U.S. Healthcare Provider Views and Practices Regarding Planned Birth Setting.

AbstractBackground: Little is known about U.S. healthcare provider views and practices regarding evidence, counseling, and shared decision-making about in-hospital versus out-of-hospital birth settings. METHODS: We conducted 19 in-depth, semistructured, qualitative interviews of eight obstetricians, eight midwives, and three pediatricians from across the United States. Interviews explored healthcare providers' interpretation of the current evidence and their personal and professional experiences with childbirth within the existing medical, ethical, and legal context in the United States. RESULTS: Themes emerged concerning risks and benefits, decision-making, and patient-provider power dynamics. Collectively, the narratives illuminated fundamental ideological tensions between in- and out-of-hospital providers arising from divergent assignment of value to described risks and benefits. The majority of physicians focused on U.S.-specific data demonstrating increased neonatal morbidity and mortality associated with delayed access to hospital-based interventions, thereby justifying hospital birth as the standard of care. By contrast, midwives emphasized data demonstrating fewer interventions and superior maternal and neonatal outcomes in high-income European countries, where out-of-hospital birth is more common for low-risk birthing people. A key gap in counseling was revealed, as no interviewees offered anticipatory counseling regarding birth setting options. Providers directly and indirectly illustrated the propensity for asymmetric power relations between birth providers and pregnant people, especially in hospital settings. CONCLUSIONS: The narratives highlight the common goal of optimizing maternal and neonatal outcomes despite tensions arising from divergent prioritization of specific maternal and neonatal risks. Our findings suggest opportunities to foster collaboration and optimize outcomes via mutual respect and improved integration of care.

Correlations between Accreditation Council for Graduate Medical Education Obstetrics and Gynecology Milestones and American Board of Obstetrics and Gynecology qualifying examination scores: an initial validity study.

BACKGROUND: Since the launch of the Outcome Project in 2001, the graduate medical education community has been working to implement the 6 general competencies. In 2014, all Obstetrics and Gynecology residency programs implemented specialty-specific milestones to advance competency-based assessment. Each clinical competency committee of the Obstetrics and Gynecology program assesses all residents twice a year on the milestones. These data are reported to the Accreditation Council for Graduate Medical Education as part of a continuous quality improvement effort in graduate medical education. OBJECTIVE: This study aimed to evaluate the correlation between the Accreditation Council for Graduate Medical Education Obstetrics and Gynecology Milestones and residency program graduates' performance on the American Board of Obstetrics and Gynecology qualifying (written) examination. STUDY DESIGN: We conducted a validity study of all graduating (postgraduate year 4) Obstetrics and Gynecology residents in 2017 within Accreditation Council for Graduate Medical Education-accredited United States training programs (1260 residents from 242 programs). This cohort of residents began receiving milestone assessments during their postgraduate year 2 in 2014; the first-year milestones were implemented for all Accreditation Council for Graduate Medical Education-accredited Obstetrics and Gynecology programs. This cohort completed their sixth and final milestone assessment at graduation in June 2017 for a total of 6 periods of milestone assessments. Data regarding each resident's milestone ratings in each of the 28 Accreditation Council for Graduate Medical Education subcompetencies for Obstetrics and Gynecology were assessed for their association with candidates' American Board of Obstetrics and Gynecology qualifying examination scores using a generalized estimating equation regression model. RESULTS: Data were available and analyzed from 1184 residents from 240 programs, representing 94% of the total academic year 2017 graduates of Obstetrics and Gynecology residency training programs. There was a substantial association between most milestone ratings at the 6 assessment points and candidates' performance on the American Board of Obstetrics and Gynecology qualifying examination. The strongest associations with the American Board of Obstetrics and Gynecology were within all 7 of the subcompetencies of Medical Knowledge (range of slope correlation coefficients at final milestone ratings 3.84-5.17; slope coefficients can be interpreted as the gain in qualifying examination points per unit increase in milestone level). At the final milestone assessment, but more modest associations with the American Board of Obstetrics and Gynecology qualifying examination scores were also seen with 9 of the 11 Patient Care and Procedural Skills subcompetencies, the 2 of 2 Practice-Based Learning and Improvement subcompetencies, the 2 of 2 Systems-Based Practice subcompetencies, and 2 of the 3 Professionalism subcompetencies. Only 1 of the 3 Interpersonal and Communication Skills subcompetencies was associated with American Board of Obstetrics and Gynecology qualifying examination scores. CONCLUSION: The pattern of associations between the qualifying examination scores and milestone ratings for the 2017 graduating cohort of Obstetrics and Gynecology residents followed a logical pattern, with the strongest associations seen in Medical Knowledge, and lower to no associations in subcompetencies not as effectively assessed on multiple-choice examinations. Although some positive associations were noted for non-Medical Knowledge milestones, these associations could be caused by correlational rating errors with further study needed to better understand these patterns.

