Use of a postpartum hemorrhage simulator for instruction and evaluation of residents.

OBJECTIVE: Postpartum hemorrhage is a common and potentially life-threatening obstetric emergency. We sought to create a realistic simulation and validate a standardized grading form to evaluate competency in the management of postpartum hemorrhage. METHODS: Residents from 3 programs underwent training with a postpartum hemorrhage simulation using a standard obstetric birthing model equipped with an inflatable uterus to simulate uterine atony. All simulations were graded by staff physicians with a standardized grading sheet constructed from the current literature on the topic. Residents were expected to recognize the hemorrhage and take appropriate steps, including asking the assistant to administer medications, to correct the problem. Objective and subjective performance was measured with standardized grading sheets, and results were analyzed for reliability using Cronbach α and intraclass correlation coefficients. This project was conducted in accordance with the hospital Institutional Review Board policies at each institution. RESULTS: Forty residents from 3 institutions underwent simulation training. The majority were unable to correct the hemorrhage within 5 minutes and almost half also made at least 1 error, either the dose or route, in the medications they requested. Reliability was evaluated with Cronbach α and demonstrated the grading sheets were valid and had good interrater reliability. DISCUSSION: A simulated postpartum hemorrhage scenario can identify important deficiencies in resident knowledge and performance, with no risk to patients. The standardized grading form worked well for our purposes and was reliable in our study. Further testing is needed to evaluate whether the training improves performance in real-life hemorrhages.

Can mentors prevent and reduce burnout in new chairs of departments of obstetrics and gynecology: results from a prospective, randomized pilot study.

OBJECTIVE: This study assessed burnout in new chairs of obstetrics and gynecology and whether mentoring by experienced chairs would prevent or reduce burnout. STUDY DESIGN: We performed a year-long prospective, randomized trial. Questionnaires were sent to new chairs to obtain demographic information and to identify need for mentoring and level of burnout. Fourteen chairs in the intervention group selected a mentor; 13 chairs served as controls. After 1 year, questionnaires were completed to determine stress and burnout and the impact of mentoring. RESULTS: Financial issues were the major stressors. New chairs identified human resources, finances, and relationships with school leaders as areas of greatest need for mentoring. Few chairs exhibited burnout. No differences were observed in burnout at the start of the study or after 1 year in the study groups. Mentors and new chairs found the mentoring relationship difficult to establish and maintain. CONCLUSION: Long-distance mentoring by experienced chairs did not alter burnout in new chairs of obstetrics and gynecology. Local mentors appear to be more effective.

An evaluation of cervical cancer in women age sixty and over.

OBJECTIVE: To assess prior cervical cancer screening, stage at time of diagnosis and outcome in women sixty years of age and over with cervical cancer. METHODS: A retrospective review of cervical cancer patients evaluated at the University of Washington identified a cohort of women age sixty and older with cervical cancer diagnosed between January 1, 1993 and December 31, 2003. Electronic medical records and the University of Washington Tumor Registry were reviewed for age, ethnicity, cervical cancer risk factors, pathology, treatment, and outcome. RESULTS: Six hundred forty-five women with cervical cancer were identified. One hundred (15.5%) women were age 60 or older with a median age of 64 years. At time of diagnosis, 41 were early stage (1A1-1B1) and 59 were advanced stage (1B2-4B). Length of time from last Pap smear significantly correlated with stage. Radical hysterectomy was performed on 29 patients, and 15 received adjuvant treatment. Forty-nine women received primary chemo-radiation, and 22 were treated with primary radiation. Lymph node metastases were identified in 65% of women with locally advanced cervical cancer. At conclusion of the study period, 80% were alive. Stage and time since last Pap smear correlated with overall outcome. CONCLUSIONS: Women 60 and older make up a significant proportion of cervical cancer patients, often fail to receive screening, present with locally advanced disease, and tolerate standard treatment protocols. Careful consideration of these findings should be made when establishing Pap smear screening guidelines for this population of women.

Development of an ovarian cancer symptom index: possibilities for earlier detection.

BACKGROUND: Currently, screening for ovarian cancer is not recommended for the general population. Targeting women with specific symptoms for screening has been evaluated only recently, because it was believed that symptoms had limited specificity. METHODS: A case-control study of 149 women with ovarian cancer, including 255 women who were in a screening program and 233 women who were referred for pelvic/abdominal ultrasound, was conducted by inviting women to complete a survey of symptoms. Patients were divided randomly into an exploratory group and a confirmatory group. Symptom types, frequency, severity, and duration were compared between cases and controls. Logistic regression analyses were used to determine which factors independently predicted cancer in the exploratory group and then were used to develop a symptom index, which was tested for sensitivity and specificity in the confirmatory group. RESULTS: Symptoms that were associated significantly with ovarian cancer were pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating/feeling full when they were present for <1 year and occurred >12 days per month. In a logistic regression analysis, symptoms that were associated independently with cancer were pelvic/abdominal pain (P < .001), increased abdominal size/bloating (P<.001), and difficulty eating/feeling full (P = .010). A symptom index was considered positive if any of those 6 symptoms occurred >12 times per month but were present for <1 year. In the confirmatory sample, the index had a sensitivity of 56.7 for early-stage disease and 79.5% for advanced-stage disease. Specificity was 90% for women age >50 years and 86.7% for women age <50 years. CONCLUSIONS: Specific symptoms in conjunction with their frequency and duration were useful in identifying women with ovarian cancer. A symptom index may be useful for identifying women who are at risk.

