Department of OB/GYN - December 2021

Department of

OBSTETRICS & GYNECOLOGY

December 2021

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2021 RESIDENT RESEARCH DAY:

BUILDING A RESEARCH INFRASTRUCTURE

RESIDENT RESEARCH HIGHLIGHTS SOCIETAL FACTORS IN WOMEN’S HEALTH

REGIONAL ALLIANCES

NNEPQIN serves as regional torchbearer of perinatal health

SUBMITTED BY ELIZABETH HARVEY, MD, HS’18-22

APRN with extensive research experience named vice chair of research page 6

RESIDENTS’ CORNER

Residency program welcomes new director page 8

Interested in joining or supporting our team?

Find Department of Obstetrics and Gynecology employment opportunities at www.

DHProviders.org.

Contact Megan Dodge in the Office of Development and Alumni Relations at megan.dodge@ hitchcock.org to learn more about opportunities to engage with and support our departmental activities.

Elizabeth Harvey, MD, HS’18-22, Shilpa Darivemula, MD, HS’18-22, Julia Mead, MD, HS’18-22, Courtney Knill, MD, HS’18-22, at Resident Research Day.

At this year’s Resident Research Day, held on June 18, 2021, residents presented their projects investigating how different medical issues such as cervical cancer screening, preterm delivery, caesarian section, and penicillin allergy testing intersect with various social determinants of health.

The event, the 21st in the department’s history, was held in person for presenters and their mentors, faculty judges, and department heads, and streamed virtually for other attendees.

Continued on page 3

DEBUT ISSUE I am thrilled to share this newsletter highlighting several exciting developments in research, teaching, and patient care in the Department of Obstetrics and Gynecology. This inaugural issue presents scholarly achievements of our faculty and trainees, along with highlighting our outreach efforts to elevate women’s health care in our community and our region. Future newsletters will present worthy clinical and academic endeavors within the obstetrics and gynecology service line, a collection of snapshots that, taken together, will tell you the story of our department.

Two years ago when I became chair of the Department of Obstetrics and Gynecology (Ob/Gyn), we were celebrating the 20th anniversary of the Ob/Gyn residency at Dartmouth-Hitchcock Health. We successfully launched our first Ob/Gyn fellowship in female pelvic medicine and reconstructive surgery (known by most as “urogynecology”) in 2019, and now have a full complement for the three-year fellowship.

As Chair, I have set my sights on expanding the academic footprint of the department and building a national reputation for the work we do serving rural communities. By creating an academic infrastructure to support the culture of scientific inquiry among our faculty, we have already seen dramatic growth in the breadth and depth of our research efforts. Part of developing this infrastructure includes naming our new vice chair of research, Daisy Goodman, DNP, MPH’14, who has an innovative plan to expand access to research support and collaboration among the faculty and to enhance partnerships with the larger Dartmouth research community. Opportunities to work with The Dartmouth Institute, Dartmouth College, Thayer School of Engineering, and Tuck School of Business will advance our tradition of innovation and accountability in healthcare delivery.

One of the department’s top priorities is to respond to the rising demand for more accessible and quality healthcare. This need has only increased as a result of the COVID-19 pandemic and the challenges it has brought into our healthcare system. Against the backdrop of many local maternity units closing and the reduction in access to complex gynecologic care in rural hospitals, we have expanded innovative partnerships with community 2

organizations to ensure that access remains. We have strengthened collaborations across our partner institutions to provide integrated, coordinated care that prioritizes access for patient and their families, as exemplified by the amazing work of organizations such as Northern New England Perinatal Quality Improvement Network (NNEPQIN).

Our department has much to celebrate. We have graduated over 80 residents in the past two decades and will soon graduate our first fellow in female pelvic medicine and reconstructive surgery. Many of our graduates have pursued teaching and research careers, serve as advocates for women in their communities and are training the next generation of health care providers.

Rebecca Evans, MD, HS’09-13, our new program director, and Amy Paris, MD, associate program director, will further enhance the breadth of the curriculum and academic culture of the residency. Our Female Pelvic Medicine and Reconstructive Surgery Fellowship has greatly improved the training experience for all our learners, and provided a model of multidisciplinary excellence in clinical care for our patients.

