Helen Morgan

Urethral Sphincter Morphology and Function With and Without Stress Incontinence

PURPOSE Using magnetic resonance images we analyzed the relationship between urethral sphincter anatomy, urethral function and pelvic floor function. MATERIALS AND METHODS A total of 103 women with stress incontinence and 108 asymptomatic continent controls underwent urethral profilometry, urethral axis measurement with a cotton swab, vaginal closure force measurement with an instrumented speculum and magnetic resonance imaging. Striated urogenital sphincter length was determined and its thickness was measured in the proximal sphincter, where its circular shape enables estimation of striated urogenital sphincter area. A length-area index was calculated as a proxy for volume. RESULTS The striated urogenital sphincter in women with stress incontinence was 12.5% smaller than that in asymptomatic continent women (mean +/- SD length-area index 766.4 +/- 294.3 vs 876.2 +/- 407.3 mm(3), p = 0.04). The groups did not differ significantly in striated urogenital sphincter length (13.2 +/- 3.4 vs 13.7 +/- 3.9 mm, p = 0.40), thickness (2.83 +/- 0.8 vs 3.11 +/- 1.4 mm, p = 0.09) or area (59.1 +/- 18.4 vs 62.9 +/- 24.7 mm(2), p = 0.24). Striated urogenital sphincter length and area, and the length-area index were associated during voluntary pelvic muscle contraction with more urethral axis elevation and increased vaginal closure force augmentation. CONCLUSIONS A smaller striated urogenital sphincter is associated with stress incontinence and poorer pelvic floor muscle function.

The flipped classroom for medical students

The objectives of this curricular innovation project were to implement a flipped classroom curriculum for the gynaecologic oncology topics of the obstetrics and gynaecology medical student clerkship, and to evaluate student satisfaction with the change.

Preparing medical students for obstetrics and gynecology milestone level one: a description of a pilot curriculum

Background The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident. Purpose We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies. Methods The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks. Results Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey. Conclusions This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGMEs Next Accreditation System.Background The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident. Purpose We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies. Methods The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks. Results Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey. Conclusions This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGMEs Next Accreditation System.

Is video review of patient encounters an effective tool for medical student learning? A review of the literature

Purpose To determine if video review of student performance during patient encounters is an effective tool for medical student learning. Methods Multiple bibliographic databases that include medical, general health care, education, psychology, and behavioral science literature were searched for the following terms: medical students, medical education, undergraduate medical education, education, self-assessment, self-evaluation, self-appraisal, feedback, videotape, video recording, televised, and DVD. The authors examined all abstracts resulting from this search and reviewed the full text of the relevant articles as well as additional articles identified in the reference lists of the relevant articles. Studies were classified by year of student (preclinical or clinical) and study design (controlled or non-controlled). Results A total of 67 articles met the final search criteria and were fully reviewed. Most studies were non-controlled and performed in the clinical years. Although the studies were quite variable in quality, design, and outcomes, in general video recording of performance and subsequent review by students with expert feedback had positive outcomes in improving feedback and ultimate performance. Video review with self-assessment alone was not found to be generally effective, but when linked with expert feedback it was superior to traditional feedback alone. Conclusion There are many methods for integrating effective use of video-captured performance into a program of learning. We recommend combining student self-assessment with feedback from faculty or other trained individuals for maximum effectiveness. We also recommend additional research in this area.

Using the ACMGE Milestones as a Handover Tool From Medical School to Surgery Residency

OBJECTIVE To map current medical school assessments for graduating students to the Accreditation Council for Graduate Medical Education (ACGME) milestones in general surgery, and to pass forward individual performance metrics on level 1 milestones to receiving residency programs. DESIGN The study included 20 senior medical students who were accepted into surgery internship positions. Data from medical school performance assessments from the third-year surgery clerkship, fourth-year surgery rotations, fourth-year surgery boot camp, Clinical Competency Assessment Examination, and United States Medical Licensing Examination (USMLE) Step 1 and 2 examinations were used to map each students competency assessments to the General Surgery Milestones based on a scoring system created and validated by independent assessors. This Milestones Assessment was then provided to each students receiving program director. SETTING The study was conducted at the University of Michigan Medical School, in Ann Arbor, Michigan. PARTICIPANTS Fourth-year medical students entering into surgical internship. RESULTS Of 16 Accreditation Council for Graduate Medical Education (ACGME) General Surgery Milestones subcompetencies, 12 were able to be evaluated with current medical school assessments. Of the 20 students, 11 met criteria for all the level 1 milestones and 9 needed improvement in at least 1 domain. CONCLUSIONS It was feasible to use medical school assessments to feed forward information about senior medical students on 12 of the 16 General Surgery Milestones subcompetency domains.

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.