A six-year study of surgical teaching and skills evaluation for obstetric/gynecologic residents in porcine and inanimate surgical models.

OBJECTIVE: This study was undertaken to evaluate an ongoing teaching and objective surgical skills testing program for obstetric/gynecologic residents in a laboratory setting, and assess the impact on residents of having 4 years of a surgical laboratory curriculum. STUDY DESIGN: From 1997 through 2002, we conducted surgical skills training sessions for all obstetric/gynecologic residents, using both inanimate and animal (porcine) models. Once a year we tested each resident on 12 structured surgical bench tasks. At the end of each year, we conducted formal objective structured assessment of technical skills (OSATS) with all residents attempting multiple surgical procedures. We compared residents who had 4 years of laboratory training with those who started residency earlier and had only 1 or 2 years of the new curriculum. We also compared residents' own performance from year to year and cohort performance by resident year. RESULTS: PGY3 and PGY4s who had 4 years of surgical laboratory training did significantly better on bench laboratory skills than PGY3 and PGY4s with fewer years of training sessions (total scores of 48.8 vs 30.3, P < .001). However, no significant improvement in surgical procedures as measured by global OSATS was found. When comparing residents' own performance between the beginning and the end of 1 year, global OSATS scores improved significantly on laparoscopic salpingotomy (P < .001) and open oophorectomy (P < .001). For the cohort of PGY4s completing 4 years of laboratory training, average global OSATS scores showed statistically significant improvement (PGY1, PGY2 < PGY3 < PGY4, P < .001). CONCLUSION: Residents who completed the 4-year curriculum showed significantly better technical skills on bench tasks but not on OSATS compared with those with less training. Resident surgical skills evaluated by OSATS significantly improve over time both individually and as a cohort by resident year.

Self-assessment of resident surgical skills: is it feasible?

OBJECTIVE: The purpose of this study was to examine obstetrics and gynecology residents' self-assessment of proficiency on a variety of surgical bench procedures and to compare their ratings with those ratings of trained faculty observers who used instruments that have been shown to be reliable and valid. STUDY DESIGN: As part of a 6-station Objective Structured Assessment of Technical Skills, 74 residents at 5 institutions estimated their overall open and laparoscopic skill level before the testing. After completing each station, residents evaluated their overall and global skills performance. RESULTS: Residents rated their proficiency higher on open skills than on laparoscopic skills. Task-specific, overall, and global assessments were correlated significantly with the faculty ratings (P < .001). Residents tended to rate themselves lower than did faculty on almost all measures; even those residents with poor skills indicated that they were aware of their deficiencies. Overall and global self-assessments increased with each resident level, which indicated good construct validity. CONCLUSION: Residents can rate their overall open and laparoscopic skills, task-specific performance, and global skills with good reliability and validity. Although they tended to score themselves lower than did faculty observers, the correlations are high (ie, residents who give themselves a higher score tended to receive a higher score from faculty, and vice versa). One of the concerns about self-assessment is that residents with poor skills might not be aware of their deficiencies. We did not find that to be the case. Therefore, when residents work on self-directed exercises, task-specific and global checklists can be used for both learning and self-assessment.

Frequency of symptoms of ovarian cancer in women presenting to primary care clinics.

CONTEXT: Women with ovarian cancer frequently report symptoms prior to diagnosis, but distinguishing these symptoms from those that normally occur in women remains problematic. OBJECTIVE: To compare the frequency, severity, and duration of symptoms between women with ovarian cancer and women presenting to primary care clinics. DESIGN, SETTING, AND PATIENTS: A prospective case-control study of women who visited 2 primary care clinics (N = 1709) and completed an anonymous survey of symptoms experienced over the past year (July 2001-January 2002). Severity of symptoms was rated on a 5-point scale, duration was recorded, and frequency was indicated as number of episodes per month. An identical survey was administered preoperatively to 128 women with a pelvic mass (84 benign and 44 malignant). MAIN OUTCOME MEASURES: Comparison of self-reported symptoms between ovarian cancer patients and women seeking care in primary care clinics. RESULTS: In the clinic population, 72% of women had recurring symptoms with a median number of 2 symptoms. The most common were back pain (45%), fatigue (34%), bloating (27%), constipation (24%), abdominal pain (22%), and urinary symptoms (16%). Comparing ovarian cancer cases to clinic controls resulted in an odds ratio of 7.4 (95% confidence interval [CI], 3.8-14.2) for increased abdominal size; 3.6 (95% CI, 1.8-7.0) for bloating; 2.5 (95% CI, 1.3-4.8) for urinary urgency; and 2.2 (95% CI, 1.2-3.9) for pelvic pain. Women with malignant masses typically experienced symptoms 20 to 30 times per month and had significantly more symptoms of higher severity and more recent onset than women with benign masses or controls. The combination of bloating, increased abdominal size, and urinary symptoms was found in 43% of those with cancer but in only 8% of those presenting to primary care clinics. CONCLUSIONS: Symptoms that are more severe or frequent than expected and of recent onset warrant further diagnostic investigation because they are more likely to be associated with both benign and malignant ovarian masses.

