Abigail Ford Winkel

Narrative Medicine Workshops for Obstetrics and Gynecology Residents and Association With Burnout Measures

OBJECTIVE: To determine whether a workshop Narrative Medicine curriculum can improve burnout among obstetrics and gynecology residents. METHODS: A Narrative Medicine curriculum was conducted at three obstetrics and gynecology training programs. An explanatory research design examined correlation between Narrative Medicine attendance and changes in survey responses. Residents completed a pretest and 1-year posttest survey that included validated measures of burnout and empathy. A within-participants design used baseline pretest scores as an internal control and measured changes in individual scores. The primary outcome of the study was change in burnout rates. Mann–Whitney U and Kruskal–Wallis tests were used to analyze the data. RESULTS: A total of 66 residents at three institutions participated in the Narrative Medicine curriculum. Of those, 54 (81%) enrolled in the study by completing any part of the surveys, and 43 (80%) of those enrolled had complete data for analysis. Burnout was high on all Maslach Burnout Inventory subscales and increased over 1 year. Participants with high Narrative Medicine attendance had decreased burnout on the Emotional Exhaustion subscale (−4.1 [±8.1]) points compared with an increase of 0.5 (±6.0) for low-attendance participants (U=134, P=.02, d=0.65). Lower self-care ratings were associated with improved Personal Accomplishment (+0.5 [±5.0]) compared with +2.0 (±2.7), U=84, P=.01]. Other characteristics did not significantly correlate with burnout or empathy. CONCLUSION: Burnout was high and worsened over time among obstetrics and gynecology residents in these three programs. Higher attendance at Narrative Medicine workshops was associated with improved Emotional Exhaustion.

Whose Problem Is It? The Priority of Physician Wellness in Residency Training

OBJECTIVE Physician wellness is associated with improved outcomes for patients and physicians. Wellness is a priority of the Accreditation Council on Graduate Medical Education, and many residencies have programs in place to improve wellness. This study sought to understand how stakeholders in graduate medical education perceive wellness among other educational priorities and whether these programs are improving the experience and training of residents. METHODS The Council on Resident Education in Obstetrics and Gynecology (OBGYN)/Association of Professors in Gynecology Wellness Task Force created a survey and distributed it electronically to all OBGYN residents and program directors (PDs) in 2015. The survey included demographics, questions about the priority of wellness in the educational programs, experience with wellness programming, and problems with resident wellness (burnout, depression, binge drinking, suicide/suicide attempts, drug use, or eating disorders). Data rated on a Likert scale were analyzed using Kruskal-Wallis and Mann-Whitney U tests. RESULTS Among 248 OBGYN PDs, 149 (60%) completed the survey. Of a total 5274 OBGYN residents nationally, 838 (16%) completed the survey. Most of the residents, 737 (89.4%) reported that they or a colleague experienced some problem with wellness. Many PDs also reported problems with wellness, but 46 (33.9%) reported not being aware of problems in the previous 5 years. When asked to rate the priority of wellness in resident education, <1% (1) PD stated that this was not a priority; however, 85 residents (10%) responded that wellness should not be a priority for residency programs. Resident reports of problems were higher as year in training increased (depression χ2 = 23.6, p ≤ 0.001; burnout χ2 = 14.0, p = 0.003; suicide attempt χ2 = 15.5, p = 0.001; drug use χ2 = 9.09, p = 0.028; and binge drinking χ2 = 10.7, p = 0.013). Compared with community programs, university programs reported slightly fewer problems with wellness (χ2 = 5.4, p = 0.02) and suicide/suicide attempts (χ2 = 13.3, p = 0.001). Most PDs reported having some programming in place, although residents reported lower rates of feeling that these programs addressed wellness. CONCLUSIONS There is a discrepancy between the perspective that residents and PDs have on resident wellness, and its priority within the residency program. PDs may not be aware of the scope of the problem of resident wellness. These problems increase with year of training, and may be more common in community programs. Current wellness programming may not be effective, and a significant minority of residents feels that wellness is beyond the scope of the training program.

