A Framework for Diversifying Obstetrics and Gynecology Training Programs.

There is an urgent need to diversify the physician workforce in obstetrics and gynecology to serve a diverse patient population and mitigate disparities in care. There is a paucity of data on how to improve recruitment of individuals from underrepresented minoritized groups to the field of obstetrics and gynecology. This article outlines important steps for sharing the department's commitment to diversity, equity, and inclusion; addresses ways to attract a diverse applicant pool; and reviews the importance of and need to perform a holistic review of applicants. This commentary also shares some approaches to support faculty and trainees that may lead to sustained increases in diversity. Using this framework, the authors successfully increased the diversity of their obstetrics and gynecology residency program.

Conception rates and contraceptive use after bariatric surgery among women with infertility: Evidence from a prospective multicenter cohort study.

BACKGROUND: Lack of prospective trials have resulted in a dearth of information regarding postbariatric surgery conception rates in women with a preoperative history of infertility. OBJECTIVE: To examine associations between preoperative history of infertility and postbariatric surgery conception. SETTING: A multicenter cohort study at 10 United States hospitals (2006-2009). METHODS: Participants completed a preoperative reproductive health questionnaire, with annual postoperative assessments for up to 7 years until January 2015. This report was restricted to women 18- to 44-years old with no history of menopause, hysterectomy, or hormone replacement therapy. The primary outcomes were postoperative (0 to <90 mo) conception rate, early conception rate (0 < 18 mo), and postoperative unprotected intercourse with a male partner while not trying to conceive. RESULTS: Of 740 eligible women, 650 (87.8%) provided required responses. Median interquartile range (IQR) preoperative age was 34 (30-39) years and follow-up was 6.5 (5.9-7.0) years. Nulliparous women with a preoperative history of infertility represented 8.0% (52/650) of the total cohort, 63.5% (33/52) of whom had never conceived. Compared with women without this history, these women had a higher postoperative conception rate (121.2 [95% confidence interval (CI), 102.3-143.5]/1000 versus 47.0 [95%CI, 34.2-62.9]/1000 woman-yr; P < .001), early conception rate (115.4 [95%CI, 96.1-138.5]/1000 versus 33.9 [95%CI, 23.6-47.1]/1,000 woman-yr; P < .01), and a higher risk of unprotected intercourse (ARR 1.48 [95% CI, 1.14-1.90], P = 0.003). CONCLUSION: After bariatric surgery, preoperative history of infertility and nulliparity was associated higher conception rates and unprotected intercourse.

Crisis Teams for Obstetric Patients.

An obstetric-specific crisis team allows institutions to optimize the care response for patients with emergent maternal or fetal needs. Characteristics of optimal obstetric rapid response teams are team member role designations; streamlined communication; prompt access to resources; ongoing education, rehearsal, and training; and continual team quality analysis. The outcomes must be incorporated into team responses and reinforced in training. Team response provides a key resource to reassure staff, physicians, and patients that prompt crisis care is only a single call away. Data show that team activation is common, improves the care process, and has promise to improve outcomes.

Contraception and Conception After Bariatric Surgery.

OBJECTIVE: To examine contraceptive practices and conception rates after bariatric surgery. METHODS: The Longitudinal Assessment of Bariatric Surgery-2 is a multicenter, prospective cohort study of adults undergoing first-time bariatric surgery as part of routine clinical care at 10 U.S. hospitals. Recruitment occurred between 2005 and 2009. Participants completed preoperative and annual postsurgical assessments for up to 7 years until January 2015. This report was restricted to women 18-44 years old with no history of menopause, hysterectomy, or estrogen and progesterone therapy. Primary outcomes were self-reported contraceptive practices, overall conception rate, and early (less than 18 months) postsurgical conception. Contraceptive practice (no intercourse, protected intercourse, unprotected intercourse, or tried to conceive) was classified based on the preceding year. Conception rates were determined from self-reported pregnancies. RESULTS: Of 740 eligible women, 710 (95.9%) completed follow-up assessment(s). Median (interquartile range) preoperative age was 34 (30-39) years. In the first postsurgical year, 12.7% (95% CI 9.4-16.0) of women had no intercourse, 40.5% (95% CI 35.6-45.4) had protected intercourse only, 41.5% (95% CI 36.4-46.6) had unprotected intercourse while not trying to conceive, and 4.3% (95% CI 2.4-6.3) tried to conceive. The prevalence of the first three groups did not significantly differ across the 7 years of follow-up (P for all >.05); however, more women tried to conceive in the second year (13.1%, 95% CI 9.3-17.0; P<.001). The conception rate was 53.8 (95% CI 40.0-71.1) per 1,000 woman-years across follow-up (median [interquartile range] 6.5 [5.9-7.0] years); 42.3 (95% CI 30.2-57.6) per 1,000 woman-years in the 18 months after surgery. Age (adjusted relative risk 0.41 [95% CI 0.19-0.89] per 10 years, P=.03), being married or living as married (adjusted relative risk 4.76 [95% CI 2.02-11.21], P<.001), and rating future pregnancy as important preoperatively (adjusted relative risk 8.50 [95% CI 2.92-24.75], P<.001) were associated with early conception. CONCLUSIONS: Postsurgical contraceptive use and conception rates do not reflect recommendations for an 18-month delay in conception after bariatric surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT00465829.

