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CONTEXT: Available literature exploring medical liability and postgraduate medical education consistently posits that postgraduate trainees worry about their exposure to medico-legal liability. This assumption has formed the basis for research and curriculum development. OBJECTIVES: The aim of this study was to describe the encounters that lead physicians-in-training to seek external medico-legal guidance. We sought to provide empirical evidence on trends and themes related to medico-legal advice requests from physicians-in-training. METHODS: Our primary dataset consisted of records of calls from physicians-in-training to the medico-legal helpline of the Canadian Medical Protective Association (CMPA), a national mutual defence organisation providing medico-legal advice and liability protection for over 95% of Canada's physicians. We conducted a trend analysis of the frequency of calls for advice over 10 years from physician-in-training compared with non-trainee physicians. Furthermore, we performed a content analysis of calls made over the most recent 2 years (2016-2017) to elucidate the concerns that led to trainees seeking medico-legal advice. RESULTS: The 10-year trend analysis revealed that the annual growth in the number of physician-in-training advice calls (8.8%) exceeded other CMPA physician groups and was in excess of trainee population growth over the same period. The content analysis identified four core themes: managing confidential information, complex care situations, academic matters and patient safety incidents. CONCLUSIONS: Our findings indicate that trainees are asking questions about their medico-legal liability with increasing frequency. This study contributes new evidence on the issues that lead to trainees seeking help. We believe that understanding trainees' medico-legal advice requests will support medical educators to tailor quality improvement education to learners' needs.
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Educación Médica , Médicos , Canadá , Humanos , Seguridad del Paciente , Encuestas y CuestionariosRESUMEN
STUDY OBJECTIVE: To determine sociodemographic, surgical, and psychologic risk factors, including pain sensitivity, for persistent postsurgical pain (PPSP) after hysterectomy. DESIGN: A prospective cohort study. SETTING: Canadian academic medical center. PATIENTS: Patients (N = 200) who underwent hysterectomy (vaginal, laparoscopic, robotic, or open) between 2013 and 2014. INTERVENTIONS: Participants completed preoperative questionnaires assessing baseline pain scores and psychologic factors, including the Pain Sensitivity Questionnaire, Brief Pain Inventory Interference Items, the Beck Depression Inventory, the Numeric Rating Scale (NRS), and the Pain Catastrophizing Scale. Pain was recorded 1 and 24 hours postoperatively using the NRS. Patients were reassessed at 6 weeks postoperatively and completed the Brief Pain Inventory Interference Items, Patient Global Impression of Change, and the NRS. Patients who reported pain at 6 weeks were reassessed at 12 weeks using the above-mentioned questionnaires. MEASUREMENTS AND MAIN RESULTS: Of 200 study participants, 58 (32%) met the definition for PPSP (NRS ≥ 1 at 12 weeks), and 11 (6.1%) met the definition for moderate to severe postsurgical pain (NRS ≥ 4 at 12 weeks). Risk factors for PPSP included baseline pain scores, depression, pain catastrophizing, uterine mass, open surgical approach, acute postoperative pain, history of chronic pain, and having a hysterectomy due to pain. Multivariate regression analysis revealed that depression, pain catastrophizing, open surgical approach, and acute postoperative pain at 1 hour represent independent predictors of PPSP. Pain sensitivity was not associated with PPSP but was associated with acute and severe acute (NRS≥4) pain at 24 hours. CONCLUSION: Patients at risk for PPSP after hysterectomy can be identified preoperatively using validated questionnaires. This information can be used to guide targeted perioperative interventions to mitigate their risk.