I look forward to continuing to share department activities with you and celebrating our achievements together as we chart a course for our future. Thank you for joining us on this exciting journey.

Ilana Cass, MD Chair, Department of Obstetrics and Gynecology Vice President, Service Line DHMC Professor, Obstetrics and Gynecology Geisel School of Medicine

dartmouth-hitchcock.org/obgyn

MARK WASHBURN

MESSAGE FROM OUR CHAIR

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RESIDENT RESEARCH DAY “I love seeing residents navigate this process of conceiving and committing to a project idea and then planning and executing the research,” says Amy Paris, MD, assistant professor of obstetrics and gynecology, and newly named associate residency program director.

Not only is grappling with research design and execution deeply valuable in itself, she says, but experiencing the challenges of conducting such studies illuminates how to interpret medical literature to inform their practice. “Seeing residents nurture their curiosity to becoming real content experts and leaders in the field by the end of their fourth year is inspiring to watch.”

Paris has been directing the research program since 2019, but she inherited a remarkably organized program that helps residents identify a topic of interest and guides

them along the process of developing their research skills.

In their first year, residents are expected to come up with a question and to conduct a literature review addressing it so that at the beginning of their second year they can plan the project and submit it for ethics approval. In the middle of their second year, they present their study design to the department to get feedback and make sure they’re on track. “That’s a really big milestone,” Paris says. Then, they gather their data and by the middle of their third year wade deep into data analysis. It all culminates in Resident Research Day – and, potentially, publication in year four.

“Residents come into our department with really variable experience with knowledge of and interest in research,” says Paris. “The research program’s structure really sets them up for success.”

All four projects made significant contributions to the field, Paris says. Julia Mead, MD, HS’18-22, won this year’s award for best research project.

2021 RESIDENT RESEARCH HIGHLIGHTS Julia Mead, MD, HS’18-22

Elizabeth Harvey, MD, HS’18-22

Prevalence of caesarean delivery among women with a history of intimate partner violence in the United States Mead’s project examined whether experiencing intimate partner violence is associated with an increased risk of caesarean section as opposed to vaginal delivery. “This was a really interesting, novel question that we could not find a lot of data about in the literature prior to her study,” Paris says.

Penicillin allergy testing in obstetric patients: A quality improvement project Harvey conducted a quality improvement study to get more pregnant patients tested for penicillin allergy, since many who have the allergy listed in their chart are not in fact allergic. “She almost doubled the rate of referral for allergy testing for pregnant patients,” Paris says.

Shilpa Darivemula, MD, HS’18-22

Courtney Knill, MD, HS’18-22

Determining the impact of socioeconomic status and distance on preterm delivery: A cross-sectional, single institution study Darivemula studied how a patient’s socioeconomic status and how far they live from the hospital affects their likelihood of having a preterm delivery.

“Families having high risk deliveries here are often traveling from far away and need to be supported,” Paris says.

Cervical cancer screening in perinatal women with opioid use disorder Knill examined the frequency of cervical cancer screening in women with opioid use disorder. “Prenatal care offers the opportunity to bring these patients into the medical system and narrow the screening gap,” Paris says.

Dartmouth-Hitchcock | Geisel School of Medicine Department of Obstetrics & Gynecology

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STRONGER TOGETHER KAREN LEE

A COLLABORATIVE NETWORK OF HEALTH PROVIDERS LEADS REGIONALLY AND NATIONALLY TO DRIVE INNOVATION IN RURAL OBSTETRICS HEALTH CARE DELIVERY

Timothy Fisher, MD (left), facilitates a session at the 2019 NNEPQIN conference.

R

Rural community hospitals that deliver babies — and the many stripes of practitioners working within them — have to band together. It’s a principle that the Northern New England Perinatal Quality Improvement Network (NNEPQIN) has long embraced. Since its founding in 2003, the organization “has been committed to improving processes of care and outcomes for childbearing people and newborns in the region,” says its medical director Timothy Fisher, MD, MED’98, MHCDS’13, an assistant professor of obstetrics and gynecology at Dartmouth-Hitchcock (D-H).

