Gynecological challenges in the diagnosis and care of patients with DSD: The role of the obstetrician gynecologist in the multidisciplinary approach to the patient.

Disorders (differences) of sex development (DSD) are identified when there is atypical chromosomal, gonadal, or anatomic sex. Given the complexity of DSD conditions, the consensus guidelines recommend that affected individuals be evaluated and cared for by teams with expertise in DSD conditions. Obstetrician gynecologists are experts in genital and reproductive anatomy, hormonal function, fertility, sexuality, and obstetrics, allowing them to provide a unique and essential function within the DSD team. Furthermore, obstetrician gynecologists with expertise in Pediatric and Adolescent Gynecology may follow individuals from birth into adulthood and provide reproductive health care for all ages, allowing these patients to "grow up" with them. Thus it is essential that gynecologists be part of a multidisciplinary team from birth through the reproductive lifespan. The purpose of this paper is to describe the role that the obstetrician gynecologist plays in the care of individuals with DSD conditions.

Primary vaginal dilation for vaginal agenesis: strategies to anticipate challenges and optimize outcomes.

PURPOSE OF REVIEW: Primary vaginal dilation is patient controlled, safe, less painful, and much lower cost compared with operative vaginoplasty and is considered first-line treatment for vaginal agenesis for women with Mayer-Rokitansky-Küster-Hauser syndrome and androgen insensitivity syndrome. RECENT FINDINGS: This review will highlight studies that assess the optimal methods of primary vaginal dilation and clarify ideal counseling, frequency of dilation, management of side-effects, and long-term physical and psychological outcomes. SUMMARY: Providers who care for women with vaginal agenesis should be prepared to not only teach the technical skill of dilation, but also to assess readiness and troubleshoot symptoms associated with dilation.

The Use of "Natural" Substances for Menstrual Hygiene: A Case Report of an Embedded Vaginal Sea Sponge.

BACKGROUND: In early adolescence, irregular menstrual bleeding patterns are common and are frequently due to anovulatory cycles or bleeding disorders. As such, the diagnosis of a vaginal foreign body might initially be missed. CASE: We describe a 14-year-old adolescent female presenting with ongoing irregular menstrual spotting despite reassuring laboratory workup and ultrasonography. She was found to have an embedded vaginal sea sponge eroding through the vaginal wall. On further discussion, she reported using a natural sea sponge for menstrual blood absorption. SUMMARY AND CONCLUSION: In cases of persistent vaginal spotting, vaginal foreign body should be considered in the differential diagnosis. Use of nontraditional menstrual hygiene products could lead to medical complications and negative health outcomes in adolescents.

Where do medical students turn? The role of the assigned mentor in the fabric of support during medical school.

BACKGROUND: The University of Washington School of Medicine implemented an assigned mentoring program in 2002. The College Mentors are assigned at matriculation, advise students throughout medical school, and teach and evaluate students in the 2nd-year Introduction to Clinical Medicine course. PURPOSE: The purpose of the study was to determine from whom students report they would seek advice and support for academic, professional, personal, and research issues. METHODS: A cross-sectional cohort survey asking students whom they would first contact about academic, personal, professional, and research issues was administered to three cohorts of students in 2007. RESULTS: Students reported that they would contact their College Mentor first for general academic progress (49.6%), personal issues (36.2%), and professional issues (64.1%) but not for research issues. CONCLUSIONS: Students identified their College Mentor as a primary contact for academic, professional, and personal issues, suggesting that neither the mentors' assigned status or evaluator role were barriers to the mentoring relationship.

A non-surgical approach to 46,XY differences in sex development through hormonal suppression at puberty: a single-center case series study.

