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Healthcare providers often perform under significant stress, during which their performance must be optimal, but is known to suffer. Stress management interventions in this context can provide cognitive support to rescue performance. This exploratory study sought to evaluate the effect of stress intervention components on stress and performance while clinicians engaged in two versions of a computer-based task, differing in overall level of demand: one high-stress and one low-stress. Participants (

Disclosure of medical errors and adverse outcomes is expected by regulatory agencies and society as a whole. Disclosure should occur in a systematic way that ensures honesty and transparency regarding the care that has been provided. It is often appropriate to seek professional help from Clinical Risk Management to assist with disclosure of any serious safety event that resulted in harm. Disclosure of medical errors facilitates efforts to prevent recurrence of safety events.

Designed for all providers of women's healthcare - including those undertaking Maintenance of Certification programs, trainees preparing for postgraduate examinations, and those initiating or growing a program of quality improvement and patient safety - this practical manual guides those implementing QI and safety programs with specific emphasis on Obstetrics and Gynecology practice. The content contains a strong case-based element to improve accessibility and understanding. An introductory section covers core attributes needed by all physicians to build a culture of patient safety, including leadership, communication and QI skills. Core clinical skills are then reviewed - in a variety of labor ward, office, operating room, and outpatient settings. Finally systems implications are highlighted, including information transparency and disclosure, training programs, and regulatory and legal implications. The editors are involved with national and international initiatives educating physicians in safety aspects of practice. The book is published in collaboration with the Foundation for EXXcellence.

Objective To integrate group-based lifestyle sessions (GBLS) within prenatal care for gestational weight gain (GWG) management. Methods In Study 1, participants attended GBLS during prenatal care visits. Participants in Study 2 attended off-site GBLS whereby care providers were asked to discuss the program with patients. Process and outcome evaluation were conducted through a mixed-methods approach. Results In both pre-experimental feasibility studies, data provide preliminary support for GBLS (eg, positive care provider and patient feedback, weight gain patterns) as well as highlight areas for future research (eg, lack of GWG management discussions, preference for GBLS location). Conclusions GBLS represents a promising approach to GWG management. Future research should assess the generalizability, sustainably, and compatibility of GBLS within prenatal care.

A common endeavor shared by physicians practicing in specialty fields of Radiology and Obstetrics and Gynecology is the comprehensive care and diagnosis of women with breast problems and breast disease. Because each specialty provides its respective clinical expertise in breast health, each also shares a concern, which is the high risk of litigation associated with a missed or delayed diagnosis of breast cancer. This shared concern is well documented for both specialties. Instead, it is argued that physicians are better prepared by engaging in the practice of evidence-based breast care in their respective specialties.

The frequency of surgical procedures in the office setting is increasing, and patient safety in this setting now has an expanded focus. Methods and strategies, including Ambulatory Patient Safety Guidelines, results tracking, communication, and risk management principles, will be reviewed in this chapter.

Objective: The purpose of this study was to compare the costs and net revenue associated with robotic versus traditional laparoscopic hysterectomies. Design: The study was designed as a retrospective chart review. Methods: The study group consisted of patients who underwent laparoscopic hysterectomies using the robotic versus standard laparoscopy from January 2005 to March 2009. Data were collected as the mean for the cohort and included total charges, total collected, total direct costs, and operative margin (OM). Total costs were divided into operating room costs (labor, supplies, and equipment), hospital costs (anesthesia, pharmacy, room, and board) and additional costs. Statistical analysis was performed comparing the two groups by the Wilcoxon rank sum test, two sided t test, and Fisher exact test. Results: Twenty-eight robotic cases were matched to 48 laparoscopic cases. Demographics were similar between groups. Total charges where higher with the robot, ($30,725 vs. $22,526, p

The purpose of this study was to determine how a medical student's self-assessment at the completion of the third-year Ob/gyn clerkship compares with the institution's final grades at Lehigh Valley Hospital. From November 2002 to November 2003 at completion of each six-week Ob/gyn clerkship rotation, 47 medical students assessed themselves on the following parameters: fund of knowledge, personal attitude, clinical problem-solving skills, written/verbal skills, and technical skills. Additionally, they were asked to predict their performance on the NBME Shelf Exam. Their assessments were then compared with their final clerkship grades in each of the above parameters. Chi-squared and Kendall-tau tests were used to analyse the data for degree of agreement and association, respectively. There was a statistically significant weak to moderate, positive correlation between students' self-assessment and final clerkship grade for written/verbal skills (p = 0.002, r = 0.390). A statistically significant agreement between raters was also revealed for written/verbal skills (p = 0.003). Weak, non-statistically significant, positive relationships were revealed for fund of knowledge, clinical problem-solving and technical skills. A weak, negative, non-significant relationship was revealed for personal attitudes, and there was no statistically significant relationship between students' prediction of NBME score and categorized true score (p = 0.717, r = 0.49). At the end of their Ob/gyn clerkship, third-year medical students are better at assessing their technical and written/verbal skills than their global fund of knowledge and personal attitudes. These results may suggest that students are not aware of their own personal attitudes and communication skills and how they can affect their effectiveness as a physician.

