FLORIDA STATEUNIVERSITY

College of Medicine

House Staff Manual2010-2011

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FLORIDA STATEUNIVERSITY

College of Medicine

TABLE OF CONTENTS

INTRODUCTION TO DEPARTMENT OF OB/GYN Page

Introduction 5

Mission Statement Due Process 6Statement of Commitment to Graduate Medical Education 7Educational Goals for Program 8 Faculty

10Resident Staff 11Mentor Assignments 12 Residency Personnel 12 Resident Recruitment Policy 2008-2009 13

Lecture Template 14Resident’s Committee Participation 15Block Schedule 16Clinic Template 17

RESIDENT EDUCATIONRegulatory and Service Organizations 18Important Dates to Note 20ACGME Essentials of Accredited Residencies 21 Resident Educational Goals and Objectives 27Night Float/Primary Care Rotation 38Ultrasound Rotation 40Obstetrics Rotations 41Gynecology Rotations 64Reproductive, Endocrinology & Fertility Rotations 86Gynecologic Oncology Rotations 92

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Critical Care, Medicine Rotation 103CREOG Educational Objectives- Reference Attachment 1 Faculty Evaluation 106 Competency Matrix 107Resident Teaching Responsibilities 107Documentation of Clinical & Surgical Experience 108Required Text Books 109

ADMINISTRATIVE GUIDELINESBackground Checks/Drug Screen 110HIPPA Privacy & Security 110Policies and Guidelines for Pharmaceutical/Vendor Interaction 110General Disaster Plan 114Harassment 116Residency Closure/Reduction 122Accommodation of Residents with Disabilities 123Physician Impairment and Substance 124Promotion, Probation, and Termination 126Resident and Program Responsibilities 127 Duration of Appointment and Conditions for Reappointment 127Discipline Polices and Procedures 128 Grievances 128Suspension 129Non-renewal 129Dismissal 130 Appeal 130 Resident Duty Hours 131On Call Activities 131 Documentation of Resident Work Hours 131Continuity Clinic Guidelines 132Polices on Supervision 132 Proper Appearances for Residents 132 Program Meeting 132Legal Documents 133Outside Professional Activities 133 Certificate of Completion 133

CONTINUING EDUCATIONFlorida Medical License 134ACOG Junior Fellowship 134 CREOG In-Training Examination 134

Resident Oral Exams 134Board Certification/ Examinations 134

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Important Dates in the ABOG Certification 135Written Examination 135Research Goals and Objectives 137Research Policies 137BENEFITS AND RESOURCESLibraries 139Communication 139

Leave for Interviewing 139

Holidays 139 Resident and Fellow Loan Deferment Requests 139Meal Vouchers 140 Medical Education Allowances 140

FINANCIAL SUPPORT AND BENEFITSStipend 141 FICA Alternative Plan-BENCOR 142Health, Life and Disability Insurance; Worker’s Compensation 142Professional Liability Coverage 143 Medical Requirements 143 Institutional Leave Policy 144Vacation / Sick Leave Policies/FMLA/Leave Form 145Pregnancy / Adoption / Paternity Policies 146

PATIENT CHARTS AND MEDICAL RECORDS GUIDELINESMedical Records 148Documentation 148Coding 149 Discharge Summaries 150Charting for Perinatal Death 150 Discharge Summary Format 151Operative Report Format 152

AppendixAppropriate Lab Ordering On Gyn Onc Services IResident Moonlighting Policy IIProgrammatic Moonlighting Approval Form IIINon-Programmatic Moonlight Approval Form IVUse of Prescriptions VOnline OB/GYN Journal via FSU COM Library VIOnline OB/GYN Books available via the FSU COM Library VIIPortfolio Basics VIIIIntern Procedure Competency List VIIIResident Evaluation Policy –Mid point and End of Year Evaluations IXAugust 2010

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INTRODUCTION

This Resident Policy and Procedure Handbook is designed to improve quality of patient care, minimize conflicts, equalize burdens, and allow you to spend more time and energy on your basic goal – that of learning the art and science of Obstetrics & Gynecology. That is why we are here. “Training begins with a task, and learning begins with a question.” In this program, you will find both with abundance.

We are available and will be happy to talk with you about anything at any time. As Faculty of the Obstetrics & Gynecology Residency Program, it is our responsibility to provide the opportunities for your education and to finally place the stamp of completion on your residency documents. We look forward to the coming year.

Clyde H. Dorr II, MDClinical Professor/Program Director

Julie Zemaitis DeCesare, MDAssociate Program Director

Joseph Peterson, MDSuzanne Bush, MDSharon Seidel, MD

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DIVISION OF OBSTETRICS AND GYNECOLOGY FLORIDA STATE UNIVERSITY

– PENSACOLA -

MISSION STATEMENT

ACADEMIC EXCELLENCE – SOCIAL COMMITMENT – COMPASSIONATE PATIENT CARE

The purpose of this four-year program is to educate the resident in the breadth and depth of the discipline of obstetrics and gynecology and to foster a lifelong commitment to the promotion of women’s health care. The resident will acquire cognitive knowledge, technical skills, and interpersonal skills through didactic lectures, small group conferences, audiovisual media, individual instruction, independent reading, and direct patient care. Upon successful completion of the training program, the resident will be fully prepared for the specialty practice of obstetrics and gynecology and for further training in a subspecialty discipline. The program is firmly committed to helping each resident recognize their full academic, clinical, and personal potential within an intellectually stimulating and emotionally supportive environment.

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STATEMENT OF COMMITMENT TO GRADUATE MEDICAL EDUCATION

The Florida State University College of Medicine (FSU COM) is committed to Graduate Medical Education (GME) as central to its mission to maintain a scholarly environment that is dedicated to excellence in education, medical care and research. The FSU COM seeks to educate tomorrow’s physicians and medical scientists and will financially support our infrastructure to do so. We will provide educational and human recourses to in order to achieve, at minimum, substantial compliance with the Accredited Council for Graduate medical Education (ACGME) Institution, Common and individual Program Requirements. We further commit ourselves to doing regular assessments (Internal Reviews) of the quality of the GME programs, the performance of their residents, and the use of outcome assessment results for program improvement.

The FSU COM provides an environment of organized GME programs in which residents develop personal, ethical, clinical and professional competence under careful guidance and supervision. Programs will assure the safe and appropriate care of patient and the progression of residents/physician responsibility consistent with each trainee’s demonstrated clinical experience. The Graduate Medical Education program is designed to provide residents and fellows with knowledge, skills and values that can serve as the basis for competent and compassionate clinical practice, scholarly research and public service.

Residents are encouraged to develop a process for self-evaluation and moral reflection to sustain a lifetime of responsible and committed practice of medicine. The education program prepares residents to continue their own education and to teach their patients, colleagues and medical residents throughout their careers. We are committed to ensuring that our graduates understand the scientific foundation of medicine and apply that knowledge to clinical practice and extend that knowledge through scholarly activities. In addition, we provide the experience necessary for residents to master the clinical skills necessary to evaluate and care for their patients.

The FSU COM is committed to having an organized administration system, including a Graduate Medical Education Committee (GMEC) and Designated Institutional Official (DIO) that complies with the ACGME Institutional Requirements.

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EDUCATIONAL GOALS FOR PROGRAM

The educational objectives of the Division of Obstetrics and Gynecology of the Florida State University, College of Medicine in Pensacola are to provide an academic environment that promotes a structured educational experience. It is dedicated towards effective and efficient patient care, stressing a graduated experience of resident responsibility.

The faculty is dedicated toward active participation in your education, with emphasis on your independent thought and decision-making capabilities.

By meeting these objectives, upon graduating from this program you will be capable of entering into the practice of obstetrics and gynecology, obtain fellowship positions in subspecialties, actively participate in research, and pursue academic careers.The program utilizes the CREOG booklet entitled “Educational Objectives for Residents in Obstetrics & Gynecology”. This booklet provided to each resident for his/her utilization and review.

