Council On Resident Education In Obstetrics And Gynecology Research Articles

Abstracts From the Proceedings of the 2014 Annual Meeting of the Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO)

The 2014 Annual Meeting of the Council on Resident Education in Obstetrics and Gynecology (CREOG) and the Association of Professors of Gynecology and Obstetrics (APGO), “Signs of Progress in Women'...

Assessing Residency Program Approaches to the Transgender Health CREOG Objective.

Purpose: The transgender population is a small yet distinctive portion of the gynecology patient population, requiring both primary care and specialty services. Recognizing the need for increased education, the Council on Resident Education in Obstetrics and Gynecology (CREOG) developed objectives specific to the care of transgender patients. This study is to assess residency program directors' knowledge about the transgender health CREOG objectives, describe how objectives are being implemented in training programs, and identify what types of educational materials would be useful if available.Methods: In May 2014, an 11-item anonymous survey was sent through e-mail to all eligible program directors of accredited obstetrics and gynecology residency programs. The short questionnaire contained questions about program demographics, approach to training residents with regard to the CREOG objectives, and opinions on tools they would like to use to train their residents on the transgender CREOG objectives.Results: Just under half (47%) of the 86 geographically diverse respondents were from hospital-based programs. The majority reported that the transgender health objectives were important (82%); however, only 70% were familiar with the objectives themselves. Most respondents (96%) felt that providing an educational activity in their training program would be beneficial for their residents' education.Conclusions: Most program directors support the CREOG transgender health objectives and are in favor of implementing educational tools to meet the objectives, suggesting that development of new tools to meet this need would be useful. Future endeavors will be made toward build a training module to facilitate obstetrics and gynecology (Ob-Gyn) programs meeting the CREOG objectives.

A Comparison of Residency Program Directors' Expectations and Council on Resident Education in Obstetrics and Gynecology Objectives for Surgical Education

PURPOSE: To determine residency program directors' (RPDs') expectations for independent performance of urogynecologic procedures during residency and to compare these expectations to the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives. BACKGROUND: Expectations for residents' performance of urogynecologic procedures are not standardized. METHODS: An anonymous Qualtrics survey was emailed to all accredited obstetrics and gynecology RPDs in the continental United States. RPDs provided their own professional and program demographic data and indicated whether they expected residents to independently perform each of 27 urogynecologic procedures. RESULTS: There was a 24.8% (n=59) response rate to the online survey with notable differences between RPD's expectations and CREOG objectives regarding several surgical procedures. While CREOG recommends independent performance of anterior and posterior repair, vaginal suspension, vaginal hysterectomy and transobturator slings, a significant number of RPDs did not expect mastery of these procedures during residency. Approximately 30% of RPDs expected residents to perform open sacralcolpopexy and vesicovaginal fistula repair, while CREOG recommends understanding these without procedural mastery. There was no difference in surgical expectations between RPDs at programs affiliated with a urogynecology fellowship and those without such an association. CONCLUSION: Although community needs vary by region and setting, CREOG objectives serve as the standard for resident surgical education, and this study highlights discordance between those objectives and RPDs' expectations for resident performance. Time invested in training for advanced procedures may limit opportunities for residents to master procedures expected by CREOG, and failure to train residents in fundamental procedures may result in substandard care for our patients.

The Effect of a Targeted Educational Activity on Resident In-Training Examination Scores

PURPOSE: To evaluate the effect of a resident study program involving the development of a repository based on program-specific high yield topics on the Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination. BACKGROUND: A CREOG Test Item Summary Booklet may help improve CREOG test scores. METHODS: In 2012, obstetrics and gynecology residents at the University of Hawaii participated in a study program involving directed research based on selected high yield questions from the CREOG Test Item Summary Booklet. Questions were considered high yield if more than 75% of the program answered them incorrectly. Topics were assigned to each resident by the program director, researched and presented at monthly teaching sessions. They were then made assessable in a wiki website. The intervention was discontinued in 2013 due to lack of resident interest. Paired Student t tests and one-way analysis of variance were used to compare the differences in mean level-specific standardized scores over that 3-year period. Only scores of residents present for the entire 3-year study period were included. RESULTS: Eleven residents were present during the study period and sat for all three CREOG examinations. During the year of the study program, mean level-specific CREOG in-training examination standardized scores increased significantly compared with the prior year (194.7 compared with 208.2, P<.05). Scores decreased when the program was discontinued (201.6, P<.05). DISCUSSION: These findings demonstrate that the CREOG Test Item Summary Booklet can be used to effectively direct educational efforts resulting in improvements in CREOG examination performance.