Effects of a 'Baby-Friendly Hospital Initiative' on exclusive breastfeeding rates at a private hospital in Lebanon: an interrupted time series analysis.

BACKGROUND: Exclusive breastfeeding (EBF) through six months of age has been scientifically validated as having a wide range of benefits, but remains infrequent in many countries. The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) is one approach to improve EBF rates. METHODS: This study documents the implementation of BFHI at Clemenceau Medical Center (CMC), a private hospital in Lebanon, and analyzes data on EBF practices among CMC's patients before, during, and after the implementation period. The process of launching the BFHI at CMC is discussed from the perspective of key stakeholders using the SQUIRE guidelines for reporting on quality improvement initiatives. As an objective measure of the program's impact, 2,002 live births from July 2015 to February 2018 were included in an interrupted time series analysis measuring the rates of EBF at discharge prior to, during, and following the bundle of BFHI interventions. RESULTS: The steps necessary to bring CMC in line with the BFHI standards were implemented during the period between November 2015 and February 2016. These steps can be grouped into three phases: updates to hospital policies and infrastructure (Phase 1); changes to healthcare staff practices (Phase 2); and improvements in patient education (Phase 3). The baseline percentage of EBF was 2.4 % of all live births. Following the BFHI intervention, the observed monthly change in EBF in the "Follow-Up" period (i.e., the 24 months following Phases 1-3) was significantly increased relative to the baseline period (+ 2.0 % points per month, p = 0.006). Overall, the observed rate of EBF at hospital discharge increased from 2.4 to 49.0 % of all live births from the first to the final month of recorded data. CONCLUSIONS: Meeting the BFHI standards is a complex process for a health facility, requiring changes to policies, practices, and infrastructure. Despite many challenges, the results of the interrupted time series analysis indicate that the BFHI reforms were successful in increasing the EBF rate among CMC's patients and sustaining that rate over time. These results further support the importance of the hospital environment and health provider practices in breastfeeding promotion, ultimately improving the health, growth, and development of newborns.

Systematic Review of Intraoperative Assessment Tools in Minimally Invasive Gynecologic Surgery.

OBJECTIVE: To collect, summarize, and evaluate the currently available intraoperative rating tools used in abdominal minimally invasive gynecologic surgery (MIGS). DATA SOURCES: Medline, Embase, and Scopus databases from January 1, 2000, to May 12, 2020. METHODS OF STUDY SELECTION: A systematic search strategy was designed and executed. Published studies evaluating an assessment tool in abdominal MIGS cases were included. Studies focused on simulation, reviews, and abstracts without a published manuscript were excluded. Risk of bias and methodological quality were assessed for each study. TABULATION, INTEGRATION, AND RESULTS: Disparate study methods prevented quantitative synthesis of the data. Ten studies were included in the analysis. The tools were grouped into global (n = 4) and procedure-specific assessments (n = 6). Most studies evaluated small numbers of surgeons and lacked a comparison group to evaluate the effectiveness of the tool. All studies demonstrated content validity and at least 1 dimension of reliability, and 2 have external validity. The intraoperative procedure-specific tools have been more thoroughly evaluated than the global scales. CONCLUSION: Procedure-specific intraoperative assessment tools for MIGS cases are more thoroughly evaluated than global tools; however, poor-quality studies and borderline reliability limit their use. Well-designed, controlled studies evaluating the effectiveness of intraoperative assessment tools in MIGS are needed.

