Military Resident Physician Training Burden: Quantifying Requirements Across the Military Health Care System.

INTRODUCTION: The Military Health Care System trains approximately 1,500 resident physicians in over 100 specialties. In addition to requirements for their specific program, active duty military trainees must complete military-specific trainings that vary by the branch of service. Excessive training requirements could contribute to physician burnout and/or negatively affect patient care. Therefore, the objective of this study was to quantify the time active duty resident physicians dedicate to this training, stratified by the branch of service. MATERIALS AND METHODS: The study protocol was submitted to the Clinical Investigations Department at Naval Medical Center Portsmouth (Portsmouth, VA, USA) and deemed exempt from the Institutional Review Board review. We conducted a descriptive study in 2021 wherein lists of all training requirements were obtained from a military treatment facility in the Army, Navy, and Air Force supporting residency training. Individual requirements were reviewed and sorted into military-specific and general categories. Information was gathered on duration, frequency, and platform for applicable requirements. RESULTS: Residents are required to complete a mean of 17.2 hours of training annually, of which 11.2 hours were military-specific. This consisted of 50, 57, and 53 individual requirements for Army, Navy, and Air Force personnel, respectively. Army resident physicians had the greatest time burden of military-specific training at 14.8 hours/year, followed by the Air Force and Navy (10.2 and 8.7 hours/year, respectively). CONCLUSIONS: Annually, active duty resident physicians spend the equivalent of more than two work days completing additional training requirements on multiple platforms. Standardizing training requirements and platforms across the Military Health Care System and aligning required trainings with job responsibilities could free up additional time for patient care, potentially decreasing fatigue and burnout.

Gynecologic Surgery and Obstetrics Leadership Roles in Academic Military Treatment Facilities by Subspecialty and Gender.

INTRODUCTION: Gender distribution in academic ob-gyn leadership positions has previously been examined in the civilian sector, but not in military medicine. OBJECTIVE: To characterize the distribution of department-level leadership positions by gender and subspecialty in academic military facilities in comparison to those reported in the civilian sector. METHODS: This is an observational cross-sectional study. We queried military obstetrics and gynecology (ob-gyn) specialty consultants, for title and gender of personnel assigned to academic military treatment facilities. Roles were characterized by gender and subspecialty, and the proportion of female leaders was compared to published civilian leadership data. RESULTS: Women comprised 25% of Department Chairs, 45% of Assistant Chairs, and 42% of Division Directors. In educational leadership roles, women comprised 25% of Residency Program Directors, 0% of Fellowship Directors, and 62% of medical Student Clerkship Directors. Female department chairs were most often uro-gynecologists (44%) followed by specialists in ob-gyn (37%). Most female residency program directors were specialists in general obstetrics and gynecology. The proportion of women in leadership roles in military departments was not different than in the civilian sector. CONCLUSION: In contrast to civilian academic leadership positions, Department Chairs were most likely to be uro-gynecologists. Similar to civilian programs, women remain underrepresented as chairs, Assistant Chairs, Fellowship Directors, and Division Directors and similarly represented as Residency Program Directors. Despite a smaller pool of women available to fill academic leadership positions in military ob-gyn departments, the proportion of women in leadership roles reaches parity with the civilian sector. This suggests that a greater proportion of women rise to leadership positions in military academic ob-gyn departments than in the civilian sector.

Comparing Compensation of U.S. Military Physicians and Civilian Physicians in Residency Training and Beyond.

Introduction  Resident physicians have a professional degree but are compensated less than other recently graduated professionals such as lawyers or nurse practitioners. The U.S. Military Healthcare System differs from the civilian setting in that physicians' salaries are based primarily on military rank. We compared military and civilian physician salaries across various specialties to determine if the increased military pay during residency compensates for military attending physicians' lower income as compared to their civilian counterparts. Methods This cross-sectional study compares military and civilian pay for resident and attending physicians in the fields of Obstetrics & Gynecology (OB/GYN), Family Medicine, and General Surgery. Military pay was obtained from 2018 Defense Finance and Accounting Service (DFAS) data. Civilian salaries were obtained from the Medscape 2018 Residents Salary & Debt Report, Medical Group Management Association (MGMA) 2018 Provider Compensation Report, and 2017-2018 Association of American Medical Colleges (AAMC) Faculty Salary Report. Results Military resident physicians earned 53% more than civilian residents while military attending physicians earned 32%-58% less (after taxes) than their civilian counterparts, varying by specialty. Military attending physicians' negative pay differential occurred in both academic and non-academic practice environments through MGMA data. Discussion The positive pay differential in military residency does not compensate for the negative pay differential of military attending physicians face as compared to their civilian counterparts. This negative pay differential persisted when comparing post-tax pay. Some military service benefits, such as decreased educational debt, are challenging to quantify and vary considerably between individuals. As the military seeks to reshape its healthcare force, military and civilian compensation differences should be considered.

Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons.

BACKGROUND: We evaluated a novel simulation-based cesarean section training program to teach critical techniques for cesarean section and hemorrhage management.  Methods: This was a prospective educational intervention. After Institutional Review Board approval, we recruited Obstetrics and Gynecology, Family Medicine, and General Surgery residents at three hospitals. All participants received didactic education. Participants were then randomized into two arms with one group to receive task-trainer based training and the other no training. Afterwards, all residents had their performance of a complete cesarean section and management of a post-partum hemorrhage evaluated on a high-fidelity simulator. Evaluators were blinded to randomization. EXPERIENCE: Thirty-three participants were recruited between July 2017 and January 2019. There were 19 trainees in the control group and 14 in the intervention group. The intervention group scored significantly higher on performance of the cesarean delivery (p-value 0.007), hemorrhage management (p-value 0.0002), and overall skill (p-value 0.008). There were no differences in the other categories. CONCLUSION: Participants trained with a combination of didactic education and task-trainers versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.

Periviability: A Review of Key Concepts and Management for Perinatal Nursing.

One of the most complex clinical problems in obstetrics and neonatology is caring for pregnant women at the threshold of viability. Births near viability boundaries are grave events that carry a high prevalence of neonatal death or an increased potential for severe lifelong complications and disabilities among those who survive. Compared with several decades ago, premature infants receiving neonatal care by today's standards have better outcomes than those born in other eras. However, preterm labor at periviability represents a more complex counseling and management challenge. Although preterm birth incidence between 20/7 and 25/7 weeks has remained unchanged, survival rates at earlier gestational ages have increased as perinatal and neonatal specialties have become more adept at caring for this at-risk population. Women face difficult choices about obstetric and neonatal interventions in light of uncertainties around survival and outcomes. This article reviews current neonatal statistics in reference to short- and long-term outcomes, key concepts in obstetric clinical management of an anticipated periviable birth, and counseling guidance to ensure shared-decision making.

Variations in prenatal screening in a US federal healthcare system: Same coverage, different options.

The Military Health System (MHS) is a federally funded organization that provides care to active duty service members and their beneficiaries. Our objective was to determine what methods of prenatal screening are used by military treatment facilities (MTFs), assess variations between institutions, and determine how practice patterns align with national recommendations. We surveyed all MTFs offering comprehensive prenatal care (n = 49). Departments were asked about aneuploidy screening options, availability of diagnostic testing, and carrier screening. In all, 43 MTFs (88%) completed the survey. Most (39/43) patients were stratified based on risk (predominantly maternal age at delivery and history). The most commonly offered test was combined 1st/2nd trimester screening (59%). Sixty percent routinely offered diagnostic testing, though less than half routinely offered microarrays. The majority offered universal carrier screening for cystic fibrosis (98%) and complete blood count with screening for thalassemias and hemoglobinopathies (88%). At the time of data collection, only five facilities (12%) had implemented spinal muscular atrophy carrier screening. Considerable heterogeneity exists in prenatal aneuploidy testing and carrier screening within the MHS. Standardized guidelines, protocols, and laboratory support would improve processes across the system. Additional resources including genetic counseling support and provider education are needed.

Idiopathic polyhydramnios: persistence across gestation and impact on pregnancy outcomes.

PURPOSE: To investigate the likelihood of resolution of idiopathic polyhydramnios in pregnant women and compare outcomes between resolved and persistent cases. METHODS: One hundred and sixty-three women with idiopathic polyhydramnios who delivered at two medical centers during a 3 year period (January 2012-January 2015) were included in the study. Exclusion criteria included congenital fetal anomalies, maternal diabetes, isoimmunization, fetal infection, placental tumors or anomalies, and multiple gestation. Polyhydramnios was defined as SDP≥8cm or AFI≥24cm. Resolved cases were defined as those with AFI and/or SDP falling and remaining below 24cm and 8cm respectively. Pregnancy outcomes were compared between resolved and persistent cases. Two-sample t-test or Wilcoxon rank-sum test was used for continuous variables while chi-square test or Fisher's exact test was used for categorical measures. RESULTS: Resolution was noted in 61 of 163 (37%) patients. There were no differences in maternal age, gravidity or parity between resolved and persistent cases. Mean gestational age at diagnosis of polyhydramnios and overall mean AFI were significantly lower in the cases that resolved (29.7±4.5 weeks vs 33.4±4.1 weeks, p<0.0001; 23.3±3.5cm vs 25.8 23.3±4.0cm, p=0.0002). Similar to AFI measurements, mean SDP was also lower in cases with resolution (p=0.002). There was no difference in induction rates, mode of delivery, amnioinfusion rates, meconium staining of amniotic fluid and fetal heart rate abnormalities influencing intrapartum management between the two groups. Induction of labor for fetal indication and rupture of membranes were significantly more common in the persistent group. Cesarean delivery for abnormal lie and fetal distress did not differ between the groups. There was an increased risk of macrosomia (>4000g) and preterm delivery (<37 weeks) in the persistent group (p<0.05). CONCLUSIONS: Resolution rate was approximately 37% and more likely in cases diagnosed earlier in pregnancy and with lower mean amniotic fluid volume. Preterm delivery and macrosomia were more common in cases that persisted across gestation.