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Robótica , Canadá , Femenino , Humanos , Histerectomía/efectos adversos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Estudios ProspectivosRESUMEN
Background: Intraoperative injuries during abdominopelvic surgery can be associated with substantial patient harm. The objective of this study was to describe abdominopelvic intraoperative injuries and their contributing factors among medicolegal cases. Methods: This study was a descriptive analysis of medicolegal matters reported to a national body, with subgroup analyses by type of surgery. We reviewed medicolegal matters involving a population-based sample of physicians who were subject to a civil legal action or complaint to a regulatory authority that was closed between 2013 and 2017 in Canada. Results: Our analysis included 181 civil legal cases and 88 complaints to a regulatory authority. Among legal cases, 155 patients (85.6%) (median age 47 yr) underwent elective procedures. The most common injury site was the bowel (53 cases [29.3%]). Injuries frequently occurred during dissection (79 [43.6%]) and ligation (38 [21.0%]), were identified postoperatively (138 [76.2%]) and necessitated further surgery (139 [76.8%]). Many patients experienced severe harm (55 [30.4%]) or died (25 [13.8%]). Peer experts in nongynecologic cases were more likely than those in gynecologic cases to include criticisms of a provider in a harmful incident (79 [71.2%] v. 30 [42.9%], p < 0.01). Peer expert criticisms often related to clinical evaluation, decision-making and misidentification of anatomy. Criticisms of nontechnical skills identified documentation and communication deficiencies. Conclusion: This study confirms the importance of provider and team training to improve clinical evaluation and decision-making, documentation and communication. Effective protocols may help support clinicians in providing safer surgical care.
Contexte: Les blessures survenant durant une chirurgie abdominopelvienne peuvent être associées à d'importants préjudices chez les patients. La présente étude avait pour but de décrire les blessures peropératoires abdominopelviennes faisant l'objet d'enquêtes médicolégales et à connaître leurs facteurs contributifs. Méthodes: Cette étude comprend une analyse descriptive d'affaires médicolégales signalées à un organisme de réglementation national, ainsi que des analyses par sousgroupes selon le type de chirurgie. Nous avons examiné des cas impliquant un échantillon de médecins canadiens représentatifs de la population qui avaient fait l'objet d'une poursuite au civil ou d'une plainte auprès d'un organisme de réglementation. Toutes les poursuites et plaintes étudiées ont été résolues entre 2013 et 2017. Résultats: Notre analyse comprenait 181 poursuites au civil et 88 plaintes auprès d'un organisme de réglementation. En ce qui concerne les poursuites au civil, 155 patients (85,6 %) (âge médian 47 ans) avaient subi une intervention non urgente. Les blessures déclarées touchaient généralement les intestins (53 cas [29,3 %]). Elles sont fréquemment survenues durant la dissection (79 cas [43,6 %]) et la ligature (38 cas [21,0 %]), ont été repérées en période postopératoire (138 cas [76,2 %]) et ont nécessité une autre chirurgie (139 cas [76,8 %]). De nombreux patients ont subi de graves préjudices (55 cas [30,4 %]) ou sont décédés (25 cas [13,8 %]). Les pairs experts dans un domaine autre que la gynécologie étaient plus susceptibles que ceux experts en gynécologie de critiquer un fournisseur en cas d'incident avec préjudice (79 cas [71,2 %] c. 30 cas [42,9 %]; p < 0,01). Les critiques formulées par les pairs experts portaient souvent sur l'évaluation clinique, la prise de décision et les erreurs d'identification des structures anatomiques. Les critiques visant les habiletés non techniques avaient trait aux lacunes dans la documentation et la communication. Conclusion: Cette étude vient confirmer l'importance que revêt la formation des fournisseurs et de leur équipe dans l'amélioration de la prise de décision, de la documentation et de la communication. Des protocoles efficaces pourraient soutenir l'offre de soins chirurgicaux sûrs par les professionnels de la santé.
