Is insufficient introspection a reason to terminate residency training? - Scrutinising introspection among residents who disputed dismissal.

INTRODUCTION: Insufficient introspection as part of the 4I's model of medical professionalism (introspection, integrity, interaction, and involvement) is considered an important impediment in trainees. How insufficient introspection relates to decisions to terminate residency training remains unclear. Insights into this subject provide opportunities to improve the training of medical professionals. METHODS: We analysed the Dutch Conciliation Board decisions regarding residents dismissed from training between 2011 and 2020. We selected the decisions on residents deemed 'insufficient' regarding introspection as part of the CanMEDS professional domain and compared their characteristics with the decisions about residents without reported insufficiencies on introspection. RESULTS: Of the 120 decisions, 86 dismissed residents were unable to fulfil the requirements of the CanMEDS professional domain. Insufficient introspection was the most prominent insufficiency (73/86). These 73 decisions described more residents' insufficiencies in CanMEDS competency domains compared to the rest of the decisions (3.8 vs. 2.7 p < 0.001), without significant differences regarding gender or years of training. CONCLUSIONS: Insufficient introspection in residents correlates with competency shortcomings programme directors reported in dismissal disputes. The 4I's model facilitates recognition and description of unprofessional behaviours, opening avenues for assessing and developing residents' introspection, but further research is needed for effective implementation in medical education.

Unprofessional behaviour of GP residents leading to a dismissal dispute: characteristics and outcomes of those who appeal.

BACKGROUND: Recognition of poor performance in General Practice trainees is important because underperformance compromises patients' health and safety. However, in General Practice, research on persistent underperformance while in training and its ultimate consequences is almost completely lacking. We aim to explore the unprofessional behaviours of residents in General Practice who were dismissed from training and who litigated against dismissal. METHODS: We performed a structured analysis using open-source data from all General Practice cases before the Conciliation Board of the Royal Dutch Medical Association between 2011 and 2020. Anonymised law cases about residents from all Dutch GP training programmes were analysed in terms of the quantitative and qualitative aspects related to performance. RESULTS: Between 2011 and 2020, 24 residents who were dismissed from training challenged their programme director's decision. Dismissed residents performed poorly in several competencies, including communication, medical expertise and most prominently, professionalism. Over 90% of dismissed residents failed on professionalism. Most lacked self-awareness and/or failed to profit from feedback. Approximately 80% failed on communication, and about 60% on medical expertise as well. A large majority (more than 80%) of dismissed residents had previously participated in some form of remediation. CONCLUSIONS: Deficiencies in both professionalism and communication were the most prevalent findings among the dismissed General Practice residents. These two deficiencies overlapped considerably. Dismissed residents who challenged their programme director's decision were considered to lack self-awareness, which requires introspection and the appreciation of feedback from others.

Dutch dismissal practices: characteristics, consequences, and contrasts in residents' case law in community-based practice versus hospital-based specialties.

BACKGROUND: In the Netherlands, 2 to 10% of the residents terminate training prematurely. Infrequently, termination of training is by dismissal. Incidentally, residents may disagree, dispute and challenge these decisions from the programme directors. Resident dismissal is always a difficult decision, most commonly made after, repeated assessments, and triangulation of the resulting assessment data and one or more remediation attempts. Nevertheless, the underlying reasons for dismissal and the policies for remediation and dismissal may differ between training programmes. Such differences may however impact the chance of remediation success, the chance of dismissal and subsequent residents' appeals. METHOD: We included a total of 70 residents from two groups (community-based and hospital-based specialties) during 10 years of appeals. Subsequently, we compared these groups on factors potentially associated with the outcome of the conciliation board decision regarding the residents' dismissal. We focused herein on remediation strategies applied, and reasons reported to dismiss residents. RESULTS: In both groups, the most alleged reason to dismiss residents was lack of trainability, > 97%. This was related to deficiencies in professionalism in community-based practice and medical expertise in hospital-based specialties respectively. A reason less frequently mentioned was endangerment of patient care, < 26%. However, none of these residents accused of endangerment, actually jeopardized the patients' health, probably due to the vigilance of their supervisors. Remediation strategies varied between the two groups, whereas hospital-based specialties preferred formal remediation plans in contrast to community-based practice. A multitude of remediation strategies per competency (medical expertise, professionalism, communication, management) were applied and described in these law cases. DISCUSSION: Residents' appeals in community-based practice were significantly less likely to succeed compared to hospital-based specialties. Hypothesised explanatory factors underlying these differences include community-based practices' more prominent attention to the longitudinal assessment of professionalism, the presence of regular quarterly progress meetings, precise documentation of deficiencies, and discretion over the timing of dismissal in contrast to dismissal in the hospital-based specialties which is only formally possible during scheduled formal summative assessment meetings.

