Competencies for Those Who Coach Physicians: A Modified Delphi Study.

The rapidly evolving coaching profession has permeated the health care industry and is gaining ground as a viable solution for addressing physician burnout, turnover, and leadership crises that plague the industry. Although various coach credentialing bodies are established, the profession has no standardized competencies for physician coaching as a specialty practice area, creating a market of aspiring coaches with varying degrees of expertise. To address this gap, we employed a modified Delphi approach to arrive at expert consensus on competencies necessary for coaching physicians and physician leaders. Informed by the National Board of Medical Examiners' practice of rapid blueprinting, a group of 11 expert physician coaches generated an initial list of key thematic areas and specific competencies within them. The competency document was then distributed for agreement rating and comment to over 100 stakeholders involved in physician coaching. Our consensus threshold was defined at 70% agreement, and actual responses ranged from 80.5% to 95.6% agreement. Comments were discussed and addressed by 3 members of the original group, resulting in a final model of 129 specific competencies in the following areas: (1) physician-specific coaching, (2) understanding physician and health care context, culture, and career span, (3) coaching theory and science, (4) diversity, equity, inclusion, and other social dynamics, (5) well-being and burnout, and (6) physician leadership. This consensus on physician coaching competencies represents a critical step toward establishing standards that inform coach education, training, and certification programs, as well as guide the selection of coaches and evaluation of coaching in health care settings.

Surgical Considerations in the Management of Adolescent Endometriosis-An Expert Commentary.

Given the complexities and controversies that exist in diagnosing adult endometriosis, as well as optimizing medical and surgical management, it is not surprising that there is even more ambiguity and inconsistency in the optimal surgical care of endometriosis in the adolescent. This collaborative commentary aimed to provide evidence-based recommendations optimizing the role of surgical interventions for endometriosis in the adolescent patient with input from experts in minimally invasive gynecologic surgery, pediatric and adolescent gynecology, and infertility/reproductive medicine.

Evaluation and Management of Endometriosis in the Adolescent.

Endometriosis is a chronic condition, with debilitating symptoms affecting all ages. Dysmenorrhea and pelvic pain often begin in adolescence, affecting school, daily activities, and relationships. Despite the profound burden of endometriosis, many adolescents experience suboptimal management and significant delay in diagnosis. The symptomatology and laparoscopic findings of endometriosis in adolescents are often different than in adults, and the medical and surgical treatments for adolescents may differ from those for adults as well. This Narrative Review summarizes the diagnosis, evaluation, and management of endometriosis in adolescents. Given the unique challenges and complexities associated with diagnosing endometriosis in this age group, it is crucial to maintain a heightened level of suspicion and to remain vigilant for signs and symptoms. By maintaining this lower threshold for consideration, we can ensure timely and accurate diagnosis, enabling early intervention and improved management in our adolescent patients.

Surgical techniques for mini-laparotomy myomectomy.

CONTEXT AND BACKGROUND: The prevalence of uterine fibroids is estimated to be approximately 80%. Fibroids can be associated with abnormal uterine bleeding, pressure symptoms, and infertility. Given this high prevalence, approximately 30,000 myomectomies are performed in the United States per year. Minimally invasive approaches are preferred, if feasible. The minimally invasive techniques include laparoscopic, robot-assisted, hysteroscopic, and mini-laparotomy. OBJECTIVE: To discuss the multiple techniques for optimizing the use of mini-laparotomy in minimally invasive myomectomy. DESIGN: We use intraoperative surgical video to demonstrate techniques that optimize the use of the mini-laparotomy for myomectomy. SETTING: Cleveland Clinic. PATIENT(S): Patient's undergoing fertility preserving, minimally invasive myomectomy at the Cleveland Clinic. The patient(s) included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites. INTERVENTION(S): After the surgeon has selected to proceed with mini-laparotomy myomectomy, different techniques can be employed to optimize management. We demonstrate and discuss these techniques to ensure that surgeons have a set of tools to tackle a fibroid uterus. These techniques include direct palpation of the fibroids, use of a uterine manipulator to visualize the endometrial cavity, use of the uterine manipulator to aid in repair of the cavity if entered, suturing technique that avoids the endometrial cavity and therefore limits foreign body exposure and decreases intrauterine adhesion formation, utilization of barbed suture in a layered fashion, in-situ debulking to avoid injury to fallopian tubes and other critical uterine structures, easy identification of the optimal enucleation plane, use of single hysterotomy for multiple fibroids, visualization of the "Tortuga" sign, and evaluation of the abdominal cavity using the mini-laparotomy site as a port site. To limit postoperative adhesion formation, the investigators place cellulose-based adhesion barriers with peritoneum closure. Although the need for prolonged postoperative observation can be made on a case-by-case basis, we consider this as an outpatient surgery and anticipate same-day discharge for our patients. MAIN OUTCOME MEASURE(S): In this video, we perform a mini-laparotomy myomectomy optimally and describe the techniques employed. RESULT(S): Specific techniques employed in mini-laparotomy myomectomy make the case safe, effective, and can lead to same-day discharge. CONCLUSION(S): Mini-laparotomy myomectomy is a technique used to perform minimally invasive myomectomy. Following the discussed steps, surgeons can be more confident in performing this method of myomectomy.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies.