Residents are expected to participate in the yearly CREOG examination. The results of this examination are used to identify areas of weakness in the resident’s knowledge. These areas will be addressed with special readings or direct tutoring.

Each resident will be evaluated by the attending physician on service. A final evaluation will be submitted to the Residency Director. You are to review your evaluations with your faculty advisor at least twice per year. Your progress will be closely monitored throughout your training. The faculty will discuss each resident’s progress at scheduled semi-annual resident performance reviews.

Contracts will be offered on a yearly basis in April prior to the coming academic year. Contracts are offered to those residents who have demonstrated the ability to matriculate to the next upward level.

The resident program at the Florida State University is of four-year duration. After satisfactory completion of four years of training, you will be expected to participate in the American Board of Obstetrics and Gynecology Examination Part I. It is anticipated and expected by the Department that you will subsequently participate in

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Part II of the American Board Examination which is usually scheduled two years after passage of Part I.

In order to assure quality educational opportunity and care, accurate record keeping is mandatory. Duty Hours statistics are to be submitted on a monthly basis. Cases will be reviewed by the Residency Director. Copies of your completed Duty Hours and Statistic forms will be available to you at graduation.

Residents are expected to keep up-to-date hospital discharge summaries and O.R. reports. All O.R. summaries are to be completed on the day of surgery. Discharge summaries must be completed on the day of discharge.

Guidelines regulating maternity leave, absences and vacations have been established and will be distributed to you upon entrance into the program.

We anticipate that your four years of training will be satisfactory and rewarding to you. We are proud to include you as members of our Division and are dedicated to your success in pursuing a career in the field of obstetrics and gynecology.

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FACULTY

Academic Year 2010-2011

PELVIC RECONSTRUCTIVE SURGERY/GENERAL OBSTETRICS AND GYNECOLOGY Clyde H. Dorr II, M.D., Clinical Professor/ Program Director and Chairman

OBSTETRICS AND GYNECOLOGYDean Altenhofen, M.D., Clinical Assistant ProfessorE.A. Antonetti, M.D., Clinical Assistant ProfessorSuzanne Y. Bush, M.D., Clinical Associate ProfessorJulie A. DeCesare, M.D., Associate Program Director and Director of Medical EducationJairan Duke-Elmore, D.O., Clinical Assistant ProfessorKurt Jones, M.D., Clinical Assistant ProfessorWilliam R. Lile, Jr., D.O., Clinical Assistant ProfessorDina M. Navarro, D.O., Clinical Assistant ProfessorJoseph E. Peterson, M.D., Clinical Assistant ProfessorSharon Luent Seidel, M.D., Clinical Assistant ProfessorBrian Sontag, D.O., Clinical Assistant ProfessorTodd Stalnaker, D.O., Clinical Assistant ProfessorDavid Turner, M.D., Clinical Assistant Professor

REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITYBarry A. Ripps, M.D., Clinical Associate Professor and Director Research

GYNECOLOGIC ONCOLOGYSteven L. DeCesare, M.D., Clinical Associate Professor and Director

MATERNAL-FETAL MEDICINEJames A. Thorp, M.D., Clinical Professor and DirectorWilliam Dobek, D.O., Clinical Assistant Professor

OB/GYN RESIDENCY COORDINATORMelinda Ross, M.S.W.

ADDITIONAL FACULTYJohn Retzloff, D.O., Internal Medicine, Clinical Assistant Professor

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RESIDENT STAFF

Academic Year 2010 – 2011

CURRENT RESIDENTS YEAR MEDICAL SCHOOL

Victor Hulstrand, M.D. 4 Florida State UniversityAndreana Johnson, M.D. 4 University of AlabamaChrisitina Shamas, M.D. 4 University of South Florida

Todd Besnoff, MD 3 Florida State UniversityAnne Marie Whitlock, M. D. 3 Florida State UniversitySasha Siassipour, M.D. 3 University of Miami

Lisa Bean, MD 2 West Virginia School of MedicineBabrette Baldwin, MD 2 Loyola University Raina Ferenchick, MD 2 Mercer University

Kathie N. Petro, MD 1 University of AlabamaAshley M. Poe, MD 1 University of AlabamaDawn M. Stanley, D.O. 1 NOVA Southeastern University

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Mentor Assignments 2010-2011

Dr. Dorr Dr. Hulstrand (PGY-4)Dr. Johnson (PGY-4) Dr. Shamas (PGY-4)

Dr. Bush Dr. Petro (PGY-1)

Dr. DeCesare Dr. Ferenchick (PGY-2)Dr. Stanley (PGY-1)Dr. Siassipour (PGY-3)

Dr. Peterson Dr. Bean (PGY-2)Dr. Besnoff (PGY-3)Dr. Baldwin (PGY-2)

Dr. Seidel Dr. Piantanida-Whitlock (PGY-4)Dr. Ashley Poe (PGY-1)

RESIDENCY PERSONNELThe coordinator, Melinda Ross, MSW, is available to assist you with any clerical or informational needs that you may have. She will handle reimbursements for course fees or licensure fees, as well as issue meal tickets.

The ACGME Designated Institutional Official (DIO) is Dr. Alma Littles, Sr. Associate Dean, FSU COM, and the COM Coordinator is Mrs. Connie Donohoe (850.645.6867, connie.donohoe@med.fsu.edu).

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RESIDENT RECRUITMENT POLICY 2010-2011

The policy outlined in the ACGME institutional requirements section II-A on residents eligibility and selection is considered.

All residency positions will be filled via the NRP, and ERAS will be utilized. Any candidate not utilizing NRP/ERAS will not be considered.

All applicants from LCME or AOA medical schools will be considered first. Applicants from medical schools outside the US and Canada will be considered for vacant interview spots.

All DO candidates must complete a DO rotating internship as per the Florida osteopathic requirement for licensures in the state. Our internship is allopathic, and does not meet this requirement.

This applicant must take the USMLE step 1 and 2, or both of the complex step 2 clinical skills and medical knowledge.

Applicants that have not successfully passed step two prior to rank will not be ranked.

Minimum of 30 applicants will be interviewed.

Interview days will be coordinated by the residency program coordinator, and will average between 5-10, max 7 candidates per day.

The rank committee will be composed of any faculty member that has interviewed, plus one resident representative per year level. The resident members will be appointed by the chief, with each resident serving on the recruitment committee at least once in their residency.

All applicants will be interviewed by 3 faculty members, and 2-3 residents.

An informal dinner the night prior to the interview will be scheduled, with 3-4 residents and 2-3 faculty members at a faculty member’s home or local restaurant.

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Lecture Template 2010-2011

First FridayGyn Onc

Second FridayMFM/OB

Third FridayREI

Last FriAdult GRGyn/OR Skills

5th Friday Gyn/OR Skills

Journal clubs/M and MEvery other month

Systems Based ConferenceQuarterly

Resident QI/QA meetingQuarterly

Staffing ConferenceEvery Friday 9:30

OSCEDecember Second week

FSU resident forum- twice yearly

Evaluations/ Portfolio review Dec/June

Seton Center Staff /Resident meeting every other month

Adult Grand Rounds last Friday Resident Retreat Yearly (Fall)

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RESIDENT COMMITTEE PARTICIPATION 2010-2011

GME Committee:Voting Members1st Thurs. QTR 12:00 NoonMedstaff ARachel Carter: x 6108

Dr. Ana Johnson Dr. Lisa Bean

Perinatal Safety Committee:4th Thurs, MO 7:30 A.M.Medstaff BOrlanda Jackson: x 4300

Dr. Todd Besnoff Dr. Christy Shamas Dr. B. Baldwin Dr. R. Ferenchick Dr. S. Siassapour Dr. A. Whitlock Dr. V. Hulstrand

Bio-Ethics Committee:Non Voting Members1st Wed, MO 12:00 NoonAdmin Bd. Rm.Rachel Carter: x 6108

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Rotation Schedule 2011-2012(4/2010)

