Hi, my name is Benjamin Yao, I'm MS4 from Case Western University and I'll be presenting medical malpractice, vacation, and non-medical related pelvic organ prolapse analysis of 91 cases. And I want to thank you for the opportunity to present this to you guys today. I have no relevant disclosures. So pelvic organ prolapse affects nearly 40% of post-menopausal women in the United States. However, this condition is not only limited to those women and can affect people of almost any age. The lifetime risk of requiring pelvic reconstructive surgery for pelvic organ prolapse or urinary incontinence is approximately 11% by the age of 80. Additionally, there is media, FDA, and current medical literature about medical litigations with a focus on mesh augmentation of pelvic organ repair. However, there has been a little or no focus on non-mesh complications. Thus, the point and objectives of this study was to characterize medical malpractice associated with non-mesh related pelvic organ prolapse surgery with focus on most common reasons and outcomes, patient demographics, nature of injury, and any demi-payments, should there be any. So what we did was we queried the West Law Legal Database, which is a national database comprised of over 40,000 databases across the country. It was queried for completed medical malpractice litigation cases related to pelvic organ prolapse surgery from 1987 to 2018. We used the following keywords, pelvic organ prolapse, vaginal wall prolapse, uterine prolapse, cystoseal, anteroseal, and rectoseal. Cases were excluded if they cited any utilization of mesh or mentioned mesh related complications in which we have our final 91 cases that were included for final analysis. So based off the initial word search, we had a total of 9,791 completed medical malpractice litigations in which we removed duplicates and non-medical malpractices that were not related to pelvic organ prolapse surgery. We ultimately had 200 unique cases in which after a complete review of the case description, we had our final 91 cases. Now in terms of patient demographics, of the 91 cases the mean age was 53 in which based on geographic region, most of these cases occurred within the northeast or the west. In terms of the jury ruling, it found that in the majority of cases that they rule in favor of the physician in 67% of the cases and there was no significant difference between median plaintiff awards or settlements. And there was no association between monetary award amount and geographic region or year of verdict. We also looked at medical malpractice claim allegations or the reason for litigation. As you can see here, negligence of surgery was the most cited reason with more than 50 cases followed by failure of informed consent and followed by failure of diagnose or treat. There was no association between case verdict and patient age nor year of verdict or any relation with geographic region or allegation. We also looked at instance of complication among all claims. We stratified them between overall, which as you can see in blue, as well as any jury verdict in terms of plaintiff or settlement, which is highlighted in yellow. As you can see here, the most common complication associated with the patient in terms of overall was damage to the bladder, ureters or the kidney, followed by urinary symptoms or incontinence, followed by unnecessary secondary surgery or repair surgery. In terms of complications in which the verdict resulted in a plaintiff verdict or a settlement, you had urinary symptoms, incontinence being the most common complication, followed by damage to bladder, ureters and kidney, and finally unnecessary secondary or repair surgeries. So based on the data that was collected, the following conclusions were reached. The leading cause of medical malpractice for non-mesh pelvic organ collapse surgery is negligence of surgery, while the most common complication was injury to urinary tract. In terms of case verdict, when these allegations are presented to a jury, they favor the physician defendant as the most likely outcome with 67% of the cases. Thank you. Okay, we have time for a few questions from the floor. Hi, Nick Rockefeller from University of New Mexico. I had a question for the presenter from Emory with the origami technique. One of the things that I noticed, you know, when I'm completing anterior repairs is that often there's a central defect where there's not a lot of strong tissue in the midline, and it seemed based on the model and then also the origami technique that sort of plication to the midline with that being the central area of any of the sutures seemed integral to that technique. So if possible, how could that be sort of altered to fit those cases where you're sort of like skipping over that weak area where there's no strong tissues, and I feel like that's the most common thing when you're doing an anterior repair? So we, this repair probably wouldn't be great for something that you didn't have a lot in the midline. We, this repair actually kind of squishes the tissue more horizontally than vertically. So we want to look at it in cadaver models to take a look and see, we just wanted to do this for a proof of concept to see if it would actually, if it was the same or better. So we'd like to look at that. Thank you. Rhonda Caterino, Chicago. This is for Dr. Giroux. Very interesting study. Two things. Your subjects were medical students, physical therapists? So we had five groups of participants, and they were equal numbers per each arm. They consisted of year two to year four medical students, family medicine residents, obstetrics