Managed health care and resident education

OBJECTIVE: We wished to determine the impact of managed health care on resident education in obstetrics and gynecology. STUDY DESIGN: A multiquestion survey was mailed to program directors of the 267 obstetrics-gynecology resident training programs in the United States. The questions ascertained departmental philosophy regarding the role of obstetrician-gynecologists as primary care versus specialist physicians, the extent of involvement with managed health care companies, educational curriculum content, the effect of managed care on patient volume, faculty time available for resident teaching, and the effect of managed care on resident education. RESULTS: Completed surveys were received from 210 (79%) program directors. One hundred twenty-six (63%) program directors responded that obstetrician-gynecologists should be primary care physicians for women, and 120 (60%) believed that the role of subspecialists will be reduced in the near future. In 1996, 177 (94%) programs had managed care contracts; many (57%) had >20 contracts. All programs participate with other specialties to teach primary care to their residents. One hundred twelve (59%) programs have had a decrease in patient volume, prompting 90 (45%) programs to increase their number of teaching sites. Of concern, 54 (26%) program directors noted that managed care companies discourage but do not restrict resident participation in the care and treatment of managed care patients, and 41 (20%) programs had some restrictions placed on such resident involvement. Budgetary constraints have decreased resources to 97 (47%) programs and threaten the time available for faculty teaching. CONCLUSIONS: Managed health care is having an effect on many resident teaching programs. Program directors are integrating managed care concepts into the educational curriculum and are negotiating with managed care organizations to involve residents in the care and treatment of managed care patients. (Am J Obstet Gynecol 1998;178:1157-64.)     

The Care of Adolescents by Obstetrician-Gynecologists: A First Look

Study ObjectiveTo determine whether obstetrician-gynecologists who typically care for adolescent patients, what this care entails, and the adequacy of training opportunities in adolescent health care.DesignA questionnaire designed to elicit information regarding practice patterns of obstetrician-gynecologists mailed to the American College of Obstetricians and Gynecologists Collaborative Ambulatory Practice Network.ParticipantsObstetrician-gynecologists whose patient populations included girls under the age of 18.Main Outcome MeasuresItems in the questionnaire were generated to determine what care obstetrician-gynecologists are providing to adolescents, whether this care meets practice guidelines of major medical organizations, and whether obstetrician-gynecologists are receiving adequate training to provide this care.ResultsObstetrician-gynecologists frequently care for adolescent patients, with 72.6% seeing adolescents either monthly or weekly. The most frequently cited service needs pertained to reproductive health. Obstetrician-gynecologists also provide primary care, with 55.2% currently providing immunizations to adolescent patients. Nearly all (96.5%) plan to provide HPV immunizations. Most (80% or more) considered their residency training in obstetrics-gynecology on reproductive health to be adequate, but many reported inadequate or no training on primary care.ConclusionsObstetrician-gynecologists are an important part of the health care team caring for female adolescent patients. There is a lack of training during residency in obstetrics-gynecology in adolescent primary care issues. Increased training of obstetrician-gynecologists in all aspects of adolescent health care may increase the pool of health care providers who care for adolescents adequately. Collaborative efforts among all adolescent health care providers can improve access to quality health care for adolescents and the health of this population.     

Primary and preventive care in a university obstetrics and gynecology group practice

Objective: Our purpose was to determine whether primary and preventive care is practiced by a university obstetrician-gynecologist group practice.Study design: A retrospective chart review spanning 2 years of four academic physicians' private practices was performed. A total of 335 patients were reviewed with 739 patient encounters and 1032 patient problems identified. The definition of a primary care physician according to The American College of Obstetricians and Gynecologists was used to standardize data collection and evaluation.Results: Obstetric complaints accounted for 27.7% of all visits, whereas 65.4% were for gynecologic problems. Almost 7% of all complaints were neither obstetric nor gynecologic, and of those 74.6% were primary care problems completely managed by the obstetrician-gynecologist. Only 19.7% of these were referred for management. More than 89% of all encounters () involved some element of primary care.Conclusion: This study provides evidence that the majority of health care provided by the obstetrician-gynecologists is primary care.     

