Obstetrics and Gynecology Residencies: Education in Preventive and Primary Health Care for Women

Objective: To test the hypothesis that the Residency Review Committee program requirements for obstetrics and gynecology residencies, when properly followed, will result in residents being educated in preventive and primary ambulatory health care for women during their residency training program as specialists in obstetrics and gynecology.Methods: The 60 requisite residency training competencies identified as essential to educate generalist physicians, and viewed by some educators as a benchmarking standard, each were evaluated to determine whether residents in obstetrics and gynecology are now being educated in each of these areas. The answer was considered affirmative if any of the following pertained: 1) the Residency Review Committee program requirements indicate that the competency “must” or “should” be taught, 2) the Residency Review Committee requests numerical verification related to the competency on the accreditation review application, or 3) by virtue of a specific rotation required by the Residency Review Committee it can be assumed that the resident will be educated in the competency. To make our assessment, we identified and listed the section of the Residency Review Committee for Obstetrics-Gynecology program requirements, which, when properly followed, would result in education in the particular competency.Results: Fifty-seven of the 60 competencies were considered applicable to obstetrician-gynecologists (care of infants, care of children, and infant/child preventive care were not), and residents in obstetrics and gynecology were found to be educated in 54 (95%).Conclusion: During their residency training programs as specialists in obstetrics and gynecology, residents are being educated to be able to be providers of preventive and ambulatory primary health care for women.     

Factors affecting fellowship satisfaction among gynecologic oncology fellows

OBJECTIVE: The objective of this study was to determine fellowship satisfaction through a survey of gynecologic oncology fellows. METHODS: A survey was sent to all gynecologic oncology fellows in May 1998. Surveys were returned anonymously and confidentially. The questions focused on demographics, research and clinical experience, education, faculty involvement, future plans, and fellowship satisfaction. Association between variables were studied using chi(2) and two-tailed t tests. RESULTS: Of the surveys 53.8% were returned. Reputation, faculty, and clinical diversity were ranked the top three reasons for choosing a fellowship program. Eighty-seven and three-tenths percent were satisfied and 89.1% would recommend their fellowship. Fellows listed the two areas they were most satisfied with as surgical training and research support. Seventy-nine and four-tenths percent agreed they spent adequate time in the operating room and 94.1% had enough variety. Sixty percent or more of the clinical fellows felt they would be uncomfortable performing vaginal radical hysterectomies, splenectomies, radical vaginectomies, laparoscopic lymph node dissection (LND), scalene LND, skin grafts, creation of neovagina, tram flaps, and ureterovaginal fistula repairs by the end of their fellowship. Of the fellows surveyed, 94.7% were currently performing research. All believed they would finish their thesis by the end of their training. Thirty percent of fellows from Gynecologic Oncology Group institutions were not required to participate in their research trials. Among the clinical fellows 62.2% thought time for self-education was lacking compared with 35.3% of the research fellows, P = 0.07. The two areas fellows were least satisfied with were didactics and lack of time for other pursuits. Performance evaluations were received by 72.2%; however, evaluations of the program and of the attending staff occurred in only 51.3 and 34.0%, respectively. Sixty-seven and three-tenths percent stated they had a mentor and 34.0% an advisor. Fellows that did not have mentors or advisors thought they spent less time with faculty in educational pursuits (P = 0.03, 0.06). CONCLUSION: Areas that could improve fellowship satisfaction include formal didactics and time for self-education. Evaluations of the fellowship and faculty could provide a forum to continue to assess their needs. Requiring a more active role of fellows in research trials may prove to increase research productivity in the future.     

Factors that affect satisfaction with neonatal-perinatal fellowship training

This study was designed to assess neonatal fellows' satisfaction with their training and the role of mentorship. A 31-question survey was sent to all second- and third-year fellows in the United States and Canada (n = 304). Responses were received from 201 fellows (66% response rate). Respondents were evenly distributed between second- and third-year fellows. Overall, 75% were satisfied with their training. Eighty percent had a mentor on the neonatal faculty. Only 2.5% believed that they would not fulfill the sub-board research requirement, but another 24% were unsure of completion. The presence of a mentor correlated with being prepared for academic practice (p = 0.013) and plans to enter academic practice (p = 0.031). Correlation between mentorship and completion of the research requirement showed a trend (p = 0.09). Twenty-five percent of neonatal fellows are not satisfied with their training and believed that they may not complete their research requirement. Fellows who had a mentor were more prepared for academic practice and were more likely to be satisfied with their fellowship training. Mentorship is important in neonatal training programs.     