PGY 421-Jun 19-Jul

16-Aug

13-Sep

11-Oct 8-Nov 6-Dec 3-Jan

31-Jan

28-Feb

28-Mar

25-Apr

Johnson GYN ONC MFM GYN ONC MFM GYN ONC MFM GYN ONC MFMShamas ONC MFM GYN ONC MFM GYN ONC MFM GYN ONC MFM GYNHultstrand MFM GYN ONC MFM GYN ONC MFM GYN ONC MFM GYN ONC

     

PGY 321-Jun 19-Jul

16-Aug

13-Sep

11-Oct 8-Nov 6-Dec 3-Jan

31-Jan

28-Feb

28-Mar

25-Apr

Besnoff OB ONC GYN OB GYN ONC GYN OB ONC OB GYN ONCP-Whitlock ONC GYN OB ONC OB GYN ONC GYN OB GYN ONC OBSiassipour GYN OB ONC GYN ONC OB OB ONC GYN ONC OB GYN

     

PGY 221-Jun 19-Jul

16-Aug

13-Sep

11-Oct 8-Nov 6-Dec 3-Jan

31-Jan

28-Feb

28-Mar

25-Apr

Baldwin GYN OB ENDO OB ENDO GYN OB GYN ENDO OB GYN MICUBean ENDO GYN OB ENDO GYN OB ENDO OB GYN GYN MICU OBFerenchck OB ENDO GYN GYN OB ENDO GYN ENDO OB MICU OB GYN

     

PGY 121-Jun 19-Jul

16-Aug

13-Sep

11-Oct 8-Nov 6-Dec 3-Jan

31-Jan

28-Feb

28-Mar

25-Apr

Petro L&D PC GYN L&D PC GYN L&D PC GYN L&D PC GYNPoe GYN L&D PC GYN L&D PC GYN L&D PC GYN L&D PCStanley PC GYN L&D PC GYN L&D PC GYN L&D PC GYN L&D

US ULTRASOUND GERIATRICS IM INTERNAL MEDICINEICU INTENSIVE CARE UNITPC PRIMARY CAREENDOREPRODUCTIVE ENDOCRINOLOGY/INFERTILITY

Each year of residency is separated into rotations that satisfy all the requirements designated by the RRC.

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Clinic/L&D TemplateContinuity Clinics are designated by (C) and are all day All clinic assignments are for entire day, except where noted

MondayMFM-OB4

Nurse practitionerGYN-2 C 2 -4 H&P am / post op clinic pmNon Night Float OB2/PC Intern am/ MFM pm

GYN 3 or 4 Post OP clinic pmL &D OB3/OBI

TuesdayOB3-C (colpo clinic pm if needed)GYN1-C Nurse Practitioner

OB2/ MFM am/Colpo Clinic pmPCI MFML &D OB4/OBI

WednesdayOB4-CREI-C (colpo clinic pm if needed)Nurse Practitioner

OB2/PCI MFM L &D OB3/OBI

ThursdayOB3 (am clinic/colpo clinic pm)Nurse PractitionerPCI C am/colpo clinic pmOB2 CEssures Endo resident (Gyn team covers if Endo resident is operating or there is no Endo resident)L &D OB4/OBI

FridayGYN3-C 4 H& PGYN 4-C 4 H &PGYN 1 and GYN 2 Loose work/Labs/STD chartsOB3 float/scheduleOB2/PCI-C scheduleEndo floatNurse Practitioner

L &D OB4/OBI

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RESIDENT EDUCATION:

REGULATORY AND SERVICE ORGANIZATIONS

The following is a list of the key organizations that have an impact on resident education in Obstetrics and Gynecology:

Regulatory Organizations

The American Board of Obstetrics and Gynecology, Inc. (ABOG)2915 Vine StreetDallas, TX 75204(214)871-1619 – phone (214)871-1943 – fax

ABOG is the certifying organization for the OB/GYN specialty. Its function is to test the qualifications of voluntary candidates for certification and recertification and to issue certificates of competence to eligible physicians who have demonstrated special knowledge and professional competence. Written examinations are given each year and may be taken after completion of an accredited residency program. Oral examinations, designed to evaluate the candidate’s knowledge and skills in solving OB/GYN clinical problems, are conducted each fall. Prerequisites for the oral examination include: a passing grade on the written examination, an unrestricted license to practice medicine, active engagement in unsupervised practice, unrestricted hospital privileges, and a listing of patients dismissed from care in hospitals for a 12-month period.

Accreditation Council for Graduate Medical Education (ACGME)515 North State Street, Suite 2000Chicago, IL 60610(312)464-4920 – phone

ACGME is composed of representatives of the American Board of Medical Specialties, the American Hospital Association, the American Medical Association (AMA), the Association of American Medical Colleges, the Council of Medical Society Specialties, and the federal government, plus a resident and a public representative. The ACGME gives delegated accreditation authority to the Residency Review Committee. To be accredited, a residency program must meet the “General Requirements” and “Special Requirements” listed in Essentials of Accredited Residencies published by the AMA.

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Residency Review Committee for OB/GYN (RRC)515 North State StreetChicago IL 60610(312)464-4920 – phone

The RRC has the authority to accredit residency programs in the OB/GYN specialty. It is composed of representatives appointed by the Board of Trustees of the AMA upon recommendation of the Council on Medical Education, the American Board of Obstetrics and Gynecology, the American College of Obstetricians and Gynecologists, and a resident representative. Programs listed in the Directory of Residency Training Programs, published by AMA, may be designated independent (intramural), affiliated, or integrated, as defined in the Special Requirements for Residency Training in Obstetrics/Gynecology.

The American College of Obstetricians and Gynecologists (ACOG)409 12th Street, S.W.Washington, DC 20024-2188(202)863-2402 or 1-800-673-8444

ACOG is the national professional society for the specialty of obstetrics and gynecology. Its objectives are to foster and stimulate improvements in all aspects of women’s health care within the scope of obstetrics and gynecology. It establishes high standards in practice, ethics and education, maintains dignity and efficiency in its relationship to public welfare, and promotes publication of medical and scientific literature. National and local leaders are elected by the members. Junior fellowship in ACOG is designed for the professional in training or in the early years of independent practice.

Council on Resident Education in Obstetrics and Gynecology (CREOG)409 12th Street, S.W.Washington, DC 20024(202)863-2554 or 1-800-673-8444

CREOG is a no regulatory organization providing services that promote and maintain high standards in resident education. Composed of six national organizations, CREOG’s unique intersocietal structure brings together representatives from its member organizations. Volunteer representatives from each organization, plus an equal number of representatives from the American College of Obstetricians and Gynecologists, serve as program directors. These program directors, who are prominent members of the specialty, apply their knowledge and experience in governing CREOG and carrying out its objectives. Major services include consultation, publications, conferences, a referral clearinghouse.

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IMPORTANT DATES TO NOTE

CREOG In-Training Examination:CREOG In-Training Examination Date January 20-22, 2011

ABOG Written Examination: Sept.1,2010-Application Window Nov. 17, 2011

Application available online at www.abog.com Available Sept. 1, 2010

ABOG Written Examination Date June 27, 2010

Resident Research Day April 28, 2011

Resident Graduation Day June 24, 2011

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ACGME ESSENTIALS OF ACCREDITED RESIDENCIES

The Accreditation Council for Graduate Medical Education (ACGME), composed of representatives of five national associations interested in medical education, and the Residency Review Committee accredit graduate education programs which meet the General and Special Requirements of the Essentials for Accredited Residencies.