and gynecology residents, family doctors, and obstetricians and gynecologists. And we looked at how many years they have been in practice and how many pelvic exams they have done in the past. And in your training, would you consider using teaching assistants rather than rubber models? That's definitely a possibility, and that's definitely something we could explore in the future. We thought about it at the beginning of our study, and for our ethics, we proceeded with a pelvic model. Thank you. So I have a question related to this. Have you plans to do this also for patients? That would be our next step, is to expand then into teaching models in patients. Your secondary outcome is the level of comfort to perform the examination. This was related to the doctors? Yes, it was a level of comfort for the learners and for the physicians before and after, and it was a subjective rating scale from one to five, one being uncomfortable and five being comfortable. So they self-rated before and after the training program. A potential future study would be to examine a level of comfort right at the session versus so many weeks or months afterwards. Okay. Do you have also plans to ask the patient then afterwards of his level of comfort when a doctor is doing the examination? That's fantastic. Thank you for that idea. Because that would be also important, I think. Thank you. Thanks. I just have one last question for you. Did you gather any data on the learner's preference between the video and the hands-on? We haven't gathered that, but that would be a really good study as well to learn about which one they would prefer, or maybe they would prefer both, to look at video first and then do the hands-on training. Right. If all things end up being equal, it would be nice to know. Okay. Thank you very much for this session. A round of applause for all our presenters. Thank you. Good morning. I'm Dr. Annick Poirier. I'm a practicing urogynecologist in Edmonton, Canada. My research work was funded by two grants, one through the Women and Children Health Research Institute and one through the Alberta Medical Association. So we all know that despite the impact of pelvic floor disorders on quality of life, women often don't seek medical care. It has been shown that lack of knowledge of pelvic floor disorders are a significant barrier to seeking care. American studies found the knowledge deficits to be greater among non-white women as compared to white women. Canada is ethically diverse, and there are no studies assessing the knowledge of pelvic floor disorder among immigrant communities. This work was very much based on a community partnership. We work closely with multicultural health brokers. This institution works with immigrant women and their family to improve their navigating the healthcare system. Our objective was to assess knowledge of pelvic floor disorders amongst women in Edmonton, and we suspected that immigrant women are less knowledgeable about pelvic floor disorder than Canadian-born women. We conducted a cross-sectional study of immigrant women and Canadian-born women. We used the Prolapse and Incontinence Knowledge questionnaire, which is a validated questionnaire. It has two scales of 12 questions each, one about urinary incontinence knowledge and one about pelvic organ prolapse knowledge. We recruited 106 immigrant women from the Cultural Broker Co-op and 102 Canadian-born women from a colposcopy clinic. Most of our women were between the age of 30 and 50 years old. Our groups were somewhat different when it came to household income and schooling. The total main PQ scores were 12.7 for immigrant women and 14.4 for Canadian women, and this was statistically different or statistically significant. The mean urinary incontinence score was 7.2 for immigrant women compared to 8.5 for Canadian-born women. This was also statistically significant. The mean pelvic organ prolapse scores were 5.6 for immigrant women and 6.0 for Canadian women, which was not significant. We conducted subgroup analysis. Immigrant women who have lived in Canada for more than 10 years had higher total PQ scores compared with women with less than 10 years in Canada. Women from the Cultural Broker Co-op had higher PQ scores than women from South Asia had higher total PQ scores, while women from Africa had the lowest score. We concluded that immigrant women have less knowledge on pelvic floor disorder than Canadian-born women. Based on our results, we designed a health promotion project to raise awareness of pelvic floor disorder among immigrant women. We created a train-the-trainer model on pelvic floor disorder knowledge for a cultural health broker who works with immigrant women. Two workshops were held. Written material was produced in 10 different languages to disseminate knowledge among immigrant communities. Brokers' perspective on the training was assessed with the Kirkpatrick Model for Evaluation and knowledge retention was assessed with the PQ questionnaire, pre- and post-workshops. We had 36 brokers that attended our workshops. The majority of our participants were female between the age of 30 to 60. Most of them were from an Asian background and were well-educated. We had, in our result, the mean urinary content scores was 9.5 pre-workshop and 11.2 post-workshop. The mean pelvic-orient prolapse scores was 7 pre-workshop and 11.2 post-workshop. The overall mean PQ score was 16.5 pre-workshop and 21 post-workshop. The knowledge improvement was statistically significant. This was a workshop done by women for women, so child care had to be 10, too. Our participants, 