Racial differences in maternal and umbilical cord blood leukocyte telomere length and their correlations.

PURPOSE: Telomere length at birth sets the baseline for telomere shortening and may influence adult disease risk like cancer. Telomere length is heritable, but may also be a marker of exposures in utero, including those influencing racial differences in risk. We examined racial differences in telomere length in maternal and umbilical cord blood from male neonates, and maternal-neonate correlations to generate hypotheses. METHODS: Black and white pregnant women were recruited in 2006-2007 and followed to postpartum. Data came from questionnaires and medical records. Relative telomere length was measured by qPCR in leukocyte DNA. We estimated mean telomere length in mothers and neonates (n = 55 pairs) using linear regression and maternal-cord blood Spearman correlations, overall and by race. RESULTS: Black mothers had shorter age- and plate-adjusted telomere length (2.49, 95% CI 2.11-2.86) than whites (2.92, 95% CI 2.63-3.22; p = 0.1) and black neonates had shorter telomere length (2.58, 95% CI 2.16-3.01) than whites (3.13, 95% CI 2.79-3.47; p = 0.1), though not statistically significant. Differences were attenuated after further adjustment for maternal factors. Maternal-cord blood correlations were moderate (r = 0.53, p < 0.0001), and did not differ by race. CONCLUSION: Telomere length may differ by race at birth due to both inherited and racial differences in maternal factors. This study was for hypothesis generation and results should be followed up in larger studies.

Empowering Women's Prenatal Communication: Does Literacy Matter?

This study was designed to evaluate the impact of an interactive computer program developed to empower prenatal communication among women with restricted literacy skills. A total of 83 women seeing 17 clinicians were randomized to a computer-based communication activation intervention (Healthy Babies Healthy Moms [HBHM]) or prenatal education (Baby Basics [BB]) prior to their prenatal visit. Visit communication was coded with the Roter Interaction Analysis System, and postvisit satisfaction was reported. Participants were on average 24 years of age and 25 weeks pregnant; 80% were African American. Two thirds scored ≤8th grade on a literacy screener. Women with literacy deficits were more verbally active, disclosed more medical and psychosocial/lifestyle information, and were rated as more dominant by coders in the HBHM group relative to their counterparts in the BB group (all ps < .05). Clinicians were less verbally dominant and more patient centered with literate HBHM relative to BB group women (p < .05); there was a similar, nonsignificant trend (p < .1) for lower literate women. Clinicians communicated less medical information and made fewer reassurance statements to lower literate women in the HBHM relative to the BB group (p < .05). There was a trend toward lower visit satisfaction for women with restricted literacy in the HBHM relative to the BB group (p < .1); no difference in satisfaction was evident for more literate women. The HBHM intervention empowered communication of all women and facilitated verbal engagement and relevant disclosure of medical and psychosocial information of women with literacy deficits. Satisfaction, however, tended to be lower for these women.

Postinterview communication with residency applicants: a call for clarity!

