Competence by Design: The Role of High-Stakes Examinations in a Competence Based Medical Education System.

Competency based medical education is developed utilizing a program of assessment that ideally supports learners to reflect on their knowledge and skills, allows them to exercise a growth mindset that prepares them for coaching and eventual lifelong learning, and can support important progression and certification decisions. Examinations can serve as an important anchor to that program of assessment, particularly when considering their strength as an independent, third-party assessment with evidence that they can predict future physician performance and patient outcomes. This paper describes the aims of the Royal College of Physicians and Surgeons of Canada's ("the Royal College") certification examinations, their future role, and how they relate to the Competence by Design model, particularly as the culture of workplace assessment and the evidence for validity evolves. For example, high-stakes examinations are stressful to candidates and focus learners on exam preparation rather than clinical learning opportunities, particularly when they should be developing greater autonomy. In response, the Royal College moved the written examination earlier in training and created an exam quality review, by a specialist uninvolved in development, to review the exam for clarity and relevance. While learners are likely to continue to focus on the examination as an important hurdle to overcome, they will be preparing earlier in training, allowing them the opportunity to be more present and refine their knowledge when discussing clinical cases with supervisors in the Transition to Practice phase. The quality review process better aligns the exam to clinical practice and can improve the educational impact of the examination preparation process.

The alignment imperative in curriculum renewal.

RATIONALE: There are perennial calls for MD curricula to reform in order to meet the changing needs of students, patients, and society. And yet, efforts at renewal have also been suggested to have minimal impact on the pedagogy and outcomes of medical education. One reason may be misalignment between the components of the curriculum during design and implementation. The University of Toronto MD program recently renewed its undergraduate preclinical Foundations curriculum. Mindful of the pitfalls of misalignment, the renewal process focused deliberately on alignment between the various components of the curriculum: instructional methods, student assessment, faculty development, and the larger purpose of serving students and society. INNOVATION: Educational evidence was used to drive the alignment process which resulted in three major changes. First, we created a spiral curriculum centered on 72 virtual patient cases designed to integrate content and prepare students for clinical learning. Second, we introduced a novel medical psychiatry component to address a core societal need in mental health. This exposed students early to experiences of complexity, ambiguity, and integrated patient care. Lastly, a shift to assessment for learning and programmatic assessment was designed and implemented concurrently to reinforce the pedagogy of the curriculum. Synchronous faculty development was developed for the new roles required of faculty. CONCLUSIONS: Early program evaluation shows alignment of these curricular components requires ongoing attention and resources in order to be successful. The potential benefits of this alignment are well prepared students who can meet the needs of their patients and society in an increasingly complex health system.

Building the Case for Nurses' Continuous Professional Development in Ethiopia: A Qualitative Study of the Sick Kids-Ethiopia Paediatrics Perioperative Nursing Training Program.

BACKGROUND: This study describes the in-service training experience of perioperative nurses from the SickKids-Ethiopia Paediatrics Perioperative Nursing Training Program in Addis Ababa, Ethiopia. The study emphasizes specifically how nurses applied the knowledge and skills gained from the Paediatrics Perioperative Nursing Training program in their subsequent practice and consider the situational factors that facilitated or hindered implementing these new knowledge and skills. METHODS: The first author led qualitative in-depth interviews with nine perioperative nurses who participated in training in September 2016, and systematically developed descriptive codes and themes to analyze the data. RESULTS: The authors found that participants experienced improved knowledge, skills, confidence, and job retention related to perioperative nursing practice after participating in Paediatrics Perioperative Nursing Training. Participants also stressed key challenges including lack of access to ongoing perioperative in-service training and problematic staffing policies that impact perioperative nurses' ability to fully utilize and share new knowledge gained during CPD training. CONCLUSION: The findings highlighted the value of specialized perioperative CPD training for Ethiopian nurses, yet also pointed to multidimensional challenges for knowledge translation and sustainability of best practices. The authors offer recommendations for individual and institutional strategies to address some of them.

Using the Readiness for Clerkship and Residency Surveys to Evaluate the Effectiveness of Four MD Programs: A Cross-Institutional Generalizability Study.

