Ob Gyn Reporter Program

2011 ACM District II Reporters

Jamie Chao, MD

Erin Gertz, MD

Jamie Kramer, MD

Iman Saleh, MD

Jaclyn Taub, MD

Reports

Jamie Chao, MD
District II, Section 9

The 59^th Annual ACOG Annual Clinical Meeting in Washington, D.C. was an exciting and rewarding educational and social experience.  Not quite knowing what to expect, I traveled to Washington, D.C. with slight apprehension.  But after the first Ob/Gyn Reporter event, the Welcome Program and Dinner, I quickly saw the potential these next 5 days had for learning, as well as building friendships with residents from around the country.

At the Welcome Program and Dinner, the Ob/Gyn Reporters met Dr. Sterling Williams, the ACOG VP of Education, Dr. Richard Waldman, ACOG President, and Dr. Cynthia Brincat, JFCAC Chair.  Despite the impressive titles these three people held, they proved to be approachable and down-to-earth, which set the tone for the rest of the ACM.

Learned a lot: Medical Disorders During Pregnancy, Misoprostol, Career Opps in Public Health, Life after Residency...

• Exhibit Hall very overwhelming
• Met great people
• Impressed by how friendly and welcoming people were, and also how approachable people were
• Proud to be part of ACOG

Erin Gertz, MD
District II, Section 1

Reporter Report: Knowledge I Gained, Pearls I’ll Use
To say I “learned a lot” at the 2011 ACOG ACM is an understatement.  Although it has been one month since the meeting, I am still processing all the information.  Two of the sessions I attended were particularly meaningful because I have a personal interest in contraception and caring for victims of sexual assault.  The following pearls were gleaned from these two sessions.

Family Planning 2011: Contraceptive Challenges Controversies and Evidence

• Facts: 50% of pregnancies in the US are unintended, 50% of those occurred while using a contraceptive method
• Strategies to Improve Contraceptive Coverage:
  • Separate contraceptive counseling from cervical cancer screening
  • Condoms: Great for STI prevention, Dismal for pregnancy prevention
  • Pay special attention to women on medications that are category D or X - only 50% are counseled about contraception
  • When looking at the WHO / CDC Medical Eligibility Criteria, consider the risks compared to the risk of that woman becoming pregnant, ex: hormonal contraceptives slightly increases VTE risk, but pregnancy significantly increases VTE risk
• Counseling:
  • Women on anticoagulation, options:  LNG-IUS: decreases menorrhagia; Implant / Depo: inhibits ovulation, therefore decrease risk for cysts / hemorrhagic cysts AND decreases menorrhagia
  • Natural Family Planning can work
  • 7-day long placebo period increases risk for escape ovulation
  • “Quick Start” does NOT increase the incidence of unscheduled bleeding
  • EC: “Gateway Drug”; Quick Start with EC: give EC dose, start method next day
  • Any method that is associated with unscheduled bleeding: as part of counseling, ask “Are you / partner comfortable with intercourse while bleeding?”, suggest carrying a panty liner in purse
  • “Nocebo” effect: don’t include vague symptoms in counseling
• Specific Contraceptives
  • POP problems: if >27 hours from last dose (I.e. 3 hours late), use a backup x 2 days - effective serum levels for only 22 hours
  • Patch: always prescribe at least 1 replacement patch (does insurance cover?)
  • Depo-Provera: can use a 4 week grace period rather than 2 week; associated decreased bone density does not equal increased fracture risk; FDA recommends discontinuing after 2 years, but WHO / ACOG / AAP disagree
  • IUD: transient increased risk of PID (only first 20 days after insertion); no need to remove IUD if PID diagnosed
• Non-Contraceptive Benefits / Uses:
  • Menorrhagia: 2-4 tabs COCs can control bleeding within 48h (no need to taper)
  • Rx antiemetic
  • Continue x 1 week after bleeding stops, then stop x 3 - 5 days, then start new package
  • Remember increased VTE risk, in smokers for example
  • Fibroids
  • Depo can shrink uterine AND fibroid size (decrease uterine volume by 48%, decrease fibroid volume by 33%)
  • LNG-IUS can decrease uterine size, but not fibroid size
  • Endometriosis
  • Depo (evidence for SC but IM probably the same) as effective as Lupron (but, bone density does not recover after Lupron)
  • LNG-IUS also effective despite lack of ovulation suppression
  • Acne / hirsutism: only COCs are effective; patch / ring miss first pass metabolism, so don’t help
  • PMDD: treat with antidepressants
• Abortion
  • IPAS can provide brochures that only mention spontaneous ab, not elective TOP
  • Music can work as analgesia during an MVS
  • Use at least 20ml of lidocaine for the local blocks, can use same amt NS
  • No increased risk of sab after 1 sab
  • Medical Ab - 5 / 1million deaths vs. Surgical Ab - 1 / 1 million deaths
  • 60-70% of women are already sexually active by 6 wk postpartum visit

