Lori R. Berkowitz

Plagiarism in Residency Application Essays

BACKGROUND Anecdotal reports suggest that some residency application essays contain plagiarized content. OBJECTIVE To determine the prevalence of plagiarism in a large cohort of residency application essays. DESIGN Retrospective cohort study. SETTING 4975 application essays submitted to residency programs at a single large academic medical center between 1 September 2005 and 22 March 2007. MEASUREMENTS Specialized software was used to compare residency application essays with a database of Internet pages, published works, and previously submitted essays and the percentage of the submission matching another source was calculated. A match of more than 10% to an existing work was defined as evidence of plagiarism. RESULTS Evidence of plagiarism was found in 5.2% (95% CI, 4.6% to 5.9%) of essays. The essays of non-U.S. citizens were more likely to demonstrate evidence of plagiarism. Other characteristics associated with the prevalence of plagiarism included medical school location outside the United States and Canada; previous residency or fellowship; lack of research experience, volunteer experience, or publications; a low United States Medical Licensing Examination Step 1 score; and non-membership in the Alpha Omega Alpha Honor Medical Society. LIMITATIONS The software database is probably incomplete, the 10%-match threshold for defining plagiarism has not been statistically validated, and the study was confined to applicants to 1 institution. Evidence of matching content in an essay cannot be used to infer the applicants intent and is not sensitive to variations in the cultural context of copying in some societies. CONCLUSION Evidence of plagiarism in residency application essays is more common in international applicants but was found in those by applicants to all specialty programs, from all medical school types, and even among applicants with significant academic honors. PRIMARY FUNDING SOURCE No external funding.

Smaller pieces of the hysterectomy pie: current challenges in resident surgical education.

Residents in obstetrics and gynecology are increasingly confronted with a wider range of techniques that must be mastered to perform hysterectomy, including abdominal, vaginal, laparoscopic, and robotic approaches. This is accompanied by a decrease in the number of hysterectomies performed annually. Possible solutions to the dilemma created for surgical teaching includes a comprehensive program evaluating surgical competency by establishing numbers needed to achieve competency for specific major procedures.

Mobilizing Faculty for Simulation

Faculty involvement in simulation training is essential for curriculum development, utilization of their clinical expertise in teaching, and ultimately for validating the importance of the training program. Several barriers to faculty involvement exist, including competing demands on time, the challenges in developing curriculum, and teaching using simulation. Through our experiences in implementing a widely expansive program, we have identified several areas to encourage and engage faculty. Further discussion as a medical education community is needed to support the interaction and involvement of our faculty to support and promote ongoing simulation education.

Credentialing based on surgical volume, physician workforce challenges, and patient access.

Advances within the medical profession have resulted in an increase in available medical therapeutic options and minimally invasive surgical techniques for common gynecologic conditions. In many circumstances, this has led to a reduction in surgical volume for many common conditions in benign gynecology. There is also some evidence that a threshold number of cases may exist, below which surgical competence may be affected. Although the practice of medicine continues to evolve, there is broad recognition of a projected workforce shortage of physicians. If credentialing or privileging bodies establish criteria based solely on the number of procedures performed by an individual physician, patient access may be greatly affected. From a public health perspective, these issues cannot be considered in isolation. Thoughtful analysis of existing data and recognition of patient access issues should be carefully weighed before any dramatic changes in hospital privileging or hiring practices. Consideration for ongoing maintenance of credentialing should be carefully balanced and strategies for ongoing assurance of competency may require creative alternatives to simple numerical documentation. Differential approaches to regions with different densities of physicians may also be necessary.