83% of our participants, agree or strongly agreed with 22 statements regarding the workshops. We concluded that our health promotion project using a train-the-trainer model was well-received by our community partners and improved pelvic floor disorders knowledge and cultural health broker. We expect that this will result in increased knowledge of pelvic floor disorder amongst immigrant women and better access to care for this population. Thank you. Thank you. We'll open the floor to questions now. Okay. Why people are thinking. Fiona, can I start with your study? I like this study. Thank you. Very good, yeah. And I think you're going to confirm your hypothesis in terms of the knowledge difference between Canadian-born and the immigrant population. But what I really was looking forward to hear from you is the train-the-trainers of your CHBs, the cultural health brokers. You used Keptakris model, and you got to the knowledge level. But have we got anything that would take us to actually see what they're doing in terms of their teaching behavior and how to transfer that to the women that they're training? Because that's really the key level that we need. Yes. So we're actually looking into this right now. So we don't yet have our long-term data. And as part of our long-term data, we're doing... So we're repeating the PQ questionnaire to see if they've maintained knowledge. But there's also another questionnaire that we're doing looking at behavior changes teaching, dissemination of knowledge. So I'll come back at the next meeting and let you know. Okay. All right. Thank you. Questions from the floor? Yes. Rhonda Caterino, Chicago, physical therapist. And this is for Dr. Quinn. Do you plan on taking a look at the content of the information in the allied health as to its quality and substance? So thank you so much for your question. The previous studies looking at similar topics, looking on Google, on other platforms, have utilized kind of standardized quality parameters to assess the quality of that information. Unfortunately, because Instagram, the captions are so short, we had to consider it. But at least within the scope of Instagram specifically, I think it would be hard to do. So thank you for allowing me to present my research today. These are our disclosures. So what can we say about preoperative education? It's obviously important and is proven to affect patient satisfaction. Typically, we talk about the nature of the procedure and its risks, benefits, and alternatives. However, standard education may not include what patients actually care about. Patient perceptions and expectations are incompletely understood with regards to pelvic floor surgery. Therefore, our primary objective was to explore information patients want prior to surgery for pelvic floor disorders. For those not familiar, qualitative methodology is often utilized when there is little known about a topic. Qualitative work may use focus groups or patient interviews. For this study, we used focus groups moderated by experienced staff to explore pre-op education, post-op experiences, and issues surrounding pain control. Four focus groups were planned based on our prior experience to reach thematic saturation or the point at which no new themes emerge. An iterative process that was team-based was used to codify our transcripts and organize them into themes, and we made these plans based on prior experience with thematic saturation. For our results, we had four focus groups with a total of 24 women, two English-speaking groups, and two Spanish-speaking groups. Age was around 57 years, and the interval since surgery was wide with a mean of just under two years. Our population was fairly well-educated and evenly split between Hispanic and white patients. This is a word cloud that represents the many concepts explored in our focus groups. A larger font here represents more frequently discussed themes. We identified five main thematic domains. I'll go through them one by one, and it'll be interspersed with some examples of patient quotations that are representative of those domains. So we'll start with preparation for surgery. Patients really like to have peer advice, whether they had access to it or not, and there was seemingly a split between those who had apprehension prior to surgery and those who had confidence. So some representative quotes. Milka Magnesia, Nectar of the Gods. One patient, obviously, this was something that was very important to their postoperative recovery, and maybe they wanted a little bit more information about that preoperatively. And then maybe it would be good if you could talk to another woman close to your age who's already gone through it and is able to tell you, you know, what is that peer-centered advice that people are desiring. Next we'll talk about pain control. So here there was a split between hearing in the news about the opioid epidemic and concern about falling victim to addiction, contrasted with a desire for adequate pain control. Patients also consistently found that ambulation and completing daily activities helped invaluably with their pain. So some representative quotations here. Did you dispose of opioids when you were finished? Of course not. That's insane. They're good for cold and coughs. And also what helped me most was getting up and walking around, not always laying down. Walking helped me a lot. So there's that postoperative ambulation kind of being something that was important to that particular patient. And this ties in well, I think, with activity and restrictions after surgery. Patients take advice from family, friends, nursing