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Bilateral Cornual Resection for Uterine-sparing Removal of Tubal Sterilization Devices.

STUDY OBJECTIVE: To describe a uterine-sparing minimally invasive surgical technique for laparoscopic resection of tubal occlusion devices using bilateral cornuectomy. DESIGN: This video reviews the background of the tubal occlusion device known as Essure and the indications and methods for surgical removal with a stepwise demonstration of a minimally invasive technique with narrated video footage. SETTING: The most cited reason for patients' desire for removal of the Essure device is pelvic pain. Both hysteroscopic and laparoscopic methods have been used for removal of these devices. Laparoscopy is indicated if it has been >3 months since insertion, if a coil is noted to be malpositioned, or if the patient desires continued permanent sterilization. Techniques for removal include salpingostomy, salpingectomy, and cornuectomy. Removal of the entire device is essential, given that any remaining coil or polyethylene terephthalate fibers may continue to cause symptoms. The coils of the device can easily be fractured; therefore, in our practice we perform a bilateral cornuectomy when uterine retention is desired Supplemental Videos 1 and 2, because fracture rates are higher with salpingectomy than cornuectomy. We demonstrate the steps of this method and highlight the critical aspects for surgeons to consider during the procedure. INTERVENTIONS: Laparoscopic bilateral cornuectomy approach to a uterine-sparing excision of Essure tubal occlusion devices to reduce the risk of coil retention and fracture: 1) Injection of dilute vasopressin at the uterine cornua for vasoconstriction and hemostasis 2) Circumferential dissection of the uterine cornua using monopolar energy 3) Confirmation of endometrial cavity entry using methylene blue 4) Excision of fallopian tube along mesosalpinx to include the fimbriated end 5) Closure of the myometrial layers using a unidirectional barbed suture in a running fashion CONCLUSION: In patients who desire uterine preservation, we recommend a minimally invasive technique of bilateral cornual resection for removal of tubal sterilization devices to avoid device fracture and inadvertent retention of coils.

Surgical techniques for excision of juvenile cystic adenomyoma.

OBJECTIVE: To review causes of pelvic pain among adolescents and discuss surgical techniques for safe and effective resection of juvenile cystic adenomyomas. DESIGN: Case report. SETTING: Academic medical center. PATIENTS: We present a 16-year-old patient with chronic pelvic pain and ultrasound evidence of a 2.4 cm adenomyoma. The lesion was thought specifically to represent a juvenile cystic adenomyoma, defined as a cystic lesion >1 cm occurring in women younger than 30 years with severe dysmenorrhea that is distinct from the uterine cavity and surrounded by hypertrophic myometrium. INTERVENTION: Given minimal relief from medical therapy and high suspicion for coexistent endometriosis, our patient elected to undergo laparoscopic resection of adenomyoma and excision of pelvic lesions. MAIN OUTCOME MEASURES: Preoperative considerations discussed in this video include imaging to identify the location of the lesion and adjacent structures, such as the uterine vessels, discontinuation of gonadotropin-releasing hormone agonist for adequate intraoperative visualization, and the high likelihood of encountering endometriosis at operation. RESULTS: We review the following surgical techniques: maximize visualization with the use of a uterine manipulator and temporary oophoropexy, optimize hemostasis via temporary uterine artery ligation and control of collateral blood vessels, complete ureterolysis, meticulous enucleation of adenomyoma, and excision of coexistent endometriotic lesions. Surgical findings demonstrated a 2 cm lesion along the left lower uterine segment and red-brown lesions along bilateral ovarian fossa, pathologically confirmed as adenomyoma and superficial endometriosis, respectively. CONCLUSION: This video presents strategies for safe and effective adenomyoma resection and treatment of refractory chronic pelvic pain in an adolescent.