Teaching the Retropubic Midurethral Sling Using a Novel Cadaver and Model-Based Approach.

OBJECTIVE: To measure the impact of a model-based teaching program on resident comfort and skill with retropubic midurethral sling (MUS). STUDY DESIGN: Residents were assessed before and after a retropubic MUS teaching session, which included a brief lecture and three interactive teaching stations (cadaver pelvis, retropubic MUS pelvic model, cystoscopy model). Self-assessment measures included MUS-related visual analog scale (VAS), Likert, and open-ended questions. Objective assessment measures were used to score blinded videos of trocar passage on a pelvic model, including a modified objective structured assessment of technical skills (mOSAT) and a retropubic MUS-specific checklist of surgical steps. Emerging themes from the open-ended questions were identified using grounded theory; analysis ceased once theme saturation was achieved. RESULTS: Twenty-five of 37 total residents participated in the training session and 24 participated in this study. Following training, VAS scores, Likert scores, and qualitative analysis indicated greater resident comfort with performing retropubic MUS, with relevant anatomy, and with trocar passage. Residents demonstrated improvement in model trocar passage post-training, with a rise in mOSAT score (47% to 65%; p = .01) and a rise in checklist score (61% to 75%; p = .11). Residents expressed discomfort due to inexperience with MUS, concern regarding trocar passage, and worry over potential complications. Residents reported feeling more prepared to perform MUS after the session. They stressed the importance of repetition and a comfortable learning environment for surgical training, and praised the "hands-on" training session. CONCLUSION: We demonstrate success using a short, single-session, hands-on group training session to improve comfort and skill with retropubic MUS.

Comparing Trainee and Staff Perceptions of Patient Safety Culture.

PURPOSE: The Accreditation Council for Graduate Medical Education implemented the Clinical Learning Environment Review (CLER) program to evaluate and improve the learning environment in teaching hospitals. Hospitals receive a report after a CLER visit with observations about patient safety, among other domains, the accuracy of which is unknown. Thus, the authors set out to identify complementary measures of trainees' patient safety experience. METHOD: In 2014, they administered the Hospital Survey on Patient Safety Culture to residents and fellows and general staff at 10 hospitals in an integrated health system. The survey measured perceptions of patient safety in 12 domains and incorporated two outcome measures (number of medical errors reported and overall patient safety). Domain scores were calculated and compared between trainees and staff. RESULTS: Of 1,426 trainees, 926 responded (65% response rate). Of 18,815 staff, 12,015 responded (64% response rate). Trainees and staff scored five domains similarly-communication openness, facility management support for patient safety, organizational learning/continuous improvement, teamwork across units, and handoffs/transitions of care. Trainees scored four domains higher than staff-nonpunitive response to error, staffing, supervisor/manager expectations and actions promoting patient safety, and teamwork within units. Trainees scored three domains lower than staff-feedback and communication about error, frequency of event reporting, and overall perceptions of patient safety. CONCLUSIONS: Generally, trainees had comparable to more favorable perceptions of patient safety culture compared with staff. They did identify opportunities for improvement though. Hospitals can use perceptions of patient safety culture to complement CLER visit reports to improve patient safety.

Vitamin D Status Relates to Reproductive Outcome in Women With Polycystic Ovary Syndrome: Secondary Analysis of a Multicenter Randomized Controlled Trial.

