The Association of Master Adaptive Learning With Less Burnout and More Resilience in Obstetrics and Gynecology Residents.

PURPOSE: Medical education should prepare learners for complex and evolving work, and should ideally include the Master Adaptive Learner (MAL) model-meta-learning skills for continuous self-regulated learning. This study aimed to measure obstetrics and gynecology (OB/GYN) residents' MAL attributes, assess associations with burnout and resilience, and explore learning task associations with MAL. METHOD: OB/GYN residents were surveyed electronically at an in-training examination in January 2022. The survey included demographic information, the 2-item Maslach Burnout Inventory, the 2-item Connor-Davidson Resilience Scale, 4 MAL items (e.g., "I take every opportunity to learn new things"), and questions about training and learning experiences. RESULTS: Of 5,761 residents, 3,741 respondents (65%) were included. A total of 1,478 of 3,386 (39%) demonstrated burnout (responded positive for burnout on emotional exhaustion or depersonalization items). The mean (SD) Connor-Davidson Resilience Scale score was 6.4 (1.2) of a total possible score of 8. The mean (SD) MAL score was 16.3 (2.8) of a total possible score of 20. The MAL score was inversely associated with burnout, with lower MAL scores for residents with (mean [SD] MAL score, 16.5 [2.4]) vs without (mean [SD], 16.0 [2.3]) burnout (P < .001). Higher MAL scores were associated with higher resilience (R = 0.29, P < .001). Higher MAL scores were associated with the statement, "I feel that I was well prepared for my first year of residency" (R = 0.19, P < .001) and a plan to complete subspecialty training after residency (mean [SD] of 16.6 [2.4] for "yes" and 16.2 [2.4] for "no," P < .001). CONCLUSIONS: Residents who scored higher on MAL showed more resilience and less burnout. Whether less resilient, burned-out residents did not have the agency to achieve MAL status or whether MAL behaviors filled the resiliency reservoir and protected against burnout is not clear.

Program Signaling in Obstetrics and Gynecology Residency Applications.

The objectives of this study were to evaluate how obstetrics and gynecology residency program directors used applicant signaling and to understand how two tiers of signals influenced interviews, ranking, and matching into programs. A multimethod, deductive-sequential design was employed using a national survey of residency program directors and a convenience sampling of programs to study how obstetrics and gynecology program directors used program signals in the 2022-2023 residency-application cycle. A total of 80.5% (236/293) of program directors receiving the survey provided information about signaling, and 20 programs provided application outcome data for applicants who signaled them. The majority of program directors (86.9%) opted into signaling, 43.4% used signals as part of their initial screening, and 33.1% used it as a tiebreaker after reviewing applications, with 45.4% feeling it improved their ability to conduct a holistic review and 41.5% inviting applicants they may not have invited previously. Among programs providing applicant data, the influence of signals on the chances of an applicant being interviewed varied, but an overall strong positive effect of signaling was observed across the sample. The mean rank was 42 for gold signals, 45 for silver, and 38 for no signal (F(3)=5.97, P <.001). Signaling was widely used by programs and was an effective tool to allow applicants to communicate real interest in a program. Signaling was associated with an increased likelihood of an applicant's being interviewed but did not influence an applicant's position on the rank list.

Away Rotations in Obstetrics and Gynecology: A Survey of Program Directors.

OBJECTIVE: To evaluate residency program director views on the purpose and value of an away rotation for students applying to a residency application in Obstetrics and Gynecology (OBGYN). DESIGN, SETTING, AND PARTICIPANTS: The Council on Resident Education in Obstetrics and Gynecology administered a 28-question survey to current U.S. program directors in OBGYN in 2022. Program directors were asked if they offered away rotations to visiting medical students and if so, what the purpose the rotation played in their application process and whether rotating students were automatically offered a residency interview. Program characteristics such as program size, geographic location, and program type (university, community, or military based) were ascertained. A test of proportions was utilized to understand the relationship between program description and survey responses. RESULTS: Seventy-nine percent (224/285) of OBGYN PDs responded to the survey and consented to participation. Programs were representative of the types of training program, size of programs, and geographic location. Of respondents, 77.2% (173/224) of PDs indicated that away rotations were offered at their institution, but only 26.6% (46/173) of residency PDs assessed prospective candidates for away electives. The opportunity to provide students an audition for a residency position was the most common reason to offer an elective. Only 34.7% (60/173) of OBGYN PDs guaranteed an interview to students who completed away electives at their institution. The majority (118/173, 68.2%) of PDs indicated less than 25% of their current residents had completed an away rotation with their program. CONCLUSIONS: Many residency programs offered away electives to prospective applicants, but the majority did not personally assess applicants for competitiveness or guarantee interviews to students completing electives. To increase transparency in the application process, programs should publicize the purpose of away rotations and provide information on the number of interviews granted to students who complete away rotations.

Delaying the Fellowship Start Date in Obstetrics and Gynecology.