PURPOSE: We aim to report outcomes and safety with hormonal suppression to facilitate gonadal preservation in a select group of patients with 46,XY differences in sex development (DSD) who are raised and identify as female yet have diagnoses with potential for androgenization at puberty. METHODS: We performed a retrospective review of the past 10 years of DSD patients treated by a multidisciplinary program. Inclusion criteria were 46,XY DSD, female sex of rearing, risk of androgenization at puberty, and plan for hormonal suppression at puberty. Patients on hormonal suppression had at least 6 months of follow-up from initiation. We excluded those with complete gonadal dysgenesis or complete androgen insensitivity. RESULTS: Four patients met inclusion criteria. Initial evaluation by DSD team was at a mean age of 6.6 years (3 weeks-16 years). All patients were evaluated in a coordinated multidisciplinary clinic. The diagnoses are listed in Table 1. Mean follow-up was 5.7 years (1.2-10.9 years). One patient presented as an infant, and is being monitored until Tanner stage 2 and/or serum hormonal evidence to initiate hormonal suppression. Three patients have been receiving hormonal suppression for 1.4 years (1.1-1.9 years) without side effects or complication. Three patients were initiated with estrogen replacement to promote desired breast development. At last follow-up, all patients had retained their gonads, all have female gender identity with no reported gender dysphoria, and no progression of androgenization. CONCLUSIONS: In our initial experience, gonadal preservation with hormonal suppression is a tool in multidisciplinary management of select DSD patients with female gender identity with conditions associated with androgenization at puberty. Patients' growth, bone health, and overall psychosocial well-being will need to be monitored closely.

Professionalism in medical education: an institutional challenge.

Despite considerable attention to professionalism in medical education nationwide, the majority of attention has focused on training medical students, and less on residents and faculty. Curricular formats are often didactic, removed from the clinical setting, and frequently focus on abstract concepts. As a result of a recent curricular innovation at the University of Washington School of Medicine (UWSOM) in which role-model faculty work with medical students in teaching and modeling clinical skills and professionalism, a new professionalism curriculum was developed for preclinical medical students. Through student feedback, that curriculum has changed over time, and has become more focused on the clinical encounter. This new and evolving curriculum has raised awareness of the existence of an "ecology of professionalism." In this ecological model, changes in the understanding of and attention to professionalism at one institutional level lead to changes at other levels. At the UWSOM, heightened attention to professionalism at the medical student level led to awareness of the need for increased attention to teaching and modeling professionalism among faculty, residents, and staff. This new understanding of professionalism as an institutional responsibility has helped UWSOM teachers and administrators recognize and promote mechanisms that create a "safe" environment for fostering professionalism. In such an institutional culture, students, residents, faculty, staff, and the institution itself are all held accountable for professional behavior, and improvement must be addressed at all levels.

Assessment of resident surgical skills: is testing feasible?

OBJECTIVE: We have previously shown that in a single residency program objective structured assessment of technical skills (OSATS) is a reliable and valid method of assessing surgical competency. Our goal was to establish feasibility of this evaluation instrument when administered at multiple residency programs throughout the US, and assess the impact of a laboratory-based surgical curriculum on results. STUDY DESIGN: An OSATS exam was administered to 116 residents from 5 residency programs. One of the residency programs had participated in a comprehensive surgical curriculum over a 4-year period of time. The exam consisted of 3 open and 3 laparoscopic tasks. Residents were graded by both a blinded and unblinded examiner with task-specific checklist, global rating scale, pass/fail assessment, and tasks were timed. All tasks were performed on life-like models. RESULTS: Examinations were successfully completed at all sites. Each exam required 90 minutes of resident time. Reliability indices calculated with Cronbach's alpha were .97 for overall global rating and .95 for checklists. Interrater reliability between blinded and unblinded examiners ranged from .71 to .97 for individual tasks and was .95 overall. Assessment of construct validity (the ability to distinguish among residency levels) found significant differences among the residents for both blinded and unblinded examiners for all evaluation outcomes except time. For the test overall, the global rating scale showed significant differences among all 4 residency levels. The checklist showed significant differences at three levels (PGY3-4 >PGY2 >PGY1). Approximate cost for replaceable items was 40 US dollars to 150 per resident depending on which tasks were chosen. Comparison of scores between residents who received a laboratory-based curriculum and those who did not revealed significantly higher scores and shorter time to complete tasks for the group who received additional training. CONCLUSION: Large-scale testing has confirmed that OSATS is an objective, reliable, and valid method to assess surgical skills, and can easily be administered in most residency programs. A laboratory-based surgical curriculum improved test results and reduced time to complete tasks.