Primary care in obstetrics and gynecology resident education: a baseline survey of residents' perceptions and experiences.

OBJECTIVE: To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology. METHODS: The Council on Resident Education in Obstetrics and Gynecology In-Service Examination in 1995, given to 4361 residents, who represented all programs in the country, included a questionnaire on whether obstetrics and gynecology was primary care and whether they planned to do primary care after residency. Primary care services were categorized by counseling and screening, as defined by the U.S. Preventive Health Services Task Force. Variables included gender, residency level (upper or lower), and type of residency (community or university based). Data were analyzed using the chi2 text and multiple analyses of variance. RESULTS: The response rate was 94% (4099 of 4361), representing a nationwide complement. Eighty-seven percent of the respondents believed that obstetrics and gynecology was primary care and 85% planned to practice accordingly after residency. Residents spend less than 25% of their time counseling on nongynecologic subjects and less than 25% of their time screening for nongynecologic entities, so their perception as primary care providers focused on traditional obstetric and gynecologic counseling and screening services. When assessments were made by gender, level of training, and type of residency, significant differences were found in many variables regarding counseling and screening practices. CONCLUSION: Our survey results suggest that most American obstetrics and gynecology residents consider obstetrics and gynecology primary care but that there were limitations in the educational venues for learning about nongynecologic primary care before the implementation of the Residency Review Committee Special Requirements. Improvement in nongynecologic primary care teaching is a reasonable expectation because residency programs have had 3 years to institute the mandated changes and provide it to residents.     

Residency Training in Pediatric and Adolescent Gynecology Across Obstetrics and Gynecology Residency Programs: A Cross-Sectional Study

Study ObjectiveTo estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs.DesignProspective, anonymous, cross-sectional study.ParticipantsUnited States program directors of Obstetrics and Gynecology residency programs, N = 242; respondents 104 (43%).Results104 residency programs responded to our survey. Among the 104 residency programs, 63% (n = 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n = 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P = .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P = .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P = .03).ConclusionsResidency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training.     

Laparoscopy training in gynecologic oncology fellowship programs

ObjectiveTo assess the adequacy of laparoscopic surgical training as perceived by gynecologic oncology fellows-in-training and to compare current opinions to those on a 2003 survey.Study designFellows were surveyed via mail or an internet website.ResultsSeventy-eight (64%) of 121 fellows responded. One-hundred percent now state that laparoscopy is important or very important in gynecologic oncology practice compared to 86% in 2003. Ninety-five percent reported that much or maximum emphasis should be placed on laparoscopic training compared to 70% previously. Currently, 69% believe that their fellowship training in laparoscopy is very good or good compared to only 25% who felt this way 4 years ago. Importantly, fellows now believe they are getting better laparoscopic training in fellowship than they did in residency. Seventy-eight percent stated that their perceived laparoscopic skills were good or very good. Upon completion of fellowship, 94% plan to perform ≥ 6 cases per month laparoscopically.ConclusionsRespondents believe that laparoscopic training should be emphasized in fellowship training and perceive their laparoscopic training to be significantly improved compared to 2003. They also envision a key role for laparoscopy in their future practice.     

Subspecialist training in surgical gynecologic oncology in the Nordic countries

To survey the centers that can provide subspecialty surgical training and education in gynecological oncology in the Nordic countries, we developed an online questionnaire in co-operation with the Nordic Society of Gynecological Oncology. The link to the survey was mailed to 22 Scandinavian gynecological centers in charge of surgical treatment of cancer patients. Twenty (91%) centers participated. Four centers reported to be accredited European subspecialty training centers, a further six were interested in being accredited, and 11 centers were accredited by the respective National Board. Fourteen (74%) centers were interested in being listed for exchange of fellows. Our data show a large Nordic potential and interest in improving the gynecologic oncology standards and can be used to enhance the awareness of gynecologic oncology training in Scandinavia and to facilitate the exchange of fellows between Nordic countries.     

