- Email: [email protected]
Office gynecology
higher, at least one double-sided disk drive, and a monitor, preferably color, with a graphics adapter. The program is written in Basic. The instructions for starting the program assume it is to be run on an IBM PC. Users with newer IBMs (XT or AT) or with IBM-compatibles must modify the startup somewhat. This is not explained in the documentation, but a tollfree number is provided for information on use with non-IBM machines. Each of the 12 disks deals with examination of the adult by body systems, such as Head, Face, Mouth and Neck; Thorax and Lungs; Abdomen, and so on. After the title screens, the user first chooses whether to run the entire unit or one section, then selects tutorial or competency mode. In tutorial mode, successive screens give information about the examination techniques appropriate to that body system interspersed with short-answer questions. Feedback is immediate, and an incorrect response will cause the relevant screen of information to reappear for the user’s review. At the end of each section a short-answer quiz tests the student’s learning and generates a percentage score. The time required to complete a unit in tutorial mode is approximately one hour. Tutorial mode opens with a screen listing learning objectives for the unit. The next screen details equipment required for examination of that particular body system. The program then takes the user through the physical examination, describing techniques for the use of each modality: inspection, palpation, percussion, and auscultation-as applicable. Normal findings and some common abnormalities are given. Competency mode is appropriate when the student wants to test retention of information from reading or from the tutorial. It simply presents section quiz questions to which the user responds. No feedback is given except for a percentage score at the end of the quiz. In either mode, scores may be printed using the Print Screen key. The program is easy to use. Pressing the space bar moves the user to the next screen. The user can only move forward in the program; if review is desired, (s)he must finish the current section first. At the end of the section quiz, the main menu appears and the user can run the same section again or begin a new one. Journal of Nurse-Midwifery
??
For this review, the units on the breast and axillae, female genitalia, anus, and rectum were selected because of their direct relevance to nurse-midwifey practice. The Breast and Axillae unit includes both the female and the male breast. The information presented is correct, but some is given in a way that may confuse a learner. For example, under inspection, the text says that the patient should be seated with arms at the sides and hands in lap, but the accompanying graphic shows a woman with her hands on her hips. Description of breast masses is covered under inspection when it should be included in palpation. The two patterns of palpation are called semicircular and side to side. Use of the terms spiral and parallel is clearer and more accurate. The program also teaches the student to avoid eye contact with the patient during palpation; one reason given for this is to reduce embarrassment. Some educators and learners may feel that avoidance of eye contact dehumanizes the patient. The Female Genitalia disk is commendable in that it encourages the learner to be aware of the patient’s comfort at all times. This includes having the patient keep her shoes on, facilitating relaxation, explaining the procedure, checking the patient’s facial expression for anxiety, and lubricating the speculum with warm water. The content of the unit is generally accurate. It omits reference to screening for any sexually transmitted diseases other than gonorrhea. The student checks for cystocele and rectocele by having the patient strain down; this maneuver is also recommended for assessment of vaginal muscle tone. In contrast, Varney’ recommends assessing tone by having the patient contract her perineal muscles around the examining fingers. The quiz questions are taken directly from the tutorial screens. Although they test the program’s objectives, they are often frustrating. Very minor spelling errors are pointed out to the learner for correction, but a typographical mistake is simply scored as incorrect. In tutorial mode, a true-false question that is false requires the learner to pick out the incorrect word or phrase and input the correction. For some true-false questions, more than one word or phrase could be corrected, but the program rewards only one. One question for which the correct response is symphysis pubis will not accept symphysis. Occasionally an answer
Vol. 33, No. 6, November/December
1988
known to be correct, i.e., taken verbatim from a content screen, will be rejected. The score generated from the section quizzes reflects only first responses to the questions. The student is not told which items were missed; this lack of feedback limits the usefulness of the quiz feature. This physical assessment software might be appropriate for an education program with a generous budget and students who are comfortable with computers or who benefit from the additional reinforcement such software can provide. It offers no particular advantage over the use of a good physical assessment textbook. REFERENCE 1. Varney H: Nurse-Midwifery, 2nd ed. Boston, Blackwell Scientific Publications, 1987.
