Effect of novel patient interaction on students’ performance of pregnancy options counseling

Background: Although options counseling is a fundamental skill for medical providers, previous research has identified gaps in medical school reproductive health education. Purpose: To determine if a 1-h novel patient interaction (NPI) improves student performance when caring for a standardized patient with an unintended pregnancy. Methods: From September 2012 to June 2013 we randomized third-year medical students at the University of Colorado School of Medicine to the standard curriculum plus an NPI, or the standard curriculum only. The NPI consisted of a 1-h small-group session with a patient who discussed her experiences with options counseling and her decision to terminate her pregnancy. Students completed an Objective Structured Clinical Examination (OSCE) at the rotation's end, which included options counseling. The primary outcome was the proportion of participants achieving ‘excellence’ on the OSCE checklist. ‘Excellence’ was defined as a score ≥90%. Examinations were flagged as ‘unsatisfactory encounters’ if core competencies were not addressed. OSCE standardized patients and evaluators were blinded to group assignment. Results: In total, 135 students were eligible and randomized: 75 to NPI; 60 to control. During the OSCE, few students achieved ‘excellence’ (24% NPI vs. 28% control, p=0.57).There were no differences between scores for components of options counseling. More students in the control group ‘appeared somewhat uncomfortable’ delivering the pregnancy test results (5% NPI vs. 18% control, p=0.006). More than half (54%) of the intervention group and 67% of controls had ‘unsatisfactory encounters’ (p=0.16), almost exclusively due to omission of adoption. Most students addressed abortion (96% NPI vs. 92% control, p=0.29). Conclusions: A 1-h NPI does not improve medical students’ performance of pregnancy options counseling and the option of adoption is routinely omitted. Adoption is clearly an area that needs greater attention when designing comprehensive reproductive health curriculum for medical students

Interest in Medication and Aspiration Abortion Training among Colorado Nurse Practitioners, Nurse Midwives, and Physician Assistants

ObjectivesWe examined advanced practice clinicians' (APCs: nurse practitioners [NPs], certified nurse midwives [CNMs], physician assistants) interest in training to provide medication and aspiration abortion in Colorado, where abortion provision by APCs is legal.MethodsWe surveyed a stratified random sample of APCs, oversampling women's health (CNMs/women's health nurse practitioners [WHNPs]) and rural APCs. We examined prevalence and predictors of interest in abortion training using weighted χ2 tests.ResultsOf 512 participants (21% response), the weighted sample is 50% NPs, 41% physician assistants, and 9% CNMs/WHNPs; 55% provide primary care. Only 12% are aware they can legally provide abortion. A minority of participants disagree that medication abortion (15%) or aspiration abortion (25%) should be in APC scope of practice. Almost one-third (29%) are interested in medication abortion training and 16% are possibly interested; interest is highest among CNMs/WHNPs (52%) (p < .01). Interest in aspiration abortion training is 15% with another 11% who are possibly interested; interest is highest among CNMs/WHNPs (34%) (p < .01). There are no significant differences in abortion training interest by rural practice location or by receipt of abortion education in graduate school. Participants not interested in medication and aspiration abortion training cited abortion being outside their specialty practice scope (44% and 38%, respectively) and religious or personal objections (42% and 34%). Among clinicians interested in medication abortion training, 33% believe their clinical facility is likely to allow them to provide this service, compared with 16% for aspiration abortion.ConclusionsInterest in abortion training among Colorado APCs is substantial. However, facility barriers to abortion provision must be addressed to increase abortion access with APCs

The impact of adjuvant antihormonal therapy versus observation on recurrence of borderline ovarian tumors: A retrospective cohort study

Objectives: Adjuvant management of borderline ovarian tumors (BOT) after surgical diagnosis and staging is not standardized. While many patients undergo observation alone, some providers have introduced the use of adjuvant antihormonal therapy for BOT, extrapolating from studies suggesting improvement in progression-free survival in the low-grade serous ovarian carcinoma population. We hypothesized that adjuvant antihormonal therapy after surgical diagnosis of BOT would improve progression-free survival compared to surveillance alone. Methods: This is a retrospective review of BOT at one academic institution over thirteen years comparing management with antihormonal therapy, including aromatase inhibitors, progestins, and selective estrogen receptor modulators, to surveillance alone. Patients with concurrent malignancy were excluded. Data were abstracted from electronic medical records. Groups were compared by bivariate statistics. Results: We identified 193 patients with BOT. Of these, 17 (8.8%) were treated with adjuvant antihormonal therapy and 24 (12.4%) recurred. Patients treated with antihormonal therapy were more likely to be obese (64.7% vs 37.9%, p = 0.032), have advanced-stage disease (70.6% vs 11.4%, p < 0.001), serous histotype (94.1% vs 59.4%, p = 0.005) or microinvasion (29.4% vs 9.7%, p = 0.030), and less likely to have undergone fertility-sparing surgery (18.8% vs 51.7%, p = 0.012). Use of antihormonal therapy was not associated with a difference in recurrence or survival. Conclusions: This study is the first retrospective cohort review of adjuvant antihormonal therapy in BOT. We found that adjuvant antihormonal therapy for BOT is not associated with recurrence. While this single institution retrospective cohort study may lack the power to confirm or refute benefit, further studies could evaluate whether a subpopulation exists in whom antihormonal therapy is worthwhile

Bevacizumab induced hypertension in gynecologic cancer: Does it resolve after completion of therapy?