Crime Scene to Courtroom - The Forensic Evaluation of the Sexual Assault Victim

• Wet stains with saline, then swab - can improve pickup of DNA
• Ask “Where was he breathing on you?” - swab that area for respiratory secretions
• Use Oral-B Super Floss - has barbs that catch sperm
• Swab above the 3^rd molar - the hardest area to clean
• Use a foley balloon to examine integrity of hymen
• Spray saline around inside of vagina, then swab
• Use an endoscope to see inside the vagina of a small child
• Blind swabbing - if pt unable to cooperate / tolerate exam, have her swab genitalia / anus with RN witness
• Toluidine Blue - spray on vulva to highlight lacerations
• UV light - help illuminate hard to see lacerations / bruises

Resources:

www.reproductiveaccess.org
who.int/reproductive health
UCSF Family Planning Consult Service: (415) 443-6318
CDC: USMEC (Medical Eligibility Criteria)
www.rcog.org.uk/files/rcog-corp/unscheduledbleeding23092009.pdf (p49)
apps.who.int/rhl/en/
www.managingcontraception.com
Soc ObGyn of Canada, JOGC 2008, 219:1050-62
www.worldmapper.org
Survey of Folk Beliefs about Induction of Labor
www.muhealth.org “For You Team”
ACOG Mentor Award (by district)
Physician Burnout (lunch session)
www.meaninginmedicine.org

Jamie Kramer, MD
District II, Section 1

This year I had the eye-opening experience of attending the ACOG Annual Clinical Meeting in Washington, DC as an Ob-Gyn Reporter. This program, designed to introduce residents to the College and the Congress exposes residents to a variety of types of programming, lectures, meetings and interactive sessions on a wide range of subjects related to women’s health.

The program started with an introductory dinner where we met some of the leaders of resident education and had an opportunity to meet Ob-Gyn Reporters from across the country and abroad. It was at this dinner, where we heard from physician leaders such as Dr. Sterling Williams, Dr. Richard Waldman and Dr. Cynthia Brincat (a woman so full of vibrancy and passion for the field and for resident education that it’s infectious) that I realized that the ACOG ACM is not simply a central venue for people to collect CMEs and present posters, but for a community to come together to share ideas, passions and experiences.

My first full day started with a talk from Dr. Patrice Weiss, who I had the pleasure of hearing from several times throughout the conference.  She spoke to us about “emotional intelligence,” a concept that is often neglected in a resident’s formal education but is arguably the one that needs to be cultivated prior to venturing into clinical rotations and responsibilities.  The remainder of my first day was spent in a post-graduate course on Menopause and Hormone Therapy.  In this series of lectures, I heard from Drs. Hugh Taylor, Lubna Pal and Joann Pinkerton on hormone therapy, perspectives on the WHI trial, management of osteoporosis, sexuality in the post-menopausal woman and the future of hormone therapy.  As a budding generalist whose education is saturated with acute inpatient issues, high risk pregnancies, emergent and complicated surgeries, it was a breath of fresh air to hear from experts on the management of issues that will make up so much of my day-to-day practice when I complete my training but that is so lacking in the resident experience. When a show of hands revealed that almost every physician in the room instructed their post-menopausal patients on the use of dilators, which I had never spoken with a patient about, I realized what a gap there was in my education thus far. The nature of a residency makes it difficult to treat a single patient over weeks to months or even years, developing the experience needed to help tailor a woman’s hormone therapy or to gradually help her with her sexual dysfunction issues over time. I furiously took notes throughout the day and vowed to use these slides to lecture my fellow residents when I returned.

