News for Your Practice

Breast density is a strong, prevalent, and potentially modifiable risk factor for breast cancer, which makes it of special interest to clinicians whose jobs involve breast cancer risk prediction. That was the theme of a talk by Karla Kerlikowske, MD, of the UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco. Dr. Kerlikowske delivered the John I. Brewer Memorial Lecture May 3 at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco.

Mammographic breast density is a radiologic term, Dr. Kerlikowske explained. “The only way to really know someone’s breast density is if they have a mammogram.” The whiter the mammogram, the denser the breast. The darker the mammogram, the fattier the breast.

According to the American College of Radiology, the following 4 categories of breast composition are defined by the “visually estimated” content of fibroglandular-density tissue within the breasts:
A. The breasts are almost entirely fatty.
B. There are scattered areas of fibroglandular density.
C. The breasts are heterogeneously dense, which may obscure small masses.
D. The breasts are extremely dense, which lowers the specificity of mammography.

Categories C and D signify dense breasts, which contain a high degree of collagen, epithelial cells, and stroma. In the United States, more than 25 million women are thought to have dense breasts.

Women who have a family history of breast cancer are more likely to have dense breasts. And women who have dense breasts have an elevated risk of breast cancer. They also have a higher risk of advanced disease, as well as a higher risk of large, high-grade, and lymph node-positive tumors, said Dr. Kerlikowske.

Breast-density legislation is increasing
Twenty-two states now have laws mandating that women found to have heterogeneously dense or extremely dense breasts be notified of their status, said Dr. Kerlikowske. That prompts the question: How should these patients be managed?

Breast density declines with age. Breast density also is influenced by body mass index (BMI). As BMI increases, density declines.

Breast density also can be affected by medications, such as hormone therapy and tamoxifen, Dr. Kerlikowske said.

For example, breast density declines about 1% to 2% per year in postmenopause. In postmenopausal women who take estrogen alone, breast density increases slightly. “But the real increase is for people who take estrogen plus progestin,” said Dr. Kerlikowske. “It’s thought that the progestin component is what increases breast density.” Estrogen-progestin therapy confers the same risk of breast cancer as that faced by a premenopausal woman with dense breasts.

As for tamoxifen, it reduces breast density by 2% to 3% per year in postmenopausal women, Dr. Kerlikowske said. “People who have a decrease of more than 10% in breast density are those who have a reduction in breast cancer.” If a woman doesn’t have that reduction with tamoxifen—about half of women don’t—there is no reduction in breast cancer mortality.

“There’s some thought that you should look at mammograms during the first year of tamoxifen use and, if you don’t see a change, consider switching to another medication,” said Dr. Kerlikowske.

More frequent mammograms and supplemental imaging are options for detecting cancers early. Among the modalities that have been studied in this regard are ultrasonography, tomosynthesis, and breast magnetic resonance imaging (MRI).

“If you do more tests, such as ultrasound, you will definitely find additional lesions,” said Dr. Kerlikowske. “There’s no question. But what are the harms?”

The biopsy rate almost doubles after ultrasonography, compared with mammography. And the number needed to screen to detect cancer is fairly high. For mammography, that number is about 250. For ultrasonography, tomosynthesis, and breast MRI, it is higher.

Tomosynthesis is more cost-effective than supplemental ultrasonography because it decreases the number of false positives, Dr. Kerlikowske said.

What’s the bottom line?
Not every woman with dense breasts is at high risk for breast cancer, said Dr. Kerlikowske. And although breast density is prevalent, it is potentially modifiable.

Nevertheless, breast density confers an elevated risk of breast cancer and can also mask tumors. Women with dense breasts likely should avoid the use of postmenopausal hormone therapy. They also may be candidates for more frequent mammography and/or supplemental imaging.

The Breast Cancer Surveillance Consortium (BCSC) Risk Calculator is the only tool that incorporates breast density. In the works is a new model that also incorporates benign breast disease.

Risk-prediction tool considers density and other factors
A risk-prediction tool from the Breast Cancer Surveillance Consortium (BCSC) is the only model to incorporate breast density. The BCSC Risk Calculator is available free of charge for the iPhone and iPad (an Android version is in the works). The tool takes 5 factors into consideration in estimating a woman’s 5-year risk of developing invasive breast cancer:
• age
• race/ethnicity
• breast density
• family history of breast cancer (first-degree relative)
• personal history of breast biopsy.
The tool is designed for use by health professionals. It is not appropriate for determining risk in women younger than 35 years or older than 79 years; women with a previous diagnosis of breast cancer, lobular carcinoma in situ, ductal carcinoma in situ, or atypical ductal hyperplasia; or women who have undergone breast augmentation. Other risk-prediction models are more appropriate for women with a BRCA mutation.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Breast density is a strong, prevalent, and potentially modifiable risk factor for breast cancer, which makes it of special interest to clinicians whose jobs involve breast cancer risk prediction. That was the theme of a talk by Karla Kerlikowske, MD, of the UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco. Dr. Kerlikowske delivered the John I. Brewer Memorial Lecture May 3 at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco.

Mammographic breast density is a radiologic term, Dr. Kerlikowske explained. “The only way to really know someone’s breast density is if they have a mammogram.” The whiter the mammogram, the denser the breast. The darker the mammogram, the fattier the breast.

According to the American College of Radiology, the following 4 categories of breast composition are defined by the “visually estimated” content of fibroglandular-density tissue within the breasts:
A. The breasts are almost entirely fatty.
B. There are scattered areas of fibroglandular density.
C. The breasts are heterogeneously dense, which may obscure small masses.
D. The breasts are extremely dense, which lowers the specificity of mammography.

Categories C and D signify dense breasts, which contain a high degree of collagen, epithelial cells, and stroma. In the United States, more than 25 million women are thought to have dense breasts.

Women who have a family history of breast cancer are more likely to have dense breasts. And women who have dense breasts have an elevated risk of breast cancer. They also have a higher risk of advanced disease, as well as a higher risk of large, high-grade, and lymph node-positive tumors, said Dr. Kerlikowske.

Breast-density legislation is increasing
Twenty-two states now have laws mandating that women found to have heterogeneously dense or extremely dense breasts be notified of their status, said Dr. Kerlikowske. That prompts the question: How should these patients be managed?

Breast density declines with age. Breast density also is influenced by body mass index (BMI). As BMI increases, density declines.

Breast density also can be affected by medications, such as hormone therapy and tamoxifen, Dr. Kerlikowske said.

For example, breast density declines about 1% to 2% per year in postmenopause. In postmenopausal women who take estrogen alone, breast density increases slightly. “But the real increase is for people who take estrogen plus progestin,” said Dr. Kerlikowske. “It’s thought that the progestin component is what increases breast density.” Estrogen-progestin therapy confers the same risk of breast cancer as that faced by a premenopausal woman with dense breasts.

As for tamoxifen, it reduces breast density by 2% to 3% per year in postmenopausal women, Dr. Kerlikowske said. “People who have a decrease of more than 10% in breast density are those who have a reduction in breast cancer.” If a woman doesn’t have that reduction with tamoxifen—about half of women don’t—there is no reduction in breast cancer mortality.

“There’s some thought that you should look at mammograms during the first year of tamoxifen use and, if you don’t see a change, consider switching to another medication,” said Dr. Kerlikowske.

More frequent mammograms and supplemental imaging are options for detecting cancers early. Among the modalities that have been studied in this regard are ultrasonography, tomosynthesis, and breast magnetic resonance imaging (MRI).

“If you do more tests, such as ultrasound, you will definitely find additional lesions,” said Dr. Kerlikowske. “There’s no question. But what are the harms?”

The biopsy rate almost doubles after ultrasonography, compared with mammography. And the number needed to screen to detect cancer is fairly high. For mammography, that number is about 250. For ultrasonography, tomosynthesis, and breast MRI, it is higher.

Tomosynthesis is more cost-effective than supplemental ultrasonography because it decreases the number of false positives, Dr. Kerlikowske said.

What’s the bottom line?
Not every woman with dense breasts is at high risk for breast cancer, said Dr. Kerlikowske. And although breast density is prevalent, it is potentially modifiable.

Nevertheless, breast density confers an elevated risk of breast cancer and can also mask tumors. Women with dense breasts likely should avoid the use of postmenopausal hormone therapy. They also may be candidates for more frequent mammography and/or supplemental imaging.

The Breast Cancer Surveillance Consortium (BCSC) Risk Calculator is the only tool that incorporates breast density. In the works is a new model that also incorporates benign breast disease.

Risk-prediction tool considers density and other factors
A risk-prediction tool from the Breast Cancer Surveillance Consortium (BCSC) is the only model to incorporate breast density. The BCSC Risk Calculator is available free of charge for the iPhone and iPad (an Android version is in the works). The tool takes 5 factors into consideration in estimating a woman’s 5-year risk of developing invasive breast cancer:
• age
• race/ethnicity
• breast density
• family history of breast cancer (first-degree relative)
• personal history of breast biopsy.
The tool is designed for use by health professionals. It is not appropriate for determining risk in women younger than 35 years or older than 79 years; women with a previous diagnosis of breast cancer, lobular carcinoma in situ, ductal carcinoma in situ, or atypical ductal hyperplasia; or women who have undergone breast augmentation. Other risk-prediction models are more appropriate for women with a BRCA mutation.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Breast density is a strong, prevalent, and potentially modifiable risk factor for breast cancer, which makes it of special interest to clinicians whose jobs involve breast cancer risk prediction. That was the theme of a talk by Karla Kerlikowske, MD, of the UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco. Dr. Kerlikowske delivered the John I. Brewer Memorial Lecture May 3 at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco.

Mammographic breast density is a radiologic term, Dr. Kerlikowske explained. “The only way to really know someone’s breast density is if they have a mammogram.” The whiter the mammogram, the denser the breast. The darker the mammogram, the fattier the breast.

According to the American College of Radiology, the following 4 categories of breast composition are defined by the “visually estimated” content of fibroglandular-density tissue within the breasts:
A. The breasts are almost entirely fatty.
B. There are scattered areas of fibroglandular density.
C. The breasts are heterogeneously dense, which may obscure small masses.
D. The breasts are extremely dense, which lowers the specificity of mammography.

Categories C and D signify dense breasts, which contain a high degree of collagen, epithelial cells, and stroma. In the United States, more than 25 million women are thought to have dense breasts.

Women who have a family history of breast cancer are more likely to have dense breasts. And women who have dense breasts have an elevated risk of breast cancer. They also have a higher risk of advanced disease, as well as a higher risk of large, high-grade, and lymph node-positive tumors, said Dr. Kerlikowske.

Breast-density legislation is increasing
Twenty-two states now have laws mandating that women found to have heterogeneously dense or extremely dense breasts be notified of their status, said Dr. Kerlikowske. That prompts the question: How should these patients be managed?