Background Klippel-Trenaunay syndrome is a rare disease characterized by capillary malformationsand soft tissue and bony hypertrophy and atypical varicosities. Management of this syndrome is focused primarily on treatment of the complications that arise from these malformations. Ascites and lymphedema are two of the more common complications in these patients. Case A 15-year-old female with Klippel-Trenaunay syndrome presented with chylous ascites, vaginal drainage, and unilateral lower extremity lymphedema. Treatment included dilation, hysteroscopy and curettage, and laparoscopic evacuation of abdomino-pelvic ascites with resolution of symptoms for 32 months. Repeat laparoscopic drainage was successful and remains symptom free after 12 months. Conclusion Vaginal drainage of chylous ascites is a rare complication from Klippel-Trenaunay syndrome and can be successfully managed by techniques to remove abdomino-pelvic ascites.

Objective: To determine if a preoperative conference impacts the resident recommended surgery on gynecology patients seen in continuity clinics. Study Design: A twice monthly preoperative conference was initiated in January of 2009 where residents presented their proposed surgical intervention. A retrospective review of the first 100 preoperative conference submission forms was performed and analysis made on how often the type or route of surgery was changed based on conference discussion and if further workup or tests were requested prior to scheduling surgery. Results: Discussion of patients through a preoperative conference venue resulted in a change in surgical management of 36% of patients, and further medical management prior to surgery was recommended in 29%. Conclusions: A preoperative gynecology conference does impact the chosen surgery for resident patients. This venue may be a valuable tool for teaching residents optimization of the preoperative evaluation and selection of the appropriate surgical intervention.

OBJECTIVE: Describe characteristics compliance efficacy and side effect profile of adolescents and young women who use intrauterine contraception (IC). STUDY DESIGN: Retrospective chart review of adolescent and young women who had IC devices placed over a 3-year period. Comparative statistics between devices and population characteristics were performed using the Fisher exact and the t test. RESULTS: Eighty-nine patients were included in the study. The mean age at insertion was 19.5 years (range 16-22 years). Copper was used in 13% of patients; levonorgestrel (LNG) was used in 87%. The mean duration of use was 331.3 days (copper vs LNG; P = .2254). Side effects included infection (9% but no pelvic inflammatory disease) pain (28%) partner felt strings (9%) and bleeding (32%). Reasons for removal included side effects (25%) desired fertility (5%) expulsion (3%) and pregnancy (2%). There were no pregnancies associated with the LNG IC and there were fewer removals because of side effects than with the copper IUD (P = .0180). CONCLUSION: IC is a reliable method of contraception in teens and young adults. There were fewer removals because of side effects in the LNG group although overall other variables are similar between methods. Copyright A(c) 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Objective: To determine if preeclampsia is an immunologic disease process consistent with a host-vs.-graft reaction by examining differences in immunoglobulin deposition at the maternal-fetal interface (Nitabuch's layer) in preeclamptic patients. Study design: A prospective study of patients at Lehigh Valley Hospital was conducted between July 1993 and April 1994. Group I (study) consisted of 11 primigravid women meeting the criteria for the diagnosis of preeclampsia. Group 2 (control) consisted of 11 primigravid women who had an uncomplicated pregnancy. At delivery, basal plate placental specimens were obtained, fixed, and processed for study by a blinded observer utilizing IgG, IgA, IgM, IgE immunofluorescence techniques. The placenta was then sent to a gynecologic pathologist for blinded evaluation and measurement of Nitabuch's membrane by light microscopy. Results: Taking the average width of 3 measurements of Nitabuch's membrane by light microscopy revealed no significant difference (group 1, .1839 mm vs. group 2, .1555 mm). Immunofluorescence techniques revealed that the thickness of immunofluorescence of Nitabuch's membrane was significantly greater in the study group vs. the control group (157.48 pixels vs. 63.80 pixels, P = .006, respectively). Conclusion: Evaluation of the maternal-fetal interface reveals the deposition of increased immunoglobulins, the physiology of which may be similar to nephropathies as seen in systemic disease processes. The deposition of immunoglobulins may be associated with a common antigen which may point to an immunologic etiology for

A common endeavor shared by physicians practicing in specialty fields of Radiology and Obstetrics and Gynecology is the comprehensive care and diagnosis of women with breast problems and breast disease. Because each specialty provides its respective clinical expertise in breast health, each also shares a concern, which is the high risk of litigation associated with a missed or delayed diagnosis of breast cancer. This shared concern is well documented for both specialties. Instead, it is argued that physicians are better prepared by engaging in the practice of evidence-based breast care in their respective specialties.