These days, NNEPQIN — a collaborative network of clinical providers from across more than 50 institutions in New Hampshire, Vermont, Maine, and Massachusetts — is growing up. After almost two decades as a quasi-independent organization, the group is formalizing its relationship with D-H. “We are exceedingly grateful to have found an administrative home within the Department of Population Health,” says Fisher. With that change in place, NNEPQIN can now access federal grants and other sources of

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financial support, and continue to expand its scope in developing best practices for providing the best care for childbearing patients and babies.

“One of NNEPQIN’s most important and enduring roles is to be a convener of multidisciplinary professionals across the region, agnostic of credentials,” says Fisher.

Participants include nurses, midwives, obstetricians, pediatricians, doulas, and childbirth educators. “We have been intentional about creating a big, welcoming tent where we bring people together who do the same kind of work,” he says. “There aren’t a lot of organizations like this.”

NNEPQIN was founded in response to a crisis: Updates to national recommendations on vaginal birth after caesarian section were so restrictive that community hospitals mostly had to stop providing this service overnight. Michele Lauria, MD, MS’03, a Maternal-Fetal Medicine specialist and Victoria Flanagan, RN, MS’03, a registered nurse and perinatal outreach educator at D-H, reached out to maternal fetal medicine clinicians at

dartmouth-hitchcock.org/obgyn

the University of Vermont to gather a group of regional clinicians to develop guidelines that met the new standards but established a path for continuing the procedure.

mortality reviews in order to provide actionable guidance on addressing It all feeds back into the idea that the underlying drivers what we are all interested in is of maternal morbidity and mortality, which in improving care and outcomes for New Hampshire are almost exclusively related families in the region.”

The crisis was averted — to maternal substance but the power in commuuse and mental health Timothy Fisher, MD nity was clear. The group disorders. More recently, began hosting continuing in October NNEPQIN education programs on a range of topics relevant to the was approved to receive $192,000 in funding through specific needs of a rural New England community. About the congressional office of Senator Jeanne Shaheen to five years ago, Flanagan and Daisy Goodman, DNP, launch the STONE pilot project, which will allow experts MPH’14, certified nurse midwife with additional crefrom D-H to train rural emergency room and emergency dentials in public health and addiction medicine at D-H, medical services personnel across New Hampshire in developed a program on the care of pregnant women the acute care of pregnant women and newborns in with opioid use disorder to compare practices across communities that no longer have inpatient obstetrical the region, collect data, and develop a care pathway. services. It will also help expand telemedicine capabilities Based in part on that work, Goodman then went on to to allow real-time connections with neonatal specialists. collaborate with a national initiative called the Alliance for Innovation on Maternal Health to develop a patient Collaborating across multiple institutions allows local safety program now disseminated across the country. practitioners to improve the care they deliver, Fisher says. “It all feeds back into the idea that what we are all NNEPQIN has also worked closely with Centers for interested in is improving care and outcomes for families Disease Control and Prevention on conducting maternal in the region.”

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We are pleased to announce the creation of a new endowed fund honoring Joan Barthold, MD, MED’85, that will strengthen the program for our residents and fellows in the Department of Obstetrics and Gynecology. A 1985 Dartmouth Medical School graduate, Joan joined the Dartmouth-Hitchcock (D-H) staff in 1989 following her Ob/Gyn residency at University of Vermont and was instrumental in developing our residency program. The Barthold Fund will support enriching educational and professional development opportunities for future physicians in women’s health. The fund will support activities such as access to specialized educational resources, professional development retreats, travel to and attendance at domestic and international scientific meetings, travel to clinical and research experiences outside of the D-H system, or direct research support. These experiences will benefit residents and fellows, and the patients they serve, now and in the future.