GENERAL CLINICAL COMPETENCIES FOR RESIDNETS IN OBSTETRICS AND GYNECOLOGY

There are six competencies that the residents will be taught and evaluated of during their tenure in our program:

1. Patient Care Residents must be able to provide care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Residents are expected to:A. Demonstrate caring and respectful behaviors when interacting with patients and their families. (PC, P, ICS)B. Gather essential information about patients by performing a complete and accurate medical history and physical examination. (PC, ICS, MK)C. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment. (PC, PBLI, MK)D. Develop, negotiate, and implement effective patient management plans. (PC, ICS, P, SBP)E. Counsel and educate patients and their families.(PC, PBLI, ICS, P, MK)F. Use information technology to support patient care decisions and patient education. (PC, PBLI, SBP)G. Perform competently all medical and invasive procedures considered essential for generalist practice in the discipline of obstetrics and gynecology. (PC, MK)H. Understand the differences between screening and diagnostic tests essential for generalist practice in obstetrics and gynecology. (PC,MK)I. Provide health care services aimed at preventing health problems or maintaining health. (PC, SBP, PBLI)J. Work with health care professionals, including those from other disciplines, to provide patient-focused care. (PC, SBP, P, ICS)

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2. Medical Knowledge

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and apply this knowledge to patient care. Resident sare expected to:A. Demonstrate an investigatory and analytic thinking approach to clinical situations. (MK, PBLI)B. Demonstrate a sound understanding of the basic science background of women’s health and apply this knowledge to clinical problem solving, clinical decision making, and critical thinking. (MK, PBLI,PC, SBP).3. Practice-based Learning and Improvement Residents must be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. Residents are expected to:A. Identify areas for personal and practice improvement and implement strategies to enhance knowledge, skills, attitudes, and processes of care, as well as making a commitment to life-long learning.(MK, P, SBP, PBLI)B. Analyze and evaluate personal practice experience and implement strategies to continually improve the quality of patient care provided using a systematic methodology. (PBLI, SBP, P, MK, PC)C. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems. (PBLI, MK, PC)D. Obtain and use information about their population of patients and the larger population from which their patients are drawn. (PBLI,SBP, PC)E. Demonstrate receptiveness to instruction and feedback.(PBLI, ICS, P)F. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness. (PBLI, MK, PC)

G. Use information technology to manage information, access online medical information, and support their education. (PBLI, P, MK)H. Facilitate the learning of students and other health care professionals. (PBLI, ICS, SBP, MK)

4. Interpersonal and Communication Skills

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Residents must be able to demonstrate interpersonal and communication skills that assist in effective information exchange and be able to team with patients, patients’ families, and professional associates.Residents are expected to:A. Sustain therapeutic and ethically sound relationships with patients, patients’ families, and colleagues. (ICS, P)B. Provide effective and professional consultation to other physicians and health care professionals. (ICS, P, SBP, MK, PBLI)C. Elicit and provide information using effective listening, non-verbal, explanatory, questioning, and writing skills. (ICS, P)D. Communicate effectively with patients in language that is appropriateto their age and educational, cultural, and socioeconomic background.(ICS, P, PC)E. Maintain comprehensive, timely, and legible medical records. (ICS,P, PC)F. Communicate effectively with others as a member or leader of a health care team or other professional group. (ICS, SBP, P)

5. Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse population. Residents are expected to:A. Demonstrate respect, compassion, integrity, and responsiveness to the needs of patients and society that supersedes self-interest. (P,ICS)B. Demonstrate accountability to patients, society, and the profession.

1. Demonstrate uncompromised honesty. (P, ICS)2. Develop and maintain habits of punctuality and efficiency. (P)3. Maintain a good work ethic (i.e., positive attitude, high level ofinitiative). (P)

C. Demonstrate a commitment to excellence and ongoing professional development. (P, PBLI)D. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care. (P, PC)E. Describe basic ethical concepts such as: autonomy, beneficence, justice, and nonmalfeasance. (P, ICS)F. Describe the process of informed healthcare decision making, including the elements that must exist and the specific components of an informed-consent discussion. (P, ICS, PC)G. The resident must demonstrate an understanding of the use of advanced directives, living wills, and durable power of attorney for health care and strategies for the resolution of ethical conflicts.(P, PC)

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H. Discuss surrogate decision making for incapacitated patients, including who can and should act as a proxy decision maker and what standards they should use to make healthcare choices for another. (P, PC, ICS)I. The resident should be able to examine their personal values and preferences for end-of-life treatment and the values of diverse patients.(P, PBLI)J. Differentiate between institution-based DNR orders, community based DNR orders (also called out-of-hospital or portable DNR orders), and advance directives. Describe the legal, ethical, and emotional issues surrounding withholding and withdrawing medicaltherapies. (P, MK, SBP, PC)K. Discuss when it is appropriate to use all available technology to sustain a life and when it is appropriate to limit treatment. (P, ICS,SBP, PC)L. Discuss the principle of justice and the use of limited medical resources.(P, MK)M. Discuss the differences in ethical decision making if the patient is an adult or a child. (P, PC)N. Discuss ethical implications of commonly used ob/gyn technologies.(P, MK, SBP, PC)O. Analyze an ethical conflict and develop a course of action that is ethically defensible and medically reasonable.(P, PC, MK, ICS)P. Discuss important issues regarding stress management, substance abuse, and sleep deprivation.

1. List preventive stress-reduction activities and describe their value. (P, MK)2. Identify the warning signs of excessive stress or substance abuse within one’s self and in others. (P, MK, ICS)3. Intervene promptly when evidence of excessive stress or substance abuse is exhibited by oneself, family members, or professional colleagues. (P, ICS, MK, PC)4. Understand the signs of sleep deprivation and intervene promptly when they are exhibited by oneself or professional colleagues. (P,MK, PC, ICS)

Q. Maintain confidentiality of patient information.1. Describe current standards for the protection of health-relatedpatient information. (P, SBP, ICS)2. List potential sources of loss of privacy in the health care system.(P, SBP)

R. Demonstrate sensitivity and responsiveness to the culture, age, sexual preferences, behaviors, socioeconomic status, beliefs, and disabilities of patients and professional colleagues. (P, ICS)S. Describe the procedure for, and the significance of, maintaining medical licensure, board certification, credentialing, hospital staff privileges, and liability insurance. (P, SBP, ICS)

6. Systems-based Practice

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Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.Residents are expected to:A. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society, and how these elements of the system affect their practices. Understand the processes for obtaining licensure, receiving hospital privileges and credentialing. (SBP, PC, P, ICS)B. Describe how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources. (SBP, ICS, PC)

1. List common systems of health care delivery, including variouspractice models. (SBP, PC)2. Describe common methods of health care financing. (SBP, PC)3. Discuss common business issues essential to running a medicalpractice. (SBP, P, ICS)4. Apply current procedural and diagnostic codes to reimbursementrequests. (SBP, PC, ICS)

C. Practice cost-effective health care and resource allocation that does not compromise quality of care. (SBP, PC, P)D. Advocate for quality patient care and assist patients in dealing with system complexities. (SBP, ICS, P)

1. Recognize that social, economic and political factors are powerful determinants of health and incorporate these factors into how they approach patient care.2. Demonstrate knowledge of disparities in health and health care in a variety of populations.3. Recognize the role of the women’s health provider to advocate for patients, particularly poor and vulnerable women, and to help develop methods of care that are effective, efficient, and accessibleto all women.4. Be aware of ACOG and community resources and advocacy on behalf of underserved and vulnerable populations such as poor women and teenagers.5. Learn to communicate effectively about women’s health concern to family and community groups.6. Recognize the role of the physician in legislation as it relates to women’s health policy.

