Development of laparoscopic skills in skills-naïve trainees using self-directed learning with take-home laparoscopic trainer boxes.

Background: To determine if take home laparoscopic trainer boxes with only self-directed learning can develop laparoscopic skills in surgically naive learners. Methods: 74 starting PGY1 OB/Gyn residents and OB/Gyn clerkship medical students volunteered for the study. Learners performed a laparoscopic peg transfer task with only task instructions and no additional training. Initial tasks were recorded and scored. The participants took home a laparoscopic trainer box for 3 weeks to practice without guidance and returned to perform the same task for a second/final score. Initial and final scores were compared for improvement. This improvement was compared to practice and variables such as demographics, surgical interest, comfort with laparoscopy, and past experiences. Results: Mean peg transfer task scores improved from 287 (SD = 136) seconds to 193 (SD = 79) seconds (p < 0.001). Score improvement showed a positive correlation with number of home practice sessions with a linear regression R2 of 0.134 (p = 0.001). More practice resulted in larger increases in comfort levels, and higher comfort levels correlated with better final task scores with a linear regression R2 of 0.152 (p < 0.001). Interest in a surgical specialty had no impact on final scores or improvement. Playing a musical instrument and having two or more dexterity-based hobbies was associated with a better baseline score (p = 0.032 and p = 0.033 respectively), but no difference in the final scores or score improvement. No other past experiences impacted scores. Conclusions: Our study demonstrates that the use of home laparoscopic box trainers can develop laparoscopic skills in surgical novices even without formal guidance or curriculum.

A Successful Dental Care Referral Program for Low-Income Pregnant Women in New York.

Despite evidence-based guidelines that advocate for dental care during pregnancy, dental utilization among pregnant women remains low, especially among low-income and racial-ethnic minority women. We investigated self-reported dental care referral and self-reported dental care attendance among a group of 298 low-income, largely racial-ethnic minority pregnant women attending two suburban prenatal care clinics that had integrated dental care referrals into their prenatal care according to these guidelines. We administered a questionnaire that asked women: (1) whether they had been referred for care by their prenatal care provider; (2) whether they had been seen by a dentist during pregnancy. Among those women who were eligible for a dental care referral (those who reported having dental symptoms, and those not having a recent dental visit), we found that 73.0% reported that they had indeed been referred for dental care by their prenatal provider, while the remaining women reported either no referral (23.5%, n = 67) or were not sure whether they had been referred (3.5%, n = 10). Among those who reported a dental care referral, 67.3% (n = 140) reported that they saw a dentist during their pregnancy, while of those who reported no dental care referral only 35.1% (n = 27) reported a dental visit (Chi-Sq. = 24.1, df = 1, p < 0.001). Having received a dental referral was a significant predictor of reporting a dental visit during pregnancy, with women who received a referral being 4.6 times more likely to report a dental visit during pregnancy compared to those women who did not report a referral. These results demonstrate that vulnerable pregnant women referred for dental care by their prenatal provider will indeed seek and utilize dental care when offered. This dental referral program may serve as a model for improving the utilization of dental care among this population.

Are Obstetrics and Gynecology Residents Equipped to Care for Transgender and Gender Nonconforming Patients? A National Survey Study.

Purpose: Our study aims to assess three self-reported outcomes: (1) comfort of, (2) competency in, and (3) curricular satisfaction of OB-GYN residents in caring for transgender and gender nonconforming (TGNC) patients. Methods: This was a cross-sectional survey of a convenience sample of OB-GYN residents consisting of 28 questions on a 4-point Likert scale. The survey was distributed to OB-GYN residents via residency program directors and coordinators. Descriptive statistics and multivariate linear regression modeling were performed to identify demographic and training characteristics associated with differences in comfort, competency, and curricular satisfaction. Results: One-hundred twenty-six surveys were completed by OB-GYN residents (response rate=12.6%). Composite mean scores were calculated in the three self-reported outcome domains: comfort (2.8±0.67), competency (2.7±0.61), and satisfaction (2.2±0.82) which correlate to being "somewhat not" and "somewhat" comfortable, competent, and satisfied. Trainees who identified as lesbian, gay, bisexual, or queer were found to have higher comfort scores. Older age and male gender identity were associated with higher competency scores. No significant differences in comfort, competency, and satisfaction scores between residency training level were observed. The majority (78.1%, N=89) of trainees "strongly agreed" that it was important for them to obtain training in TGNC care topics. Conclusion: OB-GYN residents strongly agreed that learning about care for TGNC patients was important. Residents reported being more competent and comfortable than satisfied, which suggests that further curricular and clinical exposure is necessary to address the unique health care needs of this underserved patient population and to meet the educational needs of OB-GYN residents.