The obstetrician-gynecologist's role in vaccine-preventable diseases and immunization

OBJECTIVE: To assess by survey the immunization role currently played obstetrician-gynecologists in the state of Michigan. METHODS: Masked questionnaires requesting demographic, knowledge-based, practice, and attitudinal data were sent to 850 ACOG-registered fellows. RESULTS: Three hundred sixty-five physicians responded, 313 of whom were in active practice. Most were male (70%) and graduated from medical school between 1970 and 1989 (68%). The majority provided both obstetric and gynecologic services. The minority (47%) specifically identified themselves as primary care providers. Only 15% of respondents considered screening for vaccine-preventable diseases to be outside the realm of routine obstetric-gynecologic care. In practice, however, 19% did not screen their obstetric patients for any vaccine-preventable diseases, and only 10% assessed their patients for all nine vaccine-preventable diseases listed in the questionnaire. In gynecologic patients, almost 40% of physicians did not assess for any vaccine-preventable disease. A wide range in knowledge level was identified concerning vaccine-preventable diseases, immunization recommendations, and vaccine safety. CONCLUSION: These data show a discrepancy between perceived responsibilities and actual practice patterns of obstetrician-gynecologists regarding vaccine-preventable diseases and the immunization of women. Limitations in current knowledge and practical concerns specific to vaccine administration contribute to this disparity.     

Blood Pressure Measurement for Hypertension in Pregnancy

ObjectiveAmbulatory BP monitoring (ABPM) has been proposed as a logical approach to overcoming many of the problems associated with clinical BP measurement. The extent of its use in diagnosing hypertension in pregnancy is unknown. The objective of this study was to identify the practices surrounding use of ABPM by practitioners to diagnose hypertension (HTN) and white coat hypertension (WCH) in pregnant women.MethodsWe mailed questionnaires to all obstetricians and family doctors practising obstetrics who were listed in the online medical directory of the College of Physicians and Surgeons of Alberta. Data were analyzed using SPSS.ResultsCompleted questionnaires were received from 81 obstetricians and 86 primary care physicians who manage hypertension in pregnancy. The majority of obstetricians (83%) and primary care physicians (79%) indicated that they “almost always” or “often” attempt to differentiate WCH from true HTN in pregnancy. The most popular method identified to differentiate WCH from true HTN in pregnancy was self (intermittent) home BP monitoring (78% of obstetricians and 69% of primary care physicians, P = 0.18). A minority of physicians in each group reported using ABPM to evaluate HTN in pregnancy, with significantly fewer obstetricians using ABPM diagnostically than primary care physicians (12% vs. 26%, P = 0.04).ConclusionObstetrical care providers in Alberta are aware that WCH is an issue among pregnant women. While ABPM is chosen in a minority of cases, both obstetricians and primary care physicians appear to have a strong preference to use self BP monitoring for further BP evaluation.     

An evaluation of trends in obstetrics and gynecology clerkships in the United States and Canada

OBJECTIVE: The purpose of this study was to provide an updated profile of clerkship directors and third-year clerkships for Departments of Obstetrics and Gynecology at US and Canadian medical schools. STUDY DESIGN: All 142 accredited medical schools in the US and Canada were contacted to identify the individual(s) responsible for third-year medical education in Obstetrics and Gynecology. Additional clerkship sites (n=10) were identified using the Association of Professors in Gynecology and Obstetrics' (APGO) list of current members self-identified as clerkship directors. Written surveys were mailed to the individuals identified above. The survey included questions about demographic and academic profiles, 11 attitude statements, as well as potential interest in a national organization of clerkship directors under APGO and interest in the creation of web-based resources specifically for clerkship directors. RESULTS: One hundred twenty-three (81%) responses were received. Demographic and academic characteristics of clerkship directors were similar to those published 13 (1) and 6 (2) years ago, except that the proportion of female clerkship directors has steadily increased (20% in 1989 [1], 25% in 1994 [2], and 44% in 2000, P <.0001). Thirty-five percent of departments have a specialized division of medical education, and 21% of respondents stated that their affiliated medical school had a formal multidisciplinary women's health care curriculum. Eighty-nine percent of respondents felt that their job as clerkship director was personally fulfilling. Eighty- nine percent supported a national organization of clerkship directors under APGO and the majority supported other activities specific for clerkship directors, including web-based resources. CONCLUSION: The profiles of obstetrics and gynecology clerkships and clerkship directors in the US and Canada have remained relatively stable over the last 13 years. However, the proportion of female clerkship directors continues to increase. Interest in more organized activities specifically for clerkship directors and web-based resources is high.     