Breast density declines with age. Breast density also is influenced by body mass index (BMI). As BMI increases, density declines.

Breast density also can be affected by medications, such as hormone therapy and tamoxifen, Dr. Kerlikowske said.

For example, breast density declines about 1% to 2% per year in postmenopause. In postmenopausal women who take estrogen alone, breast density increases slightly. “But the real increase is for people who take estrogen plus progestin,” said Dr. Kerlikowske. “It’s thought that the progestin component is what increases breast density.” Estrogen-progestin therapy confers the same risk of breast cancer as that faced by a premenopausal woman with dense breasts.

As for tamoxifen, it reduces breast density by 2% to 3% per year in postmenopausal women, Dr. Kerlikowske said. “People who have a decrease of more than 10% in breast density are those who have a reduction in breast cancer.” If a woman doesn’t have that reduction with tamoxifen—about half of women don’t—there is no reduction in breast cancer mortality.

“There’s some thought that you should look at mammograms during the first year of tamoxifen use and, if you don’t see a change, consider switching to another medication,” said Dr. Kerlikowske.

More frequent mammograms and supplemental imaging are options for detecting cancers early. Among the modalities that have been studied in this regard are ultrasonography, tomosynthesis, and breast magnetic resonance imaging (MRI).

“If you do more tests, such as ultrasound, you will definitely find additional lesions,” said Dr. Kerlikowske. “There’s no question. But what are the harms?”

The biopsy rate almost doubles after ultrasonography, compared with mammography. And the number needed to screen to detect cancer is fairly high. For mammography, that number is about 250. For ultrasonography, tomosynthesis, and breast MRI, it is higher.

Tomosynthesis is more cost-effective than supplemental ultrasonography because it decreases the number of false positives, Dr. Kerlikowske said.

What’s the bottom line?
Not every woman with dense breasts is at high risk for breast cancer, said Dr. Kerlikowske. And although breast density is prevalent, it is potentially modifiable.

Nevertheless, breast density confers an elevated risk of breast cancer and can also mask tumors. Women with dense breasts likely should avoid the use of postmenopausal hormone therapy. They also may be candidates for more frequent mammography and/or supplemental imaging.

The Breast Cancer Surveillance Consortium (BCSC) Risk Calculator is the only tool that incorporates breast density. In the works is a new model that also incorporates benign breast disease.

Risk-prediction tool considers density and other factors
A risk-prediction tool from the Breast Cancer Surveillance Consortium (BCSC) is the only model to incorporate breast density. The BCSC Risk Calculator is available free of charge for the iPhone and iPad (an Android version is in the works). The tool takes 5 factors into consideration in estimating a woman’s 5-year risk of developing invasive breast cancer:
• age
• race/ethnicity
• breast density
• family history of breast cancer (first-degree relative)
• personal history of breast biopsy.
The tool is designed for use by health professionals. It is not appropriate for determining risk in women younger than 35 years or older than 79 years; women with a previous diagnosis of breast cancer, lobular carcinoma in situ, ductal carcinoma in situ, or atypical ductal hyperplasia; or women who have undergone breast augmentation. Other risk-prediction models are more appropriate for women with a BRCA mutation.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.^1,2

The main stumbling block?

Faulty communication.

That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.³

In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, FAAN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.³ In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.

Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.⁴ Few of these clinicians reported that they had discussed their concerns with the parties involved.

A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.⁵

These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:

Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.

Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:

Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.

1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. They should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.

2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinician to lead the safety program and oversee team training.

3. Structure handoffs 
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.

“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”³

4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”³

5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.³

If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.

If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.

If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.

6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.

“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.

7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.

And when they do speak up, it pays to listen.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.^1,2

The main stumbling block?

Faulty communication.

That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.³

In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, FAAN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.³ In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.

Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.⁴ Few of these clinicians reported that they had discussed their concerns with the parties involved.

A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.⁵

These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:

Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.

Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:

Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.

1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. They should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.

2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinician to lead the safety program and oversee team training.

3. Structure handoffs 
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.

“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”³

4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”³

5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.³

If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.

If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.

If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.

6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.

“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.

7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.

And when they do speak up, it pays to listen.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

At least half of all cases of maternal morbidity and mortality could be prevented, or so studies suggest.^1,2

The main stumbling block?

Faulty communication.

That’s the word from the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the American College of Nurse-Midwives, and the Association of Women’s Health, Obstetric and Neonatal Nurses.³

In a joint “blueprint” to transform communication and enhance the safety culture in intrapartum care, these organizations, led by Audrey Lyndon, PhD, RN, FAAN, from the University of California, San Francisco, School of Nursing, describe the extent of the problem, steps that various team members can take to improve safety, notable success stories, and communication strategies.³ In this article, the joint blueprint is summarized, with a focus on steps obstetricians can take to improve the intrapartum safety culture.

Scope of the problem
A study of more than 3,282 physicians, midwives, and registered nurses produced a troubling statistic: More than 90% of respondents said that they had “witnessed shortcuts, missing competencies, disrespect, or performance problems” during the preceding year of practice.⁴ Few of these clinicians reported that they had discussed their concerns with the parties involved.

A second study of 1,932 clinicians found that 34% of physicians, 40% of midwives, and 56% of registered nurses had witnessed patients being put at risk within the preceding 2 years by other team members’ inattentiveness or lack of responsiveness.⁵

These findings suggest that health care providers often witness weak links in intrapartum safety but do not always address or report them. Among the reasons team members may be hesitant to speak up when they perceive a potential problem:

Although Lyndon and colleagues acknowledge that it is impossible to eliminate adverse outcomes entirely or completely eradicate human error, they argue that significant improvements can be made by adopting a number of manageable strategies.

Recommended strategies
Lyndon and colleagues describe some of the challenges of effective communication in a health care setting:

Lyndon and colleagues go on to mention a number of strategies to improve communication, boost safety, and reduce medical errors.

1. Remember that the patient is part of the team
The patient and her family play a key role in identifying the potential for harm during labor and delivery, Lyndon and colleagues assert. They should be considered members of the intrapartum team, care should be patient-focused, and any communications from the patient should not only be heard but fully considered. In fact, explicit elicitation of her experience and concerns is recommended.

2. Consider that you might be part of the problem
It is human nature to attribute a communication problem to the other people involved, rather than take responsibility for it oneself. One potential solution to this mindset is team training, where all members are encouraged to communicate clearly and listen attentively. Organizations that have been successful at improving their culture of safety have implemented such training, as well as the use of checklists, training in fetal heart-rate monitoring, formation of a patient safety committee, external review of safety practices, and designation of a key clinician to lead the safety program and oversee team training.

3. Structure handoffs 
The team should standardize handoffs so that they occur smoothly and all channels of communication remain open and clear.

“Having structured formats for debriefing and handoffs are steps in the right direction, but solving the problem of communication breakdowns is more complicated than standardizing the flow and format of information transfer,” Lyndon and colleagues assert. “Indeed, solving communication breakdowns is a matter of individual, group, organizational, and professional responsibility for creating and sustaining an environment of mutual respect, curiosity, and accountability for behavior and performance.”³

4. Learn to communicate responsibly
“Differences of opinion about clinical assessments, goals of care, and the pathway to optimal outcomes are bound to occur with some regularity in the dynamic environment of labor and delivery,” note Lyndon and colleagues. “Every person has the responsibility to contribute to improving how we relate to and communicate with each other. Collectively, we must create environments in which every team member (woman, family member, physician, midwife, nurse, unit clerk, patient care assistant, or scrub tech) is comfortable expressing and discussing concerns about safety or performance, is encouraged to do so, and has the support of the team to articulate the rationale for and urgency of the concern without fear of put-downs, retribution, or receiving poor-quality care.”³

5. Be persistent and proactive
When team members have differing expectations and communication styles, useful approaches include structured communication tools such as situation, background, assessment, recommendation (SBAR); structured handoffs; board rounds; huddles; attentive listening; and explicit elicitation of the patient’s concerns and desires.³

If someone fails to pay attention to a concern you raise, be persistent about restating that concern until you elicit a response.

If someone exhibits disruptive behavior, point to or establish a code of conduct that clearly describes professional behavior.

If there is a difference of opinion on patient management, such as fetal monitoring and interpretation, conduct regular case reviews and standardize a plan for notification of complications.

6. If you’re a team leader, set clear goals
Then ask team members what will be needed to achieve the outcomes desired.

“Team leaders need to develop outstanding skills for listening and eliciting feedback and cross-monitoring (being aware of each other’s actions and performance) from other team members,” note Lyndon and colleagues.

7. Increase public awareness of safety concepts
When these concepts and best practices are made known to the public, women and families become “empowered” to speak up when they have concerns about care.

And when they do speak up, it pays to listen.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In a poster presented at the 2015 ACOG Annual Clinical Meeting in San Francisco, Neal Marc Lonky, MD, and colleagues from the Southern California Permanente Group assessed the clinical acumen of physicians in estimating uterine size prior to elective hysterectomy for benign indications. They found that the correlation between estimates and actual uterine weight was 0.79 (P<.001), with a very low conversion rate for the surgery.¹

Lonky and colleagues collected preoperative uterine estimates and actual specimen weights prospectively for 1,079 cases of benign hysterectomy. The surgeries were performed by 186 primary surgeons and assistant surgeons at 10 Kaiser Permanente Southern California medical centers. Surgeons based the route of hysterectomy on estimates of uterine size, which were calculated using bimanual examination, ultrasonography, or both. Linear regression was used to measure and compare the relationship between estimated uterine size and the pelvic specimen weight.

Uterine size estimates ranged from 4 cm to 40 cm, and specimen weights ranged from 2 g to 4,607 g. The mean (SD) estimate of uterine size was 11.7 (4.43) cm, and the mean actual specimen weight was 334.6 (401.42) g.

The mean age of women in the sample was 47.2 (8.35) years. Overall, 379 women (35.1%) were Hispanic, 325 (30.1%) were non-Hispanic white, 281 (26.0%) were non-Hispanic black, and 81 (7.5%) were Asian/Pacific Islander. The mean body mass index (BMI) was 30.0 (6.37) kg/m², with a range of 16.8 to 67.9 kg/m².

“This is real world research,” said Dr. Lonky. “It’s called comparative effectiveness research. Basically, all patients who are undergoing the procedure are entered in the registry, and the clinical acumen of the physician—either using or not using ultrasound—is assessed.”  

“We looked at whether or not we had a bias toward one patient age group, race/ethnicity, BMI, or estimated uterine size. But there were no clusters, so this was truly a random distribution,” said Dr. Lonky.

“These findings may be population-specific to my group of doctors,” he added. “They should be replicated in other settings. It may be that residents are not going to be as linear.”

