Exploring Faculty Perceptions of Competency-Based Medical Education and Assessing Needs for Implementation in Obstetrics and Gynaecology Residency.

OBJECTIVE: The shift to competency-based medical education (CBME) is associated with changes in the way residents are taught and assessed. Although there are many purported benefits of CBME, an understanding of the preparedness of faculty to meet the needs of this new paradigm is lacking. The aim of this study was to characterize faculty needs to support the transition to CBME. METHODS: An online survey was designed with the aim of characterizing faculty understanding of the principles of CBME and common trainee assessment methods, as well as exploring barriers to the implementation of CBME in obstetrics and gynaecology residency programs across Canada. The survey was sent to faculty across Canada in English and French. RESULTS: A total of 284 responses were collected between September 2015 and December 2016. Although most faculty viewed CBME as a positive change, there were gaps in their knowledge about CBME and workplace-based assessment methods. Barriers to the implementation of CBME included lack of training in assessment of residents and feedback, financial implications, and time constraints. CONCLUSION: To facilitate the transition to CBME, institutions may need to consider establishing faculty training programs and implementing systemic change aimed at addressing faculty needs and barriers during this fundamental shift in the structure of residency training.

A Novel Approach to Simulation-Based Perineal Repair in Undergraduate Medical Education.

INTRODUCTION: There is no formalized hands-on teaching of suturing skills for clerkship students during their dedicated obstetrics and gynaecology (OB/GYN) teaching sessions at the University of Toronto. Nevertheless, the students are exposed to suturing during gynaecologic surgery, Caesarean sections, and perineal repairs. As a result, a formal pilot workshop on knot-tying and perineal laceration repair was developed for incorporation into the third-year clerkship curriculum with the goals of increasing students' knowledge and technical skills. METHODS: Participants consisted of students enrolled in their OB/GYN clerkship rotation at St. Michael's Hospital at the University of Toronto from December 2016 to August 2017. Prior to the workshop, students' (n = 82) baseline knowledge of perineal lacerations was assessed with a pre-test quiz and their knot-tying speeds (two hand-ties and two instrument ties) were recorded. Students were then taught perineal anatomy, laceration types and repair techniques, suturing, and knot-tying. Under direct supervision, students practiced the technical skills for 45 minutes. Knowledge and knot-tying speeds were then reassessed following the educational session. RESULTS: There was a statistically significant improvement in both knowledge (51% to 71%; P < 0.05) and technical skills (258.8 seconds to 197.4 seconds; P < 0.05) after the workshop. Importantly, 94% of students "agreed" or "strongly agreed" that this method of learning was more enjoyable than traditional methods. CONCLUSIONS: This pilot project demonstrates that a formal hands-on workshop improves medical knowledge, technical skills, and student satisfaction. This has the potential for students to have increased opportunities at the bedside, with higher patient acceptance and safety.

Competency-based medical education: the wave of the future.

Competency-based medical education (CBME) is a new educational paradigm that will enable the medical education community to meet societal, patient, and learner needs of the 21st century. CBME offers a renewed commitment to both clinical and educational outcomes, a new focus on assessment and developmental milestones, a mechanism to promote a true continuum of medical education, and a method to promote learner-centred curricula in the context of accountability. Accountability is central to CBME, ensuring that graduating practitioners are well-rounded and competent to provide safe and effective patient care. The structure of CBME in obstetrics and gynaecology must be rooted in, and reflect, Canadian practice. Its development and implementation require an understanding of the principles that are the foundation of CBME, along with the involvement of the entire community of obstetricians and gynaecologists and other maternity care providers. We provide here an overview of the basic principles of teaching and learning and the theories underpinning CBME.