Thriving in scrubs: a qualitative study of resident resilience

BackgroundPhysician well-being impacts both doctors and patients. In light of high rates of physician burnout, enhancing resilience is a priority. To inform effective interventions, educators need to understand how resilience develops during residency.MethodsA qualitative study using grounded theory examined the lived experience of resilience in residents. A cohort of obstetrics and gynecology residents were selected as a purposive, intensity sample.. Eighteen residents in all years of training participated in semi-structured interviews. A three-phase process of open coding, analytic coding and thematic analysis generated a conceptual model for resilience among residents.ResultsResilience among residents emerged as rooted in the resident’s calling to the work of medicine. Drive to overcome obstacles arose from personal identity and aspiration to professional ideals. Adversity caused residents to examine and cultivate coping mechanisms. Personal connections to peers and mentors as well as to patients and the work helped buffer the stress and conflicts that present. Resilience in this context is a developmental phenomenon that grows through engagement with uncertainty and adversity.ConclusionResilience in residents is rooted in personal and professional identity, and requires engagement with adversity to develop. Connections within the medical community, finding personal fulfillment in the work, and developing self-care practices enhance resilience.

Ovarian vein thrombophlebitis related to large uterine myoma.

BACKGROUND: Ovarian vein thrombophlebitis is commonly considered to be a postpartum or postoperative disease. We describe an unusual case of ovarian vein thrombophlebitis in a nonpuerperal patient without recent surgery that was associated with venous compression by a large uterine myoma. CASE: A 32-year-old nulligravid woman presented with fever, leukocytosis, and severe abdominal pain. Ultrasound demonstrated an enlarged uterus measuring 16.6×7.9×9.6 cm with a dominant left exophytic myoma; computed tomography scan revealed an intraluminal thrombus in the left ovarian vein. The patient recovered with antibiotics and anticoagulation. Abdominal myomectomy was performed to remove the structural contributor for thrombosis formation. CONCLUSION: Ovarian vein thrombophlebitis should be considered in patients with abdominal pain, fever, and evidence of venous stasis, even if they are lacking typical risk factors of pregnancy or surgery.

Interactive case-based learning improves resident knowledge and confidence in reproductive endocrinology and infertility*

Abstract Resident physicians’ scores on the REI section of the CREOG exam are traditionally low, and nearly 40% of house staff nation-wide perceive their REI knowledge to be poor. We aimed to assess whether an interactive case-based group-learning curriculum would narrow the REI knowledge gap by improving understanding and retention of core REI concepts under the time constraints affecting residents. A three-hour case-based workshop was developed to address four primary CREOG objectives. A multiple-choice test was administered immediately before and after the intervention and 7 weeks post-workshop, to evaluate both knowledge and confidence. Following the intervention, residents self-reported increased confidence with counseling and treatment of PCOS, ovulation induction cycle monitoring, counseling and treatment of POI, and breaking bad news related to infertility (p < 0.05). The multiple-choice exam was re-administered 7 weeks post-intervention, and scores remained significantly improved compared to pre-workshop scores (p < 0.05). At that time, all residents either strongly agreed (91.7%) or agreed (8.3%) that the case-based interactive format was preferable to traditional lecture-based teaching. In conclusion, a nontraditional curriculum aimed at teaching core REI concepts to residents through interactive case-based learning can be successfully integrated into a residency curriculum, and significantly improves knowledge and confidence of critical concepts in REI.

Notes from the Field: Residents' Perceptions of Simulation-Based Skills Assessment in Obstetrics and Gynecology.

Simulation in obstetrics and gynecology (OBGYN) training captures a range of interpersonal, cognitive, and technical skills. However, trainee perspectives on simulation-based assessment remain unexplored. After an observed structured clinical examination (OSCE) simulation hybrid exam, two focus groups of residents were conducted. Analysis grounded in a thematic coding guided the qualitative research process. Responses suggest a valuation of cognitive and technical skills over interpersonal skills. Realism was seen as critical and residents perceived the assessment as more valuable for the educator than the learner. Feedback was highly valued. Resident perspectives on this exam give insight into their perceptions of simulation-based assessment as well as their conceptions of their own learning through simulations.

