Playing nice: improving the professional climate between physicians and midwives in the Calgary area.

BACKGROUND: Anecdotal reports in the Calgary area indicate a lack of integration of midwives into the mainstream obstetrical community and strained relationships between obstetrical care providers. Finding ways to cultivate positive working relationships is essential for ensuring excellent patient care standards. In this study we sought to identify barriers to an effective working relationship between physicians (both obstetricians and family physicians) and midwives, and to find ways to improve the quality of professional interactions and promote team-based pregnancy care. METHODS: We conducted a mail survey within the former Calgary Health Region that included questions about professional interaction, philosophy regarding childbirth, and relationships between obstetrical practitioners. Participants included family physicians (FPs), midwives (MWs), and obstetricians (OBs) who were identified from publicly available lists. RESULTS: The overall response rate was 80% (144/180). Eligible responses were received from 56 FPs (89% female, 45% in practice < 10 years), 25 MWs (100% female, 68% < 10 years), and 37 OBs (60% female, 49% < 10 years). Responses in agreement with selected survey statements were as follows: childbirth is a dangerous process (36% FPs, 1% MWs, 57% OBs); there are many unnecessary Caesarean sections performed (23% FPs, 76% MWs, 27% OBs); MWs are well-trained professionals (68% FPs, 100% MWs, 30% OBs); residents would benefit from learning from midwives (61% FPs, 100% MWs, 38% OBs); and working relationships could be improved (89% FPs, 100% MWs, 97% OBs). CONCLUSION: Relationships between physicians and midwives are sometimes strained. Potential solutions include increased integration in learning, joint attendance at meetings and rounds, and increased opportunities for collaboration.

Contexte : Des signalements empiriques issus de la région de Calgary indiquent un manque d'intégration des sages-femmes au sein de la communauté obstétricale générale et des relations tendues entre les fournisseurs de soins obstétricaux. Il s'avère essentiel de trouver des façons de cultiver des relations de travail positives pour assurer l'excellence des soins offerts aux patientes. Dans le cadre de cette étude, nous avons cherché à identifier les obstacles à la mise en œuvre d'une relation de travail efficace entre les médecins (tant les obstétriciens que les médecins de famille) et les sages-femmes, et à trouver des façons d'améliorer la qualité des interactions professionnelles et de promouvoir l'offre de soins de maternité en équipe. Méthodes : Nous avons mené, au sein de l'ancienne Calgary Health Region, une enquête postale qui comprenait des questions au sujet de l'interaction professionnelle, de la philosophie en matière d'accouchement et des relations entre les fournisseurs de soins obstétricaux. Parmi les participants, on trouvait des médecins de famille (MF), des sages-femmes (SF) et des obstétriciens (OB) ayant été identifiés à partir des listes publiquement disponibles. Résultats : Le taux de réponse global a été de 80 % (144/180). Des réponses admissibles ont été obtenues de la part de 56 MF (femmes : 89 %, pratique < 10 ans : 45 %), de 25 SF (femmes : 100 %, pratique < 10 ans : 68 %) et de 37 OB (femmes : 60 %, pratique < 10 ans : 49 %). Les réponses indiquant l'accord du répondant pour ce qui est de certaines des affirmations de l'enquête se déclinaient comme suit : « L'accouchement est un processus dangereux ¼ (36 % des MF, 1 % des SF, 57 % des OB); « De nombreuses césariennes sont menées inutilement ¼ (23 % des MF, 76 % des SF, 27 % des OB); « Les sages-femmes sont des professionnelles bien formées ¼ (68 % des MF, 100 % des SF, 30 % des OB); « Les résidents tireraient avantage d'une participation à une séance de formation menée par des sages-femmes ¼ (61 % des MF, 100 % des SF, 38 % des OB); et « Les relations de travail pourraient être améliorées ¼ (89 % des MF, 100 % des SF, 97 % des OB). Conclusion : Les relations entre les médecins et les sages-femmes sont parfois tendues. Parmi les solutions possibles, on trouve une intégration accrue dans le cadre de l'apprentissage, la participation à des réunions et à des rondes communes, et l'augmentation du nombre d'occasions de collaborer.

Prediction of postoperative pain after gynecologic laparoscopy for nonacute pelvic pain.

OBJECTIVE: The primary objectives of this study were to explore the pain experience after gynecologic laparoscopy that is performed for nonacute pain conditions and to determine whether preoperative psychologic tests and quantitative tests of sensitization can predict postoperative pain. STUDY DESIGN: Participants included 61 women who underwent laparoscopy for nonacute pain (n = 61). A second group of 16 women who had undergone tubal ligation was included to explore whether laparoscopy induced a painful postoperative response in women without preoperative pain. Subjective tests included numeric pain scale, pain catastrophizing scale, depression scale, global assessment of change, and the McGill Pain Questionnaire Short Form. Quantitative sensory testing included abdominal cutaneous allodynia, trigger points, and reduced pain thresholds. The nonacute pain sample had 80% power to detect a difference of 0.5 standard deviation in average pain levels. Analysis included parametric and nonparametric comparisons of groups and univariate and linear regression analysis of clinically relevant variables. RESULTS: In women who underwent tubal ligation, pain levels were low before and after the procedure. In women who underwent surgery for nonacute pain, pain levels at 6 months and all psychologic test scores were reduced significantly compared with baseline (P < .001 and P = .001, respectively). Among those women with positive results on the quantitative pain tests of sensitization at baseline, average postoperative pain was also significantly reduced (P < .001). Univariate analysis demonstrated only tests of sensitization that were correlated with change in average pain level (P = .01). Regression analysis suggested that baseline pain, catastrophizing, and the presence of cutaneous allodynia significantly predicted pain levels 6 months after surgery (P < .001). CONCLUSION: Pain after laparoscopic surgery for nonacute painful conditions can be predicted by baseline pain, catastrophizing, and the presence of allodynia, which is a simple swab test that indicates sensitization.

