Multi-Center Survey of Medicine Residents and Self-Assessment on Cardiac Complications in Obstetric Patients

Abstract

Background

Internal medicine (IM) residents receive significant cardiology training, and previous surveys have evaluated IM resident competency on obstetric (OB)-related subjects. However, there is minimal literature on self-reported competence of cardiac-specific complications in OB patients. Our study assessed self-reported comfort and competency regarding cardiovascular complications in OB patients with medical residents across several specialties.

Methods

We surveyed 207 residents across 3 specialties and 3 teaching hospitals on 10 questions regarding their self-reported confidence in managing cardiovascular complications in OB patients, including practice setting, specific cardiac issues, and stages of labor. We received 42 responses. Results were obtained using Google Sheets and analyzed with Microsoft Excel.

Results

Internal medicine residents reported being less confident in managing cardiac complications in OB patients compared to family medicine (FM) and obstetrics and gynecology (OBGYN) residents across all categories. PGY3 IM residents rated themselves on par with FM/OB residents in the ICU setting. The presence of OB services in the hospital did not affect IM resident self-assessment.

Conclusion

Internal medicine residents demonstrated low self-assessment scores regarding confidence managing cardiac conditions in OB patients. There may be opportunities to introduce specific OB-related teaching material to increase confidence.

Introduction

Internal medicine (IM) residents receive significant cardiovascular disease training throughout the course of their training by accreditation standards by the Accreditation Council for Graduate Medical Education; however, training in obstetrics and gynecology (OB-GYN) is lacking compared to residency standards for OB-GYN residents and family medicine (FM) residents.¹ Previous studies have evaluated IM resident competency on OB-related subjects;² however, self-reported competence for addressing cardiac-specific complications in obstetric patients has not been thoroughly explored in the literature. Obstetric competency is essential in graduate medical education, as cardiovascular disease is the single largest cause of indirect maternal mortality, comprising greater than 30% of pregnancy-related maternal deaths.³ Proper multidisciplinary cardio-obstetric care has been associated with decreased adverse maternal and fetal outcomes.⁴ Understanding resident assessment of their own competency is important in development of future academic curricula.

The primary objective of this study was to assess self-reported comfort and competency regarding cardiovascular complications in obstetric patients for medical residents across several specialties. Previous studies have noted a relative lack of preparation for OB-specific subjects in internal medicine residents,² as well as a relative lack of awareness of associations between cardiovascular health and OB complications.⁵ As such, we hypothesize that internal medicine residents would have a lower self-assessment in the management of cardiac complications in obstetric patients.

A secondary endpoint was to evaluate subjective improvement measures to internal medicine residency curricula to improve resident education.

Methods

We surveyed IM, FM, and OB-GYN resident physicians across three teaching hospitals in the United States using Google Forms. The survey was distributed using electronic methods, such as email and social media. We gathered demographic data on these residents, including year of study, program specialty, and availability of OB services at the primary training site. We asked 10 questions regarding resident self-reported competency and comfort in the management of cardiomyopathies, arrhythmias, and other cardiovascular conditions in OB patients in first, second, third trimesters, as well as labor. We included an open-ended response question where residents could provide feedback on improvements to their respective training programs. Responses were graded on a scale of 1 to 5, with 1 demonstrating very little comfort and 5 demonstrating high comfort. We accepted survey submissions for 30 days and obtained 42 responses during this period. This study was approved by the IRB at each institution. Our data were input and analyzed using Microsoft Excel.

Results

The overall response rate was 20%, with 42 respondents out of 205 residents completing the survey. The majority of respondents were IM (n = 29, 69%), with the remainder consisting largely of FM residents (n = 7); comparatively fewer OBGYN residents responded to the survey (n = 4). One transitional year resident and 1 medical student also completed the survey (Supplemental Figure 1).

The majority of respondents were in their first 3 postgraduate years after medical school (PGY), with significantly fewer respondents at the PGY4 level and above. Respondents were fairly evenly balanced between PGY1, PGY2, and PGY3. Two respondents were at the PGY4 level and above. One respondent was a current medical school student of unknown year (Supplemental Figure 2).

The majority of respondents practiced in a mixed inpatient/outpatient setting (n = 27); fewer represented a primarily inpatient specialty (n = 13), and only one respondent reported a primarily outpatient setting (n = 1) (Supplemental Figure 3). The majority of respondents indicated that OB services were not available at their primary hospital site (n = 28) (Supplemental Figure 4).