PURPOSE: The importance of confidence for learning and performance makes learners' perceptions of readiness for the next level of training valuable indicators of curricular success. The "Readiness for Clerkship" (RfC) and "Readiness for Residency" (RfR) surveys have been shown to provide reliable ratings of the relative effectiveness of various aspects of training. This study examines the generalizability of those results. METHOD: Surveys were administered at four medical schools approximately four months after the start of clerkship and eight months after the start of residency during 2013-2015. Collected data were anonymized. A total of 647 medical students and 483 residents participated. RESULTS: Reliabilities of G = 0.8 could be obtained with only 6 to 12 medical students and 8 to 15 residents. Within MD programs, no meaningful differences in item ratings were observed across cohorts. Residents in each school consistently rated themselves higher than clerks on the majority of Medical Expert and Communicator competencies common to both surveys. Similar strengths and weaknesses were identified across programs, but differences were observed on five clerkship items and one residency item. CONCLUSIONS: Across four MD programs, the RfC and RfR surveys provided reliable ratings of the relative effectiveness of aspects of training with small numbers of respondents. The capacity of these surveys to efficiently identify perceived strengths and weaknesses held by cohorts of learners may, thereby, facilitate program improvement.

Preoperative Practice Paired With Instructor Feedback May Not Improve Obstetrics-Gynecology Residents' Operative Performance.

BACKGROUND: There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied. OBJECTIVE: We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone. METHODS: We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool. RESULTS: A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15-36) compared to the PP group (14.5; range, 10-34) and the F group (21.25; range, 10.5-32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70-0.95) using the intraclass correlation coefficient. CONCLUSIONS: This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breech Deliveries.

OBJECTIVE: Achieving clinical competence in managing safe vaginal breech delivery (VBD) is challenging in contemporary obstetrics. Novel educational strategies are required, as exposure of obstetric trainees to VBD remains limited. The aim of this study was to identify the verbal and non-verbal skills required to manage VBD through filmed demonstration by experts. METHODS: Labour and delivery nursing staff at three large university-affiliated hospitals identified clinicians whom they considered skilled in VBD. Obstetricians consistently identified were invited to participate in the study. Participants were filmed performing a VBD on a birth simulator while discussing their assessment, technique, and providing clinical pearls based on their experience. Two study members reviewed all videos and documented verbal and non-verbal components of the assessment, grouped them into common themes, and produced an integrated summary. This was circulated to all participants and reviewed by senior obstetricians from outside Canada. RESULTS: Seventeen clinicians were identified; 12 (70%) consented to participation. Themes identified were meticulous assessment and pre-pregnancy counselling; roles of the multidisciplinary team; need for careful and appropriate communication with parents; specific techniques of the delivery; and postpartum care and documentation. A clinical task list was generated based on this analysis. CONCLUSION: Derived from clinicians with extensive experience, we have developed a comprehensive task list outlining the important features involved in safe VBD. Common themes in the experts' teaching for safe VBD included rigorous antepartum selection and counselling, appreciation for when to convert to Caesarean section, and a "hands off" delivery technique.