Office Gynecology, 3rd edition. Edited by Robert H. Glass. Baltimore: Williams & Wilkins, 1988. 362 pages. $47.95, hardcover. Reviewed by: Ronald K. McGraw, PhD, Clinical Psychologist, Fort Worth, TX; Medical student, Texas College of Osteopathic Medicine, Fort Worth, TX According to the Preface to the First Edition, this book was designed to focus on “common problems” in the “office practice of gynecology” and was written for family practitioners, house officers, nurse-midwives, nurse-practitioners, and medical students, as well as gynecologists. Most of the 19 chapters are extremely well-referenced and several contain outstanding reviews of the literature, making the book valuable for researchers as well as clinicians. Several chapters deserve particular mention. The chapter on amenorrhea by Speroff, one of the leading authorities in gynecologic endocrinology, makes a very complex area clear and concise. The chapter on endometriosis by Dmowski is also concise, easy to read, and contains several useful tables, including one on the advantages and disadvantages of various treatment modalities. The chapter on infertility has valuable practical information on performing a hysterosalpingogram, while the chapter on contraception also has a number of useful practical suggestions for dealing with a missing IUD string, removal of an IUD that has perforated the cervix, and 293
managing side-effects of oral contraceptives. Chapters by Brown and Kaufman on vulvovaginitis and by Townsend on colposcopy, cryosurgery, and the carbon dioxide laser contain numerous, excellent black-and-white photographs. A very good critical review on the risks and benefits of estrogen replacement therapy is presented in the chapter on the postmenopausal woman. The role of psychological factors and the importance of emotional support and sensitivity to the patient’s feelings are noted in several chapters, including those on rape, endometriosis, and PMS. While acknowledging the physiological basis of PMS, Hoffman recognizes that insight and emotional support by means of group therapy, self-help groups, marital therapy, etc., can help minimize the problem. The book, however, is not without its flaws. The chapter on infertility states, “The initial interview and physical examination will not be discussed in this chapter . . .” There is no reason given and, unfortunately, the initial interview and physical examination are not covered elsewhere either. The chapter on sex counseling is poorly organized. After an inadequate single sentence definition of “counseling”, the author plunges into several case histories designed to illustrate what happens in sex counseling. Nowhere in the chapter does he deal with such basic issues as what training, experience, and attitudes are required to be a competent sex counselor, how the attitudes and values of the counselor/therapist affect goals and success, or why resistance develops and how it may be overcome. While suggesting in a couple of places possible referral to a “competent marpossible referral of riage counselor,” complex and resistant cases to a clinical psychologist. or psychiatrist is not mentioned. Dilator therapy for vaginismus is described but no mention is made of systematic desensitization, relaxation training, or hypnosis for this disorder. Although dysfunctional uterine bleeding is noted to be “among the most common, and perhaps the most confusing, of the problems facing the physician,” the chapter on this topic is less than nine pages long, is poorly referenced compared to other chapters, and could benefit from a few tables and/or diagrams. On the other hand, the chapter on 294