OBJECTIVE: To evaluate residents planning fellowship, their preferences for fellowship start date, and the acceptability of resultant gaps in pay and insurance coverage. METHODS: A survey was conducted during the 2022 in-service training examination querying obstetrics and gynecology residents about their desire to pursue fellowship, their preferred fellowship start date (understanding the salary gap), and the acceptability of a medical insurance gap. RESULTS: Survey analysis of respondents planning to pursue fellowship demonstrated that, acknowledging the pay gap that would occur, 93.9% preferred a fellowship start date after July 1, with the majority (65.1%, 593/911) preferring an August 1 fellowship start date. Most respondents (87.7%, 798/910) found the potential resultant gap in medical insurance coverage acceptable. Survey data showed that racial and ethnic identity was not a determining factor in either of these issues. CONCLUSION: The majority of current residents planning to pursue fellowship prefer a delayed fellowship start date, even if it means a gap in salary and insurance coverage. The results of this study, requested by a specialty-wide, consensus-building workgroup, informed a statement signed by the majority (88.9%) of workgroup constituents supporting an August 1 clinical fellowship start date.

Resident and program director confidence in resident preparedness for operative vaginal deliveries in Obstetrics and Gynecology Training Programs in the United States.

BACKGROUND: Operative vaginal delivery is used to expedite a safe vaginal delivery in the second stage of labor and is considered an essential part of residency training in obstetrics and gynecology. OBJECTIVE: To assess the self-reported readiness of obstetrics and gynecology residents in the United States to perform vacuum-assisted vaginal delivery and forceps-assisted vaginal delivery compared with the perceptions of program directors. STUDY DESIGN: The Council on Resident Education in Obstetrics and Gynecology surveyed the residents in all US training programs about their readiness to perform forceps-assisted and vacuum-assisted deliveries. The program directors were simultaneously surveyed about the readiness of their cohort to perform operative deliveries with and without attending oversight. The primary outcome of the survey was the residents' self-reported confidence in their ability to autonomously and independently perform operative deliveries. RESULTS: Α total of 5084 out of 5514 (92.9%) resident physicians and 241 out of the 292 (83%) residency program directors completed the survey. Eighty-seven percent (95% confidence interval, 84.9-88.9) of the graduating residents reported feeling that they could autonomously perform a vacuum-assisted vaginal delivery, compared with 49.5% (95% confidence interval, 46.6-52.4) for forceps-assisted vaginal delivery (P<.01). Similarly, whereas 95.9% (95% confidence interval, 94.6-97.0) of the residents felt that they could confidently perform an emergency vacuum-assisted vaginal delivery, only 42.3% (95% confidence interval, 39.4-45.2) felt confident performing an emergency forceps-assisted vaginal delivery (P<.01). The residency program directors significantly overestimated their residents' confidence in independently performing an emergency forceps-assisted vaginal delivery or vacuum-assisted vaginal delivery than the residents themselves (54% [95% confidence interval, 47.1-60.5] vs 24% [95% confidence interval, 22.5-24.9] and 98.6% [95% confidence interval, 97.0-100] vs 71.9 [95% confidence interval, 70.6-73.2] respectively P<.01). Trainees in military-based residency programs and those interested in pursuing a career as generalists or maternal-fetal medicine specialists reported significantly higher preparedness to perform a forceps-assisted vaginal delivery. CONCLUSION: Graduating obstetrics and gynecology residents report feeling less prepared to independently perform a forceps-assisted vaginal delivery than a vacuum-assisted vaginal delivery. The program directors had more confidence in the ability of their residents to perform an operative vaginal delivery than the residents themselves.

Mental Health Conditions Increase Severe Maternal Morbidity By 50 Percent And Cost $102 Million Yearly In The United States.

Perinatal mental health disorders are increasingly acknowledged as contributors to adverse maternal outcomes. We analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample (2016 and 2017) to estimate hospitalization cost, length-of-stay, and severe maternal morbidity associated with perinatal mental health disorders overall, as well as stratified by payer and by specific mental health category. We found that people with mental health disorders had $458 higher costs per delivery hospitalization and 50 percent higher rates of severe maternal morbidity compared with people without mental health disorders. We estimated increased annual delivery hospitalization costs of $102 million in the US among people with perinatal mental health conditions compared with those without. Furthermore, people diagnosed with trauma- or stress-related mental health disorders had even higher rates of hospitalization costs-$825 higher per delivery-and 87 percent higher rates of severe maternal morbidity compared with people without those diagnoses. These findings provide important information for perinatal mental health program feasibility and cost-effectiveness analyses and suggest the need for increased focus on trauma- and stress-related disorders.

Promoting Diversity, Equity, and Inclusion in the Selection of Obstetrician-Gynecologists.