Objectif : De nos jours, dans le domaine de l'obstétrique, il est difficile d'acquérir les compétences cliniques nécessaires à la tenue d'un accouchement vaginal du siège (AVS) en toute sûreté. Des stratégies pédagogiques novatrices sont requises, puisque l'exposition des stagiaires en obstétrique à l'AVS demeure limitée. Cette étude avait pour objectif d'identifier, au moyen de démonstrations filmées par des spécialistes, les compétences verbales et non verbales nécessaires à la prise en charge de l'AVS. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois importants hôpitaux universitaires ont identifié les cliniciens qu'ils considéraient comme étant compétents en matière d'AVS. Les obstétriciens les plus souvent identifiés ont été conviés à participer à l'étude. Les participants ont été filmés alors qu'ils procédaient à un AVS sur un simulateur d'accouchement; à ces occasions, nous leur avons également demandé de nous entretenir de leur évaluation et de leur technique, ainsi que de nous fournir des conseils cliniques issus de leur expérience. Deux membres de l'étude ont passé en revue toutes les vidéos et ont documenté les composantes verbales et non verbales de l'évaluation, les ont groupées en thèmes communs et en ont rédigé une synthèse. Cette synthèse a été transmise à tous les participants et a été analysée par des obstétriciens expérimentés de l'étranger. Résultats : Dix-sept cliniciens ont été identifiés; 12 (70 %) ont consenti à participer à l'étude. Parmi les thèmes identifiés, on trouvait les suivants : évaluation méticuleuse et counseling prégrossesse; rôles de l'équipe multidisciplinaire; nécessité d'une communication attentive et adéquate avec les parents; techniques d'accouchement particulières; et documentation et soins postpartum. Une liste des tâches cliniques a été générée en fonction des résultats de cette analyse. Conclusion : En nous inspirant de cliniciens vastement expérimentés, nous avons élaboré une liste exhaustive de tâches soulignant les caractéristiques importantes de la tenue d'un AVS en toute sûreté. Parmi les thèmes courants relevés par ces spécialistes à ce sujet, on trouvait la tenue antepartum d'une sélection et d'un counseling rigoureux, les connaissances requises pour savoir quand convertir l'intervention en césarienne et l'utilisation d'une technique d'accouchement « passive ¼ (hands off).

Learning From Experience: Development of a Cognitive Task List to Perform a Safe and Successful Non-Rotational Forceps Delivery.

OBJECTIVE: Increased rates of delivery by Caesarean section have resulted in a reduction in rates of instrumental deliveries. This has led to a new educational challenge for teaching and development of skills. In teaching trainees, there are subconscious tasks that the supervising staff may not review because they are automatic. This study aimed to create a new tool to meet this challenge: to identify the core steps required to perform a non-rotational forceps delivery safely and successfully. METHODS: Labour and delivery nursing staff of three large teaching hospitals were asked to identify clinicians they considered to be particularly skilled in non-rotational forceps deliveries. Obstetricians who were identified consistently in this way were invited to participate in the study. After providing written consent, participants were then filmed performing a non-rotational forceps delivery on a model. Two clinicians reviewed all videos and documented verbal and non-verbal components of the assessment. Thematic analysis combined findings into an integrated summary. The initial summary was then circulated to all participants for their approval. RESULTS: Seventeen clinicians were identified and consented. Themes identified included the need for careful assessment of suitability for operative delivery, the role of the multidisciplinary team, the need for careful and appropriate communication with the parents, the technique of delivery itself, and postpartum care and documentation. CONCLUSION: In the core steps identified, the clinicians balanced respect for the "elegant technique" of non-rotational forceps deliveries with careful assessment and knowing when to stop if safety criteria were not met.

Objectif : La hausse des taux d'accouchement par césarienne a entraîné une baisse des taux d'accouchement instrumental. Cette situation a donné lieu à un nouveau défi sur le plan pédagogique en ce qui concerne l'enseignement et l'acquisition de compétences. Dans le cadre de l'enseignement offert aux stagiaires, certaines tâches menées par le subconscient pourraient passer inaperçues (car elles sont automatiques) et donc ne pas être abordées par le personnel de supervision. Cette étude avait pour but de créer un nouvel outil pour relever ce défi : identifier les étapes de base requises pour la réussite d'un accouchement par forceps non rotationnels en toute sûreté. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois hôpitaux universitaires d'envergure ont identifié les cliniciens qu'ils considéraient comme étant particulièrement compétents en matière d'accouchements par forceps non rotationnels. Les obstétriciens dont les noms revenaient les plus souvent ont été conviés à participer à l'étude. Après avoir offert leur consentement par écrit, les participants ont été filmés pendant l'exécution d'un accouchement par forceps non rotationnels sur un modèle. Deux cliniciens ont passé en revue toutes les vidéos et ont documenté toutes les composantes verbales et non verbales de l'évaluation. Une analyse thématique a combiné les résultats en un résumé intégré. Le résumé initial a par la suite été distribué aux participants pour que l'on obtienne leur approbation. Résultats : Dix-sept cliniciens ont ainsi été identifiés et ont consenti à participer à l'étude. Les thèmes identifiés ont été les suivants : la nécessité de procéder à une évaluation rigoureuse de l'admissibilité de la patiente à un accouchement opératoire, le rôle de l'équipe multidisciplinaire, la nécessité d'une communication rigoureuse et adaptée avec les parents, la technique d'accouchement en tant que telle et les soins et la documentation pendant le postpartum. Conclusion : Au moment d'identifier les étapes de base, les cliniciens ont mis en balance leur respect envers « l'élégance de la technique ¼ utilisée pour les accouchements par forceps non rotationnels avec la nécessité de procéder à une évaluation rigoureuse et le fait de savoir quand mettre fin à l'intervention lorsque les critères de sûreté ne peuvent être satisfaits.

