BackTable Women's Health

In this episode, Dr. Veronica Lerner joins Drs. Amy Park and Mark Hoffman at the mic to shed light on simulation in gynecologic surgery.

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SHOW NOTES

Dr. Lerner is an Associate Professor at the Zucker School of Medicine at Hofstra/Northwell. She is on the Editorial Board of Obstetrics and Gynecology, and she is an associate editor for Simulation in Healthcare Journal.

The episode begins with Dr. Lerner describes her journey and training regarding simulation in gynecologic surgery, including her participation in the Center for Medical Simulation at Harvard and involvement in the American College of Obstetricians and Gynecologists Simulations Working Group, which are both involved in validating and advancing the use of simulation in healthcare. During this time, Dr. Lerner provides a framework for developing a simulation center at an institution, which begins with needs assessment and defining learning objectives. She also emphasizes the financial costs for simulation, as well as concern for institutions without adequate resources for simulation. She then defines 3 terms regarding fidelity: cost, technology, and actual fidelity. For example, Dr. Lerner has built her own mobile simulation lab, which she describes as a high-fidelity, low-cost initiative.

The physicians then discuss the role of individualized learning plans in regard to simulation. Dr. Lerner references the book, “Make It Stick,” to emphasize the importance of tailoring training to the learning strategy of the learner. She also encourages listeners to acknowledge the risk of moral injury and to combat it by acknowledging the difficulty that may come with developing competency in simulation. Lastly, she describes how listeners should leverage resources and time in order to promote simulation at individual institutions.

The episode ends with the group recognizing the benefits of simulation, as well as its relation to the field of Quality and Safety. While simulation in obstetrics is well-studied, its role in the field of gynecology has lagged due to lack of financial incentives. To address this, Dr. Lerner urges listeners to take advantage of surgical simulation in a safe environment prior to operating in the OR. During this discussion, Dr. Lerner expresses the importance of trainees to gain exposure to simulation early on and to develop an “education portfolio” over the period of residency. In order to help continue the information learned through simulation, it is important to “teach the teacher, train the trainer, and disseminate that knowledge.” Ultimately, Dr. Lerner advocates for the endless opportunity that simulation brings to the field of gynecology surgery.

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RESOURCES

ACOG simulation consortium:

https://www.acog.org/education-and-events/simulations/about

“Make it Stick” by Henry L Roediger III, Mark A McDaniel, Peter Brown

EMIGS Assessment:

https://www.abog.org/specialty-certification/surgical-skills-program-standard/essentials-in-minimally-invasive-gynecologic-surgery-emig

In this episode of BackTable ENT, Dr. Julie Wei discusses navigating disability insurance as a physician with Dr. Stephanie Pearson, a former OB/GYN who started her own personal insurance brokerage firm.

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SHOW NOTES

First, Dr. Pearson shares about her struggle with disability. Early in her career, she suffered a traumatic injury that led to the development of a frozen shoulder and ended her clinical practice. Her group disability insurance did not cover work-related injuries, and she had to sue in order to receive her worker’s compensation insurance. She did not feel like she was properly educated about insurance policy and was promptly terminated from her OB/GYN job after her medical leave was over. Her emotional recovery was challenging, but she found support from her spouse, children, and dog. She eventually found her identity outside of her role as a physician, which helped ease her guilt of being a financial burden on her family.

Her personal disability journey motivated her to co-found a personal insurance brokerage firm with an insurance broker. PearsonRavitz was started five and a half years ago and has nationwide clients, the majority of whom are medical professionals. She frequently gives online and in-person lectures about the importance of buying disability insurance to residents and new attendings. Dr. Wei agrees and compares working in a surgical subspecialty to physical labor, as repetitive motions may increase injury risk.

Both doctors agree that standardized education for residents and medical students about disability insurance is needed. Some common myths that Dr. Pearson debunks the myths that group insurance benefits are adequate, healthy doctors do not need insurance coverage, and residents cannot afford disability insurance. Finally, the doctors end the episode by discussing unique health concerns of female surgeons, such as Infertility risk and delivery complications.

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RESOURCES

PearsonRavitz

https://pearsonravitz.com/

In this episode, Dr. Ian Fields joins Dr. Mark Hoffman at the mic to discuss the role of the microbiome in obstetrical and gynecological conditions.

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SHOW NOTES

Dr. Ian Fields completed a fellowship in Female Pelvic Medicine & Reconstructive Surgery and received a Master of Clinical Research degree from Oregon Health & Sciences University. His research focuses on changes in the urinary microbiome and their association with lower urinary tract symptoms.