The majority of respondents indicated a higher level of comfort treating cardiac comorbidities in obstetric patients in the outpatient setting, compared to the inpatient and ICU setting. The majority of respondents demonstrated a low level of comfort in the ICU setting, with the majority reporting a 1 (of 6) in the ICU setting (Supplemental Figure 5).

Respondents demonstrated a similar level of comfort across all cardiac complication types surveyed, with a slightly higher comfort level for arrhythmias compared to heart failure and cardiomyopathies. The majority of residents surveyed reported a comfort level of 1 (of 5) for cardiomyopathies, compared to 3 (of 5) for arrhythmias, and a similar number of respondents scoring comfort at 1, 2, or 3 for heart failure (Supplemental Figure 6).

Most respondents indicated a lower level of comfort as stages of pregnancy progressed; and the majority of respondents indicated 1 (of 5) comfort in terms of managing cardiac complications for patients in active labor. Regardless of the stage of pregnancy the majority of residents did not feel more comfortable than a 3 (of 5), regardless of stage of pregnancy (Supplemental Figure 7).

The majority of respondents indicated a low level of confidence in their respective program training in terms of handling cardiac complications in OB patients, with 59.5% reporting a 1 (of 5) confidence in their OB training at their respective home program (Supplemental Figure 8).

Across all PGY levels, the mean comfort for treatment of cardiac complications in OB patients, grouped by practice setting, was higher for OB residents compared to FM and IM residents across all categories. The mean comfort for FM was noted to be higher than that of IM across all categories, but lower than that of OB (Figure 1).

Figure 1.

The comparison of mean comfort for all practice settings, grouped by specialty.

Abbreviation: ICU = intensive care unit

OB residents compared to FM and IM residents across all categories. The mean comfort for FM was noted to be higher than that of IM across all categories, but lower than that of OB (Figure 1).

Across all PGY levels, the mean self-assessed comfort for all categories of cardiac complication surveyed was higher for OBGYN residents and FM residents compared to IM residents (Figure 2). Interestingly, FM resident self-assessed comfort was higher for heart failure in pregnancy compared to OB residents. This difference was found to be statistically significant (P < .05).

Figure 2.

The comparison of mean comfort across all types of cardiac complications surveyed, divided by specialty.

Across all PGY levels, OBGYN residents rated themselves as more comfortable managing cardiac complications across all stages of pregnancy as compared to IM residents, and at a similar level compared to FM residents (Figure 3). The difference between IM scores and FM/OBGYN scores was found to be statistically significant (P < .05). There was a significant amount of variability in the responses of OBGYN residents, likely secondary to the low response rate (n = 4).

Figure 3.

The comparison of mean comfort for management across all stages of pregnancy, divided by specialty.

Serial one-way ANOVA testing of differences found no difference found in mean comfort between PGY levels for IM residents, across all categories polled (Supplemental Tables 1–9). The sole exception was with comfort of management of conditions in the ICU setting: mean PGY3 resident self-rating in managing cardiac complications in OB patients in the ICU = 1.91, compared to 1.33 and 1.14 for PGY2 and PGY1 residents, respectively (Table 1).

Table 1.

ANOVA One-Way for Difference of Means, Comfort in Intensive Care Unit Treatment, Grouped by Postgraduate Year Level (Statistically Significant, P < .05)

Source of variation	SS	df	MS	F	P value	F crit
Between groups	3.19	2	1.595	4.08	.029	3.385
Within groups	9.773	25	0.39
Total	12.964	27

When comparing PGY3 residents across all medical specialties, we found the mean comfort to be lowest among PGY3 IM residents, followed by FM, and OB in the ICU setting. This difference was not found to be statistically significant (Table 2).

Table 2.

One-way ANOVA for Difference of Means, Comfort in Intensive Care Unit Treatment Among Postgraduate Year 3 residents, divided by practice specialty. (Not statistically Significant, P > .05)

Source of variation	SS	df	MS	F	P value	F crit
Between groups	4.333	2	2.1677	2.6712	.1012	3.682
Within groups	12.166	15	0.8111
Total	16.5	17

Internal medicine residents with OB services available at their primary practice location rated themselves more comfortable managing complications across all categories compared to their counterparts without OB services, with the exception of management in the outpatient setting. Wilcoxon rank sum testing revealed the differences between IM with and without OB were not statistically significant; P > .05 across all categories (Table 3).