The residency match is an increasingly competitive process. Communication from medical student applicants to programs varies, and the effect this has on their rank status is unclear. We assessed how obstetrics and gynecology program directors interpret and act on postinterview communication initiated by applicants by conducting an anonymous cross-sectional web-based survey of allopathic obstetrics and gynecology program directors. One hundred thirty-seven program directors (55%) responded to the survey. Twenty-nine percent would consider ranking an applicant more favorably if the applicant expressed interest (beyond a routine thank you) or if a faculty mentor personally known to the program director stated that the applicant was ranking the program first. Fifty-two percent indicated that they would rank an applicant more favorably if a mentor known to them endorsed the applicant as outstanding. Approximately 30% responded that applicants who did not communicate with their program were disadvantaged compared with those who did. Approximately 17% stated it was desirable to create additional specialty-specific guidelines regarding postinterview contact between programs and applications. Based on the wide variation in how program directors interpret and act on postinterview communication from applicants, residency programs should formulate and communicate a clear policy about whether they request and how they respond to postinterview communication from applicants and their mentors. This will establish a more level playing field and eliminate potential inequities resulting from inconsistent communication practices.

The Johns Hopkins Physician-Scientist Training Program to Enhance Institutional Retention and Entry Into Academic Positions: An Evaluation of Program Effectiveness and Outcomes.

PURPOSE: The Johns Hopkins Physician-Scientist Training Program (PSTP) was implemented to overcome well-documented challenges in training and retaining physician-scientists by providing physician-scientist pathway training for residents and clinical fellows. The program's core tenets include monthly seminars, individualized feedback on project proposals, access to mentors, and institutional funding opportunities. This study evaluated the effectiveness and outcomes of the PTSP and provides a framework for replication. METHOD: A query of institutional demographic data and bibliometric variables of the PSTP participants (2017-2020) at a single academic medical center was conducted in 2021. In addition, a voluntary survey collected personal and program evaluation information. RESULTS: Of 145 PSTP scholars, 59 (41%) were women, and 41 (31%), 8 (6%), and 6 (5%) of scholars self-identified as Asian, Hispanic, and Black, respectively. Thirty-three (23%) scholars received PSTP research support or career development microgrants. Of 66 PSTP graduates, 29 (44%) remained at Johns Hopkins as clinical fellows or faculty. Of 48 PSTP graduates in a post-training position, 42 (88%) were in academia, with the majority, 29 (76%), holding the rank of assistant professor. Fifty-nine of 140 available participants responded to the survey (42% response rate). The top-cited reason for joining the PSTP was exposure to mentors and administration (50/58 respondents, 86%), followed by seeking scholarly opportunities (37/58 respondents, 64%). Most scholars intended to continue a career as a physician-scientist. CONCLUSIONS: The PSTP provides internal research support and institutional oversight. Although establishing close mentor-mentee relationships requires individualized approaches, the PSTP provided structured academic pathways that enhanced participating scholars' ability to apply for grants and jobs. The vast majority continued their careers as physician-scientists after training. In light of the national evidence of a "leaky physician-scientist pipeline," programs such as the PSTP can be critical to entry into early academic career positions and institutional retention.

Racial variation in vitamin D cord blood concentration in white and black male neonates.

AIM: The aim of this study is to evaluate racial variation in umbilical cord blood concentration of vitamin D and to explore its correlation with markers of the insulin-like growth factor axis (IGFs) and sex steroid hormones in white and black male neonates. METHODS: In 2004-2005, venous umbilical cord blood samples were collected from 75 black and 38 white male neonates, along with maternal and birth characteristics from two hospitals in Maryland, United States. 25-Hydroxyvitamin D [25(OH)D] and 1,25-dihydroxyvitamin D [1,25(OH)(2)D] were measured by radioimmunoassay and testosterone, estradiol, and sex hormone-binding globulin (SHBG) by immunoassay and IGF-1, IGF-2, and IGF-binding protein-3 by ELISA. Crude and multivariable-adjusted geometric mean concentrations were computed. RESULTS: Mean 25(OH)D levels were lower in black than in white neonates (11.44; 95 % CI 10.10-12.95 ng/mL vs. 18.24; 95 % CI 15.32-21.72 ng/mL; p < 0.0001). Black neonates were at higher risk of suboptimal vitamin D levels [25(OH)D < 20 ng/mL] than whites (84 vs. 63 %). 25(OH)D concentrations varied by season in whites but not in blacks and were significantly inversely correlated with mother's parity (number of live births) in blacks but not in whites. Mean concentration of 1,25(OH)(2)D did not differ by race. 25(OH)D and 1,25(OH)(2)D did not correlate with IGFs, sex steroid hormones, and SHBG. CONCLUSIONS: Suboptimal vitamin D levels were prevalent especially in blacks and influenced by mother's parity and by season. The observed vitamin D differences between black and white neonates warrant further evaluation of the etiology of the disparity in chronic diseases in adulthood.

