GYN residency programs in Michigan

J Pediatr Adolesc Gynecol (1999) 12:215-218

Pediatric and Adolescent Gynecology Experience in Academic and Community OB/GYN Residency Programs in Michigan Elisabeth A. Wagner, DO, Betsy Schroeder, MD, and Carole Kowalczyk, MD Hutzel Hospital. Wayne State University School of Medicine. Detroit. Michigan

Abstract. Objectives: The purpose of this study is to assess training in Pediatric and Adolescent Gynecology (PAG) at the Obstetrics and Gynecology (OB/GYN) resident level. Setting: Two large Michigan programs were studied: a university-based. inner-city program. and a suburban. communitybased program. Seventy-one questionnaires were distributed to the residents. and descriptive and inferential analysis of answers to demographic, training, attitude. and knowledge-b ased questions regarding PAG was performed. Results: Sixty-one questionnaires were returned, a response rate of 86%. The majority of respondents reported no PAG rotations or clinics and recalled limited didactic sessions with only 0-2 lectures. Ninety-eight percent of university residents and 94% of community residents requested more PAG training. Comfort levels about PAG issues were assessed on a 5 point scale (I = low. 5 = high comfort); university residents scored 3.7 with pediatric patients and 4.4 with adolescents. and community residents scored 4.0 with the pediatric age group and 4.3 with adolescents. However, both groups responded with familiarity to knowledge based questions only 61 % of the time. Conclusions: OB/GYN residents in both academic and community programs report little experience and scant training in PAG but express interest in obtaining the skills and information needed. It is concerning that residents lack the basic knowledge that is required for the routine daily care of this patient population. More emphasis needs to be placed on these issues in OB/GYN residency training programs.

Key Words: Pediatric and adolescent gynecologyObstetrics and gynecology residency-Medical training-Residency programs

Introduction Obstetrics and Gynecology (OB/GYN) residents may not anticipate caring for pediatric or adolescent patients fol-

lowing completion of training; however, it is extremely likely that these patients will present to them for routine OB/GYN care. Studies have revealed that 56% of females are sexually active by the age of 18,I 10% of women aged 15-19 become pregnant each year,? and 50% of abortions are obtained by women less than 25 years old, with peak incidence at 18-19 years of age.' It is clear, then, that the general OB/GYN needs to be prepared to care for this group of patients and should be exposed to this population during residency training. The purpose of this study is to assess training in Pediatric and Adolescent Gynecology (PAG) at the OB/GYN residency level. Materials and Methods Two large OB/GYN residency programs in Michigan were selected. One is an inner-city, university-based program in Detroit that educates 12 residents per year, for a total of 48 residents. The other is a large communitybased program located in a suburb of Detroit. Each residency year consists of 6 members, for a total of 24 residents. A questionnaire was developed to assess and compare the training in Pediatric and Adolescent Gynecology in these two residency programs. All OB/GYN residents. excluding the primary investigator, received a short answer/multiple choice 48-item questionna ire. The questions assessed demographics as well as the following areas of PAG: training, attitudes. comfort level, and general knowledge. Descriptive and inferential analysis, including Pearson Chi-Square and Student T test, of responses was performed. P < 0.05 determined statistical significance . Results

Address reprint requests to: E. Wagner. DO. Hutzel Hospital. Department of Obstetrics and Gynecology. 4707 St. Antoine. Detroit.Michigan 48201. ~

1999 Nonh American Society for Pediatric and AdolescentGynecology Published by ElsevierScience Inc,

A total of 61 questionnaires (86%) were completed and returned, with 94% of university and 70% of community 1083-31881991$20,00 PI! S1083·3188(99)00022-4

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Table 1. Demographics Demographics

University

Community

N Year in residency Jr Sr Race African-American Caucasian Other Sex Male Female

44/47 (94%)

17/24(70%)

48% 52%

53% 47%

30% 50% 27%

6% 65% 30%

27% 73%

35% 53%

their patient populations; university program respondents estimated that 14.5% of their total patient volume consisted of adolescents, while community based residents claimed that adolescents represented 8.3% of their patient population. Respondents from the community program denied having any faculty members with PAG experience, but the university residents reported one such faculty member. At least one lecture focusing on PAG issues was remembered by 91% of the university residents in contrast to only 35% of the community based residents. All but two respondents (one from each group) requested more formal PAG training. The residents were asked to gauge their level of comfort in dealing with specific PAG-related issues, including sexual history, sex, sexual abuse, physical abuse, substance abuse, and birth control, with pediatric and adolescent patients (Table 3). The residents scored their comfort level on a I to 5 scale, with I being very uncomfortable and 5 being highly comfortable. There were no statistically significant differences between the two groups. Nine questions representing basic PAG topics surveyed resident knowledge in PAG (Table 4). The answers were short answer and scored as correct (completely or partially), incorrect, and unknown or no answer. The answers were reviewed and scored by two examiners, using 1. Sanfilippo's (ed.) Pediatric and Adolescent Gynecology and SJ. Eman and D. Goldstein's (eds.) Pediatric and Adolescent Gynecology texts as references. There were statistically significant differences in the responses to three topics. The community based residents more often correctly answered question 4, regarding the etiology of vaginal discharge in the prepubertal child, while the university based residents answered questions 8 (when is it ok to begin use of oral contraceptive pills?) and 9 (exam positions of the prepubertal child) correctly more often. Neither group demonstrated awareness of normal hymenal anatomy, with only 12% of the university residents and 6% of the community residents able to name at least one normal hymenal variant. Overall, scores were similar between the two groups, with scores of 61.4% and 61.2%.

