Patient acceptance of medical student participation in an outpatient obstetric/gynecologic clinic

OBJECTIVE: To determine which patients, based on selected patient, physician and visit information, were more likely to accept medical student participation in an outpatient visit. STUDY DESIGN: A cross-sectional study conducted at a university-based private practice, evaluated 560 patients presenting for routine outpatient obstetric or gynecologic care. Participants completed a consent form regarding medical student participation in their visit. Patient, visit and physician demographic variables were abstracted. Comparison groups were those patients who accepted vs. those who refused medical student involvement. RESULTS: The majority of patients (75.8%) accepted student participation in their care. Patients who were black, were new to the office, were scheduled to see junior faculty and were evaluated for a vaginal discharge were more likely to refuse student participation. Patients seen for urinary incontinence were more likely to agree to medical student participation. CONCLUSION: The majority of patients consented to medical student involvement. Using a brief survey, we identified patients who are more likely to allow medical students to participate in their visit. We will continue to query all patients regarding medical student teaching but will assign medical students accordingly to maximize their learning experience. We will also educate patients on the benefits of including medical students in the outpatient visit.     

Women's perceptions of and experiences with medical student involvement in outpatient obstetric and gynecologic care in the United Arab Emirates

OBJECTIVE: The purpose of this study was to determine the experiences, satisfaction, and comfort of women with medical student participation in outpatient care during obstetric and gynecology clerkships. STUDY DESIGN: A consecutive sample of 303 women who attended the clinic were interviewed before consultation; a structured questionnaire was used. RESULTS: Two hundred sixty-four women (87.1%) accepted student involvement; 158 women (59.8%) and 173 women (66.5%), respectively, preferred female students or preceptors. Comfort levels were significantly lower with male students or preceptors in all skills that were tested (P <.0001), particularly pelvic examination and the discussion of sexual problems. Acceptance was associated significantly with older age (P <.0001), higher parity (P <.0001), higher education (P =.002), husband's occupation (P =.006), obstetric consultation (P <.0001), previous teaching encounters (P =.0006), recognition of the students' roles (P =.004), and satisfaction with clinical service (P = 0.01). Reasons for nonacceptance (n = 39 women, 12.9%) were concern about privacy during examination (53.8%) or counseling (25.6%) and the extent of the students' involvement (20.5%). CONCLUSION: Most women agreed to participate in the teaching of obstetric and gynecologic skills to medical students.     

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.     

Impact of educational messages on patient acceptance of male medical students in OB–GYN encounters

Introduction: Although training in obstetrics and gynecology is a key part of medical education, male students receive less extensive experience, due in part to patient refusals. However, there is limited work seeking to reduce patient refusal rates of male students. The current study examined the efficacy of two messages at increasing male medical student acceptance into a well-woman visit. Methods: A total of 656 college women participated in a simulation study where they viewed a video of a nurse asking for permission to have a male medical student participate in their well-woman visit. The 30.5% of women who refused student participation (n?=?181) were randomly assigned to view a video of the nurse either describing students’ medical knowledge and technical skills training (e.g. training in performing pelvic exams) or empathic skills training (e.g. training in communication about sensitive issues). They were again asked if they would be willing to have the student participate. Results: Both messages similarly increased student acceptance with 44.8% of those receiving the empathic skills training message and 48.9% of those who received the medical/technical skills training message accepting student participation, χ² (1, N?=?181)?=?0.3, p?=?0.58. Discussion: Educational messages about medical student training delivered in an engaging fashion by a credible source are a potentially effective tool to increase male student acceptance into sensitive patient encounters. Future work should test these messages in real-world settings as part of a focus on patient education to increase comfort with student participation.     

Patterns of ambulatory care use for gynecologic conditions: A national study

OBJECTIVE: This study was undertaken to describe the site of ambulatory care visits for gynecologic conditions in the United States and to identify patient factors associated with the site of care for these conditions. STUDY DESIGN: We conducted a national cross-sectional study using data from the 1995-1996 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Visits to private physician offices, hospital outpatient departments, and emergency departments were selected if the principal diagnoses were consistent with 1 of 9 gynecologic categories. Multiple logistic regression was used for all diagnoses to identify factors associated with visits to emergency departments or hospital-based outpatient departments compared with factors associated with visits to private physician offices. Separate regression models were developed for individual diagnoses to test the hypothesis that the factors associated with the site of care would vary across different gynecologic conditions. RESULTS: There were 23,194,000 visits for gynecologic conditions during the 2-year study period. Genital dysplasia, ovarian disorders, and uterine disorders were associated with greater use of hospital outpatient departments and emergency departments compared with physician offices. There was a 30% to 50% reduction in emergency room use for visits by women aged 45 years and older compared with visits by women aged 18 to 29 years. Emergency department use for several gynecologic conditions was 5 to 8 times greater for visits by women with household income <$29,000 than for visits by women with household income > or =$40,000. CONCLUSION: Specific gynecologic diagnoses and patient factors are associated with greater use of emergency departments or hospital outpatient departments compared with physician offices. The association of these factors with the site of care varies across different gynecologic conditions.     