staff, and their surgeon. However, this sometimes leads to misinformation and differing understanding between the patient and the surgeon of what their restrictions actually are. So for example, for my family, they told me, since you're stubborn and we know that you aren't going to sit still, remember that you just had an operation and even donkeys lay down. And then also, yeah, I was told I couldn't take a bath or I couldn't bathe, I couldn't take a bath, that I could shower. I was told not to vacuum because I could rip my stitches. I was told I couldn't carry a purse. And so this is obviously a little bit of miscommunication. There was something that went awry in terms of the understanding of what the surgeon maybe said and what other people may have. Next, this leads into communication. So patients who had negative experiences found communication suboptimal and may have seen that as the reason their experience could have been better. Patients with more pain than expected also blamed poor counseling. So for example, they explained everything that was going to happen and what to do and what to prepare for. I didn't have no problems with it. They really told me what was going to happen. And then this is contrasted with someone that the expectations maybe weren't the same as what happened. I remember being told it'll hurt a little bit, but I felt like that wasn't really a realistic assessment of how it really was. It was a lot more painful than I expected. And so, obviously, two sort of dichotomous patient stories there. The care experiences, so this is just a page that I put a couple of, I think, poignant quotes that tell two different stories about people's expectations. So on the right-hand side, the doctor gave me a lot of security, a lot of encouragement to go to the operating room, and I liked that. So this is a patient that obviously the expectations aligned with the reality of what happened afterwards, whereas the other patient, I just want somebody to believe me. And this is about sort of complications that happened in the hospital, things that they didn't expect to happen that happened and were unpleasant to them. And so this is someone that wants somebody to be on their side in that respect. And I think it's just important to see both sides of that. In terms of conclusions, patients' expectations don't align with their actual experience, and that's a problem. One reason for this could be that pre-op education can be ambiguous and may not address their actual concerns. Our priorities as surgeons and the priorities of patients for education are currently misaligned, and adding patient-centered education to pre-op counseling may help with this issue and patients may be happier with their surgical experience. Thank you. Thank you. I just wanted to introduce myself again. I'm Alex Chen. I'm a fourth-year medical student at the Zucker School of Medicine in New York. I'd like to thank AUGS, IUGA, and Northwell Health for supporting me in this very millennial project, hashtag Euroguide, what's trending on Instagram. I have no disclosures. So why is everyone talking about social media? So either anecdotally or from what you've seen online, we know that social media has exploded exponentially in the last 10 years and is unequivocally changing the ways in which patients interact with our healthcare system. A recent Consumer Report showed that patients are posting about their healthcare encounters online, that they are using Google and other platforms to look up treatment options and physician selections prior to seeing you guys at your first visit, but most importantly, they would trust information online posted by a physician. And in our study, we wanted to focus on Instagram because as of June 2018, it is one of the world's most popular social media platforms with over 1 billion users. So what do we know about social media and urogynecology already? To summarize these studies, there are three points. One, patients coming to your practices are going online to find information, but two, the information online is often poorly written and of low quality. And what I liked about Sejati et al.'s conclusion in 2011 was that physicians need to kind of be the mentors for patients in guiding them on how to use the internet as a reference for their diagnoses. So the objective of our study, we hope to answer three questions. Who is posting on Instagram? What is being posted? And who is posting what? Our method, it was a cross-sectional observational study. We derived 20 hashtags from the American Urogynecology Society's patient fact sheets. We queried these into Instagram and found over half a million posts, which was surprising to us. From there, we looked at the top nine posts and the most recent 30 posts of each of those 20 and then performed chi-square analysis using graph pad prism. So for those who aren't savvy or have never been on Instagram, I wanted to show you guys what it looks like. So on the left, I put in pelvic floor and then underneath you can see the related hashtags that come up and also the number of hashtags. So on the right, we've listed the top five most popular hashtags on Instagram. Pelvic floor, interstitial cystitis, pelvic pain, incontinence, and prolapse. So to answer the question of who was posting, as you can see from the figure, the largest percentage of posters were the patients themselves, followed by our allied health professionals, this other category which comprised nurses, non-licensed exercise professionals, non-physician holistic medicine practitioners, and so on and so forth. And unfortunately, physicians