Dr. Fields begins the episode by describing the microbiome as “all of the things outside of our cells that make up the human body,” which includes bacteria, viruses, and fungi. He explains that the microbiome may play a role in how humans maintain states of health, in addition to having large impacts on the pathophysiology or development of disease states. Dr. Fields references the Human Microbiome Project, a United States National Institutes of Health research initiative that was aimed to improve the understanding of microbiota in relation to human health and diseases.

The physicians then transition to cover the role of the microbiome, specifically in the field of obstetrics and gynecology. Dr. Fields explains that the most studied condition is bacterial vaginosis. From a urogynecology perspective, he expresses a particular interest in urinary tract disorders, such as urinary incontinence, recurrent urinary tract infections, and interstitial cystitis. Dr. Fields emphasizes to listeners that urine is not sterile. In addition, he highlights how the use of vaginal estrogen increases the presence of lactobacillus within the genital microbiome, and thus is beneficial in the settings of genitourinary syndrome of menopause and recurrent menopause.

Dr. Fields concludes the episode by briefly addressing other areas of study regarding the microbiome in the field of obstetrics and gynecology. For example, studies have revealed a link between vaginal microbiota and risk of preterm birth, as well as neonatal gut microbiota and the mode of delivery. Ultimately, Dr. Fields states that the microbiome is an underfunded and understudied aspect of medicine, and he urges listeners to acknowledge the large potential the field has.

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RESOURCES

The Human Microbiome Project:

https://hmpdacc.org/hmp/overview/

Brubaker L, Nager CW, Richter HE, Visco A, Nygaard I, Barber MD, Schaffer J, Meikle S, Wallace D, Shibata N, Wolfe AJ. Urinary bacteria in adult women with urgency urinary incontinence. Int Urogynecol J. 2014 Sep;25(9):1179-84.

Wolfe AJ, Toh E, Shibata N, Rong R, Kenton K, Fitzgerald M, Mueller ER, Schreckenberger P, Dong Q, Nelson DE, Brubaker L. Evidence of uncultivated bacteria in the adult female bladder. J Clin Microbiol. 2012 Apr;50(4):1376-83.

Hoffman C, Siddiqui NY, Fields I, Gregory WT, Simon HM, Mooney MA, Wolfe AJ, Karstens L. Species-Level Resolution of Female Bladder Microbiota from 16S rRNA Amplicon Sequencing. mSystems. 2021 Oct 26;6(5):e0051821.

Richter HE, Carnes MU, Komesu YM, Lukacz ES, Arya L, Bradley M, Rogers RG, Sung VW, Siddiqui NY, Carper B, Mazloomdoost D, Dinwiddie D, Gantz MG; Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Association between the urogenital microbiome and surgical treatment response in women undergoing midurethral sling operation for mixed urinary incontinence. Am J Obstet Gynecol. 2022 Jan;226(1):93.e1-93.e15.

Fettweis, J.M., Serrano, M.G., Brooks, J.P. et al. The vaginal microbiome and preterm birth. Nat Med 25, 1012–1021 (2019).

In this episode, Dr. Mark Hoffman invites Dr. Cheryl Iglesia to shed light on the topic of cosmetic gynecology.

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SHOW NOTES

Dr. Iglesia is the Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center, as well the current President of the Society of Gynecologic Surgeons. In addition to being involved with a consensus document regarding cosmetic gynecology, Dr. Iglesia has contributed numerous studies to the growing field and hopes to educate other providers on the topic.

The episode begins with Dr. Iglesia sharing how she became passionate about cosmetic gynecology. Her experience initially began with a weekend course in California learning about topics such as “laser vaginal rejuvenation” and “designer laser vaginoplasty,” which were early marketing terms used for the field. After multiple years of training and education within a field filled with gray areas and limited evidence-based medicine, she later helped develop a consensus document about cosmetic gynecology procedures, which provides clarification for patients and opportunity for future research studies.

Dr. Iglesia then describes the field of cosmetic gynecology, which includes the elective intervention to alter the aesthetic appearance of the external genitalia or modify the genital organs. These elective, functional procedures may be performed in the absence of any pathology (e.g., no incontinence, prolapse, etc.) with the goal of improving a person’s quality of life (e.g., sexual function). She describes two pillars of the field, including cosmetic (e.g., labiaplasty) versus functional (e.g., surgical tightening of the vagina for vaginal laxity) procedures. The physicians then address the concerns of societal pressure, agreeing that the goal is to help patients make well-informed, ethical decisions, which requires discussing goals with patients.