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Kielland Forceps Deliveries.

OBJECTIVE: Fetal malposition is a common indication for Caesarean section in the second stage of labour. Rotational (Kielland) forceps are a valuable tool in select situations for successful vaginal delivery; however, learning opportunities are scarce. Our aim was to identify the verbal and non-verbal components of performing a safe Kielland forceps delivery through filmed demonstrations by expert practitioners on models to develop a task list for training purposes. METHODS: Labour and delivery nurses at three university-affiliated hospitals identified clinicians whom they considered skilled in Kielland forceps deliveries. These physicians gave consent and were filmed performing Kielland forceps deliveries on a model, describing their assessment and technique and sharing clinical pearls based on their experience. Two clinicians reviewed the videos independently and recorded verbal and non-verbal components of the assessment; thematic analysis was performed and a core task list was developed. The algorithm was circulated to participants to ensure consensus. RESULTS: Eleven clinicians were identified; eight participated. Common themes were prevention of persistent malposition where possible, a thorough assessment to determine suitability for forceps delivery, roles of the multidisciplinary team, description of the Kielland forceps and technical aspects related to their use, the importance of communication with the parents and the team (including consent, debriefing, and documentation), and "red flags" that indicate the need to stop when safety criteria cannot be met. CONCLUSION: Development of a cognitive task list, derived from years of experience with Kielland forceps deliveries by expert clinicians, provides an inclusive algorithm that may facilitate standardized resident training to enhance education in rotational forceps deliveries.

Objectif : La malposition fœtale constitue une indication courante menant à la tenue d'une césarienne au cours du deuxième stade du travail. Les forceps de Kielland sont un outil utile dans certaines situations pour assurer la réussite de l'accouchement vaginal; toutefois, les occasions d'en apprendre l'utilisation se font rares. Nous avions pour objectif d'identifier les composantes verbales et non verbales de la tenue en toute sûreté d'un accouchement au moyen de forceps de Kielland en filmant des démonstrations menées par des praticiens spécialisés sur des modèles, et ce, dans le but de rédiger une liste de tâches à des fins pédagogiques. Méthodes : Les infirmières du service d'obstétrique de trois hôpitaux universitaires ont identifié les cliniciens qu'elles considéraient comme étant compétents en ce qui concerne les accouchements par forceps de Kielland. Ces médecins ont consenti à l'entreprise et ont été filmés pendant l'exécution d'un accouchement par forceps de Kielland sur un modèle; pendant cette simulation, ils ont pris soin de décrire leur évaluation et leur technique, en plus de partager des conseils cliniques fondés sur leur expérience. Deux cliniciens ont passé en revue les vidéos de façon indépendante et ont consigné les composantes verbales et non verbales de l'évaluation; une analyse thématique a été menée et une liste de tâches de base a été élaborée. L'algorithme a été distribué aux participants afin d'assurer un consensus. Résultats : Onze cliniciens ont été identifiés; huit d'entre eux ont consenti à participer au projet. Les thèmes communs ont été la prévention de la malposition persistante (dans la mesure du possible), une évaluation exhaustive visant à déterminer la pertinence de la tenue d'un accouchement par forceps, les rôles de l'équipe multidisciplinaire, la description des forceps de Kielland et les aspects techniques associés à leur utilisation, l'importance de la communication avec les parents et l'équipe (y compris le consentement, le débreffage et la documentation), et les « signaux d'alarme ¼ qui indiquent la nécessité de mettre fin à l'intervention lorsque les critères d'innocuité ne peuvent être assurés. Conclusion : L'élaboration d'une liste de tâches cognitives, tirée des années d'expérience de cliniciens spécialisés en ce qui a trait à la tenue d'accouchements par forceps de Kielland, offre un riche algorithme qui pourrait faciliter la standardisation de la formation des résidents, de façon à améliorer l'enseignement de tels accouchements.

