Educational guidelines on sexual orientation, gender identity and expression, and sex characteristics biases in medical education.

A commitment to diversity, equity, inclusion, and belonging in medical education requires addressing both explicit and implicit biases based on sexual orientation, gender identity and expression, and sex characteristics and the intersectionality with other identities. Heterosexism and heteronormative attitudes contribute to health and healthcare disparities for lesbian, gay, bisexual, transgender and queer or questioning, intersex, asexual individuals. Student, trainee, and faculty competencies in medical education curricula regarding the care of lesbian, gay, bisexual, transgender and queer or questioning, intersex, asexual patients and those who are gender nonconforming or born with differences of sex development allow for better understanding and belonging within the clinical learning environment of lesbian, gay, bisexual, transgender and queer/questioning, intersex, asexual learners and educators. The Association of Professors of Gynecology and Obstetrics issued a call to action to achieve a future free from racism and bias through inclusivity in obstetrics and gynecology education and healthcare, which led to the creation of the Association of Professors of Gynecology and Obstetrics Diversity, Equity, and Inclusion Guidelines Task Force. The task force initially addressed racism, racial- and ethnicity-based bias, and discrimination in medical education and additionally identified other groups that are subject to bias and discrimination, including sexual orientation, gender identity and expression, and sex characteristic identities, persons with disabilities, and individuals with various religious and spiritual practices. In this scholarly perspective, the authors expand on previously developed guidelines to address sexual orientation, gender identity and expression, and sex characteristics bias, heterosexism, and heteronormative attitudes in obstetrics and gynecology educational products, materials, and clinical learning environments to improve access and equitable care to vulnerable individuals of the lesbian, gay, bisexual, transgender and queer or questioning, intersex, asexual community.

Current practices and perspectives on clerkship grading in obstetrics and gynecology.

BACKGROUND: Clerkship grades in obstetrics and gynecology play an increasingly important role in the competitive application process to residency programs. An analysis of clerkship grading practices has not been queried in the past 2 decades in our specialty. OBJECTIVE: This study aimed to investigate obstetrics and gynecology clerkship directors' practices and perspectives in grading. STUDY DESIGN: A 12-item electronic survey was developed and distributed to clerkship directors with active memberships in the Association of Professors of Gynecology and Obstetrics. RESULTS: A total of 174 of 236 clerkship directors responded to the survey (a response rate of 73.7%). Respondents reported various grading systems with the fewest (20/173 [11.6%]) using a 2-tiered or pass or fail system and the most (72/173 [41.6%]) using a 4-tiered system. Nearly one-third of clerkship directors (57/163 [35.0%]) used a National Board of Medical Examiners subject examination score threshold to achieve the highest grade. Approximately 45 of 151 clerkship directors (30.0%) had grading committees. Exactly half of the clerkship directors (87/174 [50.0%]) reported requiring unconscious bias training for faculty who assess students. In addition, some responded that students from groups underrepresented in medicine (50/173 [28.9%]) and introverted students (105/173 [60.7%]) received lower evaluations. Finally, 65 of 173 clerkship directors (37.6%) agreed that grades should be pass or fail. CONCLUSION: Considerable heterogeneity exists in obstetrics and gynecology clerkship directors' practices and perspectives in grading. Strategies to mitigate inequities and improve the reliability of grading include the elimination of a subject examination score threshold to achieve the highest grade and the implementation of both unconscious bias training and grading committees.

Obstetrics and gynecology clerkship directors' experiences advising residency applicants.

BACKGROUND: The evolving landscape of application processes for obstetrics and gynecology residency applicants poses many challenges for applicants and advisors. The lack of data coordination among national groups creates crucial gaps in information for stakeholder groups. OBJECTIVE: This study aimed to identify the current state of the advising milieu for obstetrics and gynecology residency applicants and their career advisors, the annual Association of Professors of Gynecology and Obstetrics survey focused on US clerkship directors' experiences advising students through these processes. STUDY DESIGN: A 23-item anonymous survey was developed that asked respondents about demographics and outcomes for the students that they advised through the 2021 application process and their experiences with dual applicants and students not matching. The survey was sent electronically to all obstetrics and gynecology clerkship directors with active Association of Professors of Gynecology and Obstetrics memberships in April 2021. RESULTS: Of 224 total clerkship directors, 143 (63.8%) responded to the survey, Of the 143 respondents, almost all (136 [95.1%]) served as career advisors, and 50 (35.0%) were aware of students dual applying. Furthermore, obstetrics and gynecology was rarely the backup to a more competitive specialty. For the 2021 application cycle, 79 of 143 respondents (55.2%) reported having students not successfully match into obstetrics and gynecology, with "academic concerns" followed by "poor communication skills" as the primary reasons cited for students not matching. CONCLUSION: This snapshot of clerkship directors' experiences advising students in the residency application process reveals notably high rates of dual applicants and students not matching into obstetrics and gynecology. This work fills key gaps in our knowledge of current processes and highlights the importance of career advising at multiple points during the application process.