In a poster presented at the 2015 ACOG Annual Clinical Meeting in San Francisco, Neal Marc Lonky, MD, and colleagues from the Southern California Permanente Group assessed the clinical acumen of physicians in estimating uterine size prior to elective hysterectomy for benign indications. They found that the correlation between estimates and actual uterine weight was 0.79 (P<.001), with a very low conversion rate for the surgery.¹

Lonky and colleagues collected preoperative uterine estimates and actual specimen weights prospectively for 1,079 cases of benign hysterectomy. The surgeries were performed by 186 primary surgeons and assistant surgeons at 10 Kaiser Permanente Southern California medical centers. Surgeons based the route of hysterectomy on estimates of uterine size, which were calculated using bimanual examination, ultrasonography, or both. Linear regression was used to measure and compare the relationship between estimated uterine size and the pelvic specimen weight.

Uterine size estimates ranged from 4 cm to 40 cm, and specimen weights ranged from 2 g to 4,607 g. The mean (SD) estimate of uterine size was 11.7 (4.43) cm, and the mean actual specimen weight was 334.6 (401.42) g.

The mean age of women in the sample was 47.2 (8.35) years. Overall, 379 women (35.1%) were Hispanic, 325 (30.1%) were non-Hispanic white, 281 (26.0%) were non-Hispanic black, and 81 (7.5%) were Asian/Pacific Islander. The mean body mass index (BMI) was 30.0 (6.37) kg/m², with a range of 16.8 to 67.9 kg/m².

“This is real world research,” said Dr. Lonky. “It’s called comparative effectiveness research. Basically, all patients who are undergoing the procedure are entered in the registry, and the clinical acumen of the physician—either using or not using ultrasound—is assessed.”  

“We looked at whether or not we had a bias toward one patient age group, race/ethnicity, BMI, or estimated uterine size. But there were no clusters, so this was truly a random distribution,” said Dr. Lonky.

“These findings may be population-specific to my group of doctors,” he added. “They should be replicated in other settings. It may be that residents are not going to be as linear.”

In a poster presented at the 2015 ACOG Annual Clinical Meeting in San Francisco, Neal Marc Lonky, MD, and colleagues from the Southern California Permanente Group assessed the clinical acumen of physicians in estimating uterine size prior to elective hysterectomy for benign indications. They found that the correlation between estimates and actual uterine weight was 0.79 (P<.001), with a very low conversion rate for the surgery.¹

Lonky and colleagues collected preoperative uterine estimates and actual specimen weights prospectively for 1,079 cases of benign hysterectomy. The surgeries were performed by 186 primary surgeons and assistant surgeons at 10 Kaiser Permanente Southern California medical centers. Surgeons based the route of hysterectomy on estimates of uterine size, which were calculated using bimanual examination, ultrasonography, or both. Linear regression was used to measure and compare the relationship between estimated uterine size and the pelvic specimen weight.

Uterine size estimates ranged from 4 cm to 40 cm, and specimen weights ranged from 2 g to 4,607 g. The mean (SD) estimate of uterine size was 11.7 (4.43) cm, and the mean actual specimen weight was 334.6 (401.42) g.

The mean age of women in the sample was 47.2 (8.35) years. Overall, 379 women (35.1%) were Hispanic, 325 (30.1%) were non-Hispanic white, 281 (26.0%) were non-Hispanic black, and 81 (7.5%) were Asian/Pacific Islander. The mean body mass index (BMI) was 30.0 (6.37) kg/m², with a range of 16.8 to 67.9 kg/m².

“This is real world research,” said Dr. Lonky. “It’s called comparative effectiveness research. Basically, all patients who are undergoing the procedure are entered in the registry, and the clinical acumen of the physician—either using or not using ultrasound—is assessed.”  

“We looked at whether or not we had a bias toward one patient age group, race/ethnicity, BMI, or estimated uterine size. But there were no clusters, so this was truly a random distribution,” said Dr. Lonky.

“These findings may be population-specific to my group of doctors,” he added. “They should be replicated in other settings. It may be that residents are not going to be as linear.”

Tissue extraction during laparoscopic or robot-assisted laparoscopic gynecologic surgery raises safety concerns for dissemination of tissue during the open, or uncontained, electromechanical morcellation process. Researchers from Brigham & Women’s Hospital in Boston, Massachusetts, investigated whether contained tissue extraction using power morcellators entirely within a bag is safe and practical for preventing tissue spillage. Goggins and colleagues presented their findings in a poster at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco, California.

A total of 76 women at 4 institutions underwent laparoscopic or robotic multiport surgery (42 hysterectomy; 34 myomectomy). The average (SD) age and body mass index of the women were 43.16 (8.53) years and 26.47 kg/m² (5.93), respectively. After surgical dissection, each specimen was placed into a containment bag that also included blue dye. The bag was insufflated intracorporeally and electromechanical morcellation and extraction of tissue were performed. The bag was evaluated visually for dye leakage or tears before and after the procedure.

Results
In one case, there was a tear in the bag before morcellation; no bag tears occurred during the morcellation process. Spillage of dye or tissue was noted in 7 cases, although containment bags were intact in each instance. One patient experienced intraoperative blood loss (3600 mL), and that procedure was converted to open radical hysterectomy. The most common pathologic finding was benign leiomyoma.

Conclusion
Goggins and colleagues concluded, “Contained tissue extraction using electromechanical morcellation and intracorporeally insufflated bags may provide a safe alternative to uncontained morcellation by decreasing the spread of tissue in the peritoneal cavity while allowing for the traditional benefits of laparoscopy.”

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Tissue extraction during laparoscopic or robot-assisted laparoscopic gynecologic surgery raises safety concerns for dissemination of tissue during the open, or uncontained, electromechanical morcellation process. Researchers from Brigham & Women’s Hospital in Boston, Massachusetts, investigated whether contained tissue extraction using power morcellators entirely within a bag is safe and practical for preventing tissue spillage. Goggins and colleagues presented their findings in a poster at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco, California.

A total of 76 women at 4 institutions underwent laparoscopic or robotic multiport surgery (42 hysterectomy; 34 myomectomy). The average (SD) age and body mass index of the women were 43.16 (8.53) years and 26.47 kg/m² (5.93), respectively. After surgical dissection, each specimen was placed into a containment bag that also included blue dye. The bag was insufflated intracorporeally and electromechanical morcellation and extraction of tissue were performed. The bag was evaluated visually for dye leakage or tears before and after the procedure.

Results
In one case, there was a tear in the bag before morcellation; no bag tears occurred during the morcellation process. Spillage of dye or tissue was noted in 7 cases, although containment bags were intact in each instance. One patient experienced intraoperative blood loss (3600 mL), and that procedure was converted to open radical hysterectomy. The most common pathologic finding was benign leiomyoma.

Conclusion
Goggins and colleagues concluded, “Contained tissue extraction using electromechanical morcellation and intracorporeally insufflated bags may provide a safe alternative to uncontained morcellation by decreasing the spread of tissue in the peritoneal cavity while allowing for the traditional benefits of laparoscopy.”

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Tissue extraction during laparoscopic or robot-assisted laparoscopic gynecologic surgery raises safety concerns for dissemination of tissue during the open, or uncontained, electromechanical morcellation process. Researchers from Brigham & Women’s Hospital in Boston, Massachusetts, investigated whether contained tissue extraction using power morcellators entirely within a bag is safe and practical for preventing tissue spillage. Goggins and colleagues presented their findings in a poster at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco, California.

A total of 76 women at 4 institutions underwent laparoscopic or robotic multiport surgery (42 hysterectomy; 34 myomectomy). The average (SD) age and body mass index of the women were 43.16 (8.53) years and 26.47 kg/m² (5.93), respectively. After surgical dissection, each specimen was placed into a containment bag that also included blue dye. The bag was insufflated intracorporeally and electromechanical morcellation and extraction of tissue were performed. The bag was evaluated visually for dye leakage or tears before and after the procedure.

Results
In one case, there was a tear in the bag before morcellation; no bag tears occurred during the morcellation process. Spillage of dye or tissue was noted in 7 cases, although containment bags were intact in each instance. One patient experienced intraoperative blood loss (3600 mL), and that procedure was converted to open radical hysterectomy. The most common pathologic finding was benign leiomyoma.

Conclusion
Goggins and colleagues concluded, “Contained tissue extraction using electromechanical morcellation and intracorporeally insufflated bags may provide a safe alternative to uncontained morcellation by decreasing the spread of tissue in the peritoneal cavity while allowing for the traditional benefits of laparoscopy.”

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Use of long-acting reversible contraception (LARC) has increased nearly 5-fold in the last decade, reported the Centers for Disease Control and Prevention (CDC) in a National Center for Health Statistics (NCHS) Data Brief on the trends in LARC use among US women aged 15 to 44.¹ 

Data from the National Survey of Family Growth indicate that LARCs, which include intrauterine devices (IUDs) and subdermal hormonal implants, are gaining popularity because of their high efficacy in preventing unintended pregnancies. LARCs have demonstrated greater efficacy in preventing unintended pregnancy among all women compared with other contraceptive methods, including the oral contraceptive pill and the transdermal patch.

Age-related trends
For women aged 15 to 44, LARC use doubled between 2002 (1.5%) and the period 2006–2010 (3.8%) and then nearly doubled again for 2011–2013 (7.2%). IUD use increased 83% from the 2006–2010 period (3.5%) to the 2011–2013 period (6.4%). Implant use tripled from 2002 (0.3%) to the 2011–2013 period (0.8%).

LARC use was higher among women aged 25 to 34 than among women aged 15 to 24. The difference in LARC use was not statistically significant between women aged 25 to 34 and women aged 35 to 44.

•  LARC use increased nearly 4-fold for women aged 15 to 24 between 2002 (0.6%) and 2006–2010 (2.3%), and doubled again for 2011–2013 (5.0%).
• LARC use almost doubled among women aged 25 to 34 from 2006–2010 to 2011–2013 (5.3% to 11.1%).
• LARC use tripled between 2002 (1.1%) and 2006–2010 (3.8%) for women aged 35 to 44, and increased to 5.3% in 2011–2013.

Patterns of use by race
Although LARC use tripled for non-Hispanic white women and increased 4-fold for non-Hispanic black women between 2002 and 2006–2010, use among Hispanic women declined 10% during this period. LARC use increased by 129% among Hispanic women and by 128% among non-Hispanic white women from 2006–2010 to 2011–2013. Use of LARCs in non-Hispanic black women increased by 30% during this same period.

Parous vs nulliparous women
Women who have had at least one birth use LARC at a higher rate than women who have had no previous births. During the period 2011–2013, rate of use was 3 times greater among parous (11.0%) women compared with nulliparous (2.8%) women.

• Among parous women, LARC use increased from 2.4% in 2002 to 6.3% in 2006–2010, and to 10.6% in 2011–2013.
• In nulliparous women, LARC use increased 10-fold between 2006–2010 and 2011–2013.