Learning from experience: development of a cognitive task-list to assess the second stage of labour for operative delivery.

OBJECTIVE: Ensuring the availability of operative vaginal delivery is one strategy for reducing the rising Caesarean section rate. However, current training programs appear inadequate. We sought to systematically identify the core steps in assessing women in the second stage of labour for safe operative delivery, and to produce an expert task-list to assist residents and obstetricians in deciding on the safest mode of delivery for their patients. METHODS: Labour and delivery nursing staff of three large university-associated hospitals identified clinicians they considered to be skilled in operative vaginal deliveries. Obstetricians who were identified consistently were invited to participate in the study. Participants were filmed performing their normal assessment of the second stage of labour on a model. Two clinicians reviewed all videos and documented all verbal and non-verbal components of the assessment; these components were grouped into overarching themes and combined into an integrated expert task-list. The task-list was then circulated to all participants for additional comments, checked against SOGC guidelines, and redrafted, allowing production of a final expert task-list. RESULTS: Thirty clinicians were identified by this process and 20 agreed to participate. Themes identified were assessment of suitability, focused history, physical examination including importance of an abdominal examination, strategies to accurately assess fetal position, station, and the likelihood of success, cautionary signs to prompt reassessment in the operating room, and warning signs to abandon operative delivery for Caesarean section. Communication strategies were emphasized. CONCLUSION: Having expert clinicians teach assessment in the second stage of labour is an important step in the education of residents and junior obstetricians to improve confidence in managing the second stage of labour.

Objectif : Le fait d'assurer la disponibilité de l'accouchement vaginal opératoire constitue l'une des stratégies pouvant permettre d'atténuer la hausse des taux de césarienne. Toutefois, les programmes de formation actuels semblent inadéquats. Nous avons cherché à identifier, de façon systématique, les étapes de base de l'évaluation des femmes en étant au deuxième stade du travail afin de déterminer si la tenue d'un accouchement opératoire sûr s'avère possible dans leur cas, ainsi qu'à formuler une liste de tâches spécialisée visant à aider les résidents et les obstétriciens à déterminer le mode d'accouchement le plus sûr pour leurs patientes. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois hôpitaux universitaires d'envergure ont identifié les cliniciens qu'ils considéraient comme étant particulièrement compétents en matière d'accouchements vaginaux opératoires. Les obstétriciens dont les noms revenaient les plus souvent ont été conviés à participer à l'étude. Les participants ont été filmés pendant l'exécution d'une évaluation normale du deuxième stade du travail sur un modèle. Deux cliniciens ont passé en revue toutes les vidéos et ont documenté toutes les composantes verbales et non verbales de l'évaluation; ces composantes ont été groupées en thèmes généraux et combinées sous forme d'une liste de tâches spécialisée intégrée. Cette liste de tâches a par la suite été remise à tous les participants pour qu'ils puissent formuler des commentaires additionnels, vérifiée en fonction des directives cliniques de la SOGC et reformulées, ce qui a permis la production d'une liste de tâches spécialisée finale. Résultats : Trente cliniciens ont ainsi été identifiés et 20 d'entre eux ont consenti à participer à l'étude. Les thèmes identifiés ont été les suivants : évaluation du caractère adéquat de l'intervention, anamnèse ciblée, examen physique (y compris l'importance de la tenue d'un examen abdominal), stratégies permettant de déterminer avec précision la position et la station fœtales (et la probabilité de réussite), signes de mise en garde devant mener à une réévaluation immédiate en salle d'opération et signes d'avertissement devant mener à l'abandon de l'accouchement opératoire au profit de la césarienne. Des stratégies de communication ont été soulignées. Conclusion : Le fait de pouvoir compter sur l'apport de cliniciens spécialisés pour l'enseignement de l'évaluation au cours du deuxième stade du travail constitue un facteur important dans l'éducation des résidents et des obstétriciens débutants, de façon à ce qu'ils puissent gagner en confiance pour ce qui est de la prise en charge du deuxième stade du travail.