Council on Resident Education in Obstetrics and Gynecology In-Training Examination Results

BACKGROUND: The Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination (ITE) was designed to serve as a tool to provide feedback on resident progress along with training program strengths and weaknesses. OBJECTIVE: The objective of this study was to identify predictive factors for success on American Board of Obstetrics and Gynecology (ABOG) Written Examination using CREOG ITE scores. METHODS: CREOG ITE and ABOG written examination results collected from 2002 to 2012, inclusive, from Reading Hospital and Greenville Health System residents who took the CREOG ITE exam for 4 years. Data were analyzed using logistic regression to identify key factors in predicting ABOG written examination outcomes. Categorical data were analyzed using χ2. RESULTS: Seventy-one residents were included for analysis, of whom 68.9% were female. Gender differences existed. For women, a low score starting in postgraduate year (PGY)-1 was correlated with ABOG failure (P<.001), but it was not associated in men (P=NS) until PGY-3. Results showed that while each year's score contributed to the chance of pass–fail, the contribution increased each year. For every point increase in year 4 examination score, chances of passing increased by 21.5% (P=.001). Calculations using all 4 years resulted in an area-under-the-curve (AUC) of 0.920, significantly better (P<.001) than the null hypothesis of 50%. CONCLUSION: Results indicate that the score of each subsequent PGY is more important than the previous PGY's score. CREOG ITE scores could be a useful tool for identifying residents requiring structured interventions.

Create a Collaborative Learning Environment With the Payoff of Improved Council on Resident Education in Obstetrics and Gynecology Performance [383

INTRODUCTION: An anonymous survey of residents regarding education indicated a desire to change the didactic curriculum focusing on the Council on Resident Education in Obstetrics and Gynecology (CREOG) examination and peer-led teaching. The objective was to assess improvement in overall CREOG scores after instituting resident learning communities. METHODS: The source of didactic material was the CREOG Overall Item Summary Booklet. Learning communities, with representation from each resident year, were created to foster a collaborative learning environment. Each community was responsible for creating a PowerPoint presentation on a selected group of questions and teaching the material to their peers. The scores from the two CREOG examinations before the curricular changes were used as a control. The scores from the two examinations subsequent to didactic change were reviewed. Average scores were obtained by examination year and by class year. Comparison was made across years and within resident classes to assess improvement. RESULTS: The overall average score increased by 10 points for the second CREOG examination after intervention initiation. The average scores of the first year class from 2014 were 21 points higher than the average of the class from 2011. The third-year resident class of 2014 scored 12 points higher than equivalent residents from 2011. Comparison of CREOG scores by class, after initiation of learning communities, more residents demonstrated a consistent increase in scores in subsequent years. CONCLUSION: Initial data from CREOG examination scores are promising. It points to improved academic performance that can be sustainable and supports peer-initiated and peer-to-peer teaching as well.