For additional information, visit the NCHS Data Brief at http://www.cdc.gov/nchs/data/databriefs/db188.htm

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Use of long-acting reversible contraception (LARC) has increased nearly 5-fold in the last decade, reported the Centers for Disease Control and Prevention (CDC) in a National Center for Health Statistics (NCHS) Data Brief on the trends in LARC use among US women aged 15 to 44.¹ 

Data from the National Survey of Family Growth indicate that LARCs, which include intrauterine devices (IUDs) and subdermal hormonal implants, are gaining popularity because of their high efficacy in preventing unintended pregnancies. LARCs have demonstrated greater efficacy in preventing unintended pregnancy among all women compared with other contraceptive methods, including the oral contraceptive pill and the transdermal patch.

Age-related trends
For women aged 15 to 44, LARC use doubled between 2002 (1.5%) and the period 2006–2010 (3.8%) and then nearly doubled again for 2011–2013 (7.2%). IUD use increased 83% from the 2006–2010 period (3.5%) to the 2011–2013 period (6.4%). Implant use tripled from 2002 (0.3%) to the 2011–2013 period (0.8%).

LARC use was higher among women aged 25 to 34 than among women aged 15 to 24. The difference in LARC use was not statistically significant between women aged 25 to 34 and women aged 35 to 44.

•  LARC use increased nearly 4-fold for women aged 15 to 24 between 2002 (0.6%) and 2006–2010 (2.3%), and doubled again for 2011–2013 (5.0%).
• LARC use almost doubled among women aged 25 to 34 from 2006–2010 to 2011–2013 (5.3% to 11.1%).
• LARC use tripled between 2002 (1.1%) and 2006–2010 (3.8%) for women aged 35 to 44, and increased to 5.3% in 2011–2013.

Patterns of use by race
Although LARC use tripled for non-Hispanic white women and increased 4-fold for non-Hispanic black women between 2002 and 2006–2010, use among Hispanic women declined 10% during this period. LARC use increased by 129% among Hispanic women and by 128% among non-Hispanic white women from 2006–2010 to 2011–2013. Use of LARCs in non-Hispanic black women increased by 30% during this same period.

Parous vs nulliparous women
Women who have had at least one birth use LARC at a higher rate than women who have had no previous births. During the period 2011–2013, rate of use was 3 times greater among parous (11.0%) women compared with nulliparous (2.8%) women.

• Among parous women, LARC use increased from 2.4% in 2002 to 6.3% in 2006–2010, and to 10.6% in 2011–2013.
• In nulliparous women, LARC use increased 10-fold between 2006–2010 and 2011–2013.

For additional information, visit the NCHS Data Brief at http://www.cdc.gov/nchs/data/databriefs/db188.htm

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Use of long-acting reversible contraception (LARC) has increased nearly 5-fold in the last decade, reported the Centers for Disease Control and Prevention (CDC) in a National Center for Health Statistics (NCHS) Data Brief on the trends in LARC use among US women aged 15 to 44.¹ 

Data from the National Survey of Family Growth indicate that LARCs, which include intrauterine devices (IUDs) and subdermal hormonal implants, are gaining popularity because of their high efficacy in preventing unintended pregnancies. LARCs have demonstrated greater efficacy in preventing unintended pregnancy among all women compared with other contraceptive methods, including the oral contraceptive pill and the transdermal patch.

Age-related trends
For women aged 15 to 44, LARC use doubled between 2002 (1.5%) and the period 2006–2010 (3.8%) and then nearly doubled again for 2011–2013 (7.2%). IUD use increased 83% from the 2006–2010 period (3.5%) to the 2011–2013 period (6.4%). Implant use tripled from 2002 (0.3%) to the 2011–2013 period (0.8%).

LARC use was higher among women aged 25 to 34 than among women aged 15 to 24. The difference in LARC use was not statistically significant between women aged 25 to 34 and women aged 35 to 44.

•  LARC use increased nearly 4-fold for women aged 15 to 24 between 2002 (0.6%) and 2006–2010 (2.3%), and doubled again for 2011–2013 (5.0%).
• LARC use almost doubled among women aged 25 to 34 from 2006–2010 to 2011–2013 (5.3% to 11.1%).
• LARC use tripled between 2002 (1.1%) and 2006–2010 (3.8%) for women aged 35 to 44, and increased to 5.3% in 2011–2013.

Patterns of use by race
Although LARC use tripled for non-Hispanic white women and increased 4-fold for non-Hispanic black women between 2002 and 2006–2010, use among Hispanic women declined 10% during this period. LARC use increased by 129% among Hispanic women and by 128% among non-Hispanic white women from 2006–2010 to 2011–2013. Use of LARCs in non-Hispanic black women increased by 30% during this same period.

Parous vs nulliparous women
Women who have had at least one birth use LARC at a higher rate than women who have had no previous births. During the period 2011–2013, rate of use was 3 times greater among parous (11.0%) women compared with nulliparous (2.8%) women.

• Among parous women, LARC use increased from 2.4% in 2002 to 6.3% in 2006–2010, and to 10.6% in 2011–2013.
• In nulliparous women, LARC use increased 10-fold between 2006–2010 and 2011–2013.

For additional information, visit the NCHS Data Brief at http://www.cdc.gov/nchs/data/databriefs/db188.htm

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

3/24/15, Day 3 at SGS

Many topics, many learning opportunities   

The morning’s focus topics at SGS were divided up in small-group academic roundtables, with 15 experts in the field providing authoritative know-how and guidance to attendees. Topics ranged from tips for in-bag tissue extraction, endometriosis surgery, surviving health care transformation, cost-effectiveness, and single-site surgery to innovative treatments for fecal incontinence.

In the main hall, the fourth scientific session included oral presentations and videos that focused on anatomic landmarks and variations and included data presentation from an interesting prospective randomized trial in which the authors found bladder support is reduced by pregnancy, regardless of delivery method.

The highlight of the morning was certainly the debate over "power" morcellation. Dr. Cheryl Iglesia moderated in her charming and comical manner. Dr. Andrew Sokol and Dr. Jubilee Brown argued that power morcellation still should be available to a select group of appropriately chosen, low-risk women, and backed their arguments up with solid data. Dr. Eric Sokol, Andrew’s twin (and better looking, per him) brother, and Dr. Carl Zimmerman argued against the use of power morcellation, instead urging everyone in the audience to perform more vaginal hysterectomies. Though spirited and based largely on sound medical evidence, the debate did not have a clear winner. The overall consensus seemed to be that this controversial topic needed further evaluation and more data to support either claim.

"Sesame street graduates” and andragogy

We were then honored to have Vice President for Education, American College of Obstetricians and Gynecologists Dr. Sandra Carson as the esteemed TeLinde Lecturer. Her talk, “Teaching Medicine and Surgery to Sesame Street Graduates,” outlined the challenges in teaching surgery to a new generation of ObGyn residents as well as identified opportunities for improvement. She restated what seems to be the running theme at SGS this year: young faculty and residents are losing the skill for vaginal hysterectomy.

Dr. Carson introduced members of the audience to the adult theory of learning called andragogy. Adults like active learning, which is problem centered, rather than content oriented; linking new concepts to prior experience; and learning what is relevant to them, she noted. Then she shared ACOG’s strategies for applying these learning principles in resident education. She discussed ACOG’s recently formed Vaginal Hysterectomy Teaching Taskforce, which has put together a simulation consortium online toolkit and a surgical skills module to help educate residents on vaginal hysterectomy techniques. This toolkit and module can be accessed by doing a quick search after signing into the ACOG Web site.

Dr. Carson, a reproductive endocrinologist formerly at Brown University, is also now an honorary member of SGS.

Wise words from a wise physician

In his presidential address Dr. Stephen Metz acknowledged that all physicians are subject to even subtle “conflicts of interest,” reminding us to treat our patients as people not as a disease or a procedure.

“What does my patient really want from me? She wants me to get to know her to develop the right recommendations for her,” he said. His career has spanned multiple decades, and his service to the field of gynecology is outstanding. He received a well-deserved standing ovation at the end of his address.

Sport and socialization a necessity in sunny Florida!

The afternoon adjourned after the business meeting, and members were able to play golf, tennis, paddleboard in Winter Park, or just relax at the resort. Congratulations to the winners of the golf tournament (Drs. Hopkins, Rasmussen, Hurd, and Flora) and the tennis tournament (Dr. Ted Lee)!

Everyone convened at the outside terrace for the evening “Mojito Night in the Caribbean” reception, sharing good times, cocktails, and hors d’oeuvres. Proceeds from each ticket sold helped support Surgeons Helping Advance Research and Education (SHARE).

Tomorrow looks to be an excellent conclusion to a well-planned and very well-executed meeting. Kudos, and large thanks, to the SGS leadership.

3/23/15, Day 2 at SGS

Surgeons from 17 countries converge

The first day of the SGS scientific sessions was another energetic and interactive day. Sixteen new SGS members were recognized and welcomed in the main conference hall. Dr. Charles Rardin presented a brief overview and some basic statistics related to this year’s meeting—the largest ever in the history of SGS. A total of 401 attendees representing 17 countries are here in Orlando for SGS 2015! 

In the first scientific session, oral presentations touched on the subjects of preoperative dexamethasone use, vaginal packing, surgical site infections, and a new treatment modality for fecal incontinence. An excellent technique video on laparoscopic ureterolysis by Dr. Cara King then followed, in which she demonstrated excellent surgical skills with amazingly clear anatomy. Her video was recognized later in the day with a well-deserved award—congratulations! 

A short break in the exhibit hall allowed for mingling with other attendees, many of whom have been active on social media surrounding the meeting, and for visiting the booths of the industry sponsors. The second scientific session then picked up where the first left off, with more scientifically sound research presented on such topics as mechanical bowel preparation use in laparoscopy and pelvic floor disorders in women with gynecologic malignancies.

No room for fads in gyn surgery

Dr. David Grimes, a true leader in our field, provided an exceptional keynote address, “Is Teaching Evidence-Based Surgery Possible?" He shared his expertise of evidence-based medicine, and described (in sometimes very comical but always stimulating and provocative terms) the need for incorporating evidence-based surgery in gynecology. He urged us to strive to do best by our patients by applying evidenced-based practices rather than following fads and gizmos.

Gyn surgery training: Have we reached a “perfect storm”?

The afternoon brought with it a panel discussion on "Teaching the Next Generation of GYN Surgeons," with Dr. Hal Lawrence moderating and Dr. Mark Walters and Dr. Dee Fenner serving as panelists. They discussed the future of ObGyn residency training in great detail: increasing subspecialization, a stable birth rate, declining hysterectomy rates, increasing safety and quality monitoring, and increased access to data and informed consumers. All of these trends were highlighted as reasons for a perfect storm in gynecologic surgery training. In addition, the panel presented some surprising statistics: 

• The majority of hysterectomies in the United States are being done by surgeons who perform less than 1 per month.
• The higher volume surgeons provide higher value and tend to utilize more minimally invasive approaches.

