Abstract
In response to major practice changes in obstetrics and gynecology (OB/GYN), the 2015 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists responded with modification of the program organization, methods of presenting the information (debates, hands on, flip classrooms) and increased emphasis on current clinical research. The Presidential Program covered broad themes of changes in healthcare technology, teamwork in OB/GYN practice and the importance of advocating for patients. Over 400 abstracts representing a broad range of clinical and basic science research were presented. Changes in the Annual Clinical and Scientific Meeting should allow the membership to be more prepared and pro-active as the practice of OB/GYN evolves.
Keywords
During the past 20 years there have been major changes in the practice of obstetrics and gynecology (OB-GYN). Clinical care has been impacted by increasing specialization, hospital based practices, hospitalists/laborists, gender shift in membership, increasing emphasis on team/based patient care and new techniques in both outpatient and inpatient surgery, to name a few. The practice challenges have also increased with electronic medical records, increased documentation, ICD-10, third-party payers including the Affordable Care Act (ACA) and practice safety emphasis. With more opportunities for online continuing medical education (CME) the American College of Obstetricians and Gynecologists (ACOG) has responded with a number of improvements in the organization of the meeting to accommodate the needs and desires of the membership.
Changes with the meeting structure
The new ACSM meeting structure offered widespread learning, social and networking opportunities in a more time efficient manner. ACOG and the Scientific Program Committee shifted the ACSM from a traditional Monday–Wednesday activity with Postgraduate courses on Saturday and Sunday to a meeting from Saturday through Monday with optional postgraduate courses offered through Tuesday. Each meeting day had a clinical focus which allowed individuals to select specific days of interest. In 2015, the themes were: Obstetric Emergencies, Operative Gynecology, Contraception, Menopause and Patient Safety/Office Practice. In response to literature on adult learning many of the plenary sessions were presented as debates (topics included uterine power morcellation, out of hospital births, routine salpingectomy and universal cervical length screening). Hands-on sessions included simulated emergencies in obstetrics, forceps deliveries, basic obstetric ultrasound and simulated vaginal and laparoscopic hysterectomies. Interactive sessions commonly called flipped classrooms included perinatal depression, sexual problems, strategies for prevention of near miss maternal mortality and cervical insufficiency. Electronic posters were a new and successful addition in 2015 with 400 posters being presented during scheduled and structured times. This allowed a formal presentation by the poster author followed by opportunity for questions. In addition, 24/7 access to the posters was available for members.
President's program
In the spring of 2014, Dr John C Jennings, professor of obstetrics and gynecology at Texas Tech University Health Sciences became the 65th president of the American Congress of Obstetrics and Gynecology. In his inaugural address, he called for obstetricians and gynecologists to be leaders in providing team based care that is coordinated, standardized and utilize information technology to improve the health of our patients. He emphasized using healthcare resources wisely and carefully, and explained that healthcare in the USA is necessarily moving toward a system which focuses on high value, cost conscious care.
During the 2015 ACSM, Dr Jennings invited speakers as part of his President's Program which built upon this theme. The Hale Lecture, Improving Women's Healthcare with Organized Medicine and Technology, was given by Dr Robert Wah, the 169th president of the American Medical Association (AMA). Dr Wah gave an overview of the AMA, emphasizing that the AMA represents physicians of all age groups with a growing membership, now reaching 250,000 members. With increasing complexity of new electronic health records, government regulations and new payment models, the AMA is committed to developing practice management tools to help physicians thrive in the era of healthcare reform. Additionally the AMA has a physician wellness work group to remind and encourage physicians to remain aware and appreciative of the joys of medicine.
A large part of Dr Wah's message concerned the excitement around the transformation of medical practice from the growth of information technology. With the vast improvements in collecting healthcare data across all types of practices, information about the total population can be obtained and analyzed. Patterns will emerge leading to the ability to see associations and predict healthcare outcomes. This ability to gather data will be unlike anything that could ever be accomplished with paper records. Pitfalls were also acknowledged with emphasis on willingness for continuous improvement in IT. Meaningful Use was used as an example of a pitfall. Intended as a way to improve care for patients, it is currently estimated that 52% of physicians are failing to comply with Meaningful Use and will be penalized. With a failure rate this high, it seems obvious that its design is flawed and has become an administrative burden to physicians.
The second speaker was Dr CMA ‘Max’ Rogers, IV, MD who delivered the Anna Maria D'Amico lecture titled ‘Leading your high performing women's healthcare team: The ‘How To’ checklist'. With Dr Rogers’ background as a military fighter pilot, he compared safety in military aviation with safety in healthcare. Emphasis was given to structured and purposeful communication within the healthcare team-acknowledging that the physician is the team leader with responsibility to allow all team members to feel safe to participate in the conversation. He recommended debriefing for both good and unexpected outcomes in order to identify places in the process that were good and should be repeated – or bad and should be corrected. He also stressed the importance of simulations, particularly practicing simulated emergencies, and emphasized the need for repetitive practice to create clinically meaningful improvement.