Postpartum contraceptive acceptance in León, Mexico: a multivariate analysis.

OBJECTIVES: The aim of the present study was to identify the reasons for the acceptance or rejection of contraceptive methods among postpartum women at the Hospital of Obstetrics and Gynecology in León, Mexico. METHODS: A prospective cross-sectional study of 1025 postpartum women was undertaken. Reasons for acceptance or refusal of contraceptives were registered in a written survey. Twelve sociodemographic variables were included as predictors in a logistic regression analysis; the acceptance or refusal was the dependent variable, and statistical significance was set at 0.05. RESULTS: There were 513 patients who accepted contraceptives (50.0%) and 512 (50.0%) who refused them. The main reasons for accepting contraceptives were definitive desire for no more children (17.0%) and satisfaction with previous contraceptive methods (21.5%). The main contraceptive methods chosen were intrauterine device (67.7%) and tubal sterilization (28.5%). Reasons for contraceptive refusal were husband's rejection (33.2%) and delaying contraceptive use until after finishing the postpartum period (31.8%). In the logistic regression model, the variables previous deliveries (p < 0.001), number of Cesarean sections (p < 0.001) and women's level of education (p < 0.02) were included as predictors of acceptance. CONCLUSIONS: Previous deliveries, previous Cesarean sections and women's level of education were significant in contraception acceptance. The rejection of contraceptives was mainly attributed to husbands.     

Chaperone use by obstetrician/gynecologists.

OBJECTIVE: To describe current practices of chaperone use during pelvic examinations among obstetrician/gynecologists affiliated with a large tertiary care teaching hospital. STUDY DESIGN: Questionnaires were distributed at department of obstetrics and gynecology grand rounds to all practicing attending physicians to obtain physician demographic data, including age, years in practice, practice type (solo or group) and whether chaperones were currently used when performing pelvic examinations at the first obstetric or gynecologic office visit. Physicians were also asked whether they were taught to use chaperones for pelvic examinations during medical school or residency. RESULTS: Of the 59 attending physicians, 100% responded to the questionnaire. As compared to female physicians, male physicians used chaperones more at the first obstetric examination (76.9% vs. 27.8%, P < .002), at gynecologic office visits (70.0% vs. 22.2%, P < .002) and for breast examinations (51.2% vs. 11.1%, P < .01). Physicians greater than 40 years old, in practice longer than 10 years and taught as medical students or residents to use chaperones were statistically more likely to use chaperones. No attendings, male or female, reported losing a patient to another provider or being sued or threatened with legal action because of not using a chaperone. CONCLUSION: Chaperones were used more frequently during pelvic examinations by male physicians, age greater than 40, solo practice, and physicians in practice longer than 10 years. Education affected current practices as specific medical student or residency training influenced the use of chaperones in private practice.     

Obstetric and gynecologic operations in the United States, 1979 to 1984

An in-depth analysis of numbers of obstetric and gynecologic operations from 1979 to 1984 was performed using data from the National Center for Health Statistics. During the study period, there was a decrease in total numbers of obstetric and gynecologic procedures of 1%. During the same five-year period the numbers of physicians who label themselves as obstetrician-gynecologists increased 22%. In 1983, a total of 809,000 cesarean sections were performed. It has become the most common hospital-based operation in this country. Twenty-one percent of all live births are now by cesarean section. The second most common obstetric and gynecologic operation is hysterectomy (673,000), and diagnostic dilation and curettage of uterus (632,000) third. These operations are also the second and third most common procedures performed in the United States. In 1983, obstetric and gynecologic operations represented 23% of all surgery completed in this country. These figures demonstrate the dynamics of obstetric and gynecologic surgical practice. They show that numbers of obstetric and gynecologic operations have decreased over the last five years, in spite of constantly increasing numbers of obstetrician-gynecologists. If current trends continue, future individual operative workloads, on average, will decrease with possible adverse effects on quality of obstetric-gynecologic surgical care.     