Videofest!

The scientific day concluded with a videofest that included complex robotic, laparoscopic, hysteroscopic, cystoscopic, and vaginal surgeries, demonstrating the surgical talents and ingenuity of SGS members.

Simultaneously, the Fellows’ Pelvic Research Network (FPRN) met to update their ongoing projects and to review new proposals. The meeting sought to unite FPRMS and MIS fellows to conduct multicenter studies. This was an enlightening and engaging session, which should give everyone great hope to see the creativity and energy of the next generation of researchers.

A grounder for attendees

All in attendance were treated to a unique, eye-opening, motivational, and very moving talk by Professor (and Sir) Ajay Rane, MD, PhD from Australia on female genital mutilation. He stressed the importance of respecting women for who they are, not what they do.

“My idea of feminism is applauding a woman who gives birth. Celebrate women for who they are," he said. He highlighted the work being done by his team in Australia and India, and urged everyone in attendance to become more aware of the staggering statistics and reality of female genital mutilation.

The jam-packed day wrapped with the awards ceremony in the main hall. Lifelong mentors were honored by their mentees and SGS President Dr. Stephen Metz and Scientific Program Chair Dr. Charles Rardin presented various awards to those who had submitted and presented novel and groundbreaking research.

One last surprise

The President’s Reception in the exhibit hall was lively, with meeting sponsors, colleagues, and friends in attendance. And, of course, a visit from special guest! (Thanks to SGS Fellow Christina Saad, MD @XtinaSaad for the pic!)

See you all tomorrow for another educational, enlightening, and spirited day at #SGS2015! 

3/22/15. DAY 1 AT SGS

A focus on evidence-based medicine

Strong analytic skills (of your own research as well as the published literature) translates to better patient care, was the underlying theme of the opening postgraduate course here in Orlando, Florida, for day 1 of the 41st annual meeting of the Society of Gynecologic Surgeons.

Building on the success of last year’s course on evidence-based medicine (EBM), Dr. Vivian Sung and Dr. Ike Rahn put together an amazing team to review and apply the principles of so-called EBM, a workshop that was in part sponsored by ABOG.

A quick introduction to EBM principles by Dr. Thomas Wheeler was followed by small break-out groups, where attendees used the PICO-DD model to define a Population, Intervention, Comparator, Outcomes, Duration, and study Design. Further talks focused on the benefits and caveats of randomized controlled trials (RCTs), surrogate and intermediate outcomes, and systematic reviews and meta-analyses.

Dr. Ethan Balk cautioned us to consider the costly and underpowered RCT, and lack of generalizability needed to define rigorous study inclusion and outcome criteria. Dr. Sung then pointed out that, while the perfect surrogate outcome would allow us to shorten study lengths (and save money), the seduction of association and causation can lead to some questionable conclusions.

When using a clinical practice guideline, Dr. Miles Murphy indicated that a systematic review needs to be included, although a meta-analysis is not always required. The poor quality and paucity of RCTs for most patient populations is what limits us.

Dr. Rahn gave an excellent presentation on subgroup analysis, recommending to attendees that they perform these analyses cautiously, describe which groups are analyzed, and have statistical back-up for power and P value calculations.

Dr. Kristen Matteson then spoke about interpreting the literature on screening and diagnostic tests, giving a thorough but understandable review of the basics of statistics. Dr. John Wong rounded out the course, suggesting that because RCTs are expensive and comprise less than 5% of published studies, the analysis of observational studies as RCTs would allow us to better inform our patients and our colleagues on the best treatments, using patient-centered outcomes, efficacy data, and multiple providers. He urged us all to be more skeptical and ask critical questions when dealing with evidence in medicine.

Sharpening ultrasonography skills

Simultaneously, others attended a hands-on learning course on comprehensive pelvic floor ultrasonography, including transperineal, endovaginal, and endoanal imaging, organized by Dr. Abbas Shobeiri.

Tips for the difficult hysterectomy

Dr. Ted Lee (with help from Drs. Arnold P. Advincula, Rosanne Kho, and Matthew Seidhoff) prepared a surgical tutorial on laparoscopic, robotic, and vaginal strategies and techniques for approaching the difficult hysterectomy. The course was phenomenal, as described by many of the members fortunate enough to learn some of the tips and tricks demonstrated by the master surgeons.

Training for the NIH application process

Following the postgraduate courses, Dr. Katherine Hartmann led an “NIH Application Training Camp,” an offering supported by SGS research donations and a generous donation from Dr. Holly Richter. Dr. Hartmann provided in-depth insight into the world of NIH grant funding and provided background prep for a K or R award application. A mock NIH application study section, in which two actual applications were reviewed, demystified the process of grant review (and rejection). 

A social end to day 1

To end the first day, a welcome reception was held where residents, fellows, and attendings from different fields of ObGyn mingled and shared drinks, stories, and good laughs.

The "social" activities continue on social media for the rest of the conference. Follow #SGS2015, @gynsurgery, @obgmanagement, and @sukrantmehta for more!

3/24/15, Day 3 at SGS

Many topics, many learning opportunities   

The morning’s focus topics at SGS were divided up in small-group academic roundtables, with 15 experts in the field providing authoritative know-how and guidance to attendees. Topics ranged from tips for in-bag tissue extraction, endometriosis surgery, surviving health care transformation, cost-effectiveness, and single-site surgery to innovative treatments for fecal incontinence.

In the main hall, the fourth scientific session included oral presentations and videos that focused on anatomic landmarks and variations and included data presentation from an interesting prospective randomized trial in which the authors found bladder support is reduced by pregnancy, regardless of delivery method.

The highlight of the morning was certainly the debate over "power" morcellation. Dr. Cheryl Iglesia moderated in her charming and comical manner. Dr. Andrew Sokol and Dr. Jubilee Brown argued that power morcellation still should be available to a select group of appropriately chosen, low-risk women, and backed their arguments up with solid data. Dr. Eric Sokol, Andrew’s twin (and better looking, per him) brother, and Dr. Carl Zimmerman argued against the use of power morcellation, instead urging everyone in the audience to perform more vaginal hysterectomies. Though spirited and based largely on sound medical evidence, the debate did not have a clear winner. The overall consensus seemed to be that this controversial topic needed further evaluation and more data to support either claim.

"Sesame street graduates” and andragogy

We were then honored to have Vice President for Education, American College of Obstetricians and Gynecologists Dr. Sandra Carson as the esteemed TeLinde Lecturer. Her talk, “Teaching Medicine and Surgery to Sesame Street Graduates,” outlined the challenges in teaching surgery to a new generation of ObGyn residents as well as identified opportunities for improvement. She restated what seems to be the running theme at SGS this year: young faculty and residents are losing the skill for vaginal hysterectomy.

Dr. Carson introduced members of the audience to the adult theory of learning called andragogy. Adults like active learning, which is problem centered, rather than content oriented; linking new concepts to prior experience; and learning what is relevant to them, she noted. Then she shared ACOG’s strategies for applying these learning principles in resident education. She discussed ACOG’s recently formed Vaginal Hysterectomy Teaching Taskforce, which has put together a simulation consortium online toolkit and a surgical skills module to help educate residents on vaginal hysterectomy techniques. This toolkit and module can be accessed by doing a quick search after signing into the ACOG Web site.

Dr. Carson, a reproductive endocrinologist formerly at Brown University, is also now an honorary member of SGS.

Wise words from a wise physician

In his presidential address Dr. Stephen Metz acknowledged that all physicians are subject to even subtle “conflicts of interest,” reminding us to treat our patients as people not as a disease or a procedure.

“What does my patient really want from me? She wants me to get to know her to develop the right recommendations for her,” he said. His career has spanned multiple decades, and his service to the field of gynecology is outstanding. He received a well-deserved standing ovation at the end of his address.

Sport and socialization a necessity in sunny Florida!

The afternoon adjourned after the business meeting, and members were able to play golf, tennis, paddleboard in Winter Park, or just relax at the resort. Congratulations to the winners of the golf tournament (Drs. Hopkins, Rasmussen, Hurd, and Flora) and the tennis tournament (Dr. Ted Lee)!

Everyone convened at the outside terrace for the evening “Mojito Night in the Caribbean” reception, sharing good times, cocktails, and hors d’oeuvres. Proceeds from each ticket sold helped support Surgeons Helping Advance Research and Education (SHARE).

Tomorrow looks to be an excellent conclusion to a well-planned and very well-executed meeting. Kudos, and large thanks, to the SGS leadership.

3/23/15, Day 2 at SGS

Surgeons from 17 countries converge

The first day of the SGS scientific sessions was another energetic and interactive day. Sixteen new SGS members were recognized and welcomed in the main conference hall. Dr. Charles Rardin presented a brief overview and some basic statistics related to this year’s meeting—the largest ever in the history of SGS. A total of 401 attendees representing 17 countries are here in Orlando for SGS 2015! 

In the first scientific session, oral presentations touched on the subjects of preoperative dexamethasone use, vaginal packing, surgical site infections, and a new treatment modality for fecal incontinence. An excellent technique video on laparoscopic ureterolysis by Dr. Cara King then followed, in which she demonstrated excellent surgical skills with amazingly clear anatomy. Her video was recognized later in the day with a well-deserved award—congratulations! 

A short break in the exhibit hall allowed for mingling with other attendees, many of whom have been active on social media surrounding the meeting, and for visiting the booths of the industry sponsors. The second scientific session then picked up where the first left off, with more scientifically sound research presented on such topics as mechanical bowel preparation use in laparoscopy and pelvic floor disorders in women with gynecologic malignancies.

No room for fads in gyn surgery

Dr. David Grimes, a true leader in our field, provided an exceptional keynote address, “Is Teaching Evidence-Based Surgery Possible?" He shared his expertise of evidence-based medicine, and described (in sometimes very comical but always stimulating and provocative terms) the need for incorporating evidence-based surgery in gynecology. He urged us to strive to do best by our patients by applying evidenced-based practices rather than following fads and gizmos.

Gyn surgery training: Have we reached a “perfect storm”?

The afternoon brought with it a panel discussion on "Teaching the Next Generation of GYN Surgeons," with Dr. Hal Lawrence moderating and Dr. Mark Walters and Dr. Dee Fenner serving as panelists. They discussed the future of ObGyn residency training in great detail: increasing subspecialization, a stable birth rate, declining hysterectomy rates, increasing safety and quality monitoring, and increased access to data and informed consumers. All of these trends were highlighted as reasons for a perfect storm in gynecologic surgery training. In addition, the panel presented some surprising statistics: 

• The majority of hysterectomies in the United States are being done by surgeons who perform less than 1 per month.
• The higher volume surgeons provide higher value and tend to utilize more minimally invasive approaches.

Videofest!