In the evening, the residents were given the opportunity to meet and socialize with all of the conference attendees and their families at the festive welcome reception that kept people up and dancing well into the night.

Day two began with another breakfast seminar, this time led by Dr. Owen Montgomery on the difficult subject of domestic violence. He opened our eyes to how widespread this issue is and that it is one that affects ALL our patients. He made it clear that it is a failure on the part of an Ob/Gyn to not ask our patients if they are safe in their homes and their relationships, as it is that simple question that will frequently stand between years of abuse and violence and a woman seeking and obtaining the help she so desperately needs.

Following the breakfast we attended the opening ceremonies, which included a special tribute to Dr. Ralph Hale as well as an introduction to one of the topics which permeated the entire meeting, that of maternal mortality. This subject was not only the subject of dedicated talks and programs, but was addressed in may of the various lectures throughout the program in a way that made everyone feel a sense of responsibility to our field and to women to try to make a change in the rates of and disparities in maternal morbidity in this country.

We also heard from three captivating speakers at the opening ceremonies on a variety of subjects. Dr. Francis S. Collins from the NIH spoke to a packed room about opportunities in biomedical research, enumerating the latest development as well as future opportunities and implications of these advances. Dr. Roberto J. Romero then addressed the audience on prevention of preterm birth, the use of progesterone in patients with short cervix and the physiology and prevention of cerebral palsy and its ties to intrauterine infection.  Lastly, Dr. David A. Grimes gave a powerful and moving talk on Misogyny and Women’s Health.  He talked about the rates of maternal deaths in countries around the world and why those numbers exist. He addressed ways in which some countries treat women as lower class citizens with fewer rights and little importance while others that are considered by some to be more “developed” degrade women socially through music, advertising and social media.  He reminded the physicians in the room of the days when women bled to death in hotel rooms trying to obtain illegal abortions because of the restrictions on women’s rights and how our country is currently moving backwards in that arena.  He reminded us all of our responsibility to women not just as their physicians, but as their voices and advocates.

When the opening ceremonies concluded, it was on to smaller sessions and mine was a talk, again by Dr. Patrice Weiss, entitled “How to Say I’m Sorry.”  She addressed the difficult issue of how to face a patient when there has either been a bad outcome or a medical error. She emphasized the importance of including residents in these experiences to learn how to navigate situations that they may be faced with themselves in the near future.

The afternoon was spent in a program for residents only designed to address our paths as we approach fellowships and careers as generalists. We heard from several different speakers on what to look for when interviewing for a generalist position, how to make yourself an appealing applicant and tips for finding out what kind of practice or fellowship is right for you. Though there were formal lectures, it quickly became an interactive session as residents barraged the speakers with questions about when, where, how and why to interview for jobs and fellowships.  We then broke into smaller groups, divided by generalist and fellowship-bound residents to answer some of the more specific and practical questions that we all had. It was interesting to hear the perspectives from generalists who were all on such different paths, ranging from a small, family-run practice in Georgia to a sub-specialized gyn focus at a large academic center, to a young new attending in a private practice.

Day three started with a Junior Fellows breakfast, where the Ob-Gyn Reporters interacted with the Junior Fellows, giving us a chance to learn a little bit more about what they do while also hearing from more esteemed speakers.

This was followed by the very entertaining “Stump the Professors” program, where residents from various programs presented rare cases they had come across and challenged esteemed physicians in our field to make a diagnosis.  In most cases, the residents were indeed able to stump the panel (though I’m proud to say my fellow resident diagnosed a case of Moya-Moya that the panel failed to diagnose!).

