Tag Archives: gynecology

Doctors Face Fallout from Adverse Events

When things go wrong medically or surgically – whether or not a mistake was made – two parties get hurt: the patient and the physician. It’s nice to see increasing attention on the effects of bad outcomes on physicians, as I reported in a previous post.

A new video helps ob.gyns. cope when things go wrong. (Sherry Boschert/IMNG Medical Media)

Here are the latest examples. The American College of Obstetricians and Gynecologists (ACOG) just released a new DVD that it is sending to all ob.gyn. residency program directors to view with their residents. Called “Healing Our Own: Adverse Events in Obstetrics and Gynecology,” the video features ob.gyns. describing the painful effects that adverse events have had on them, and how they recovered.

The video can be viewed in a members-only section of the ACOG website and it was shown in the Exhibit Hall during ACOG’s recent annual meeting.

Both members and non-members are welcome to join (for a fee) an ACOG-sponsored webinar on Adverse Events, Stress, and Litigation on July 10 at 1 p.m. Eastern Time. The webinar will address feelings of isolation, guilt, and shame that physicians commonly experience when bad things happen to their patients, feelings that only get exacerbated if the event leads to a lawsuit.

Ob.gyns. are the sixth most likely medical specialists to get sued regardless of whether a mistake was made, according to a 2011 report in the New England Journal of Medicine.

The stress created by adverse events is just a part of the higher than usual stress levels that physicians try to cope with every day. Tools like the American Medical Association’s A Physician’s Guide To Personal Health offer strategies for staying sane and healthy under stress. Non-profit groups like Medically Induced Trauma Support Services (MITSS) offer tools and templates for health care workers after adverse events, though they mainly focus on helping patients through the trauma. MITSS did post an extensive bibliography online for articles and resources related to the impact of adverse events on caregivers.

If you know of other medical specialty organizations like ACOG that are helping physicians cope with the fallout from adverse events, let us know and we’ll share the resources with our readers.

–Sherry Boschert (on Twitter @sherryboschert)

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Filed under Family Medicine, IMNG, Obstetrics and Gynecology, Uncategorized

Survival of the Abstinent Teen

Image courtesy of Wikimedia Creative Commons

Having a daughter who’s a “band nerd” may be music to a parent’s ear in more ways than one.

A new survey of 282 adolescent girls aged 12-21 reports that participation in band is significantly associated with current sexual abstinence.

The researchers came to the project with high hopes that potentially intervenable factors such as higher academic achievement, greater involvement in activities, and open family communication about sexual activity would be positively associated with abstinence.

That didn’t really play out, author and fourth-year medical student Kathryn Squires said at the recent meeting of the North American Society for Pediatric and Adolescent Gynecology.

There was no difference in GPA, involvement in sports, or most curricular and non-school-related activities between sexually active and abstinent teens.

Sexual activity, however, was associated with the typical risk factors of age of at least 18 years, having a job, having an increased number of boyfriends or an older recent boyfriend, and risky peer behaviors.

Positive influences on abstinence in all age groups were: participation in band, participation in school clubs, having abstinent friends, and personal and peer avoidance of alcohol and drugs, reported Ms. Squires and her colleagues at Washington University in St. Louis.

So what is it about band that helps adolescents elect to remain sexually abstinent?

Was the study group somehow unique? Not likely. When surveyed during 2008-2009 at a scheduled gynecologic visit with her parent present, 68% of participants reported being abstinent. This falls roughly in line with the 2009 Youth Risk Behavior Surveillance Survey, in which 46% of high school females reported ever being sexually active.

Is it the music? Not likely. Marching bands, like the one at the University of Michigan, are side-stepping the likes of John Philip Sousa today in favor of such hipsters as Lady Gaga.

Is it the geek factor?

“We had a lot of other what could probably be considered geeky things on there, like the newspaper, and those didn’t seem to make a difference,” Ms. Squires said. (I take umbrage at this remark, but then I grew up thinking Woodward & Bernstein were cool.)

“Maybe band is just more involved, but then sports are more involved too, as far as practices. So I don’t think it’s the time commitment.”

Having had any number of band nerds in our house over the years, I asked my two college daughters about the finding. After the giggling stopped, they suggested that band members, quite simply, are a very tight-knit group of kids. I wouldn’t assign a P value to this anecdotal info, but there’s something to be said for having a posse of friends to turn to when an adolescent considers taking that first step toward sex.

