Financial Toxicity in Relation to Childbirth.

OBJECTIVE: To measure change in financial toxicity from pregnancy to the postpartum period and to identify factors associated with this change. DESIGN: Repeated cross-sectional survey. SETTING: Obstetric clinics at an academic medical center in Massachusetts between May 2020 and May 2022. PARTICIPANTS: Obstetric patients who were 18 years of age or older (N = 242). METHODS: Respondents completed surveys that included the Comprehensive Score for Financial Toxicity tool during pregnancy and in the postpartum period. We collected additional medical record data, including gestational age, birth weight, and cesarean birth. We used paired t tests to assess changes in financial toxicity before and after childbirth and one-way analysis of variance to compare average change in financial toxicity by demographic and medical variables. RESULTS: The mean current financial toxicity score was significantly lower after childbirth (M = 19.0, SD = 4.6) than during pregnancy (M = 21.8, SD = 5.4), t(241) = 13.31, p < .001. Concern for future financial toxicity was not significantly different after childbirth (M = 8.5, SD = 2.9) compared to during pregnancy (M = 8.2, SD = 3.0), t(241) = -1.80, p = .07. Individual-level sociodemographic variables (e.g., racial/ethnic category, insurance, employment) and medical factors (e.g., cesarean birth, preterm birth) were not associated with change in financial toxicity. CONCLUSION: Among respondents, financial toxicity worsened after childbirth, and patients are at risk regardless of their individual socioeconomic and medical conditions.

Association between density of food retailers and fitness centers and gestational diabetes mellitus in Eastern Massachusetts, USA: population-based study.

Background: Few studies have investigated the relationship between the food and physical activity environment and odds of gestational diabetes mellitus (GDM). This study quantifies the association between densities of several types of food establishments and fitness centers with the odds of having GDM. Methods: The density of supermarkets, fast-food restaurants, full-service restaurants, convenience stores and fitness centers at 500, 1000 and 1500 m (m) buffers was counted at residential addresses of 68,779 pregnant individuals from Eastern Massachusetts during 2000-2016. The 'healthy food index' assessed the relative availability of healthy (supermarkets) vs unhealthy (fast-food restaurants, convenience stores) food retailers. Multivariable logistic regression quantified the cross-sectional association between exposure variables and the odds of having GDM, adjusting for individual and area-level characteristics. Effect modification by area-level socioeconomic status (SES) was assessed. Findings: In fully adjusted models, pregnant individuals living in the highest density tertile of fast-food restaurants had higher GDM odds compared to those living in the lowest density tertile (500 m: odds ratio (OR):1.17 95% CI: [1.04, 1.31]; 1000 m: 1.33 95% CI: [1.15, 1.53]); 1500 m: 1.18 95% CI: [1.01, 1.38]). Greater residential density of supermarkets was associated with lower odds of GDM (1000 m: 0.86 95% CI: [0.74, 0.99]; 1500 m: 0.86 95% CI: [0.72, 1.01]). Similarly, living in the highest fitness center density tertile was associated with decreased GDM odds (500 m:0.87 95% CI: [0.76, 0.99]; 1500 m: 0.89 95% CI: [0.79, 1.01]). There was no evidence of effect modification by SES and no association found between the healthy food index and GDM odds. Interpretation: In Eastern Massachusetts, living near a greater density of fast-food establishments was associated with higher GDM odds. Greater residential access to supermarkets and fitness centers was associated with lower the odds of having GDM. Funding: NIH.

Hiding in Plain Sight: Resident Remediation in Obstetrics and Gynecology.

OBJECTIVE: Residents who are in need of remediation are prevalent across residency programs and often tend to be deficient in multiple competencies that the American Council for Graduate Medical Education (ACGME) has established. The purpose of this study was to determine the prevalence of residents requiring remediation, understand the scope of the challenges in resident remediation, and assess what resources were used to aid in remediation in obstetrics and gynecology programs. DESIGN: An anonymous survey was emailed to obstetrics and gynecology program directors. Survey responses were summarized through descriptive statistics. SETTING: Obstetrics and gynecology residency program directors were invited to respond to this survey. PARTICIPANTS: Thirty-nine respondents out of 241 residency training programs responded (16%). RESULTS: The majority (84.6%) of programs had placed a resident on remediation. The most common area requiring remediation was professionalism (75.8%), followed by medical knowledge (72.7%), interpersonal communication (60.6%), laparoscopic technical skills (54.6%), and inpatient care (42.4%). Residents who required remediation were identified in a number of ways, most commonly through feedback from the Clinical Competency Committee (87.8%) and faculty feedback (84.8%). Program directors utilized a variety of resources, most commonly prior remediation plans from the program, to create remediation plans. Sixty percent of programs had residents who failed remediation. CONCLUSION: This study highlighted the prevalence of resident remediation in obstetrics and gynecology training programs and the importance of faculty in identifying residents in need of remediation, evaluating residents, and mentoring residents.

