Preparing medical students for obstetrics and gynecology milestone level one: a description of a pilot curriculum

Background The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident. Purpose We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies. Methods The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks. Results Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey. Conclusions This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGME's Next Accreditation System.

M ilestones, as defined by the Accreditation Council for Graduate Medical Education (ACGME), are competency-based, developmental outcome expectations that can be demonstrated progressively by residents and fellows from the beginning of their education, through graduation, and then into unsupervised practice in their specialty. The Milestones Project is a part of the ACGME's Next Accreditation System (NAS) (1), and was implemented in obstetrics and gynecology in July 2014. Milestones specific for obstetrics and gynecology were defined and described by a joint initiative consisting of the ACGME, the American Board of Obstetrics and Gynecology (ABOG), and the American College of Obstetrics and Gynecology (ACOG); and were released in September 2013 (2). Milestones Level One are defined as the level expected of an incoming first-year resident.

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Medical Education Online 2014. # 2014 Helen Morgan et al. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. At this time, there is a lack of formal curricula targeting Milestones Level One for fourth-year medical students planning to enter obstetrics and gynecology residencies. Although some programs have implemented intern preparatory courses as part of their residency programing, there is a need for a comprehensive program for educating and assessing graduating seniors (3), and for facilitating their transition to residency (4). The University of Michigan Department of Obstetrics and Gynecology designed, implemented, and evaluated a 4-week elective, which utilized a multimodal approach to teaching and assessing the Milestones One competencies. The objective of this paper is to provide a detailed description of the pilot curriculum.

Course design
The curriculum was organized by an education team that consisted of leadership from the Residency program, the Medical Student Clerkship, and the Department of Medical Education. Resident and medical student feedback was also obtained during monthly planning meetings. The 4-week, 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and freshfrozen cadaver operative procedures. The content for the learning objectives was initially mapped to the preliminary version of the Obstetrics and Gynecology Milestones as outlined by the American Professors of Gynecology and Obstetrics (APGO) and the Council on Resident Education in Obstetrics and Gynecology (CREOG) Milestones One Educational Taskforce (

Didactic lectures
One-third of the curriculum was delivered in a traditional didactic format including PowerPoint presentations and case discussions. Topics delivered in this method included general topics such as diabetes and hypertension in pregnancy, gynecologic wound care, contraception, and informed consent.

Flipped classroom sessions
The flipped classroom curricular model was utilized for the topics of prolapse and incontinence, gynecological oncology cases, vulvar disorders, first trimester bleeding, and gynecologic office management cases. For these sessions, students were assigned content to review prior to the teaching session. This preclass assignment consisted of either reviewing a high content video, or completing a reading assignment. Classroom time was then used for the application of knowledge in the form of a casebased active learning session. We utilized the open source learning design site Learning Activity Management System (LAMS) (6) for these sessions. The LAMS program enables each student to respond individually to short answer questions, while working through clinical cases together as a group. Students replied individually to short answer prompts on the differential diagnoses, laboratory evaluation, and management of the cases. Collective responses were then projected anonymously and used for discussion.

Simulated paging curriculum
A paging curriculum consisting of four gynecological and four obstetrical patient scenarios was created and modeled after a similar paging curriculum used in a surgery residency preparation course (7). The scenarios consisted of common paging scenarios such as tachycardia in the postoperative unit, or postpartum urinary retention (Table 3). Eight certified nurse midwifes (CNM) were recruited to page learners at randomly selected times, 24 hours a day, 7 days a week over the 4-week period. The CNM, playing the role of a clinical bedside nurse, used standardized scripts containing relevant clinical information. Specific details were only conveyed if specifically requested by the student. The scenario ended with the completion of the call, and immediate feedback was given to the student. A paging debrief session was held the last week of the course to review the eight cases and reinforce the important clinical teaching points. A paging confidence survey was administered on the first and last day of the elective.

Simulation training
A selection of clinical scenarios that utilized obstetrics and gynecology simulation cases, previously used in our residency curriculum (8), served as the basis for the simulation sessions. For obstetrical simulations, SimMom † and Noelle † human birth simulators were utilized. Traditional box trainers were used for hysteroscopic and laparoscopic simulations. For each clinical case, a short didactic presentation was made on the clinical presentation of each scenario. Each participant was then given a brief clinical vignette, and instructed to manage the patient for the particular scenario. Items for evaluation included knowledge of clinical situation, recognition of pertinent signs of the clinical problem, management, and team communication where applicable. Upon completion of each session, learners were given direct feedback Helen Morgan et al.
in each area. Learners were then given the opportunity to repeat the station.

Anatomic dissections
Basic pelvic anatomy sessions, utilizing embalmed cadavers, were designed and conducted by anatomy department faculty. These sessions covered layers of the abdominal wall, pelvic viscera and blood supply, pelvic floor muscles, and perineal anatomy. One faculty member from the Division of Anatomical Sciences taught all five sessions.

Operative procedures
The clinical anatomy sessions utilized fresh-frozen cadaveric pelvises and were conducted by two obstetrics and gynecology faculty. These sessions covered two basic firstyear level surgical cases (tubal ligation and second-degree perineal laceration), and two advanced level cases (abdo-minal hysterectomy and bilateral salpingo-oophorectomy) to reinforce the clinical relevance of the pelvic anatomy sessions. The fresh-frozen dissections were performed over a 2-day period with a cadaver-to-student ratio of 1:2.5. Instruction included an introduction to the surgical instruments and sutures used for each procedure as well as a brief review of the clinical anatomy. Students then performed a tubal ligation, a second-degree perineal laceration repair, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy on their cadavers. Learners were given feedback as to economy of moves, proper use of instruments, and quality of knots tied. Throughout each procedure, common complications and potential variations in anatomy and technique were described. The cost per fresh cadaver was $1,245 each, and the surgical instruments from the university operating rooms were used at no cost.