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Abdomen/cirugía , Bases de Datos Factuales , Intestinos/lesiones , Complicaciones Intraoperatorias , Pelvis/cirugía , Procedimientos Quirúrgicos Operativos/legislación & jurisprudencia , Adulto , Anciano , Canadá , Femenino , Humanos , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/terapia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Heridas y Lesiones/epidemiología , Heridas y Lesiones/terapiaRESUMEN
OBJECTIVE: This study implemented a quality improvement program based on knowledge of medico-legal risk in obstetrics and sought to evaluate the impact of this program on workplace culture. METHODS: The study conducted needs assessments with front-line providers working in the obstetrical unit of the Queensway Carleton Hospital, an urban community hospital in Ottawa, Ontario, and included the safety, communication, operational reliability, and engagement (SCORE) survey. The study investigators delivered training in quality improvement science and co-developed three projects that were based on their alignment with local needs and aggregate medico-legal risk data: an organized team response to the need for an immediate cesarean section, a protocol for managing patients who present at term with pre-labour rupture of membranes, and regular morning team briefings. Outcome measures were determined for each project from a quality improvement indicator framework, and coaching was provided to project leads. Participants completed the SCORE survey and a program effectiveness tool after the intervention. RESULTS: The majority of participants (75.2% of 153 pre-intervention and 63.1% of 157 post-intervention participants) completed the SCORE surveys. Post-intervention improvements were found in teamwork, learning environment, and safety climate, whereas levels of provider burnout remained high. Program effectiveness was highly rated, and most projects showed qualitative improvements. CONCLUSION: This study showed positive workplace culture change associated with the quality improvement intervention. Lessons learned from the implementation of this program can inform future quality improvement initiatives.
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Rotura Prematura de Membranas Fetales , Cultura Organizacional , Pautas de la Práctica en Medicina/normas , Lugar de Trabajo , Femenino , Hospitales Comunitarios , Humanos , Ontario , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Embarazo , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad , Encuestas y CuestionariosRESUMEN
OBJECTIVE: This study sought to determine whether physician-nurse bedside rounds and ward task list improve quality of care as measured by patient satisfaction, earlier discharge, and reduced trainee interruptions. METHODS: This prospective, single-blind, pre- and post-intervention study included patients admitted to the gynaecology ward at St. Michael's Hospital in Toronto, Ontario, involving a 6-week baseline, 6-week intervention, and 2-week second baseline phase. During the intervention phase, a chief resident and charge nurse rounded at the bedside simultaneously daily. Nurses recorded non-urgent issues on a ward task list. Patients completed a subset of the National Research Corporation Picker satisfaction questionnaire, discharge times were noted, and residents recorded pages (Canadian Task Force Classification II-2). RESULTS: There were 89, 104, and 30 admissions during baseline care, intervention, and second baseline phases, respectively. Mean discharge time in the intervention phase was significantly earlier than baseline (11:18 am ± 1 hour 59 minutes vs. 12:37 pm ± 2 hours 37 minutes, P < 0.001), with early discharges doubling (69% vs. 36%, P < 0.001). Discharge times returned to baseline after the intervention (12:36 pm ± 2 hours 39 minutes). Intervention phase patients appreciated bedside care plans (86 of 94 patients, 92%), with improved National Research Corporation Picker responses, which diminished post-intervention. Paging interruptions were lower during the intervention phase compared with the baseline phase (1.0 ± 1.1 vs. 3.4 ± 2.1, P < 0.001), with non-urgent pages decreasing most (0.5 ± 0.8 vs. 3.0 ± 2.0, P < 0.001). CONCLUSION: Combining physician-nurse bedside rounds and ward task list reduces trainee interruptions, positively affects patient satisfaction, and promotes early discharge. Following these initiatives, discharge time, patient satisfaction, and resident paging interruptions returned to baseline.
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Internado y Residencia , Personal de Enfermería en Hospital , Servicio de Ginecología y Obstetricia en Hospital/normas , Mejoramiento de la Calidad , Rondas de Enseñanza/métodos , Adulto , Femenino , Humanos , Persona de Mediana Edad , Ontario , Planificación de Atención al Paciente , Alta del Paciente , Satisfacción del Paciente , Estudios Prospectivos , Método Simple Ciego , Factores de TiempoRESUMEN
This paper describes the recommendations of a national panel on quality improvement in obstetrics to identify priorities for action among five areas of greatest medico-legal risk. Using previously conducted medico-legal data analyses and a systematic literature review, the panel reviewed existing data and developed recommendations for areas of focus in quality improvement in five obstetrical high-risk areas. The panel recommended clarification of definitions in some areas, identified needs for data collection and standardization of practices in others. The most promising interventions to improve care in the five areas were grouped into: standardized processes (such as protocols and communication tools), checklists, audit and feedback, mentoring and coaching, inter-professional communication, simulation and training, and shared decision making guides. This national panel of experts created 18 action-oriented recommendations focused on quality improvement to reduce medico-legal risk and improve the safety of care for Canadian mothers and babies.