Peer Mentorship: Career Support in Full Bloom.

Peer mentorship, referring to interactions among colleagues at similar career stages for the purpose of bidirectional career development, is a powerful tool to promote personal and professional growth. While dyadic mentoring has traditionally been the norm in academia, the needs of junior faculty may span multiple domains that a single senior mentor may not be able to address. 1,2 A vibrant community garden of peer mentors can help to harvest ideas, encourage mutual collaboration, increase personal satisfaction, and promote career advancement.

Procedural Teaching: Focusing on the Conscious Patient.

OBJECTIVE: In this perspective, the authors discuss how to teach procedures at the bedside with an awake patient. DESIGN/SETTING: The teaching process is divided into 3 stages: preprocedural, intraprocedural, and postprocedural. PARTICIPANTS: Each stage focuses on a specific set of educational goals and aims for the learner, with specific tips for how the faculty member should be teaching the learner. We discuss how to deal with challenging situations, such as when the faculty member needs to take over the procedure, and how to allow the learner to troubleshoot if they come across the unexpected. CONCLUSION: With the guidance provided in this perspective, we aim to make procedural teaching at the bedside less daunting for faculty members.

Executive Summary of the Lower Anogenital Tract Cancer Evidence Review Conference.

The Centers for Disease Control and Prevention sponsored a project conducted by the American College of Obstetricians and Gynecologists to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. For this final module, focusing on the cancers of the lower anogenital tract (vulva, vagina, and anus), a panel of experts in evidence assessment from the Society for Academic Specialists in General Obstetrics and Gynecology, ASCCP, and the Society of Gynecologic Oncology reviewed relevant literature and current guidelines. Panel members conducted structured literature reviews, which were then reviewed by other panel members. Representatives from stakeholder professional and patient advocacy organizations met virtually in September 2022 to review and provide comment. This article is the executive summary of the review. It covers prevention, early diagnosis, and special considerations of lower anogenital tract cancer. Knowledge gaps are summarized to provide guidance for future research.

Utilization of three-dimensional framework theory in identifying the motivational factors for selecting a postgraduate dental specialty-A pilot study.

OBJECTIVES: Three-dimensional framework theory classifies factors influencing career selection into intrinsic, extrinsic, and interpersonal dimensions. The objectives of this pilot research were to assess the psychometric properties of a scale encompassing factors affecting post-graduation specialty selection according to three-dimensional framework theory and identify motivational factors that affect dental students' and interns' choice of post-graduation specialty. METHODOLOGY: A closed-ended self-structured research instrument consisting of a list of 19 factors was presented to dental students and dental interns at Margalla Dental College, Rawalpindi, Pakistan, and Islamic International Dental College, Islamabad, Pakistan (n = 235). Exploratory factor analysis and Cronbach-alpha (α) were used to assess the construct validity and reliability (internal consistency) of the scale respectively. Descriptive analysis and non-parametric tests were used for data analysis with a level of significance at ≤0.05. RESULTS: A 3-factor solution with 11 items was stabilized. Cronbach-alpha of the pilot study turned out to be 0.72. With a response rate of 92.15%, the most common motivational factor affecting post-graduation specialty selection was the Intrinsic factor "personnel joy and motivation to work hard." Dental interns and male participants were more likely to select the post-graduation specialty due to intrinsic motivational factors (p < 0.05). Inspiration from the family member and supporting the family also influenced male participants and interns respectively (p < 0.05). Female participants preferred to choose a less saturated field (p < 0.05). A medium positive statistically significant correlation was observed between the interpersonal motivational factor "inspiration by a teacher" and the choice of "basic sciences" as a post-graduation specialty (p < 0.01). CONCLUSION: This pilot study resulted in the development of a scale with a 3-factor solution stabilized at 11 items. The internal consistency of the scale turned out to be 0.72. Oral and maxillofacial surgery was the first choice of post-graduation chosen by 35.5% of the respondents. Fellowship was chosen as the preferred type of post-graduation by 46% of the respondents. Irrespective of gender and designation, the top most influential factor, chosen by 88.5% of the respondents, was the intrinsic motivational factor "personal joy and motivation to work hard."

Financial toxicity in pregnancy and postpartum.