La formation médicale axée sur les compétences (FMAC) est un nouveau paradigme pédagogique qui permettra à la communauté de la formation médicale de répondre aux besoins de la société, des patients et des apprenants du 21e siècle. La FMAC offre un engagement renouvelé envers les issues tant cliniques que pédagogiques, un nouvel accent sur l'évaluation et les jalons du développement, un mécanisme visant à promouvoir un réel continuum de formation médicale, ainsi qu'une méthode permettant de promouvoir un curriculum axé sur l'apprenant dans le contexte de la responsabilité. La responsabilité est au cœur de la FMAC, ce qui permet d'assurer l'obtention de diplômés épanouis et compétents qui seront en mesure d'offrir des soins sûrs et efficaces aux patients. Dans le domaine de l'obstétrique-gynécologie, la structure de la FMAC doit être fondée sur la pratique canadienne et la refléter. Son élaboration et sa mise en œuvre nécessitent une compréhension des principes qui étayent la FMAC, en plus de solliciter la participation de l'ensemble de la communauté des obstétriciens-gynécologues et celle d'autres fournisseurs de soins de maternité. Nous offrons ici un aperçu des principes de base de l'enseignement et de l'apprentissage, et des théories qui sous-tendent la FMAC.

Competency-Based Medical Education: Developing a Framework for Obstetrics and Gynaecology.

The development of a Canadian competency-based medical education (CBME) curriculum in obstetrics and gynaecology, slated to begin in 2017, must be rooted in, and aligned with, the principles of CanMEDS 2015 and Competence by Design. It must also reflect the unique realities of the practice of the specialty. The Dutch Society of Obstetrics and Gynaecology has been at the forefront of the movement to design and implement competency-based training for obstetrics and gynaecology. The Dutch curriculum represents a practical example of how such a program could be developed. Several CBME curricular initiatives have now also begun across Canada.

La mise sur pied d'un curriculum canadien de formation médicale fondée sur les compétences (FMFC) en obstétrique-gynécologie (devant débuter en 2017) doit être ancrée dans les principes des programmes « CanMEDS 2015 ¼ et « La compétence par conception ¼. Ce curriculum doit également refléter les réalités particulières de la pratique de la spécialité. La Dutch Society of Obstetrics and Gynaecology est à l'avant-garde du mouvement visant la conception et la mise en œuvre de la formation fondée sur les compétences en obstétrique-gynécologie. Le curriculum hollandais représente un exemple pratique de la façon dont un tel programme pourrait être élaboré. Plusieurs initiatives de FMFC ont maintenant vu le jour au Canada.

An examination of the historical context of interprofessional collaboration in Dutch obstetrical care.

Collaboration between different groups of health care professionals is often rooted in a long and often difficult history. This history can exert a strong influence on how professionals collaborate and historical tensions can contribute to problems in contemporary practice. However, literature about interprofessional collaboration often ignores the historical underpinnings of collaboration. In this paper, the historical development of interprofessional collaboration between obstetricians and midwives within the setting of Dutch obstetrical care is explored using a review of Dutch and English literature for documents explicitly or implicitly describing the historical development of this collaboration. This literature delineates the establishment of professional boundaries and the formalization of the collaboration between the two professions. It also details the history of physician domination over the midwives both in midwifery practice and education and the relatively recent reversal of this situation. Moreover, the shift in collaborative partner from general practitioner to obstetrician and its effect on collaboration is examined. Insight into the historical foundations of Dutch maternity care collaboration may allow us to understand the origins, and thus formulate possible solutions, for contemporary problems within this collaboration.

Can paediatric and adolescent gynecological care be delivered via Telehealth?