Emergency Contraception Services for Adolescents: a National Survey of Children's Hospital Emergency Department Directors

Study ObjectiveTo assess emergency contraception (EC) counseling and prescribing practices of children's hospital emergency department (ED) directors and the use of EC protocols in these settings.DesignCross-sectional study of children's hospital ED directors responding to a 15-minute 44-item semi-structured survey during telephone interviews.Participants50 of 96 eligible directors of children's hospital EDs in the United States.Main Outcome MeasuresEC protocols, EC counseling processes, EC prescribing practices.ResultsMost (80%) ED directors reported always offering EC as part of sexual assault care; 66% were more likely to provide onsite EC in these situations. Only 52% identified the progestin-only regimen as the EC dispensed in their ED, and most (96%) limited provision to fewer than 120 hours after sex. Although 58% of ED directors reported ever prescribing ongoing contraception when providing EC, none had prescribed EC for future use. Written ED protocols for providing EC were more common for sexual assault care (76%) than for non-sexual assault care (14%). Directors who worked at hospitals with a sexual assault program were less likely to discuss all the recommended topics for EC counseling.ConclusionsThe recommended standard of care for providing EC to adolescents in children's hospital EDs is not being met. Although risk of pregnancy following sexual assault and consensual unprotected sex is identical, discrepant practices emerged from this survey of pediatric ED directors. Increased education and policy initiatives within children's hospital EDs are needed to standardize EC services for adolescents in this setting.     

National Canadian Survey on the Management of Noneuploid Embryos

ObjectiveTo comprehensively describe current preimplantation genetic testing for aneuploidy (PGT-A) practices and management of non-euploid embryos in Canada.MethodsThis was a cross-sectional study utilizing an online survey distributed by email to all medical directors of fertility clinics with independent in vitro fertilization (IVF) embryology laboratories. The survey was designed to determine practice patterns regarding PGT-A usage; PGT-A reference laboratory, platform, and thresholds for classifying embryos; and management of embryos classified as mosaic, inconclusive, or aneuploid.ResultsTwenty-five medical directors (69%) participated in the survey. The majority of clinics (91%) offered PGT-A screening, with 45% of clinics offering PGT-A as routine screening. The majority of clinics (90%) that offered PGT-A received mosaicism data; 61% of these clinics had transferred mosaic embryos, and 94% would transfer mosaic embryos. Clinics that performed ≥1000 IVF cycles annually were more likely to have transferred mosaic embryos (100% vs. 45.5%; P = 0.043). The mean percentage of IVF cycles using PGT-A was lower in clinics that had transferred mosaic embryos (12.3% vs. 30.4%; P = 0.033). Only 1 clinic had transferred an aneuploid embryo, but 2 other clinics would consider this option. The majority of clinics (61%) that receive mosaicism data would recommend noninvasive prenatal testing (NIPT) following mosaic embryo transfer, with 22% of clinics indicating that this would be the only genetic test offered.ConclusionWe report significant practice variation in PGT-A and management of non-euploid embryos across Canada and highlight areas where consensus should be encouraged.     

Anxiety and Depression Among Sexual Minority Women and Men in Sweden: Is the Risk Equally Spread Within the Sexual Minority Population?

