Scott Graziano

Peripartum urinary incontinence in a racially diverse obstetrical population

To determine the rates of urinary incontinence in a racially diverse, tertiary care obstetrical population during the third trimester and postpartum using a validated symptom-screening questionnaire. Third trimester prenatal patients receiving obstetric care at Loyola University Medical Center between March and November 2003 participated in this prospective study approved by the Institutional Review Board. Third-trimester participants completed the 15-item, validated Medical, Epidemiological, and Social Aspects of Aging (MESA) questionnaire and the Hunskaar Severity Index. The MESA was readministered to participants during a 6- to 8-week postpartum visit. One hundred and thirteen women completed antenatal and postpartum MESAs. Seventy-four percent (83 of 113) of the patients in the third trimester were categorized as incontinent. The postpartum incontinence rates decreased to 44% (50 of 113). Twenty-one percent (24 of 113) of the participants after delivery reported pure stress incontinence, 3% (3 of 113) urge incontinence, and 20% (23 of 113) mixed incontinence. Only 4% (5 of 113) of the women developed de novo incontinence postpartum: three reported symptoms of pure stress incontinence and two reported symptoms consistent with urge incontinence. The MESA questionnaire identifies more women with antenatal and postpartum urinary incontinence than currently described in the literature.

Randomized surgical training for medical students: resident versus peer-led teaching

OBJECTIVE Medical students spend significant portions of their time in the operating room, with many learning skills through trial and error. Peer-assisted learning is a useful teaching and learning method. Our hypothesis is that students will perform basic skills in the operating room environment more often when taught by their peers. STUDY DESIGN Sixty third-year medical students participated in an operating room introduction course. Learners were randomized into 2 cohorts: 1 led by obstetrics and gynecology residents, 1 led by fourth-year medical students. Assessment was performed using an objective, structured clinical exercise. RESULTS Peer-assisted learners performed more steps correctly during the objective exercise compared with resident-assisted learners (16.1 vs 14.4 of 22 total steps assessed, P < .01). CONCLUSION Peer-assisted learning may be a useful teaching method for simulation training. Third-year medical students may benefit from this low threat and informal environment.

Incidence and predictors of anal incontinence after obstetric anal sphincter injury in primiparous women

Objective This study aimed to describe the incidence of fecal incontinence (FI) at 6, 12, and 24 weeks postpartum; anal incontinence (AI) and fecal urgency at 24 weeks; and identify predictors of AI in women with obstetric anal sphincter injury (OASI). Methods Primiparous women sustaining OASIs were identified at 8 clinical sites. Third-degree OASIs were characterized using World Health Organization criteria, 3a (<50%) or 3b (>50%) tear through the sphincter. Fecal incontinence was defined as leakage of liquid/solid stool and/or mucus in the past month; AI was defined as leakage of liquid/solid stool and/or mucus and/or gas in the past month and was assessed at 6, 12, and 24 weeks postpartum using the Fecal Incontinence Severity Index. Logistic regression identified variables associated with AI. Results Three hundred forty-three women participated: 297 subjects sustained a third-degree OASI, 168 type 3a, 98 type 3b and 31 indeterminant; 45 had a fourth-degree OASI. Overall FI incidence at 6, 12, and 24 weeks was 7% [23/326; 95% confidence interval (CI), 4%–10%], 4% (6/145; 95% CI, 2%–9%), and 9% (13/138; 95% CI, 5%–16%), respectively. At 24 weeks, AI incidence was 24% (95% CI, 17%–32%) and fecal urgency 21% (95% CI, 15%–29%). No significant differences in FI and AI rates were noted by third-degree type or between groups with third and fourth OASI. Flatal incontinence was greater in women sustaining a fourth-degree tear (35% vs 16%, P = 0.04). White race (adjusted odds ratio, 4.64; 95% CI, 1.35–16.02) and shorter duration of second stage (adjusted odds ratio, 1.47 per 30 minute decrease; 95% CI, 1.12–1.92) were associated with AI at 24 weeks. Conclusions Overall 24-week incidence of FI is 9% (95% CI, 5%–16%) and AI is 24% (95% CI, 17%–32%). In women with OASI, white race and shorter second-stage labor were associated with postpartum AI. Clinical Trial Registration: NCT01166399 (http://clinicaltrials.gov)

Life-threatening reaction to indigo carmine--a sulfa allergy?

Indigo carmine is commonly used during cystoscopy when evaluating for lower urinary tract safety after gynecologic surgery. We report a case of severe hypotension and bradycardia following intravenous indigo carmine injection in a patient with known sulfa allergy.