The effect of gynecologic algorithm pathways on emergency department visit times.

BACKGROUND: The use of multidisciplinary algorithmic pathways is one strategy to improve efficiency and quality of care in Emergency Departments (EDs). To this end, in the fall of 2005, we implemented algorithmic pathways for evaluation of ED patients with common gynecologic complaints. OBJECTIVES: The goals of this initiative were to improve length of stay as a marker for operational efficiency and to reduce health care disparities by ensuring consistent management regimens for all patients. METHODS: A retrospective observational comparison study was performed through a review of consults in the year preceding and the year after implementation of the pathways. The length of stay was calculated based on time of initial triage until discharge. The length of stay from both groups was compared using an unpaired Student's t-test analysis. RESULTS: There was an 85-min decrease in the mean visit time between the pre-intervention group (108 patients, 610 min, SD 345.4) and the post-intervention group (105 patients, 525 min, SD 251.5), p=0.04. CONCLUSIONS: Algorithmic pathways had a positive impact on patient care as measured by the average amount of time our patients spent in the ED. Gynecologic care in the ED was standardized, and length of stay for patients with gynecologic complaints decreased. The implementation of algorithms resulted in more consistent care with earlier initiation of pertinent studies, while facilitating more rapid critical decision-making by providers from both departments. Further analysis is required to examine cost-effectiveness as well as patient safety and provider satisfaction issues.

The Undergraduate to Graduate Medical Education Transition as a Systems Problem: A Root Cause Analysis.

The transition from undergraduate medical education (UME) to graduate medical education (GME) constitutes a complex system with important implications for learner progression and patient safety. The transition is currently dysfunctional, requiring students and residency programs to spend significant time, money, and energy on the process. Applications and interviews continue to increase despite stable match rates. Although many in the medical community acknowledge the problems with the UME-GME transition and learners have called for prompt action to address these concerns, the underlying causes are complex and have defied easy fixes. This article describes the work of the Coalition for Physician Accountability's Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) to apply a quality improvement approach and systems thinking to explore the underlying causes of dysfunction in the UME-GME transition. The UGRC performed a root cause analysis using the 5 whys and an Ishikawa (or fishbone) diagram to deeply explore problems in the UME-GME transition. The root causes of problems identified include culture, costs and limited resources, bias, systems, lack of standards, and lack of alignment. Using the principles of systems thinking (components, connections, and purpose), the UGRC considered interactions among the root causes and developed recommendations to improve the UME-GME transition. Several of the UGRC's recommendations stemming from this work are explained. Sustained monitoring will be necessary to ensure interventions move the process forward to better serve applicants, programs, and the public good.

Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice.

Importance: Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice. Objective: To investigate the association between resident Milestone ratings and posttraining patient complaints. Design, Setting, and Participants: This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023. Exposures: Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training. Main Outcomes and Measures: PARS year 1 index scores, based on recency and severity of complaints. Results: The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance: In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

Racial variation in umbilical cord blood sex steroid hormones and the insulin-like growth factor axis in African-American and white female neonates.