Racial and ethnic disparities in surgical care for endometriosis across the United States.

BACKGROUND: Despite an estimated 10% prevalence of endometriosis among reproductive-age women, surgical population-based data are limited. OBJECTIVE: We sought to investigate racial and ethnic disparities in surgical interventions and complications among patients undergoing endometriosis surgery across the United States. STUDY DESIGN: We performed a retrospective cohort study of American College of Surgeons National Surgical Quality Improvement Program data from 2010 to 2018 identifying International Classification of Diseases, Ninth/Tenth Revision codes for endometriosis We compared procedures, surgical routes (laparoscopy vs laparotomy), and 30-day postoperative complications by race and ethnicity. RESULTS: We identified 11,936 patients who underwent surgery for endometriosis (65% White, 8.2% Hispanic, 7.3% Black or African American, 6.2% Asian, 1.0% Native Hawaiian or Pacific Islander, 0.6% American Indian or Alaska Native, and 11.5% of unknown race). Perioperative complications occurred in 9.6% of cases. After adjusting for confounders, being Hispanic (adjusted odds ratio, 1.31; 95% confidence interval, 1.06-1.64), Black or African American (adjusted odds ratio, 1.71; confidence interval, 1.39-2.10), Native Hawaiian or Pacific Islander (adjusted odds ratio, 2.08; confidence interval, 1.28-3.37), or American Indian or Alaska Native (adjusted odds ratio, 2.34; confidence interval, 1.32-4.17) was associated with surgical complications. Hysterectomies among Hispanic (adjusted odds ratio, 1.68; confidence interval, 1.38-2.06), Black or African American (adjusted odds ratio, 1.77; confidence interval, 1.43-2.18), Asian (adjusted odds ratio, 1.87; confidence interval, 1.43-2.46), Native Hawaiian or Pacific Islander (adjusted odds ratio, 4.16; confidence interval, 2.14-8.10), and patients of unknown race or ethnicity (adjusted odds ratio, 2.07; confidence interval, 1.75-2.47) were more likely to be open. Being Hispanic (adjusted odds ratio, 1.64; confidence interval, 1.16-2.30) or Black or African American (adjusted odds ratio, 2.64; confidence interval, 1.95-3.58) was also associated with receipt of laparotomy for nonhysterectomy procedures. The likelihood of undergoing oophorectomy was increased for Hispanic and Black women (adjusted odds ratio, 2.57; confidence interval, 1.96-3.37 and adjusted odds ratio, 2.06; confidence interval, 1.51-2.80, respectively), especially at younger ages. CONCLUSION: Race and ethnicity were independently associated with surgical care for endometriosis, with elevated complication rates experienced by Hispanic, Black or African American, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native patients.

Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning.

The American Board of Medical Specialties, of which the American Board of Obstetrics and Gynecology is a member, released recommendations in 2019 reimagining specialty certification and highlighting the importance of individualized feedback and data-driven advances in clinical practice throughout the physicians' careers. In this article, we presented surgical coaching as an evidence-based strategy for achieving lifelong learning and practice improvement that can help to fulfill the vision of the American Board of Medical Specialties. Surgical coaching involves the development of a partnership between 2 surgeons in which 1 surgeon (the coach) guides the other (the participant) in identifying goals, providing feedback, and facilitating action planning. Previous literature has demonstrated that surgical coaching is viewed as valuable by both coaches and participants. In particular, video-based coaching involves reviewing recorded surgical cases and can be integrated into the physicians' busy schedules as a means of acquiring and advancing both technical and nontechnical skills. Establishing surgical coaching as an option for continuous learning and improvement in practice has the potential to elevate surgical performance and patient care.