IntroductionSexual minority individuals have a higher risk of anxiety and depression compared with heterosexuals. However, whether the higher risk is spread equally across the sexual minority population is not clear.AimTo investigate the association between sexual orientation and self-reported current anxiety and a history of diagnosis of depression, paying particular attention to possible subgroup differences in risks within the sexual minority population, stratified by sex and to examine participants' history of medical care for anxiety disorders and depression.MethodsWe conducted a population-based study of 874 lesbians and gays, 841 bisexuals, and 67,980 heterosexuals recruited in 2010 in Stockholm County. Data were obtained from self-administered surveys that were linked to nationwide registers.Main Outcome MeasuresBy using logistic regression, we compared risks of current anxiety, histories of diagnosed depression, and register-based medical care for anxiety and/or depression in lesbian and gay, bisexual, and heterosexual individuals.ResultsBisexual women and gay men were more likely to report anxiety compared with their heterosexual peers. Bisexual individuals and gay men also were more likely to report a past diagnosis of depression. All sexual minority groups had an increased risk of having used medical care for anxiety and depression compared with heterosexuals, with bisexual women having the highest risk.ConclusionBisexual women appear to be a particularly vulnerable sexual minority group. Advocating for non-discrimination and protections for lesbian, gay, and bisexual people is a logical extension of the effort to lower the prevalence of mental illness.Björkenstam C, Björkenstam E, Andersson G, et al. Anxiety and Depression Among Sexual Minority Women and Men in Sweden: Is the Risk Equally Spread Within the Sexual Minority Population? J Sex Med 2017;14:396–403.     

Residents’ Confidence in Performing Robotic Hysterectomy in Obstetrics and Gynecologic Training Programs

Study ObjectiveTo compare residents’ perceptions of readiness to perform robotic-assisted laparoscopic hysterectomy with the perceptions of residency program directors in obstetrics and gynecology programs throughout the United States.DesignA survey was administered to all residents taking the 2019 Council on Resident Education in Obstetrics and Gynecology Exam and concurrently to program directors in all Accreditation Council for Graduate Medical Education–accredited training programs.SettingThe survey was designed to assess resident confidence to perform robotic hysterectomies by the time of graduation.PatientsNo patients were included in the study.InterventionsThe only intervention was administration of the survey.Measurements and Main ResultsDe-identified survey data were analyzed using chi-squared and Fisher's exact tests. A total of 5473 resident respondents and 241 residency program directors were included in the study. Fifty-two percent of graduating residents reported that they felt they were given surgical autonomy to perform robotic hysterectomies, and 53.7% reported that they could perform one independently (if it was an “emergency” and they had to). By the time of graduation, only 59% of residents reported confidence performing a robotic hysterectomy, and only 56% reported they felt that it would be an important procedure for their future career. Program directors were significantly more likely to report that their residents were given autonomy to perform robotic hysterectomy by graduation (61.0% [95% confidence interval (CI), 54.3–67.3]), could perform a robotic hysterectomy independently (60.9% [95% CI, 53.9–67.6]), or could perform a robotic hysterectomy by graduation (70.2% [95% CI, 63.5–76.3]) than residents themselves (38.6% [95% CI, 37.2–40.0], 22.8% [95% CI, 21.6–24.0], 62.6% [95% CI, 61.2–64.0], respectively).ConclusionAt the time of graduation, residents’ confidence in performing robotic hysterectomy independently is lower than their confidence in performing all other approaches to hysterectomy.     

Women's awareness of long-acting,reversible contraceptive methods (LARCs) in community family planning clinics and general practice

Objectives To investigate whether awareness and choice of long-acting reversible contraceptives (LARCs) of women attending a community family planning clinic differ from those of women seeing general practitioners (GPs).

Methods Information was collected from women in their reproductive years about their current contraceptive method, their awareness of LARCs and whether they felt well informed about their options. After additional information was provided the respondents were asked whether they would consider changing their method and if their GP offered this option.