In the setting of long-standing structural racism in health care, it is imperative to highlight inequities in the medical school-to-residency transition. In obstetrics and gynecology, the percentage of Black residents has decreased in the past decade. The etiology for this troubling decrease is unknown, but racial and ethnic biases inherent in key residency application metrics are finally being recognized, while the use of these metrics to filter applicants is increasing. Now is the time for action and for transformational change to rectify the factors that are detrimentally affecting the racial diversity of our residents. This will benefit our patients and learners with equitable health care and better outcomes.

Surveying Obstetrics and Gynecology Residents About Their Residency Applications, Interviews, and Ranking.

BACKGROUND: Residency applications have increased in the last decade, creating growing challenges for applicants and programs. OBJECTIVE: We evaluated factors associated with application and match into obstetrics and gynecology residency. METHODS: During the annual in-training examination administered to all obstetrics and gynecology residents in the United States, residents were surveyed on the residency application process. RESULTS: Ninety-five percent (5094 of 5347) residents responded to the survey. Thirty-six percent reported applying to 30 or fewer programs, 26.7% applied to more than 31 programs, and 37.1% opted not to answer this question. Forty-nine percent of residents received honors in their obstetrics and gynecology clerkship and 37.1% did not. The majority of residents (88.6%) reported scoring between 200 and 250 on USMLE Step 1. Eighty-six percent matched into one of their top 5 programs. The only factor associated with matching in residents' top 5 programs was receiving honors in their clerkship (OR 1.29; 95% CI 1.08-1.54; P < .005). The only factor associated with matching below the top 5 programs was a couples match (OR 0.56; 95% CI 0.43-0.72; P < .001). In choosing where to apply, residents identified program location and reputation as the most important factors, while for ranking, location and residency culture were the most important. CONCLUSIONS: Most obstetrics and gynecology residents reported matching into their top 5 choices. Receiving an honors grade in the clerkship was the only factor associated with matching in applicants' top 5 programs. Location was the most important factor for applying to and ranking of programs.

Associations Between Comorbidities and Severe Maternal Morbidity.

OBJECTIVE: To evaluate the associations between the number of chronic conditions and maternal race and ethnicity (race) with the risk of severe maternal morbidity. METHODS: Using the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, years 2016-2017, we examined risk of severe maternal morbidity among 1,480,925 delivery hospitalizations among women of different races and with different numbers of comorbid conditions using multivariable logistic regression. RESULTS: The rate of severe maternal morbidity was 139.7 per 10,000 deliveries. Compared with women with no comorbidities (rate 48.5/10,000), there was increased risk of severe maternal morbidity among women with one comorbidity (rate 238.6; odds ratio [OR] 5.0, 95% CI 4.8-5.2), two comorbidities (rate 379.9; OR 8.1, 95% CI 7.8-8.5), or three or more comorbidities (rate 560; OR 12.1, 95% CI 11.5-12.7). In multivariable regressions, similar associations were noted for women with one (adjusted odds ratio [aOR] 4.4, 95% CI 4.2-4.6), two (aOR 6.6, 95% CI 6.3-6.9), or three or more comorbidities (aOR 9.1, 95% CI 8.7-9.6). Black women had higher rates of comorbid conditions than all other racial and ethnic groups, with 55% (95% CI 54-56%) of Black women having no comorbidities, compared with 67% (95% CI 67-68%) of White women, 68% (95% CI 67-69%) of Hispanic women, and 72% (95% CI 71-73%) of Asian women. CONCLUSION: We found a dose-response relationship between number of comorbidities and risk of severe maternal morbidity, with the highest rates of severe maternal morbidity among women with three or more comorbidities. Focusing on the prevention and treatment of chronic conditions among women of childbearing age may have the potential to improve maternal outcomes across races and ethnicities.

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.

Mifepristone versus laminaria: a randomized controlled trial of cervical ripening in midtrimester termination.

BACKGROUND: Mifepristone was compared with laminaria for cervical ripening in second-trimester induction of labor (IOL). STUDY DESIGN: We performed a randomized, controlled, open-label study of women undergoing second-trimester IOL for fetal demise, aneuploidy or anomalies at a single tertiary care center from January 2004 to May 2006. Main outcome measures were induction-to-delivery time and pain with cervical ripening. RESULTS: Of 50 eligible women, 37 were enrolled in the study, of whom 33 completed the study: 16 were randomized to laminaria and 17 to mifepristone. Induction-to-delivery time was significantly shorter in the mifepristone arm (mean=10 h vs. 16 h, p=.01; median=7.5 h vs. 13.4 h, p=.01). Pain with cervical ripening was also significantly less in the mifepristone group than in the laminaria group (median=1 vs. 6 on an 11-point visual analogue scale, p<.001). Maternal age, parity, gestational age, fetal demise prior to induction, need for postpartum curettage, blood loss, pain during induction, delivery and at the time of discharge were not significantly different between the two groups. CONCLUSION: Mifepristone shortens the induction-to-delivery time and decreases pain with cervical ripening when compared with laminaria for second-trimester induction.