INTRODUCTION: The financial burden of pregnancy in the United States can be high and is associated with worse mental health and birth outcomes. Research on the financial burden of health care, such as the development of the COmprehensive Score for Financial Toxicity (COST) tool, has been conducted primarily among patients with cancer. This study aimed to validate the COST tool and use it to measure financial toxicity and its impacts among obstetric patients. METHODS: We used survey and medical record data from obstetric patients at a large medical center in the United States. We validated the COST tool using common factor analysis. We used linear regression to identify risk factors for financial toxicity and to investigate associations between financial toxicity and patient outcomes including satisfaction, access, mental health, and birth outcomes. RESULTS: The COST tool measured two distinct constructs of financial toxicity in this sample: current financial toxicity and concern over future financial toxicity. Racial/ethnic category, insurance, neighborhood deprivation, caregiving, and employment were associated with current financial toxicity (P < 0.05 for all). Only racial/ethnic category and caregiving were associated with concern over future financial toxicity (P < 0.05 for all). Both current and future financial toxicity were associated with worse patient-provider communication, depressive symptoms, and stress (P < 0.05 for all). Financial toxicity was not associated with birth outcomes or keeping obstetric visits. CONCLUSIONS: The COST tool captures two constructs among obstetric patients, current and future financial toxicity, both of which are associated with worse mental health and patient-provider communication.

Sanctity.

In this narrative medicine essay, an obstetrician finds relief from the frenetic intrusions of text messages, pages, and emails when in the operating room, where all devices are turned off and all her attention is turned on to her patient.

Postmenopausal Vaginal and Cervical Cancer Risk Related to In Utero Diethylstilbestrol Exposure.

OBJECTIVES: Women exposed to diethylstilbestrol (DES) in utero have an increased risk of clear cell adenocarcinoma of the lower genital tract, requiring lifelong cervical and vaginal cancer screening. We examined the incidence of DES-related cancers in postmenopausal women 50 years and older. MATERIALS AND METHODS: We conducted a retrospective chart review of patients 50 years and older exposed to DES in utero who received care at our institution. Patients were identified using billing codes and/or searching through the electronic record for the word DES. With this 2-pronged approach, we reviewed a total of 503 charts with confirmed DES exposure to identify gynecologic cancer occurrence. RESULTS: Within the 503 selected charts, 28 cases of gynecologic cancer occurrence were identified. Ten patients had cervical cancer and one patient had vaginal cancer. Only 1 woman of 503 developed a DES-related cervical or vaginal malignancy after age 50 years. No patients were diagnosed with cervical or vaginal cancer after age 65 years. CONCLUSIONS: Diethylstilbestrol-related malignancies are rare in those older than 50 years. Current cervical cancer screening guidelines recommend cessation of screening in an average risk, adequately screened patient at age 65 years, but patients exposed to DES have historically received lifelong screening. However, we found no cases of cervical or vaginal cancer related to DES after age 65 years, suggesting that screening recommendations could be changed for these patients to align with current screening guidelines.

Imperceptible learners: Students' reasons for keeping webcams off and strategies to address students' challenges.

BACKGROUND: "Should students keep their webcams on or off during synchronous online classes?" is an unanswered question with educators' opinions divided on this aspect. Along with educators' perspectives, it is also important to unfold students' perspectives on this question. The objectives of this study were to determine the routine and opinion of students' regarding webcam usage and identification of students' reasons for not using webcams during online learning. MATERIALS AND METHODS: A cross-sectional study was carried out at Margalla Institute of Health Sciences, Rawalpindi, Pakistan. Census was done for data collection by including all dental students (n = 180) enrolled at the institute attending synchronous online preclinical and clinical operative dentistry classes. Data collection was carried out using a self-administrated questionnaire. Descriptive analysis was used to describe survey item responses. Pair-wise differences between demographic categories (female vs. male, and preclinical vs. clinical) were analyzed using the Pearson Chi-Square test. Correlation of routine and opinion with students' reasons were done using Spearman correlation. Ordinal regression analysis was done to associate routine and opinion with reasons. The level of significance (P value) was set at 0.05. RESULTS: Out of 180 students, 141 submitted the survey form, with a response rate of 77.47%. The majority of the students (n = 117, 83%) used to keep their webcams off during online classes and were (n = 69, 48.9%) of the opinion that webcams should be kept off during online classes. The most common reasons for keeping the webcam off during online classes were "comfort" (n = 87, 61.7%) and "distractions" (n = 84, 59.6%). A statistically significant association of gender was obtained, with females more likely than males due to distraction, self-consciousness, and appearance (P = 0.000, 0.003, and 0.016, respectively). The odds of gender highly influenced routine use of cameras, and this was statistically significant (OR: 3.478, P = 0.011). Students tended to keep their webcam off when they were inattentative during online classes (OR; 3.743, P < 0.001). CONCLUSION: The majority of the students did not agree to keep the webcam on during online synchronous learning. The main reasons for students' reluctance to keep the webcam on were self-consciousness, surrounding consciousness, distractions, and technological issues. Students can be encouraged to turn the webcam on by framing strategies according to students' concerns.