were dead last at 13.4%. So to answer the question of what is being posted, you can see that the most common content group was informational at 36.9, followed by patient experience and advertisement. So this graph answers the question of who was posting what. Our chi-square analysis showed that there was a statistically significant difference in author type and content profile. And the two takeaway points that I want you guys to look at is one, the bottom row informational are allied health professionals, our pelvic floor PTs, are the ones who are posting the most informational information on Instagram, followed by physicians. And two, this is purely conjecture just from looking at these posts, but that tagged but not directly related category that's dominated by patients is interesting. For example, one patient on Instagram is a patient with interstitial cystitis, posted a selfie of herself going to the grocery store, just buying groceries, but still hashtagged interstitial cystitis. So the question is, what is the motivation? I think it lends support that these diagnoses are so salient to the patient identity and could be explored in terms of physician engagement and support groups. So to conclude, to our knowledge, this is the first study to look at urogynecologic hashtags on Instagram. We identified over half a million posts. The majority were educational in nature, but a small minority of those were authored by physicians. And to end the presentation, I want to just share with you guys a caption from one of the posts from the patient. So she's a young postpartum patient, and her caption reads, my bladder prolapsed, and I still can't jump without consequence and risk. I want to look like I'd never had a baby, retain the body I had before I had the baby, but still never loved myself completely. I was stretched and scarred, the creams never worked, and my body will never be the same. I wanted to be a mom of more than one, but I'm too scared of what will happen to my body to even contemplate doing that again. I visualized motherhood in so many ways other than how it played out. All I really wanted was a daughter of my dreams, and now I have her. As I hold her, watch her grow every day, I realize that's all I ever wanted. Thanks so much for your time. Thank you. Thank you for the opportunity to present my work. These are our disclosures. As most providers in the audience know, the treatment for pelvic organ prolapse is a decision best made based upon patient preference when consulting with a physician, making it a preference-sensitive condition. How information is presented that includes efficacy, risks, and benefits can also impact the decision. In a prior study, we identified patient questions and concerns regarding treatment and developed two decision aids for the treatment of pelvic organ prolapse. In this study, we looked to measure the effectiveness of those decision aids. Our objective was to determine if decision aids improve shared decision-making among women with stage 2 or greater pelvic organ prolapse who receive counseling on treatment options by a FPMRS board-certified physician. All women were surveyed at the end of their new patient visit after discussion of treatment options. We initially surveyed women who received standard counseling. A second, separate cohort of women were surveyed after counseling with the decision aids. Two decision aids were available for use depending on the patient's goals. The treatment option decision aid outlined watchful waiting, pelvic floor exercises, including both formal physical therapy and self-directed, pessary or surgery. The surgery options decision aid included native tissue repair, sacral copepaxi and obliterative procedures. Women were surveyed if they were a new referral to an FPMRS clinic at Dartmouth-Hitchcock Medical Center, St. Louis University or Yale University and were diagnosed with stage two or greater pelvic organ prolapse. Finally, counseling about treatment options was completed during the visit. Our outcome was the degree of shared decision making as perceived by the women. It was measured with three validated survey tools, the Collaborate 10, Shared Decision Making Questionnaire 9 and Satisfaction with Decision Scale for Pelvic Floor Disorders. We compared the mean scores from the two cohorts first using a T-test, then a linear regression adjusting for race, age and insurance. There was a 78% response rate. There was no difference in study participant characteristics or clinical history between the two groups, except there were more women with prior oophorectomies or who had trialed pessaries in the standard counseling group. On initial analysis, there was no significant difference in patient perceived degree of shared decision making with use of the decision aids. Baseline scores were high in all three tools. A statistically significant difference emerged in the SDS-PFD after adjusting for race, age and insurance. This may be because the SDS-PFD is the only tool specifically validated in pelvic floor disorders. Strengths of our study include implementing the decision aid at three geographically unique sites among seven FPMRS board certified physicians. We anticipate that providers will use the tool as an adjunct to their standard counseling and mimic that application for this study. Limitations of our study include variable participation across the three sites. It has been demonstrated in prior work with other shared decision aids that standardized provider education prior to implementation can increase the impact of the decision aid. Finally, we were not prescriptive