Matthew Brennan

Attrition Rates Between Residents in Obstetrics and Gynecology and Other Clinical Specialties, 2000–2009

BACKGROUND As resident attrition disrupts educational and workload balance and reduces the number of graduating physicians to care for patients, an ongoing goal of graduate medical education programs is to retain residents. OBJECTIVE We compared annual rates of resident attrition in obstetrics and gynecology (Ob-Gyn) with other clinical specialties of similar or larger size during a recent 10-year period, and explored the reasons for resident attrition. METHODS In this observational study, we analyzed annual data from the American Medical Association Graduate Medical Education Census between academic years 2000 and 2009 for residents who entered Ob-Gyn and other core clinical specialties. Our primary outcome was the trend in averaged annual attrition rates. RESULTS The average annual attrition was 196 ± 12 (SD) residents, representing 4.2% ± 0.5% of all Ob-Gyn residents. Rates of attrition were consistently higher among men (5.3%) and international medical school graduates (7.6%). The annual rate of attrition was similar to that for other clinical specialties (mean: 4.0%; range: from 1.5% in emergency medicine to 7.9% in psychiatry). The attrition rates for Ob-Gyn residents were relatively stable for the 10-year period (range: 3.6% in 2008 to 5.1% in 2006). Common reasons for attrition were transition to another specialty (30.0%), withdrawal/dismissal (28.2%), transfer to another Ob-Gyn program (25.4%), and leave of absence (2.2%). These proportions remained fairly constant during this 10-year period. CONCLUSIONS The average annual attrition rate of residents in Ob-Gyn was 4.2%, comparable to most other core clinical specialties.

Improved climate, culture, and communication through multidisciplinary training and instruction

OBJECTIVE The objective of the study was to determine the effectiveness of multidisciplinary team training on organizational culture and team communication. STUDY DESIGN The training included a 6-step protocol: (1) a pretest survey assessing cultural attitudes and perceptions, (2) a baseline high-fidelity simulation session, (3) invitational medical rhetoric instruction, (4) a second high-fidelity simulation session, (5) a posttest survey assessing changed cultural attitudes and perceptions, and (6) a debriefing with participants. Teams of 4 physicians trained together: 2 obstetricians and 2 anesthesiologists. Forty-four physicians completed the training protocol during 2010 and 2011. RESULTS Paired-sample t tests demonstrated significant decreases in autonomous cultural attitudes and perceptions (t = 8.23, P < .001) and significant increases in teamwork cultural attitudes and perceptions (t = -4.05, P < .001). Paired-sample t tests also demonstrated significant increases in communication climate that invited participation and integrated information from both medical services (t = -5.80, P < .001). CONCLUSION The multidisciplinary team training program specified in this report resulted in increased teamwork among obstetricians and anesthesiologists.

Counseling about risks of congenital anomalies from prescription opioids.

The use of prescription opioids is becoming an increasing problem among women of reproductive age. More than half of pregnancies are unintended; therefore, many first-trimester exposures to opioids occur before pregnancy confirmation. Studies are limited about the fetal risks to opioid exposure in early pregnancy. One large study demonstrated an increased risk of certain heart defects and spina bifida with first-trimester exposure to opioids. It is important to counsel women whose fetuses were exposed to opioids in early pregnancy about the potential risks, encourage them to cease using opioids or seek alternative treatments when appropriate, and use the lowest effective dose when opioid treatment is to be continued. It is also valuable to screen for anatomic abnormalities such as neural tube and cardiac defects with available maternal serum testing and ultrasound imaging in the early second trimester. Birth Defects Research (Part A) 94:620-625, 2012.

Retention of dinoprostone vaginal insert beyond 12 hours for induction of labor.