Objective structured assessment of technical skills for episiotomy repair.

OBJECTIVE: This study was undertaken to estimate the reliability and validity of an objective structured assessment of technical skills (OSATS) for midline episiotomy repair using a lifelike anatomic model. STUDY DESIGN: Eighteen residents were administered an episiotomy OSATS. Two evaluators independently completed an objective score sheet assessing six key components of the repair, seven global surgical skills, and a pass/fail score for each resident. Residents also completed an anonymous self-assessment. RESULTS: Reliability indices were 0.95 for the checklist and global surgical skills rating. Construct validity found significant differences on the checklist, global surgical skills, and pass/fail score sheets by residency level. Residents more often assessed their own global surgical skills performance lower than the independent evaluators. Surprisingly, 61% (11/18) of the residents failed the assessment, including all postgraduate year 1 and postgraduate year 2 residents. CONCLUSION: Episiotomy OSATS that used task-specific and global checklists provide a reliable and valid method of assessing resident skills in this anatomic model, and performance correlates with resident year level of training.

Interleukin-18 in the plasma of women with preeclampsia.

OBJECTIVE: Interleukin-18 (IL-18) is a proinflammatory cytokine capable of stimulating interferon gamma and tumor necrosis factor-alpha production. Our purpose was to determine whether abnormal levels of IL-18 in maternal plasma correlate with the diagnosis of preeclampsia. STUDY DESIGN: A case control study design was used to enroll 61 patients: controls (n = 31) and preeclamptic women (n = 30). A standard enzyme-linked immunosorbent assay measured plasma IL-18. Statistical methods included Student t tests and chi(2) tests. RESULTS: Mean IL-18 levels were lower in preeclampsia than in controls (185 +/- 74 pg/mL vs 224 +/- 75 pg/mL, P =.053). Administration of betamethasone (BMZ) and/or hydralazine (HYD) was significantly associated with a lower IL-18 compared with controls (159 +/- 50 pg/mL vs 224 +/- 75 pg/mL, P =.002). After women who received BMZ or HYD were excluded, levels of IL-18 in preeclampsia were similar to those of controls (213 +/- 87 pg/mL, P =.69). There was no association between gestational age and IL-18. CONCLUSION: Lower IL-18 was associated with administration of either BMZ or HYD. After patients receiving these medications were excluded, IL-18 levels were similar in controls and preeclamptic women. IL-18 was not associated with gestational age.

Surgical skills assessment: a blinded examination of obstetrics and gynecology residents.

OBJECTIVE: We have previously shown that objective structured assessment of technical skills (OSATS) is an innovative, reliable, and valid method of assessing surgical skills. Our goal was to establish the feasibility, reliability, and validity of our surgical skills assessment instrument when administered in a blinded fashion. STUDY DESIGN: A 7-station OSATS was administered to 16 obstetric and gynecology residents from Madigan Army Medical Center. The test included laparoscopic (salpingostomy, intracorporeal knot, and ligation of vessels with clips) and open abdominal procedures (subcuticular closure, bladder neck suspension, enterotomy repair, and abdominal wall closure). All tasks were performed with lifelike surgical models. Residents were timed and assessed at each station with 3 methods of scoring: task-specific checklist, global rating scale, and pass/fail grade. Each resident was evaluated by one examiner blinded as to the postgraduate year level and one examiner who had previously worked with the resident. RESULTS: Assessment of construct validity (the ability to distinguish between resident levels) found significant differences on the checklist, global rating scale, and pass/fail grade by residency level for both blinded and unblinded examiners. Reliability indices calculated with Cronbach's alpha were.82 for the checklists and.93 for the global rating scale. Overall interrater reliability between blinded and unblinded examiners was 0.95 for global rating scale and ranged from 0.74 to 0.97 for the checklists. The cost to administer the exam for the 16 residents was approximately $1000. CONCLUSIONS: OSATS administered in either a blinded or unblinded fashion can assess residents' surgical skills with a high degree of reliability and validity. This study provides further evidence that OSATS can be used to establish surgical competence.