The scientific day concluded with a videofest that included complex robotic, laparoscopic, hysteroscopic, cystoscopic, and vaginal surgeries, demonstrating the surgical talents and ingenuity of SGS members.

Simultaneously, the Fellows’ Pelvic Research Network (FPRN) met to update their ongoing projects and to review new proposals. The meeting sought to unite FPRMS and MIS fellows to conduct multicenter studies. This was an enlightening and engaging session, which should give everyone great hope to see the creativity and energy of the next generation of researchers.

A grounder for attendees

All in attendance were treated to a unique, eye-opening, motivational, and very moving talk by Professor (and Sir) Ajay Rane, MD, PhD from Australia on female genital mutilation. He stressed the importance of respecting women for who they are, not what they do.

“My idea of feminism is applauding a woman who gives birth. Celebrate women for who they are," he said. He highlighted the work being done by his team in Australia and India, and urged everyone in attendance to become more aware of the staggering statistics and reality of female genital mutilation.

The jam-packed day wrapped with the awards ceremony in the main hall. Lifelong mentors were honored by their mentees and SGS President Dr. Stephen Metz and Scientific Program Chair Dr. Charles Rardin presented various awards to those who had submitted and presented novel and groundbreaking research.

One last surprise

The President’s Reception in the exhibit hall was lively, with meeting sponsors, colleagues, and friends in attendance. And, of course, a visit from special guest! (Thanks to SGS Fellow Christina Saad, MD @XtinaSaad for the pic!)

See you all tomorrow for another educational, enlightening, and spirited day at #SGS2015! 

3/22/15. DAY 1 AT SGS

A focus on evidence-based medicine

Strong analytic skills (of your own research as well as the published literature) translates to better patient care, was the underlying theme of the opening postgraduate course here in Orlando, Florida, for day 1 of the 41st annual meeting of the Society of Gynecologic Surgeons.

Building on the success of last year’s course on evidence-based medicine (EBM), Dr. Vivian Sung and Dr. Ike Rahn put together an amazing team to review and apply the principles of so-called EBM, a workshop that was in part sponsored by ABOG.

A quick introduction to EBM principles by Dr. Thomas Wheeler was followed by small break-out groups, where attendees used the PICO-DD model to define a Population, Intervention, Comparator, Outcomes, Duration, and study Design. Further talks focused on the benefits and caveats of randomized controlled trials (RCTs), surrogate and intermediate outcomes, and systematic reviews and meta-analyses.

Dr. Ethan Balk cautioned us to consider the costly and underpowered RCT, and lack of generalizability needed to define rigorous study inclusion and outcome criteria. Dr. Sung then pointed out that, while the perfect surrogate outcome would allow us to shorten study lengths (and save money), the seduction of association and causation can lead to some questionable conclusions.

When using a clinical practice guideline, Dr. Miles Murphy indicated that a systematic review needs to be included, although a meta-analysis is not always required. The poor quality and paucity of RCTs for most patient populations is what limits us.

Dr. Rahn gave an excellent presentation on subgroup analysis, recommending to attendees that they perform these analyses cautiously, describe which groups are analyzed, and have statistical back-up for power and P value calculations.

Dr. Kristen Matteson then spoke about interpreting the literature on screening and diagnostic tests, giving a thorough but understandable review of the basics of statistics. Dr. John Wong rounded out the course, suggesting that because RCTs are expensive and comprise less than 5% of published studies, the analysis of observational studies as RCTs would allow us to better inform our patients and our colleagues on the best treatments, using patient-centered outcomes, efficacy data, and multiple providers. He urged us all to be more skeptical and ask critical questions when dealing with evidence in medicine.

Sharpening ultrasonography skills

Simultaneously, others attended a hands-on learning course on comprehensive pelvic floor ultrasonography, including transperineal, endovaginal, and endoanal imaging, organized by Dr. Abbas Shobeiri.

Tips for the difficult hysterectomy

Dr. Ted Lee (with help from Drs. Arnold P. Advincula, Rosanne Kho, and Matthew Seidhoff) prepared a surgical tutorial on laparoscopic, robotic, and vaginal strategies and techniques for approaching the difficult hysterectomy. The course was phenomenal, as described by many of the members fortunate enough to learn some of the tips and tricks demonstrated by the master surgeons.

Training for the NIH application process

Following the postgraduate courses, Dr. Katherine Hartmann led an “NIH Application Training Camp,” an offering supported by SGS research donations and a generous donation from Dr. Holly Richter. Dr. Hartmann provided in-depth insight into the world of NIH grant funding and provided background prep for a K or R award application. A mock NIH application study section, in which two actual applications were reviewed, demystified the process of grant review (and rejection). 

A social end to day 1

To end the first day, a welcome reception was held where residents, fellows, and attendings from different fields of ObGyn mingled and shared drinks, stories, and good laughs.

The "social" activities continue on social media for the rest of the conference. Follow #SGS2015, @gynsurgery, @obgmanagement, and @sukrantmehta for more!

3/24/15, Day 3 at SGS

Many topics, many learning opportunities   

The morning’s focus topics at SGS were divided up in small-group academic roundtables, with 15 experts in the field providing authoritative know-how and guidance to attendees. Topics ranged from tips for in-bag tissue extraction, endometriosis surgery, surviving health care transformation, cost-effectiveness, and single-site surgery to innovative treatments for fecal incontinence.

In the main hall, the fourth scientific session included oral presentations and videos that focused on anatomic landmarks and variations and included data presentation from an interesting prospective randomized trial in which the authors found bladder support is reduced by pregnancy, regardless of delivery method.

The highlight of the morning was certainly the debate over "power" morcellation. Dr. Cheryl Iglesia moderated in her charming and comical manner. Dr. Andrew Sokol and Dr. Jubilee Brown argued that power morcellation still should be available to a select group of appropriately chosen, low-risk women, and backed their arguments up with solid data. Dr. Eric Sokol, Andrew’s twin (and better looking, per him) brother, and Dr. Carl Zimmerman argued against the use of power morcellation, instead urging everyone in the audience to perform more vaginal hysterectomies. Though spirited and based largely on sound medical evidence, the debate did not have a clear winner. The overall consensus seemed to be that this controversial topic needed further evaluation and more data to support either claim.

"Sesame street graduates” and andragogy

We were then honored to have Vice President for Education, American College of Obstetricians and Gynecologists Dr. Sandra Carson as the esteemed TeLinde Lecturer. Her talk, “Teaching Medicine and Surgery to Sesame Street Graduates,” outlined the challenges in teaching surgery to a new generation of ObGyn residents as well as identified opportunities for improvement. She restated what seems to be the running theme at SGS this year: young faculty and residents are losing the skill for vaginal hysterectomy.

Dr. Carson introduced members of the audience to the adult theory of learning called andragogy. Adults like active learning, which is problem centered, rather than content oriented; linking new concepts to prior experience; and learning what is relevant to them, she noted. Then she shared ACOG’s strategies for applying these learning principles in resident education. She discussed ACOG’s recently formed Vaginal Hysterectomy Teaching Taskforce, which has put together a simulation consortium online toolkit and a surgical skills module to help educate residents on vaginal hysterectomy techniques. This toolkit and module can be accessed by doing a quick search after signing into the ACOG Web site.

Dr. Carson, a reproductive endocrinologist formerly at Brown University, is also now an honorary member of SGS.

Wise words from a wise physician

In his presidential address Dr. Stephen Metz acknowledged that all physicians are subject to even subtle “conflicts of interest,” reminding us to treat our patients as people not as a disease or a procedure.

“What does my patient really want from me? She wants me to get to know her to develop the right recommendations for her,” he said. His career has spanned multiple decades, and his service to the field of gynecology is outstanding. He received a well-deserved standing ovation at the end of his address.

Sport and socialization a necessity in sunny Florida!

The afternoon adjourned after the business meeting, and members were able to play golf, tennis, paddleboard in Winter Park, or just relax at the resort. Congratulations to the winners of the golf tournament (Drs. Hopkins, Rasmussen, Hurd, and Flora) and the tennis tournament (Dr. Ted Lee)!

Everyone convened at the outside terrace for the evening “Mojito Night in the Caribbean” reception, sharing good times, cocktails, and hors d’oeuvres. Proceeds from each ticket sold helped support Surgeons Helping Advance Research and Education (SHARE).

Tomorrow looks to be an excellent conclusion to a well-planned and very well-executed meeting. Kudos, and large thanks, to the SGS leadership.

3/23/15, Day 2 at SGS

Surgeons from 17 countries converge

The first day of the SGS scientific sessions was another energetic and interactive day. Sixteen new SGS members were recognized and welcomed in the main conference hall. Dr. Charles Rardin presented a brief overview and some basic statistics related to this year’s meeting—the largest ever in the history of SGS. A total of 401 attendees representing 17 countries are here in Orlando for SGS 2015! 

In the first scientific session, oral presentations touched on the subjects of preoperative dexamethasone use, vaginal packing, surgical site infections, and a new treatment modality for fecal incontinence. An excellent technique video on laparoscopic ureterolysis by Dr. Cara King then followed, in which she demonstrated excellent surgical skills with amazingly clear anatomy. Her video was recognized later in the day with a well-deserved award—congratulations! 

A short break in the exhibit hall allowed for mingling with other attendees, many of whom have been active on social media surrounding the meeting, and for visiting the booths of the industry sponsors. The second scientific session then picked up where the first left off, with more scientifically sound research presented on such topics as mechanical bowel preparation use in laparoscopy and pelvic floor disorders in women with gynecologic malignancies.

No room for fads in gyn surgery

Dr. David Grimes, a true leader in our field, provided an exceptional keynote address, “Is Teaching Evidence-Based Surgery Possible?" He shared his expertise of evidence-based medicine, and described (in sometimes very comical but always stimulating and provocative terms) the need for incorporating evidence-based surgery in gynecology. He urged us to strive to do best by our patients by applying evidenced-based practices rather than following fads and gizmos.

Gyn surgery training: Have we reached a “perfect storm”?

The afternoon brought with it a panel discussion on "Teaching the Next Generation of GYN Surgeons," with Dr. Hal Lawrence moderating and Dr. Mark Walters and Dr. Dee Fenner serving as panelists. They discussed the future of ObGyn residency training in great detail: increasing subspecialization, a stable birth rate, declining hysterectomy rates, increasing safety and quality monitoring, and increased access to data and informed consumers. All of these trends were highlighted as reasons for a perfect storm in gynecologic surgery training. In addition, the panel presented some surprising statistics: 

• The majority of hysterectomies in the United States are being done by surgeons who perform less than 1 per month.
• The higher volume surgeons provide higher value and tend to utilize more minimally invasive approaches.

Videofest!

The scientific day concluded with a videofest that included complex robotic, laparoscopic, hysteroscopic, cystoscopic, and vaginal surgeries, demonstrating the surgical talents and ingenuity of SGS members.