Essentials in Minimally Invasive Gynecology Manual Skills Construct Validation Trial.

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: 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.

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy.

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

Cancer overturned: Endometrioma mimicking granulosa cell tumor and the importance of FOXL2 analysis.

BACKGROUND: Various ovarian neoplasms may show histological findings that are morphologically indistinguishable from adult granulosa cell tumor (AGCT). CASE PRESENTATION: A 36 year-old women presented with left lower extremity pain and numbness. Ultrasound revealed a 10 cm left adnexal mass treated with ovarian cystectomy. Histopathology revealed endometriotic cyst with intramural granulosa cell tumor. She underwent a laparoscopic left salpingo-oophorectomy and omental biopsy by Gynecologic Oncology. Pathologic review of residual ovarian abnormality prompted a molecular analysis. FOXL2 gene mutation was absent supporting the diagnosis of benign endometrioma. CONCLUSIONS: A somatic missense mutation in the FOXL2 gene is a sensitive molecular marker for AGCT. Mutation analysis can help distinguish malignant from benign pathology to provide appropriate treatment and disease surveillance.

Total Laparoscopic Hysterectomy and Laparoscopic-Assisted Vaginal Hysterectomy.

Vaginal hysterectomy has been shown to have the lowest complication rate, better cosmesis, and decreased cost compared with alternate routes of hysterectomy. However, there are times when a vaginal hysterectomy is not feasible and an open abdominal hysterectomy should be avoided. Minimally invasive surgery has evolved over the last several decades; with the improvement in optics and surgical instruments, laparoscopic hysterectomy is becoming increasingly common. A total laparoscopic hysterectomy is possible with proper training, including sound technique in laparoscopic suturing for closure of the vaginal cuff.

Techniques in minimally invasive surgery for advanced endometriosis.

PURPOSE OF REVIEW: Surgery can be an important treatment option for women with symptomatic endometriosis. This review summarizes the recommended preoperative work up and techniques in minimally invasive surgery for treatment of deeply infiltrating endometriosis (DIE) involving the obliterated posterior cul-de-sac, bowel, urinary tract, and extrapelvic locations. RECENT FINDINGS: Surgical management of DIE can pose a challenge to the gynecologic surgeon given that an extensive dissection is usually necessary. Given the high risk of recurrence, it is vital that an adequate excision is performed. With improved imaging modalities, preoperative counseling and surgical planning can be optimized. It is essential to execute meticulous surgical technique and include a multidisciplinary surgical team when indicated for optimal results. SUMMARY: Advanced laparoscopic skills are often necessary to completely excise DIE. A thorough preoperative work up is essential to provide correct patient counseling and incorporation of the preferred surgical team to decrease complications and optimize surgical outcomes. Surgical management of endometriosis is aimed at ameliorating symptoms and preventing recurrence.

Development and Validation of a Laparoscopic Simulation Model for Suturing the Vaginal Cuff.

OBJECTIVE: To create a novel surgical simulation model for training laparoscopic suturing of the vaginal cuff and to present evidence regarding its validity as a training and assessment tool. METHODS: The three phases of this study included model construction, validity and reliability testing, and evaluation of the model as an assessment tool. The model was created using corduroy, quilt batting, and neoprene. Construct validity was determined by comparing the scores on the Global Operative Assessment of Laparoscopic Skills scale (25 points) between "expert" and "novice" groups. Experts included gynecologic surgeons (n=5) experienced in total laparoscopic hysterectomies, and novices (n=20) included gynecology trainees (postgraduate year [PGY]-2 to PGY-7). Three additional novel metrics were added to the Global Operative Laparoscopic Assessment of Laparoscopic Skills scale for a total of 40 points. The contrasting groups method was used to determine the minimum passing score. RESULTS: More than 90% of the participants "agreed" that the model resembled live surgery. Advanced novices (PGY-5 to PGY-7) performed similarly to the experts with similar median times (experts 7.3 minutes compared with advanced novices 6.3 minutes, P=.40) and total score (experts 36.5 compared with advanced novices 35.5, P=.34). In contrast, early novices (PGY-2 to PGY-4) tended to take significantly longer than experts (11.8 compared with 7.3 minutes, P<.01) and had a significantly lower total score (27 compared with 36.5, P<.01). Prior surgical experience was strongly correlated with total scores (ρ=0.68). The passing total score was 32 out of 40. CONCLUSION: This novel laparoscopic surgical simulation model allows novice surgeons to practice techniques of laparoscopic suturing to achieve competence before entering the operating room.