To the Point: optimizing the learning environment in labor and delivery.

The labor and delivery floor is a unique learning environment that poses challenges to teaching medical students, with a potentially detrimental effect on their evaluations of the obstetrics and gynecology clerkship. This article, from the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, offers specific suggestions for improving undergraduate medical education in obstetrics with attention to student preparation, faculty development, nonphysician staff involvement, and patient education. Optimizing the learning environment in labor and delivery would improve student experiences and perceptions of our specialty.

Strategies to Create a More Gender Identity Inclusive Learning Environment in Preclinical and Clinical Medical Education.

ABSTRACT: Recognition of the spectrum of gender identities has been a recent phenomenon in the medical profession. Over the past 20 years, medical literature related to gender identity diversity has increased several-fold, yet it more commonly addresses clinical care rather than aspects related to medical education. Medical educators continue to struggle with appropriate language and inclusive approaches when discussing gender-based aspects of medical education. Reproductive health education, including obstetrics and gynecology clerkships, is particularly vulnerable to missteps and anachronisms regarding gender identity.This article aims to provide preclinical and clinical medical educators with strategies to identify and predict situations where missteps related to gender identity inclusivity may occur in their curriculum or learning environment, and to develop approaches to improve gender identity inclusivity within medical education. The authors explore 3 areas that commonly pose challenges for medical educators: inclusive language and terminology, anatomy education, and reproductive genetics and genetic counseling. They hope the tools and strategies provided here will be useful to reproductive health medical educators across specialties to enable the realization of a more inclusive learning environment in reproductive health.

Clerkship director confidence in medical student career advising in obstetrics and gynecology.

BACKGROUND: Given the increasing complexities of the residency application processes, there is an ever-increasing need for faculty to serve in the role of fourth-year medical student career advisors. OBJECTIVE: This study aimed to investigate obstetrics and gynecology clerkship directors' confidence and fulfillment with serving in the role of faculty career advisors. STUDY DESIGN: A 25-item electronic survey was developed and distributed to the 225 US obstetrics and gynecology clerkship directors in university-based and community-based medical schools with active memberships in the Association of Professors of Gynecology and Obstetrics. Items queried respondents on demographics, confidence in fourth-year advising, satisfaction with this aspect of their career, and resources used for advising. RESULTS: Of 225 clerkship directors, 143 (63.6%) responded to the survey. Nearly all clerkship directors (136/143 [95%]) reported advising fourth-year students. A median of 5.0 hours (interquartile range, 3.0-10.0) was spent per student in this advisory role, with 29 of 141 clerkship directors (20.5%) reporting some form of compensation for advising. Confidence in the ability to advise fourth-year medical students correlated significantly with number of years as a faculty, number of years as a clerkship director, and a higher full-time equivalent allotted as clerkship director. Fulfillment as a faculty career advisor was correlated with number of years as a clerkship director and a higher number of students advised. CONCLUSION: Obstetrics and gynecology clerkship directors regularly serve in the crucial role of faculty career advisor. Confidence in advising fourth-year students, advising fulfillment, and satisfaction with advising resources were all significantly correlated. We recommend that clerkship directors review resources available for advising and that they be provided academic time to serve as career advisors.

Encouraging workforce diversity- supporting medical students with mobility and sensory disabilities.