Anatomical Gynecological Anomalies in Girls Born with Anorectal Malformations: A Retrospective Cohort Study of 128 Patients.

STUDY OBJECTIVE: In girls born with an anorectal malformation (ARM), anatomical gynecological anomalies (GA) may be present and might need treatment. Therefore, the aim of this study was to provide an overview of GA in girls born with ARM in our cohort. Additionally, diagnostic timing and methods for GA were assessed. METHODS: A retrospective mono-center study was performed from January 2000 to December 2022. All patients assigned female at birth were eligible for inclusion. GA were classified according to ESHRE/ESGE classification. Outcomes were the number of girls with GA with subsequent screening methods, factors associated with GA, and GA requiring treatment. Uni- and multivariable logistic regression analyses were performed to identify the association between baseline characteristics and the presence of GA. RESULTS: In total, 128 girls were included, of whom 30 (24.1%) had additional GA, with vaginal anomalies being present most often (n = 17). Fifty-six patients (43.8%) underwent full screening, and this number improved over time (37.7% before 2018 vs 72.7% after 2018; P = .003). Thirteen of 30 patients (43.3%) required surgical treatment for their GA, without the occurrence of postoperative complications. CONCLUSION: Additional GA were present in almost a quarter of the girls born with an ARM, with vaginal anomalies most often identified. Despite GA being most often found in patients with cloacal malformations, these anomalies were also identified in patients with other ARM types. Surgical treatment was required in almost half of the girls with GA. Therefore, this study emphasizes the importance of screening for GA in patients with an ARM, regardless of the ARM type.

Potential benefits of routine cystoscopy and vaginoscopy prior to reconstructive surgery in patients with an anorectal malformation.

PURPOSE: First, to assess the number of patients with anorectal malformations (ARM) in whom additional urological and/or gynecological anomalies were identified through routine screening with cysto- or vaginoscopy prior to reconstructive surgery. Second, to assess potential procedure-related complications. METHODS: Retrospective mono-center cohort study, including all ARM patients born between January 2019 and December 2022. Routine screening consisted of cystoscopy for male patients, with the addition of vaginoscopy for female patients. Chi-square was used to compare the screening percentages over time. RESULTS: In total, 38 patients were included, of whom 27 (71.1%) underwent cystoscopy ± vaginoscopy, without the occurrence of complications. Nine of 13 females (69.2%) underwent cysto- and vaginoscopy and 18 of 25 males (72.0%) underwent a cystoscopy. The percentage of patients that underwent these procedures improved over the 2 time periods (50.0% in 2019-2020 vs 90.0% in 2021-2022, p = 0.011). In 15 of 27 patients (55.6%) that underwent cystoscopy ± vaginoscopy, additional anomalies were found that were not identified through physical examination or US-kidney. CONCLUSIONS: In 56% of the patients that underwent cysto- ± vaginoscopy, additional anomalies were identified that were not with imaging studies or physical examination. This study emphasizes the potential benefit of routine cysto- and vaginoscopy in the diagnostic work-up of children with ARM. LEVEL OF EVIDENCE: III.

Outcome after vaginal delivery of women with a previous medical history of surgically corrected anorectal malformations: a systematic review.