Lastly, Dr CO Granai, MD presented the Jim and Midge Breeden lecture titled ‘The Good Fight’. Dr Granai is an associate professor at Brown University and director of the Program in Women's Oncology in the Department of Obstetrics and Gynecology. His message was clear and uplifting – as physicians, we are here to advocate for our patients to live life well and with meaning. Healthcare will always change due to external forces including business and financial pressures, social and political expectations, scientific advances and developments in technology. One thing will never change; we as physicians are here foremost to care for patients.
Presentation of original research
First prize paper
Headache in pregnancy is a common problem, with limited pharmacotherapy available. Scolari Childress and colleagues randomized normotensive pregnant women to treatment with iv. metoclopramide and diphenhydramine versus oral codeine [1]. Findings revealed a significant benefit of the metoclopramide/diphenhydramine combination over codeine in terms of symptom relief and acceptability. Use of metoclopramide/diphenhydramine regimen in pregnancy for relief of headache may be preferable due to the apparent high efficacy and avoidance of narcotics.
Second prize paper
Intrauterine devices (IUD) are increasingly used for long term reversible contraception yet pain during insertion remains as a barrier for nulliparous women. Singh and colleagues conducted a double blind randomized controlled trial of a 50/50 mix of nitrous oxide and oxygen versus oxygen alone during IUD insertion in nulliparous women [2]. Women in the nitrous oxide group did not have lower pain scores but did have higher overall satisfaction with pain management than those in the control group. Nitrous oxide may not be the optimal strategy for analgesia during IUD insertion, thus further research into more effective regimens is warranted.
Third prize paper
Vaginal yeast infection remains one of the most common conditions encountered in gynecology. Treatment is straightforward with either over the counter or prescription regimes. Williams et al. compared 150 mg of oral fluconazole versus vaginal 2% miconazole cream for treatment of clinician confirmed yeast vaginitis. Women were randomized to either treatment [3]. The miconazole cream provided faster relief than the oral fluconazole. It appears that the vaginal cream is a better choice for treatment of yeast infections given availability over the counter without a prescription in many countries and rapid relief of symptoms.
Donald F Richardson prize papers
In 2009, the Institute of Medicine (IOM) issued recommendations for maternal weight gain in pregnancy, amidst an increase in the prevalence of obesity in pregnancy and the associated adverse outcomes [4]. Cox-Bauer et al. evaluated the effect of weight loss on maternal and neonatal outcomes using existing data from 12 hospitals [5]. Weight loss in pregnancy was associated with an increased odds of small for gestational age (SGA) neonates; however, loss or maintenance of weight during pregnancy led to a decreased chance of developing gestational hypertension. Excessive weight gain during pregnancy increased the risks of cesarean delivery, gestational hypertension and neonatal intensive care unit admission. These data can guide practitioners and patients regarding the importance of adherence to IOM guidelines for weight gain in pregnancy.
Postpartum hemorrhage rates have been increasing over the last 10 years and management of the problem remains a significant issue for obstetrical providers worldwide [6,7]. Mitchell and colleagues studied the effects of uterine cooling during cesarean delivery on blood loss [8]. Women undergoing both scheduled and labor cesarean delivery were randomized to intraoperative uterine cooling versus standard care. Blood loss in the experimental arm was 29% less than in the control arm while uterine cooling also lead to a 57% decreased incidence of postpartum hemorrhage. Clinical outcomes such as need for uterotonics or transfusion were not different between the groups. Uterine cooling appears to be a simple yet promising technique for control of hemorrhage during cesarean delivery.
Other notable research
The risk of disseminating occult uterine sarcoma by power morcellation during hysterectomy has generated considerable controversy in the last 2 years. Identifying women with sarcoma prior to hysterectomy remains a challenge. Kho et al. analyzed data from the records of women undergoing hysterectomy for benign indications over 11 years at a single institution [9]. The incidence of occult sarcoma in this series of 10,130 hysterectomies was 9 per 10,000. This rate appears to be lower than the rate of 1 in 350 from recent US FDA analysis [10]. These results suggest that local or regional factors may influence the rate of occult sarcoma and should be considered in surgical planning.
Future perspective
The ACOG ACSM was a success in 2015 and more improvements in the meeting structure will be seen in 2016. Changes in women's healthcare will continue to challenge the OB/GYN to improve teamwork, patient safety and incorporate information from new healthcare databases into practice.
Footnotes
The views expressed are solely those of the authors and do not necessarily reflect the views of the ACOG Committee on Scientific Program.
The authors are members of the ACOG Committee on Scientific Program. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.