Third year medical students impersonalize and hedge when providing negative upward feedback to clinical faculty.

Medical students provide clinical teaching faculty with feedback on their skills as educators through anonymous surveys at the end of their clerkship rotation. Because faculty are in a position of power, students are hesitant to provide candid feedback. Our objective was to determine if medical students were willing to provide negative upward feedback to clinical faculty and describe how they conveyed their feedback. A qualitative analysis of third year medical students' open-ended comments from evaluations of six clerkships was performed using politeness theory as a conceptual framework. Students were asked to describe how the clerkship enhanced their learning and how it could be improved. Midway through the academic year, instructions to provide full names of faculty/residents was added. Overall, there were significantly more comments on what worked well than suggestions for improvement regarding faculty/residents. Instructing students to name-names increased the rate of naming from 35% to 75% for what worked well and from 13% to 39% for suggestions for improvement. Hedging language was included in 61% of suggestions for improvement, but only 2% of what worked well. Students described the variability of their experience, used passive language and qualified negative experiences with positive ones. Medical students may use linguistic strategies, such as impersonalizing and hedging, to mitigate the impact of negative upward feedback. Working towards a culture that supports upward feedback would allow students to feel more comfortable providing candid comments about their experience.

Acute Myocardial Infarction in the First Trimester of Pregnancy in a Great Grand Multiparous Woman with Poorly Controlled Chronic Hypertension.

INTRODUCTION: Acute myocardial infarction (MI) in pregnancy is a rare event, usually occurring late in gestation, either in the third trimester or in the puerperium. It is associated with significant maternal and fetal morbidity and mortality. Although diagnosis and management of MI in pregnancy has been discussed in the literature, management of pregnancy following an early antepartum MI, which may have more consequences for the fetus, has not received as much attention. CASE: A 38-year-old great grand multiparous woman presented to the emergency department complaining of acute onset chest pain. The patient had a history of chronic hypertension and was an active smoker. She was incidentally found to be 5 weeks pregnant. She was diagnosed with an acute MI, which was treated by primary percutaneous coronary intervention. Her subsequent pregnancy course was complicated by poorly controlled chronic hypertension, but she ultimately delivered a healthy newborn at 36 weeks of gestational age. CONCLUSION: Good pregnancy outcomes are possible after early antepartum MI, especially with early diagnosis, appropriate treatment, and a multidisciplinary team approach to prenatal care. Delivery should occur in a tertiary referral center with experience managing high-risk obstetric patients with cardiac disease.

Not for industry only: medical students and office-based academic detailing the PIVOT (Pregnant women Influenza Vaccine Optimization Team) initiative.

Academic detailing is a method of educational outreach that utilizes individualized encounters with physicians to broach specific medical issues in an evidence-based and quality-driven manner. Medical students utilized the matter of influenza vaccination during pregnancy as a lens through which to explore the methods of academic detailing in a community setting. Structured and customized dialogues between North Shore-LIJ affiliated obstetricians and Hofstra North Shore-LIJ medical students were conducted regarding the disparity between the proportion of providers that recommend the vaccine and the percentage of pregnant women being vaccinated annually. Ultimately the project aimed to increase vaccine-carrying rates throughout office based practices in the community, while establishing a viable method for up-to-date information exchange between practicing physicians and academic medicine. While the extent of affected change is currently being quantified, the project proved successful insofar as academic detailing allowed the students to gain access to physicians, and engage in compelling and educational conversations. Both the physicians and students felt these interactions were valuable and well worth continuing. The goal for the future is to expand these practices to other pressing public health issues while continuing to refine the technique.