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Original research presentation at the APGO/CREOG Annual Meeting, held February 27th - March 1st, 2014 in Atlanta, GA.

Original research presentation at the APGO/CREOG Annual Meeting, held February 27th - March 1st, 2014 in Atlanta, GA.

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GO FOR IT Trial Oral Abstract Presentation Presentation Transcript

  • 1. Does an Intensive Two-Week Post Residency-Match M4 Elective Improve Competency Prior to Starting OBGYN Residency? Gynecology and Obstetrics Fundamentals of Residency: Internship Training Trial Francis S. Nuthalapaty, MD For Collaborative Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Office of Philanthropy and Partnership
  • 2. Investigators Greenville Health System/University of South Carolina School of Medicine Carolinas Medical Center •  Francis S. Nuthalapaty, MD (PI) •  H. Lee Higdon, PhD •  David A. Forstein, DO •  Robert V. Higgins, MD Medical College of Georgia •  Palmetto Health/University of South Carolina School of Medicine •  Chadburn Ray, MD •  Medical University of South Carolina Ashlyn Savage, MD Sarah Smith, MD University of Tennessee at Knoxville Florida State University College of Medicine •  •  Julie Z. DeCesare, MD St. Vincent’s Hospital •  Spencer G. Kuper, MD University of Tennessee Memphis •  Claudette Shepherd, MD Nikki B. Zite, MD Mayo Clinic College of Medicine •  Brian C. Brost, MD Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 3. Disclosure I have no relevant conflicts of interest to disclose Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 4. Purpose of the M4 Year Walling and Merando, Acad Med 2010 1. To facilitate completion of the predoctoral phase of medical education 2. To transition to the residency phase of medical education Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 5. Study Objective To determine the impact of participation in an intensive twoweek post residency-match M4 elective, as compared to usual student activities, on basic clinical, procedural, and knowledge competencies assessed at the start of OBGYN internship. Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 6. Study Design Phase 1 Oct 2011 – Sept 2012 Collaborator recruitment, training and IRB approval Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 7. Collaborative Centers 8 ACGME Accredited Residency Programs: 1. Greenville Health System/University of South Carolina Program | Greenville, SC 2. Carolinas Medical Center Program | Charlotte, NC 3. Florida State University College of Medicine Program | Pensacola, FL 4. Medical College of Georgia Program | Augusta, GA 5. Medical University of South Carolina Program | Charleston, SC 6. Palmetto Health/University of South Carolina School of Medicine | Columbia, SC 7. University of Tennessee Program | Memphis, TN 8. University of Tennessee Medical Center at Knoxville Program | Knoxville, TN Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 8. Study Design Phase 1 Mar 2012 – Sept 2012 Collaborator recruitment, training and IRB approval Phase 2 Oct 2012 – Jan 2013 Participant recruitment during residency interviews Phase 3 Phase 4 March 2013 April 2013 – June 2013 Participant enrollment Group assignment, study interventions and posttesting Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 9. Study Design Contingency Plan Intervention Study Population Measurement Randomize Control Measurement Study Group 1 Intervention Measurement Study Group 2 Control Measurement Experimental post-test only control group Quasi experimental static group Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Health System Office of Philanthropy and Partnership
  • 10. Study Subjects •  Inclusions: –  Participated in the 2013 NRMP –  Applied to ObGyn Residency –  Matched into one of the Collaborative Centers –  Available to relocate to Primary Study Center from April 15th – 26th, 2013 Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 11. Study Subjects •  Exclusions: –  Unavailable to complete end-of-study assessments Support  for  this  project  was  made  possible  in  part  by  the  APGO  Medical  Education  Endowment  Fund  and  the  Greenville  Hospital  System  OfAice  of  Philanthropy  and  Partnership
  • 12. Curriculum Design •  APGO/CREOG Milestone 1 Project Learning Outcomes –  35 Medical Knowledge –  29 Clinical / Procedural Skills •  Ranked in order of importance –  19 Medical Knowledge –  14 Clinical / Procedural Skills Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 13. Clinical/Procedural Skills 1.  2.  3.  4.  5.  6.  7.  Comprehensive women’s health history Breast and pelvic exam Two-handed surgical knot Intrapartum cervical exam Ruptured membranes evaluation Fetal heart rate monitor interpretation Pap smear and cervical cultures 8.  Names and uses of basic surgical instruments 9.  Wet mount interpretation of vaginal discharge 10.  Suture types and properties 11.  2nd degree vaginal laceration repair 12.  Spontaneous vaginal delivery 13.  Endometrial biopsy 14.  IUD Insertion Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 14. Curriculum Sources •  Search for existing teaching and learning tools –  Open-access, peer-reviewed (e.g. PubMed, MedEdPortal) –  Professional societies (e.g. APGO, CREOG, ASCCP, AIUM, CDC) –  Commercial learning tools (e.g. GE Healthcare) Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 15. Curriculum Delivery 1.  Live didactics (12 hours) –  Lecture, case-based discussion, webinar 2.  Live skills labs (50 hours) –  Self-directed online videos 3.  