OBJECTIVE: Discussion remains on how to advise women with a past medical history of surgically corrected anorectal malformations (ARMs) regarding vaginal delivery. The aim of this review is to evaluate and review the reported obstetrical complications and outcomes after vaginal delivery for these women. DATA SOURCES: A systematic search was performed from inception up to 25 July 2022 in PubMed, Embase.com and Clarivate Analytics/Web of Science Core Collection, with backward citation tracking. STUDY ELIGIBILITY CRITERIA/APPRAISAL: All articles reported on the outcomes of interest in women with a past medical history of surgically corrected anorectal malformation and had a vaginal delivery were included with the exception of editorial comments or invitational commentaries. Screening, data extraction and risk of bias assessment was done by two authors independently with a third and fourth reviewer in case of disagreement. Tool for Quality assessment depended on the type of article. As low quality evidence was expected no meta-analysis was performed. RESULTS: Only five of the 2377 articles screened were eligible for inclusion with a total of 13 attempted vaginal deliveries in eight women. In three patients complications were reported: failed vaginal delivery requiring urgent cesarean section in two patients, and vaginal tearing in one patient. CONCLUSION: High quality evidence regarding outcomes and complications after vaginal delivery in women with a history of surgically corrected anorectal malformation is lacking. Therefore, based upon this systematic review no formal recommendation can be formulated regarding its safety. Future studies are essential to address this problem. TRIAL REGISTRATION: CRD42020201390. Date: 28-07-2020s.

Do deficiencies in CanMEDS competencies of dismissed residents differ according to specialty?

INTRODUCTION: Program directors dismiss a small percentage of residents from residency training programs, presumably due to underperformance or lack of progress. Whether underperformance in competency domains differs by residents' specialty is unknown. METHODS: In 2021, we analysed the case law of Dutch residents who were dismissed from training by the program director, and who challenged this dismissal before the national conciliation board between 2011 and 2020. Across medical specialties we compared which of the CanMEDS competency domains these residents failed to meet. RESULTS: We found 116 cases of residents dismissed from their training programmes who challenged the decision of the program director before the board. In general, most residents were unable to meet the requirements of several CanMEDS competency domains (usually: medical expert, communicator, and professional). In surgery, all dismissed residents failed to meet the competency domain of the medical expert, while most of the dismissed psychiatry residents met this domain. In specialties with a primarily diagnostic task, more dismissed residents failed to meet the competency domain of the scholar, while dismissed general medicine residents (for example family medicine and nursing homecare) were less likely to do so. Residents in general medicine, more often than other specialties, however, failed to meet the competency domain of the professional. CONCLUSION: Residents dismissed from training, who challenged their dismissal, failed to meet the requirements of multiple CanMEDS competency domains. Competency domain failures differ by specialty.

[Treatment of anxiety in COPD with CBT]. / Angst bij COPD behandelen met CGT.

A major part of COPD patients suffers from anxiety. The presence of an anxiety or stress disorder compromises their quality of life. Anxiety and (posttraumatic) stress disorders may be treated with cognitive behavior therapy (CBT). CBT encompasses different treatment interventions and protocols. Some of these interventions have been investigated to treat anxiety in patients with COPD. Those that have been proven to be effective, should be offered to COPD patients with anxiety. Examples are: education about symptoms in COPD (mostly dyspnea) and the bodily anxiety response; education about the positive and negative anxiety and breathing circle; breathing, posture and relaxation exercises; identification and correction of catastrophic thoughts; setting goals and planning activities (behavior activation) and pacing.

Neonatal Uterine Bleedings: An Ignored Sign but a Possible Cause of Early-Onset Endometriosis - A Systematic Review.

OBJECTIVE: Based on the hypothesis that neonatal uterine bleedings (NUB), occurring mostly in the first week after birth, could represent a pathogenetic mechanism for early-onset endometriosis, this systematic review (SR) was undertaken to evaluate the prevalence and screening strategies used to assess and quantify NUB. DESIGN: Both a SR and a sample literature search in PubMed and Embase were conducted to gather information on NUB prevalence and screening techniques. This was performed by an information specialist. Only full-text articles regarding the assessment of NUB in neonates in the first 2 weeks after birth were included. No limit on language or publication data was used. MATERIALS AND METHODS: The SR was registered in PROSPERO (CRD42019138121). Data was first assessed for eligibility on title and abstract by 2 blinded review authors. Any disagreements were discussed with a third reviewer if necessary. Subsequently, full-text articles were read and assessed for quality using the Cochrane Collaboration Handbook. RESULTS: Out of 1,988 articles in the systematic search, 10 relevant articles were selected, of which 8 were identified through the systematic search and 2 were found through other sources. The sample search of 4,445 articles did not bring up relevant articles. Results were not comparable due to the heterogeneity of screening techniques, although data showed consensus. The prevalence of visible bleeding ranged from 3.3 to 53.8% and the prevalence of occult bleeding from 25.4 to 96.7%. The occurrence was the highest between the 3rd and 7th day postpartum (PP) and the bleeding lasted for 3-4 days on average. Various screening techniques for detecting NUB were found in the literature, including the use of hemoglobin detection devices (such as Hemastix) in the vaginal vestibulum, comparison of diapers with stains of known volume, colposcopy, and ultrasonography. CONCLUSION: The reported prevalence of NUB varies considerably, with a consistent occurrence between the 3rd and the 7th day PP. Literature to assess NUB is dated. The techniques are poorly described and heterogeneous. Future research should focus on prospective cohort studies in order to attempt to correlate NUB cases to (early-onset) endometriosis.