OBJECTIVE: Paediatric and adolescent gynecology (PAG) is an evolving subspecialty, with patients often having to travel large distances to access care. The goal of the present study was to assess whether Telehealth (TH) would be appropriate for PAG services in a tertiary care centre and to determine patient/family interest. METHODS: The present study was a prospective observational study of patients who attended PAG clinics over the course of one year. Patient data collected on each visit included postal code, diagnosis, availability of a local hospital with TH, patient appropriateness for TH and patient/family reasons for accepting TH. Visits were stratified by diagnosis to determine if certain conditions were more amenable to TH. RESULTS: From the total visits through the year (July 15, 2008 to July 15, 2009), 1541 (79.6%) patients were approached for participation; 8 (0.5%) declined. The final sample size was 1533 patient visits. Four hundred sixty-nine visits (30.6%) were potentially appropriate for TH based on geography. According to clinic physicians, only 51 of these 469 visits (10.9%) were appropriate for TH. The main reasons for being inappropriate were the need for physical examination (n=238, 57.0%), imaging (n=57, 13.6%), or issues regarding sexuality/privacy (n=45, 10.8%). Of the 51 appropriate visits, 28 patients/families (55.0%) expressed interest in TH. Of those not interested in TH, the main reasons included the desire for a face-to-face encounter and the need to coordinate with other health care appointments. CONCLUSION: Of the patient visits considered for TH (based on the fact that patients lived a considerable distance from the hospital), 10.9% were deemed appropriate for TH by the PAG team, but 45.0% of families/patients in this group said they would prefer a traditional clinic visit. Currently, TH appears to be appropriate for only a small subset of patients/families.

OBJECTIF : La gynécologie pour les enfants et les adolescentes (GEA) est une surspécialité en évolution, et les patientes doivent souvent parcourir de longues distances pour accéder aux soins. La présente étude visait à évaluer si la télésanté (TS) peut convenir pour prodiguer des services de GEA dans un centre de soins tertiaires et pour déterminer l'intérêt des patientes et de la famille. MÉTHODOLOGIE : La présente étude d'observation prospective portait sur des patientes qui avaient fréquenté des cliniques de GEA pendant un an. Les données sur les patientes colligées à chaque visite incluaient le code postal, le diagnostic, l'accès à un hôpital local doté de la TS, l'applicabilité des patientes à la TS et les raisons pour que la patiente et sa famille acceptent la TS. Les visites étaient stratifiées selon le diagnostic afin de déterminer si certaines maladies étaient plus acceptables pour la télésanté. RÉSULTATS : D'après le nombre total de visites tout au long de l'année (du 15 juillet 2008 au 15 juillet 2009), les chercheurs ont demandé à 1 541 patientes (79,6 %) de participer, mais huit (0,5 %) ont refusé. La dimension définitive de l'échantillon était de 1 533 visites-patients. Quatre cent soixante-neuf visites (30,6 %) avaient le potentiel de convenir à la TS d'après le facteur géographique. Selon les médecins de la clinique, seulement 51 de ces 469 visites (10,9 %) convenaient à la TS. Les principales raisons des rejets étaient la nécessité de procéder à un examen physique (n=238, 57,0 %) ou à une imagerie (n=57, 13,6 %) ou les questions relatives à la sexualité ou au respect de la vie privée (n=45, 10,8 %). Des 51 visites pertinentes, 28 patientes ou familles (55,0 %) ont exprimé leur intérêt envers la TS. Parmi les personnes qui n'y étaient pas intéressées, les principales raisons invoquées étaient le souhait d'une rencontre en personne et la nécessité de coordonner avec d'autres rendez-vous de santé. CONCLUSION : Parmi les visites de patientes envisagées pour la TS (parce que les patientes vivaient très loin de l'hôpital), 11 % étaient réputées convenir selon l'équipe de GEA, mais 45,0 % des familles et des patientes de ce groupe affirmaient préférer une visite classique en clinique. Pour l'instant, la TS semble convenir seulement à un petit sous-groupe de patientes et de familles.

Repeat screening for sexually transmitted infection in adolescent obstetric patients.