Using a situational awareness global assessment technique for interprofessional obstetrical team training with high fidelity simulation.

Evidence suggests that breakdowns in communication and a lack of situation awareness contribute to poor performance of medical teams. In this pilot study, three interprofessional obstetrical teams determined the feasibility of using the situation awareness global assessment technique (SAGAT) during simulated critical event management of three obstetrical scenarios. After each scenario, teams were asked to complete questionnaires assessing their opinion of how their performance was affected by the introduction of questions during a SAGAT stop. Fifteen obstetrical professionals took part in the study and completed the three scenarios in teams consisting of five members. At nine questions per stop, more participants agreed or strongly agreed that there were too many questions per stop (57.1%) than when we asked six questions per stop (13%) and three questions per stop (0%). A number of interprofessional differences in response to this interprofessional experience were noted. A team SAGAT score was determined by calculating the proportion of correct responses for each individual. Higher scores were associated with better adherence to outcome times, although not statistically significant. A robust study design building on our pilot data is needed to probe the differing interprofessional perceptions of SAGAT and the potential association between its scores and clinical outcome times.

Does surgical "warming up" improve laparoscopic simulator performance?

INTRODUCTION: The objective of this study was to determine if preoperative warming up by obstetrics and gynecology trainees, using a validated bench model for intracorporeal suturing, improves efficiency, precision, and quality of laparoscopic suturing. METHODS: A randomized crossover design was used. Fourteen obstetrics and gynecology residents were randomized [3 junior (year 2) and 11 senior (years 3-5) residents]. Participants were randomized to warm-up or no warm-up and then acted as their own controls at least 2 weeks later. Warm-up consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes. All participants performed a prevalidated intracorporeal suturing task (after either warm-up or no warm-up), which was scored based on time, precision, and knot strength. Each participant also completed a questionnaire anonymously to determine if they believed that warming up improved their performance, regardless of the score they received. RESULTS: Thirteen participants completed the study. There was no difference in score when warm-up was compared with no warm-up for the group as a whole. When the junior residents were excluded from the analysis, however, analysis of variance showed a significant improvement in score only when a warm-up was completed in the second session (P = 0.022). The questionnaire revealed that 81.8% of participants felt that warming up subjectively improved their ability, independent of their actual score. CONCLUSIONS: This study demonstrates that a preoperative warm-up, combined with repetition, is beneficial in improving senior obstetrics and gynecology residents' laparoscopic suturing performance. This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills.

Determination of the psychometric properties of a behavioural marking system for obstetrical team training using high-fidelity simulation.

BACKGROUND: To determine the effectiveness of high-fidelity simulation for team training, a valid and reliable tool is required. This study investigated the internal consistency, inter-rater reliability and test-retest reliability of two newly developed tools to assess obstetrical team performance. METHODS: After research ethics board approval, multidisciplinary obstetrical teams participated in three sessions separated by 5-9 months and managed four high-fidelity simulation scenarios. Two tools, an 18-item Assessment of Obstetric Team Performance (AOTP) and a six-item Global Assessment of Obstetric Team Performance (GAOTP) were used.(5) Eight reviewers rated the DVDs of all teams' performances. RESULTS: Two AOTP items were consistently incomplete and omitted from the analyses. Cronbach's α for the 16-item AOTP was 0.96, and 0.91 for the six-item GAOTP. The eight-rater α for the GAOTP was 0.81 (single-rater intra-class correlation coefficient, 0.34) indicating acceptable inter-rater reliability. The 'four-scenario' α for the 12 teams was 0.79 for session 1, 0.88 for session 2, and 0.86 for session 3, suggesting that performance is not being strongly affected by the context specificity of the cases. Pearson's correlation of team performance scores for the four scenarios were 0.59, 0.35, 0.40 and 0.33, and for the total score across scenarios it was 0.47, indicating moderate test-retest reliability. CONCLUSIONS: The results from this study indicate that the GAOTP would be a sufficient assessment tool for obstetrical team performance using simulation provided that it is used to assess teams with at least eight raters to ensure a sufficiently stable score. This could allow the quantitative evaluation of an educational intervention.