Comparison of enhanced laparoscopic imaging techniques in endometriosis surgery: a diagnostic accuracy study.

BACKGROUND: For surgical endometriosis, treatment key is to properly identify the peritoneal lesions. The aim of this clinical study was to investigate if advanced imaging improves the detection rate by comparing narrow-band imaging (NBI), near-infrared imaging with indocyanine green (NIR-ICG), or three-dimensional white-light imaging (3D), to conventional two-dimensional white-light imaging (2D) for the detection of peritoneal endometriotic lesions. METHODS: This study was a prospective, single-center, randomized within-subject, clinical trial. The trial was conducted at Amsterdam UMC-Location VUmc, a tertiary referral hospital for endometriosis. 20 patients with ASRM stage III-IV endometriosis, scheduled for elective laparoscopic treatment of their endometriosis, were included. During laparoscopy, the pelvic region was systematically inspected with conventional 2D white-light imaging followed by inspection with NBI, NIR-ICG, and 3D imaging in a randomized order. Suspected endometriotic lesions and control biopsies of presumably healthy peritoneum were taken for histological examination. The pathologist was blinded for the method of laparoscopic detection. Sensitivity and specificity rates of the enhanced imaging techniques were analyzed. McNemar's test was used to compare sensitivity to 2D white-light imaging and Method of Tango to assess non-inferiority of specificity. RESULTS: In total, 180 biopsies were taken (117 biopsies from lesions suspected for endometriosis; 63 control biopsies). 3D showed a significantly improved sensitivity rate (83.5% vs. 75.8%, p = 0.016) and a non-inferior specificity rate (82.4% vs. 84.7%, p = 0.009) when compared to 2D white-light imaging. The single use of NBI or NIR-ICG showed no improvement in the detection of endometriosis. Combining the results of 3D and NBI resulted in a sensitivity rate of 91.2% (p < 0.001). CONCLUSION: Enhanced laparoscopic imaging with 3D white light, combined with NBI, improves the detection rate of peritoneal endometriosis when compared to conventional 2D white-light imaging. The use of these imaging techniques enables a more complete laparoscopic resection of endometriosis.

The effect of antipsychotic medication on facial affect recognition in schizophrenia: a review.

Patients with schizophrenia suffer from impairments in facial affect recognition and social functioning. Since antipsychotic medication affects different areas in the brain, they may also affect target areas involved in emotional processing mechanisms. In this article, we review the findings of the effect of antipsychotic medication on facial affect recognition in schizophrenia. We searched PubMed for articles in English with the keywords schizophrenia, facial, affect, emotion, antipsychotic and medication, published till January 2008. Eight relevant articles were found describing original studies. No substantial improvements in facial affect recognition were found after treatment with either typical or atypical antipsychotic drugs. Facial affect recognition was not related to neuropsychological functioning, and it was unclear whether improvement of symptom severity was related to performance on the facial affect recognition tasks. It is recommended that future research should focus on measuring social skills and social functioning more directly, and by investigating the effects of additional behavioural treatments on facial affect recognition and social functioning relative to treatment with antipsychotic medication alone.

A complex malformation of the uterus: report of a tricavitated uterus.