Gynecologic oncologist as surgical consultant: Intraoperative consultations during general gynecologic surgery as an important focus of gynecologic oncology training

OBJECTIVE The aim of this study is to explore the previously unexamined role of the Gynecologic Oncologist as an intraoperative consultant during general gynecologic surgery. METHODS Demographic and clinical data were collected on 98 major gynecologic surgeries that included both a general Gynecologist and a Gynecologic Oncologist between October 2010 and August 2014. Data were analyzed using XLSTAT-Prov2014.2.02. RESULTS Of 794 major gynecologic surgeries, 98 (12.3%) cases that involved an intraoperative consultation were identified. There were 36 (37%) planned consults and 62 (63%) unplanned consults. Significantly more planned consults were during laparoscopy (100% v 58%; p<0.01) and significantly more unplanned consults were during laparotomy (42% v 0%; p<0.01). The majority of planned consults were for surgical training (86%) and the most common reasons for unplanned consults were adhesions (40%), bowel injury (19%), inability to identify ureter (19%), and cancer (11%). The most common interventions performed during unplanned consults were identification of anatomy (55%), lysis of adhesions (42%), and retroperitoneal dissection (27%). Average surgeon years in practice were significantly lower for unplanned consults (9 v 15; p<0.01). A total of 25 major adverse events occurred in 15 cases with the majority occurring in cases with unplanned consults (23% v 3%; p<0.01). After controlling for laparotomy, unplanned consultation was not significantly associated with major events (OR=6.67, 95%CI 0.69-64.39; p=0.10). CONCLUSIONS Gynecologic Oncologists play a pivotal role in the support of generalist colleagues during pelvic surgery. In this series, Gynecologic Oncologists were consulted frequently for complex major benign surgeries. It is important to incorporate the skills required of an intraoperative consultant into Gynecologic Oncology fellowship training.

New Challenges for a Core Procedure: Development of a Faculty Workshop for Skills Maintenance for Abdominal Hysterectomy

OBJECTIVE To describe the development of a low-cost educational module for OB/GYN faculty skills maintenance for total abdominal hysterectomy (TAH), a low frequency core procedure in obstetrics and gynecology. DESIGN After review of existing educational tools and utilization of a modified Delphi method to establish consensus regarding key procedural components for skills maintenance, a 2-hour workshop was developed to review knowledge and participate in a simulation focused on the critical steps in performing TAH. An expert in TAH delivered a lecture highlighting important surgical considerations. Participants then rotated through simulation stations for critical steps in TAH: dissecting the bladder, identifying the ureter, and closing the cuff. Knowledge gains were assessed with a written pre- and posttest. Consecutive focus groups were conducted with participants on effectiveness of the workshop, and suggestions for improvement. Ideas identified in the first focus group were incorporated into the second workshop. SETTING Massachusetts General Hospital, an academic tertiary care facility with a single Obstetrics and Gynecology faculty group, located in Boston, Massachusetts. PARTICIPANTS Eligible participants were recruited via email from full time specialists in General Obstetrics and Gynecology at Massachusetts General Hospital. Of the 25 eligible gynecology faculty subjects, 22 participated (88%). RESULTS On pre or post-test comparison, 70% of participants scored higher on the posttest, demonstrating an increase in knowledge of critical TAH surgical steps. Focus group analyses identified the need for increased review and training demonstrations of TAH, and recommended continued offering of the workshop. CONCLUSIONS Based on focus group responses and pre or posttest comparisons, the workshop was deemed feasible and enhanced short-term learning. Future directions include utilizing more challenging anatomic models and simulation scenarios and optimizing integration of expert demonstration and individualized coaching, as well as identifying regionally tailored surgical workshop programming.

Pregnancy and Parental Leave among Obstetrics and Gynecology Residents: Results of a Nationwide Survey of Program Directors