Incivility in online learning environment: Perception of dental students and faculty.

OBJECTIVES: The objectives of this study were to assess the extent of incivility and perception of dental students and faculty regarding uncivil behaviors in the online learning environment. METHODS: Incivility in online environment (IOLE) survey was used to collect data from dental students (n = 232) and faculty (n = 35) at Margalla Institute of Health Sciences, Rawalpindi, Pakistan from September to December 2021. A 4- point Likert scale was used for respondents to indicate their perceptions regarding incivility in IOLE, and a list of students' and faculty's uncivil behaviors. Descriptive analysis, chi-square test, and Spearman's correlation coefficient were used for data analysis. The level of significance was kept at ≤0.05. RESULTS: The majority of the students reported online incivility as either "a moderate or serious problem" (n = 103, 72.0%), and the majority of faculty (n = 12, 56%) reported incivility as "no to a mild problem" (p = 0.018). Both students and faculty agreed that students are more likely to engage in uncivil behavior in OLE as compared to faculty. Various forms of rude/threatening comments and posting ambiguous or vague responses that do not add meaning to the online discussion were considered uncivil student behaviors by both students and faculty (p ≤ 0.05). Assigning grades without providing useful feedback and threatening to fail students for not complying with faculty's demands were perceived as uncivil faculty behaviors (p ≤ 0.05). Female students and students with less self-reported expertise in online learning had greater mean scores for faculty uncivil behaviors (p ≤ 0.05). CONCLUSION: Incivility exists in OLE in dentistry with the more likely engagement of students in uncivil behaviors. With the increasing use of online platforms for education in dentistry, there is a need for further research and training courses for both students and faculty to reduce the extent of incivility and create a healthy and conducive learning environment.

A scoping review of peer mentoring in medicine.

BACKGROUND: While studies have demonstrated the benefits of mentoring between junior and senior faculty, the dearth of senior mentors remains a challenge. Peer mentoring arose out of scarcity by creating communities among faculty at similar stages. Although demonstrative studies abound, no synthesis of the literature exists to characterise programme structure, content and impact on faculty. METHODS: We conducted a scoping review of peer mentoring programmes for faculty in academic medicine. We searched MEDLINE, Embase, Web of Science and ERIC for studies of peer mentoring programmes. Two authors independently reviewed the articles and extracted data. FINDINGS: We reviewed the titles and abstracts of 1513 studies, 75 full-text articles, and selected 19 studies for our review. About half of peer mentoring programmes were department-sponsored. The overall size varied from 3 to 104 participants; most were organised into small groups and met monthly. Fifty-eight percent included a didactic curriculum. Several studies showed an increase in publications, grant funding, retention rates and promotion, in addition to increased personal satisfaction. Qualitative data demonstrated themes of collaboration and mutual support. DISCUSSION: Programme outcomes were invariably positive with respect to participant satisfaction, and additionally, some studies showed an increase in publications, grant funding, retention rates and promotion. Camaraderie emerged as a strong theme in the programmes. CONCLUSIONS: This scoping review of peer mentoring programmes can guide institutions in their efforts to create similar initiatives.

Improving the Obstetrics and Gynecology Learning Environment Through Faculty Development.

Introduction: The learning environment is shaped by both formal and hidden curricula. Faculty play a critical role in the learning environment but may not be prepared to address the hidden curriculum. This workshop teaches faculty how to manage the hidden curriculum's challenges. Methods: Medical students' end-of-clerkship evaluations revealed low ratings in the domains of feedback, respectful interactions, professional language use, and empathy. We created a virtual 60-minute case-based faculty development workshop to highlight the role of faculty in improving the learning environment. A preworkshop survey was emailed to participants. At the workshop, following a brief introduction, participants were divided into groups to discuss the cases and develop strategies to improve the learning environment. A postworkshop survey was used to assess the workshop. Results: Sixty faculty members attended the seminar. Fifty-seven percent completed a preworkshop survey, and 33% completed the postworkshop survey. After the workshop, more faculty felt well prepared to engage students and residents. The majority of participants (85%) reported being more aware of issues around the learning environment. Most (85%) felt that their interactions with medical students would change in a positive way after the workshop. Ninety percent agreed the workshop was relevant to their needs, 70% agreed they learned a new skill in the workshop, and 80% committed to creating an inclusive learning environment after the workshop. Discussion: This workshop was well received by participants and was associated with an improvement in learning environment ratings. Faculty development seminars are an efficient tool to improve the learning environment.