Clinical practice in prevention of neonatal HSV infection: a survey of obstetrical care providers in Alberta.

OBJECTIVE: To identify the current practice patterns of physicians providing prenatal care in Alberta with respect to prevention of neonatal herpes simplex virus (HSV) infection. METHOD: A 22-item questionnaire was mailed to all obstetricians and family physicians providing obstetrical care in Alberta. The questionnaire included demographic and practice details, and details of management of patients with a history or symptoms of HSV lesions, including practice in prescribing antiviral therapy, recommending elective Caesarean section, and ordering serology. Two reminders were mailed as necessary. RESULTS: Responses were received from 89 obstetricians (57%) and 94 family physicians (54%). Antiviral therapy was prescribed for the prevention of neonatal HSV infection in the third trimester by 97% of obstetricians versus 84% of family physicians (P = 0.007), with acyclovir being the most commonly prescribed agent. Caesarean section was offered "most of the time" to women with primary HSV infection in the third trimester by 65% of physicians, to women with prodromal symptoms during the intrapartum period by 57% (no significant differences between groups), and to women with HSV lesions by 92% of obstetricians and 82% of family physicians (P = 0.032). Women with a negative HSV history but whose partner had known HSV were offered serological testing "most of the time" by 30% of physicians (no significant difference between groups). CONCLUSION: Despite the encouraging survey results, obstetrical providers should be encouraged to offer Caesarean section to women with a primary HSV infection in the third trimester and to offer serological testing in discordant couples. These simple strategies can help to prevent neonatal HSV infection and its long-term consequences.

Assessing image quality of low-cost laparoscopic box trainers: options for residents training at home.

INTRODUCTION: Low-cost laparoscopic box trainers built using home computers and webcams may provide residents with a useful tool for practice at home. This study set out to evaluate the image quality of low-cost laparoscopic box trainers compared with a commercially available model. METHODS: Five low-cost laparoscopic box trainers including the components listed were compared in random order to one commercially available box trainer: A (high-definition USB 2.0 webcam, PC laptop), B (Firewire webcam, Mac laptop), C (high-definition USB 2.0 webcam, Mac laptop), D (standard USB webcam, PC desktop), E (Firewire webcam, PC desktop), and F (the TRLCD03 3-DMEd Standard Minimally Invasive Training System). Participants observed still image quality and performed a peg transfer task using each box trainer. Participants rated still image quality, image quality with motion, and whether the box trainer had sufficient image quality to be useful for training. RESULTS: Sixteen residents in obstetrics and gynecology took part in the study. The box trainers showing no statistically significant difference from the commercially available model were A, B, C, D, and E for still image quality; A for image quality with motion; and A and B for usefulness of the simulator based on image quality. The cost of the box trainers A-E is approximately $100 to $160 each, not including a computer or laparoscopic instruments. CONCLUSIONS: Laparoscopic box trainers built from a high-definition USB 2.0 webcam with a PC (box trainer A) or from a Firewire webcam with a Mac (box trainer B) provide image quality comparable with a commercial standard.

Blood pressure measurement for hypertension in pregnancy.

OBJECTIVE: Ambulatory BP monitoring (ABPM) has been proposed as a logical approach to overcoming many of the problems associated with clinical BP measurement. The extent of its use in diagnosing hypertension in pregnancy is unknown. The objective of this study was to identify the practices surrounding use of ABPM by practitioners to diagnose hypertension (HTN) and white coat hypertension (WCH) in pregnant women. METHODS: We mailed questionnaires to all obstetricians and family doctors practising obstetrics who were listed in the online medical directory of the College of Physicians and Surgeons of Alberta. Data were analyzed using SPSS. RESULTS: Completed questionnaires were received from 81 obstetricians and 86 primary care physicians who manage hypertension in pregnancy. The majority of obstetricians (83%) and primary care physicians (79%) indicated that they "almost always" or "often" attempt to differentiate WCH from true HTN in pregnancy. The most popular method identified to differentiate WCH from true HTN in pregnancy was self (intermittent) home BP monitoring (78% of obstetricians and 69% of primary care physicians, P = 0.18). A minority of physicians in each group reported using ABPM to evaluate HTN in pregnancy, with significantly fewer obstetricians using ABPM diagnostically than primary care physicians (12% vs. 26%, P = 0.04). CONCLUSION: Obstetrical care providers in Alberta are aware that WCH is an issue among pregnant women. While ABPM is chosen in a minority of cases, both obstetricians and primary care physicians appear to have a strong preference to use self BP monitoring for further BP evaluation.