CONTEXT: Experimental evidence supports a relevance of vitamin D (VitD) for reproduction; however, data in humans are sparse and inconsistent. OBJECTIVE: To assess the relationship of VitD status with ovulation induction (OI) outcomes in women with polycystic ovary syndrome (PCOS). DESIGN: A retrospective cohort. SETTING: Secondary analysis of randomized controlled trial data. PARTICIPANTS: Participants in the Pregnancy in PCOS I (PPCOS I) randomized controlled trial (n = 540) met the National Institutes of Health diagnostic criteria for PCOS. INTERVENTIONS: Serum 25OHD levels were measured in stored sera. MAIN OUTCOME MEASURES: Primary, live birth (LB); secondary, ovulation and pregnancy loss after OI. RESULTS: Likelihood for LB was reduced by 44% for women if the 25OHD level was < 30 ng/mL (<75 nmol/L; odds ratio [OR], 0.58 [0.35-0.92]). Progressive improvement in the odds for LB was noted at thresholds of ≥38 ng/mL (≥95 nmol/L; OR, 1.42 [1.08-1.8]), ≥40 ng/mL (≥100 nmol/L; OR, 1.51 [1.05-2.17]), and ≥45 ng/mL (≥112.5 nmol/L; OR, 4.46 [1.27-15.72]). On adjusted analyses, VitD status was an independent predictor of LB and ovulation after OI. CONCLUSIONS: In women with PCOS, serum 25OHD was an independent predictor of measures of reproductive success after OI. Our data identify reproductive thresholds for serum 25OHD that are higher than recommended for the nonpregnant population.

Evaluating the Clinical Learning Environment: Resident and Fellow Perceptions of Patient Safety Culture.

BACKGROUND: The Accreditation Council for Graduate Medical Education has begun to evaluate teaching institutions' learning environments with Clinical Learning Environment Review visits, including trainee involvement in institutions' patient safety and quality improvement efforts. OBJECTIVE: We sought to address the dearth of metrics that assess trainee patient safety perceptions of the clinical environment. METHODS: Using the Hospital Survey on Patient Safety Culture (HSOPSC), we measured resident and fellow perceptions of patient safety culture in 50 graduate medical education programs at 10 hospitals within an integrated health system. As institution-specific physician scores were not available, resident and fellow scores on the HSOPSC were compared with national data from 29 162 practicing providers at 543 hospitals. RESULTS: Of the 1337 residents and fellows surveyed, 955 (71.4%) responded. Compared with national practicing providers, trainees had lower perceptions of patient safety culture in 6 of 12 domains, including teamwork within units, organizational learning, management support for patient safety, overall perceptions of patient safety, feedback and communication about error, and communication openness. Higher perceptions were observed for manager/supervisor actions promoting patient safety and for staffing. Perceptions equaled national norms in 4 domains. Perceptions of patient safety culture did not improve with advancing postgraduate year. CONCLUSIONS: Trainees in a large integrated health system have variable perceptions of patient safety culture, as compared with national norms for some practicing providers. Administration of the HSOPSC was feasible and acceptable to trainees, and may be used to track perceptions over time.

Smoking in infertile women with polycystic ovary syndrome: baseline validation of self-report and effects on phenotype.

STUDY QUESTION: Do women with polycystic ovary syndrome (PCOS) seeking fertility treatment report smoking accurately and does participation in infertility treatment alter smoking? SUMMARY ANSWER: Self-report of smoking in infertile women with PCOS is accurate (based on serum cotinine levels) and smoking is unlikely to change over time with infertility treatment. WHAT IS KNOWN ALREADY: Women with PCOS have high rates of smoking and it is associated with worse insulin resistance and metabolic dysfunction. STUDY DESIGN, SIZE, DURATION: Secondary study of smoking history from a large randomized controlled trial of infertility treatments in women with PCOS (N = 626) including a nested case-control study (N = 148) of serum cotinine levels within this cohort to validate self-report of smoking. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women with PCOS, age 18-40, seeking fertility who participated in a multi-center clinical trial testing first-line ovulation induction agents conducted at academic health centers in the USA. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, self-report of smoking in the nested case-control study agreed well with smoking status as determined by measure of serum cotinine levels, at 90% or better for each of the groups at baseline (98% of never smokers had cotinine levels <15 ng/ml compared with 90% of past smokers and 6% of current smokers). There were minor changes in smoking status as determined by serum cotinine levels over time, with the greatest change found in the smoking groups (past or current smokers). In the larger cohort, hirsutism scores at baseline were lower in the never smokers compared with past smokers. Total testosterone levels at baseline were also lower in the never smokers compared with current smokers. At end of study follow-up insulin levels and homeostatic index of insulin resistance increased in the current smokers (P < 0.01 for both) compared with baseline and with non-smokers. The chance for ovulation was not associated with smoking status, but live birth rates were increased (non-significantly) in never or past smokers. LIMITATIONS, REASONS FOR CAUTION: The limitations include the selection bias involved in our nested case-control study, the possibility of misclassifying exposure to second hand smoke as smoking and our failure to capture self-reported changes in smoking status after enrollment in the trial. WIDER IMPLICATIONS OF THE FINDINGS: Because self-report of smoking is accurate, further testing of smoking status is not necessary in women with PCOS. Because smoking status is unlikely to change during infertility treatment, extra attention should be focused on smoking cessation in current or recent smokers who seek or who are receiving infertility treatment. STUDY FUNDING/COMPETING INTERESTS: Sponsored by the Eugene Kennedy Shriver National Institute of Child Health and Human Development of the U.S. National Institutes of Health. CLINICAL TRIAL REGISTRATION NUMBERS: ClinicalTrials.gov numbers, NCT00068861 and NCT00719186.