Adaptation of prenatal care and ultrasound

In the spring of 2020, expeditious changes to obstetric care were required in New York as cases of COVID-19 increased and pandemic panic ensued. A reduction of in-person office visits was planned with provider appointments scheduled to coincide with routine maternal blood tests and obstetric ultrasounds. Dating scans were combined with nuchal translucency assessments to reduce outpatient ultrasound visits. Telehealth was quickly adopted for selected prenatal visits and consultations when deemed appropriate. The more sensitive cell-free fetal DNA test was commonly used to screen for aneuploidy in an effort to decrease return visits for diagnostic genetic procedures. Antenatal testing guidelines were modified with a focus on providing evidence-based testing for maternal and fetal conditions. For complex pregnancies, fetal interventions were undertaken earlier to avoid serial surveillance and repeated in-person hospital visits. These rapid adaptations to traditional prenatal care were designed to decrease the risk of coronavirus exposure of patients, staff, and physicians while continuing to provide safe and comprehensive obstetric care.     

Far forward gynecologic care of the female soldier

OBJECTIVE: To evaluate the value, unit cost and medical effectiveness of providing specialized obstetric and gynecologic care far forward, at echelon III, the combat support hospital (CSH), in the operating theater of Afghanistan during Operation Enduring Freedom (OEF), rotation 5. STUDY DESIGN: Between April 2004 and September 2004, records were reviewed from the outpatient gynecology clinic at Bagram Air Field (BAF), in Afghanistan, through an approved protocol request. Cohort analysis was performed on all gynecologic patients. Significant differences in distribution of clinical factors were determined by Student's t test. RESULTS: A total of 62 cases were extracted for analysis over the 6-month period. Fifty-seven total patients were seen at echelon III, the CSH at BAF, while 5 were sent to level IV or V echelon care in Landstuhl, Germany. The average distance traveled for the patients coming to BAF was 158 km, while those sent to Germany averaged 5,204 km. The mean travel time in days was significantly lower among patients seen at BAF, 0.5 versus 7 days for patients sent to Germany. The time to appointment was also significantly lower among those patients seen at BAF: 0.04 versus 13 days for patients sent to Germany. CONCLUSION: We devised and implemented the concept of far forward specialized gynecologic care for women participating in OEF. This substantially decreased the woman-hours lost by their individual units. The far forward availability of gynecologic care and the supplies to evaluate and treat abnormal Pap smears should be considered by all military services in their plans for providing health care for the modern female soldier.     

Educational responsibilities and resources of obstetrics and gynecology departments in 1975

A survey of 108 departments of obstetrics and gynecology in United States medical schools was completed for 1975, and a statistical evaluation of their resources was made. The mean data showed that the student core clerkship had a duration of 6.9 weeks and an enrollment of 17.8 students. The departments had 11.3 full-time faculty members, 69.5 obstetric beds and 56.9 gynecologic beds. There were 3,891 deliveries, 1,846 minor gynecologic operations and 1,418 major gynecologic operations performed. These results should provide a data base upon which to compare the changes in departments in the future.     

Primed for a pandemic: Implementation of telehealth outpatient monitoring for women with mild COVID-19

Close observation and rapid escalation of care is essential for obstetric patients with COVID-19. The pandemic forced widespread conversion of in-person to virtual care delivery and telehealth was primed to enable outpatient surveillance of infected patients. We describe the experience and lessons learned while designing and implementing a virtual telemonitoring COVID-19 clinic for obstetric patients. All patients with suspected for confirmed COVID-19 were referred and enrolled. Telehealth visits were conducted every 24 to 72 hours based on the severity of symptoms and care was escalated to in person when necessary. The outcome of the majority (96.1%) of telehealth visits was to continue outpatient management. With regard to escalation of care, 25 patients (26.6%) presented for in person evaluation and five patients (5.3%) required inpatient admission. A virtual telemonitoring clinic for obstetric patients with mild COVID-19 offers an effective surveillance strategy as it allows for close monitoring, direct connection to in person evaluation, minimization of patient and provider exposure, and scalability.     

Characteristics of patients seen and services provided in primary care visits in obstetrics/gynecology: data from NAMCS and NHAMCS

Debate continues on the role of obstetricians/gynecologists in women's primary care and there is conflicting data on what these physicians actually do. Using data from nationally representative surveys, we found that obstetricians/gynecologists identify themselves as primary care providers for 21.7% of private physician office visits and 22.2% of hospital-based outpatient clinic visits. Primary care visits more often involved pregnancy care and less often included referred patients. Other demographic characteristics had different effects in community office practices versus hospital outpatient clinic visits. In general, preventive services and counseling were more likely to be provided in general/gynecologic examinations not designated as primary care provider visits. However, the more frequent provision of mental health counseling and lower rates of mammography services in primary care visits suggest that these obstetricians/gynecologists may serve a more longitudinal role in care for their patients. Overall, there continues to be strong variation in the role of obstetricians/gynecologists in women's primary care.     