PURPOSE: This article is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee and provides educators recommendations for optimizing inclusive education for our students with disabilities. Medical educators are increasingly encountering students with disabilities and have the responsibility of ensuring requirements are met. METHOD: Medical education committee members from the US and Canada reviewed the literature on disabilities in medical student education to identify best practices and key discussion points. An iterative review process was used to determine the contents of an informative paper. RESULTS: Medical schools are required to develop technical standards for admission, retention, and graduation of their students to practice medicine safely and effectively with reasonable accommodation. A review of the literature and obstetrics and gynecology expert opinion formed a practical list of accommodation strategies and administrative steps to assist educators and students. CONCLUSION: Medical schools must support the inclusion of students with disabilities. We recommend a collaborative approach to the interactive process of determining reasonable and effective accommodations that includes the students, a disability resource professional and faculty as needed. Recruiting and supporting medical students with a disability strengthens the diversity commitment and creates a more inclusive workforce.IMPLICATIONS FOR REHABILITATIONMedical School EducationMedical schools have the responsibility to train a diverse physician workforce including those with disabilities.The integration of students with disabilities is important and should be done in a structured and timely manner that maximizes the individual's abilities and incorporates reasonable accommodations in the clinical learning environment.Though the definition of disability traverses a wide variety of diagnoses, this review highlights sensory and physical disabilities and the various accommodations to facilitate access and successful completion of required objectives.

The time is now: addressing implicit bias in obstetrics and gynecology education.

Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.

The Dobbs Decision and Undergraduate Medical Education: The Unintended Consequences and Strategies to Optimize Reproductive Health and a Competent Workforce for the Future.

The June 2022 U.S. Supreme Court decision on Dobbs v Jackson Women's Health Organization resulted in state-specific differences in abortion care access across the country. The primary concern in the obstetrics and gynecology education community has been the impact on resident and fellowship training programs. However, the impact on undergraduate medical education and the broad implications for future generations of physicians are crucial to address. It is estimated that 48% of matriculants to MD-granting medical schools will receive their medical education in the 26 states with significant abortion restrictions or bans. Undergraduate medical educators need to continue to adequately teach the basic science, clinical care, and population health outcomes of reproductive medicine, including pregnancy and abortion. In addition, students in states with more restrictions on abortion will have less or no clinical exposure, and those in states with few restrictions may be excluded due to overcrowding of learners from restricted states. Students' own health care also needs to be considered, as access to abortion care for themselves or their partners may create applicant pool demographic shifts by state as applicants consider options for where to pursue their medical education. It is important to ensure that teaching of foundational science of pregnancy, abortion, and reproductive health continues throughout the United States. Undergraduate and graduate medical educators will need to closely monitor the downstream impact of decreased clinical exposure of abortion. Further study of the personal health impact of abortion care access for medical students and awareness of the changing applicant pool demographics by state is needed.

Educational guidelines for diversity and inclusion: addressing racism and eliminating biases in medical education.

Racism and bias contribute to healthcare disparities at a patient and population health level and also contribute to the stagnation or even regression of progress toward equitable representation in the workforce and in healthcare leadership. Medical education and healthcare systems have expended tremendous efforts over the past several years to address these inequities. However, systemic racism continues to impact health outcomes and the future physician workforce. The Association of Professors of Gynecology and Obstetrics called for action to achieve a future free from racism in obstetrics and gynecology education and healthcare. As a result of this call to action, the Diversity, Equity, and Inclusion Guidelines Task Force was created. The mission of the Task Force was to support educators in their efforts to identify and create educational materials that augment antiracist educational goals and prepare, recruit, and retain a talented and diverse workforce. In this Special Report, the authors share these guidelines that describe best practices and set new standards to increase diversity, foster inclusivity, address systemic racism, and eliminate bias in obstetrics and gynecology educational products, materials, and environments.

Enhancing interprofessional collaboration and interprofessional education in women's health.

This article is from the 'To The Point' series from the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. The purpose of this review is to provide an understanding of the differing yet complementary nature of interprofessional collaboration and interprofessional education as well as their importance to the specialty of Obstetrics and Gynecology. We provide a historical perspective of how interprofessional collaboration and interprofessional education have become key aspects of clinical and educational programs, enhancing both patient care and learner development. Opportunities to incorporate interprofessional education within women's health educational programs across organizations are suggested. This is a resource for medical educators, learners, and practicing clinicians from any field of medicine or any health-care profession.

Evaluation and Management of Infertility for Patients Without Insurance Coverage.

Infertility is a common condition which causes substantial patient distress and prompts patients to seek care in outpatient gynecologic offices. The evaluation and treatment of infertility can be costly and insurance coverage for these services varies widely. Obstetrician-gynecologists and other women's health care professionals often struggle with the approach for patients without insurance coverage for infertility care. This article reviews the status of insurance coverage for infertility services, reviews options for both the evaluation and management of infertility for patients who do not have infertility insurance coverage, and provides resources for ongoing advocacy and support for these patients.

Medical Education and Safety as Co-priorities in the Coronavirus Disease 2019 (COVID-19) Era: We Can Do Both.