on how the decision aid was used in the visit to allow for provider counseling preference. In conclusion, women demonstrated a high level of decision making with or without use of the decision aid for pelvic organ prolapse when counseled by an FPMRS physician. The only difference was seen after linear regression in the SDS-PFD, which may be sensitive to identify differences in degree and SDM because it was specifically validated in the PFD population. We are planning on evaluating the decision aid among groups of providers who manage pelvic floor disorders less frequently to see if it has a larger impact on shared decision making. Additionally, there may be a role for a digital or web-based tool to supplement the paper decision aid. Thank you and I welcome your questions. Thank you for allowing us to present our research. These are our disclosures. The decision making process for surgery is a complex process. It includes multiple components including improving preparedness, fostering realistic expectations, enhancing patient understanding and it's a shared decision making process. The mitral-atrial sling is considered the gold standard surgery for stress-renewing condoms. However, many patients are ill-prepared and require making difficult decisions. The objective of this study was to compare the impact of a physician-centered versus a peer-centered video for mitral-atrial sling surgery counseling. The primary outcome was to assess patient preparedness. Secondary outcomes include assessing satisfaction, patient video preference and time counseling sessions. This was a multi-centered randomized control trial. Participants were recruited from urogynecology clinics from UNM as well as Dell Medical School. And inclusion criteria included participants with stress-renewing condoms undergoing a mitral-atrial sling surgery. The elements of the video content are listed in this table. In brief, the peer-centered video to the left column featured a woman who had undergone mitral-atrial sling surgery and included standard components for mitral-atrial sling surgery including risks and benefits as well as additional information previously identified in prior work as important to patients. The physician-centered video contained a surgeon discussing standard risks and benefits of the mitral-atrial sling surgery. Our primary outcome was between group differences in the six-week post-op PPQ, question number 11, overall preparedness. Preoperatively, patients viewed the video at their preoperative visit and completed the patient preparedness PPQ as well as patient satisfaction, the surgical decision satisfaction questionnaire as well as urinary distress inventory and a health literacy form. In-person surgical consent was then obtained by surgeons masked to video assignment. And counseling sessions were timed and compared to the institution's historical standard for mitral-atrial sling counseling. Postoperatively, the PPQ decision regret scale and a questionnaire about video preference were administered at their six-week post-op visit. Statistical analysis was performed and power was calculated. Between July 2017 to 2019, 71 women were enrolled in the overall sample. A total of 32 participants watched the peer counseling video and 30 watched the physician counseling video. No differences were noted between groups. However, both groups were relatively highly educated with high literacy. Preoperatively, there are no differences in preparedness, satisfaction, distress symptoms or counseling times. Postoperatively, there are no differences in the post-op PPQ between groups, including overall preparedness. Postoperatively, there were no differences in the decision regret and UDI-6 scores between groups. However, upon performing an INCOVA model, UDI was identified as a confounding factor. And when we controlled for UDI, arm assignment was not responsible for statistical significance in decision regret. When evaluating counseling times, in-person counseling times decreased after watching either video compared to the institution's historical standard. For video counseling, it was 8 minutes and 27 seconds and the historical standard was 11 minutes and 34 seconds. And when evaluating preferences, although not statistically significant, both groups preferred the peer counseling video and both groups found recovery to be the most helpful. In conclusion, patient preparedness or satisfaction did not differ between groups. Unsatisfactory resolution of urinary symptoms is associated with regret. Regret did not differ between groups when adjusted for. And video counseling improved time efficiency. And the majority of patients preferred a peer-centered video, although not significant. Thank you. Thank you. So now we've had our three presenters. We've got five minutes for questions to any of the three presenters before we move on to the next set of presentations. Okay. While you are thinking about it, let me start off. What do you want to start off, ladies? So I have a question for Dr. Kim. Did you guys use any handouts or pamphlets prior to the study for your patient? Right. So the reason why the quality project was started was that I would routinely give patients education material regarding prolapse and incontinence, pessaries in their native language. Just so they had something to read after their first visit and then we would have them come back for a follow-up to ask questions. And I have to say, a majority of them said they had no idea what they read. And they actually didn't understand any of the pictures even though they were very familiar with the picture, having seen