Cambio del modelo asistencial en una unidad de uroginecología de un hospital de tercer nivel: impacto de la pandemia por COVID-19 en la presencialidad

The COVID-19 pandemic caused a sudden change in the usual care practice of our urogynaecology unit. Therefore, we designed a new healthcare model to adapt our practice to the epidemiological situation. The central axis of the new model was reduced hospital attendance, offering the same healthcare quality through the introduction of telemedicine.To achieve this aim, we made the following changes: a first telematic medical visit was the first step, telematic monitoring visits for conservative and pharmacological treatments and pack visit. We created the following packs: LUTS, postpartum and post-discharge pack. All packs included visits and diagnostic tests performed on the same day.The LUTS pack is indicated in patients with lower urinary tract symptoms, associated or not with pelvic organ prolapse. It includes two visits (nursing and medical) and two tests (urodynamics and pelvic floor ultrasound).The postpartum pack is indicated in women with symptoms of urinary incontinence, anal incontinence, pelvic organ prolapse and sexual disfunctions after delivery, as well as asymptomatic patients with a history of obstetric perineal trauma. It includes a medical visit, a pelvic floor ultrasound and a visit with the physiotherapist.The post-discharge pack is scheduled a month after the surgery and includes two tests (pelvic floor ultrasound and uroflowmetry) and a medical visit.Some face-to-face visits were maintained, as were physiotherapy treatments and other visits following medical criteria.     

The physician as a factor in outpatient medical care after laparoscopically assisted vaginal hysterectomy: a multivariate analysis

OBJECTIVE: To evaluate whether physician experience affects outpatient medical care utilization after laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: A total of 120 patients who underwent LAVH were included in the study; 84 underwent LAVH by 2 senior physicians, who had performed an average of 3 LAVHs per month for >6 years; 36 patients underwent LAVH by 3 junior physicians, who had performed an average of 1 case per month for < 3 years. Data were analyzed by the multiple linear regression model. The dependent variable was the number of outpatient visits within 3 months after discharge. The independent variables were patient age, parity, pelvic adhesions, chronic disease and physicians performing LAVH > 6 years. RESULTS: The patients in the 2 groups did not differ in age, parity, chronic disease or pelvic adhesions. The level of physician experience significantly influenced the mean number of outpatient visits after LAVH within 3 months. After controlling for patient characteristics, the mean number of outpatient visits after discharge within 3 months of LAVH performed by senior physicians with 6 years of experience was reduced (-1.98). CONCLUSION: LAVH performed by experienced physicians reduces the need for patients to seek postoperative outpatient medical care, thereby controlling medical costs incurred under the hospital global budget payment system. However, adding more variables to the multiple regression model, such as the socioeconomic status of patients, habits of seeking medical help, distance between home and hospital and relationship between patient and physician, may further explain the factors affecting outpatient medical care utilization.     

Analysis of 500 obstetric and gynecologic malpractice claims: causes and prevention

Five hundred obstetric and gynecologic malpractice litigation claims were analyzed to determine the incidence of claims that could not be defended because of breach of standards of care, problems with documentation, or both. Of the 500 claims, 294 were obstetric and 206 were gynecologic. Of the obstetric claims, 79 (27%) were indefensible because of breaches of standards of care (71%), problems with documentation (5%), or both (24%). Of the 206 gynecologic claims, 45 (22%) were indefensible because of breaches of standards of care (62%), problems with documentation (24%), or both (13%). The incidence of indefensible obstetric and gynecologic claims was 25%. Indefensible claims were analyzed to determine the common medical and surgical problems that instigated the malpractice suits. Recommendations are made that should reduce the incidence of indefensible malpractice suits.     

Bridging the Gap Between Textbook and Maternity Patient: A Nurse‐Developed Teaching Model for First‐Year Medical Students

Abstract: Background: Providing more opportunities for first‐year medical students to interact with patients in clinical settings is a current discussion topic in medical student education reform. Early clinical experience helps students bridge the gap between textbook and patient while observing patient‐centered care, and serves as a first step for students to develop the skills needed to work cooperatively as members of a multidisciplinary health care team. The author developed a model to provide perinatal education to first‐year medical students, consistent with the concept of interprofessional education. Methods: Primarily first‐year medical students participated in the nurse‐developed education model, a component of a noncredit extracurricular, student‐run perinatal program at a Midwestern university medical center. Students were placed at the bedsides of hospitalized women to provide support and education to them during perinatal procedures, labor, childbirth, and cesarean delivery. Results: A total of 350 students participated over a period of 13 school calendar years. Students remarked that participation in the program reinforced the importance of their concurrent anatomy and physiology classes. They observed interdependence and cooperation among the members of the health care team caring for women, and their evaluations of their experiences at the bedside were highly positive. Women consistently expressed appreciation for the additional individualized attention and education received from our student and nurse team. Conclusions: Nurses can enhance the learning of first‐year medical students in the maternity care clinical setting. This nurse‐developed education program provided students with a variety of vivid clinical experiences with maternity patients. (BIRTH 37:4 December 2010)