Education Columns

by Kara W. Greeley, MD; Andrew Wang, PhD, MPH, CPH; Lawndale Christian Family Medicine Residency, Chicago, IL

Abstract

Family Medicine residency programs have the challenge of rapidly readying newly graduated doctors to rotate through all core hospital units and primary care outpatient disciplines. Students who experienced their clinical clerkships during the COVID-19 global pandemic reported decreased hands-on patient encounters.^1,2  This can lead to discomfort with obstetrics, which involves specialized knowledge and technical skills. Patient simulation helps alleviate this, but simulation laboratories are only available for highly-resourced residency programs. We created a half-day “boot camp” for our residency based in a federally qualified health center on the west side of Chicago using materials costing less than $50.  A survey of our residents before and after the session demonstrated an improved confidence to start their obstetrics rotation.

Background

Family medicine involves caring for patients throughout their lifespan in both inpatient and outpatient settings. Including obstetrics enables continuity for pregnant patients and naturally fits with our family-centered model of care, but many incoming residents express feeling unprepared for this aspect of their training.

The use of high-fidelity simulation has demonstrated improvement in learners’ confidence and in team performance in the stressful environment of labor and delivery.^3,4 Our family medicine residency welcomed its first class in July 2022, funded through the Teaching Health Center Graduate Medical Education (THCGME) program. Our community experiences high levels of poor maternal outcomes and our residency aims to help reverse these disparities by providing excellent pregnancy care. When we approached our local state university to have our residents utilize their simulation lab, the cost was $20,000, which was prohibitive for our small program. We created an alternative means to ready our residents for their obstetrics rotations and implemented a survey to assess its effectiveness.

Methods

The educational objectives for our “boot camp” were to acquire the knowledge and skills to safely triage patients during labor and delivery and to have foundational knowledge in peripartum care. Our residents completed a survey before and after the training to assess its efficacy.

This study was reviewed and received an exemption by the Institutional Review Board at Sinai Chicago.

Through slideshow presentations on core topics and workshops to practice key clinical skills we conveyed critical knowledge needed to ensure patient safety on day one of the rotation, including initial questions for the OB patient, when to get help quickly, best practices when performing pelvic exams, interpretation of fetal heart tracing, and intrauterine resuscitation.

We crafted models based on a template described in the literature using plastic containers, used softballs and pool noodles, foam pipe insulation, stockinette and elastic bandages, and sponges. ⁵ We made six models with varying dilation and effacement.^{Fig a, b, c} Gamification has been demonstrated to improve learners’ engagement with and retention of information.⁷ We used our six models to make a fun game for our residents to practice cervical exams. We also utilized the models to experience placing an IUPC, used citrus fruit to simulate applying fetal scalp electrodes, and used water balloons for performing amniotomy.⁶

Results

We surveyed our residents before and after the 4-hour “boot camp” to assess how prepared they felt to start their obstetrics rotations, and specifically regarding each topic we reviewed, using a scale from 0 to 10. Average answers are tabulated below, showing reported improvement in each area and in their overall sense of readiness.

Discussion

Incoming family medicine residents who experienced medical school during the COVID-19 pandemic had the additional difficulty of having limited hands-on patient care experiences.^1,2 Labor and delivery is a department where new residents must be ready to recognize and respond to emergencies from the moment they arrive on the floor. They also must perform several physical exam skills and technical interventions that are unique to that unit.

Trying to adequately prepare new residents to perform safely on labor and delivery during a packed orientation schedule presents a dilemma for educators in family medicine. We implemented a brief but efficient, low-cost method that improved our residents’ sense of preparedness for their obstetrics rotations. There were several limitations noted. The models utilized were helpful to get an idea of how to perform cervical exams but did not realistically simulate the feel of an actual patient. The amount of information presented and the potential delay between the time of the orientation and the start of their rotation may affect their ability to retain the sense of preparation.

Conclusion

A half-day orientation curriculum comprised of a series of interactive presentations on core obstetrical topics and hands-on workshops to practice key technical skills is a low-cost, enjoyable, and effective method to help incoming family medicine residents feel prepared for their rotations in obstetrics.

References

1. Franklin G, Martin C, Ruszaj M, et al. How the COVID-19 Pandemic Impacted Medical Education during the Last Year of Medical School: A Class Survey. Life (Basel). 2021;11(4):294. doi:10.3390/life11040294
2. Ribeiro LS, Francisco RPV, Cabar FR. COVID-19 pandemic repercussions on undergraduate teaching in obstetrics and gynecology. Clinics (Sao Paulo). 2022;77:100025. doi:10.1016/j.clinsp.2022.100025
3. Mannella P, Antonelli R, Montt-Guevara MM, et al. Simulation of childbirth improves clinical management capacity and self-confidence in medical students. BMJ Simul Technol Enhanc Learn. 2018;4(4):184-189. Doi:10.1136/bmjstel-2017-000259
4. Pliego JF, Wehbe-Janek H, Rajab MH, Browning JL, Fothergill RE. OB/GYN boot cAMP using high-fidelity human simulators: enhancing residents’ perceived competency, confidence in taking a leadership role, and stress hardiness. Simul Healthc. 2008;3(2):82-89. doi:10.1097/SIH.0b013e3181658188
5. Perry JD, Maples JM, Deisher HN, et al. A Novel Approach to Teaching the Cervical Exam: A Versatile, Low-Cost Simulation for Labor and Delivery Learners. Cureus. Published online December 7, 2021. Doi:10.7759/cureus.20235
6. Shea KL, Rovera EJ. Vaginal Examination Simulation Using Citrus Fruit to Simulate Cervical Dilation and Effacement. Cureus. Published online September 1, 2015. Doi:10.7759/cureus.314
7. O’Connell A, Tomaselli PJ, Stobart-Gallagher M. Effective Use of Virtual Gamification During COVID-19 to Deliver the OB-GYN Core Curriculum in an Emergency Medicine Resident Conference. Cureus. 2020;12(6):e8397. doi:10.7759/cureus.8397