Table 3.

Wilcoxon Rank-Sum Test for Comparison of Comfort in Internal Medicine Residents With Obstetric Services, Compared to Internal Medicine Residents Without Obstetric Services Across All Categories Polled

Surveyed Categories	IM without OB		IM with OB		W-score	P value
	Mean	SD	Mean	SD
Inpatient	1.84	0.85	2.33	1.15	15	.679
Outpatient	2.04	0.88	2.00	1.00	20	.407
Intensive care unit	1.52	0.71	1.66	0.57	21	.348
Cardiomyopathies	1.88	0.92	2.33	1.15	16	.624
Arrhythmias	2.16	0.98	2.33	1.15	18	.500
Heart failure	2.00	0.91	2.00	1.00	20	.381
First trimester	2.08	0.9	2.33	1.15	15	.679
Second trimester	1.92	0.86	2.00	1.00	19	.469
Third trimester	1.80	0.86	1.66	0.57	21	.696
Active labor	1.28	0.54	1.66	0	25	.216

Discussion

Our initial data suggests that internal medicine residents rate themselves significantly lower in comfort compared to family medicine and OB residents. FM residents in turn rate themselves lower in comfort compared to OB residents. As residents in OB-GYN programs have significantly higher exposure to obstetric conditions, it is reasonable to associate these differences to implicit program and training differences. As FM residents are also exposed to pregnant patients, albeit to a lesser extent than OBGYN residents, this differential in comfort is within expectations for implicit training differences.

We found no differences in comfort between internal medicine training years 1 through 3 across all practice settings, cardiac pathologies, and stages of pregnancy, except for comfort in the ICU. PGY3 residents reported they were significantly more comfortable managing cardiovascular complications in obstetric patients in the ICU setting compared to their junior counterparts. One explanation for this may be increased rotation exposure by the PGY3 year compared to PGY2 and PGY1 years. PGY3 residents will, at minimum, have been exposed to eight weeks of intensive care training per guidelines by the ACGME¹; as survey answers were acquired during the winter months, it is possible that many of the PGY1 and PGY2 residents surveyed may not have completed their intensive care rotations.

There was a difference noted between comfort managing cardiovascular complications in the ICU between PGY3 residents in different specialties; however, this difference between PGY3 years was not found to be statistically significant. These findings suggests that IM PGY3 residents find themselves equally comfortable managing cardiac complications in the ICU compared to their counterparts in OBGYN and FM. Explanations for this may be increased comfort in the ICU setting in general compared to FM and OBGYN residents, versus a limited spectrum of cardiovascular pathologies that require ICU-level care, of which the management is irrespective of OB status. There are limited data regarding IM vs FM vs OB-GYN resident competency in the intensive care setting specifically; more research in this field is warranted.

We found no statistically significant difference in comfort levels between IM residents with OB services available at their hospital compared to IM residents without OB services, across all practice settings, cardiac pathologies, and stages of labor surveyed. This suggests that the presence of OB services is insufficient to provide sufficient training to match subjective comfort for FM and OB residents. When asked about what improvements could be made to their respective training programs, residents made a variety of suggestions including addition of specific didactics addressing OB topics, additional rotations at hospitals with OB services, and lectures with OB-GYN specialists. As exposure to OB patients does not appear to affect subjective comfort for IM residents, additional didactic training may be of more utility.

Interpretation of these data may be confounded by intrinsic self-bias—our questionnaire assessed self-reported subjective comfort in management of conditions, in contrast to objective competency in these fields. Overconfident and underconfident residents across all three specialties surveyed may contribute to data skew. In addition, PGY3 IM residents may feel more confident in managing conditions exclusive of obstetric conditions, and this confidence may affect responses regardless of actual competence. Possible future investigations may investigate differences in In-Training Exam (ITE) scoring across PGY levels and specialties to more objectively quantitate competency in these fields.

Another limitation of this study is the relatively low response rate and overall sample sizing. Our surveyed population was majority IM, with relatively few FM and OBGYN residents. Of note, there were very few respondents above the PGY2 level for OBGYN; as a result, individual differences not reflected by the general population may adversely affect our survey results. Further investigations may benefit from increasing the sample size from more institutions.