E. Acknowledge that patient safety is always the first concern of the physician.1. Demonstrate the ability to discuss errors in management with peers and patients to improve patient safety. (SBP, ICS, P, PBLI)2. Develop and maintain a willingness to learn from errors and use errors to improve the system or process of care. (SBP, P, ICS,PBLI, PC, MK)3. Participate in hospital/departmental QI activities and PatientSafety initiatives (SBP, P, PBLI, ICS)4. Recognize the value of input from all members of the health care team and methods by which to facilitate communication among

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team members. (SBP, ICS, P, PC, PBLI)5. Demonstrate understanding of institutional disclosure processes and participate in disclosure and discussions of adverse events with patients. (SBP, ICS, P, PC)

F. Partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance. (P, ICS, PC, PBLI)

1. Describe the process of quality assessment and improvement including the role of clinical indicators, criteria sets, and utilization review. (SBP, ICS, P, PC)2. Participate in organized peer review activities and use outcomes of such reviews to improve personal and system-wide practicepatterns. (SBP, P, ICS, PBLI, PC)3. Demonstrate an ability to cooperate with other medical personnel to correct system problems and improve patient care. (SBP, P,ICS, PC, PBLI)

G. Risk management and professional liability1. List the major types and providers of insurance. (SBP)2. Describe the most common reasons for professional liability claims. (SBP, P, ICS)3. Describe a systematic plan for minimizing the risk of professional liability claims in clinical practice. (SBP, PC, P, ICS)4. Describe basic medical-legal concepts regarding a professional liability claim and list the steps in processing a claim. (SBP, P, ICS)

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Resident Educational Goals & Objectives

Night Float/Primary Care Rotation/Continuity Clinic

Goals and Objectives:Obstetrician–gynecologists provide primary health care services to their patients both within and outside the traditional purview of reproductive medicine. As primary care physicians, obstetrician–gynecologists establish relationships with their patients that transcend the disease spectrum and extend to routine assessments, preventive care, early intervention, and management of medical disorders. Periodic assessments provide an excellent opportunity to counsel patients about preventive care. These assessments should include screening, evaluation, and counseling based on age and risk factors. As the major providers of reproductive health care for women, obstetrician–gynecologists are responsible for all aspects of care of reproductive disorders. Both the role of primary care physician and the role of reproductive health care provider require specialized skills and training and should be recognized as essential components in the practice of obstetrics and gynecology. Even when certain disorders extend beyond the scope of their practice and require referral, obstetrician–gynecologists serve in a consultant capacity in 99which they are involved in the continuing health maintenance of their patients.

This rotation is assigned to a PGY 1 resident. The PGY-1 schedule (A verses B) will be assigned by the chief resident, based on vacation choice. (Residents may not take vacation while on Night float, to assure even call distribution) Night float responsibilities are shared with the PGY-2 Obstetrical resident. The main objectives of the rotation are two-fold: to expand resident primary care experience thru the Seton Center clinic, and to cover night time duties for the obstetrical and gynecological services.

Additionally, these primary care objectives cover resident’s continuity clinics. The continuity clinic occurs weekly through out the residents 4 years of training, with the exception of Night Float weeks and Gynecology Oncology rotations.

Periodic Health Assessments

A. Perform initial assessmentTo gain the patient’s confidence and cooperation in obtaining the history and performing the physical examination, the resident should appreciate the effects of age; racial, ethnic, and cultural backgrounds; sexual orientation; personality; mental status; and the patient’s level of comfort and modesty. (PBLI, P)

1. Obtain a complete medical history, including a history of genetic diseases. (PC, ICS, P)2. Perform an appropriate general or focused physical examination.(PC, P)

UNIT 2B. Perform routine screening for selected diseasesThe content and frequency of routine health examinations for screening and counseling should be tailored to risk factors (see Table) and the patient’s age (see Periodic

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Assessment). Major causes of morbidity and mortality by age can direct attention to areas that warrant special care. (PC, MK, P)

1. Ages 12 years and youngerFor the preadolescent patient, the obstetrician–gynecologist usually serves as a consultant. All primary care can be performed by a pediatrician or family physician after assessment of the specific problem for which the patient was referred. (PC)Specific objectives for the obstetrician–gynecologist in this patient population are found in Unit 5 under Pediatric gynecology (birth to menarche).2. Ages 13–18 yearsFor adolescents, the obstetrician–gynecologist serves either as a consultant or as a primary health care provider, depending on the nature of his or her practice and level of expertise in the spectrum of reproductive tract disorders. (These disorders are described in Unit 5 under Adolescent gynecology.) The following areas warrant special attention in this age group:

a. Assess patients for evidence of substance use (tobacco, alcohol, and other drugs). (PC, ICS, P)b. Perform a Pap test for sexually active adolescents in accordance with current guidelines. (PC, P)c. Assess reproductive concerns, such as: (P, PC, MK)

(1.) Family planning(2.) Prevention of STIs(3.) Pregnancy care(4.) Infertility

d. Test sexually active adolescents for sexually transmitted infections (STIs), such as: (PC, P)

(1.) Gonorrhea(2.) Chlamydia(3.) Syphilis(4.) Hepatitis B(5.) Human immunodeficiency virus (HIV) infection

e. Counsel adolescents about the use of automobile safety beltsand bicycle helmets. (PC, ICS, P)f. Evaluate psychosocial well-being, including issues regarding abuse. (PC, ICS, P)g. Assess nutritional and growth status. (PC, P)

3. Ages 19–39 yearsThe obstetrician–gynecologist usually is the chief care provider for women ages 19–39 and provides both specialist care in obstetrics and gynecology and primary preventive health care. The following areas warrant special attention in this age group:

a. Describe normal reproductive physiology, including issues such as fecundity and sexuality. (MK, P)b. Assess reproductive concerns, such as: (P, PC, MK)

(1.) Family planning

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( 2.) Prevention of STIs(3.) Pregnancy care(4.) Infertility

c. Treat menstrual disorders, such as: (PC, MK, P)(1.) Amenorrhea(2.) Oligomenorrhea(3.) Abnormal uterine bleeding

d. Manage breast disorders, such as: (PC, MK)(1.) Mastitis(2.) Galactorrhea(3.) Mastodynia

e. Evaluate psychosocial well-being including issues regarding abuse. (PC, ICS, P)f. Describe the principal reproductive health care issues of women with developmental delay and physical disabilities. (MK)

4. Ages 40–64 yearsWomen ages 40–64 are in a time of transition and may face reproductive and perimenopausal concerns, medical conditions, and psychosocial issues. The following areas warrant special attention in this age group:

a. Assess and manage reproductive concerns, such as:(PC, MK, P)

(1.) Family planning until menopause(2.) Prevention of STIs(3.) Pregnancy care (e.g., offering genetic counseling/prenatal diagnosis with amniocentesis or chorionic villus sampling)(4.) Infertility

b. Evaluate and treat perimenopause/menopause concerns: (PC,MK, P)

(1.) Normal aging, lifestyle modifications, and hormone therapy.(2.) Risk factors for osteoporosis.

c. Assess risks for cancers (e.g., lung, breast, endometrium, ovary, colon, and skin). (PC, MK, P)d. Evaluate psychosocial risks and well-being including issues of abuse. (PC, ICS, P)e. Describe the appropriate interventions to prevent fractures in older women. (MK)f. List the major risk factors for cardiovascular disease. (MK)g. Assess risks for cancers (e.g., lung, breast, endometrium, ovary, colon, and skin). (PC, MK)h. Describe the appropriate assessment for urinary and fecal incontinence. (PC, MK)

5. Ages 65 years and older

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The goal of health maintenance in older women is improvement of the quality of life and prolongation of a disease-free state. The following areas warrant special attention in these patients:

a. Describe the biologic effect of aging on major organ systems.(MK)b. Describe the psychologic problems that may be associated with aging, such as: (MK)

(1.) Depression(2.) Emotional abuse or neglect(3.) Change in sexual function

c. Describe the appropriate interventions to prevent fractures inolder women. (MK)d. Describe the appropriate assessment for urinary and fecal incontinence. (MK)e. List the major risk factors for cardiovascular disease. (MK)f. Assess risks for cancers (e.g., lung, breast, endometrium, ovary, colon, and skin). (PC, MK)g. Describe the altered pharmacokinetics of drugs in the elderly population and the likelihood of drug interactions with medications commonly prescribed in this age group. (MK)h. List the drugs that most commonly cause adverse reactions in geriatric patients. (MK)i. Summarize age-related changes in common laboratory values. (MK)j. Assess nutritional status. (PC, MK)k. Perform a basic assessment of functional status including: (PC, MK, P)

(1.) Activities of daily living(2.) Mini-mental status examination(3.) Capacity for independent decision making

C. Counsel PatientsCounseling encourages patients to adopt healthy behaviors andto seek regular preventive care that may reduce the prevalence of disorders later in life. The obstetrician–gynecologist is in a position to evaluate the patient’s general health and to counsel her regarding general health risk behavior. Patients should be counseled about high-risk and health maintenance behaviors at least annually. Counseling should include factors such as: (PC, ICS, MK, P)

1. The importance of a healthy diet and exercise.2. Risk factors and health problems associated with substance abuse.3. Weight management4. Contraception5. Prevention of STIs6. Interventions to prevent accidents in the home and workplace.7. Interventions for preserving good dental health, such as regular tooth brushing and flossing and regular dental appointments.8. Psychosocial issues

D. Provide immunizations (PC, MK)

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Describe the appropriate indications for selective immunizations such as Human Papilloma Virus (HPV), rubella, measles, varicella, hepatitis A and B, influenza, pneumococcal infection, tetanus, and diphtheria.