Large benign adnexal masses may be safely managed with single-site laparoscopy., Introduction: Single-site laparoscopy is gaining acceptance in many surgical fields including gynecology. The purpose of this report is to demonstrate the technique and outcome for removing a large adnexal mass through a single site. Case Description: A 41-y-old female was referred to gynecology oncology for increased abdominal girth for 3 mo. An ultrasound confirmed a benign-appearing, 37-cm left adnexal mass. The mass was removed through a single-site laparoscopic incision with the aid of drainage and a morcellator. The operating time was 84 min. The patient was discharged 2 h and 35 min later with full return to normal activity in 5 d. Conclusion: Large, benign-appearing adnexal masses can be managed safely with superior cosmetic results using single-site laparoscopy.

Up to 14 percent of women experience irregular or excessively heavy menstrual bleeding. This abnormal uterine bleeding generally can be divided into anovulatory and ovulatory patterns. Chronic anovulation can lead to irregular bleeding, prolonged unopposed estrogen stimulation of the endometrium, and increased risk of endometrial cancer. Causes include polycystic ovary syndrome, uncontrolled diabetes mellitus, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics. Women 35 years or older with recurrent anovulation, women younger than 35 years with risk factors for endometrial cancer, and women with excessive bleeding unresponsive to medical therapy should undergo endometrial biopsy. Treatment with combination oral contraceptives or progestins may regulate menstrual cycles. Histologic findings of hyperplasia without atypia may be treated with cyclic or continuous progestin. Women who have hyperplasia with atypia or adenocarcinoma should be referred to a gynecologist or gynecologic oncologist, respectively. Ovulatory abnormal uterine bleeding, or menorrhagia, may be caused by thyroid dysfunction, coagulation defects (most commonly von Willebrand disease), endometrial polyps, and submucosal fibroids. Transvaginal ultrasonography or saline infusion sonohysterography may be used to evaluate menorrhagia. The levonorgestrel-releasing intrauterine system is an effective treatment for menorrhagia. Oral progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs are also effective. Tranexamic acid is approved by the U.S. Food and Drug Administration for the treatment of ovulatory bleeding, but is expensive. When clear structural causes are identified or medical management is ineffective, polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation may be considered. Hysterectomy is the most definitive treatment.

The challenges inherent in medical education are multiple, including recognition of different learning styles among students, incorporation of the Accreditation Council for Graduate Medical Education competencies and outcomes measurement into the curriculum, and compliance with mandated duty hours along with a heightened awareness of patient safety required by our regulatory institutions. With the requirement that safety become an explicit part of the residency curriculum across all specialties, educators are charged with innovative ways of achieving this goal. The following commentary addresses this need and suggests an innovative approach to the traditional daily rounds' SOAP (subjective, objective, assessment, and plan) note to incorporate a second S for safety. The use of a SOAPS note elevates each encounter by integrating quality and error avoidance as a component of care. This method teaches the next generation of physicians the importance of patient safety as an integral part of every doctor-patient interaction.

To investigate the relationship between ERAS-based preinterview scores, residency program postinterview scores and candidate rank order for the match.Two hundred sixty-three candidates' preinterview and postinterview scores and rank order were evaluated. The rank order was stratified as 1-4, 5-8, 9-12,13 and unranked. Spearman's p statistical analysis was used.There was a moderate relationship, r2 = 0.543, between preinterview and postinterview scores for all applicants. There was a significant inverse correlation between preinterview score and rank order, r2 = -0.763, and for the postinterview and rank order, r2 = -0.768. However, there were no significant relationships between factors significant for the top 4 ranked candidates.Preinterview and postinterview scores significantly correlated with each other and with the rank order list except for top-ranked candidates. Other factors may influence the rank order list.

To compare the use of episiotomy by private practitioners vs. resident staff and to determine if number of years in practice influences episiotomy use.A retrospective chart review of vaginal deliveries at 35 weeks or greater between January 2001 and June 2001. The number of years in practice by each private physician was documented. Independent sample t tests and chi2 tests were used to analyze data.In 995 deliveries, episiotomies were performed in 6% of low-risk resident deliveries vs. 26% of low-risk private deliveries (p0.001). Physicians in practiceor = 15 years performed episiotomies in 32% of low-risk births. Physicians in practice15 years performed episiotomies in 22% of low-risk births (p = 0.027).Deliveries performed by private practitioners are associated with a higher rate of episiotomy than those by resident staff. The number of episiotomies appears to increase by number of years in practice.

A retrospective study was performed comparing centralized monitoring to noncentralized monitoring in regard to perinatal outcome. The study was conducted at Lehigh Valley Hospital (Allentown, PA) between August 1994 and February 1995. All deliveries during a 28-week-period were studied retrospectively. The study was designed such that for 14 weeks all patients were centrally monitored (Group A). During the following 14 weeks, no patients were centrally monitored (Group B). Patients not requiring monitoring, such as elective cesarean sections, were excluded from the study. The variables that were studied were the 5-minute Apgar, cord blood pH, perinatal mortality, admissions to the neonatal intensive care unit (NICU), spontaneous vaginal deliveries, cesarean sections, and operative vaginal deliveries. A total of 1,622 deliveries occurred during the 28 weeks of antenatal care. Group A consisted of 805 centralized monitored patients and Group B had 817 noncentralized monitored patients. There was no statisti...