Resident continuity clinics: a learning design for group private practice.

Continuity clinics are required for residents in obstetrics and gynecology in the U.S., but are costly and difficult to administer. Organizing them into group resident continuity clinic programs which emulate the group private practice most residents will join, creates a design that is parsimonious of clinic resources, while providing a type of continuity with which patients, nurses, and physicians are familiar and comfortable.

Alzheimer's disease: an estrogen link?

The prospect that Alzheimer's disease is caused by or related to estrogen deficiency, and treatable or even preventable by estrogen replacement therapy, is alluring. At present, evidence that Alzheimer's disease is an estrogen deficiency disease is lacking. However, there is much evidence that beneficial effects of estrogen replacement therapy on the areas of the brain associated with Alzheimer's disease may prevent or slow the progress of Alzheimer's disease or the expression of Alzheimer's disease symptoms. Given the proven value of estrogen replacement therapy for most women for other indications, this probable additional benefit is welcome. Further research is needed.

Interpreting fetal heart rate tracings. Is there a difference between labor and delivery nurses and obstetricians?

OBJECTIVE: To analyze the influence of increasing education and clinical experience on fetal heart rate interpretation by health care providers in labor and delivery areas. STUDY DESIGN: Eleven tracings representing a variety of fetal heart rate patterns and neonatal outcomes were selected. Respondents were asked to interpret the tracing strips on a 1-5 scale and predict Apgar scores and cord blood gases. RESULTS: Seventy nurses and physicians participated. Experience with labor and delivery and provider classification correlated significantly with correct interpretation. Certified nurse midwives differed significantly in number of correct interpretations from both first-year residents and low-risk nurses. Providers did not differ on ability to predict Apgar scores or cord gases. CONCLUSION: Length of clinical experience correlated positively with the interpretation of fetal heart rate tracings but not with the prediction of Apgar scores or cord blood gas measurements. These data will be useful in designing educational and orientation programs for physicians and nurses in the labor and delivery setting.

Accuracy of maternal perception of preterm uterine activity.

OBJECTIVE: Our purpose was to compare the accuracy of maternal perception of preterm uterine activity by self-palpation versus home uterine activity monitoring. STUDY DESIGN: A total of 72,962 uterine activity records of 778 women receiving home uterine activity monitoring services were analyzed. Simultaneously with home uterine activity monitoring, the women indicated by an electronic marker when they felt a "contraction" through self-palpation. The perceptions of the women were compared to the tocodynamometrically measured uterine activity. RESULTS: Using self-palpation, women correctly identified 17.2% of contractions recorded by tocodynamometry. Overall mean percent correct correlation per patient was only 14.1%. Patients missed an average of 85.7% of their contractions. Patients incorrectly perceived contractions that were not present an average of 40.3% of the time. Singleton gestations had significantly better correct correlations than twin gestations. Multiparous women had improved correlations compared with primiparous women. No significant correlation was found between maternal perceptive ability and gestational age. CONCLUSION: Women were unable to perceive accurately the presence or absence of preterm uterine activity through self-palpation compared with simultaneous measurement by home uterine tocodynamometry.

Perinatal and health care management consequences of twice-a-day versus once-a-day evaluation of home uterine activity monitoring data.

There was a significant increase in the number of physician interventions (additional testing of mother or baby; extra office, emergency, or labor and delivery unit visits; and especially extra hospitalizations) but no significant difference in perinatal outcome (illness in mother or baby) when women at high-risk for preterm labor on home uterine activity monitoring services had scheduled twice-a-day review (BID review) of the home uterine activity monitoring data they had collected versus once-a-day review (OD review).

Computer-assisted video evaluation of surgical skills.

Compact video cameras have allowed the review of operations in self-directed learning sessions. Controlling the video viewing process by computer allows the selection of specific videotape segments containing the desired psychomotor skills to be evaluated--in this study, the steps involving laparoscopic tubal banding. Six faculty members were able to evaluate 23 videotapes efficiently without knowledge of the resident operator's identity. Because the computer allowed selection of only those frames of the videotape containing the skills to be evaluated, the duration of videotape seen was reduced by an average of 34% from the actual surgical time, with an increase in time saved as experience with the system was gained. Faculty members evaluated these events using a self-made checklist. It was possible to calculate the performance scores of each resident for the individual psychomotor skill components of the reviewed procedure. Computer-assisted video evaluation of surgical skills is technically feasible, allowing time-efficient review by multiple evaluators. With the development of psychometrically valid checklists for use with this technology, computer-assisted video evaluation of surgical skills may provide a new, innovative means of assessing surgical skills and training.

A model for resident surgical training in laparoscopic sterilization.