Later that day, I went to a “lunch with the experts” session entitled, “The New Model of Generalist: Are we Training Well for the Position? Review of Trends and Surveys.”  This turned out to be a fascinating conversation between a very diverse group of generalists. The session was led by Dr. Maria Manriquez from the University of Arizona College of Medicine and was attended by myself (a budding generalist), a jaded and disillusioned generalist from New Jersey, a generalist who does both obstetrics and gynecology in Australia and an army MFM specialist who did a few years of generalist practice and was about to start a position as a program director.  I got to hear the pitfalls in as negative a light as one could shed and the arguments against those from three people in three very different types of practice. The conversation certainly raised my awareness of some issues I might face but in the end made me realize that general Ob/Gyn is what one makes of it and that it is the choices one makes in their career path that enable one to maintain the same passion and love of their career that they started with.

In the afternoon, I had another educational lecture on vaginitis with talks from Drs. Kevin A Ault and Jennifer Gunter.  They addressed the 2010 CDC updates on Chlamydia, Gonorrhea, HPV, HSV and HIV, clarifying screening and treatment guidelines. They also gave frank and practical advice on the management of candidial vaginitis, recurrent vaginitis, bacterial vaginosis and patient concerns surrounding vaginal odor and physiologic discharge.

Throughout the day, there was some free time to explore the poster sessions and vendor booths, seeing what some of the current and exciting research was focusing on and what new technologies, medications and supplies are available to Ob/Gyns in every specialty.

The last morning we had the honor of attending the Presidential Inauguration and Convocation where new Fellows were inducted and outgoing leaders ceded to new ones.  It was a touching ceremony that again drove home the sense of community that ACOG creates.

The ACM helped me to realize several things. First, we are not physicians working in isolation; we are a community that learns from and with one another. The field of general Ob/Gyn encompasses a vast amount of information and of women’s needs and there is always someone to turn to who knows more than you about a particular subject. ACOG helps to create an atmosphere where it is not only okay to reach out to one another to learn more about a subject or to get a second opinion, but our duty to do so.   Second, medical care is just one aspect of what we provide for our patients. We are also the person in whom they can place their trust, the one that can help to ensure safety in their personal lives and the one who can provide a voice for those who are for some reason unable to raise their own.  Third, our responsibilities extend far beyond our duties to our patients. We are representatives of women’s health and thereby of women’s rights. It is our job, as physicians equipped with medical knowledge to defend our positions to stand up for women’s rights in this country and throughout the world. If those of us with an education and a firm understanding of the consequences of limiting those rights do not make our voices heard then there can be no social change for the better.  It can seem hard to face such daunting social challenges such as those that are in our House and Senate right now, but ACOG can help provide the tools and the motivation. Since returning from the ACM, I have arranged to have a lawyer from the ACLU Reproductive Freedom Project come educate the residents in my program about the recent legislation that has been passed and that is being proposed in various states. This is a small step but to me an important one in doing my part as an Ob/Gyn and a provider of healthcare to women everywhere.  I thank ACOG for the opportunity to attend the ACM and for the wake-up call it provided for myself and so many other attendees and I look forward to attending the next ACM in 2012.

Iman Saleh, MD
District II, Section 4

At times, residency feels like a jail sentence - the physical, emotional and mental “torture” that we all feel at one point in time during our careers. The daily grind to get work done as well as the need to be continually learning at times drains physicians that are going through residency, especially in Ob/Gyn.  It is during residency that every physician grows and learns to be healers to others and ourselves.

The ACOG Ob-Gyn Reporter Program was an incredible experience.  The program revived hopes and aspirations that were the essence of why I went into OB/GYN. In addition to the multiple academic lectures attended during the Annual clinical meeting, there were multiple resident lectures that continuously reminded of our role as an Ob/Gyn in society. The role of an Ob/Gyn is not just merely delivering babies, treating fibroid or even performing annual pap smears. We as ob/gyns have the obligation and honor of taking a public health approach to prevention in women’s health. As advocates of women’s health, we do not only deliver or even treat gynecological issues, but also should be screening women for substance abuse, depression, domestic violence and medical co-morbidities such as obesity and diabetes. We have a great responsibility and role in society that we should take very seriously to improve the health status of women in the United States. Unfortunately, during residency, we sometimes focus on the gynecologic morbidities and we forget the multiple elements that make up the female patient. Such strong speakers and lectures during the Ob-Gyn Reporter’s program reminded us of the multi-tiered approach that we should take with our patients and the impact that this can have on society.

