Obstetrics and Gynecology and Reparations: The Debt We Owe (and Continue to Accumulate).

Obstetrics and gynecology (OBGYN) is rife with exploitation and oppression of Black individuals and disparate health outcomes. We posit that racial disparities in OBGYN are fueled by racism and the racial wealth gap stemming from slavery, legal segregation, and institutionalized discrimination against Black Americans. We believe reparations are not only morally requisite, but would also improve health outcomes for our patients. Supporting legislation to explore and remedy the harms of slavery and its legacy is critical to address systemic racism that results in disparate health outcomes.

Attitudes of Trainees in Obstetrics and Gynecology Regarding the Structure of Residency Training.

OBJECTIVE: To measure future and current resident perspectives on obstetrics and gynecology residency training structure and possible future models. METHODS: Medical students invited for obstetrics and gynecology residency interviews and residents (postgraduate year [PGY]-1-4) at the University of Colorado, the University of Washington, the University of California San Francisco, Loyola University, Saint Joseph's Hospital, and Texas A&M in 2017-2018 received a voluntary, electronic survey regarding possible models for restructuring residency training. Student and resident responses were compared using χ test for categorical and two-sample t-test for continuous items. RESULTS: Applicants (63%, 280/444) and residents (66%, 101/153) had similar response rates (overall response rate 64%). Applicants (24%) and residents (29%) reported having concerns about the current structure of residency training. The ideal residency duration was reported as 4 years by 72% of applicants and 85% of residents. Lack of gynecologic surgical volume was the most frequently reported concern among applicants (75%) and residents (72%). Fourth-year tracking (focusing on training aligned with postgraduation career path) was preferred by 90% of applicants and 77% of residents (P=.002) and 92% among respondents planning fellowship. Most applicants (68%) and residents (75%) preferred not starting fellowship training after the 3rd year of residency. DISCUSSION: The majority of learners surveyed support a 4-year training structure but likewise support individualizing training in PGY-4. It is imperative that obstetrics and gynecology leadership consider this and other feedback from learners when considering modifications to the current training paradigm.

Reconfiguring a One-Way Street: A Position Paper on Why and How to Improve Equity in Global Physician Training.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.

Impact of mode of delivery on pregnancy outcomes in women with premature rupture of membranes after 28 weeks of gestation in a low-resource setting: A prospective cohort study.

BACKGROUND: Despite the high prevalence of premature rupture of membranes (PROM) in low-resource settings, the preferred mode of delivery remains unclear. We compared the perinatal mortality in a prospective cohort of women with PROM after 28 weeks following vaginal or caesarean delivery at Mulago Hospital with the aim of adopting evidence based practice and improving patient care. METHODS: Between November 2015 and May 2016, 1455 women with PROM after 28 weeks of gestation and their newborns were prospectively followed from admission to discharge at Mulago Hospital. The primary outcome was perinatal mortality. Secondary neonatal outcomes included sepsis and admission to the Special Care Unit. Maternal outcomes included maternal deaths and complications. Outcomes were compared between women who had vaginal vs. caesarean delivery using multivariable logistic regression. All statistical tests were 2-sided with the level of statistical significance set at p < 0.05. RESULTS: The incidence of PROM was 12.1%. The perinatal mortality following PROM was 65 per 1000 live births. Of the 1425 women with PROM, 991 (69.5%) had vaginal delivery and 434 (30.5%) underwent Caesarean section. There was no statistical difference in perinatal mortality by the mode of delivery (vaginal vs. caesarean) in PROM (p = 0.12). The risk factors for perinatal mortality included chorioamnionitis, failure to administer corticosteroids in preterm PROM, gestational age (28-33 weeks), duration of drainage of liquor (24-48 hours), and presence of maternal complications. Caesarean delivery was associated with increased maternal postpartum infections, admission to the Special Care Unit and maternal death. CONCLUSION: In low resource settings, vaginal delivery is the preferred mode of delivery for PROM after 28 weeks gestation. It is associated with lesser maternal and perinatal morbidity when compared to caesarean delivery.

Career Expectations of Obstetrics and Gynecology Residents and Future Residents.