Diethylstilbestrol (DES)-exposed women is over 11 pages. The use of DES during pregnancy ended 17 years ago, and there were less than 10 cases of DES-associated clear cell adenocarcinoma in the U.S. in 1985. To devote so much space to this topic seems questionable when there is little or nothing in the book on breast cancer, ovarian tumors, endometrial cancer, adenomyosis, ectopic pregnancy, pelvic relaxation and stress incontinence, uterine fibroids (leiomyomas), or vulvar diseases (other than sexuallytransmitted diseases). The book could also be strengthened by chapters on physical assessment and on pediatric gynecology. Overall, with the few exceptions noted, what this book covers, it covers well. Its weakness is that there are a number of major gynecologic disorders that either are minimally discussed or not discussed at all. Because of the limited coverage, this reviewer cannot recommend Office Gynecology as one’s sole gynecology text. However, it would be quite useful as a supplemental text for nurse-midwives, nurse-practitioners, medical students, house officers, and general practitioners. Obstetrics and Gynecology, 8th edition. Edited by J. Robert Willson, MDand Elsie Reid Canington, MD. St. Louis: The C.V. Mosby Company, 1987. 754 pages. $39.95, hardcover. Reviewed by: Martha Barry, CNM, MS, Clinical Faculty, University of Illinois, Department of Maternal-Child Nursing, Nurse-Midwifey Program, Chicago, IL. Obstetrics and Gynecology, 8th edition, is written for any student who is learning the basic principles of the discipline. Both of the editors are adjunct professors in the Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine in Albuquerque. Five of the seven other contributors are obstetricians-gynecologists in clinical or academic practice; one is a psychiatrist; and one is in the field of family, community, and emergency medicine. In the 30 years since this volume was first published, the content has been greatly expanded to provide a more thorough understanding of the female patient. New chapters in this edition are: Sexual Responses of Women; Dysmenorrhea and the Premenstrual Syndrome; and Sexual Assault. Journal of Nurse-Midwifery
The obstetric sections, covering prenatal care through the puerperium, include chapters on the normal processes as well as many medical and obstetric problems. Only a few pages address the neonate, and these are concerned primanly with immediate care and resuscitation. As in previous editions, the gynecology content includes material ranging from pediatric gynecology through the aging woman. The normal psychologic and physical processes involved in wellwoman gynecology are discussed followed by information about common gynecologic problems and their management. The text does not attempt to cover complicated surgical techniques, therapeutic regimens for gynecologic oncology, or other less common conditions that might be handled by a specialist. The most valuable features of this book are its fairly comprehensive coverage of the ever expanding fields of obstetrics and gynecology and its emphasis on the thorough and organized workup of a clinical problem. The student is warned of possible diagnostic errors and given the clinical tools to avoid them. The authors are also to be commended on their consistent stress on the woman’s psychosocial state, and the impact of the clinician’s manner on his/her ability to treat the patient. This is especially well emphasized in the sections on history taking, habitual abortion, sexual dysfunction, and infertility. The discussions of ectopic pregnancies, bleeding disorders in pregnancy, and amenorrhea are particularly good with helpful management charts showing the process of diagnosis and treatment. The role of the nursemidwife, as part of the obstetric team, is acknowledged and supported as appropriate for full scope care of the low risk patient but only in a hospital setting. Because the intended audience of this book are students of obstetrics and gynecology, it is vital to present information to these future clinicians that is current, accurate and, as much as possible, research based. Although much of the clinical management discussions meet these criteria, there are, unfortunately, many omissions, errors, biases, and, also, statements that seem based on tradition rather than validated by research. Two surprising omissions are the lack of any mention of AIDS and the lack of a chapter on lactation. An example of an error is the statement that there are no IUDs available in the US at this time.
??Vol.
33, No. 6, November/December 1988
??