Elective Induction of Labor Compared With Expectant Management of Nulliparous Women at 39 Weeks of Gestation: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether the elective induction of labor in nulliparous women with an unfavorable cervix affects the cesarean delivery rate. METHODS: We conducted a randomized controlled trial at a tertiary care medical center. Nulliparous woman between 38 0/7 and 38 6/7 weeks of gestation who were least 18 years of age with a singleton gestation and a Bishop score of 5 or less were randomized to elective induction of labor or expectant management. The induction of labor group was induced within 1 week of enrollment but not before 39 0/7 weeks of gestation. The control group continued routine prenatal care with admission for labor or obstetric indication. The primary outcome was cesarean delivery. Assuming a 20% rate in women in a control group, 80% power, and a goal to detect a twofold increase to 40% in the induction of labor group, 162 patients were needed. RESULTS: From March 2010 to February 2014, 82 patients were randomly allocated to induction of labor and 80 to expectant management. Baseline characteristics were similar between groups. The cesarean delivery rate in the induction of labor group was 30.5% (25/82) compared with 17.7% (14/79) in the expectant management group (relative risk 1.72, 95% confidence interval 0.96-3.06). CONCLUSION: In nulliparous women with a Bishop score of 5 or less, elective induction after 39 0/7 weeks of gestation compared with expectant management of pregnancy did not double the rate of cesarean delivery. CLINICAL TRIAL REGISTRACTION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01076062. LEVEL OF EVIDENCE: I.

Accuracy of the Adverse Outcome Index: An Obstetrical Quality Measure.

BACKGROUND: In obstetrics, a nationally accepted set of quality indicators for patient safety was not available in the United States until the development of a set of 10 adverse outcome measures-the Adverse Outcome Index (AOI). The National Perinatal Information Center (NPIC) developed hospital discharge data-based algorithms combined with a small set of supplemental patient data for calculation of the AOI. A study was conducted to determine the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the AOI by using the National Perinatal Information Center (NPIC) algorithm. METHODS: A retrospective chart review of 4,252 obstetrical and neonatal charts from 2003 through 2007 was performed. NPIC definitions were compared with the "gold standard"-chart review. RESULTS: A total of 229 deliveries among the 4,000 randomly selected charts had at least one adverse outcome, reflecting an AOI of 5.7%. For detection of the 10 adverse outcomes within the AOI, the overall sensitivity of the AOI was 81.7%, specificity was 98.2%, PPV was 86.3%, and NPV was 97.4%. The Kappa value for agreement between the coded charts and the chart review was 0.82 (standard deviation=0.01, 95% confidence interval [CI]=0.80-0.85), which is considered very good. DISCUSSION: The AOI is highly reliant on accurate coding and provider documentation and requires validation with manual chart review. Concurrent chart review improves the accuracy of the AOI. Caution is advised when using the AOI as an exclusive measure of assessing obstetric quality because it may be heavily influenced by a single outcome measure; perineal laceration rates represented twice the frequency of all other outcomes combined. The AOI should be modified to better measure preventable adverse events and include a means of accounting for preexisting conditions.

Noninvasive prenatal testing: limitations and unanswered questions.

The clinical use of noninvasive prenatal testing to screen high-risk patients for fetal aneuploidy is becoming increasingly common. Initial studies have demonstrated high sensitivity and specificity, and there is hope that these tests will result in a reduction of invasive diagnostic procedures as well as their associated risks. Guidelines on the use of this testing in clinical practice have been published; however, data on actual test performance in a clinical setting are lacking, and there are no guidelines on quality control and assurance. The different noninvasive prenatal tests employ complex methodologies, which may be challenging for health-care providers to understand and utilize in counseling patients, particularly as the field continues to evolve. How these new tests should be integrated into current screening programs and their effect on health-care costs remain uncertain.

