Fellowship for Academic Generalists in Obstetrics and Gynecology: Is It Overdue?

Academic specialists in general obstetrics and gynecology are clinicians practicing the full breadth of the specialty while also contributing to medical education and scientific discovery. Residency programs in obstetrics and gynecology provide exposure to research training that is variable but frequently limited. This creates challenges for junior faculty and in many cases limits their research productivity, typically measured by published original research articles and grant funding. This frequently disadvantages academic specialists in promotion compared with their subspecialty fellowship-trained colleagues. A few research fellowship programs were recently launched to address this issue. However, these programs are not uniform and encounter challenges such as sustainable funding. In this article, building on knowledge from current academic specialist fellowship programs, we discuss the needs, challenges, and proposed solutions. We also propose some details needing further discussion among the academic obstetrics and gynecology community. We discuss how such fellowships can integrate with current development and training opportunities such as the Women's Reproductive Health Research award, Building Interdisciplinary Research Careers in Women's Health award, other K and K-type career development programs, NIH T32 grants, and clinical research courses for obstetricians and gynecologists. Academic specialist fellowship programs can have synergy with other women's health fellowship programs offered by other specialties. They can additionally leverage institutional resources. We conclude by summarizing a proposed model for academic specialist research fellowship programs.

ACR Appropriateness Criteria® Acute pelvic pain in the reproductive age group: 2023 update

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (ß-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative ß-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive ß-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative ß-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update.

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (ß-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative ß-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive ß-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative ß-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The APGO Academic Scholars and Leaders Program: Supporting obstetrics and gynecology faculty development for 20 years.

PURPOSE: We evaluate the impacts of the Academic Scholars and Leaders (ASL) Program in achieving 3 key objectives: treatment of education as a scholarly pursuit, improved education leadership, and career advancement. MATERIALS AND METHODS: We report on the twenty-year experience of the ASL Program-a national, longitudinal faculty development program of the Association of Professors of Obstetrics and Gynecology (APGO) covering instruction, curriculum development/program evaluation, assessment/feedback, leadership/professional development, and educational scholarship. We conducted a cross-sectional, online survey of ASL participants who graduated in 1999-2017. We sought evidence of impact using Kirkpatrick's 4-level framework. Descriptive quantitative data were analyzed, and open-ended comments were organized using content analysis. RESULTS: 64% (260) of graduates responded. The vast majority (96%) felt the program was extremely worthwhile (Kirkpatrick level 1). Graduates cited learned skills they had applied to their work, most commonly curricular development (48%) and direct teaching (38%) (Kirkpatrick 2&3 A). Since participation, 82% of graduates have held institutional, education-focused leadership roles (Kirkpatrick 3B). Nineteen percent had published the ASL project as a manuscript and 46% additional education papers (Kirkpatrick 3B). CONCLUSIONS: The APGO ASL program has been associated with successful outcomes in treatment of education as a scholarly pursuit, education leadership, and career advancement. Going forward, APGO is considering ways to diversify the ASL community and to support educational research training.

ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality.

Palpable scrotal abnormalities are caused by a variety of disorders, ranging from indolent benign conditions to aggressive tumors, and infectious and vascular processes. In these patients the diagnostic workup typically begins with a complete clinical, history, and physical examinations, including analysis of risk factors. If imaging is required, ultrasound examination is the diagnostic modality of choice. In few select patients with very large scrotal masses, MRI may be appropriate. However, the use of gadolinium-based contrast should be evaluated critically depending on specific patient factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females.

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Uterine Artery Embolization for Symptomatic Adenomyosis: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel.

Adenomyosis poses an important diagnostic and therapeutic challenge in women's health because of a variety of clinical/imaging presentations and frequent coexistence with other benign gynecologic conditions. In recent years, uterine artery embolization (UAE) for the treatment of adenomyosis has shown encouraging and favorable outcomes and long-term symptom improvement. To expand the current understanding of adenomyosis pathophysiology, imaging diagnostic criteria, and treatment outcomes, the Society of Interventional Radiology Foundation gathered a multidisciplinary Research Consensus Panel with experts from diverse backgrounds. The topics addressed were centered around the following: (i) the clinical presentation and imaging findings to diagnose adenomyosis; (ii) the currently available medical, interventional, and surgical treatment options; and (iii) existing literature for and experiences with UAE in symptomatic disease. The panel acknowledged that before the pursuit of a clinical trial, it would be necessary to first evaluate the imaging criteria for adenomyosis and correlate them with pathology and symptoms to establish a noninvasive imaging classification system. Second priority was given to the development of a quality of life questionnaire to assess patient outcomes following treatment. The third priority was the performance of a prospective clinical trial comparing UAE with medical therapy, which would help establish UAE in the treatment algorithm and societal guidelines for symptomatic adenomyosis.

The DoCTRINE Guidelines: Defined Criteria To Report INnovations in Education.