Simultaneously, the Fellows’ Pelvic Research Network (FPRN) met to update their ongoing projects and to review new proposals. The meeting sought to unite FPRMS and MIS fellows to conduct multicenter studies. This was an enlightening and engaging session, which should give everyone great hope to see the creativity and energy of the next generation of researchers.

A grounder for attendees

All in attendance were treated to a unique, eye-opening, motivational, and very moving talk by Professor (and Sir) Ajay Rane, MD, PhD from Australia on female genital mutilation. He stressed the importance of respecting women for who they are, not what they do.

“My idea of feminism is applauding a woman who gives birth. Celebrate women for who they are," he said. He highlighted the work being done by his team in Australia and India, and urged everyone in attendance to become more aware of the staggering statistics and reality of female genital mutilation.

The jam-packed day wrapped with the awards ceremony in the main hall. Lifelong mentors were honored by their mentees and SGS President Dr. Stephen Metz and Scientific Program Chair Dr. Charles Rardin presented various awards to those who had submitted and presented novel and groundbreaking research.

One last surprise

The President’s Reception in the exhibit hall was lively, with meeting sponsors, colleagues, and friends in attendance. And, of course, a visit from special guest! (Thanks to SGS Fellow Christina Saad, MD @XtinaSaad for the pic!)

See you all tomorrow for another educational, enlightening, and spirited day at #SGS2015! 

3/22/15. DAY 1 AT SGS

A focus on evidence-based medicine

Strong analytic skills (of your own research as well as the published literature) translates to better patient care, was the underlying theme of the opening postgraduate course here in Orlando, Florida, for day 1 of the 41st annual meeting of the Society of Gynecologic Surgeons.

Building on the success of last year’s course on evidence-based medicine (EBM), Dr. Vivian Sung and Dr. Ike Rahn put together an amazing team to review and apply the principles of so-called EBM, a workshop that was in part sponsored by ABOG.

A quick introduction to EBM principles by Dr. Thomas Wheeler was followed by small break-out groups, where attendees used the PICO-DD model to define a Population, Intervention, Comparator, Outcomes, Duration, and study Design. Further talks focused on the benefits and caveats of randomized controlled trials (RCTs), surrogate and intermediate outcomes, and systematic reviews and meta-analyses.

Dr. Ethan Balk cautioned us to consider the costly and underpowered RCT, and lack of generalizability needed to define rigorous study inclusion and outcome criteria. Dr. Sung then pointed out that, while the perfect surrogate outcome would allow us to shorten study lengths (and save money), the seduction of association and causation can lead to some questionable conclusions.

When using a clinical practice guideline, Dr. Miles Murphy indicated that a systematic review needs to be included, although a meta-analysis is not always required. The poor quality and paucity of RCTs for most patient populations is what limits us.

Dr. Rahn gave an excellent presentation on subgroup analysis, recommending to attendees that they perform these analyses cautiously, describe which groups are analyzed, and have statistical back-up for power and P value calculations.

Dr. Kristen Matteson then spoke about interpreting the literature on screening and diagnostic tests, giving a thorough but understandable review of the basics of statistics. Dr. John Wong rounded out the course, suggesting that because RCTs are expensive and comprise less than 5% of published studies, the analysis of observational studies as RCTs would allow us to better inform our patients and our colleagues on the best treatments, using patient-centered outcomes, efficacy data, and multiple providers. He urged us all to be more skeptical and ask critical questions when dealing with evidence in medicine.

Sharpening ultrasonography skills

Simultaneously, others attended a hands-on learning course on comprehensive pelvic floor ultrasonography, including transperineal, endovaginal, and endoanal imaging, organized by Dr. Abbas Shobeiri.

Tips for the difficult hysterectomy

Dr. Ted Lee (with help from Drs. Arnold P. Advincula, Rosanne Kho, and Matthew Seidhoff) prepared a surgical tutorial on laparoscopic, robotic, and vaginal strategies and techniques for approaching the difficult hysterectomy. The course was phenomenal, as described by many of the members fortunate enough to learn some of the tips and tricks demonstrated by the master surgeons.

Training for the NIH application process

Following the postgraduate courses, Dr. Katherine Hartmann led an “NIH Application Training Camp,” an offering supported by SGS research donations and a generous donation from Dr. Holly Richter. Dr. Hartmann provided in-depth insight into the world of NIH grant funding and provided background prep for a K or R award application. A mock NIH application study section, in which two actual applications were reviewed, demystified the process of grant review (and rejection). 

A social end to day 1

To end the first day, a welcome reception was held where residents, fellows, and attendings from different fields of ObGyn mingled and shared drinks, stories, and good laughs.

The "social" activities continue on social media for the rest of the conference. Follow #SGS2015, @gynsurgery, @obgmanagement, and @sukrantmehta for more!

Responses from both sides of the home-birth controversy are parried in an Opinion Page debate titled “Is Home Birth Ever a Safe Choice?” published on February 24, 2015, in the New York Times.

Debaters include John Jennings, MD, President of the American Congress of Obstetricians and Gynecologists (ACOG); Tekoa King, a certified nurse midwife (CNM) and Deputy Editor of the Journal of Midwifery & Women’s Health; Amos Grunebaum, MD, Director of Obstetrics, and Frank Chervenak, MD, Obstetrician and Gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University; Marinah Valenzuela Farrell, a certified professional midwife (CPM) and president of the Midwives Alliance of North America; Aaron Caughey, MD, Chair of the Department of Obstetrics and Gynecology and Associate Dean for Women’s Health Research and Policy at Oregon Health and Science University’s School of Medicine; and Aja Graydon, a musician who experienced home birth.

To read the New York Times article, click here.

Responses from both sides of the home-birth controversy are parried in an Opinion Page debate titled “Is Home Birth Ever a Safe Choice?” published on February 24, 2015, in the New York Times.

Debaters include John Jennings, MD, President of the American Congress of Obstetricians and Gynecologists (ACOG); Tekoa King, a certified nurse midwife (CNM) and Deputy Editor of the Journal of Midwifery & Women’s Health; Amos Grunebaum, MD, Director of Obstetrics, and Frank Chervenak, MD, Obstetrician and Gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University; Marinah Valenzuela Farrell, a certified professional midwife (CPM) and president of the Midwives Alliance of North America; Aaron Caughey, MD, Chair of the Department of Obstetrics and Gynecology and Associate Dean for Women’s Health Research and Policy at Oregon Health and Science University’s School of Medicine; and Aja Graydon, a musician who experienced home birth.

To read the New York Times article, click here.

Responses from both sides of the home-birth controversy are parried in an Opinion Page debate titled “Is Home Birth Ever a Safe Choice?” published on February 24, 2015, in the New York Times.

Debaters include John Jennings, MD, President of the American Congress of Obstetricians and Gynecologists (ACOG); Tekoa King, a certified nurse midwife (CNM) and Deputy Editor of the Journal of Midwifery & Women’s Health; Amos Grunebaum, MD, Director of Obstetrics, and Frank Chervenak, MD, Obstetrician and Gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University; Marinah Valenzuela Farrell, a certified professional midwife (CPM) and president of the Midwives Alliance of North America; Aaron Caughey, MD, Chair of the Department of Obstetrics and Gynecology and Associate Dean for Women’s Health Research and Policy at Oregon Health and Science University’s School of Medicine; and Aja Graydon, a musician who experienced home birth.

To read the New York Times article, click here.

Frequent menopausal vasomotor symptoms (VMS), including hot flashes and night sweats, lasted longer than 7 years during the transition to menopause for more than 50% of women in the Study of Women’s Health Across the Nation (SWAN).¹ Among the factors related to a longer duration of VMS:

• younger age
• African American heritage
• lower educational level
• greater perceived stress and symptom sensitivity
• higher depressive symptoms and anxiety at the first report of VMS.

Details of the study
Avis and colleagues analyzed data from SWAN, a multiracial/multiethnic study of women transitioning to menopause that was conducted from February 1996 through April 2013. The analyses included 1,449 women with frequent VMS (ie, occurring at least 6 days in the previous 2 weeks).

Baseline eligibility was age between 42 and 52 years, an intact uterus and at least one ovary, report of a menstrual cycle in the 3 months before screening, absence of pregnancy and lactation, and no use of oral contraceptives or hormone therapy (HT). Women were assessed in person at baseline and approximately annually over the course of the study (mean and maximum follow-up durations were 12.7 and 17.2 years, respectively).

The main outcomes were total VMS duration (in years) and persistence of VMS (in years) beyond the final menstrual period (FMP).

Among the findings:

• The unadjusted median total VMS duration was 7.4 years
• Women who were premenopausal or early perimenopausal when they first reported frequent VMS had the longest total duration of VMS (median, >11.8 years) and longest persistence of VMS beyond the FMP (median, 9.4 years)
• Women who were postmenopausal at the onset of VMS had the shortest total VMS duration after the FMP (median, 3.4 years; P<.001).
• The median total VMS duration varied significantly by race, with African American women reporting the longest total VMS duration (median, 10.1 years) and Japanese and Chinese women reporting the shortest total duration (median, 4.8 and 5.4 years, respectively). Non-Hispanic white women had a median total VMS duration of 6.5 years; among Hispanic women, the median was 8.9 years.

Key takeaway
“These findings can help health-care professionals counsel patients about expectations regarding VMS and assist women in making treatment decisions based on the probability of their VMS persisting,” Avis and colleagues concluded. “In addition, the median total duration of 7.4 years highlights the limitations of guidance recommending short-term HT use and emphasizes the need to identify safe long-term therapies for the treatment of VMS.”

SWAN is the largest and longest longitudinal study to date to report on total duration of VMS and their persistence beyond the FMP.

“More than 50% of midlife women experience frequent VMS, yet clinical guidelines typically underestimate their true duration,” Avis and colleagues observed.

Frequent menopausal vasomotor symptoms (VMS), including hot flashes and night sweats, lasted longer than 7 years during the transition to menopause for more than 50% of women in the Study of Women’s Health Across the Nation (SWAN).¹ Among the factors related to a longer duration of VMS:

• younger age
• African American heritage
• lower educational level
• greater perceived stress and symptom sensitivity
• higher depressive symptoms and anxiety at the first report of VMS.

Details of the study
Avis and colleagues analyzed data from SWAN, a multiracial/multiethnic study of women transitioning to menopause that was conducted from February 1996 through April 2013. The analyses included 1,449 women with frequent VMS (ie, occurring at least 6 days in the previous 2 weeks).

Baseline eligibility was age between 42 and 52 years, an intact uterus and at least one ovary, report of a menstrual cycle in the 3 months before screening, absence of pregnancy and lactation, and no use of oral contraceptives or hormone therapy (HT). Women were assessed in person at baseline and approximately annually over the course of the study (mean and maximum follow-up durations were 12.7 and 17.2 years, respectively).