Altering hirsutism through ovulation induction in women with polycystic ovary syndrome.

OBJECTIVE: Many women with polycystic ovary syndrome (PCOS) experience infertility and hirsutism and often seek treatment for both concurrently. We investigated whether women who ovulate in response to treatment with clomiphene citrate, metformin, or both would have greater improvement in hirsutism compared with those who did not ovulate. METHODS: This is a secondary analysis evaluating the change in Ferriman-Gallwey score for the hirsute women (n=505 [80.7%]) from the Pregnancy in Polycystic Ovary Syndrome I study. This was a prospective, randomized, doubled-blind trial of 626 women with PCOS and infertility recruited from 12 university sites. They were treated with clomiphene citrate, metformin, or both (combination) for up to six cycles, and hirsutism evaluators were blinded to group assignment. RESULTS: There was a significant decrease in the Ferriman-Gallwey score between baseline and completion of the study in each of the three individual groups (clomiphene citrate, P=.024; metformin, P=.005; combination, P<.001). There was no significant difference in the degree to which the hirsutism score changed when comparing the three groups (P=.44). The change in hirsutism was not associated with the duration of treatment or with the presence or absence of ovulation. CONCLUSION: In infertile hirsute women with PCOS, treatment with clomiphene citrate, metformin, or both for up to six cycles does not alter hirsutism. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068861. LEVEL OF EVIDENCE: II.

Endometrial shedding effect on conception and live birth in women with polycystic ovary syndrome.

OBJECTIVE: To estimate whether progestin-induced endometrial shedding, before ovulation induction with clomiphene citrate, metformin, or a combination of both, affects ovulation, conception, and live birth rates in women with polycystic ovary syndrome (PCOS). METHODS: A secondary analysis of the data from 626 women with PCOS from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Network trial was performed. Women had been randomized to up to six cycles of clomiphene citrate alone, metformin alone, or clomiphene citrate plus metformin. Women were assessed for occurrence of ovulation, conception, and live birth in relation to prior bleeding episodes (after either ovulation or exogenous progestin-induced withdrawal bleed). RESULTS: Although ovulation rates were higher in cycles preceded by spontaneous endometrial shedding than after anovulatory cycles (with or without prior progestin withdrawal), both conception and live birth rates were significantly higher after anovulatory cycles without progestin-induced withdrawal bleeding (live births per cycle: spontaneous menses 2.2%; anovulatory with progestin withdrawal 1.6%; anovulatory without progestin withdrawal 5.3%; P<.001). The difference was more marked when rate was calculated per ovulation (live births per ovulation: spontaneous menses 3.0%; anovulatory with progestin withdrawal 5.4%; anovulatory without progestin withdrawal 19.7%; P<.001). CONCLUSION: Conception and live birth rates are lower in women with PCOS after a spontaneous menses or progestin-induced withdrawal bleeding as compared with anovulatory cycles without progestin withdrawal. The common clinical practice of inducing endometrial shedding with progestin before ovarian stimulation may have an adverse effect on rates of conception and live birth in anovulatory women with PCOS. LEVEL OF EVIDENCE: II.