After discussing the field as a whole, Dr. Iglesia then highlights different procedures and technologies. For example, a fractionated laser may be used to stimulate tissue growth and may be utilized for diagnosis such as genitourinary syndrome (GSM) of menopause or lichen sclerosis. In addition, she briefly mentions aesthetic procedures, including a clitoral frenulum reduction (frenulectomy) or clitoral amplification with platelet rich plasma or the O-Shot. She addresses that a lot of the procedures and technologies are proprietary, have limited evidence, and are not risk-free. Ultimately, Dr. Iglesia states that there is a need for more data, urging the need for future level I trials.

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RESOURCES

Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Joint Report on Terminology for Cosmetic Gynecology. Int Urogynecol J. 2022 Jun;33(6):1367-1386.

Li FG, Maheux-Lacroix S, Deans R, Nesbitt-Hawes E, Budden A, Nguyen K, Lim CY, Song S, McCormack L, Lyons SD, Segelov E, Abbott JA. Effect of Fractional Carbon Dioxide Laser vs Sham Treatment on Symptom Severity in Women With Postmenopausal Vaginal Symptoms: A Randomized Clinical Trial. JAMA. 2021 Oct 12;326(14):1381-1389.

Paraiso MFR, Ferrando CA, Sokol ER, Rardin CR, Matthews CA, Karram MM, Iglesia CB. A randomized clinical trial comparing vaginal laser therapy to vaginal estrogen therapy in women with genitourinary syndrome of menopause: The VeLVET Trial. Menopause. 2020 Jan;27(1):50-56.

Burkett LS, Siddique M, Zeymo A, Brunn EA, Gutman RE, Park AJ, Iglesia CB. Clobetasol Compared With Fractionated Carbon Dioxide Laser for Lichen Sclerosus: A Randomized Controlled Trial. Obstet Gynecol. 2021 Jun 1;137(6):968-978.

Cosmetic Gynecology and the Elusive Quest for the “Perfect” Vagina:

https://journals.lww.com/greenjournal/Citation/2012/10000/Cosmetic_Gynecology_and_the_Elusive_Quest_for_the.34.aspx

In this episode, Drs. Maya Hammoud and Helen Morgan of the University of Michigan join Drs. Amy Park and Mark Hoffman to discuss the OB/GYN residency application process.

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SHOW NOTES

Dr. Maya Hammoud is Chief of Women’s Health Division and Associate Chair for Education at the University of Michigan. Dr. Helen Morgan is the Director of Residency Preparation Courses at the University of Michigan. Together, Drs. Hammoud and Morgan are leading the $1.7 million American Medical Association (AMA) Reimagining Residency Grant for Association of Professors of Gynecology and Obstetrics (APGO) Right Resident, Right Program, Ready Day One.

The episode begins with Drs. Hammoud and Morgan sharing a call to action regarding the need to transition the emphasis of applying to residency from the lens of individual achievements to that of an individual’s competency as a future physician. The two physicians share what inspired them to contribute to making changes in the realm of OB/GYN, including personal experiences from advising medical students at the University of Michigan to their own family members. During this time, they address pitfalls of the current system, including the financial expenses for applications.

The group then transitions to describe the 5-year grant that led to the development of Right Resident, Right Program, Ready Day One. The program addresses 2 components: (1) the application process itself, and (2) students’ readiness for residency. The physicians cover the topic of “application fever” (i.e., the large increase in the number of applications that each student submits), and how the field of OB/GYN has adopted “program signaling” with the hope to mitigate this ongoing trend. Drs. Hammoud and Morgan also address topics such as growth mindset, holistic review of applications, importance of coaching for preparation for residency, and the increasing popularity of OB/GYN as a specialty.

Lastly, the group highlights other aspects of the residency application process, including methods to ensure an equitable review process, the need to increase diversity in the field, the standardized letter of evaluation (SLOE), and best practices to facilitate transition to residency. During this conversation, Drs. Hammoud and Morgan share about the residency preparation courses that are available for medical students at the University of Michigan.

In this episode, Drs. Amy Park and Mark Hoffman welcome Dr. Angela Chaudhari, Chief of Gynecology and Gynecologic Surgery at Northwestern Memorial Hospital, to share her experience promoting a culture of physician wellness as the Director of the P2P Network for Physician Peer Support.