Reproductive Endocrinology and Infertility Match: A Survey of the 2011-2013 Applicant Pool

Objective: The purpose of this study was to determine what objective applicant characteristics increased the likelihood of successfully matching into a Reproductive Endocrinology and Infertility (REI) fellowship position. Methods: A prospective electronic survey was distributed to 130 applicants who participated in the 2011-2013 REI fellowship match. Applicants were asked questions regarding demographic/educational background, research experience, abstract/publication record, Council on Resident Education in Obstetrics and Gynecology (CREOG) exam scores, interview invitations, and match results. Statistical analysis was performed with Mann-Whitney U test to compare continuous and discrete ordinal variables, and Chi-square or Fisher's exact test to compare nominal variables, where appropriate. Results: Candidates that matched were younger (30.0 vs. 32.4 years old, p=0.02); otherwise, there were no other significant differences in candidates' demographic background. Matched applicants had significantly more first author poster abstracts accepted (3.4 ± 0.4 vs. 1.1 ± 0.4, p=0.01). There was also a trend for matched applicants to have more publications accepted (3.3 ± 0.8 vs. 2.0 ± 1.0, p=0.14) and submitted (1.5 ± 0.4 vs. 0.8 ± 0.4, p=0.16). While candidates applied to a similar number of programs, matched applicants received more interview offers (17.1 ± 1.1 vs. 8.7 ± 2.1, p=0.002), attended more interviews (13.7 ± 0.7 vs. 8.1 ± 1.8, p=0.01), and ranked more programs (13.3 ± 0.7 vs. 8.1 ± 1.8, p=0.01). Conclusions: Research experience, particularly presenting poster abstracts as first author, was significantly associated with successful match into REI fellowship. There was also a trend for matched applicants to have more publications accepted and submitted at the time of the interview process. Categories: Obstetrics/Gynecology, Medical Education

Positive peritoneal cytology in patients with endometrial cancer: Continued controversy despite shift in staging

Endometrial cancer remains the most common gynecologic malignancy in developed countries and the second most common in developing parts of the world.1 In the United States, an estimated 50,000 new cases and over 8000 deaths from the disease were reported in 2013.1 Endometrioid histology represents the most common subtype and generally presents at an early stage, with a favorable prognosis. Other histologic subtypes, including serous and clear cell, tend to be more aggressive and have been documented to have a poorer outcome. Endometrial carcinoma is surgically staged based on the joint 2010 International Federation of Gynecology and Obstetrics (FIGO)/TNM classification system. Treatment includes total hysterectomy and bilateral salpingo-oophorectomy. In tumors with certain high-risk features, pelvic and para-aortic lymph node dissection also is performed. These features include high-grade histology (grade 3 endometrioid, serous, or clear cell), deeply invasive tumors, cervical involvement, and primary tumors >2 cm in greatest dimension. Compared with laparotomy, laparoscopic staging and treatment of endometrial carcinoma is associated with lower perioperative morbidity and comparable treatment effectiveness. A meta-analysis of 4 randomized trials supports this minimally invasive approach. In a randomized trial conducted by the Gynecologic Oncology Group (GOG) of over 2600 patients with uterine malignancy randomized to laparoscopy or laparotomy, it was noted that laparoscopic surgery was feasible and safe.3 Complication, recurrence, and survival rates were similar between the 2 groups, supporting the laparoscopic approach as less morbid. Other minimally invasive approaches, such as robot-assisted and single-port or laparoendoscopic single-site surgery (LESS), are newer techniques used for endometrial carcinoma staging. LESS technology allows the surgeon to complete the hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection, if performed, through a single incision. All surgical instruments, including the camera, are inserted through a single surgical site that measures approximately 1.5 cm in greatest dimension, usually placed at the level of the umbilicus. The 2010 staging system continues to require the collection of peritoneal cytology. However, under this new system, positive pelvic washings are no longer formally considered part of the staging system and, consequently, do not alter staging. No clear explanation or rationale was offered in the new staging system to explain the continued request to collect cytology without its results altering or impacting clinical care. An estimated 11% of patients undergoing staging for endometrial cancer will have positive peritoneal cytology, most commonly in the presence of extra-uterine disease.2 The prognostic significance of isolated positive cytology in the absence of extra-uterine disease is controversial. In a systematic review of over 50 studies, the prognosis associated with positive cytology varied based on the presence of other factors.4 The presence of positive peritoneal cytology in patients with otherwise low-risk tumors (grade 1 or 2, myometrial invasion <50%, no cervical involvement, no lymphovascular space invasion) had a significantly lower rate of recurrence (4.1% vs 32%) compared with other patients who had positive cytology and high-risk tumors.4 However, in another study of 14,704 patients using data from the Surveillance, Epidemiology, and End Results (SEER) registry, positive peritoneal cytology was an independent predictor of mortality, regardless of histologic subtype, among women with early stage (stage I or II) endometrial carcinoma.5 In that study, patients with high-risk disease, such as grade 3 endometrioid, clear cell, or serous histology, were more likely to have positive cytology compared with those who did not have these high-risk factors (17.5% vs 7.5%, respectively; P < .0001).5 Positive cytology also predicted significantly poorer survival, irrespective of histology and tumor grade.5 The risk of death was significantly greater among patients who had positive cytology compared with that among patients who had negative peritoneal cytology and stage IA disease (hazard ratio, 4.6; 95% confidence interval, 3.79-5.66).5 We generally do not consider positive cytology alone as a high-risk tumor criterion in the formulation of adjuvant treatment planning of patients with endometrial cancer. Treatment decisions in women with endometrial cancer should be based on extent of disease, as determined by staging, and final pathologic tumor features. Marcela del Carmen, MD, MPH, is Associate Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School. She has served on the Ovarian Cancer Committee for the Gynecologic Oncology Group, is a member of the American Board of Obstetrics and Gynecology PROLOG Task Force, and serves as oral examiner for the American Board of Obstetrics and Gynecology for both general gynecology and gynecologic oncology. Dr. del Carmen is the recipient of numerous teaching and service awards, including the National Council on Resident Education in Obstetrics and Gynecology (CREOG) Award, the Howard Ulfelder Teaching Award, the CINE Golden Eagle Award, CBS Cares, and the McGovern Award for Clinical Excellence. Dr. del Carmen's research focuses on surgical treatment of ovarian cancer and innovation in the treatment of rare gynecologic tumors.