OBJECTIVE: To determine if repeat screening for sexually transmitted infection is appropriate for adolescent obstetric patients and to identify any risk factors associated with increased risk of contracting a sexually transmitted infection (STI) during pregnancy. METHODS: We conducted a retrospective review of the medical records of adolescent obstetric patients seen over a five-year period in the Young Prenatal Program at the Hospital for Sick Children (Toronto, Ontario). RESULTS: Between January 2003 and December 2007, 201 patients with 211 pregnancies attended the Young Prenatal Program. Of the 211 pregnancies reviewed, all patients had screening at baseline for HIV, syphilis, hepatitis B, chlamydia, gonorrhea, and trichomonas; 173 patients were screened in the third trimester, two were tested at another point in the pregnancy because of symptoms, and 161 were screened at their postpartum visit. In 53 pregnancies, STI was diagnosed either during pregnancy or postpartum. Fourteen patients had multiple sexually transmitted infections for a total of 71 infections. Thirty-four infections were diagnosed at baseline, 15 in the third trimester, two because of symptoms, and seven were diagnosed postpartum. In patients who did not develop an STI during pregnancy, the previous use of contraception (excluding condoms), being in a relationship with the baby's father, and living with their partner were identified as significant protective factors against STI. There was a trend towards significance for contracting an STI in patients with a history of abuse, in those with a higher than average number of sexual partners, and in those with a younger than average age of coitarche. CONCLUSION: Sexually transmitted infections were diagnosed in 25.1% of adolescent pregnancies (53/211) in our cohort. Of the 71 sexually transmitted infections diagnosed, 22.5% (16/71) were diagnosed on routine third trimester screening. Because of the high rates of STI and the small number of identified risk factors, routine repeat screening in the third trimester for chlamydia, gonorrhea, and trichomonas is warranted in pregnant adolescents.

Retrospective review of unintentional female genital trauma at a pediatric referral center.

UNLABELLED: Unintentional female genital trauma is a complaint commonly seen and managed through the emergency department. The purpose of this study was to review all unintentional female genital trauma evaluated at The Hospital for Sick Children for 3.5 years to determine the factors associated with gynecologic consultation and need for operative repair. METHODS: One hundred five patients were identified by health record coding. Data were extracted to study factors associated with gynecologic consultation and operative repair. Statistical analyses were performed to evaluate the significance of these associations. Surgical choices were also evaluated. RESULTS: Mean age was 5.60 years. Mean time to presentation was 7.05 hours. Straddle injury was the most common mechanism (81.90%), and only 4.76% injuries were penetrating. Of the 105 patients, 48.57% consulted the gynecology section, 19.05% were taken to the operating room, and 6.66% were treated under conscious sedation. Overall, 20.95% required surgical repair. The most common complication was dysuria. Six patients had other injuries, the most common of which were pelvic fractures related to trauma.Factors significantly associated with gynecologic consultation and operative management included older age, transfer to our institution, shorter time to presentation, laceration-type injury, hymenal injury, and larger size of injury. Straddle injuries were significantly less likely to be taken to the operating room. When cases were stratified by a surgeon, there were no significant differences in management. CONCLUSIONS: Unintentional female pediatric genital traumas most commonly result from straddle injuries. Most injuries are minor, and in this cohort, only 48.57% received gynecologic consultation and 19.05% required operative management. Future prospective studies would be useful to better evaluate the efficacy of surgical choices.

Obstetrics and gynaecology training in Europe needs a next step.

Changing societal demands on doctors necessitate changes in the training of gynaecologists. Adapting this training will need well-thought-out and comprehensive planning that addresses the needs of the major stakeholders: society, patients, and doctors themselves. Doctors need to be cognizant of societal issues such as rapidly rising healthcare costs and budgetary crises, and be able to participate in the solutions. This demands effective medical leadership, which has been a neglected area in postgraduate training. It has become increasingly evident that a holistic view of the patient rooted in proper teamwork and systems-based practice is essential to provide patient-centered care. Specialists need to expand their skill set to participate in this kind of care. Furthermore, the feminisation of the medical profession and a new generation of doctors rejecting the constraints of the traditional model of medical care introduce new professional perspectives. This manuscript briefly reviews the challenges faced in the training of European gynaecologists in an effort to provoke discussion about how to best train the gynaecologists of the future.