PURPOSE: To evaluate whether there is racial variation in venous umbilical cord blood concentrations of sex steroid hormones and the insulin-like growth factor (IGF) axis between female African-American and white neonates. METHODS: Maternal and birth characteristics and venous umbilical cord blood samples were collected from 77 African-American and 41 white full-term uncomplicated births at two urban hospitals in 2004 and 2005. Cord blood was measured for testosterone, dehydroespiandrosterone-sulfate, estradiol, and sex steroid hormone-binding globulin (SHBG) by immunoassay. IGF-1, IGF-2, and IGF-binding protein-3 (IGFBP-3) were measured by ELISA. Crude and multivariable-adjusted geometric mean concentrations were computed for the hormones. RESULTS: African-American neonates weighed less at birth (3,228 g vs. 3,424 g, p < 0.004) than whites. Birth weight was positively correlated with IGF-1, IGFBP-3, and the molar ratio of IGF-1 to IGFBP-3, but inversely correlated with the molar ratio of IGF-2 to IGFBP-3. Adjusted models showed higher testosterone (1.82 ng/ml vs. 1.47 ng/ml, p = 0.006) and the molar ratio of testosterone to SHBG (0.42 vs. 0.30, p = 0.03) in African-American compared to white female neonates. IGF-1, IGF-2, and IGFBP-3 were lower in African-American compared to white female neonates, but only the difference for IGF-2 remained significant (496.5 ng/ml vs. 539.2 ng/ml, p = 0.04). CONCLUSION: We provide evidence of racial variation in cord blood testosterone and testosterone to SHBG in African-American compared to white female neonates, and higher IGF-2 in white compared to African-American female neonates. Findings suggest plausible explanations for a prenatal influence on subsequent breast cancer risk and mortality. Further work is needed to confirm these observations.

Can Factor V Leiden and prothrombin G20210A testing in women with recurrent pregnancy loss result in improved pregnancy outcomes?: Results from a targeted evidence-based review.

Women with recurrent pregnancy loss are offered Factor V Leiden (F5) and/or prothrombin G20210A (F2) testing to identify candidates for anticoagulation to improve outcomes. A systematic literature review was performed to estimate test performance, effect sizes, and treatment effectiveness. Electronic searches were performed through April 2011, with review of references from included articles. English-language studies addressed analytic validity, clinical validity, and/or clinical utility and satisfied predefined inclusion criteria. Adequate evidence showed high analytic sensitivity and specificity for F5 and F2 testing. Evidence for clinical validity was adequate. The summary odds ratio for association of recurrent pregnancy loss with F5 in case-controlled studies was 2.02 (95% confidence interval, 1.60-2.55), with moderate heterogeneity and suggestion of publication bias. Longitudinal studies in women with recurrent pregnancy loss or unselected cohorts showed F5 carriers were more likely to have a subsequent loss than noncarriers (odds ratios: 1.93 and 2.03, respectively). Results for F2 testing were similar. For clinical utility, evidence was adequate that anticoagulation treatments were ineffective (except in antiphospholipid antibody syndrome) and had treatment-associated harms. The certainty of evidence is moderate (high, moderate, and low) that anticoagulation of women with recurrent pregnancy loss and F5/F2 variants would currently lead to net harms.

Multimodality, anatomical, and diffusion-weighted fetal imaging of a spontaneously thrombosing congenital dural sinus malformation.

We report on the conventional and diffusion-weighted (DWI) magnetic resonance imaging (MRI) findings of a partially thrombosed torcular Herophili dural sinus malformation. DWI confirmed the intralesional partial thrombosis/blood clot characterized by restricted diffusion. In addition, focal or global intracerebral complications were excluded by fetal DWI. Our findings suggest that DWI is a valuable adjunct to the standard T1- and T2-weighted fetal MRI sequences.

UGRC 2021 recommendations on GME transition: pros and cons, opportunities and limitations.