OBJECTIVE: To measure the effects of a specific instructional program designed to teach residents laparoscopic sterilization. METHODS: The teaching module consisted of a 40-minute videotape and monograph, which each resident studied 1-3 days before beginning a 4-5-week rotation on which he or she performed laparoscopic sterilization procedures. The change in knowledge was measured by comparing pre- and post-test assessments. Twenty-three PGY-2 gynecology residents were administered the peer-reviewed and validated pre-test, which consisted of 31 multiple-choice questions covering the following aspects of laparoscopic sterilization: 1) indications and complications, 2) general aspects of sterilization, 3) sterilization methods, and 4) technical aspects of occlusive device application. A post-test, which consisted of the identical 31 items with the question order changed, was administered after the teaching module was completed. RESULTS: The mean number of correct answers on the post-test (27.2 +/- 2.3, range 22-31) was significantly higher (P < .05) than the mean number of correct answers on the pre-test (17.9 +/- 3.4, range 13-24). There was no difference in residence scores if the module was completed early or late in the academic year or during the first or second year that the program was in effect. CONCLUSION: This study demonstrates that knowledge of a specific surgical technique can be measured and that structured learning packages can be effective. Efforts to teach residents a specific curriculum can have a significant effect on their fund of knowledge. Other specially designed programs may be applicable to procedures commonly performed by gynecologic residents.

Instruction in surgical anatomy for gynecology residents using prosected human cadavers.

Prosected human cadavers were used by a team of anatomists and gynecologic surgeons to teach surgical anatomy to gynecology residents. The course was offered at the start of each 8-week gynecologic surgery rotation. Hemisections and other similar prosections were used to demonstrate anatomic relationships and surgical procedures from vantage points unobtainable at the operating table. The initial response from the faculty and residents was encouraging. The residents believed the program to be beneficial and were satisfied with it. Both the anatomy faculty and the gynecology faculty found new insights into teaching issues during the interdisciplinary process of course preparation and teaching.

Senior obstetric-gynecologic residents' perceptions of their surgical training, experiences and skill.

Senior obstetric and gynecologic residents' self-perceptions of surgical skill seem to be unrelated to the kinds of didactic experiences received or to the number of basic gynecologic procedures performed during training. These data offer further support for the need for a comprehensive reevaluation of the components of gynecologic surgical curricula; the cognitive, behavioral and psychomotor educational objectives of such training; and the methods by which the outcomes for these objectives are measured.

A conference on ethics for obstetric and gynaecological clerkship students.

Integrating the teaching of medical ethics into medical students' clinical education is challenging, given the competing demands on students' time and the need for teaching to be clinically relevant. This paper describes a model programme for incorporating ethics teaching into the obstetrics and gynaecology clerkship for third-year medical students. The programme is taught by two attending teachers and a medical ethicist with experience teaching in the clinical setting of obstetrics and gynaecology. Objective pretests and posttests showed substantial improvement in students' knowledge, and student feedback has been very positive.

Gynaecological teaching associates in the 1990s.

Chairmen of academic obstetrics and gynaecology departments in the USA and Canada were asked if they used gynaecological teaching associates (GTAs) and their opinions of their educational and cost effectiveness. Three-quarters of chairmen used GTAs and were satisfied with the educational aspects of GTA instruction. Departmental discretionary funds provided all or part of the GTA funding in 40% of departments and the medical school all or part of the GTA funding in 72%. As more monies came from departmental discretionary funds, chairmen were increasingly dissatisfied. Because the 1990s will be difficult financially, it was hypothesized that chairmen may eventually cancel GTA programmes as expendable 'luxuries'.

Auscultation with an esophageal stethoscope. A new test for pneumoperitoneum.

Auscultation for the tympanic sound characteristic of developing pneumoperitoneum during insufflation of the abdomen at laparoscopy was performed with an esophageal stethoscope. Such auscultation detected pneumoperitoneum as soon as or sooner than did the other, standard methods to which it was compared. This test requires no additional maneuvers beyond those routine in standard laparoscopic and anesthetic procedures, providing a useful adjunctive test for pneumoperitoneum acquisition.

Effect of a structured antepartum exercise program on pregnancy and labor outcome in primiparas.

The labor and delivery outcomes were compared for 50 low-risk primiparas who voluntarily participated in a structured, nonendurance antepartum exercise program and a similar, nonexercising control group. No adverse effects on fetal well-being were noted in the exercising group. However, those who exercised had significantly shorter first and second stages of labor (mean length, 7.55 and 1.33 hours, respectively; P less than .001) as compared to those who did not exercise (mean length, 14.46 and 2.47 hours, respectively; P less than .001). The exercising primiparas were also less likely to require oxytocin augmentation of labor and more likely to have spontaneous vaginal deliveries. The data suggest that there might be beneficial effects from nonendurance antepartum exercise regimens for women with normal pregnancies. Hence, the data have implications for the counsel given pregnant women about antenatal exercise and for future research on exercise during pregnancy.

Undergraduate medical education in obstetrics and gynaecology in the USA and Canada, 1985.

Many factors have led to a movement from the emphasis of the 1960s and 1970s on departmental expansion towards an emphasis on cost-effective undergraduate medical education emphasizing the 'art' as well as the 'science' of medicine. In January 1985 a questionnaire was sent under the auspices of the Undergraduate Education Committee of the Association of Professors of Obstetrics and Gynecology to all chairmen of departments of obstetrics and gynecology in the USA and Canada seeking their opinions about these trends and information about the educational programmes in their departments. The information from this study indicates that the chairmen are aware of and responding to this new direction in medical education. A stabilization of teaching staff and clerkship sizes and the emphasis on clinical as well as cognitive evaluation, despite recognition of the cost of the former, shows active interventions towards these ends. An emphasis on education in 'basic' as compared to 'subspecialty' areas which is independent of the subspecialty of the academic chairman also supports this trend.