Editorial introductions

Editorial introductions

Abstracts From the Proceedings of the 2012 Annual Meeting of the Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO)

The mission of the Association of Professors of Gynecology and Obstetrics (APGO) is to promote excellence in women's health care by providing optimal resources and support to educators who inspire, instruct, develop, and empower women's health care providers of tomorrow. Each year, APGO holds a joint meeting with the Council on Resident Education in Obstetrics and Gynecology, which focuses on improving medical education for students and residents studying women's health. The 2012 meeting entitled “Embracing Transitions in Healthcare: Educating for Tomorrow, Today” was held March 7 to 10, 2012, in Orlando, Florida, and exhibited a wide variety of abstracts and breakout sessions, including the first annual Film Festival featuring videos for learners related to teaching procedural, clinical, and educational skills. The main plenary sessions included David Irby, PhD, from UCSF School of Medicine, whose address “Rethinking How We Educate Physicians Across the Continuum” focused on the sweeping changes occurring as a result of the 2010 Carnegie report, and Valerie Arkoosh, MD, PhD, President of the National Physicians Alliance, whose lecture “Educating for Tomorrow: The Future of Health Care and Education Under the Patient Protection and Affordable Care Act (PPACA)” addressed the impact the changes brought about by the PPACA will have on medical education. The following oral abstracts, as selected by representatives from both organizations, address several topics including the impact new innovations and curricula have on learners’ experiences, issues related to residency training including the balance between service and education and the impact of duty hour restrictions.

Reproductive Endocrinology and Infertility Match: A Survey of the 2011-2012 Applicant Pool

The Reproductive Endocrinology and Infertility (REI) fellowship match remains one of the most highly competitive processes among obstetrics and gynecology subspecialties. Between 2008 and 2012, the unmatched applicant rate ranged from 32.4% to 48.6%.a Several factors might influence an applicant’s chances of successfully matching into an REI fellowship position, such as prior research experience, publication record, and Council on Resident Education in Obstetrics and Gynecology (CREOG) scores. To our knowledge, no studies have been conducted analyzing factors that may affect an REI applicant’s likelihood to match.

