How well are we training residents in female pelvic medicine and reconstructive surgery?

OBJECTIVE: The objective of the study was to compare the familiarity of recently trained obstetrician-gynecologists (OGs) with the American Urogynecologic Society (AUGS) resident educational objectives (REOs) and their abilities to perform reconstructive pelvic surgeries (RPS) with those of residency program directors (PDs). STUDY DESIGN: Recent trainee and PD responses to a written survey assessing knowledge of AUGS REO and residents' abilities to perform RPS were compared with those of PD. RESULTS: Fewer OGs (18%) than PDs (58%) were familiar with the AUGS REO (P < .001). OGs were less likely than PDs to respond that they could "independently perform" nearly all listed RPS." Only 79% of OGs responded they could do a vaginal hysterectomy "on their own," in contrast to 94% of PDs (P = .002). CONCLUSIONS: The perceptions of recently trained OGs of their abilities to perform RPS are low and inconsistent with PD perceptions or AUGS REOs. This discrepancy warrants further investigation to clarify whether we need to reassess educational goals or improve surgical training in RPS.

Prevalence of genital prolapse in 3 ethnic groups.

OBJECTIVE: To compare the prevalence of genital prolapse stratified by Asian American, black and white ethnic groups in women presenting for routine gynecologic examinations and to screen them for symptoms of pelvic floor problems. STUDY DESIGN: This was a descriptive study of women presenting for annual examinations. Demographic information on age, weight, gravidity, parity, weight of largest vaginally delivered infant, gynecologic surgery, medical problems (including hypertension, diabetes, pulmonary disease, smoking) and menopausal status were obtained from the patient and chart. Pelvic organ prolapse was assessed using the quantitative pelvic organ prolapse system. Subjects completed the Pelvic Floor Distress Inventory, which was graded along the 3 scales of Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory and Colorectal-Anal Distress Inventory. RESULTS: One hundred sixty-seven women completed the study, including 73 whites, 60 Asian Americans and 34 blacks. The populations differed in that black women had higher body weight and were more likely to smoke, while white patients had lower parity and more use of hormone replacement therapy. Sixty-seven percent of Asian American patients had stage 2 or higher prolapse as compared to 26% of black and 28% of white patients. Multiple logistic regression showed that Asian American ethnicity independently correlated with higher rates of pelvic organ prolapse. There was no difference in survey results by race. CONCLUSION: There may be significant racial differences in the incidence of pelvic floor prolapse, with higher rates of stage 2 prolapse in asymptomatic Asian American women.

The objective structured assessment of technical skills and the ACGME competencies.

Objective structured assessment of technical skills is structured operating room or laboratory assessment of residents' surgical skills. It can be used to evaluate and teach both basic and complex skills to residents. The literature on its use is reviewed. Future use of virtual reality simulators is discussed.

Urinary incontinence in primary care: a comparison of older African-American and Caucasian women.

Urinary incontinence is a common problem for aging women. Little is known about urinary incontinence in nonwhite populations. A telephone survey was used to compare the prevalence and severity of urinary incontinence as well as common risk factors for urinary incontinence in 194 African-American (AA) and Caucasian (C) women over the age of 50 who made a visit to a primary care practice within the prior 2 years. A high prevalence of UI was found among these women (62%AA, 67%C), though no significant difference was noted among the two groups. More Caucasian women than African-American women reported symptoms of stress incontinence. For both groups, the use of HRT was associated with reporting urinary incontinence. Higher body mass index and prior hysterectomy was associated with urinary incontinence for African-American women only. For both groups, low rates of 'botheredness' (28%AA, 32%C) and treatment seeking (39%AA, 52%C) were found.

A resident conference for systems-based practice and practice-based learning.

Improving patient safety and quality of care is part of systems-based practice and practice-based learning for residents. We expanded our obstetrics and gynecology department's regularly scheduled morbidity and mortality conferences to teach quality assurance concepts based on patient care on obstetrics and gynecology fourth-year resident rotations. Obstetrics and gynecology fourth-year residents on one of the two rotations each presented and analyzed a systems-based problem they encountered during patient care. They used an online learning module and proposed solutions, many of which were effectively implemented. Over 5 years, case presentations from 33 conferences were available with problems identified in emergency preparedness, coordination of care, scheduling and supervision, communication, medical practice, documentation, and lack of equipment or facilities. Twenty-two of the suggested solutions were partially or totally implemented. Barriers to implementation were identified. In conclusion, a conference presentation by fourth-year residents can identify patient safety problems, aid in their resolution, and suggest changes to patient care while teaching the principles of systems-based practice and practice-based learning.

The state of residency training in female pelvic medicine and reconstructive surgery.

To evaluate the state of resident training in female pelvic medicine and reconstructive surgery, the American Urogynecology Society (AUGS) education committee surveyed obstetrics and gynecology program directors on resident training and competence in performing common urogynecologic surgical and office procedure skills. One hundred thirty-two programs (50%) responded. Programs averaged 9 weeks of pelvic floor rotations during residency training. Program directors reported that 77% of residents could independently do some type of anti-incontinence procedure, but only 58% could independently perform apical vaginal support procedures. In 85% of the programs, residents could perform without help only four out of ten urogynecological procedures identified as procedures that residents should be able to do independently by the Council for Resident Education in Obstetrics and Gynecology and AUGS' guidelines.

Racial differences in severe perineal lacerations after vaginal delivery.

OBJECTIVE: The purpose of this study was to determine the relationship between maternal race and rates of third- and fourth-degree laceration after vaginal delivery. STUDY DESIGN: An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 through 2000 was completed. Univariate and multivariable models were computed with the use of logistic regression models. RESULTS: From the database, 34,048 vaginal deliveries were identified, with 3487 deliveries resulting in third- or fourth-degree laceration (10.2%). Overall severe laceration rates by race with all vaginal deliveries for patients without and with episiotomy were as follows: white, 4.3% and 15.1%; black, 2.0% and 19.3%; Asian 9.1% and 32.3%; Hispanic, 3.4% and 17.0%, respectively. After being controled for other variables with multivariable logistic regression in all vaginal deliveries, Asian race (odds ratio, 2.04; 95% CI, 1.43-2.92), forceps (odds ratio, 3.71; 95% CI, 3.39-4.05), vacuum-assisted delivery (odds ratio, 1.86; 95% CI, 1.64-2.10), large size for gestational age (odds ratio, 1.94; 95% CI, 1.21-3.09), and episiotomy (odds ratio, 3.09; 95% CI, 2.66-3.59) were associated significantly with severe lacerations. CONCLUSION: Race is an independent risk factor for severe perineal lacerations after vaginal delivery, with Asian women at highest risk. Asian women who undergo episiotomy and operative vaginal delivery are especially at high risk for rectal sphincter injury.

Vesicouterine fistula after uterine artery embolization: a case report.

Complications of uterine artery embolization (UAE) for treatment of leiomyoma uteri include contrast reactions, hematoma, postembolization syndrome, infection, pulmonary embolus, premature ovarian failure, and uterine necrosis. We present a case of vesicouterine fistula and extrusion of a degenerating leiomyoma into the bladder after UAE, necessitating hysterectomy and partial cystectomy for repair.