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Obstetricia , Mejoramiento de la Calidad , Canadá , Parto Obstétrico/normas , Femenino , Humanos , Obstetricia/organización & administración , Obstetricia/normas , Seguridad del Paciente , EmbarazoRESUMEN
Summary: The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, 2018. The following 6 principles outline the consensus of this symposium, which included diverse stakeholders and surgeon leaders across Canada: 1) a Canadian quality-improvement strategy for surgery is needed; 2) quality improvement requires continuous, active and intentional effort; 3) outcome measurement alone will not drive improvement; 4) increased focus on standardization and process improvement is necessary; 5) new, large electronic medical record systems pose challenges as well as benefits in Canadian hospitals; and 6) surgeons in remote and rural hospitals must be engaged using tailored approaches.
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Cirugía General/organización & administración , Mejoramiento de la Calidad/organización & administración , Canadá , HumanosRESUMEN
STUDY OBJECTIVE: To assess the improvement of cognitive surgical knowledge of laparoscopic hysterectomy in postgraduate year (PGY) 1 and 2 gynecology residents who used an interactive computer-based Laparoscopic Hysterectomy Trainer (Red Llama, Inc., Seattle, WA). DESIGN: A multicenter, randomized, controlled study (Canadian Task Force classification I). SETTING: Five departments of obstetrics and gynecology: Keck School of Medicine of the University of Southern California, Los Angeles, CA; University of California, Los Angeles, Los Angeles, CA; University of Washington, Seattle, WA; University of British Columbia, Vancouver, British Columbia, Canada; and University of Toronto, Toronto, Ontario, Canada. PARTICIPANTS: Gynecology residents, fellows, faculty, and minimally invasive surgeons. INTERVENTIONS: The use of an interactive computer-based Laparoscopic Hysterectomy Trainer. MEASUREMENTS AND MAIN RESULTS: In phase 1 of this 3-phase multicenter study, 2 hysterectomy knowledge assessment tests (A and B) were developed using a modified Delphi technique. Phase 2 administered these 2 online tests to PGY 3 and 4 gynecology residents, gynecology surgical fellows, faculty, and minimally invasive surgeons (n = 60). In phase 3, PGY 1 and 2 gynecology residents (n = 128) were recruited, and 101 chose to participate, were pretested (test A), and then randomized to the control or intervention group. Both groups continued site-specific training while the intervention group additionally used the Laparoscopic Hysterectomy Trainer. Participant residents were subsequently posttested (test B). Phase 2 results showed no differences between cognitive tests A and B when assessed for equivalence, internal consistency, and reliability. Construct validity was shown for both tests (p < .001). In phase 3, the pretest mean score for the control group was 242 (standard deviation [SD] = 56.5), and for the intervention group it was 217 (SD = 57.6) (nonsignificant difference, p = .089). The t test comparing the posttest control group (mean = 297, SD = 53.6) and the posttest intervention group (mean = 343, SD = 50.9) yielded a significant difference (p < .001, 95% confidence interval, 48.4-108.8). Posttest scores for the intervention group were significantly better than for the control group (p < .001). CONCLUSION: Using the Laparoscopic Hysterectomy Trainer significantly increased knowledge of the hysterectomy procedure in PGY 1 and 2 gynecology residents.