Metformin and/or clomiphene do not adversely affect liver or renal function in women with polycystic ovary syndrome.

CONTEXT: Nonalcoholic fatty liver disease is common to insulin-resistant states such as polycystic ovary syndrome (PCOS). Metformin (MET) is often used to treat PCOS but information is limited as to its effects on liver function. OBJECTIVE: We sought to determine the effects of MET on serum hepatic parameters in PCOS patients. DESIGN: This was a secondary analysis of a randomized, doubled-blind trial from 2002-2004. SETTING: This multi-center clinical trial was conducted in academic centers. PATIENTS: Six hundred twenty-six infertile women with PCOS with serum liver function parameters less than twice the upper limit of normal were included. INTERVENTIONS: Clomiphene citrate (n = 209), MET (n = 208), or combined (n = 209) were given for up to 6 months. MAIN OUTCOME MEASURE: The percent change from baseline in renal and liver function between- and within-treatment arms was assessed. RESULTS: Renal function improved in all treatment arms with significant decreases in serum blood urea nitrogen levels (range, -14.7 to -21.3%) as well as creatinine (-4.2 to -6.9%). There were similar decreases in liver transaminase levels in the clomiphene citrate and combined arms (-10% in bilirubin, -9 to -11% in transaminases) without significant changes in the MET arm. When categorizing baseline bilirubin, aspartate aminotransferase, and alanine aminotransferase into tertiles, there were significant within-treatment arm differences between the tertiles with the highest tertile having the largest decrease from baseline regardless of treatment arm. CONCLUSION: Women with PCOS can safely use metformin and clomiphene even in the setting of mildly abnormal liver function parameters, and both result in improved renal function.

Total testosterone assays in women with polycystic ovary syndrome: precision and correlation with hirsutism.

CONTEXT: There is no standardized assay of testosterone in women. Liquid chromatography mass spectrometry (LC/MS) has been proposed as the preferable assay by an Endocrine Society Position Statement. OBJECTIVE: The aim was to compare assay results from a direct RIA with two LC/MS. DESIGN AND SETTING: We conducted a blinded laboratory study including masked duplicate samples at three laboratories--two academic (University of Virginia, RIA; and Mayo Clinic, LC/MS) and one commercial (Quest, LC/MS). PARTICIPANTS AND INTERVENTIONS: Baseline testosterone levels from 596 women with PCOS who participated in a large, multicenter, randomized controlled infertility trial performed at academic health centers in the United States were run by varying assays, and results were compared. MAIN OUTCOME MEASURE: We measured assay precision and correlation and baseline Ferriman-Gallwey hirsutism scores. RESULTS: Median testosterone levels were highest with RIA. The correlations between the blinded samples that were run in duplicate were comparable. The correlation coefficient (CC) between LC/MS at Quest and Mayo was 0.83 [95% confidence interval (CI), 0.80-0.85], between RIA and LC/MS at Mayo was 0.79 (95% CI, 0.76-0.82), and between RIA and LC/MS at Quest was 0.67 (95% CI, 0.63-0.72). Interassay variation was highest at the lower levels of total testosterone (≤50 ng/dl). The CC for Quest LC/MS was significantly different from those derived from the other assays. We found similar correlations between total testosterone levels and hirsutism score with the RIA (CC=0.24), LC/MS at Mayo (CC=0.15), or Quest (CC=0.17). CONCLUSIONS: A testosterone RIA is comparable to LC/MS assays. There is significant variability between LC/MS assays and poor precision with all assays at low testosterone levels.

Reproductive health of women electing bariatric surgery.

OBJECTIVE: To describe the reproductive health history and characteristics of women having bariatric surgery and to determine whether this differs by age of onset of obesity. DESIGN: Retrospective and cross-sectional analyses of self-reported survey data. SETTING: Six sites of the Longitudinal Assessment of Bariatric Surgery-2 study. PATIENT(S): The study included 1,538 females having bariatric surgery. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reported polycystic ovary syndrome (PCOS), pregnancy and fertility history, contraceptive use, and plans for pregnancies. RESULT(S): Mean age was 44.8 years (range, 18-78 years); mean body mass index was 47.2 kg/m2 (range, 33.8-87.3 kg/m2). PCOS had been diagnosed by a health care provider in 13.1% of subjects. Of women who had tried to conceive, 41.9% experienced infertility and 61.4% had a live birth after experiencing infertility. In the whole group, prior live birth was reported by 72.5%. Women who were obese by 18 years old were more likely to report PCOS and infertility and less likely to have ever been pregnant, compared with women who became obese later in life. Future pregnancy was important to 30.3% of women younger than 45 years, whereas 48.6% did not plan to become pregnant in the future. In the year before surgery, 51.8% used contraception. CONCLUSION(S): Self-reporting of obesity by age 18 appears to be related to reproductive morbidity. Women undergoing bariatric surgery have important reproductive health care needs, including reliable contraception and counseling about plans for postoperative pregnancy.