Factors affecting fellowship satisfaction,thesis completion,and career direction among maternal-fetal medicine fellows

Objective: To determine fellowship satisfaction through a survey of maternal-fetal medicine fellows.Methods: We constructed a survey using multiple choice, Likert scale, ordinal, and categorical scale questions. The questions focused on faculty involvement, mentorship, research time and productivity, education, fellowship selection, ultimate goals of fellows, and satisfaction. We sent the survey in two mailings to all maternal-fetal medicine fellows during April and May 1996.Results: One hundred thirty-eight surveys were mailed, and 136 were returned (98.5% return rate). Twenty-seven percent of fellows did not believe they would complete their thesis by the end of their fellowship. No statistically significant relationship was noted between the fellows’ predicted thesis completion and the availability of funding, support for statistical analysis, the presence of animal research facilities, age, number of dependents, or year of fellowship. The presence of a mentor on the maternal-fetal medicine faculty increased the likelihood of thesis completion from 52.3% to 83.5% (P < .001). Similarly, the presence of a faculty advisor increased the likelihood of thesis completion from 58.9% to 83.5% (P = .001). Thirty-two percent of the respondents did not have a mentor on the faculty, and 41% did not have a faculty advisor. Forty percent indicated that they were too involved in clinical pursuits to perform research. This group was significantly more likely to believe that their theses would not be completed (63% versus 80%, P = .029). Overall, 22% of the fellows would not recommend their fellowships. Fellows with a mentor (88.2% versus 55.8%; P < .001) or faculty advisor (87.3% versus 64.9%; P = .002) were more likely than those without to recommend their fellowship.Conclusion: A mentor or faculty advisor plays a significant role in the training of maternal-fetal medicine fellows and is associated with a higher incidence of satisfaction with the fellowship program, thesis completion, and entrance into academic practice.     

The role of gender in an obstetrics and gynecology residency program

A brief historical review of the role of female medical students and female physicians in American medicine is presented. The 1985-1986 Council on Resident Education in Obstetrics and Gynecology Residency Data Bank was analyzed for gender distribution. Questionnaire studies were undertaken to study the possible effect of the increasing number of female residents in an obstetrics and gynecology residency program. Queries were sent to current and former residents, the attending staff, and the nursing and anesthesiology staffs. In order to evaluate the national scene, letters were mailed to directors of programs with 20 or more residents. The overall results indicated female residents have a positive effect on residency training.     

Gynecologic oncologists' perceptions of fellowship training

OBJECTIVE: To determine fellowship satisfaction through a survey of practicing gynecologic oncologists. STUDY DESIGN: A survey was sent to all candidate members of the Society of Gynecologic Oncologists listed in the 2000 directory. Surveys were returned anonymously and confidentially. Questions focused on demographics, research, clinical opportunity and educational experience, satisfaction with fellowship training and career choice. Associations between variables were studied using chi2 and two-tailed t tests. RESULTS: Of the surveys sent, 47.1% (71/156) were returned. Average time out of fellowship was 3.6 years, 94.6% were currently performing research, and 47.3% did not publish their basic science research as a fellow, with 20.3% citing lack of mentorship as the main reason. Clinically, hands-on experience and faculty involvement were the top areas influencing surgical training during fellowship. Surgical, chemotherapy and radiation therapy training was adequate according to 90.5%, 94.6%, and 98.6%, respectively. Of those surveyed, 86.5% recommended a statistics course, and 81.5% recommended didactics specific to fellows; however, only 59.5% had received such teaching. Of the respondents, 44.6% and 40.8% had an opportunity to evaluate their fellowship and attending staff, respectively, as compared to 70.8% receiving routine performance evaluations (p = 0.001 and 0.0003, respectively); 98.6% and 89.2% were satisfied and recommended their fellowships. The areas of greatest satisfaction were surgical training and clinical experience. The areas of least satisfaction were didactics, basic science and clinical research. In all, 95.9% were satisfied with their career choice. CONCLUSION: Areas in which fellowship satisfaction could improve are formal didactics and improved mentoring in research. Fellowship and faculty evaluations could provide a forum to continue to improve training programs. Respondents thought that they were sufficiently trained and were satisfied with their career choice.     

Survey of robotic surgery training in obstetrics and gynecology residency

To examine the status of resident training in robotic surgery in obstetrics and gynecology programs in the United States, an online survey was emailed to residency program directors of 247 accredited programs identified through the Accreditation Council for Graduate Medical Education website. Eighty-three of 247 program directors responded, representing a 34% response rate. Robotic surgical systems for gynecologic procedures were used at 65 (78%) institutions. Robotic surgery training was part of residency curriculum at 48 (58%) residency programs. Half of respondents were undecided on training effectiveness. Most program directors believed the role of robotic surgery would increase and play a more integral role in gynecologic surgery. Robotic surgery was widely reported in residency training hospitals with limited availability of effective resident training. Robotic surgery training in obstetrics and gynecology residency needs further assessment and may benefit from a structured curriculum.     