Trends in menstrual concerns and suppression in adolescents with developmental disabilities.

PURPOSE: Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital. METHODS: Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003). RESULTS: Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%). CONCLUSIONS: Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.

Pediatric synchronous bilateral ovarian torsion: a case report and review of the literature.

Ovarian torsion is a surgical emergency that can present with a variety of symptoms and hence is difficult to diagnose. We present the first case of a pediatric synchronous bilateral ovarian torsion in ovaries without pathology and review its presentation, diagnosis, treatment, outcome, and the associated literature.

Hysteroscopic unification of a complete obstructing uterine septum: case report and review of the literature.

OBJECTIVE: To report a case of complete obstructing uterine septum repaired in a minimally invasive manner by operative hysteroscopy under laparoscopic guidance. A complete obstructing uterine septum is a rare congenital abnormality. To date, management of such abnormalities has traditionally been by metroplasty. DESIGN: Case report and review of the literature. SETTING: Pediatric and adolescent gynecology service at a tertiary care hospital. PATIENT(S): A 16-year-old nulligravid presented with severe, persistent dysmenorrhea and a history of significant endometriosis. Imaging initially suggested a functional, noncommunicating uterine horn, but magnetic resonance imaging review confirmed a complete obstructing septate uterus. INTERVENTION(S): The patient was managed by menstrual suppression until the time of surgery. The septum was resected by operative hysteroscopy under laparoscopic guidance. The procedure was without complication. MAIN OUTCOME MEASURE(S): The patient recovered well and resumed spontaneous menses without dysmenorrhea. RESULT(S): A second-look hysteroscopy 4 months later confirmed patency of the previously obstructed side and allowed the opportunity to complete the resection of the septum. CONCLUSION(S): Operative hysteroscopy is an effective and safe minimally invasive technique to manage the rare complete obstructing uterine septum. Hysteroscopy is less invasive than traditional metroplasty and is associated with easier recovery. Additionally, there is no uterine scar and thus less implication for future fertility. Further series of such procedures are required to offer greater experience and proof of safety of this approach.

Videoconferencing for resident teaching of subspecialty topics: the pediatric and adolescent gynecology experience at the Hospital for Sick Children.

STUDY OBJECTIVE: Videoconferencing enables distance learning and subspecialty teaching. The objective of this study is to describe and evaluate a 3-hour teaching session on Pediatric and Adolescent Gynecology held by videoconferencing from the Hospital for Sick Children and broadcast to 8 other Canadian universities. DESIGN: Evaluation forms were completed by attendees on the clinical applicability, content quality, delivery quality, meeting of objectives and overall assessment of each session. Further evaluations asked whether presentations were received clearly, material could be followed, method of videoconferencing seemed too impersonal, and whether there were any technical problems. Presenters were asked for a qualitative assessment of their experience. SETTING: The teaching session was broadcast from Toronto. Local residents attended and 8 other centers were connected by videoconferencing. PARTICIPANTS: Participants were residents at the 9 involved Canadian centers. INTERVENTION: PowerPoint presentations were shown at each location with rotating views of the 4 presenters. Monitors enabled each location to view fellow participants. After participating in a videoconferenced teaching session, participants were asked to fill out evaluations. Presenters were asked for a qualitative assessment of their experience providing the session. MAIN OUTCOME MEASURE: Successful use of videoconferencing as a means of subspecialty resident education. RESULTS AND CONCLUSIONS: There were at most 61 responses to evaluation questions. Presentations were well received; 98.6% of responses were "excellent," "very good," or "good." Comments indicated significant variability in video quality received at different centers. Presenters felt the experience was positive but that there was a lack of connection with the distant audience. Videoconferencing offers opportunities for expanding medical subspecialty education to geographical areas without subspecialty representation. Overall, this experience was positive but recommendations to ensure equal levels of technology at all centers and to enhance the interactive nature of the presentation would be made for future experiences.