residents responding. Demographic data (Table I) reveals an equal distribution of junior (1st & 2nd year) and senior (3rd & 4th year) level residents responding from each program. The racial distribution between the two programs differed: the university program contained 50% Caucasian, 30% African American, and 27% other races, compared to the community based program which consisted of 65% Caucasian, 6% African American, and 30% other races. The majority of respondents from both institutions were female. The university residents cared for an inner city population while the community program cared for a suburban population. Table 2 represents resident assessments of their training experience in PAG. The great majority had neither PAG rotations nor formal clinics in PAG. Both groups reported that pediatric patients accounted for <2% of

Table 2. Resident Assessment of PAG Training Training

University

Community

Pediatric patients Adolescent patients No PAG rotations No PAG clinics PAG lectures # PAG faculty Desiring more PAG training

1.6% 14.6% 89% 84% 91% 1 98%

1.6% 8.3% 100% 92% 35%

o 94%

Table 3. Resident Comfort with Issues in Pediatric and Adolescent Age Groups

Topic

Pediatrics University

Pediatrics Community

Sexual History Sex Sexual Abuse Physical Abuse Substance Abuse Birth Control Overall Comfort

3.74 3.72 3.35 3.67 3.97 3.95 3.73

4.07 4.13 3.67 3.67 4.13 4.27 3.99

"P < .05 _ significance

P

.447 .817 .854 .405 .101 .857

Adolescents University

Adolescents Community

4.59 4.54 3.97 4.12 4.55 4.69 4.41

4.38 4.44 3.88 4.19 4.56 4.63 4.34

P

.028a

.ou.240 .200 .225 .162

Pediatrics Univ/Comm

Adolescents Univ/Comm

3.91 3.93 3.51 3.67 4.05 4.11 3.86

4.99 4.49 3.93 4.16 4.56 4.64 4.38

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Table 4. Knowledge-based Questions I. How do you treat an imperforate hymen? 2. How do you treat labial adhesions in a prepubertal child? What instructions do you give the mother? 3. What is the most common etiology for vulvovaginitis in a prepubertal child? 4. What is the most common etiology for vaginal discharge in a prepubertal child? S. When should you do your first speculum exam on your adolescent patient? 6. What are some preferred positions to examine the prepubertal child? 7. Name the different types of normal hymens? Abnormal hymens? 8. When in an adolescent's development is it OK to start the oral contraceptive pill?

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Table S. Resident Familiarity with Topics in PAG Knowledge-based Questions % Residents Demonstrating Familiarity in PAG Topics

University

Community

p

Treatment of imperforate hymen Treatment of labial adhesions Etiology of vulvovaginitis" Etiology of vaginal discharge" Indication for 1st speculum exam Normal hymenal anatomy Abnormal hymenal anatomy Initiation of OCPs Exam positions"

93% 93% 21% 60% 86% 12% 45% 68% 90%

7S% 81% 0% 94% 94% 6% 19% 37% 75%

.089 .194 .242 .047b .539 .806 .238 .037b .OO3b

"In prepubertal patients. bp < 0.05 = significance.

Discussion Pediatric and Adolescent Gynecology is an important but long neglected field within Obstetrics and Gynecology. While interesthas grown tremendously over the past few years, training is still limited, withonly one Pediatric and Adolescent Gynecology fellowship in the United States for the 1997-98 academic year. The Council of Resident Education in Obstetrics and Gynecology (CREOG) identifies Pediatric and Adolescent Gynecology as part of their core curriculum. The CREOG Educational Objectives' cite several specific categories within pediatric and adolescent gynecology: developmental anomalies of the urogenital tract, pediatric gynecology (birth to menarche), adolescent gynecology (post-menarche), precocious puberty, and delayed puberty. Proficiency in these areas is tested during annual in-service exams,on national boards, and ultimately by the patient and her family on presentation to the physician's office. Little has been done to assess resident experience and training within this field. Only one other study' has been published, in which Muram and colleagues documented limited knowledge of hymenal anatomy among residents in Obstetrics and Gynecology, Family Practice, and Pediatrics. They were able to demonstrate that a welldefined program in PAG improved the residents' abilities to perform GYN evaluations of children and adolescents. Although only two residency programs in close proximity to each other were studied, they represent a wide array of resident experiences. Each is large, and patient volume is high and involves suburban and inner-city patient populations. There is representation of both community and academic programs. Due to this diversity, Pediatric and Adolescent Gynecology experiences of residents in these two programs should make the collective exposure similar to that of most OB/GYN residents across the country. The residents surveyed felt that they had little patient exposure to the pediatric and adolescent populations, es-