Resident Education and Training in Female Sexuality: Results of a National Survey

Considering the prevalence of female sexual dysfunction, the lack of education and training in female sexual function and dysfunction (FSF&D) during and obstetrics and gynecology residency highlights a need for greater focus on this topic. To assess understanding and confidence among third and fourth year Ob/Gyn residents with respect to FSF&D. An Internet-based survey was constructed to evaluate third and fourth year residents in American Council for Graduate Medical Education-approved Ob/Gyn programs. Residents were asked about familiarity, knowledge, and confidence in treating various aspects of FSF&D, based on the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives for Ob/Gyn training. They were also queried regarding areas of improvement for their education. Responses to survey instrument. Two hundred thirty-four residents responded. The majority (91.5%) reported attending ≤5 didactic activities on FSF&D. Only 19.6% reported often or always screening women for sexual function problems; most had very little or no knowledge in administering or interpreting screening questionnaires. While many (82.8%) felt confident about obtaining a complete sexual history, only 54.7% felt able to perform a targeted physical exam. Although most residents had cared for women with dyspareunia (55.1%), a minority had managed many women with low desire (18.4%), arousal problems (8.1%), anorgasmia (5.6%), or vaginismus (16.7%). In treating patients, 34-56% reported rarely or never suggesting ancillary therapy such as counseling and medications. However, the majority believed that their confidence would increase through FSF&D lectures (97.9%), FSF&D patient observations (97.4%), rotating with a urogynecologist (94.4%), and online modules (90.6%). Despite CREOG requirements for Ob/Gyn training in female sexuality, most residents feel ill-equipped to address these problems. Additional evidence-based educational and didactic activities would enhance residents' knowledge and confidence in treating these common, quality-of-life issues.

Resident Performance on the In-Training and Board Examinations in Obstetrics and Gynecology: Implications for the ACGME Outcome Project

Background: The Accreditation Council on Graduate Medical Education (ACGME) Outcomes Project has endorsed the in-training examination (ITE) as an example of a multiple-choice question examination that is a valid measure of a resident's attainment of medical knowledge. An outcome measure for performance on the ITE would be the subsequent performance on the board certification examination. However, there are few reports that attempt to correlate a resident's performance on the ITE to subsequent performance on the board certification examination. Purpose: The Council on Resident Education in Obstetrics and Gynecology (CREOG) has administered the ITE annually since 1970. This study tested the hypothesis that the CREOG–ITE score is a valid assessment tool to predict performance on the American Board of Obstetrics and Gynecology (ABOG) written examination. Methods: CREOG–ITE and ABOG written board examination results were collected for 69 resident graduates between the years 1998 and 2005. Logistic regression and receiver operating characteristic analyses were used to estimate the relationship between a resident's score on the CREOG–ITE and subsequent performance on the ABOG written examination. Results: Fifty-seven resident graduates passed (82.6%) and 12 graduates failed (17.4%) the ABOG written examination. The correlation between the CREOG–ITE overall score and performance on the ABOG examination was weak (correlation coefficient =.38, p =.001). Receiver operating characteristic analysis for the CREOG–ITE overall scores and the probability of passing or failing the ABOG examination revealed moderate accuracy (area under the curve = 0.77, 95% CI = 0.62–0.92) with a CREOG–ITE score of 187.5 yielding the best trade-off between specificity (0.79) and sensitivity (0.75). At the cutoff value of 187.5 there was a weak positive predictive value of 43% (i.e., 43% of residents with a score less than 187.5 will fail the ABOG exam) and a strong negative predictive value of 94% (i.e., 94% of the residents with a score above 187.5 will pass the ABOG exam). Logistic regression analysis also revealed a statistically significant relationship between the CREOG–ITE overall score and performance on the ABOG written examination (p = .003). Conclusions: Similar to other specialties, resident performance on the CREOG–ITE is a weak assessment tool to predict the probability of a resident failing the ABOG written examination. Our study highlights the need, in the spirit of the ACGME Outcome Project, for residency and board specialty organizations to coordinate efforts to develop more reliable and correlative measures of a resident's medical knowledge and ability to pass the boards.