Role of embryo transfer in fellowship training

Our objective was to survey training in ET techniques among fellows, its perceived importance, and potential barriers to ET training during fellowship. Although ET training remains an important issue for most fellows and recent graduates, 44% of respondents did not receive this training during their fellowship.     

The anatomy of complications workshop: an educational strategy to improve the training and performance of fellows in gynecologic oncology

OBJECTIVES: In Australasia, the USA, and Canada, certified gynecologic oncologists (CGO) are expected to be competent in performing intestinal, urological, and vascular procedures relevant to gynecologic oncology. This competency may be difficult to achieve and experience with simulation rather than human patients may be preferable during initial training. We present the structure, objectives, rationale, and outcomes for a surgical skill workshop aimed to improve the performance of fellows in gynecologic oncology. WORKSHOP STRUCTURE: The overall objective of the workshop is the prevention and management of complications in gynecologic oncology surgery. Preworkshop preparation includes anatomical illustrations to guide reading and a training video describing surgical procedures and the relevant aspects of ovine and porcine anatomy. There are four modules: (i) Anatomy includes an interactive lecture, cadaveric dissection, and examination of prosections. (ii) Porcine surgery involves the demonstration, practice, and learning of techniques needed to deal with unexpected or deliberate operative injury to bowel, bladder, ureter, and major blood vessels and performance of less common operations. (iii) Live ovine surgery allows further supervised practice of these procedures plus the repair of vascular injury. (iv) Case presentations allow each participant to present a complicated case in a facilitated group session with discussion and feedback from their peers. This session is controlled, nonthreatening, and interactive. CONCLUSION: Participant feedback and evaluation suggests that this workshop format and the opportunity to practice less common procedures are helpful to clinical practice. This educational model is presented in the hope that it may act as a template for the development of similar programs for fellows in other countries.     

Laparoscopic training and practice in gynecologic oncology among Society of Gynecologic Oncologists members and fellows-in-training

OBJECTIVE: To determine the proportion of Society of Gynecologic Oncologists (SGO) members performing laparoscopic procedures and to determine SGO members' and fellows' opinions regarding indications for and the adequacy of training in laparoscopy. METHODS: Surveys were mailed to SGO members and fellows-in-training in December 2002. Anonymous responses were collected by mail or through a Web site. The survey was mailed twice and was estimated to take 5 min to complete. The data were analyzed using frequency distributions and nonparametric tests. RESULTS: Three hundred thirty-six SGO members (45%) and fifty-seven fellows (49%) responded. Among SGO members, 272 (84%) currently performed laparoscopic surgeries. Reasons cited for performing laparoscopy were decreased length of hospital stay (74%), improved patient quality of life (57%), patient preference (48%), improved cosmesis (46%), and better visualization (18%). Among those who did not perform laparoscopy, 50% cited increased operating time as their main reason. When asked to indicate the laparoscopic procedure most commonly performed in their practice, 69% reported diagnosis of an adnexal mass; 11%, prophylactic bilateral salpingo-oophorectomies; and 10%, laparoscopically assisted vaginal hysterectomy and lymph node staging for uterine cancer. Only 3% of SGO respondents performed more than 50% of their procedures laparoscopically, and all respondents reported converting from laparoscopy to laparotomy less than 25% of the time. Most respondents had limited laparoscopic training during their fellowships: 39% received none, and 46% received limited (less than five procedures per month) training. Nevertheless, 78% of SGO respondents rated their laparoscopic skills as either very good or good. Among fellows, only 25% believed they were receiving very good or good laparoscopic training. Eighty percent of SGO respondents believe that at least six procedures per month were necessary for adequate training, yet only 33% of fellows performed that many procedures. CONCLUSIONS: Most SGO respondents used laparoscopy for selective indications, and most developed their laparoscopic skills after their fellowship training. SGO respondents believed laparoscopic instruction is an important part of training, but most fellows perceived their laparoscopic training as inadequate.     

Training in chorionic villus sampling: limited experience for US fellows

OBJECTIVE: This study was undertaken to assess training availability, methods, and plans for future practice of invasive procedures for maternal fetal medicine (MFM) fellows. STUDY DESIGN: A survey was sent to all MFM fellows registered with the American Board of Obstetrics and Gynecology in March of 2001. RESULTS: Of 91 surveys, 55 (60.4%) were returned. All respondents were trained in second-trimester amniocentesis and planned on performing the procedure after fellowship. Of the 55 respondents, 53 (96.4%) were trained on continuing pregnancies. Despite 82% of training institutions performing chorionic villus sampling (CVS), only 24 of 45 (53%) fellows had availability for training. Of those 24, 14 (58%) initiated training on pregnancies that were undergoing termination. Median number of procedures performed by fellows (continuing pregnancies and before termination) was 3 (range 0-120), with 40 procedures (range 0-140) expected to be performed before completing fellowship. Twenty-eight fellows planned on performing CVS after training. CONCLUSION: The number of centers training MFM fellows in CVS and the number of procedures performed in the United States is limited.     