Development and validation of a laparoscopic sacrocolpopexy simulation model for surgical training.

STUDY OBJECTIVE: To develop a valid laparoscopic sacrocolpopexy simulation model for use as an assessment and learning tool for performing this procedure. DESIGN: Simulation study (Canadian Task Force classification II-2). SETTING: Two tertiary academic centers. INTERVENTION: A training model was developed to simulate performance of a laparoscopic sacrocolpopexy. Construct validity was measured by comparing observed masked performances on the model between experienced Female Pelvic Medicine and Reconstructive Surgeons (experts) and upper level trainees. All videotaped performances were scored by 2 surgeons who were masked to subject identity and using the valid and reliable Global Operative Assessment of Laparoscopic Skills scale. MEASUREMENTS AND MAIN RESULTS: The expert group included Female Pelvic Medicine and Reconstructive Surgeons (n = 5) experienced in laparoscopic sacrocolpopexy, and the trainee group (n = 15) included fourth-year gynecology residents (n = 5) and fellows in Female Pelvic Medicine and Reconstructive Surgery and in Minimally Invasive Gynecologic Surgery (n = 10). The experts performed significantly better than the trainees in total score and in every domain of the Global Operative Assessment of Laparoscopic Skills scale (median [range] score: expert group, 33 [30.5-39] vs. trainee group, 20.5 [13.5-30.5]; p = .002). Previous surgical experience had a strong association with performance on the model (rho > 0.75). Most subjects "agreed" or "strongly agreed" that the model was authentic to the live procedure and a useful training tool. There was strong agreement between masked raters (interclass correlation coefficient 0.84). CONCLUSION: This simulation model is valid and reliable for assessing performance of laparoscopic sacrocolpopexy and may be used for practicing key steps of the procedure.

Adherence to practice guidelines for atypical glandular cells on cervical cytology.

BACKGROUND: Atypical glandular cells (AGC) on cervical cytology are high-risk, requiring an extensive evaluation. Compliance with practice guidelines for AGC, however, has been low. Some AGC cytology reports contain cytopathologist recommendations for evaluation. This study determines whether evaluation rates for AGC have improved over time, and whether cytopathologists' recommendations correlate with the types of evaluation women receive. METHODS: Evaluation rates from 284 women with AGC (2004-2007) were compared with findings from 1998-2001. Rates of evaluations were compared based on cytology report recommendations. RESULTS: A total of 76.1% of the AGC cases had histologic sampling, and 58.8% had a comprehensive evaluation. These rates are higher than those from 1998-2001 (63.5% and 35.8%, respectively; P<.01). Rates of evaluations of women with AGC "favor neoplasia" did not increase between the 2 time periods. Between 2004-2005 and 2006-2007, rates of comprehensive initial evaluations and endometrial sampling in women ≥35 years of age did not increase. Of the AGC reports that did contain cytopathologist recommendations, 28% were consistent with practice guidelines, 26% recommended an incomplete histologic evaluation, and 46% recommended repeat cytology. Women whose AGC report recommended a comprehensive evaluation or any histologic evaluation were more likely to have a comprehensive work-up (79%) than those whose reports did not contain recommendations (55%, P <0.01) or recommended repeat cytology (51%, P<0.02). CONCLUSIONS: Adherence to practice guidelines for the evaluation of women with AGC has improved but continues to be suboptimal. Our findings suggest that continuing education and including practice guidelines on AGC cytology reports may improve compliance.