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Competencia Clínica , Histerectomía/educación , Internado y Residencia , Entrenamiento Simulado , California , Femenino , Humanos , Masculino , Modelos AnatómicosRESUMEN
OBJECTIVE: This guideline reviews the evidence relating to the potential benefits of the vaginal hysterectomy (VH) and supracervical hysterectomy (SCH) versus total abdominal hysterectomy (TAH) with respect to postoperative sexual function, urinary function, and peri- and postoperative complications. Laparoscopic options are not included in this guideline. OPTIONS: Women considering hysterectomy for benign disease can be given the option of retaining the cervix or proceeding with a total hysterectomy. OUTCOMES: The outcomes measured are postoperative sexual function and urinary function, and peri- and postoperative complications. EVIDENCE: The Cochrane Library, Medline, and Embase were searched for articles published in English from January 1950 to March 2008 specifically comparing VH and SCH with TAH in the prevention of sexual dysfunction, urinary dysfunction, and peri- and postoperative complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Additional publications were identified from the bibliographies of these articles. Randomized controlled trials were considered evidence of the highest quality, followed by cohort studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table).
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Cuello del Útero/cirugía , Histerectomía Vaginal/normas , Canadá , Femenino , Ginecología , Humanos , Obstetricia , Sociedades MédicasRESUMEN
OBJECTIVE: To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully. OPTIONS: The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners. OUTCOMES: Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits. EVIDENCE: Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery. RECOMMENDATIONS: Benign Disease Preinvasive Disease Invasive Disease Acute Conditions Other Indications Surgical Approach VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.
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Histerectomía/normas , Canadá , Femenino , Ginecología , Humanos , Obstetricia , Sociedades MédicasRESUMEN
STUDY OBJECTIVE: To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH). DESIGN: A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I). SETTING: A university teaching hospital. PATIENTS: All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation. INTERVENTIONS: Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany). MEASUREMENTS AND MAIN RESULTS: A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 µm to 5232 µm but was not significantly different between groups (median maximum thermal damage = 1043 µm [IQR, 682-1934] vs 1522 µm [IQR, 884-2144], p = .211). CONCLUSION: Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.
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Histerectomía/instrumentación , Laparoscopía/instrumentación , Útero/cirugía , Vagina/cirugía , Adulto , Colpotomía/instrumentación , Colpotomía/métodos , Femenino , Alemania , Calor/efectos adversos , Humanos , Histerectomía/métodos , Laparoscopía/métodos , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Embarazo , Complicaciones del Embarazo/cirugía , Dehiscencia de la Herida Operatoria , Útero/patología , Vagina/patologíaRESUMEN
OBJECTIVES: This study sought to determine whether social factors (neighbourhood education and income) and geographic factors (urban or rural dwelling and local service area) are associated with hysterectomy rates, proportion of hysterectomies performed minimally invasively, and hysterectomy complication and readmission rates in Ontario. METHODS: The Canadian Institute for Health Information Discharge Abstract Database was used to perform a population-based retrospective cross-sectional study on women who had an abdominal, vaginal, and laparoscopic hysterectomy in 2007 for benign gynaecologic conditions in hospitals in Ontario, Canada. Crude and age-standardized rates of hysterectomy, proportion of hysterectomy performed minimally invasively (vaginal or laparoscopic), and rates of surgical complications were analyzed by neighbourhood educational attainment, neighbourhood income, rural or urban residency, and health service delivery area (Canadian Task Force Classification of Study Design II). RESULTS: A total of 13 511 women who underwent hysterectomy were included. Age-standardized hysterectomy rates were higher for the lowest neighbourhood educational quartile compared with the highest (relative risk [RR] 1.49; 95% CI 1.39-1.60), higher with rural compared with urban dwelling (RR 1.54; 95% CI 1.47-1.61), varied with local health service delivery area (Local Health Integration Network [LHIN]) (range 133.4-439.5 per 100 000 women), and also varied non-linearly with neighbourhood income quintile. Proportion of hysterectomies performed minimally invasively did not vary with neighbourhood education or income, were higher for rural compared with urban areas (RR 1.10; 95% CI 1.03-1.19), and varied with LHIN (range 30.0-62.9 per 100 hysterectomies). Surgical complications varied with neighbourhood educational quartile, but not with income or urban or rural residence. CONCLUSIONS: Considerable social and geographic variation exists in rates of hysterectomy in Ontario, whereas only geographic variation is seen in use of minimally invasive routes. Surgical complication rates vary only by neighbourhood education. Such findings suggest inequities in hysterectomy practice in Ontario, and there is a need to evaluate factors influencing patients' decision making, physicians' clinical and surgical practice, and health system policies to help address the observed disparities.