A novel means of assessing evidence-based medicine skills

What problems were addressed? Residents are expected to learn and demonstrate competency in using medical literature to guide their practice. Although medical students are instructed on the principles of constructing appropriate questions and searching through literature to identify solutions, it is difficult to observe and assess these skills in an objective manner, especially among doctors-in-training in whom it is particularly critical to establish good practices. Objective structured clinical examinations (OSCEs) present the appealing potential to assess a range of aptitudes in the setting of a realistic scenario of patient interaction. What was tried? Twenty-four obstetrics and gynaecology residents in postgraduate years (PGY) 1–4 participated in a five-station OSCE that assessed a range of abilities through a set of scenarios involving standardised patient (SP) interactions and focused skills testing. In the medical literature station, the patient presented for counselling after her sister had been diagnosed with a BRCA-1 gene mutation. The residents were given instructions to use the materials available through the online medical library to locate evidence to facilitate educating the patient about her risk for cancer and the effect of riskreducing surgery. The station had three parts: a literature review by the resident (8 minutes); interaction with the SP (8 minutes), and feedback with a faculty member (5 minutes). Using a remote desktop software program, a faculty member, who is also a clinical librarian, observed the resident’s search. Following the interaction with the patient, the faculty member discussed the framing query used by the resident and provided feedback. The faculty member rated the search according to source of information, framing query and strength of data based on a 3point scale (Does not meet expectations, Meets expectations, Exceeds information). The data were analysed using IBM SPSS Version 19 (IBM Corp., Armonk, NY, USA). Interactions at the station were videotaped so that they could be used for further training and research. What lessons were learned? All residents were able to complete the station and received ratings of at least ‘Meets expectations’ on all items. Residents received a rating of ‘Exceeds expectations’ if they used PubMed Clinical Queries, EMBASE or the Cochrane Library of Systematic Reviews and demonstrated a systematic approach to gathering data by using a real clinical question, or located prospective studies or clinical reviews. For all 24 residents, the mean standard deviation (SD) score for ‘Exceeds expectations’ was 37 35%; mean SD scores by PGY group were 44 39% for PGY-1 residents, 47 29% for PGY-2 residents, 41 41% for PGY-3 residents, and 18 31% for PGY-4 residents. Although these results are not statistically significant given the small sample size, it is notable that junior residents performed better than senior residents, and that the range of performance varied greatly among individual residents. This shows us that residents’ use of the medical literature may be assessed using an OSCE format, and that it may be worthwhile to perform an objective assessment of this skill in order to evaluate residents’ ability in this important area. Further evaluation of this method will help to refine the scoring system and establish the validity of the assessment, in addition to determining the areas in which additional evidencebased training is needed.

Physician resilience: a grounded theory study of obstetrics and gynaecology residents

Enhancing physician resilience has the promise of addressing the problem of burnout, which threatens both doctors and patients and increases in residents with each year of training. Programmes aimed at enhancing physician resilience are heterogeneous and use varied targets to measure efficacy, because there is a lack of clarity regarding this concept. A more robust understanding of how resilience is manifested could enhance efforts to create and measure it in physicians in training.

Surgical Catastrophe. Supporting the Gynecologic Surgeon after an Adverse Event

Medical errors and adverse events (AEs) are unavoidable, and the effect of adverse outcomes on providers can be devastating. An intraoperative AE is often directly attributable to surgeon technical error or suboptimal intraoperative judgment. To prevent the potential devastating psychological consequences that cases with adverse outcome pose to surgeons involved, it is essential to provide adequate support to the individuals involved in cases with intraoperative AEs. Common reactions to AEs and individual and organizational strategies to support clinicians through the aftermath are reviewed. The goal of this commentary is to create awareness of the mental health impact and to describe options to help physicians involved in intraoperative AEs to recover from their experience related to bad surgical outcomes.

Assessment of Developmental Progress Using an Objective Structured Clinical Examination-Simulation Hybrid Examination for Obstetrics and Gynecology Residents

OBJECTIVE The Test of Integrated Professional Skills (TIPS) is an objective structured clinical examination-simulation hybrid examination that assesses resident integration of technical, cognitive, and affective skills in Obstetrics and Gynecology (OBGYN) residents. The aim of this study was to analyze performance patterns and reactions of residents to the test to understand how it may fit within a comprehensive assessment program. DESIGN A retrospective, mixed methods review of the design and implementation of the examination, patterns of performance of trainees at different levels of training, focus group data, and description of use of TIPS results for resident remediation and curriculum development. SETTING OBGYN residents at New York University Langone Medical Center, a tertiary-care, urban academic health center. PARTICIPANTS OBGYN residents in all years of training, postgraduate year-1 through postgraduate year, all residents completing the TIPS examination and consenting to participate in focus groups were included. RESULTS In all, 24 residents completed the TIPS examination. Performance on the examination varied widely among individuals at each stage of training, and did not follow developmental trends, except for technical skills. Cronbach α for both standardized patient and faculty ratings ranged from 0.69 to 0.84, suggesting internal consistency. Focus group results indicated that residents respond to the TIPS examination in complex ways, ranging from anxiety about performance to mixed feelings about how to use the data for their learning. CONCLUSION TIPS assesses a range of attributes, and can support both formative and summative evaluation. Lack of clear developmental differences and wide variation in performance by learners at the same level of training support the argument for individualized learning plans and competency-based education.