To the point: medical education, technology, and the millennial learner

&NA; This article, from the “To The Point” series that was prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides an overview of the characteristics of millennials and describes how medical educators can customize and reframe their curricula and teaching methods to maximize millennial learning. A literature search was performed to identify articles on generational learning. We summarize the importance of understanding the attitudes, ideas, and priorities of millennials to tailor educational methods to stimulate and enhance learning. Where relevant, a special focus on the obstetrics and gynecology curriculum is highlighted.

Functional bowel disorders in pregnancy: effect on quality of life, evaluation and management

To characterize functional bowel disorders in a population of pregnant women, evaluating effects on quality of life, management and follow up.

Perceptions of posthysterectomy cystoscopy training in obstetrics and gynecology residency programs.

Objective The objective of this study was to characterize the training practices of obstetrics and gynecology (OG) residency programs regarding posthysterectomy cystoscopy. Methods Two separate electronic surveys were sent to program directors and residents at American Council of Graduate Medical Education–accredited OG programs. Measures included the type of cystoscopy training available, estimates on indications and how often posthysterectomy cystoscopy is performed, and exposure to female pelvic medicine and reconstructive surgery (FPMRS). Results Sixty-one (26%) of 235 program directors and 394 (29.7%) of 1325 residents completed the survey. The majority of residents (95%) who received training reported having experience with cystoscopy in the operating room. Residents with FPMRS fellowships were more likely to perform routine cystoscopy after hysterectomy during their training compared with residents without fellowships (39% vs 27%, P = 0.01). Residents graduating from programs with FMPRS fellowships reported they planned to always perform routine cystoscopy more often than did those without a fellowship program (30.3% vs 17%, P = 0.01). Program directors most frequently defined competency as direct observation of the procedure (95%), followed by the number performed (53%) and a competency checklist (45%). No significant differences were noted in the reported use of routine cystoscopy by program directors after hysterectomy, with or without a fellowship program (62% vs 48%, P = 0.38). Conclusions Residents in OG programs are receiving cystoscopy training, most commonly in the operating room, less often with simulation. Nineteen percent reported receiving no training. Graduating residents exposed to FPMRS fellowships more frequently reported planning to always perform cystoscopy after hysterectomy than did those without fellowship exposure.

Undergraduate obstetrics and gynecology medical education: why are we underrated and underappreciated?

Obstetrics and gynecology education is one of the lowestranked medical school experiences by US medical school graduates. The inability to provide students with experiential excellence could be a detriment to our patients. The causes of student dissatisfaction are not unexpected: long work hours, minimal hands-on experience, limited faculty interactions, ineffective teaching by residents/fellows, and mistreatment issues. The purpose of this Viewpoint article is to discuss these clerkship weaknesses identified by national and local survey data. Strategies employed by nationally recognized obstetrics and gynecology educators to develop adaptive behaviors to address these educational shortcomings will be reviewed. Background

Clinical medical students' self-assessed comfort with technical skills.

Objectives: Medical students spend significant time in the operating room during clinical training. Many technical skill domains are learned through trial and error, which can affect student confidence and patient safety. This project assessed the technical knowledge and comfort of third-year medical students to identify their needs for technical skills training before surgical exposure. Methods: One hundred nine students provided data in an anonymous survey on the first day of their core obstetrics/gynecology clerkship. The survey used a 4-point Likert scale to query self-assessed competence, comfort, and knowledge of technical skill domains for the operating room. Results: Students who rated introductory skill domains positively rated themselves higher on complex skill domains (2.47 vs 3.75, P < 0.001). Most students (91%) who positively assessed complex domains also rated introductory domains positively. There was good correlation with comfort in the operating room and the introductory skill domains of surgical scrub (0.782) and gowning and gloving (0.784) (P < 0.001). Conclusions: Students who rate complex domains highly overwhelmingly rate introductory skills highly, providing an opportunity to triage technical skill knowledge. A focus on introductory skill domains may be beneficial for preparing preclinical students for the operating room.

Barriers and Strategies to Engaging Our Community-Based Preceptors

ABSTRACT Issue: This article, from the “To the Point” series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of commonly cited barriers to recruiting and retaining community-based preceptors in undergraduate medical education and potential strategies to overcome them. Evidence: Community-based preceptors have traditionally served as volunteer, nonsalaried faculty, with academic institutions relying on intrinsic teaching rewards to sustain this model. However, increasing numbers of learners, the burdens of incorporating the electronic medical record in practice, and increasing demands for clinical productivity are making recruitment and retention of community-based preceptors more challenging. Implications: General challenges to engaging preceptors, as well as those unique to womens health, are discussed. Potential solutions are reviewed, including alternative recruitment strategies, faculty development to emphasize efficient teaching practices in the ambulatory setting, offers of online educational resources, and opportunities to incorporate students in value-added roles. Through examples cited in this review, clerkship directors and medical school administrators should have a solid foundation to actively engage their community-based preceptors.