The Coalition for Physician Accountability's Undergraduate Medical Education-Graduate Medical Education (UME-GME) Review Committee (UGRC): Recommendations for Comprehensive Improvement of the UME-GME Transition final report includes a total of 34 recommendations and outlines opportunities to transform the current processes of learner transition from a US-based MD- or DO-granting medical school or international medical education pathway into residency training in the United States. This review provides a reflection on the recommendations from the authors, all members of the UGRC, describing the pros and cons and the opportunities and limitations, in the hopes that they might inspire readers to dig deeper into the report and contribute to meaningful improvements to the current transition. The UGRC Recommendations highlight the many opportunities for improvement in the UME-to-GME transition. They are built on the connection to the system of education and formation of physicians to a more just healthcare system, with attention to diversity, equity, and inclusion to improve health disparities and to the quality of care that patients receive. However, there are justifiable concerns about changes that are not fully understood or that could potentially lead to unintentional consequences. This analysis, reached through author consensus, considers the pros and cons in the potential application of the UGRC Recommendations to improve the UME-to-GME transition. Further debate and discussion are warranted, without undue delay, all with the intention to continue to improve the education of tomorrow's physicians and the care for the patients who we have the privilege to serve.

Facilitating an Optimal Transition to Residency in Obstetrics and Gynecology.

The transition to residency in obstetrics and gynecology is difficult, threatening the well-being of residents as well as their preparedness to care for patients. In addition to essential foundational knowledge and skills, obstetrics and gynecology interns must develop professional identity and a growth mindset toward learning to acquire the self-directed learning skills required of physicians throughout their careers. The transition to residency is a critical opportunity for learning and development. A group of educators and learners from around the country created a preparedness program building on available resources. The result is a national curriculum for improving the transition to obstetrics and gynecology residency on three levels: self-directed learning, facilitated small-group workshops, and coaching. Sharing tools for preparing matched applicants for residency in obstetrics and gynecology ensures adequate residency preparation for all interns, independent of medical school attended. This program aims to address potential threats to equity in the training of our future workforce and to ensure that all obstetrics and gynecology interns are prepared to thrive in residency training.

How We Do It: Student Perspectives on Changes to the Obstetrics and Gynecology Residency Application Process.

OBJECTIVE: To describe the perspectives of obstetrics and gynecology (OBGYN) residency applicants regarding new standards for the 2019 to 2020 application cycle. DESIGN: An anonymous electronic survey was sent to all OBGYN residency applicants to US programs retrospectively evaluating 5 new recommended standards for the application process. This 15-item survey assessed the importance of the proposed standards and their impact on applicants' anxiety. SETTING: The OBGYN residency application process is marked by increasing application numbers and no standardization for managing interview offers. The Association of Professors of Gynecology and Obstetrics (APGO) received a 5-year Reimagining Residency grant from the American Medical Association to improve the transition from undergraduate medical education (UME) to graduate medical education (GME) within OBGYN. The multiphase project, "Transforming the UME to GME Transition for Obstetrics and Gynecology- Right Resident, Right Program, Ready Day One (RRR)," began with Standardizing the OBGYN Application and Interview Process (SOAIP). This group recommended 5 new standards for all US OBGYN residency programs and applicants. PARTICIPANTS: Applicants for US OBGYN residency programs for the 2019 to 2020 application cycle completed the survey, with a 904/2508 (36.0%) response rate, including 762 complete responses (30.4%). RESULTS: Applicants reported that all 5 of the new standards would cause the least self-perceived anxiety (range 76.8% - 96.5%). The impact of the standards on perceived anxiety varied by student group, with International Medical Graduates (IMGs) and students with USMLE Step I scores <200 describing lesser impact compared to others. Despite these differences, all 5 standards were consistently noted to cause the least anxiety for all groups. Despite varying degrees of effects in different groups, the new OBGYN residency application standards caused the least anxiety for all subgroups of applicants. CONCLUSIONS: Implementing universal standards for the OBGYN residency application process was favorably perceived by applicants and caused the least anxiety for applicants.