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SHOW NOTES

Dr. Chaudhari discusses how her inspiration to advocate for physician wellness began when she herself was experiencing feelings of burnout. Initially an open ear for colleagues on an individual level, Dr. Chaudhari was later trained on the topic of wellness through the Scholars of Wellness Program and received her Organization Leadership and Coaching Certificate at Northwestern University.

Dr. Chaudhari then explains that, through the program, volunteers from both medical and non-medical backgrounds are trained to provide support for those experiencing adverse events, “compassion fatigue,” and discriminatory patient experiences. In addition, peers are also available to provide feedback or education. Specific metrics for the program include retention, wellbeing scores, and culture surveys to identify “pain points'' within the Institution.

Next, the doctors discuss the topic of “work-life integration,” rather than work-life balance, and how to promote this in your own practice. While acknowledging that it may be difficult to advocate for yourself and set boundaries early on in your career, the group emphasizes the role of mentorship and how this can empower trainees/learners to take action sooner rather than later.

The episode ends with a discussion on creating culture in your workplace. The doctors express sentiments that maintaining an intentional, positive outlook and treating all colleagues with respect is a key aspect in promoting wellness. In addition, they encourage listeners to acknowledge difficult situations and to share personal experiences to further promote an environment of support and growth.

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RESOURCES

Define Measure Analyze Improve Control (DMAIC) Process:

https://asq.org/quality-resources/dmaic

Stolarski A, Moseley JM, O’Neal P, Whang E, Kristo G. Retired Surgeons’ Reflections on Their Careers. JAMA Surg. 2020;155(4):359–361. doi:10.1001/jamasurg.2019.5476

In this episode, Dr. Jessica Branham, a board-certified obstetrician-gynecologist affiliated with Highlands ARH Regional Medical Center invites listeners to learn about practicing OB/GYN in a rural setting. As a Kentucky native who was born and raised in Eastern Kentucky, Dr. Branham shares her personal experiences and the challenges that she has faced caring for a population that often requires the most medical attention, yet has the least access to resources.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/29D37F

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SHOW NOTES

The episode begins with Dr. Branham describing her day-to-day work schedule. As she shares the workflow of her clinic and OR days, as well as call shifts, she emphasizes how her patients’ care is typically subject to herself as their sole medical provider (e.g., handling a postpartum hemorrhage without access to Interventional Radiology). Due to this, Dr. Branham routinely thinks multiple steps ahead in regard to her patients’ care in order to decide if she can continue herself or if the patient has to be transported to a higher-acuity center.

Dr. Branham then transitions to discuss the challenges that she faces as a physician practicing in a rural setting. Using personal anecdotes and published data, she emphasizes barriers such as decreasing numbers of OB/GYNs choosing to practice in rural areas, as well as the weather conditions dictating whether or not a patient may be transported via helicopter or ambulance to an alternative hospital. In addition, she covers the impact of the opioid use epidemic that largely impacts the Appalachian region.

Lastly, Dr. Branham ends the episode by sharing why she passionately chooses to practice in rural Kentucky, despite the challenges she may face: her dedication to serving patients who are often in the most need of medical care. She also describes current systems in place to help improve care for her patients, including the Blue Angels Program, which provides telehealth visits with Maternal Fetal Medicine specialists at the University of Kentucky and traveling ultrasound clinics to specific areas in rural Kentucky counties.

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RESOURCES

The Blue Angels Program:

https://kytelecare.med.uky.edu/kytelecare-telehealth-mobile

In this episode, Dr. Cara King, the Fellowship Director for Minimally Invasive Gynecologic Surgery at Cleveland Clinic and a member of the Board of Directors of the Academy for Surgical Coaching, discusses the topic of surgical coaching and its benefits for physicians, trainees, and learners.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/8NpBpF

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SHOW NOTES

Dr. King begins the episode by describing surgical coaching as an act of asking open-ended questions, determining where a “coachee” is currently at, identifying their goals, and then empowering them to make specific actions that are needed to close this gap. During the discussion, she emphasizes the importance of prioritizing self-assessment as a coach.

Dr. King then explains how to find a surgical coach through the Academy for Surgical Coaching. The process requires a “coachee” to complete a form that identifies their personal goals, and then the “coachee” is paired with a coach from the pool of physicians from various specialties. Coaching experiences are performed through various platforms (e.g., in-person, video-based, etc.) and are ideally conducted for 3-, 6-, or 12-month periods. Dr. King also covers how outcomes and metrics are evaluated, describing the differences between technical and non-technical (e.g., judgment) skills.