Student assessment Knowledge
A 100-question knowledge assessment for all educational objectives domains was constructed based on content drawn from current ACOG Practice Bulletins and Committee Opinions, peer-reviewed publications, and traditional textbook chapters. The multiple-choice test was administered via Qualtrics † on the first and last day of the course. Excel † was used to create a report of test scores, a list of all educational outcomes, and a personalized reading list of references for all missed questions. Each student had an individual feedback session after the knowledge pretest, where they were given their report with their test scores, their personalized reading lists, and recommended course of study to be completed over the 4-week period. For the paging curriculum, a pre-and postparticipation paging confidence assessment was administered using SurveyMonkey † . Students rated their confidence in handling pages related to the specific gynecological and obstetrical scenarios on a six-point Likert scale (0 0Not at all, to 60I can teach someone how to do it). In addition, scoring rubrics that evaluated participants on assessment and management for each scenario were developed and the CNM who performed the paging scenario filled out the evaluation on the student.

Skills
An open skills assessment was performed on the first and last days of the course, using an abbreviated version of a previously validated open skills curriculum (9). Students were timed performing a two-handed knot tie without tension, one-handed knot tie without tension, two-handed surgeon's knot under tension, simple interrupted suture, and simple running suture. Laparoscopic skills assessment was performed with a pre-and posttest utilizing basic laparoscopy skill on a box trainer. Students were given a surgical kit for use throughout the elective that consisted of surgical instruments, sutures, a Dog Abdominal Surrogate for Instructional Exercise (10), and practice worksheets.

Course evaluation
Student satisfaction with course content was collected utilizing SurveyMonkey, an online survey instrument, upon completion of each of the 4 weeks. Students were asked to evaluate each session on its relevance, organization, opportunity for discussion, meeting of learning objectives, preparation for residency, and whether the session should remain part of the course in the future, with ratings assigned on a five-point Likert scale. Data

Student assessment Knowledge
There was significant improvement in overall knowledge, as well as improvements in office, gynecology, and obstetrical topics at the completion of the course. Pre-and postcourse scores for the knowledge assessment are demonstrated in Table 2. Student performance on the assessment and management of the eight paging scenarios are demonstrated in Table 3. Students performedwell in the assessment and management of acute situations such as an acute abdomen in a postoperative patient. One of the scenarios however was a simple request for Simethicone in a postoperative patient, and the students had the lowest scores for assessment and management for this common case. Paging confidence trended toward improvement for all of the scenarios covered by the paging curriculum.

Skills
There was a trend toward improvement in the times for all of the open and laparoscopic skills, with significant improvement demonstrated in the two-handed surgeon's knot under tension and the basic laparoscopy skill on the box trainer. Pre-and postcourse times for the skills assessments are demonstrated in Table 2. Two of the students were not able to complete a one-handed knot at the time of the pretest, and all five students were able to tie a one-handed knot at the time of the posttest.

Course evaluation
There was a 100% response rate to the online satisfaction survey, and overall satisfaction was very high for all components of the course. The satisfaction scores were highest for the active learning components of the curriculum, specifically the flipped classroom, simulation, anatomic dissections, and operative procedures.

Discussion
This 4-week elective in Advanced Clinical Skills in Obstetrics and Gynecology led to improvement in knowledge, paging confidence, and surgical skills, and had very high student satisfaction evaluations. These findings, although limited by the small sample in the pilot study, are consistent with findings previously published on general surgery residency preparation electives for fourth-year medical students (11,12). Many medical schools are currently struggling with the creation of individual curricula in order to meet the Milestones requirement for the various specialties (13), and this pilot experience suggests that a 1-month clinical preparation course can successfully help prepare fourth-year students for the expectations of Milestones One in obstetrics and gynecology.
This program also demonstrates that a comprehensive curriculum can be completed on a relatively low budget, but requires significant faculty time for the active learning components. Our course incorporated a considerable amount of active learning with flipped classroom active learning sessions, simulation, and anatomic dissections. Learner satisfaction data demonstrated higher student satisfaction with these active learning sessions. Although a traditional didactic curriculum may be a seemingly more simple way to meet the minimal standards for compliance with requirements such as Milestones One, active learning leads to better engagement and retention of both knowledge and skills (14). This curriculum presents an example of the use of active learning for preparation for year one of residency.
A limitation of this pilot experience is the small number of students that participated in the course. The Advanced Clinical Skills Course will be offered annually, and we have 13 students enrolled in the course for the upcoming 2014 session. The final ACGME Milestones, released in September 2013, map very similarly to the preliminary APGO/CREOG Milestones on which our curriculum was modeled. The final ACGME Milestones contain more systems-based practice and practice-based learning and improvement components that will be included in our 2014 course. In addition, we are in the process of collaborating with multiple programs to further assess the overall cost and effectiveness of the elective and we plan to survey program directors where students who went through this program match to assess their competency relative to students who did not go through such a course in their fourth year. Future studies will be needed to assess Milestones Level One competencies in learners who  participated in a preparation elective compared to those who did not. The organization and implementation of these electives is labor intensive, and future studies will also need to assess whether there are longer term benefits to learners.
In conclusion, this pilot study demonstrates a practical and effective approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. As medical schools and specific specialties work to meet the first step in the ACGME's NAS, this curriculum can serve as a framework for other specialties.