Self-directed learning (4 hours) –  Computer-based training Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 16. Curriculum Schedule Day 1 Day 2 Day 3 Orientation Day 4 Day 5 Didactics (1.5 hrs) Baseline Skills Assessment Skills Labs (3.0 hrs) Debrief Skills Labs (3.0 hrs) Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 17. Curriculum Schedule Day 6 Day 7 Day 8 Didactics (1.5 hrs) Skills Labs (3.0 hrs) Day 9 Day 10 Debrief Final Skills Assessment Skills Labs (3.0 hrs) Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 18. Study Assessments •  Medical Knowledge –  NBME ObGyn Subject Exam –  Surgical instrument identification –  Suture identification –  Surgical needle / blade identification Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 19. Study Assessments •  OSCE (Standardized Patient) –  Comprehensive women’s health history –  Breast and pelvic exam Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 20. Study Assessments •  OSAT –  Two-handed square knot –  IUD insertion –  Endometrial biopsy –  Intrapartum cervical assessment –  Spontaneous vaginal delivery –  2nd degree vaginal laceration repair Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 21. Assessment Design •  Analysis of published guidelines, texts •  Development of anchored checklist –  Complete –  Incomplete –  Not performed •  Reviewed by 1-2 faculty for content validity Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 22. Performance Checklist Assessment Design Name: Site: CMC FSU GHS MCG MUSC USC UT-Mem UT-Knox Cannot Judge Not Done Performance Checklist Complete Grading Key: Complete (2 points) = Examinee performed the task meeting all criteria in the description. Incomplete (1 point) = Examinee performed the task, but failed to meet all criteria in the Competency Assessment description. Not Done (0 points) = Examinee failed to perform the task. Vaginal Delivery Station 3: Normal Cannot Judge (0 points) = Unable to determine if the examinee performed the task. Incomplete Date: Performance Checklist General Approach / Interpersonal Communication Skills Name: 2 MUSC USC UT-Mem UT-Knox Examinee used either hand sanitizer or soap/water and proper technique to clean his/her hands upon entering the room. Introduction / Communication Incomplete Complete Grading Key: Upon entering the room, examinee greeted the patient, stated his/her name, Complete (2 points) = Examinee performed the task meeting all criteria in the participate in her care. ascertained/confirmed  the  patient’s  name and voiced intent to description. Incomplete (1 point) = Examinee performed the task, but failed to meet all criteria in the description. Not Done (0 points) = Examinee failed to perform the task. Labor Assessment / Preparation Cannot Judge (0 points) = Unable to determine if the examinee performed the task. 3 Examination Performance Checklist Examinee verbalized intent to perform a pelvic exam, performed the exam and then Cannot Judge Date: Hand Cleansing CMC FSU GHS MCG Not Done 1 Site: verbalized the need to prepare for delivery. General Approach / Interpersonal Communication Skills Delivery table 1 4 Hand Cleansing The examinee positioned the delivery table within arms reach. Examinee used either hand sanitizer or soap/water and proper technique to clean his/her hands upon entering the room. 2 Introduction / Communication Support for this project was made possible in part by the Universal Precautions Upon entering the room, the patient, stated his/her name, APGO Medical Educationexaminee greetedFund and the to participate in her care. System Office of Philanthropy and Partnership Endowment and voiced intent Greenville Hospital ascertained/confirmed  the  patient’s  name
  • 23. Study Interventions •  Baseline Self-Assessment of Competency •  GO FOR IT Group: –  Relocated to Greenville, SC –  April 15th – 26th, 2013 –  Participated in curricular activities •  Control Group: –  Usual activities Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 24. End-of-study Assessments •  NBME ObGyn Subject Exam –  June 15th – June 29th, 2013 –  Prometric testing center –  Scheduled at student’s convenience Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 25. End-of-study Assessments •  OSCE / OSAT Assessments: –  June 18th – July 2nd, 2013 –  Conducted at 5 of the collaborative centers –  Standardized assessment toolbox –  Video recording of all procedural stations Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 26. End-of-study Assessments •  Assessment Toolbox: –  Learning Outcomes –  Case Scenario (if applicable) –  Materials / Supplies / Personnel –  Student Instructions –  Assessment Checklist –  Photos –  Scoring Instructions (if applicable) Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 27. Data Management •  Scored immediately at time of testing by Proctor: –  Health History OSCE –  Breast and Pelvic Exam OSCE –  Vaginal Delivery OSAT –  2nd Degree Vaginal Laceration Repair OSAT Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 28. Data Management •  Scored post-hoc at Data Coordination Center (DCC) via video review: –  IUD Insertion OSAT –  Endometrial Biopsy OSAT Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 29. Data Management •  Scored post-hoc at DCC: –  Square Knot –  Intrapartum Cervical Assessment –  Instruments, Sutures, Needles, Blades Identification Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 30. Study Outcomes •  Primary: –  Composite score of all OSCE / OSAT end-ofstudy assessments •  Secondary: –  Individual OSCE / OSAT assessment scores –  NBME percentile score Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 31. Sample Size and Power •  Estimate of Primary Outcome: –  GO FOR IT Group: 80% –  Control Group: 64% –  Standard Deviation: 15% •  Alpha: .05 Power: 80% •  Two-tailed t-test Sample Size = 