The doctors transition to emphasize the importance of incorporating coaching into a surgeon’s practice. Dr. King shares 2 methods to do so, including (1) replacing 1-hour of grand rounds or meetings with 1 hour of coaching sessions, as well as (2) integrating coaching at the level of national societies (e.g., American Association of Gynecologic Laparoscopists). The doctors go on to highlight also incorporating coaching at the level of medical schools and residency in order to instill the mentality of continual improvement early on in a physician’s career.

The episode ends with Dr. King sharing the steps to becoming a surgical coach through the Academy for Surgical Coaching, which includes a paid certification program.

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RESOURCES

Atul Gawande, “Personal Best”:

https://www.newyorker.com/magazine/2011/10/03/personal-best

The Academy for Surgical Coaching:

https://surgicalcoaching.org

Greenberg CC, Byrnes ME, Engler TA, Quamme SPR, Thumma JR, Dimick JB. Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions. Ann Surg. 2021 Jun 1;273(6):1034-1039.

In this episode, Dr. Bagrodia discusses cultivating a healthy culture inside and outside of the operating room with Dr. Chris Kane, Dean of Clinical Affairs at UCSD and CEO of the UCSD Physician Group.

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SHOW NOTES

First, the doctors discuss the definition of culture, which Dr. Kane defines as the norms of behavior and relationships within an organization. Culture can include dress code, meeting rules, and punctuality. Most of the time, institutional culture is established in an unspoken way. Dr. Kane emphasizes the importance of having a conscious strategy to create a healthy culture and reiterates that trust is a crucial foundation for motivating cultural changes.

Next, the doctors discuss helping team members find meaning in their work. Dr. Kane recommends that surgeons share patient gratitude with their other colleagues who are not frontline medical workers. He acknowledges his staff’s contributions during meetings and expresses his gratitude through written notes. He also recommends communication training for everybody on his team. Then, he shares tips for assessing organizational culture. He believes that it is most important to ask team members what they think the overarching goal of the institution is and to assess the attrition rate through exit surveys. He emphasizes that behavioral norms matter most, as department leaders often lead by example. One detrimental practice is favoritism, which Dr. Kane regards as disrespectful to other team members. Additionally, he shares his personal experiences with changing cultures at different institutions and utilizing change management theories.

Finally, Dr. Kane shares general leadership advice. He highlights the importance of creating a patient-centered environment, leading by influence rather than authority, and the power of positivity.

In episode 8, Dr. Mark Hoffman invites Drs. Melissa Wong of Cedars-Sinai and Tony Shanks of Indiana University to share the mic and talk about the use of virtual reality (VR) in labor.

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SHOW NOTES

Dr. Melissa Wong, MD, MHDS is a board-certified Maternal Fetal Medicine specialist and an Assistant Professor of OB/GYN at Cedars-Sinai in Los Angeles, California. She also works in the division of informatics and with the National Institutes of Health Office of Research on Women’s Health. Dr. Wong has studied the use of VR to mitigate the pain associated with labor, and she is continually finding opportunities for the use of VR to enhance the field of OB/GYN.

Dr. Tony Shanks, MD, a co-host of BackTable OBGYN, joins the podcast again as a Maternal Fetal Medicine specialist at Indiana University. He currently serves as the Vice Chair of Education at the institution, as well as the Maternal Fetal Medicine Fellowship Director.

In this episode, Dr. Wong describes the methods and conclusions of her study, “Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial,” which ultimately determined that the use of VR was associated with a reduction in pain during labor compared to patients who received no intervention.

The group also discusses the potential for VR within the obstetrical and gynecologic sides of the field, as well as the field of medicine in general. Some topics that were mentioned include the use of VR for in-office procedures and patient education through visualization of complicated surgical procedures. In addition, the group highlights the potential for additional technological advancements in medicine through augmented reality, artificial intelligence, and informatics.

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RESOURCES

Wong MS, Spiegel BMR, Gregory KD. Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial. Am J Perinatol. 2021 Aug;38(S 01):e167-e172. doi: 10.1055/s-0040-1708851. Epub 2020 Jun 2. PMID: 32485759.

Sridhar A, Shiliang Z, Woodson R, Kwan L. Non-pharmacological anxiety reduction with immersive virtual reality for first-trimester dilation and curettage: a pilot study. Eur J Contracept Reprod Health Care. 2020 Dec;25(6):480-483. doi: 10.1080/13625187.2020.1836146. PMID: 33140989.

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