II. Special Gynecologic ConditionsA. ContraceptionThe gynecologist is in a unique position to serve as a resource person for the community or the individual regarding family planning and contraception. On the community level, the obstetrician–gynecologist should be able to speak to any audience on the subject of birth control. He or she should be able to discuss the cultural, societal, ethical, and religious implications of contraceptives as well as describe their effectiveness, medicalbenefits, and side effects. (P, PC, MK, ICS, PBLI)

1. Define the terms: method effectiveness and user effectiveness. (MK)2. Describe national and local policies that affect control of reproduction. (MK, SBP)3. Describe how religious, ethical, and cultural differences affect providers and users of contraception. (PBLI)4. Describe the impact of contraception on population growth in the United States and other nations. (MK, SBP)5. Describe the factors that influence the individual patient’s choice of contraception. (MK, PBLI)6. Elicit a pertinent history from a patient requesting information about contraception. (PC, ICS, P)7. Perform a focused physical examination to detect findings that might influence the choice of contraception. (P, PC)8. Interpret the results of selected laboratory tests that might influence a patient’s choice of contraception. (MK)9. Describe the advantages, disadvantages, failure rates, mechanisms of action and complications associated with the following methods of contraception:

a. Sterilizationb. Oral steroid contraceptionc. Transdermal steroid contraceptiond. Vaginal steroid contraceptione. Injectable steroid contraceptionf. Implantable steroid contraceptiong. Intrauterine devicesh. Barrier methodsi. Natural family planning

10. Describe the pharmacology of hormonal contraception.11. Describe appropriate methods for postcoital contraception.(MK)12. Describe the appropriate follow-up for a woman using any of the aforementioned methods of contraception. (MK)

B. Induced abortion

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One should be able to counsel pregnant patients on all the alternatives available to them, including induced abortion. Residents, who decide not to provide this service because of a moral objection still should be able to counsel patients, make appropriatereferrals, and manage postabortal complications. (PC, ICS, PBLI, P)

1. Elicit a pertinent history from a patient requesting an induced abortion. (ICS, P)2. Perform a targeted physical examination to confirm the presence of an intrauterine pregnancy, accurately determine gestational age, and identify other abnormal physical findings that may influence the choice of abortion method. (PC, P)3. Order and interpret selected laboratory tests in patients requesting induced abortion. (PC)4. Describe the principal techniques for pregnancy termination, such as: (PC, MK, P)

a. Suction curettageb. Dilation and evacuationc. Medical abortiond. Induction termination

5. Describe and treat the principal complications of induced abortion. (PC, MK, P)6. Describe the possible psychologic aftermath of induced abortion.(PC, MK, P)

C. SexualityThe obstetrician–gynecologist should understand the concepts of sexual development and identity, as well as the psychology of sexual relations. The practitioner also should understand the ways in which a patient’s sexuality may be altered by physicalor psychological conditions, including menopause and advancing age. The obstetrician–gynecologist should be familiar and comfortable with the terminology used in sexual counseling and should understand the range of disorders of sexual function.(PC, ICS, PBLI)

1. Describe the stages of the normal sexual response: desire, arousal, orgasm, resolution, and refractory period. (MK)2. Describe the principal disorders of sexual function, including: (PC, MK)

a. Hypoactive sexual desire disorderb. Female sexual arousal disorderc. Sexual aversion disorderd. Female orgasmic disordere. Vaginismusf. Dyspareunia

3. Elicit a complete sexual history. (PC, ICS)4. Perform a targeted physical examination to evaluate sexual dysfunction. (PC)5. Describe possible interventions for patients with disorders of sexual function. (PC, MK)6. Be able to discuss common sexual concerns with patients with understanding of their background, religious/moral beliefs, age, and social situation.7. Understand the effects of age and menopause on sexual function, and be able to discuss these effects with patients.

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8. Know the effects of common medications on sexual function.a. Contraceptivesb. Antidepressants and antipsychoticsc. Antihypertensivesd. Anti-epilepticse. Illicit drugs (alcohol, cocaine, marijuana, narcotics)

9. Describe the appropriate long-term follow-up for patients with disorders of sexual function. (PC)

D. Lesbian healthThe obstetrician–gynecologist should be sensitive and knowledgeable regarding methods to promote health for lesbian women. (PBLI, P)

1. Display sensitivity to sexual preferences and describe ways to promote an office environment that is respectful of patients’ sexuality. (PBLI, P)2. Describe health risks that may be higher or lower in the lesbian population and conduct appropriate health screening for lesbian patients. (PC, MK, P)

E. Transgender healthThe obstetrician–gynecologist should be sensitive and knowledgeable regarding methods to promote health for transgender women. (PBLI, P)

1. Display sensitivity to gender identity and describe ways to promote an office environment that is respectful of patients’ gender identity. (PBLI, P)2. Describe health risks that may be higher or lower in the transgender population and conduct appropriate health screening for transgender patients. (PC, MK, P)3. Describe the various surgical procedures that might be requested by a transgendered patient.4. Refer, when appropriate, to specialists, such as reproductive endocrinologists, urologists and urogynecologists.

F. Crisis interventionThe obstetrician–gynecologist should be able to identify an abused woman, provide immediate medical evaluation and treatment for her and, if indicated, assist with referrals for legal assistance and psychologic counseling. (PC, ICS, SBP, P)

1. Discuss the principal types of violence against women of allages:

a. Incestb. Rapec. Physical abused. Psychologic abuse

2. Elicit a pertinent history from a possible victim of physical, psychologic, or sexual abuse. (PC, ICS, P)3. Perform a focused mental status examination and physical examination to detect findings of physical, psychologic, or sexual abuse. (PC, P)4. Describe the appropriate legal safeguards that must be observed in evaluating a victim of abuse, such as maintaining the proper chain of evidence in handling laboratory specimens and reporting the crime to the appropriate authorities.(SBP)5. Perform or order selected laboratory tests to evaluate a victim of abuse. (PC, P)6. Provide immediate treatment for the victim of abuse: (PC, P)

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a. Prophylaxis for STIsb. Postcoital contraception

7. Provide appropriate follow-up care and referrals for victims of abuse. (PC, SBP, P)

Management of Nongynecologic ConditionsMany nongynecologic conditions can be managed effectively with a team approach in which the obstetrician–gynecologist plays a key role. The obstetrician–gynecologist is encouraged to develop collaborative relationships with other specialists to allow timely referrals as well as to enhance clinical skills. Residents must be able to diagnose and treat many uncomplicated nongynecologic conditions and know when and to whom patients should be referred. (PC, SBP, P)A. Allergic rhinitis

1. Describe the signs and symptoms of allergic rhinitis. (MK)2. Elicit a history and perform a targeted physical examination to diagnose allergic rhinitis. (PC, ICS, P)3. Describe the differential diagnosis of allergic rhinitis. (MK)4. Counsel patients about the impact of environmental allergens and initiate basic medical treatment for allergic rhinitis. (P,PC, ICS)

B. Respiratory tract infection1. Discuss the differential diagnosis of respiratory tract infection. (MK)2. Elicit a pertinent history in a patient with suspected respiratory tract infection. (PC, ICS)3. Describe the usual signs and symptoms of respiratory tract infection. (MK)4. Perform a targeted physical examination to diagnose respiratory tract infection. (PC, P)5. Interpret the results of selected tests to diagnose respiratory tract infection, such as: (PC, MK)

a. Chest x-rayb. Tuberculin skin test

6. Treat uncomplicated respiratory tract infection.7. Describe the indications for referral of a patient with a more severe respiratory tract infection.