BACKGROUND: The health and economic benefits of paid parental leave have been well‐documented. In 2016, the American College of Obstetricians and Gynecologists released a policy statement about recommended parental leave for trainees; however, data on adoption of said guidelines are nonexistent, and published data on parental leave policies in obstetrics‐gynecology are outdated. The objective of our study was to understand existing parental leave policies in obstetrics‐gynecology training programs and to evaluate program director opinions on these policies and on parenting in residency. OBJECTIVE: A Web‐based survey regarding parental leave policies and coverage practices was sent to all program directors of accredited US obstetrics‐gynecology residency programs. STUDY DESIGN: Cross‐sectional Web‐based survey. RESULTS: Sixty‐five percent (163/250) of program directors completed the survey. Most program directors (71%) were either not aware of or not familiar with the recommendations of the American College of Obstetricians and Gynecologists 2016 policy statement on parental leave. Nearly all responding programs (98%) had arranged parental leave for ≥1 residents in the past 5 years. Formal leave policies for childbearing and nonchildbearing parents exist at 83% and 55% of programs, respectively. Program directors reported that, on average, programs offer shorter parental leaves than program directors think trainees should receive. Coverage for residents on leave is most often provided by co‐residents (98.7%), usually without compensation or schedule rearrangement to reduce work hours at another time (45.4%). Most program directors (82.8%) believed that becoming a parent negatively affected resident performance, and approximately one‐half of the program directors believed that having a child in residency decreased well‐being (50.9%), although 19.0% believed that it increased resident well‐being. Qualitative responses were mixed and highlighted the complex challenges and competing priorities related to parental leave. CONCLUSION: Most residency programs are not aligned with the American College of Obstetricians and Gynecologists recommendations on paid parental leave in residency. Complex issues regarding conflicting policies, burden to covering co‐residents, and impaired training were raised.

Vacuum-Assisted Closure for Episiotomy Dehiscence.

BACKGROUND: Episiotomy dehiscence can result in a large vulvovaginal defect not amenable to delayed primary closure. CASE: A 26-year-old woman who underwent a forceps-assisted vaginal delivery with mediolateral episiotomy presented on postpartum day 5 with complete wound breakdown. Surgical exploration of the wound revealed a defect extending from the perineum into the vagina and deep into the ischiorectal fossa with poor tissue quality not amenable to a timely delayed primary closure. A vacuum-assisted closure device was used in lieu of traditional wound preparation and resulted in wound closure after 11 days of vacuum-assisted wound therapy. CONCLUSION: A vacuum-assisted closure device may be appropriate in cases of complex episiotomy breakdown and may expedite wound healing in the outpatient setting.

Levatorplasty for Symptomatic Posterior Prolapse due to Recurrent Malignant Ascites.

Background Although infrequently described, massive ascites due to malignancy contributes to symptomatic pelvic organ prolapse. Case A 73-year-old woman with recurrent ovarian cancer and massive ascites underwent a levatorplasty for repair of posterior prolapse after failing conservative management. Conclusions Management of patient with cancer with prolapse is complex. Patients with cancer with ascites also have pelvic organ prolapse, in addition to other, better described sequelae of increased intra-abdominal pressure. These patients should be treated specifically for prolapse, with therapy, including type of surgery, chosen with special consideration of their underlying disease.

Confidence in repair of obstetric anal sphincter injuries and objective assessment in obstetricians

Objective: To describe attending obstetricians’ self-reported confidence to recognize and repair Obstetric Anal Sphincter Injuries (OASIS), assess knowledge of anatomy and risk factors for OASIS and evaluate the need for a protocol. Study design: A questionnaire was distributed to attending obstetricians at seven major medical centers. The survey was divided into categories including demographics, self-reported confidence at recognition of OASIS, self–reported competence at OASIS repair, questions on anatomy and risk factors for OASIS and need for a protocol for OASIS repair. Results: We collected 82 questionnaires for a response rate of 40.2 percent. Twenty-two (26.8%) and 59 (72%) survey respondents were respectively mostly confident or very confident and only one (1.2%) was somewhat confident at OASIS recognition. Thirty-two (39%) participants felt mostly competent, and 47 (57.3%) felt very competent at OASIS repairs. Percentage of correct answers to the objective questions on anatomy and risk factors ranged from 45.1 to 58.5. Overall performance in objective questions did not differ by self-reported competence in repair of higher order lacerations (p=0.09). Conclusions: Our study shows that self-reported confidence in detecting OASIS and competence in repair of OASIS does not correlate with knowledge of anatomy and risk factors of OASIS.