As hospitals and medical schools confronted coronavirus disease 2019 (COVID-19), medical students were essentially restricted from all clinical work in an effort to prioritize their safety and the safety of others. One downstream effect of this decision was that students were designated as nonessential, in contrast to other members of health care teams. As we acclimate to our new clinical environment and medical students return to the frontlines of health care, we advocate for medical students to be reconsidered as physicians-in-training who bring valuable skills to patient care and to maintain their status as valued team members despite surges in COVID-19 or future pandemics. In addition to the contributions students provide to medical teams, they also serve to benefit from the formative experiences of caring for patients during a pandemic rather than being relegated to the sidelines. In this commentary, we discuss factors that led to students' being excluded from this pandemic despite being required at the bedside during prior U.S. public health crises this past century, and we review educational principles that support maintaining students in clinical environments during this and future pandemics.

Label-free, High-Resolution Optical Metabolic Imaging of Human Cervical Precancers Reveals Potential for Intraepithelial Neoplasia Diagnosis.

While metabolic changes are considered a cancer hallmark, their assessment has not been incorporated in the detection of early or precancers, when treatment is most effective. Here, we demonstrate that metabolic changes are detected in freshly excised human cervical precancerous tissues using label-free, non-destructive imaging of the entire epithelium. The images rely on two-photon excited fluorescence from two metabolic co-enzymes, NAD(P)H and FAD, and have micron-level resolution, enabling sensitive assessments of the redox ratio and mitochondrial fragmentation, which yield metrics of metabolic function and heterogeneity. Simultaneous characterization of morphological features, such as the depth-dependent variation of the nuclear:cytoplasmic ratio, is demonstrated. Multi-parametric analysis combining several metabolic metrics with morphological ones enhances significantly the diagnostic accuracy of identifying high-grade squamous intraepithelial lesions. Our results motivate the translation of such functional metabolic imaging to in vivo studies, which may enable improved identification of cervical lesions, and other precancers, at the bedside.

Consent for the Pelvic Examination Under Anesthesia by Medical Students: Recommendations by the Association of Professors of Gynecology and Obstetrics.

The pelvic examination is a critical tool for the diagnosis of women's health conditions and remains an important skill necessary for students to master before becoming physicians. Recently, concerns regarding student involvement in pelvic examinations-specifically those performed while a woman is under anesthesia-have been raised in the scientific, professional, and lay literature. These concerns have led to calls to limit or halt the performance of pelvic examinations by students while a woman is under anesthesia. Although ensuring adequate informed consent for teaching pelvic examinations is a priority, we must not lose sight of the critical pedagogical value of teaching pelvic examination in familiarizing students with the female anatomy and instilling a physician workforce with confidence in pelvic examination skills. A compromise that addresses all of these values is possible. In this commentary, we review the educational and legal aspects of the pelvic examination under anesthesia, then provide strategies that individuals and institutions can consider to optimize processes regarding consent for pelvic examination under anesthesia.

Feasibility of a Regional Approach to an Obstetrics and Gynecology Transition to Residency Course.

OBJECTIVE: To demonstrate the feasibility of a regional Obstetrics and Gynecology (Ob/Gyn) Transition to Residency Course (TRC) through compliance, satisfaction, and sustainability. METHODS: We implemented a two-week, multi-institutional regional TRC (RTRC) for fourth-year medical students matched in Ob/Gyn or Family Medicine from four New England medical schools. Curriculum was developed to meet Ob/Gyn Milestone One (M1) and Core Entrustable Professional Activity (CEPA) objectives. Compliance, satisfaction, and sustainability were identified as feasibility outcomes. RESULTS: From 2015-2018, a total of 63 fourth-year students have participated. The number of students remained stable each year. All students attended 100% of sessions. There was an average of >9/10 in all satisfaction metrics all four years. The number of faculty members from each institution remained stable over the four years. CONCLUSION: A RTRC is feasible as measured through compliance, satisfaction and sustainability.

A Call to Action to Address Gender Equity Within Our Specialty: Time's Up on Waiting for Change.

Although national attention has been focused on sexual harassment and gender inequity in the United States, leaders within the obstetrics and gynecology community have remained relatively silent. Sexual harassment and gender inequity remain pervasive in our specialty. This article serves as a call to action for leadership as well as physicians within obstetrics and gynecology to implement ethical and evidence-based approaches to reduce gender inequity and improve workplace culture within our specialty.