C. Asthma1. Elicit a pertinent history from a patient with asthma. (PC,ICS, P)2. Perform a targeted physical examination to detect findings associated with asthma. (PC, P)3. Interpret the results of basic pulmonary function tests, such as: (MK)

a. Forced expiratory volume in 1 second (FEV1)4. Describe the differential diagnosis of asthma. (MK)5. Treat mild asthma with appropriate medications. (PC)6. Describe the indications for referral of a patient with more severe asthma. (PC, MK, SBP)

D. Hypertension1. Describe the criteria for the diagnosis of hypertension. (MK)2. Describe the major causes of hypertension. (MK)

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3. Describe the long-term consequences of untreated hypertension.(MK)4. Describe the principal symptoms of hypertension. (MK)5. Initiate a treatment plan for mild hypertension. (PC)6. Describe the indications for referral of a patient with hypertension.(PC, SBP)

E. Abdominal pain1. Elicit a pertinent history in a patient with abdominal pain.(PC, ICS, P)2. Perform a targeted physical examination to evaluate a patient with abdominal pain. (PC, P)3. Describe the differential diagnosis of abdominal pain. (MK)4. Interpret the results of selected laboratory, radiologic, and endoscopic tests to determine the etiology of abdominal pain.(PC, MK)5. Treat selected patients with abdominal pain, and describe the indications for referral. (PC, SBP)

F. Gastrointestinal disorders1. Describe the signs and symptoms of common gastrointestinal disorders, such as: (PC, MK)

a. Acute diarrheab. Constipationc. Diverticulosis/diverticulitisd. Gastroenteritise. Gastroesophageal refl uxf. Irritable bowel syndrome

2. Elicit a pertinent history and perform a targeted physical examination to evaluate a patient with gastrointestinal symptoms.(PC, ICS, P)3. Interpret the results of selected laboratory, radiologic, and endoscopic tests to determine the etiology of a patient’s gastrointestinal symptoms. (PC, MK)4. Treat selected patients with gastrointestinal disorders anddescribe the indications for referral. (PC, SBP)

G. Urinary tract disordersResidents should understand the treatment of acute urethritis, acute cystitis, acute pyelonephritis, and ureteral calculi. Learning objectives for the management of conditions affecting the urinary system are found in Gynecology. (PC, MK)H. Headache

1. Describe the principal causes of headache. (MK)2. Elicit a pertinent history and perform a focused physical examination to evaluate a patient with headaches.(PC, ICS, P)3. Treat muscle tension, mild migraine and menstrual migraine headaches. (PC)4. Describe indications for referral of patients with unusual/severe headaches. (PC, SBP)

I. Depression1. Describe risk factors for depression. (MK)2. Describe the signs and symptoms of depression. (PC, MK)3. Discuss the differential diagnosis of depression. (MK)4. Describe the use and interpretation of screening instruments for the identification of depression. (PC, MK)

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5. Elicit a pertinent history from a patient with signs of depression. (PC, ICS, P)6. Identify patients at risk for suicide or other harmful acts.(PC, MK, P)7. Treat depression with interventions, such as administration of antidepressants or referral for counseling. (PC, SBP)

J. Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)1. Define premenstrual symptoms, PMS, and PMDD. (MK)2. Describe the signs and symptoms of PMS/PMDD. (PC, MK)3. Describe the differential diagnosis of PMS/PMDD. (MK)4. Describe the relevance of a symptom diary in the diagnosis ofPMS/PMDD. (PC, MK)5. Elicit a pertinent history from a patient with signs of PMS/PMDD. (PC, ICS, P)6. Treat PMS/PMDD with interventions, such as lifestyle changes,supplements, non-prescription analgesics and prescriptionmedications. (PC)

K. Anxiety1. Describe the differential diagnosis of patients with an apparentanxiety disorder. (MK)2. Elicit a pertinent history for a patient with signs of an anxietydisorder. (PC, ICS, P)3. Treat mild anxiety with interventions such as administrationof anxiolytic agents or referral for counseling. (PC, SBP)

L. Skin disorders1. Obtain a history relevant to dermatologic risk factors:(PC, ICS, P)

a. Environmental exposure to ultraviolet lightb. Personal and hygienic habits predisposing to skin lesions

2. Perform a physical examination of all areas of skin, including those susceptible to chronic exposure to ultraviolet light. (PC,P)3. Perform a skin biopsy and interpret the results of the biopsy.(PC, MK)

4. Treat selected dermatologic conditions, such as: (PC)a. Uncomplicated sunburnb. Uncomplicated irritative or inflammatory skin disordersc. Poison ivy, oak, or sumac.d. Contact dermatitise. Insect bitesf. Fungal dermatitisg. Eczematous lesionsh. Mild acne

5. Describe the characteristic physical findings of basal cell carcinoma, squamous cell carcinoma, melanoma, and Paget’s disease. (PC, MK)6. Describe skin conditions that may be manifestations of significant systemic diseases. (MK)7. Describe the indications for referral of patients with skindisorders. (PC, SBP)

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M. Diabetes mellitus1. Describe the American Diabetes Association classification ofdiabetes mellitus. (MK)2. Describe risk factors for diabetes mellitus. (PC, MK)3. Describe signs and symptoms of diabetes mellitus. (PC, MK)4. Elicit a pertinent history in a patient with suspected diabetes mellitus. (PC, ICS, P)5. Describe the criteria for the diagnosis of diabetes mellitus. (MK)6. Describe the use of diet, oral hypoglycemic agents, and insulin for treatment of diabetes mellitus. (PC, MK)7. Assess glycemic control by laboratory studies. (PC)8. Describe indications for referral of patients with diabetes mellitus. (PC, SBP)

N. Thyroid diseases1. Describe the most common causes of hypothyroidism and hyperthyroidism. (MK)2. Describe the most common signs and symptoms of hypothyroidism and hyperthyroidism. (PC, MK)3. Elicit a pertinent history and perform a targeted physical examination to evaluate thyroid disease. (PC, ICS, P)4. Interpret the results of selected diagnostic tests to confirm the diagnosis of hypothyroidism or hyperthyroidism. (PC,MK)5. Describe the indications for referral of a patient with thyroid disease. (PC, SBP)

O. Low back pain1. Describe the differential diagnosis of low back pain. (MK)2. Obtain a pertinent history in a patient with low back pain.(PC, ICS, P)3. Perform a targeted physical examination to evaluate low back pain symptoms to evaluate possible gynecologic causes. (PC)4. Describe indications for referral of patients with more severe low back pain. (PC, SBP)

P. Osteoporosis1. Describe risk factors for osteoporosis. (MK)2. Describe the use and interpretation of screening tests for the identification of osteoporosis. (PC, MK)3. Describe the evaluation of secondary causes of osteoporosis. (MK)4. List preventive measures for osteoporotic bone loss and fracture.(MK)5. Treat osteoporosis and provide appropriate follow-up care. (PC, SBP)

ProceduresThe following Table lists the procedures pertinent to primary and preventive ambulatory care and summarizes the level of technical proficiency that should be achieved by a graduating resident. The resident should either understand a procedure (including indications, contraindications, and principles) or be able to perform it independently. These distinctions are based on the premise that knowledge of a procedure is implicit in the ability to perform it. (PC)

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Night Float/Primary Care RotationWEEKLY SCHEDULES