Results Questionnaires were completed by 177 women attending a city-centre contraception and sexual health (CASH) clinic (n = 96) and a GP's surgery in a neighbouring city (n = 81). Forty percent of women in the CASH cohort and 6% in the primary care group were using LARCs. Women attending the CASH service were more aware of their contraceptive options and felt better informed but less than 50% in either group had heard of the levonorgestrel-releasing intrauterine system. At least 50% of women would consider using a LARC yet few knew if their GP fitted/provided these methods.

Conclusion LARC usage was considerably higher in CASH services compared to primary care. Those providing contraceptive care should give up-to-date information covering all methods and referral to local specialist services, as appropriate.     

Obstetrician-gynecologists are primary physicians to women.

Our studies of the practice patterns of Michigan obstetrician-gynecologists indicate that they serve in a dual capacity: that of primary physicians to women and that of specialist obstetrician-gynecologists. They provide a considerable amount of general medical care for their own patients in the former role, and traditional specialist services for their own patients and for those referred by other physicians in the latter. The objectives and educational content of most house officer training programs do not reflect these changes. Training is directed almost exclusively toward preparing residents for specialty practice and often does not offer them basic experience and permit them to develop basic skills in other disciplines, notably internal medicine nad psychiatry, which they will need to practice as parimary physicians to women. An educational program designed to prepare residents more broadly for what they will actually be doing in practice without compromising their training as specialists is described.     

The Leadership Landscape: The Role of Gender in Current Leadership Positions in Obstetrics and Gynecology Departments

Study ObjectiveTo describe the proportion of female faculty in departmental administrative and educational leadership roles in Obstetrics and Gynecology departments.DesignCross-sectional observational study (II-3).SettingAccredited Obstetrics and Gynecology residency programs.ParticipantsA total of 288 accredited residency programs were identified from 2019 to 2020 with 1237 individuals in leadership positions.InterventionsSimilar to a 2012 to 2013 survey by Hofler et al, residency program websites and corresponding fellowships (Maternal Fetal Medicine, Female Pelvic Medicine and Reconstructive Surgery, Reproductive Endocrinology and Infertility, and Gynecologic Oncology), departmental websites, and divisional websites were queried for those in administrative and educational leadership positions. Information regarding gender (as determined by the surrogates of name and photographic gender expression), medical and academic degrees, academic rank, and subspecialty certification was abstracted.Measurements and Main ResultsWithin administrative leadership roles, women comprised 29% of chairs, 46% of vice chairs, and 47% of division directors, all significantly lower than men in administrative leadership (p <.001). In educational leadership, women made up 71% of medical school clerkship directors, 58% of residency directors, and 50% fellowship directors. Women were more likely to hold educational leadership positions (56% vs 40%; p <.001), although men were more likely to hold administrative leadership positions (68% vs 52%; p <.001). Among subspecialties, there was greatest gender equity within Female Pelvic Medicine and Reconstructive Surgery. Female leaders were more likely to have received additional academic degrees (e.g. MBA, MPH) than their male counterparts (19% vs 13%; p = .002).ConclusionWomen continue to be underrepresented in administrative leadership positions. Compared with 2012 to 2013, there is only a 9% increase in proportion of women chairing and 10% vice chairing Obstetrics and Gynecology departments; however, the increase is more substantial in other positions, such as division directors (17%). Our findings demonstrate ongoing gender disparity in the highest levels of departmental leadership and the need to further improve on diversity and gender equity within leadership roles.     