15 subjects per group Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 32. Data Analysis •  All data entered into Research Electronic Data Capture (REDCap) at DCC •  Exported to SPSS for analysis –  Descriptive statistics –  Student t-test for continuous data –  Chi-square for categorical data Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 33. Enrollment Results 42 Matched into OBGYN 9 2 21 10 Available to Participate in either Study Group Willing to Participate with School Permission Able to participate in Control Group only Declined Participation 11 21 GO FOR IT Group Control Group Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 34. Demographics GO FOR IT (N=11) Control (N=21) P value 27 26 .3 Graduation in 2013 91% 100% .4 USMLE Results Step 1 Step 2 CK Step 2 CS (pass) 224 241 100% 221 238 95% .6 .5 .6 Characteristic Age (yrs) Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 35. M3/M4 Experience 11.7 wks 9.4 wks 6.5 wks 5.4 wks Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 36. M3/M4 Experience 72.7% 77.7% 81.8% 50.0% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 37. Self-rated Competence GO FOR IT (N=11) Control (N=21) P value Two-handed knot tying 2.9 ± 0.7 3.6 ± 0.7 .01 Normal vaginal delivery 1.9 ± 0.3 2.5 ± 0.5 .001 Clinical Skill / Procedure •  1 = I am unable to perform the entire procedure under supervision •  2 = I am able to perform the procedure under supervision •  3 = I usually do not require supervision but may need help occasionally •  4 = I am competent to perform the procedure unsupervised (I can deal with complications). Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 38. Primary Outcome Composite Score on OSCE / OSAT GO FOR IT Control 70.8% 40.6% SD =13.2 vs. SD =19.5 p=.0003 Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 39. Secondary Outcomes 80.0% 76.8% 59.0% 59.7% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 40. Secondary Outcomes 65.5% 56.4% 26.0% 26.0% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 41. Secondary Outcomes 90.2% 62.1% 36.6% 49.6% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 42. Secondary Outcomes 62.9% 61.0% 41.3% 55.8% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 43. Secondary Outcomes 83.9% 61.3% 25.0% 32.9% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 44. Secondary Outcomes 75.8% 69.3% 58.9% 28.6% 26.7% 6.9% Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 45. Secondary Outcomes Square Knot GO FOR IT Control 100% 85.7% (11/11) vs. (18/21) p=.5 Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 46. Secondary Outcomes NBME ObGyn Subject Exam Overall-year percentile GO FOR IT Control 57.8 49.6 SD = 29.0 vs. SD =28.9 p=.5 Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 47. Conclusion Participation in an intensive twoweek post residency-match M4 elective results in significantly greater clinical, procedural, and knowledge competency as compared to the usual activities students pursue at the conclusion of the M4 year. Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 48. Discussion •  Greatest impact on procedural skills •  Lesser impact on medical knowledge •  Effect was sustained over 8-10 week period between training and final testing •  Self-rated competency did not correlate with outcomes Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 49. Weaknesses •  Quasi-experimental design •  Un-weighted procedural checklists •  Non-blinded procedural rating •  Exposure bias in GO FOR IT group •  Unknown transference to actual clinical performance and outcomes Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 50. Strengths •  Multicenter •  Large sample size •  Heterogeneous study population •  Reproducible curriculum based on national recommendations and non-proprietary tools •  Multiple forms of competency assessment Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 51. Recommendations •  OBGYN educators should implement intensive residency preparation opportunities near the end of the M4 year to assure achievement of desired competency prior to starting residency Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 52. Questions? goforitcourse.com
  • 53. Investigators Greenville Health System/University of South Carolina School of Medicine Carolinas Medical Center •  Francis S. Nuthalapaty, MD (PI) •  H. Lee Higdon, PhD •  David A. Forstein, DO •  Robert V. Higgins, MD Medical College of Georgia •  Palmetto Health/University of South Carolina School of Medicine •  Chadburn Ray, MD •  Medical University of South Carolina Ashlyn Savage, MD Sarah Smith, MD University of Tennessee at Knoxville Florida State University College of Medicine •  •  Julie Z. DeCesare, MD St. Vincent’s Hospital •  Spencer G. Kuper, MD University of Tennessee Memphis •  Claudette Shepherd, MD Nikki B. Zite, MD Mayo Clinic College of Medicine •  Brian C. Brost, MD Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 54. Course Length/Content Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 55. Course Timing Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 56. Financial Responsibility Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 57. Participant Comments “Thank you Thank you Thank you. You have saved my butt. I didn't realize how much I had forgotten and how much I didn't know. You have made me feel much more confident and competent going into July.” “The amount of confidence gained from this course alone has made it worthwhile. I don't feel as much as an imposter anymore :)” Support for this project was made possible in part by the APGO Medical Education Endowment Fund and the Greenville Hospital System Office of Philanthropy and Partnership
  • 58. goforitcourse.com