Skill, Duty, and Adaptability: How Expert Gynecologic Surgeons Conceptualize Expertise

Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S26 Oral Poster 10 Skill, Duty, and Adaptability: How Expert Gynecologic Surgeons Conceptualize Expertise Nihira MA,1 LeClaire E,2 Hardre P.3 1OB/GYN, University of Oklahoma, Oklahoma City, Oklahoma; 2OB/GYN, University of Kansas, Wichita, Kansas; 3College of Education, University of Oklahoma, Norman, Oklahoma Objectives: Defining expertise is critical in developing assessment criteria for current trainees as well as practicing surgeons. Expertise in medicine is comprised of specialty-specific technical and general skill domains. For gynecologic surgery, these domains have not been defined. Best practices in educational measurement and performance assessment require definitions to be derived from experts in the field. Materials and Methods: Semi-structured interviews were conducted with 16 experts in Female Pelvic Medicine and Reconstructive Surgery. Each were asked 6 semi-structured, open-ended questions that prompted disclosure of their perceptions of how they conceptualized their professional expertise, and what specific opportunities and experiences initiated and supported their development toward expertise in their field. Interviews were audio-recorded, then transcribed by a medical transcriptionist. Investigators, who were blinded to subject identity, analyzed transcripts for emergent themes. Questions that guided analysis were: What are the key elements of expertise in gynecologic surgical practice? How did they develop into experts in gynecologic surgery; what were their journeys to expertise in this complex and changing subspecialty? To what specific educational opportunities and activities do they attribute their success and high-quality skill development, and why? Results: All subjects are currently active, practicing surgeons at 16 different high-volume institutions in 12 U.S. states and one foreign nation. All have published articles in high-impact medical journals and presented papers at prestigious national and international medical conferences. All experts perform at least 80-100 vaginal procedures per year, are board certified, and supervise multiple surgical residents and fellows. Other demographics were as follows: 9 (53%) male and 7 (47%) female; age 35-72 years (Mean = 49); years in practice since residency 5-36 (Mean = 17). Analysis revealed the following common themes: Humility is required to develop and maintain expertise. Commitment to patient care is a consistent source of motivation. The ‘‘Trifecta of expertise’’: researcher, teacher-mentor, surgeonpractitioner. Expertise is continuously evolving, continuous learning, it includes risktaking as well as recognizing one’s limits. Experts must be willing to accept the challenges of ambiguity and be adaptive to new challenges. Conclusion: There are common themes that unite experts when it comes to establishing the components of expertise in gynecologic surgery. Knowledge, skill, and experience domains, however, are not the only elements. Personal commitment and sacrifice toward skill development on behalf of patients, humility while facing complexities balanced by educated risk-taking, and productivity in scholarly activity were cited by this cohort as key components of gynecologic surgical expertise. Consistent with evidence derived in other professional fields, these experts have a unique perspective that enables a broad understanding of a task that is greater than the sum of their training and experience. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Mikio A. Nihira: Nothing to disclose Edgar LeClaire: Nothing to disclose Patricia Hardre: Nothing to disclose Oral Poster 11 Effect of Anesthesia Type on Perioperative Outcomes for Midurethral Sling Dave B,1 Jaber C,3 Leader-Cramer A,1 Higgins N,2 Mueller M,1 Johnson LL,1 Lewicky-Gaupp C,1 Kenton K.1 1Female Pelvic Medicine and Reconstructive Surgery, Northwestern University Feinberg School of

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Medicine, Chicago, Illinois; Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; 3Loyola University Chicago Stritch School of Medicine, Chicago, Illinois Objectives: To determine if there is a difference between intra- and perioperative outcomes for patients undergoing midurethral sling (MUS) placement under general anesthesia (GA) as compared to monitored anesthesia care (MAC). Materials and Methods: A retrospective cohort analysis was performed on consecutive women undergoing placement of a synthetic retropubic MUS by one of four female pelvic medicine & reconstructive surgeons from 2009 to 2014 at a single academic medical center. Patients undergoing concomitant procedures were excluded. Demographic, intraoperative, and immediate postoperative data, including anesthesia type was obtained from electronic medical records. Patients underwent a standardized voiding trial with retrograde fill in the recovery room, and voiding dysfunction was defined as discharge from the hospital using intermittent straight catheterization (ISC) or Foley catheter. SPSS Version 21 was used for statistical analysis. Continuous variables were compared between anesthesia groups using the independent samples t-test (normal distribution) or Mann-Whitney U test (non-normal distribution). Chi-squared test of association was used for categorical variables. Results: Two hundred twenty-five patients were included in the final analysis (141 GA, 84 MAC). Three patients requiring overnight hospitalization (all GA) and one patient requiring conversion from MAC to GA were excluded. There was no difference in baseline characteristics (age, BMI, ASA class, prolapse stage, parity, smoking) between the two groups. In the GA group, both operating room time (Mean  SD, 67.6  13.3 min vs. 56.9  11.8 min, p \ 0.001) and recovery room time (240.0  69.8 min vs. 190.1  78.3 min, p \ 0.001) were longer, whereas there was no difference in actual surgical time (30.0  8.9 min vs. 29.0  9.7 min, p = 0.436) between anesthesia groups. Based on our institutional rate of $133 per minute, average charge for operating room time was $1,423.10 greater in the GA group. No major intraoperative complications were identified in either group. Patients with GA had higher rates of voiding dysfunction (27% vs.16%, p = 0.045) and higher pain scores as measured by verbal rating scale (VRS) (Median = 1.7, IQR = 0.56, 3.00 vs. 0.94, IQR = 0.00, 2.45, p = 0.006) than those with MAC. There was no difference in rates of bladder perforation (6.4% vs. 11.9%, p = 0.337) or antiemetic use in the recovery room (12.1% vs. 9.5%, p = 0.791). Conclusion: Monitored anesthesia care (MAC) offers significant benefits over general anesthesia (GA) in women undergoing retropubic midurethral sling, including shorter operating room times and less voiding dysfunction in the immediate postoperative period with no increase in complications. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Bhumy Dave: Nothing to disclose Camaleigh Jaber: Nothing to disclose Alix Leader-Cramer: Nothing to disclose Nicole Higgins: Nothing to disclose Margaret Mueller: Nothing to disclose Lisa L. Johnson: Nothing to disclose Christina Lewicky-Gaupp: Nothing to disclose Kimberly Kenton: Nothing to disclose Oral Poster 12 A Simple Method for Postoperative Voiding Assessment following Urogynecologic Surgery Dolgun N, Jones K, Rauktys A, Behrens P, Harmanli O. Obstetrics and Gynecology, Tufts University School of Medicine Baystate Medical Center, Obstetrics and Gynecology, Massachusetts, Springfield, Massachusetts Objectives: Recently, assessment of voiding function solely based on patient’s subjective grading of her force of voiding stream technique was found to be equally safe and effective compared to retrograde fill method. In our institution, we use a similar less stringent and noninterventional method based on the first voided amount. We aim to