We evaluate the likelihood of cesarean delivery and identify risks of retaining a sustained-release dinoprostone vaginal insert beyond 12 hours. In a secondary analysis of outcomes, data were collected during a large, randomized trial comparing different sustained-release prostaglandin vaginal inserts for labor induction. Outcomes were compared between cases in whom the dinoprostone insert was removed early (within 12 hours) or late (12 to 24 hours). A total of 431 subjects had the dinoprostone vaginal insert in place for 12 to 24 hours ( N = 226, 52.4%) or within 12 hours ( N = 205, 47.6%). Insert removal for labor complications was less frequent in the late group than in the early group (5.8% versus 21.5%; P ≤ 0.001). Abnormal uterine contractility patterns were less common in the late than early group (25.2% versus 37.6%; P = 0.03). Rates of cesarean delivery during the first hospitalization were similar for late and early groups (25.0% versus 29.2%; P = 0.33). Percentages of infants requiring immediate attention or intensive care were low and similar between groups. Sustained-release intravaginal dinoprostone left in place beyond 12 hours did not increase the risks of intrapartum complications, cesarean delivery, or immediate adverse neonatal events.

Physician Communication in the Operating Room

In this study, communication research was conducted with multidisciplinary groups of operating-room physicians. Theoretical frameworks from intercultural communication and rhetoric were used to (a) measure latent cultural communication variables and (b) conduct communication training with the physicians. A six-step protocol guided the research with teams of physicians from different surgical specialties: anesthesiologists, general surgeons, and obstetrician–gynecologists (n = 85). Latent cultural communication variables were measured by surveys administered to physicians before and after completion of the protocol. The centerpiece of the 2-hour research protocol was an instructional session that informed the surgical physicians about rhetorical choices that support participatory communication. Post-training results demonstrated scores increased on communication variables that contribute to collaborative communication and teamwork among the physicians. This study expands health communication research through application of combined intercultural and rhetorical frameworks, and establishes new ways communication theory can contribute to medical education.

Pulmonary Embolism and Amniotic Fluid Embolism in Pregnancy

Amniotic fluid embolism and pulmonary embolism are 2 of the most common causes of maternal mortality in the developed world. Symptoms of pulmonary embolism include tachycardia, tachypnea, and shortness of breath, all of which are common complaints in pregnancy. Heightened awareness leads to rapid diagnosis and institution of therapy. Amniotic fluid embolism is associated with maternal collapse. There are currently no proven therapies, although rapid initiation of supportive care may decrease the risk of mortality.

The multicenter urogynecology study on education: Associations between educational outcomes and clerkship center characteristics

Objective: The objective of the study was to examine the effect of center characteristics on educational experiences and female pelvic medicine knowledge changes in third-year students at 6 medical schools. Methods: In this secondary analysis of data acquired during a prospective, multicenter study conducted from May 2008 through June 2009, preclerkship and postclerkship third-year medical students scored their knowledge of 12 female pelvic medicine topics and 4 office procedures (knowledge scores [KSs]). Postclerkship, students also reported the number and type of learning experiences they had encountered. Participating investigators provided data on length of clerkship, number of residents, number of fellowship-trained urogynecologists, presence of a fellowship program, clerkship grading system type, presence of a urogynecology clerkship rotation, and presence of a urogynecology lecture. Analyses used Wilcoxon tests/Spearman correlation, with an &agr; = 0.05. Results: Paired preclerkship and postclerkship survey data were available for 323 students. Increased numbers of learning experiences were positively associated with number of clerkship weeks (rs = 0.22, P < 0.001), presence of a urogynecology rotation (P = 0.03), and urogynecology lecture (P < 0.001). Knowledge scores were positively associated with the number of fellowship-trained urogynecology faculty (rs = 0.17, P = 0.002) and grading system (letter grades > pass/fail) (P < 0.001). Knowledge scores were negatively associated with increasing numbers of residents (rs = −0.29, P < 0.001) and presence of a urogynecology fellowship program (P < 0.001). The center characteristics of fellowship program and number of residents were highly correlated (rs = 0.74, P < 0.001); thus, multivariate modeling was not performed. Conclusions: The presence of fellowship-trained faculty, urogynecology rotation, longer duration of clerkship, and urogynecology lecture were positively correlated with higher subjective KSs. The inverse association of KS with increased resident number and presence of fellowship was an unexpected finding.