MARK WASHBURN

JOAN CRANE BARTHOLD, MD, RESIDENT AND FELLOW EDUCATION FUND

Joan Barthold, MD, MED’85

If you are interested in making a gift to add to this fund, please contact Tracy Walsh at Tracy.A.Walsh@hitchcock.org or (603) 646-5320 or visit: https://go.d-h.org/barthold.

Dartmouth-Hitchcock | Geisel School of Medicine Department of Obstetrics & Gynecology

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MARK WASHBURN

RESEARCH FOCUS NEWLY NAMED VICE CHAIR BUILDS RESEARCH INFRASTRUCTURE Daisy Goodman, DNP, MPH’14, an advanced practice registered nurse and a certified nurse midwife who has garnered millions in research funding during her tenure at Dartmouth-Hitchcock (D-H) to date, has been named the vice chair of research for the Department of Obstetrics and Gynecology (Ob/Gyn).

Daisy Goodman, DNP, MPH’14, vice chair of research for the Department of Obstetrics and Gynecology (right).

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Goodman, an assistant professor of obstetrics and gynecology, says she is deeply honored to take on the role and credits Ilana Cass, MD, chair of the department, with having the vison to expand scholarship within the department — and with restoring the vice chair position, which has lain dormant for several years. dartmouth-hitchcock.org/obgyn

“It’s great to see this focus on research come to the forefront again in our department, and it’s certainly a testament to Dr. Cass’s leadership,” says Goodman.

Clinician investigators in the department already conduct research on a wide range of topics, from foundational research on

reproductive embryology, medical device testing and clinical trials, through community engaged research on patients’ interactions with medical systems, and qualitative research on provider burnout. “These topics seem worlds apart, and yet they exist under the same umbrella, in the same discipline, and all serve to make people’s lives better,” Goodman says.

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It’s great to see this focus on research come to the forefront again in our department, and it’s certainly a testament to Dr. Cass’s leadership.”

Daisy Goodman, DNP, MPH’14

The job of a vice chair of research in any department is to support the research endeavor by encouraging communication and collaboration within the department and by helping smooth the process of applying for grants by helping investigators plug into the institutional infrastructure, Goodman says. “I see my role as supporting my clinician-scholar colleagues, and serving as a liaison between our department and the larger research enterprise of the hospital and health system.”

Previously, investigators at D-H plugged into the research infrastructure at the Geisel School of Medicine, but D-H is now building its own, with the recent hire of a chief research officer and the launch of its own institutional review board. “There are a lot of new and exciting opportunities in funding for Ob/Gyn research, and a lot more support at our institution” Goodman says — and her aim is to provide practical assistance in accessing both.

Goodman herself first felt the call to research working as a clinician in rural Maine, when

she realized that her pregnant patients with opioid use disorder had extremely limited access to care. She returned to school to obtain a doctorate of nursing practice at Massachusetts General Hospital’s Institute for Health Professions, where she investigated how to effectively provide care for rural women in such circumstances. Goodman has continued her investigations in this area since arriving at D-H in 2013. Her $5.3 million award in 2018 from the PatientCentered Outcomes Research Institute, with Co-Principal Investigator Sarah Lord, PhD, to study medication-assisted treatment for women with substance use disorder was one of the first large grants at D-H to be awarded to an APRN. She currently leads two HRSA-funded implementation projects to improve systems of care for perinatal substance use, as well as a study addressing disparities in access to telehealth for low income pregnant people.

Goodman’s clinically focused research experience puts her in an ideal position to move departmental research forward in exciting new ways. “We want to generate excitement about the idea of research in the department, and to promote the notion that no project is too small, if it is meaningful in improving care and outcomes. In fact, successful pilots have the potential to turn into large projects with federal funding,” she says. In a department that is expanding its research program, facilitation is critical.

To that end, she has instituted a First Friday Research Roundtable, a monthly meeting at which members of the department can informally discuss potential research projects, exchange ideas, and strike up collaborations.

Investigators also showcase their ongoing work at a forum held twice per year.

Goodman underscores that the research her department conducts is simply the other side of the coin to serving patients. Clinical practice must be informed by research — and in turn, it shapes research by raising questions that must be answered scientifically.