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Histerectomía/estadística & datos numéricos , Adolescente , Adulto , Anciano , Estudios Transversales , Femenino , Humanos , Histerectomía/efectos adversos , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/estadística & datos numéricos , Ontario/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Población Rural/estadística & datos numéricos , Factores Socioeconómicos , Población Urbana/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND: Residency programs struggle with integrating simulation training into curricula, despite evidence that simulation leads to improved operating room performance and patient outcomes. Currently, there is no standardized laparoscopic training program available for gynecology residents. OBJECTIVE: The purpose of this study was to develop and validate a comprehensive ex vivo training curriculum for gynecologic laparoscopy. STUDY DESIGN: In a prospective, single-blinded randomized controlled trial (Canadian Task Force Classification I) postgraduate year 1 and 2 gynecology residents were allocated randomly to receive either conventional residency training or an evidence-based laparoscopy curriculum. The 7-week curriculum consisted of cognitive didactic and interactive sessions, low-fidelity box trainer and high-fidelity virtual reality simulator technical skills, and high-fidelity team simulation. The primary outcome measure was the technical procedure score at laparoscopic salpingectomy with the use of the objective structured assessment of laparoscopic salpingectomy tool. Secondary outcome measures related to performance in multiple-choice questions and technical performance at box trainer and virtual reality simulator tasks. A sample size of 10 residents per group was planned (n = 20). Results are reported as medians (interquartile ranges), and data were compared between groups with the Mann-Whitney U, chi-square, and Fisher's exact tests (P ≤ .05). RESULTS: In July 2013, 27 residents were assigned randomly (14 curriculum, 13 conventional). Both groups were similar at baseline. Twenty-one residents (10 curriculum, 11 conventional) completed the surgical procedure-based assessment in the operating room (September to December 2013). Our primary outcome indicated that curriculum-trained residents displayed superior performance at laparoscopic salpingectomy (P = .043). Secondary outcomes demonstrated that curriculum-trained residents had higher performance scores on the cognitive multiple-choice questions (P < .001), the nontechnical skills multiple-choice questions (P = .016), box trainer task time (P < .001), and all virtual reality simulator parameters. CONCLUSION: Participation in a comprehensive simulation-based training curriculum for gynecologic laparoscopy leads to a superior improvement in knowledge and technical performance in the operating room compared with conventional residency training.
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Competencia Clínica , Curriculum/normas , Ginecología/educación , Laparoscopía/educación , Simulación por Computador , Femenino , Humanos , Internado y Residencia , Curva de Aprendizaje , Método Simple CiegoRESUMEN
Simulator education is essential to surgical training and it should be a requirement at all training programs across North America. Yet, in a survey of North American obstetrics and gynecology program directors (response rate 52%), we found that while 73% (n = 98) of programs teach laparoscopic skills, only 59% (n = 81) were satisfied with their curriculum. Most programs lacked standard setting in the form of theoretical examinations (94%, n = 127) or skills assessments (91%, n = 123) prior to residents performing surgery on patients in the operating room. Most programs (97%, n = 131) were interested in standardizing laparoscopy education by implementing a common curriculum. We present 3 core recommendations to ensure that gynecologists across North America are receiving adequate training in gynecologic laparoscopic surgery as residents: (1) uniform simulator education should be implemented at all training programs across North American residency programs; (2) a standardized curriculum should be developed using evidence-based techniques; and (3) standardized assessments should take place prior to operating room performance and specialty certification. Future collaborative research initiatives should focus on establishing the content of a standardized laparoscopy curriculum for gynecology residents utilizing a consensus method approach.