Maternal pulse pressure at admission is a risk factor for fetal heart rate changes after initial dosing of a labor epidural: a retrospective cohort study.

OBJECTIVE: To examine low maternal admission pulse pressure (PP) as a risk factor for new onset postepidural fetal heart rate (FHR) abnormalities. STUDY DESIGN: Retrospective cohort study of nulliparous, singleton, vertex-presenting women admitted to labor and delivery after 37 0/7 weeks that received an epidural during labor. Women with a low admission PP were compared with those with a normal admission PP. The primary outcome was new onset FHR abnormalities defined as recurrent late or prolonged FHR decelerations in the first hour after initial dosing of a labor epidural. RESULTS: New onset FHR abnormalities, defined as recurrent late decelerations and/or prolonged decelerations, occurred in 6% of subjects in the normal PP cohort compared with 27% in the low PP cohort (odds ratio, 5.6; 95% confidence interval, 2.1-14.3; P < .001). A multivariate logistic regression analysis generated an adjusted odds ratio of 28.9 (95% confidence interval, 3.7-221.4; P < .001). CONCLUSION: New onset FHR abnormalities after initial labor epidural dosing occur more frequently in women with a low admission PP than those with a normal admission pulse. Admission PP appears to be a novel predictor of new onset postepidural FHR abnormalities.

Improving knowledge about prenatal screening options: can group education make a difference?

OBJECTIVE: To determine if the addition of group education regarding maternal serum screening and diagnostic testing for aneuploidy and neural tube defects improves patient knowledge and affects the uptake of testing compared to individual education alone. METHOD: We conducted a prospective study of 443 obstetric patients to assess knowledge of prenatal testing options based on individual provider counseling (n = 331) or provider counseling with supplemental group education (n = 112). We used a chi-square test to compare the number of correct survey answers between the two groups. RESULTS: There was no difference in baseline knowledge. Patients receiving group education showed a statistically significant improvement in knowledge. After initiation of group education, the uptake of maternal serum screening declined while the uptake of amniocentesis remained unchanged. CONCLUSION: Group education in addition to individual counseling to discuss prenatal testing options appears to be effective in improving knowledge compared to individual provider counseling alone. Improved knowledge may affect uptake of prenatal screening tests due to more informed decision making.

Intramuscular 17α-hydroxyprogesterone caproate administration attenuates immunoresponsiveness of maternal peripheral blood mononuclear cells.

OBJECTIVE: 17α-hydroxyprogesterone caproate (17P) may decrease risk of prematurity by suppressing maternal immunity. We hypothesized that in vivo 17P treatment attenuates immunoresponsiveness of peripheral blood mononuclear cells (PBMCs). STUDY DESIGN: Study subjects were gravidas receiving weekly prophylactic intramuscular 17P injections. Peripheral blood samples were obtained at 21-27 weeks' gestation. Gestational age-matched, drug-naïve gravidas served as controls. To simulate infection, isolated PBMCs were stimulated with lipoteichoic acid (LTA) or lipopolysaccharide (LPS). Extracellular interleukin-6 (IL-6) concentrations were quantified by an enzyme-linked immunosorbent assay. RESULTS: Unstimulated IL-6 levels were comparable in PBMCs derived from drug-naïve and 17P-treated subjects. LPS and LTA induced a dose-dependent elevation of IL-6 in control PBMCs. In patients who received exogenous 17P, LPS, and LTA stimulated induction of IL-6 was significantly decreased compared with controls (P = .005 and P = .02). CONCLUSION: In vivo 17P attenuated immunoreactivity of PBMCs in our in vitro model of Gram-positive and Gram-negative bacterial infection.

Effects of deployment on depression screening scores in pregnancy at an army military treatment facility.

OBJECTIVE: To estimate the relationship of positive screening for depression during and after pregnancy with deployment status of the spouse. METHODS: We conducted a retrospective cohort study by reviewing a departmental database of women who completed the Edinburgh Postpartum Depression Scale during pregnancy from 2007 to 2009. Per departmental protocol, screening is offered at the initial obstetric visit, at 28 weeks of gestation, and at 6 weeks postpartum. A score of 14 or higher was considered high risk for having depression, and referral for additional evaluation was recommended. Included in our survey was an additional question that asked if the patient's spouse was currently deployed, returning from deployment, preparing to deploy, or if no deployment was planned. All data were entered into an electronic database and statistical analysis performed comparing Edinburgh Postpartum Depression Scale scores at each time period and deployment status. RESULTS: A total of 3,956 surveys were complete and available for analysis. The risk of a positive screen was more than doubled compared with the control group (no deployment planned) if the spouse was deployed during the 28-32 week visit (4.3% compared with 13.1%, P=.012) or the postpartum period (8.1% compared with 16.2%, P=.006). CONCLUSION: Deployment status has a measurable effect on the prevalence of elevated depression screening scores during pregnancy and in the postpartum period. These findings suggest that more intense monitoring, assessment, and treatment may be warranted for this at-risk population. LEVEL OF EVIDENCE: II.