The relationship between sexual functioning and depressive symptomatology in postpartum women: a pilot study.

INTRODUCTION: Previous research on postpartum sexuality has primarily focused on the impact of physical factors on the resumption and frequency of sexual intercourse; fewer studies have focused on the impact of psychological factors on women's sexual functioning. AIM: The aim of this study is to assess current sexual functioning and sexual behavior in women with and without symptoms of postpartum depression using validated measures of postpartum depression and sexual functioning. METHODS: Women attending postpartum appointments were consecutively recruited over a 12-month period and completed questionnaires assessing sexual functioning, current sexual behavior, and mental health. MAIN OUTCOME MEASURES: The Female Sexual Function Index (FSFI), the Edinburgh Postnatal Depression Scale (EPDS), and items assessing current sexual behaviors. RESULTS: A total of 77 women returned completed questionnaire packages (mean postpartum weeks: 13, range 3-24). Of these, 57 women (74%) had engaged in sexual activity with a partner in the 4 weeks prior to completing the questionnaire. The mean FSFI score was 23.0 (range 6-34), with 37 women (65%) scoring in the range associated with clinical sexual dysfunction. Women with elevated EPDS scores had significantly lower total FSFI, arousal, orgasm, and satisfaction FSFI subscale scores (all P values <0.005) than nondepressed women, suggesting more problematic sexual functioning. Desire, lubrication, and pain FSFI subscale scores were not significantly associated with depression status. CONCLUSIONS: A substantial proportion of women experience sexual problems in the postpartum period; these problems are particularly pronounced among women with symptoms of postpartum depression. Longitudinal research is needed to better understand the relationship between sexual dysfunction and depression among postpartum women, and to identify implications for prevention and treatment of both conditions.

Omega-3 supplements in pregnancy: are we too late to identify the possible benefits?

OBJECTIVE: Postpartum depression (PPD) is a common and recurring illness. Most women who experience PPD do not seek professional help; for those who do, the available treatment options are not supported by extensive research evidence. Several lines of research have linked omega-3 fatty acids (omega-3) supplementation with a reduced risk of PPD. Although it has been suggested that women in the perinatal period consume sufficient omega-3 to potentially prevent PPD, there is a lack of definitive research evidence. This pilot study surveyed pregnant women's current use of omega-3, multivitamin, and other supplements, as well as their attitudes toward omega-3 research during pregnancy, to assess the feasibility of pregnant women's participation in a large randomized controlled trial evaluating omega-3 supplementation. METHODS: Women attending prenatal clinics over a three-week period were invited to participate in a survey. The survey contained an information letter that was followed by a brief questionnaire assessing the use of nutritional supplements and opinions regarding the likelihood of participating in a clinical trial during pregnancy. RESULTS: Of the 176 women who completed the survey, six women were in the first trimester of pregnancy, 82 were in the second trimester, and 87 were in the third trimester. One hundred fifty-nine respondents (90.3%) reported taking a multivitamin supplement but none were taking a supplement that contained omega-3; only 20 (11.4%) were taking omega-3. Seventy-eight women (44.4%) responded that they would participate in a clinical study evaluating the effects of fish oil on their health. CONCLUSION: The results of our study indicate that many pregnant women take prenatal multivitamins and nutritional supplements, that there are currently few pregnant women attending clinics at our hospitals who are supplementing with omega-3, and that pregnant women would be willing to participate in a clinical trial evaluating the effects of omega-3.

Evaluating teamwork in a simulated obstetric environment.