Do U.S. Medical Licensure Examination Step 1 Scores Correlate with Council on Resident Education in Obstetrics and Gynecology In-Training Examination Scores and American Board of Obstetrics and Gynecology Written Examination Performance?

The purpose of this study was to assess the possible association between scores of >200 on U.S. Medical Licensure Examination (USMLE) step 1 and the Council on Resident Education in Obstetrics and Gynecology (CREOG) in-training examinations and the pass rate on the American Board of Obstetrics and Gynecology (ABOG) written examination. The USMLE step 1 and postgraduate year 1 to 4 CREOG in-training examination scores for the graduating chief residents in eight accredited obstetrics and gynecology residency programs were obtained. Performance on USMLE step 1 was correlated with ABOG examination performance and CREOG in-training examination scores. The correlations between USMLE step 1 and CREOG in-training examination scores and ABOG examination performance were analyzed by using the Spearman correlation coefficient. USMLE step 1 scores were significantly correlated with CREOG in-training examination scores (p < 0.000). None of the residents who scored >200 on USMLE step 1 and a mean of >200 on the CREOG in-training examinations failed the ABOG written examination. Program directors have used USMLE step 1 to identify trainees who are likely to perform well on the CREOG in-training examination. The CREOG in-training examination has been used to identify residents who are likely to pass the ABOG written examination. The results of this study document the strength of these associations.

Resident performance on the Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination: Years 1996 through 2002

Objective This study was undertaken to evaluate the Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination scores for significant trends. Study design The percent-correct scores for each of the 6 published examination objectives from 7 consecutive years were analyzed. The data set was analyzed by multivariate analysis of variance using gender, examination year, and postgraduate year as categorical variables, and each year was analyzed separately by gender and postgraduate year. Scores of residents who took the examination for 4 consecutive years were analyzed by using repeated measures analysis of covariance. Results Variation by examination year appeared random, although scores monotonically increased with postgraduate year for all objectives and all years. The mean relative scores of women were higher than men on the primary/preventive care objective, but the reverse was true for the general considerations objective. Conclusion The CREOG In-Training Examination appears to be a dependable measure of residents' improvement in cognitive knowledge.

Effect of a Resident-Created Study Guide on Examination Scores

In Brief OBJECTIVE To evaluate the effect of a resident-created study guide on Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training and American Board of Obstetrics and Gynecology (ABOG) written examination scores. METHODS In 1995, a group of residents at the University of Texas Southwestern Medical Center began creating an annual study guide based on the CREOG Test Item Summary Booklet. Individual, program, and national scores for 3 years before the intervention were compared with scores for 3 years after the intervention. A four-way analysis of variance was used to evaluate the effect of the intervention accounting for sex, Alpha Omega Alpha Medical Honor Society (AOA) status, and calendar year. A random effects model was also used to adjust for confounders. Categoric variables were compared using Mantel-Haenszel χ2. Program failure rates for the ABOG written examination before and after the intervention were compared with relative risks. RESULTS After introduction of the study guide, the annual difference between our program and the national percent correct increased significantly (2.1% versus 4.8%, P < .001), after adjustment for AOA status and calendar year. The improvement was distributed among resident levels 2–4 (all P < .02) and for non-AOA residents (P ≤ .001). The relative risk of failure of the written ABOG examination before the study guide was 3.5 (95% confidence interval 0.77, 15.9). CONCLUSION These findings demonstrate an important cooperative use of the Test Item Summary Booklet as an educational resource. A resident-created study guide based on the CREOG Test Item Summary Booklet is useful in examination preparation.