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Competencia Clínica , Curriculum/normas , Ginecología/educación , Internado y Residencia/normas , Laparoscopía/educación , Canadá , Curriculum/estadística & datos numéricos , Recolección de Datos , Humanos , Internado y Residencia/métodos , Internado y Residencia/estadística & datos numéricos , Estados UnidosRESUMEN
Uterine leiomyomas are underrecognized as a cause of acute urinary retention (AUR) in women. The objective of this study was to present a case series and systematic review of the literature, to elucidate the pathogenesis of leiomyoma-related AUR, and to suggest management strategies. We included patients presenting with AUR and uterine leiomyomas at our institution between January 2011 and December 2013. Further, we systematically searched the Cochrane Library (from 1898 to June 2014), EMBASE (from 1947 to June 2014), and MEDLINE (from 1946 to June 2014) databases according to the PRISMA guidelines. A total of six patients with AUR and leiomyomas presented to our institution. Through the systematic review, another 31 cases of AUR were identified. Combined patient ages ranged from 25 to 75 years. Uterine size ranged from 10 to 22 weeks on physical examination and from 5.5 to 26 cm on imaging. The dominant leiomyoma size ranged from 5.7 to 22.4 cm. Significant risk factors were posterior or fundal leiomyoma position and the presence of a retroverted uterus. Proposed mechanisms for leiomyoma-related AUR include proximal urethra or bladder-neck compression, premenstrual pelvic congestion, vascular steal effect, and compression of pudendal or sacral nerves. Patients were treated with hysterectomy, myomectomy, uterine fibroid embolization, hormones, or by conservative management alone. In the absence of neurologic disorders or other risk factors, neither urodynamic studies nor neuromuscular testing seem to contribute to diagnosis or guide management in women with uterine leiomyomas and AUR. Patients presenting to gynecologists seem to experience shorter times to diagnosis and treatment compared with other specialties. It is essential to recognize leiomyomas as a potential cause of AUR in order to reduce unnecessary testing and delays in diagnosis and management.
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Leiomioma/complicaciones , Retención Urinaria/etiología , Neoplasias Uterinas/complicaciones , Adulto , Femenino , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Uterine fibroid necrosis and infection is a rare but potentially serious event following uterine artery embolization (UAE). We describe a case of surgical removal of an infected necrotic uterine fibroid. CASE: A 31-year-old Jehovah's Witness with severe anemia presented with sepsis following UAE. The uterus was preserved by performing transvaginal surgical removal. Final pathology demonstrated Escherichia Coli infection of the necrotic fibroid. The patient improved postoperatively. CONCLUSION: Surgical removal of an infected necrotic fibroid may be a preferred option for women wishing to avoid hysterectomy following UAE. Appropriate case selection and optimization of hemoglobin concentration before UAE is important to minimize complications.
Contexte : La nécrose et l'infection d'un fibromyome utérin constituent un événement rare, mais potentiellement grave, à la suite de l'embolisation de l'artère utérine (EAU). Nous décrivons un cas de retrait chirurgical d'un fibromyome utérin nécrosé et infecté. Cas : Une témoin de Jéhovah de 31 ans connaissant une anémie grave a présenté une sepsie à la suite d'une EAU. L'utérus a été préservé au moyen de l'exécution d'un retrait chirurgical transvaginal. L'examen pathologique final a démontré la présence d'une infection à Escherichia Coli dans le fibromyome nécrosé. L'état de la patiente s'est amélioré à la suite de l'opération. Conclusion : Le retrait chirurgical d'un fibromyome utérin nécrosé et infecté pourrait constituer l'option à privilégier pour les femmes qui souhaitent éviter l'hystérectomie à la suite d'une EAU. Avant la tenue d'une EAU, il s'avère important de bien sélectionner les patientes qui pourraient en tirer avantage et d'optimiser la concentration en hémoglobine, et ce, afin de minimiser les complications.