OBJECTIVE: To understand contemporary fourth-year medical student and resident career expectations in obstetrics and gynecology. METHODS: Students invited for obstetrics and gynecology residency interviews and residents (postgraduate years 1-4) at the University of Colorado, University of Washington, University of California San Francisco, Loyola University, St. Joseph's Hospital, and Texas A&M in 2016-2017 received a voluntary, electronic survey regarding career expectations. Questions were compared between students and residents using a χ test for category responses and for age a two-sample t test. RESULTS: Response rates were similar between students (68% [277/409]) and residents (63% [97/153]). Residents compared with students were more frequently planning to enter private practice (43% vs 19%) and less frequently planning an academic career (19.4% vs 30.4%) or subspecialties (38% vs 51%) (P<.001). Although most respondents planned to work full-time (96% vs 94.9%), 83% (vs 94%) of residents planned to work greater than 40 hours per week (P<.001). Respondents reported greater than $150,000 in educational debt (65%) and anticipated starting salary greater than $200,000 (89%). More residents planned to retire by age 60 years (23% vs 7%) (P<.001). Thirty-eight percent of residents reported having changed career plans during residency, citing work-life balance as the most important factor (89%). DISCUSSION: Trainees' career expectations appear to evolve over time moving toward a higher likelihood to pursue private practice, work fewer hours, and retire earlier despite large educational debt. It is critical that the specialty understand these trends when planning to address national workforce needs.

Obstetricians and Gynecologists of the Future: A Survey of Medical Students Applying to Residency.

OBJECTIVE: To understand the characteristics and career goals of medical students selecting a career in obstetrics and gynecology. METHODS: In 2015-2016, medical students invited for interviews for obstetrics and gynecology residency at the University of Colorado, University of Washington, University of California San Francisco, Loyola University, and New York University received a voluntary 20-item electronic survey regarding factors influencing their choice of medical specialty. RESULTS: Two hundred twenty-six of 356 students responded (63%). Mean age was 27 years, and 88% (n=199) were women. General surgery was the most common alternate specialty (36%, n=81). The most commonly cited drawback to obstetrics and gynecology was "long hours" (66%, n=148). After residency, 157 (70%) applicants planned to complete fellowship training, 127 (56%) pursue international work, 156 (69%) seek an academic position, and 207 (92%) practice in an urban setting. One hundred twenty-four applicants (55%) planned to work 51-60 hours per week and 111 (49%) planned to take 2-3 nights of call per month. Two thirds (n=150) predicted they will have greater than $100,000 educational debt on graduation. CONCLUSION: Contemporary residency applicants have high educational debt and disproportionately plan to pursue fellowship, international work, careers in academic medicine, and work in urban centers. Based on the projected career plans among obstetrics and gynecology applicants, the workforce needs of the population may not be met.

Advising and Interview Patterns of Medical Students Pursuing Obstetrics and Gynecology Residency.

OBJECTIVE: To describe the advising practices at medical schools and interview patterns among medical students pursuing obstetrics and gynecology residency training. METHODS: A voluntary, anonymous survey was distributed to all applicants interviewing for obstetrics and gynecology residency during the 2014-2015 cycle at the University of Colorado, University of Washington, University of California, San Francisco, and Loyola University. Demographic data were obtained. The survey explored student advising in the residency application process including number of applications and interviews recommended by advisors. Data are reported as percentage for each survey item and compared by select demographics using an exact χ. RESULTS: Among 315 unique possible applicants, 73% (n=230) responded. Students were most commonly advised by the obstetrics and gynecology clerkship director (33%) with recommendations to apply to 21-30 programs (48%). Thirty-four percent of students applied to 21-30 programs, 32% to 31-40 programs, and 30% to greater than 40 programs. Students were advised (70%) and planned (55%) to interview at 10-14 programs. Concern over competitiveness of the applicant pool was the most important factor (31%) in determining the number of applications. The number of programs advised to or plan to interview at was greater for those in the couples match (P<.001). CONCLUSION: Medical students pursuing obstetrics and gynecology are most likely to be advised by obstetrics and gynecology clerkship directors and concern over the competitiveness of the applicant pool results in students applying to large numbers of programs. This practice may adversely affect the obstetrics and gynecology match process for both programs and applicants through the requirements of managing additional applications and potentially needing to complete a greater number of interviews.