PURPOSE: Reporting guidelines assist authors in conducting and describing their research in alignment with evidence-based and expert-determined standards. However, published research-oriented guidelines do not capture all of the components that must be present in descriptions of educational innovations in health professions education. The authors aimed to create guidelines for educational innovations in curriculum development that would be easy for early-career educators to use, support reporting necessary details, and promote educational scholarship. METHOD: Beginning in 2017, the authors systematically developed a reporting checklist for educational innovations in curriculum development, called Defined Criteria To Report INnovations in Education (DoCTRINE), and collected validity evidence for its use according to the 4 inferences of Kane's framework. They derived the items using a modified Delphi method, followed by pilot testing, cognitive interviewing, and interrater reliability testing. In May-November 2019, they implemented DoCTRINE for authors submitting to MedEdPORTAL, half of whom were randomized to receive the checklist (intervention group). The authors scored manuscripts using DoCTRINE while blinded to group assignment, and they collected data on final editorial decisions. RESULTS: The final DoCTRINE checklist consists of 19 items, categorized into 5 components: introduction, curriculum development, curriculum implementation, results, and discussion. The overall interrater agreement was 0.91. Among the 108 manuscripts submitted to MedEdPORTAL during the study period, the mean (SD) total score was higher for accepted than rejected submissions (16.9 [1.73] vs 15.7 [2.24], P = .006). There were no significant differences in DoCTRINE scores between the intervention group, who received the checklist, and the control group, who did not. CONCLUSIONS: The authors developed DoCTRINE, using systematic approaches, for the scholarly reporting of educational innovations in curriculum development. This checklist may be a useful tool for supporting the publishing efforts of early-career faculty.

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain.

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

[Box: see text]With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Building Health Systems Science Education from the Core Domain of Interprofessional Education at Virginia Tech Carilion School of Medicine.

The Virginia Tech Carilion School of Medicine (VTCSOM) is a 4-year allopathic medical school in Roanoke, VA. The curriculum is organized into four learning domains: basic science, clinical science, research, and interprofessionalism (IPE). A recent curriculum renewal effort allowed the school to embark upon a redesign of the IPE learning domain to incorporate new core content from health systems science (HSS). We describe how our unique approach to IPE is being preserved as we innovate to produce graduates who are future thought leaders and "systems citizens," prepared to deliver patient care with an expanded knowledge of the health systems in which they will eventually practice.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding.

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks. Most of the causes of PPH can be diagnosed clinically, but imaging plays an important role in the diagnosis of many causes of PPH. Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH. Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Contributions, Aspirations, and Challenges of Academic Specialist Divisions in Obstetrics and Gynecology.

Shortly after its inception, the Society for Academic Specialists in General Obstetrics and Gynecology recognized that no data described the composition and faculty activities of "academic generalist divisions." Consequently, in 2018, the Society for Academic Specialists in General Obstetrics and Gynecology appointed a presidential task force and conducted the current surveys of chairs and division directors and key informant interviews to understand the composition and faculty activities in divisions of academic specialists in departments of obstetrics and gynecology and propose criteria for excellence in each mission area to guide development of divisions. In 2014, with Society for Academic Specialists in General Obstetrics and Gynecology's guidance, these divisions were referred to as academic specialists divisions and the faculty within as academic specialists to emphasize that they provide specialized women's health care in academic settings. The divisions comprised approximately 30% of departments' full-time faculty (median 12). In 27% of the departments, these divisions contributed more than half of departmental revenue, and 49% contributed 26-50%. Nearly 90% of divisions provided a sizeable proportion of the department's total teaching efforts. Compensation relied more on clinical productivity than on seniority, quality, academic contributions, or academic rank. Subsequently, five performance domains were identified to help divisions define divisional excellence: clinical, education, research, service & advocacy, and academic environment. Furthermore, excellent divisions were characterized as those with outstanding clinicians and educators who emphasize scholarly productivity. Although academic specialists contribute significantly to their departments' financial, clinical, and educational productivity, many have limited opportunities for scholarly activity. Achieving divisional excellence likely will depend on the ability to recruit and retain faculty with career expectations that align with the division's prioritized performance domains.

Implementation and Initial Construct Validity Evidence of a Tool, myTIPreport, for Interactive Workplace Feedback on ACGME Milestones.

OBJECTIVE: To describe implementation of myTIPreport for milestone feedback and to initiate construct validity testing of myTIPreport for milestones. DESIGN: myTIPreport was used to provide workplace feedback on Accreditation Council for Graduate Medical Education required milestone sets. Performance of senior learners (postgraduate year [PGY]-4s) was compared to that of junior learners (PGY-1s) to begin the process of construct validity testing for myTIPreport. SETTING: A convenience-based site selection of Obstetrics and Gynecology (OBGYN) residency programs. PARTICIPANTS: OBGYN residents and faculty. RESULTS: Amongst the 12 participating OBGYN residency programs, there were 444 unique learners and 343 unique faculty teachers. A total of 5293 milestone feedback encounters were recorded. Mean PGY-4 performance was rated higher than mean PGY-1 performance on all 25 of the compared milestone sets, with statistically significant differences seen for 19 (76%) of these 25 milestone sets and nonsignificant differences in the predicted direction observed for the other 6 milestone sets. CONCLUSIONS: myTIPreport detected differences between senior and junior learners for the majority of compared feedback encounters for OBGYN residents. Findings support the emerging construct validity of myTIPreport for milestone feedback.

ACR Appropriateness Criteria® Female Infertility.

The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.

ACR Appropriateness Criteria® Postmenopausal Subacute or Chronic Pelvic Pain.

Pelvic pain is common in both reproductive age and postmenopausal women, and the major etiologies change throughout the life cycle. Chronic pain is defined as lasting for at least 6 months. There are many gastrointestinal and urinary disorders associated with chronic pain in this age group, which are not discussed in this guideline. Pain may be localized to the deep pelvis, with potential causes including pelvic congestion syndrome, intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis. Ultrasound is the initial imaging modality of choice, while CT and MRI may be appropriate for further characterization of sonographic findings. Alternatively, pain may be localized to the vagina, vulva, or perineum, with potential causes including vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Imaging is primarily indicated in context of an abnormal physical exam and ultrasound is the initial modality of choice, while MRI may be appropriate for further characterization in select cases. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.