Hypertension (HTN) induced by bevacizumab is a side effect that is often thought to resolve after treatment. However, there are currently no reports on rates of resolution. We assess the incidence and timing of the resolution of bevacizumab induced HTN. We evaluated all patients treated with bevacizumab for gynecologic malignancies at a single institution from 2012 through 2014. HTN was retrospectively diagnosed and staged by CTCAE v4.0 criteria. Resolution of HTN was defined as ≥2 values return to baseline blood pressure and/or discontinuation/decrease of blood pressure medications. We identified 104 patients; 35 were excluded due to receiving bevacizumab at time of analysis. Grade 2 or higher induced HTN was identified in 34/69 (49.3%) patients, of which 26/69 (37.7%) had grade 2 HTN and 8/69 (11.6%) had grade 3/4 HTN. Onset of HTN occurred at a median of 67 (14–791) days. Resolution of HTN occurred in 28/34 (82.4%) patients with a median time to resolution of 87 (3–236) days. BMI, history of HTN, blood pressure medications, prior bevacizumab treatment, number of bevacizumab cycles, CA-125 and albumin at initiation of treatment were not independent risk factors associated with developing HTN in multivariate analysis. Median PFS for those with HTN was 12.5 (1.9–45.8) months vs 11.0 (2.1–44.7) for those without (p = 0.17). Hypertension induced by bevacizumab resolved in 82% of patients in a median of 87 days. There were no identifiable risk factors associated with induced HTN and HTN was not a biomarker for improved prognosis in our cohort

Patient Views on Religious Institutional Health Care

Importance: Federal protections allow health facilities to limit options to patients on the basis of religious values. Little is known about whether US adults consider religious affiliation when selecting facilities and whether they agree with such limitations. Objective: To understand patient views on religious institutional care. Design, Setting, and Participants: This is a population-based, cross-sectional survey study of US adults recruited from the probability-based AmeriSpeak Omnibus panel available from NORC (formerly the National Opinion Research Center) at the University of Chicago. Surveys were administered via internet or telephone during a 3-day fielding period in November 2017. Data analysis was performed from January 2018 to October 2019. Exposures: Participant characteristics, including religiosity measures. Main Outcomes and Measures: Whether patients consider religious affiliation when selecting a health care facility and their views on whether an institution's religious values should take precedence over their health choices. Responses were compared by gender. When gender differences existed, regression models were performed, and thematic content analysis was applied to open-ended responses. Results: There were 1446 participants (745 [51.5%] male; mean [SD] age, 46 [17] years), for a survey completion rate of 24.5% and weighted cumulative response weight of 7.3%. Most respondents (62.6%) were white, and the most common religion was Protestant (28.2%). When specifically asked, only 6.4% reported that they considered religious affiliation when selecting a health care facility; most participants (71.3%) reported when selecting a health care facility that they did not care whether it is religiously affiliated, 13.4% preferred a religious affiliation, and 15.3% preferred no religious affiliation. There were no gender differences. Most participants (71.4%) believed that their health choices should take priority over an institution's religious affiliation in services offered, and this was more common for women than for men (74.9% vs 68.1%; difference, 6.8%; 95% CI, 5.6%-8.2%; P = .005), who more commonly endorsed concerns for personal choice and autonomy over one's own body. Conclusions and Relevance: This study suggests that most patients value their personal choices, yet do not consider an institution's religious affiliation when choosing their source of health care. Women placed greater emphasis on their autonomy in comparison with an institution's right to invoke religious restrictions to care. Given the growth in ownership of health care facilities by religious entities in the United States and increasing attention to conscientious objections, these findings point to a need for advocacy and legislation that effectively balances protections for religious institutions with protections for patients.</p

Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology

Residency training in obstetrics and gynecology is being challenged by increasingly stringent regulations and decreased operative experience. We sought to determine the perception of preparedness of incoming gynecologic oncology fellows for advanced surgical training in gynecologic oncology. An online survey was sent to gynecologic oncologists involved in fellowship training in the United States. They were asked to evaluate their most recent incoming clinical fellows in the domains of professionalism, level of independence/graduated responsibility, psychomotor ability, clinical evaluation and management, and academia and scholarship using a standard Likert-style scale. The response rate among attending physicians was 40% (n = 105/260) and 61% (n = 28/46) for program directors. Of those who participated, 49% reported that their incoming fellows could not independently perform a hysterectomy, 59% reported that they could not independently perform 30 min of a major procedure, 40% reported that they could not control bleeding, 40% reported that they could not recognize anatomy and tissue planes, and 58% reported that they could not dissect tissue planes. Fellows lacked an understanding of pathophysiology, treatment recommendations, and the ability to identify and treat critically ill patients. In the academic domain, respondents agreed that fellows were deficient in the areas of protocol design (54%), statistical analysis (54%), and manuscript writing (65%). These results suggest that general Ob/Gyn residency is ineffective in preparing fellows for advanced training in gynecologic oncology and should prompt a revision of the goals and objectives of resident education to correct these deficiencies