreatment issues such as public humiliation and sexual and racial harassment need to be made transparent through institutional and departmental policies. Additionally, reporting mechanisms at both levels need to be created and acted upon. Passive mistreatment issues such as unclear expectations and neglect can also be addressed at institutional and departmental levels through training modules and appropriate communication loops to address these concerns. To fully confront and solve this challenging issue regarding learner mistreatment at the undergraduate medical education level, solutions to need to be implemented for faculty, residents, and students in the institutional, departmental, and clerkship settings.

To the Point: The expanding role of simulation in obstetrics and gynecology medical student education.

This article, from the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC), provides educators with an overview of the use of simulation in undergraduate medical education in the field of obstetrics and gynecology. Simulation plays an important role in the education of medical students. Students are increasingly serving as clinical observers and providing less direct patient care. Simulation can help standardize education and ensure quality and comparability across an enlarging educational environment. This article summarizes the expanding role of simulation in undergraduate medical education in obstetrics and gynecology and its effect on important learner outcomes such as confidence, knowledge, skills, workplace behaviors, and translation to patient care.

To the point: gender differences in the obstetrics and gynecology clerkship.

Gender differences in performance on the obstetrics and gynecology clerkship have been reported, with female students outperforming male students. Male students report that their gender negatively affects their experience during the clerkship. Additionally, there are fewer male students applying for obstetric/gynecology residency. This "To The Point" article by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee will describe the gender differences that have been found, examine factors that could be contributing to these issues, and propose measures to correct these disparities.

Barriers and Strategies to Engaging Our Community-Based Preceptors.

ISSUE: This article, from the "To the Point" series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of commonly cited barriers to recruiting and retaining community-based preceptors in undergraduate medical education and potential strategies to overcome them. EVIDENCE: Community-based preceptors have traditionally served as volunteer, nonsalaried faculty, with academic institutions relying on intrinsic teaching rewards to sustain this model. However, increasing numbers of learners, the burdens of incorporating the electronic medical record in practice, and increasing demands for clinical productivity are making recruitment and retention of community-based preceptors more challenging. IMPLICATIONS: General challenges to engaging preceptors, as well as those unique to women's health, are discussed. Potential solutions are reviewed, including alternative recruitment strategies, faculty development to emphasize efficient teaching practices in the ambulatory setting, offers of online educational resources, and opportunities to incorporate students in value-added roles. Through examples cited in this review, clerkship directors and medical school administrators should have a solid foundation to actively engage their community-based preceptors.

To the point: medical education, technology, and the millennial learner.

This article, from the "To The Point" series that was prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides an overview of the characteristics of millennials and describes how medical educators can customize and reframe their curricula and teaching methods to maximize millennial learning. A literature search was performed to identify articles on generational learning. We summarize the importance of understanding the attitudes, ideas, and priorities of millennials to tailor educational methods to stimulate and enhance learning. Where relevant, a special focus on the obstetrics and gynecology curriculum is highlighted.

Pelvic and breast examination skills curricula in United States medical schools: a survey of obstetrics and gynecology clerkship directors.

BACKGROUND: Learning to perform pelvic and breast examinations produces anxiety for many medical students. Clerkship directors have long sought strategies to help students become comfortable with the sensitive nature of these examinations. Incorporating standardized patients, simulation and gynecologic teaching associates (GTAs) are approaches gaining widespread use. However, there is a paucity of literature guiding optimal approach and timing. Our primary objective was to survey obstetrics and gynecology (Ob/Gyn) clerkship directors regarding timing and methods for teaching and assessment of pelvic and breast examination skills in United States medical school curricula, and to assess clerkship director satisfaction with current educational strategies at their institutions. METHODS: Ob/Gyn clerkship directors from all 135 Liaison Committee on Medical Education accredited allopathic United States medical schools were invited to complete an anonymous 15-item web-based questionnaire. RESULTS: The response rate was 70%. Pelvic and breast examinations are most commonly taught during the second and third years of medical school. Pelvic examinations are primarily taught during the Ob/Gyn and Family Medicine (FM) clerkships, while breast examinations are taught during the Ob/Gyn, Surgery and FM clerkships. GTAs teach pelvic and breast examinations at 72 and 65% of schools, respectively. Over 60% of schools use some type of simulation to teach examination skills. Direct observation by Ob/Gyn faculty is used to evaluate pelvic exam skills at 87% of schools and breast exam skills at 80% of schools. Only 40% of Ob/Gyn clerkship directors rated pelvic examination training as excellent, while 18% rated breast examination training as excellent. CONCLUSIONS: Pelvic and breast examinations are most commonly taught during the Ob/Gyn clerkship using GTAs, simulation trainers and clinical patients, and are assessed by direct faculty observation during the Ob/Gyn clerkship. While the majority of Ob/Gyn clerkship directors were not highly satisfied with either pelvic or breast examination training programs, they were less likely to describe their breast examination training programs as excellent as compared to pelvic examination training-overall suggesting an opportunity for improvement. The survey results will be useful in identifying future challenges in teaching such skills in a cost-effective manner.