One of the most important take away messages from the program was that although we are healers, we too, need time and outlets for ourselves to heal and recover from poor medical outcomes and errors.  Physicians become the “second victim” without even the acknowledgment of this fact. We as residents are so immersed in the daily grind and expectations that we sometimes don’t acknowledge the need to stop and reflect on the poor outcomes and how it affects us---until it takes a negative effect on our daily routine. Immediate Emotional First Aid for residents and physicians should be available at every hospital to focus on the “second victim” emotions and alleviating effects such burnout, anxiety, decreased confidence, sleep disturbances and substances in the healers of society. This is a topic that I would address in my hospital. Although the environment is very open to help residents discuss and reflect on poor outcomes, I feel a more formal approach may be beneficial to the residency program.

Although there was plenty of learning during this wonderful experience, one of the most important things I learned during this meeting is to never stop learning. Meeting residents from around the country taught me that many of our daily management and procedures have countless permutations and that I should not be only stuck to one way. That thought has inspired me to take back techniques that other programs are using and to question our own management to fully advocate and manage our patient population.

Thank you very much for a wonderful experience and opportunity. This experience has inspired me to be a greater advocate for women’s health and to play an active role in doing so.

Jaclyn Taub, MD
District II, Section 2

The Ob/GYN Reporter Program allowed me to experience ACOG and the Annual Clinical Meeting in a way in which I would have not otherwise been able to experience.  From the first moment that I arrived, I was immediately struck by how eager ACOG and all of its participants are to getting young residents involved.  From Dr. Williams' welcome speech, I could easily see how important my position is.  The members of the districts throughout the country all gathered together in a way to bring about change in the College and improve Women’s Health.

We began each day with lectures about our profession.  Not just knowing the correct dosages of medications and how to perform particular surgeries, but how to be a physician. Through these lectures, I remembered how important the human aspect of medicine is.  Obstetrics and Gynecology initially amazed me in medical school because of how intimately you may get to know your patients.  Pregnancy is one of the most beautiful, but potentially scary experiences of a woman’s life.  Often, in residency, we come to know the patients with the most dire or threatening situations the closest.  The negative experiences I have encountered in my past 2 years in residency has made me realize how important it is to be a human, and how this makes me a better doctor. Throughout each of these morning lectures, I remembered why I originally wanted to go into medicine when I was in college.

In my experience in residency thus far, I can honestly say that I feel more confidant and comfortable with obstetrics.  As a first year resident, I ran around the labor room, delivering babies, excited to hold the scalpel for a cesarean section and eager to learn more.  However, as I approach my third year, I am beginning to be involved with my gynecology cases.  Coincidentally, my scheduled lectures throughout the ACM were all GYN.  I learned the newest advances in minimally invasive gynecology. I watched videos and learned about common laparoscopic mistakes and how to avoid and improve upon my skills.  I learned about inherited breast and gynecologic cancers and genetic tests to screen for these conditions.  I learned how important family history is and how so much can be known from a detailed history.  Lastly, I learned about medical malpractice and expert legal testimony.  These are all areas that I have not yet had that much experience, but are so important for my future.

The last aspect that I learned that I am most excited about is ACOG itself. There are so many opportunities for young doctors to get involved and take part in the activities that go on throughout this organization. I was amazed by the different committees and groups that are eagerly looking for participants. I learned about the toolbox program and thought how easy and practical it is to have this available at my hospital.  I have already taken the step to contact my district, District 2, and am finding out how I can get more involved.  I am very excited to learn about the advances ACOG is making about maternal mortality.  There is so much we have yet to learn about women with co-morbidities and pregnancy and I am really looking forward to learning more about how to help women.

All in all, I have had a wonderful experience at ACM and am very grateful to Teva for funding this opportunity.  I have met so many wonderful people and am extremely excited to become more involved in the future.  Thank you and I look forward to working with you again in the future

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