timating that less than 2% of their patient population is pediatric and between 5% and 15% of their patients are adolescents. The actual numberof pediatric patients, defined as those 12 years of age or younger, was 15, accounting for 22 visits to the university OB/GYN clinic and representing 0.04% of the residents' patient population in 1996. Adolescent patients, or those 13-19 years of age, numbered 1116, accounting for 5916 visits and 3.8% of the residents' total patient volume. Clearlythere is a need for more exposure to this group of patients. Educational opportunities and rotations in PAG must be soughtand may be obtained through alternative training sites. Children's hospitals and clinics, with both general pediatrics and adolescent medicine, should be consideredas sites for rotations if a divisionof Pediatric and Adolescent Gynecology is not established within the department of Obstetrics and Gynecology. Several residents in the university-based program soughtextra training through the Adolescent Medicine Division at nearby Children's Hospital of Michigan. Community awareness must be increased, both withinthe physician referral system and in the community at large, so that youngpatients with obstetric and gynecologic problems receive appropriate care, while also providing patients for resident education. Finally, normal anatomy can be evaluated on female infants in the delivery rooms on the OB service. In addition to clinical experience, didactic teaching is also required. Of the two programs studied, only the university-based program had a faculty member pursuing Pediatric and Adolescent Gynecology. This responsibility was part-time and the practice just developing. In contrast, the community-based program had neither faculty nor formal PAG training. Residents reported only modestdidactic teaching on PAG issues, with 91 % at the university-based program and 35% at the communitybased program recalling one or more lectures during their residency. In 1996 there were three hours of lecture time dedicated to PAG at the university program. Not enoughemphasis is placedon PAG issues in the curricu-

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lum to prepare residents to provide competent care to these patients after residency. When an expert in the field is not available to teach PAG to the residents, other options are available. Residents can teach each other through texts and journal reviews guided by faculty members. This accomplishes two goals: a better understanding of PAG topics and improved presentation skills. The faculty lecture schedule should address PAG topics in appropriate proportion to the remainder of the curriculum . Weakness in PAG is most clearly demonstrated with the knowledge-based questions. Basic topics required to care for the PAG patients, such as how to examine a prepubertal child, when to do the first speculum exam, or when birth control pills could be initiated, were assessed. Overall mean scores, demonstrating familiarity rather than complete understanding, were only 61 % for the two groups. On an individual basis, the best residents (N = 2) answered only 4/9 questions completely and correctly. In spite of the lack of clinical experience, didactic teaching, and knowledge, residents from each program expressed moderate levels of comfort in dealing with PAG issues. In general, residents were less comfortable with each issue in the pediatric group than in the adolescent group, perhaps reflecting their degree of experience with each group. The residents were most uncomfortable dealing with abuse, particularly sexual abuse, and most comfortable with birth control, again likely a reflection of exposure to these topics. In an effort to improve residents' ability to care for patients with these problems, emphasis, especially on sexual abuse, should be placed on these issues during residency .

Conclusions Both university- and community-based residents in Obstetrics and Gynecology report little practical experience and scant training in Pediatric and Adolescent Gynecology. There is a discrepancy between the comfort levels described by the residents and their actual fund of knowledge as demonstrated by the knowledge based questions . This suggests a false sense of security in counseling and treating pediatric and adolescent patients. It is concerning that the residents surveyed lack the basic knowledge that is required in the routine daily care of the PAG population. The same residents expressed interest in formal PAG training. This interest is supported by CREOG, and more importantly by the patients who expect quality care. More emphasis needs to be placed on these issues in OB/GYN training programs.

References 1. The Alan Guttmacher Institute: Sex and America's Teenagers. The Alan Guttmacher Institute, New York, NY, 1994 2. Trussell J: Teenage pregnancy in the United States. Family Planning Perspectives 1988; 20(6):262 3. Koonin L, Smith J, Raminck M: Abortion surveillance in the United States 1991. MMWR 1995; 44:23 4. CREOG Educational Objectives: Core curriculum in OBI GYN,1996. 5. Muram D, Jones CE, Hostetler BR, et al: Teaching pediatric and adolescent gynecology: A pilot study at one institution. J Pediatr Adolesc Gynecol 1996; 9:12