Predictors of pregnancy in women with polycystic ovary syndrome.

CONTEXT: Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. The selection of first-line therapies for ovulation induction is empiric. OBJECTIVE: The aim of the study was to develop a clinically useful predictive model of live birth with varying ovulation induction methods. DESIGN, SETTING, AND PARTICIPANTS: We built four prognostic models from a large multicenter randomized controlled infertility trial of 626 women with PCOS performed at academic health centers in the United States to predict success of ovulation, conception, pregnancy, and live birth, evaluating the influence of patients' baseline characteristics. INTERVENTIONS: Ovulation was induced with clomiphene, metformin, or the combination of both for up to six cycles or conception. MAIN OUTCOME MEASURE: The primary outcome of the trial was the rate of live births. RESULTS: Baseline free androgen index, baseline proinsulin level, interaction of treatment arm with body mass index, and duration of attempting conception were significant predictors in all four models. History of a prior loss predicted ovulation and conception, but not pregnancy or live birth. A modified Ferriman Gallwey hirsutism score of less than 8 was predictive of conception, pregnancy, and live birth (although it did not predict ovulation success). Age was a divergent predictor based on outcome; age greater than 34 predicted ovulation, whereas age less than 35 was a predictive factor for a successful pregnancy and live birth. Smoking history had no predictive value. CONCLUSIONS: A live birth prediction chart developed from basic clinical parameters (body mass index, age, hirsutism score, and duration of attempting conception) may help physicians counsel and select infertility treatments for women with PCOS.

Simulation-based crisis team training for multidisciplinary obstetric providers.

BACKGROUND: The use of team training programs is promising with regards to their ability to impact knowledge, attitudes, and behavior about team skills. The purpose of this study was to evaluate a simulation-based team training program called Obstetric Crisis Team Training Program (OBCTT) (based on the original training program of Crisis Team Training) framed within a multilevel team theoretical model. We hypothesized that participation in OBCTT would positively impact 10 variables: individual's knowledge (about team process and obstetric emergency care); confidence and competence in handling obstetric emergencies; and participant attitudes (toward the utility of a rapid response team, simulation technology as a teaching methodology, the utility of team skills in the workplace, comfort in assuming team roles; and individual and team performance). Improvement of objectively measured team performance in a simulated environment was also assessed. METHODS: Twenty-two perinatal health care professionals (attending physicians, nurses, resident, and nurse midwives) volunteered to participate in this pretest-posttest study design. All participants were given an online module to study before attending a 4-hour training session. Training consisted of participation in four standardized, simulated crisis scenarios with a female birthing simulator mannequin. Team simulations were video recorded. Debriefings were conducted after each simulation by having team members review the video and discuss team behaviors and member skills. Self-report measures of perinatal and team knowledge as well as several attitude surveys were given at the beginning and again at the end of the training session. A postsimulation attitude survey was administered immediately after the first and last simulation, and a course reaction survey was administered at the end of the training program. Objective task completion scores were computed after each simulation to assess performance. RESULTS: There were significant (P<0.004) improvements in three of the outcome variables, after controlling for type I error with Bonferroni's correction; attitudes toward competence in handling obstetric emergencies (t=1.6), as well as individual (t=4.2), and team performance (t=4.1). The remaining 6 variables, attitude toward simulation technology, attitude toward the rapid response team; confidence in handling obstetric emergencies; utility of team skills in the workplace; comfort in assuming various team roles; and knowledge, were not statistically significant. Overall task completion from the first to the last simulation (XF, df=3, n=3, 8.2, P=0.042) substantially improved (P<0.05). CONCLUSION: The crisis team training model is applicable to obstetric emergencies. Trainees exhibit a positive change in attitude; perception of individual and team performance, and overall team performance in a simulated environment. The ability of individuals to accurately assess their performance improved as a result of training.