For physicians disinclined to advise parents to push their kids towards the tuba or trombone, Ms. Squires points out that ages 15-17 appear to be a critical period in which teens value their parents’ opinion the most, and it makes the most difference in delaying sexual initiation. “So that might be a good time for parental involvement or a medical intervention,” she said.

That said, I’m not so sure there’s ever a bad time for parental involvement, but then I didn’t ask my girls about that.

By Patrice Wendling

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Filed under Family Medicine, IMNG, Obstetrics and Gynecology, Pediatrics, Primary care

Hysterectomy Disconnect

At least two-thirds of hysterectomies in the United States are still performed through an abdominal incision, despite the availability of minimally invasive approaches that are associated with less pain, shorter hospital stay, more rapid recovery, and better cosmesis. In an attempt to change that, the AAGL  Advancing Minimally Invasive Gynecology Worldwide has just issued a position statement calling for nearly all hysterectomies that are done for benign uterine disease to be performed vaginally or laparoscopically, rather than abdominally.

"TAH" stands for Total Abdominal Hysterectomy. Image courtesy of Intuitive Surgical Inc.

According to the AAGL, the few contraindications to laparoscopic hysterectomy (LH) include conditions in which the risks of general anesthesia or intraperitoneal pressure are deemed unacceptable or where uterine malignancy is suspected. For both LH and vaginal hysterectomy (VH), exceptions include situations where trained surgeons or required facilities are unavailable, or in certain cases of distorted anatomy.

Otherwise, AAGL said, “When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice.” 

So why aren’t they?  After all, in some European countries the rate of abdominal hysterectomy (AH) is less than 25%.  Interesting insight can be found in the results of a recently published online/paper survey sent to a random sample of 1,500 practicing U.S. obstetrician-gynecologists.

Among the 376 who responded, the most commonly performed hysterectomy procedure in the previous year was AH (by 84% of respondents), followed by VH (76%).  But when asked to rank which hysterectomy approach they would prefer for themselves or their partner, 56% ranked VH as their first choice and 41% ranked LH as their first choice, with only 8% opting for AH. 

When asked about barriers to performing minimally invasive procedures, the most common ones reported for VH included technical difficulty, potential for complications, and personal caseload. For LH, respondents cited lack of training during residency, technical difficulty, personal surgical experience, and operating time as barriers. 

Nonetheless, when asked about their ideal goal for mode of access, the respondents felt on average that minimally invasive techniques should comprise 79% of all hysterectomy procedures. 

According to the AAGL’s position statement, “Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do, or should refer patients requiring hysterectomy to such individuals for their surgical care.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Anesthesia and Analgesia, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology, Plastic Surgery, Practice Trends, Surgery, Uncategorized

Where Do Incompetent Surgical Trainees Go?

From the Society of Gynecologic Surgeons, New Orleans.

It’s something you might not want to contemplate: what happens to surgeons who don’t really shine during training for their chosen specialty? Do they get the equivalent of social advancement and, thus, are turned loose to operate regardless of their competency? Or are they held back in the interest of preventing yet another malpractice suit?

Credit: Flickr user get directly down

Credit: Flickr user get directly down

That discussion unfolded as Dr. J. Eric Jelovsek of the Cleveland Clinic presented data on a study of ob-gyn surgical residents and fellows showing that it was possible to set training standards and establish minimum cut-offs proving competency.  Currently, surgical skills are not assessed by any licensing body or by the American Board of Obstetrics and Gynecology, said Dr. Jelovsek.

All of the surgeons-in-training in the trial — whose operations were videotaped and evaluated by experts — proved to be competent at performing vaginal hysterectomy, Dr. Jelovsek said.

But many of the surgeons in the audience wondered aloud whether instructors in the OR had subtly influenced performance through coaching — and thus invalidated results.  And, of more concern, they said, was what happens to residents and fellows who don’t meet such competency cut-offs.

Dr. Jelovsek said that the cut-offs have been used at Cleveland Clinic to tell trainees they should not attempt vaginal hysterectomy for the first year in practice without supervision or to say “we highly advise you do not perform this procedure in your practice.”  Some have been held back for another year of training.

But there was a clear sense of unease among attendees.

One questioner raised the specter of litigation and asked if results for incompetent trainees might be considered “discoverable” by plaintiffs’ attorneys.  Dr. Jelovsek advised surgeons to check laws in their states.

—Alicia Ault (on Twitter @aliciaault)
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Filed under Obstetrics and Gynecology, Practice Trends