“We are all committed to providing the most excellent care for our patients,” she says.

“And that really requires that we engage with research in some way or other.”

Dartmouth-Hitchcock | Geisel School of Medicine Department of Obstetrics & Gynecology

RESEARCH

BY THE NUMBERS

12

TOTAL GRANTS

8

of which are

RURAL GRANTS

GRANTS AWARDED BY • Patient-Centered Outcomes Research Institute (PCORI) • New Hampshire Department of Health and Human Services • Dartmouth College Spark Seed Funding • New Hampshire Charitable Foundation • Health Resources and Services Administration (HRSA) • Robert Wood Johnson Foundation • HRSA North Country Maternal Network • NIH Small Business Grants • American Cancer Society (ACS) Institutional Research Grant • Dartmouth-Hitchcock Health Cancer Research Fellows Funding • AUGS-SGS Group for the FPRN • Clin-STAR pilot grant

PUBLICATIONS

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RESIDENTS’ CORNER MARK WASHBURN

ALUMNA LEADS RESIDENCY PROGRAM Rebecca Evans, MD, HS’09-13, remembers her first visit to Dartmouth-Hitchcock (D-H) in December 2008, to interview with the Department of Obstetrics and Gynecology Residency Program. It was eight degrees out and her pantsuit was frozen to her legs. But when she walked into the Faulkner Building, where Karen George, MD, MPH’18, then the residency program director, was hosting a breakfast for faculty and prospective residents, she felt she had found her place. “I realized I’d get a very academic education in a supportive environment,” Evans says.

Her experience as a resident confirmed her hunch. And this year, more than a decade later, Evans took the helm as director of the residency program herself.

As director, Evans intends to bolster the program’s collegial ethos as well its academic rigor. Creating a culture of psychological safety is a key component of her mission.

“When residents feel safe to ask questions and to work, they actually learn better and deliver better care to their patients,” she says. Another focus is to help residents identify and build on their unique strengths and interests to become leaders in healthcare. She recalls a mentor’s advice to develop a niche — “something special that will be inspiring to you and will also help serve a need,’” she says. “One of my goals as director is helping faculty help residents find those niches.”

Evans took over as the program director from Timothy Fisher, MD, MED’98, MHCDS’13, after serving as associate director since 2017. Working with Amy Paris, MD, who was recently named associate residency program director, as well as program coordinator Sarah Probst, she will continue building on many initiatives started during that time. One project is revamping the residency curriculum.

“We have really expanded our generalist division, and the residents are getting a lot of great surgical experience,” she says. Two new general specialty clinics, a pediatric and adolescent gynecology clinic that she started in 2017, and a transgender clinic that launched in 2019, add to

One Medical Center Dr. Lebanon, NH 03766 dartmouth-hitchcock.org

Left to right: Alena Tofte, MD PGY3; Rebecca Evans, MD, Obgyn Residency Program Director; Jill Roberts, MD, PGY3; Elizabeth Harvey, MD, PGY4.

residents’ learning opportunities. Curriculum development is a continuous process, Evans says. “We are constantly thinking about how we need to change with the times to keep up with residents’ education and with technology.”

Another ongoing focus is diversity and inclusion. Evans and her colleagues recently introduced a fully virtual interview process, making applying more affordable while still fully conveying the program’s mission and character. “The aim is to help us recruit applicants from more diverse backgrounds, especially given our geographical limitations in the middle of New Hampshire.” And last year, one of the chief residents, Shilpa Darivemula, MD, HS’18-22, designed and implemented a diversity, equity, inclusion, and belonging training program that goes beyond the basics of the topic to help guide residents on providing care to the specific population that D-H serves. “We’ve been really impressed to see the residents do that,” Evans says.

Ultimately, she says, “the residents are really what make the program.” Many from her cohort, who sat together in auditorium orienting as new interns two decades ago, remain in contact. Hopefully, Evans says, today’s residents will feel a similar sense of pride for having taken care of patients together.

Designer: Linnea Spelman

Writer: Alla Katsnelson