Teaching error disclosure to residents: a curricular innovation and pilot study.

OBJECTIVE: To compare change in obstetrics and gynecology residents' self-efficacy in disclosing medical errors after a formal educational session. METHODS: This was a retrospective postintervention survey to assess change in perceived preparedness to disclose medical errors. We used a 4-hour educational seminar that included a didactic component (30 minutes) and experiential learning with a trained facilitator (3 hours). Change in self-efficacy was measured using a 5-point Likert-type scale (1 is lowest, and 5 is highest) and was compared using sign test (α  =  .05). RESULTS: In our pilot study, 13 of 15 residents reported having previously participated in error disclosure. After the session, residents considered themselves more prepared for the following: to know what to include in and how to introduce error discussions, to deal with a patient's emotional reaction, to respond to a patient's questions regarding how an error occurred, and to recognize one's own emotions when discussing medical errors. Residents believed that they would be likely to use the skills learned in the remainder of residency and in their future career. CONCLUSIONS: This curriculum was associated with improvement in self-efficacy regarding error disclosure. Given the unique malpractice issues that obstetricians/gynecologists face, it seems particularly useful for residents to learn these skills early in their career. In addition, this topic represents an ideal educational opportunity for residencies to improve patient care and to address other core competencies in resident education such as communication skills and professionalism.

Burnout, psychological skills, and empathy: balint training in obstetrics and gynecology residents.

OBJECTIVES: To assess burnout, behavioral-medicine skills, and empathy among obstetrics and gynecology residents before and after implementation of Balint training. METHODS: This was a prospective educational study. Balint training was introduced into the obstetrics and gynecology residency curriculum in July 2005. All 36 residents were approached for this study. The Psychological Medicine Inventory, the Maslach Burnout Inventory, and the Jefferson Scale of Physician Empathy were administered prior to initiating training and at 12 months. Baseline and 12-month scores were compared by Wilcoxon signed rank test. RESULTS: Seventeen residents completed baseline and 12-month questionnaires: 6 were postgraduate year (PGY) 1, 3 were PGY-2, 6 were PGY-3, and 2 were PGY-4. At baseline, 70% of participating residents reported high burnout scores. Burnout and empathy remained unchanged at 12 months. Psychological medicine skills improved at 12 months. CONCLUSIONS: This study showed that obstetrics and gynecology residents are at high risk for burnout. Interest and confidence in handling psychological aspects of patient care improved at 12 months after the introduction of Balint training.

Extended-release metformin does not reduce the clomiphene citrate dose required to induce ovulation in polycystic ovary syndrome.

CONTEXT: When used for ovulation induction, higher doses of clomiphene may lead to antiestrogenic side effects that reduce fecundity. It has been suggested that metformin in combination with clomiphene can restore ovulation to some clomiphene-resistant anovulators with polycystic ovary syndrome (PCOS). OBJECTIVE: Our objective was to determine if cotreatment with extended-release metformin (metformin XR) can lower the threshold dose of clomiphene needed to induce ovulation in women with PCOS. DESIGN: A secondary analysis of data from the National Institute of Child Health and Human Development Cooperative Multicenter Reproductive Medicine Network prospective, double-blind, placebo-controlled multicenter clinical trial, Pregnancy in Polycystic Ovary Syndrome, was performed. SETTING: Study volunteers at multiple academic medical centers were included. PARTICIPANTS: Women with PCOS and elevated serum testosterone who were randomized to clomiphene alone or with metformin (n = 209 in each group) were included in the study. INTERVENTIONS: Clomiphene citrate, 50 mg daily for 5 d, was increased to 100 and 150 mg in subsequent cycles if ovulation was not achieved; half also received metformin XR, 1000 mg twice daily. Treatment was for up to 30 wk or six cycles, or until first pregnancy. MAIN OUTCOME MEASURES: Ovulation was confirmed by a serum progesterone more than or equal to 5 ng/ml, drawn prospectively every 1-2 wk. RESULTS: The overall prevalence of at least one ovulation after clomiphene was 75 and 83% (P = 0.04) for the clomiphene-only and clomiphene plus metformin groups, respectively. Using available data from 314 ovulators, the frequency distribution of the lowest clomiphene dose (50, 100, or 150 mg daily) resulting in ovulation was indistinguishable between the two treatment groups. CONCLUSION: Metformin XR does not reduce the lowest dose of clomiphene that induces ovulation in women with PCOS.