Effect of a resident-created study guide on examination scores

OBJECTIVE: To evaluate the effect of a resident-created study guide on Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training and American Board of Obstetrics and Gynecology (ABOG) written examination scores. METHODS: In 1995, a group of residents at the University of Texas Southwestern Medical Center began creating an annual study guide based on the CREOG Test Item Summary Booklet. Individual, program, and national scores for 3 years before the intervention were compared with scores for 3 years after the intervention. A four-way analysis of variance was used to evaluate the effect of the intervention accounting for sex, Alpha Omega Alpha Medical Honor Society (AOA) status, and calendar year. A random effects model was also used to adjust for confounders. Categoric variables were compared using Mantel-Haenszel χ 2. Program failure rates for the ABOG written examination before and after the intervention were compared with relative risks. RESULTS: After introduction of the study guide, the annual difference between our program and the national percent correct increased significantly (2.1% versus 4.8%, P < .001), after adjustment for AOA status and calendar year. The improvement was distributed among resident levels 2–4 (all P < .02) and for non-AOA residents ( P ≤ .001). The relative risk of failure of the written ABOG examination before the study guide was 3.5 (95% confidence interval 0.77, 15.9). CONCLUSION: These findings demonstrate an important cooperative use of the Test Item Summary Booklet as an educational resource.

Technique for Total Abdominal Hysterectomy

Since the first refined total abdominal hysterectomy was performed by Wilhelm Alexander Freund of Breslau on January 30, 1878, various techniques have been introduced over the past 110 years. Hysterectomy, numbering over 650,000 procedures annually, is the most commonly performed major surgical procedure next to cesarean section in the United States. Although CREOG (Council on Resident Education in Obstetrics and Gynecology) emphasizes the importance of basic pelvic surgical skills and competency in gynecological surgical procedures, cost-effective patient management dictates the shortest hospitalization and most uncomplicated procedure possible. Various techniques of abdominal hysterectomy have been reappraised in view of present-day medical practice concepts. It seems that we are entering a new age wherein a simplified, cost-effective alternative to a classical total abdominal hysterectomy is indeed needed for some cases, and if a hysterectomy is planned, it should be performed in the safest way in the shortest possible operating time for a well-indicated case. Keeping this objective in mind, one Japanese technique of total abdominal hysterectomy and its modification are described with the intent that this will assist Ob/Gyn resident physicians in surgical skill development and also help gynecologists in practice to meet rapidly changing practice patterns of the specialty.

Accommodating to restrictions on residentsʼ working hours

In 1988, New York became the first state to implement regulatory measures limiting housestaff work hours. Because restrictions on residents' work hours will have such profound and far-reaching implications for how obstetrics and gynecology residencies are conducted, the Council on Resident Education in Obstetrics and Gynecology (CREOG) requested that a survey be conducted to solicit information from program directors of U.S. obstetrics and gynecology residencies who had already begun to alter their call schedules. Two hundred and ninety-six programs were contacted, and representatives of those that had implemented changes were requested to respond. Eighty-two responses were received; 26 of these contained information that could be collated. From these 26 responses the authors have structured a prototypic call schedule and presented its application. A key feature necessary to implement the new type of schedule is the use of a night float system. It is concluded that changes can and will be made by obstetrics and gynecology residencies. Creative scheduling, as described in this article, is essential and will facilitate the task; however, the current standards of education and patient care will be difficult to maintain without additional economic and human resources.

The Council on Resident Education in Obstetrics and Gynecology: Current activities and future projections

The Council on Resident Education in Obstetrics and Gynecology (CREOG) was formed in 1967, following recommendations of a 1965 intersociety conference on residency education and subsequent authorization and funding by The American College of Obstetricians and Gynecologists. The Council is charged with the duty of working to improve all aspects of residency training in obstetrics and gynecology and the responsibility for developing programs in this area in accord with the aims and purposes of the organizations represented. Current activities include consultative services for program directors, in-training examinations for evaluation of residents' progress, annual conferences of program directors, and development of basic curricula in residency programs. Future projections call for continued study of the changing responsibilities of the obstetrician-gynecologist in community institutions and health agencies, and preparation of the resident for his developing role in these changes. An assessment of the current programs and future activities of the Council is presented.