it in the OB-GYN office. But they didn't know what it was and why the pictures were hanging up in the office anyway. And so has that changed after the study? How do you counsel your patients differently? So there's a lot more education involved. So I do an education assessment to see what their baseline knowledge is even before the first visit when they are being taken in for intake. And the conversation starts from the very beginning like what do you know about your body? What do you think is going on? And from there kind of expanding on that for education. Because a lot of these women who are immigrants have, most people think that there's one opening and if you're doing surgery they're not going to be able to urinate or defecate or not going to be able to have intercourse anymore. So many misconceptions because they just, they don't know what's going on. I've got a question. Just kind of building on that, Beth Shelley, physical therapist. Do you have handouts you have now created that are more appropriate? And will they be available? Because I agree with you. The iUGA handouts I've not been able to use because they're too high level for my patients. Right. So all those pamphlets have actually been studied and they're definitely above the 6th grade education level. And the impetus for this was to try to get more simpler pamphlets translated. All of it needs funding. If you're trying to do something more graphically because OGS has a PopQ program where if you click the next button it is like an illustrated picture of this is a bladder. This is what happens when the bladder drops. This is stress. And when I use that picture to educate patients they seem to have a better understanding. They're like, oh, because they don't understand what the word bladder means even in English. You know, it holds the urine. That, you know, you have to use layman's terms. It holds pee. You know, and this is the bag. This is the straw. And you're really going down to a very basic level. And when they can see it at the same time as you're explaining it, it's better. But all of that requires funding. So, you know, this is step one of many to try to get that information. We'll be waiting. Yes. Can I interject a little bit there? Disclosure, conflict of interest because I'm the PR committee chair that produces Ayuga leaflets. So, sorry, a small conflict there. I agree with you. When you look at some of them you've got to look at the level in terms of where we're trying to pitch it. But at the same time I suppose you've got to look at it that these are meant to be guides used in conjunction during the consultation together with the pictures that go with it and the anatomy to be able to point it out. But I take your point that the ones that we translate and ask patients to download from various places all over the world, we've got to start to rethink that because we've got about 21 languages and it's difficult to keep translating into all these languages, 40 leaflets. Right. And meanwhile, you know, because we have the advent of iPhones and apps, you know, in theory you could create one infographic at a low baseline readability level and then you have the magic of software to translate it verbally. Because also I didn't take a query on how many of these patients could actually read. Older patients, they can't read the handbook. The font is too tiny. Or because their education level is too low, they can't, they're illiterate, they actually cannot read. So, you know, those are also big things. Thank you. We've got some. Bigger handouts, yes. Yes. I know two people have been waiting forever. Oh. Hi, Liz Erickson from Dartmouth. I have a question for Dr. Krantz. Our issue, excellent study. How did you find the perfect patient to be able to do a video like that? And did you have to actually shoot multiple videos with multiple patients? Because I have, in my experience, had patients who I've like, wow, this is going to be the great peer review, peer reference and it doesn't necessarily always translate when you're looking for them. Yeah, thanks for that question. I think that's what's kind of hard to explain in this five-minute presentation. There are multiple components that are included to make the peer video. First, basically how to do a qualitative study from a previous study to figure out the points that are the most important that all the patients found to be important to include. And then after we did that, we had patients who were actually in that study review all of the, like everything they were going to present and then added their own points of how it would be presented. And then we also included what was important to the patient. Patients found or wanted either a female physician or someone who was female actually to present the information. And we used someone who was in the peer study prior to actually present the information. So there are kind of a lot of key components that we needed. And even with that, one of the interesting things we found from the study is even though a majority of patients wanted a peer patient and they found that really helpful for peer-centered video, there are still patients who want a physician to talk to them and everyone's different. So I think having some type of access to review like from a peer-centered approach or different patients and different physicians, something that patients want. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

patient education

pelvic organ prolapse

misconceptions

treatment options

simplified educational materials

social media

urogynecology

quality of information

counseling approaches