Continuous infusion of 17-hydroxyprogesterone caproate into either the fetoplacental or intervillous circulation of a placental cotyledon attenuates vasoconstriction of the fetoplacental arteries by thromboxane mimetic U46619.

OBJECTIVE: The objective of the study was to determine whether pretreatment of fetal or maternal placental vasculature with 17-hydroxyprogesterone caproate (17-P) attenuates the vasoactive effect of the thromboxane mimetic U46619. STUDY DESIGN: Two cotyledons were obtained from each placenta studied. For the first 5 placentas, the fetal artery of 1 cotyledon from each pair was infused with 17-P. After 30 minutes, a bolus dose of U46619 was administered to both cotyledons. An identical procedure was carried out on the next 5 placentas except that 17-P was infused into the intervillous space. RESULTS: The pressure excursion caused by bolus administration of U46619 was less in the cotyledons infused with 17-P, both in the 5 cases in which the fetal vasculature was infused with 17-P (P = .0035) and in the 5 cases in which the maternal vasculature was infused with 17-P (P = .038). CONCLUSION: Pretreatment of either the fetal or maternal circuits of the placenta with 17-P attenuates U46619-mediated fetoplacental vasoconstriction.

Post-partum exacerbation of idiopathic pulmonary hemosiderosis.

Idiopathic pulmonary hemosiderosis is a disease causing diffuse alveolar hemorrhage and has rarely been reported in pregnancy. We present the first described case of a post-partum exacerbation after an uncomplicated prenatal course.

Maternal glucose levels after dexamethasone for fetal lung development in twin vs singleton pregnancies.

OBJECTIVE: Betamethasone administration in singleton pregnancies causes maternal hyperglycemia. With the increased risk of glucose intolerance in twin pregnancies, we sought to determine whether maternal hyperglycemia after dexamethasone administration is different in twin vs singleton pregnancies. STUDY DESIGN: Patients with singleton or twin pregnancies admitted between 24 and 34 weeks' gestation with diagnoses requiring steroid administration were approached. Exclusion criteria included diabetes, abnormal glucose tolerance test, infection, or medications known to interfere with glucose metabolism. Patients were NPO for 24 hours and received dexamethasone per protocol. Maternal glucose levels were checked at baseline and then at specified intervals after the initial dose; appropriate statistical analysis was performed. RESULTS: Ten singleton and 9 twin gestations were enrolled. There were no differences in mean maternal or gestational ages. Mean glucose levels were significantly higher in the twin group at 4 hours (114 mg/dL vs 95.6 mg/dL), 8 hours (121.4 mg/dL vs 90.9 mg/dL), and 24 hours (116 mg/dL vs 81 mg/dL) (P < .01 for all). CONCLUSION: Twin pregnancies had higher mean glucose values than singleton pregnancies in the first 24 hours after dexamethasone administration.

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.

Evaluation of a clinical skills orientation program for residents.

OBJECTIVE: Our purpose was to implement and evaluate an orientation program for residents, focusing on outpatient clinical skills. STUDY DESIGN: Eleven of 12 residents participated in a clinical skills orientation program immediately preceding the academic year. The skill stations included evaluation of abnormal uterine bleeding, intrauterine device insertion, basic infertility evaluation, endometrial and vulvar biopsies, pelvic organ prolapse quantification examination, hysterosalpingography and office hysteroscopy, ultrasound scanning, labor and delivery triage, and clinic administrative responsibilities. Before test, after test, and anonymous resident evaluations were used to evaluate the program. RESULTS: First-year residents demonstrated a statistically significant increase in posttest scores compared to pretest scores (42.5% vs 71.3%, P=.003). Only first-year resident posttest scores for the labor and delivery triage and basic infertility evaluation stations demonstrated statistically significant increases over pretest scores (14.3% vs 46.4%, P=.009; and 41.7% vs 83.3%, P=.049, respectively). Sixty-four percent of the residents rated the program as "very helpful." Most residents felt that the program was well organized and that the facilities were conducive to learning; all of the participants recommended an annual clinical orientation program. CONCLUSION: A clinical skills orientation program was well received and strongly desired by residents. First-year residents appeared to benefit the most from this orientation.