Current status of obstetrics and gynecology resident medical-legal education: a survey of program directors

OBJECTIVE: To assess the level and type of medical-legal education offered to obstetrics and gynecology residents and medical students. METHODS: All obstetrics and gynecology program directors (n = 252) were asked to complete a survey questioning the availability of, type of, and desire for medical-legal education within their programs. RESULTS: Seventy-eight percent of the program directors answered the survey with 86% reporting some degree of formal medical-legal education. The most common formats were didactic lectures (38%), grand rounds (30%), case conferences (19%), mock trials (9%), and other (4%). These sessions most commonly contained information on proper documentation (48%), testifying (25%), and giving a deposition (24%). The average number of sessions per year was 4.1 with a median of 3 sessions per year. Despite this high percentage of some formal education, 88% expressed an interest in pursuing other educational options on these topics. CONCLUSION: Most obstetrics and gynecology residency programs provide some form of medical-legal instruction to residents, but the small number of sessions suggests that this is inadequate. Residency programs may benefit from a larger and more formal resident education program on medical-legal issues.     

The effect of board-imposed changes on maternal-fetal medicine fellowships

OBJECTIVE: A 1996 survey of Maternal-Fetal Medicine fellows revealed that there was cause for serious concern over fellow experience. In 1997, Maternal-Fetal Medicine fellowships underwent significant changes, including a lengthening of the program and more stringent requirements for protected research performance. We investigated whether the changes imposed in Maternal-Fetal Medicine fellowships in 1997 have improved fellow experience. METHODS: Fellows were identified through the Society of Maternal-Fetal Medicine. An identical survey to a 1996 survey using the Likert scale, ordinal- and categorical-scale questions were used. The results of the 1996 survey were compared with the results of the 2000 survey. chi2, Mann-Whitney U test, Fisher exact test, and analysis of variance were used where appropriate. RESULTS: Sixty-five of 100 fellows returned the survey (return rate, 65%). Overall, there has been improvement in many areas of fellow experience. Significant changes include an increase in research time (7 months versus 18 months; P <.001), number of research projects (2.9 versus 4.3 projects/fellow; P <.001), fellows rating research time as adequate (66.4% versus 85.6%; P=.003), fellows receiving grant training (20.2% versus 37.1%; P=.012), 2 or more research presentations (36.2% versus 47.1%; P=.028), pursuit of a postgraduate degree (5.7% versus 32.9%; P <.001), presence of a mentor (68.1% versus 80.8%; P=.049), and the rating of mentorship as strong (59.4% versus 77.9%; P=.039). Of concern, 24.3% of current fellows did not believe they would receive their full-protected research time. CONCLUSION: The changes imposed in Maternal-Fetal Medicine fellowships in 1997 appear to have had a positive impact on fellows' experience, especially the ability to perform and present research.     

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program

STUDY OBJECTIVE: Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. DESIGN: Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children's Hospital for locally advanced cervical cancer between June 2002 and June 2005. SETTING: Gynecologic oncology fellowship training program at a University-County Hospital PATIENTS: Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. INTERVENTIONS: Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. MEASUREMENTS AND MAIN RESULTS: A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. CONCLUSIONS: It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.     

Teaching operative dictation. A survey of obstetrics/gynecology residency program directors

OBJECTIVE: To assess current efforts to teach operative dictation in obstetrics and gynecology residency programs. STUDY DESIGN: A survey detailing the didactics of operative dictation was distributed in a single mailing to all program directors listed in the roster of the Council on Residency Education in Obstetrics and Gynecology. RESULTS: Of 274 surveys distributed, 115 (42%) were returned. Ten percent of program directors reported defined curricula related to operative dictation. Using a combination of lectures, personal instruction and review of previous notes, attendings and senior residents share the responsibility for teaching operative dictation in the majority (78%) of programs. Sixty percent of program directors were in favor of more formal guidelines for residency education in the technique of operative dictation, 34% were opposed, and 6% offered no opinion. CONCLUSION: Obstetrics and gynecology residency programs rarely have a structured curriculum for teaching operative dictation, and the majority of program directors support the institution of more formal guidelines.