For this review, the units on the breast and axillae, female genitalia, anus, and rectum were selected because of their direct relevance to nurse-midwifey practice. The Breast and Axillae unit includes both the female and the male breast. The information presented is correct, but some is given in a way that may confuse a learner. For example, under inspection, the text says that the patient should be seated with arms at the sides and hands in lap, but the accompanying graphic shows a woman with her hands on her hips. Description of breast masses is covered under inspection when it should be included in palpation. The two patterns of palpation are called semicircular and side to side. Use of the terms spiral and parallel is clearer and more accurate. The program also teaches the student to avoid eye contact with the patient during palpation; one reason given for this is to reduce embarrassment. Some educators and learners may feel that avoidance of eye contact dehumanizes the patient. The Female Genitalia disk is commendable in that it encourages the learner to be aware of the patient’s comfort at all times. This includes having the patient keep her shoes on, facilitating relaxation, explaining the procedure, checking the patient’s facial expression for anxiety, and lubricating the speculum with warm water. The content of the unit is generally accurate. It omits reference to screening for any sexually transmitted diseases other than gonorrhea. The student checks for cystocele and rectocele by having the patient strain down; this maneuver is also recommended for assessment of vaginal muscle tone. In contrast, Varney’ recommends assessing tone by having the patient contract her perineal muscles around the examining fingers. The quiz questions are taken directly from the tutorial screens. Although they test the program’s objectives, they are often frustrating. Very minor spelling errors are pointed out to the learner for correction, but a typographical mistake is simply scored as incorrect. In tutorial mode, a true-false question that is false requires the learner to pick out the incorrect word or phrase and input the correction. For some true-false questions, more than one word or phrase could be corrected, but the program rewards only one. One question for which the correct response is symphysis pubis will not accept symphysis. Occasionally an answer
Vol. 33, No. 6, November/December
1988
known to be correct, i.e., taken verbatim from a content screen, will be rejected. The score generated from the section quizzes reflects only first responses to the questions. The student is not told which items were missed; this lack of feedback limits the usefulness of the quiz feature. This physical assessment software might be appropriate for an education program with a generous budget and students who are comfortable with computers or who benefit from the additional reinforcement such software can provide. It offers no particular advantage over the use of a good physical assessment textbook. REFERENCE 1. Varney H: Nurse-Midwifery, 2nd ed. Boston, Blackwell Scientific Publications, 1987.
Office Gynecology, 3rd edition. Edited by Robert H. Glass. Baltimore: Williams & Wilkins, 1988. 362 pages. $47.95, hardcover. Reviewed by: Ronald K. McGraw, PhD, Clinical Psychologist, Fort Worth, TX; Medical student, Texas College of Osteopathic Medicine, Fort Worth, TX According to the Preface to the First Edition, this book was designed to focus on “common problems” in the “office practice of gynecology” and was written for family practitioners, house officers, nurse-midwives, nurse-practitioners, and medical students, as well as gynecologists. Most of the 19 chapters are extremely well-referenced and several contain outstanding reviews of the literature, making the book valuable for researchers as well as clinicians. Several chapters deserve particular mention. The chapter on amenorrhea by Speroff, one of the leading authorities in gynecologic endocrinology, makes a very complex area clear and concise. The chapter on endometriosis by Dmowski is also concise, easy to read, and contains several useful tables, including one on the advantages and disadvantages of various treatment modalities. The chapter on infertility has valuable practical information on performing a hysterosalpingogram, while the chapter on contraception also has a number of useful practical suggestions for dealing with a missing IUD string, removal of an IUD that has perforated the cervix, and 293
managing side-effects of oral contraceptives. Chapters by Brown and Kaufman on vulvovaginitis and by Townsend on colposcopy, cryosurgery, and the carbon dioxide laser contain numerous, excellent black-and-white photographs. A very good critical review on the risks and benefits of estrogen replacement therapy is presented in the chapter on the postmenopausal woman. The role of psychological factors and the importance of emotional support and sensitivity to the patient’s feelings are noted in several chapters, including those on rape, endometriosis, and PMS. While acknowledging the physiological basis of PMS, Hoffman recognizes that insight and emotional support by means of group therapy, self-help groups, marital therapy, etc., can help minimize the problem. The book, however, is not without its flaws. The chapter on infertility states, “The initial interview and physical examination will not be discussed in this chapter . . .” There is no reason given and, unfortunately, the initial interview and physical examination are not covered elsewhere either. The chapter on sex counseling is poorly organized. After an inadequate single sentence definition of “counseling”, the author plunges into several case histories designed to illustrate what happens in sex counseling. Nowhere in the chapter does he deal with such basic issues as what training, experience, and attitudes are required to be a competent sex counselor, how the attitudes and values of the counselor/therapist affect goals and success, or why resistance develops and how it may be overcome. While suggesting in a couple of places possible referral to a “competent marpossible referral of riage counselor,” complex and resistant cases to a clinical psychologist. or psychiatrist is not mentioned. Dilator therapy for vaginismus is described but no mention is made of systematic desensitization, relaxation training, or hypnosis for this disorder. Although dysfunctional uterine bleeding is noted to be “among the most common, and perhaps the most confusing, of the problems facing the physician,” the chapter on this topic is less than nine pages long, is poorly referenced compared to other chapters, and could benefit from a few tables and/or diagrams. On the other hand, the chapter on 294
Diethylstilbestrol (DES)-exposed women is over 11 pages. The use of DES during pregnancy ended 17 years ago, and there were less than 10 cases of DES-associated clear cell adenocarcinoma in the U.S. in 1985. To devote so much space to this topic seems questionable when there is little or nothing in the book on breast cancer, ovarian tumors, endometrial cancer, adenomyosis, ectopic pregnancy, pelvic relaxation and stress incontinence, uterine fibroids (leiomyomas), or vulvar diseases (other than sexuallytransmitted diseases). The book could also be strengthened by chapters on physical assessment and on pediatric gynecology. Overall, with the few exceptions noted, what this book covers, it covers well. Its weakness is that there are a number of major gynecologic disorders that either are minimally discussed or not discussed at all. Because of the limited coverage, this reviewer cannot recommend Office Gynecology as one’s sole gynecology text. However, it would be quite useful as a supplemental text for nurse-midwives, nurse-practitioners, medical students, house officers, and general practitioners. Obstetrics and Gynecology, 8th edition. Edited by J. Robert Willson, MDand Elsie Reid Canington, MD. St. Louis: The C.V. Mosby Company, 1987. 754 pages. $39.95, hardcover. Reviewed by: Martha Barry, CNM, MS, Clinical Faculty, University of Illinois, Department of Maternal-Child Nursing, Nurse-Midwifey Program, Chicago, IL. Obstetrics and Gynecology, 8th edition, is written for any student who is learning the basic principles of the discipline. Both of the editors are adjunct professors in the Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine in Albuquerque. Five of the seven other contributors are obstetricians-gynecologists in clinical or academic practice; one is a psychiatrist; and one is in the field of family, community, and emergency medicine. In the 30 years since this volume was first published, the content has been greatly expanded to provide a more thorough understanding of the female patient. New chapters in this edition are: Sexual Responses of Women; Dysmenorrhea and the Premenstrual Syndrome; and Sexual Assault. Journal of Nurse-Midwifery
The obstetric sections, covering prenatal care through the puerperium, include chapters on the normal processes as well as many medical and obstetric problems. Only a few pages address the neonate, and these are concerned primanly with immediate care and resuscitation. As in previous editions, the gynecology content includes material ranging from pediatric gynecology through the aging woman. The normal psychologic and physical processes involved in wellwoman gynecology are discussed followed by information about common gynecologic problems and their management. The text does not attempt to cover complicated surgical techniques, therapeutic regimens for gynecologic oncology, or other less common conditions that might be handled by a specialist. The most valuable features of this book are its fairly comprehensive coverage of the ever expanding fields of obstetrics and gynecology and its emphasis on the thorough and organized workup of a clinical problem. The student is warned of possible diagnostic errors and given the clinical tools to avoid them. The authors are also to be commended on their consistent stress on the woman’s psychosocial state, and the impact of the clinician’s manner on his/her ability to treat the patient. This is especially well emphasized in the sections on history taking, habitual abortion, sexual dysfunction, and infertility. The discussions of ectopic pregnancies, bleeding disorders in pregnancy, and amenorrhea are particularly good with helpful management charts showing the process of diagnosis and treatment. The role of the nursemidwife, as part of the obstetric team, is acknowledged and supported as appropriate for full scope care of the low risk patient but only in a hospital setting. Because the intended audience of this book are students of obstetrics and gynecology, it is vital to present information to these future clinicians that is current, accurate and, as much as possible, research based. Although much of the clinical management discussions meet these criteria, there are, unfortunately, many omissions, errors, biases, and, also, statements that seem based on tradition rather than validated by research. Two surprising omissions are the lack of any mention of AIDS and the lack of a chapter on lactation. An example of an error is the statement that there are no IUDs available in the US at this time.
??Vol.
33, No. 6, November/December 1988