The main outcomes were total VMS duration (in years) and persistence of VMS (in years) beyond the final menstrual period (FMP).

Among the findings:

• The unadjusted median total VMS duration was 7.4 years
• Women who were premenopausal or early perimenopausal when they first reported frequent VMS had the longest total duration of VMS (median, >11.8 years) and longest persistence of VMS beyond the FMP (median, 9.4 years)
• Women who were postmenopausal at the onset of VMS had the shortest total VMS duration after the FMP (median, 3.4 years; P<.001).
• The median total VMS duration varied significantly by race, with African American women reporting the longest total VMS duration (median, 10.1 years) and Japanese and Chinese women reporting the shortest total duration (median, 4.8 and 5.4 years, respectively). Non-Hispanic white women had a median total VMS duration of 6.5 years; among Hispanic women, the median was 8.9 years.

Key takeaway
“These findings can help health-care professionals counsel patients about expectations regarding VMS and assist women in making treatment decisions based on the probability of their VMS persisting,” Avis and colleagues concluded. “In addition, the median total duration of 7.4 years highlights the limitations of guidance recommending short-term HT use and emphasizes the need to identify safe long-term therapies for the treatment of VMS.”

SWAN is the largest and longest longitudinal study to date to report on total duration of VMS and their persistence beyond the FMP.

“More than 50% of midlife women experience frequent VMS, yet clinical guidelines typically underestimate their true duration,” Avis and colleagues observed.

Frequent menopausal vasomotor symptoms (VMS), including hot flashes and night sweats, lasted longer than 7 years during the transition to menopause for more than 50% of women in the Study of Women’s Health Across the Nation (SWAN).¹ Among the factors related to a longer duration of VMS:

• younger age
• African American heritage
• lower educational level
• greater perceived stress and symptom sensitivity
• higher depressive symptoms and anxiety at the first report of VMS.

Details of the study
Avis and colleagues analyzed data from SWAN, a multiracial/multiethnic study of women transitioning to menopause that was conducted from February 1996 through April 2013. The analyses included 1,449 women with frequent VMS (ie, occurring at least 6 days in the previous 2 weeks).

Baseline eligibility was age between 42 and 52 years, an intact uterus and at least one ovary, report of a menstrual cycle in the 3 months before screening, absence of pregnancy and lactation, and no use of oral contraceptives or hormone therapy (HT). Women were assessed in person at baseline and approximately annually over the course of the study (mean and maximum follow-up durations were 12.7 and 17.2 years, respectively).

The main outcomes were total VMS duration (in years) and persistence of VMS (in years) beyond the final menstrual period (FMP).

Among the findings:

• The unadjusted median total VMS duration was 7.4 years
• Women who were premenopausal or early perimenopausal when they first reported frequent VMS had the longest total duration of VMS (median, >11.8 years) and longest persistence of VMS beyond the FMP (median, 9.4 years)
• Women who were postmenopausal at the onset of VMS had the shortest total VMS duration after the FMP (median, 3.4 years; P<.001).
• The median total VMS duration varied significantly by race, with African American women reporting the longest total VMS duration (median, 10.1 years) and Japanese and Chinese women reporting the shortest total duration (median, 4.8 and 5.4 years, respectively). Non-Hispanic white women had a median total VMS duration of 6.5 years; among Hispanic women, the median was 8.9 years.

Key takeaway
“These findings can help health-care professionals counsel patients about expectations regarding VMS and assist women in making treatment decisions based on the probability of their VMS persisting,” Avis and colleagues concluded. “In addition, the median total duration of 7.4 years highlights the limitations of guidance recommending short-term HT use and emphasizes the need to identify safe long-term therapies for the treatment of VMS.”

SWAN is the largest and longest longitudinal study to date to report on total duration of VMS and their persistence beyond the FMP.

“More than 50% of midlife women experience frequent VMS, yet clinical guidelines typically underestimate their true duration,” Avis and colleagues observed.

The etonogestrel contraceptive implant and the 52-mg levonorgestrel intrauterine system (LNG-IUS) remain highly effective for an additional year beyond the FDA-approved intervals of 3 and 5 years, respectively, according to a newly published prospective study.¹

In the study, implant users (n = 237) contributed 229.4 women-years of follow-up, with 123 women using the implant for 4 years and 34 using it for 5 years. No pregnancies were documented—a failure rate of 0 (one-sided 97.5% confidence interval [CI], 0–1.61) per 100 women-years.

Of 263 LNG-IUS users, 197.7 women-years of follow-up found only one pregnancy—a failure rate of 0.51 (95% CI, 0.01–2.82) per 100 women-years.

Among implant users with serum etonogestrel levels assessed, the median at 3 years of use was 188.8 pg/mL (range, 63.8–802.6 pg/mL). At 4 years, the median etonogestrel level was 177.0 pg/mL (range, 67,9–470.5 pg/mL). Etonogestrel levels did not vary by body mass index at either 3 years (P = .79) or 4 years (P = .47). These serum levels indicate that the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use.

The etonogestrel contraceptive implant and the 52-mg levonorgestrel intrauterine system (LNG-IUS) remain highly effective for an additional year beyond the FDA-approved intervals of 3 and 5 years, respectively, according to a newly published prospective study.¹

In the study, implant users (n = 237) contributed 229.4 women-years of follow-up, with 123 women using the implant for 4 years and 34 using it for 5 years. No pregnancies were documented—a failure rate of 0 (one-sided 97.5% confidence interval [CI], 0–1.61) per 100 women-years.

Of 263 LNG-IUS users, 197.7 women-years of follow-up found only one pregnancy—a failure rate of 0.51 (95% CI, 0.01–2.82) per 100 women-years.

Among implant users with serum etonogestrel levels assessed, the median at 3 years of use was 188.8 pg/mL (range, 63.8–802.6 pg/mL). At 4 years, the median etonogestrel level was 177.0 pg/mL (range, 67,9–470.5 pg/mL). Etonogestrel levels did not vary by body mass index at either 3 years (P = .79) or 4 years (P = .47). These serum levels indicate that the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use.

The etonogestrel contraceptive implant and the 52-mg levonorgestrel intrauterine system (LNG-IUS) remain highly effective for an additional year beyond the FDA-approved intervals of 3 and 5 years, respectively, according to a newly published prospective study.¹

In the study, implant users (n = 237) contributed 229.4 women-years of follow-up, with 123 women using the implant for 4 years and 34 using it for 5 years. No pregnancies were documented—a failure rate of 0 (one-sided 97.5% confidence interval [CI], 0–1.61) per 100 women-years.

Of 263 LNG-IUS users, 197.7 women-years of follow-up found only one pregnancy—a failure rate of 0.51 (95% CI, 0.01–2.82) per 100 women-years.

Among implant users with serum etonogestrel levels assessed, the median at 3 years of use was 188.8 pg/mL (range, 63.8–802.6 pg/mL). At 4 years, the median etonogestrel level was 177.0 pg/mL (range, 67,9–470.5 pg/mL). Etonogestrel levels did not vary by body mass index at either 3 years (P = .79) or 4 years (P = .47). These serum levels indicate that the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use.

In an effort to determine how to curb rapid repeat adolescent pregnancy, researchers at MedStar Washington Hospital Center in Washington, DC, conducted a retrospective cohort study with first-time adolescent mothers, aged 19 years or younger. The repeat pregnancy rate at 2 years was 35% (n = 340). The average (SD) time from delivery to the second pregnancy was 9.9 (6.4) months.

Damle and colleagues found that leaving the hospital after giving birth without initiating any contraception was associated with more than double the risk of repeat pregnancy (odds ratio [OR], 2.447; 95% confidence interval [CI], 1.326–4.515). Follow-up in clinic within an 8-week postpartum period significantly reduced the chance of repeat pregnancy (OR, 0.322; 95% CI, 0.172–0.603). And placement of a long-acting reversible contraception (LARC), including intrauterine device or etonogestrel subdermal implant, by 8 weeks’ postpartum decreased the chance of rapid repeat pregnancy (OR, 0.118; 95% CI, 0.035-0.397).

Researchers Damle and colleagues concluded that adolescent mothers who begin to use a LARC within 8 weeks’ postpartum are less likely to have a repeat pregnancy within 2 years than those who chose another method or no contraception at all.

“First time adolescent mothers should be counseled about this advantage of using LARC,” wrote the authors.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In an effort to determine how to curb rapid repeat adolescent pregnancy, researchers at MedStar Washington Hospital Center in Washington, DC, conducted a retrospective cohort study with first-time adolescent mothers, aged 19 years or younger. The repeat pregnancy rate at 2 years was 35% (n = 340). The average (SD) time from delivery to the second pregnancy was 9.9 (6.4) months.

Damle and colleagues found that leaving the hospital after giving birth without initiating any contraception was associated with more than double the risk of repeat pregnancy (odds ratio [OR], 2.447; 95% confidence interval [CI], 1.326–4.515). Follow-up in clinic within an 8-week postpartum period significantly reduced the chance of repeat pregnancy (OR, 0.322; 95% CI, 0.172–0.603). And placement of a long-acting reversible contraception (LARC), including intrauterine device or etonogestrel subdermal implant, by 8 weeks’ postpartum decreased the chance of rapid repeat pregnancy (OR, 0.118; 95% CI, 0.035-0.397).

Researchers Damle and colleagues concluded that adolescent mothers who begin to use a LARC within 8 weeks’ postpartum are less likely to have a repeat pregnancy within 2 years than those who chose another method or no contraception at all.

“First time adolescent mothers should be counseled about this advantage of using LARC,” wrote the authors.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In an effort to determine how to curb rapid repeat adolescent pregnancy, researchers at MedStar Washington Hospital Center in Washington, DC, conducted a retrospective cohort study with first-time adolescent mothers, aged 19 years or younger. The repeat pregnancy rate at 2 years was 35% (n = 340). The average (SD) time from delivery to the second pregnancy was 9.9 (6.4) months.

Damle and colleagues found that leaving the hospital after giving birth without initiating any contraception was associated with more than double the risk of repeat pregnancy (odds ratio [OR], 2.447; 95% confidence interval [CI], 1.326–4.515). Follow-up in clinic within an 8-week postpartum period significantly reduced the chance of repeat pregnancy (OR, 0.322; 95% CI, 0.172–0.603). And placement of a long-acting reversible contraception (LARC), including intrauterine device or etonogestrel subdermal implant, by 8 weeks’ postpartum decreased the chance of rapid repeat pregnancy (OR, 0.118; 95% CI, 0.035-0.397).

Researchers Damle and colleagues concluded that adolescent mothers who begin to use a LARC within 8 weeks’ postpartum are less likely to have a repeat pregnancy within 2 years than those who chose another method or no contraception at all.

“First time adolescent mothers should be counseled about this advantage of using LARC,” wrote the authors.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.