OBJECTIVE: To report a case of a previously unknown anomaly of the uterus in a patient suffering from primary infertility. DESIGN: Case report. SETTING: University Medical Center. PATIENT(S): A woman with a tricavitated uterus. INTERVENTION(S): During laparotomy both spherical structures and tubes were removed. MAIN OUTCOME MEASURE(S): Hysterosalpingography showed nonpatent tubes and dilatation in the proximal part of the tubes. By ultrasound, two spherical-shaped structures were found with a density resembling the density of myometrium and an inner lining similar to the endometrium. RESULT(S): Pathologic examination revealed that both spherical structures consisted of uterine muscle on the outside and functional endometrium on the inside. After two IVF cycles the patient became pregnant and delivered a healthy baby boy by cesarean section. CONCLUSION(S): The pathogenesis of this tricavitated anomaly of the uterus is discussed, but cannot be clearly explained, according to the classification for uterine malformations by the American Fertility Society.

Diagnostic laparoscopy is needed after abnormal hysterosalpingography to prevent over-treatment with IVF.

The additional value of laparoscopy was investigated with respect to diagnosis and further treatment decisions after abnormal hysterosalpingography (HSG) and prior to intrauterine insemination (IUI). In a retrospective chart review, the number of patients with abnormal HSG who finally need IVF treatment based on the laparoscopic findings was evaluated. Independent of whether HSG showed unilateral or bilateral tubal pathology, IVF was the final treatment decision in only 74 (29%) cases where laparoscopy showed bilateral abnormalities. IUI treatment was advised in 121 (48%) patients with laparoscopically normal findings or unilateral abnormalities. Fifty-seven (23%) patients were treated by IUI after receiving laparoscopic surgery of unilateral adhesions or endometriosis stage 1-2 or after ablation of moderate-severe endometriosis in a second operation. In cases of bilateral tubal abnormalities revealed by HSG, bilateral pathology was confirmed by laparoscopy in at least 58 (46%) patients and they were advised to be treated by IVF after laparoscopy. The agreement between abnormalities found by HSG and abnormalities found by laparoscopy requiring IVF treatment was poor even when HSG showed bilateral pathology. Based on these findings, it is concluded that laparoscopy is mandatory after abnormal HSG findings in the work-up prior to IUI to prevent over-treatment with IVF.

Do histologic changes in the skin-lined neovagina of male-to-female transsexuals really occur?

Controversy exists on whether or not the epidermal keratinizing squamous epithelium of skin grafts and flaps applied to line a neovagina changes histologically to a nonkeratinizing mucosal type squamous epithelium after vaginoplasty in male-to-female transsexuals. To end this discussion, the aim of this study was to objectify the short-term and long-term histologic aspect of this neovaginal epithelial lining. Biopsies were taken from the epithelium lining of the neovagina of 9 male-to-female transsexuals, from the moment of vaginoplasty up to 14 years after. These were stained with hematoxylin-eosin and periodic acid-Schiff stain for histologic comparison to normal vaginal biopsies. Because no changes that might have been induced by local influences or hormonal therapy were found, we concluded that short-term and long-term changes in the histologic aspect of inverted skin flaps do not occur after penile and scrotal skin vaginoplasty in male-to-female transsexuals.

Saving labium minus skin to treat possible urethral stenosis in female-to-male transsexuals.

In our hands, neourethral stenosis is the main complication following metaidoioplasty in female-to-male transsexuals. We introduce the use of surplus of minor labial skin to correct these stenoses. The surplus was used as a subcutaneously pedicled flap with a 1.5 x 3.5 cm skin paddle to correct the circumferential deficit of neourethral lining at the level of the stenosis. After minimum undermining, the pedicle was retracted laterally to allow for a median external urethrotomy. The skin paddle was turned outside in to fit the resulting longitudinal neourethral defect. Subsequently, the major labial subcutis and skin were approximated in layers to cover the subcutaneous pedicled flap and to close the labioscrotum in the midline. Patients were kept immobilized for 3 days, and a suprapubic catheter was left open for 7 days. This technique was applied successfully in 15 of the 70 female-to-male transsexuals who consequently underwent metaidoioplasty in Amsterdam up to March of 1999. We conclude that the surplus of labial skin ought to be retained during primary surgery because it is an ideal substitute to correct neourethral stenosis.