BACKGROUND: The National Confidential Enquiry into Maternal Deaths identified "lack of communication and teamwork" as a leading cause of substandard obstetric care. The authors used high-fidelity simulation to present obstetric scenarios for team assessment. METHODS: Obstetric nurses, physicians, and resident physicians were repeatedly assigned to teams of five or six, each team managing one of four scenarios. Each person participated in two or three scenarios with differently constructed teams. Participants and nine external raters rated the teams' performances using a Human Factors Rating Scale (HFRS) and a Global Rating Scale (GRS). Interrater reliability was determined using intraclass correlations and the Cronbach alpha. Analyses of variance were used to determine the reliability of the two measures, and effects of both scenario and rater profession (R.N. vs. M.D.) on scores. Pearson product-moment correlations were used to compare external with self-generated assessments. RESULTS: The average of nine external rater scores showed good reliability for both HFRS and GRS; however, the intraclass correlation coefficients for a single rater was low. There was some effect of rater profession on self-generated HFRS but not on GRS. An analysis of profession-specific subscores on the HFRS revealed no interaction between profession of rater and profession being rated. There was low correlation between externally and self-generated team assessments. CONCLUSIONS: This study does not support the use of the HFRS for assessment of obstetric teams. The GRS shows promise as a summative but not a formative assessment tool. It is necessary to develop a domain specific behavioral marking system for obstetric teams.

Factors affecting academic promotion in obstetrics and gynaecology in Canada.

OBJECTIVE: (1) To determine if women faculty members in departments of Obstetrics and Gynaecology were less likely than men to achieve promotion; and (2) to assess gender differences in attitudes towards promotion. METHODS: Department chairs at the 16 medical schools in Canada were approached to participate in this study. A questionnaire was mailed to the obstetricians/gynaecologists in faculties of medicine at the 15 Canadian medical schools that agreed to participate. Likelihood of promotion for women and men was compared using survival analysis, controlling for other factors. Survival (event) time was the time in years between completion of residency and achieving promotion. RESULTS: The response rate was 72% (376/522). Overall, 37% of respondents were women, and 63% were men. The women respondents were younger than the men, with a mean age of 43.4 +/- 7.9 years compared to 52.8 +/- 8.9 years. Of those in an academic stream, 39% of women (29/75) and 62% of men (90/145) had attained senior academic ranks. Completing residency more recently was associated with a higher likelihood of promotion to Assistant Professor (hazard ratio [HR], 1.05; P <0.001). The likelihood of promotion to Professor was lower for women than for men (HR, 0.40; P = 0.05). Having a mentor was associated with a higher likelihood of promotion to Professor (HR, 2.33; P = 0.002). Women were more likely to perceive barriers to promotion, such as family care responsibilities (P <0.001). CONCLUSION: Independent of the respondent's gender, recent completion of residency and having a mentor were the most significant factors increasing the likelihood of promotion in Canadian medical school departments of Obstetrics and Gynaecology. As women were found to be less likely than men to achieve promotion to Professor, mentoring and strategies that focus on facilitating promotion for women should be encouraged to ensure there are academic leaders in obstetrics and gynaecology in the future.

Reliability Study of the Laparoscopic Skills Index (LSI): a new measure of gynaecologic laparoscopic surgical skills.

OBJECTIVE: To construct and test the reliability of the Laparoscopic Skills Index (LSI) as a new, multi-item, objective measure of laparoscopic skills in gynaecology. METHODS: Construction of the LSI involved (1). item selection, (2). choosing a method to scale responses, (3). design, and (4). choosing a scoring method. Internal consistency and rater reliability were tested. One community-based gynaecologist (rater A) and 3 teaching faculty gynaecologists (raters B, C, and D) reviewed 20 videotaped gynaecologic laparoscopy operations and scored operator (subject) performance. RESULTS: Cronbach's a was 0.95, indicating a high level of internal consistency. The intraclass correlation coefficient (ICC) for all 4 raters was 0.51 (95% confidence interval [CI], 0.20-0.76), indicative of moderate interrater reliability. A systematic observer bias was seen wherein rater A's scores closely paralleled, but were consistently higher than, those of raters B, C, and D. The ICC for raters B, C, and D only was 0.77 (95% CI, 0.56-0.90), which is consistent with very good rater agreement. CONCLUSION: The LSI appears to have the properties of a reliable, unidimensional index, in which the item variables are true components of the overall attribute, that is, laparoscopic skill.