Impact of Urinary Incontinence on Sexual Functioning in Community‐Dwelling Older Women

IntroductionKnowledge on the sexual health of patients with urinary incontinence in primary care is scarce; therefore, the impact of urinary incontinence on sexual functioning was examined in community‐dwelling older women.AimThe aim of this study was to provide primary health care professionals with more information on the sexual health of older women with urinary incontinence, which can be used to discuss this sensitive topic during a consultation.MethodA cross‐sectional survey among the 350 women aged ≥55 years participating in a primary care trial on urinary incontinence was conducted.Main Outcome MeasuresAmong patients with a partner, sexual problems of the sexually active patients were described as well as reasons for not being sexually active. A multivariate logistic regression model was performed to identify factors that are predictors of sexual activity, and odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.ResultsOf all participants with a partner, 68% (95% CI: 61–74) were sexually active. Of these, 25% (95% CI: 17–35) felt restricted in (or avoided) sexual activity because of their urinary incontinence. Urine leakage during sexual activity was present in 26% (95% CI: 19–34). The most frequent reason for not being sexually active was a physical problem of their partner (28%, 95% CI: 18–40); only 5% (95%‐CI: 2–13) reported that urinary incontinence was a reason for not having sex. Increasing age was the only independent (negative) predictor of sexual activity (OR: 0.95, 95%‐CI: 0.90–1.00).ConclusionsMost of these older women with urinary incontinence were sexually active, if they had a partner. The main reason for not being sexually active was a partner‐related problem. Although for only 5% was urinary incontinence the main reason for not having sex, about 25% of the sexually active women reported a negative influence of urine loss on their sex life. This implies that assessing sexual function is relevant in older women with urinary incontinence. Visser E, de Bock GH, Berger MY, and Dekker JH. Impact of urinary incontinence on sexual functioning in community‐dwelling older women. J Sex Med 2014;11:1757–1765.     

Support following miscarriage: what women want

Objective: Miscarriage is a frequent pregnancy complication often accompanied by psychological distress. The current study seeks to query women about their desire for support following miscarriage and specific aspects of content, type and timing of support. Method: An experimenter‐designed questionnaire was presented to Internet forums dealing with miscarriage or gynecological medical information. Three hundred and five women participated in the study. Results: The majority of women indicated that they would appreciate support following miscarriage. All proposed interventions appeared useful to women, particularly those dealing with the medical aspects of miscarriage. Women indicated that they felt poorly informed following miscarriage and had particular difficulty dealing with the emotional impact of their miscarriage. Conclusion: The results emphasise the need for providing more comprehensive care for women who have experienced miscarriage and provide information about how support could be best provided     

Obstetrician-Gynecologists’ Experience and Comfort in Treating Children and Adolescents with Gynecologic Needs

Study ObjectiveTo determine which obstetrician-gynecologists care for pediatric and adolescent patients, their practice and referral patterns for common gynecologic symptoms, and desired training opportunities in pediatric and adolescent health careDesignAn Internet-based questionnaire designed to elicit information regarding the practice patterns of obstetrician-gynecologistsSettingUnited StatesParticipantsObstetrician-gynecologists practicing clinical medicine and participating in the Pregnancy-Related Research Network (PRCRN)InterventionsNoneMain Outcome MeasuresPractice patterns of obstetrician-gynecologists in treating gynecologic issues in pediatric and adolescent patientsResultsOf the 103 participants that met the inclusion criteria, most see pediatric patients rarely, if ever. Most participants treat adolescent patients at least monthly in their clinical practice. Just over half (n = 60, 58.3%) have a pediatric-adolescent gynecologist within 50 miles of their practice location, which is associated with referring pediatric patients with vulvar itching but not in the treatment of other gynecologic conditions. The areas in which participants feel they had the least adequate training and had interest in receiving more training were vulvar conditions in pediatric patients and abnormal pubertal development.ConclusionObstetrician-gynecologists feel comfortable managing most adolescent gynecologic conditions themselves and less comfortable managing pediatric gynecologic conditions. Referral patterns vary by distance to pediatric-adolescent gynecologists only in the scenario of pediatric vulvar itching. Participants expressed interest in future training in pediatric gynecologic conditions, especially vulvar conditions and pubertal development. Understanding the patterns and gaps in provision of care for these patients is key to enacting effective interventions to improve the quality of care for young women and children with gynecologic needs.