Applied clinical anatomy: the successful integration of anatomy into specialty-specific senior electives

PurposeA strong foundation in anatomical knowledge is essential for physicians in all fields. Despite this established importance, anatomy continues to be primarily taught only during the pre-clinical years of medical school. Senior medical students have more mature clinical reasoning and analytical skills; therefore, advanced anatomy courses have great potential to integrate basic and clinical sciences to better prepare senior medical students for residency.MethodsAt our institution, five electives have been implemented that integrate anatomical education in clinical contexts in the fields of emergency medicine, musculoskeletal medicine, radiology, surgery, and obstetrics and gynecology. These 4-week courses are all offered in the spring of the final year of medical school. The course curricula, content, and evaluation data are described for each of the courses.ResultsThe five electives have been extremely popular at our institution, and all have been consistently filled each year by students entering diverse disciplines. Course evaluations have been positive and students specifically note how these courses allow them the opportunity to integrate basic anatomical knowledge into clinical contexts. Students have marked improvement in anatomical knowledge after completion of these electives.ConclusionsAdvanced anatomy courses that integrate anatomical education with clinical reasoning are important curricular innovations that are popular with students and lead to important improvements in anatomical knowledge. Anatomists can lead the charge for better integration of basic sciences into senior medical school curricula.

The Decision to Incision Curriculum: Teaching Preoperative Skills and Achieving Level 1 Milestones

OBJECTIVE To evaluate the effectiveness of a preoperative skills curriculum, and to assess and document competence in associated Obstetrics and Gynecology Level 1 Milestones. DESIGN The Decision to Incision curriculum was developed by a team of medical educators with the goal of teaching and evaluating 5 skills pertinent to Milestone 1: Preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time-out. Competence, overall skill performance, and knowledge were assessed by evaluator rating using checklists before and after the educational intervention. Differences between preintervention and postintervention skills performance and competence were assessed using Wilcoxon rank test and Fisher exact test, respectively. SETTING Clinical Simulation Center at an academic medical center. PARTICIPANTS Overall, 29 fourth year medical students matriculating into Obstetrics and Gynecology residencies. RESULTS The proportion of participants meeting Milestone competence significantly increased in all 5 skills, with competence achieved in 95.6% (95% CI: 92.1-99.0) of posttest skills assessments. Median overall performance also significantly improved for all 5 skills, with 83.6% (95% CI: 77.3-89.9) earning scores of 4 out of 5 or greater on the posttest. For knowledge testing, the proportion of correct responses significantly increased for both topics evaluated, from 45.2% to 99.7% (p < 0.0001) for positioning and from 32.8% to 83.1% (p < 0.0001) for time-out. CONCLUSIONS The decision to incision curriculum significantly improved preoperative skills, including skills that may be required on day 1 of residency. This curriculum also facilitated achievement and documentation of competence in multiple Milestones.

A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning

Purpose Learning to make decisions under uncertain conditions is a critical component of diagnostic and therapeutic reasoning. This study sought to determine treatment decisions medical students make when presented with different thresholds of diagnostic uncertainty and whether they appropriately adjust diagnostic probabilities with test information. Method Two classes (2015, 2016) of fourth-year students (N = 342) were presented a patient with viral pneumonia and given 10%, 20%, or 50% pretest probabilities of that patient having a superimposed bacterial infection. Students decided to not treat, order a diagnostic test to guide management, or treat without testing based on these probabilities. The 2015 class was provided a posttest probability of 10% or 50% and asked to adjust their initial treatment decision. Results When given a low (10%) pretest probability, students were less likely to decide to treat (6%) and more likely to decide not to treat (36%). The percentage of students deciding to treat increased as the pretest probability of a superimposed infection increased from 10% to 50%, while the percentage of students not wanting to treat decreased. Interestingly, at 10%, 20%, and 50% pretest probability levels, most students were unable to decide and chose to order another test (57%, 67%, and 64%, respectively). When provided low and high posttest probabilities, students appropriately adjusted their decision making, but 29% to 32% still wanted additional testing. Conclusions Students adjusted treatment decisions to reflect different levels of diagnostic uncertainty, but varied considerably in their individual thresholds to make decisions, possibly contributing to unnecessary testing.

Is There a Role for Internal Medicine Residency Preparation Courses in the Fourth Year Curriculum? A Single-Center Experience

The transition from medical school to residency represents a substantial increase in patient care responsibilities for graduating medical students. In order to prepare for this transition, most medical schools require at least one sub-internship during the fourth (M4) year. The benefits of sub-internships have been well described; however, there is growing concern that essential skills required for residency are not reliably addressed in the face of restricted duty hours. For example, decreased overnight experiences may lead to less training in cross-coverage and medical emergencies. In addition, it has been demonstrated that few students receive formal handoff training. Capstone courses, also known as BResidency Preparation Courses^ (RPCs), or BBoot Camps,^ represent an emerging strategy to bridge this gap and are well described in the surgical literature. However, little has been described about the potential value added from internal medicine (IM) RPCs. Our goal is to explore the differences between our IM RPC and sub-internship experiences.