Schedule ASunday Monday Tuesday Wednesday Thursday Friday

Weeks 1 and 2

Night float 7am-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Lecture AM

Weeks 3 and 4

Off US Clinic/US Clinic/US ContinuityClinic

Clinic

Schedule BSunday Monday Tuesday Wednesday Thursday Friday

Weeks 1 and 2

Off US Clinic/US Clinic/US Continuity Clinic

Ultrasound at Seton Center

Weeks 3 and 4

Night float 7am-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Lecture and AM

NIGHT FLOAT/PRIMARY CARE READING SCHEDULE

Précis Series Primary and Preventive care,4rd editionACOG Committee Opinion on Primary Care number 357; December 2006

NIGHT FLOAT/PRIMARY CARE/CONTINUITY CLINIC

Procedure Level of Training Understanding Understandingand Perform

Arterial blood gas assessment R1 X

Auditory acuity testing R1 X

Bone densitometry studies R1 X

Complete physical examination R1 X

Electrocardiography R1 X

External auditory canal and

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tympanic membrane examination R1 X

Fecal occult blood testing R1 X

Funduscopic examination (basic) R1 X

Gastrointestinal endoscopy R1 X

Insertion and removal ofintrauterine device R1 X

Insertion and removal of implantable R1steroid contraception X

Peak expiratory flow (FEV) R1 Xdetermination

Fitting of diaphragm or cervical cap R1 X

Pulse oximetry R1 X

Skin biopsy R1 X

Scrapping of skin lesions for microscopy R1 X

Visual acuity testing(i.e., standard eye chart) R1 X

Visual field deficit testing R1 X

ULTRASOUND ROTATION

Goals and Objectives:This PGY-1 or PGY-2 rotation is incorporated into the PC rotation (for the PGY-1) or the OB-2 rotation (for the PGY-2), occurring within the first six rotation blocks of the academic year. This rotation occurs in the regional perinatal testing center, under the supervision of the Maternal Fetal Medicine faculty.

1. The main objective of this rotation is an introduction to the proper techniques and basics of obstetrical and gynecological ultrasound.

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WEEKLY SCHEDULE

Days will be assigned for protected ultrasound time in the RPC. This will occur every Monday, as well as additional days assigned by the PD or the assistant PD. These days will appear on the clinic schedule.

ULTRASOUND ROTATION READING SCHEDULE

Obstetrics Normal and Problem Pregnancies 5th edition Gabbe, Neibyl and SimpsonChapters 9,11

Williams Obstetrics 22 edChapter 16

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OBSTERICS ROTATIONS

Obstetrician–gynecologists must be able to recognize the physiologic changes of pregnancy and describe the gross anatomic changes of pregnancy. They must be able to recognize those factors in the history and physical examination that indicate possible medical or obstetric complications. They must understand how to obtain and apply information from the history, physical examination, and diagnostic studies to evaluate the course of pregnancy. In evaluating patients for preconception care, obstetrician–gynecologists must assess those factors of the history, physical examination, and diagnostic studies that pregnancy would alter; assess the patient’s access to, and compliance with, a plan of prenatal care; and consult with, or refer her to, other experts on specific conditions that may arise during the pregnancy.

In the clinical management of a normal term pregnancy, an understanding of the labor and delivery process is mandatory. Obstetrician–gynecologists must be able to determine the correct timing of delivery and to perform spontaneous vaginal, operative vaginal, as well as abdominal deliveries. The principles and practice of immediate newborn resuscitation remain an important function for the obstetrician and should be taught at the appropriate postgraduate level in conjunction with the obstetrics component of the residency curriculum.

Although the obstetrics resident is trained to address a variety of normal and complicated obstetric conditions, the resident should recognize that additional expertise may be required in certain patients and should refer to subspecialty- trained physicians as appropriate. The obstetrician–gynecologist must be familiar with the principles of obstetric anesthesia, including conduction anesthesia, general anesthesia, and local anesthesia techniques. Although the performance of these procedures is usually the responsibility of attendants trained in anesthesia, the obstetrician must be aware of the indications and contraindications for different anesthetic techniques and must be capable of managing anesthetic-related complications such as hypotension, seizures, and respiratory arrest.

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OBSTETRICS 1 ROTATION

Goals and Objectives:The PGY 1 rotation is four months in length, divided over the year. The resident is assigned to Labor and Delivery, and makes postpartum rounds on the floor.

A. Genetics 1. Describe the basic structure and replication of DNA. (MK)2. Describe the processes of mitosis and meiosis. (MK)3. Describe the clinical significance of karyotype abnormalities,such as: (MK)

a. Trisomyb. Monosomyc. Deletionsd. Inversions

4. Describe the clinical signifi cance of heritable diseases, such as cystic fibrosis, Tay-Sachs disease, and hemophilia.(MK)

B. Embryology and developmental biology 1. Describe the normal process of gametogenesis. (MK)2. Describe the normal process of fertilization. (MK)3. Describe the normal process of embryologic developmentof the singleton pregnancy. (MK)4. Describe the embryology of multiple gestations. (MK)

C. Anatomy 1. Describe the muscular and vascular anatomy of the pelvis and vulva. (MK)2. Describe the anatomic changes in the mother caused by normal physiologic adaptation to pregnancy. (MK)3. Describe the anatomic changes that occur during the intrapartum period, such as cervical effacement and dilatation. (MK)4. Describe the anatomic changes that occur during the puerperium, such as alterations in the breast and uterineinvolution. (MK)

D. Pharmacology 1. Describe the role for nutritional supplementation in pregnancy(e.g., iron, folic acid). (MK)2. Describe the impact of pregnancy on serum and tissue drug concentrations and drug efficacy. (MK)3. Describe the factors that influence transplacental drug transfer, such as: (MK)

a. Molecular sizeb. Lipid solubilityc. Degree of ionization at physiologic pHd. Protein binding

4. Describe the possible teratogenic effects of prescriptiondrugs in pregnancy, such as: (MK)

43

a. Tetracyclineb. Angiotensin-converting enzyme inhibitors and angiotensin antagonistsc. Quinolone antibioticsd. Lithiume. Isotretinoinf. Seizure medicationsg. Depression and anxiolytic medications

5. Describe the possible teratogenic effects of nonprescription drugs, such as: (MK)

a. Alcoholb. Heroinc. Cocained. Tobacco

C. Prenatal care 1. Perform a comprehensive history and physical examination. (ICS)2. Order and interpret routine laboratory tests and those required because of risk factors during pregnancy. (PC,SBP)3. Counsel patients about lifestyle modifi cations that improve pregnancy outcome. (ICS, P)4. Counsel patients about warning signs of adverse pregnancy events. (ICS, P)5. Schedule and perform appropriate antepartum follow-up visits for routine and high-risk obstetric care. (PC, PBLI,SBP)6. Counsel patients about appropriate immunizations during pregnancy. (ICS, SBP)7. Counsel patients about the benefits of breast feeding.(ICS, SBP)

D. Antepartum fetal monitoring 1. Describe the indications, contraindications, advantages, and disadvantages of antepartum diagnostic tests, such as: (MK, PC)

a. Nonstress testb. Contraction stress testc. Biophysical profiled. Vibroacoustic stimulation teste. Doppler velocimetry

2. Perform and interpret antepartum diagnostic tests accurately and integrate the interpretation of such tests into clinical management algorithms. (MK, PC, SBP)

E. Intrapartum fetal assessment1. Perform and interpret the following methods of fetal monitoring:(PC)

a. Intermittent auscultationb. Electronic monitoringc. Fetal scalp stimulationd. Vibroacoustic stimulation

2. Interpret the results of umbilical artery Doppler velocimetry.(PC)3. Describe the possible causes for, and clinical signifi cance of, abnormal fetal heart rate patterns: (MK)

a. Bradycardia

44

b. Tachycardiac. Variabilityd. Early decelerationse. Variable decelerationsf. Late decelerationsg. Sinusoidal waveform

4. Implement appropriate interventions, such as operative vaginal delivery and cesarean delivery for fetal heart rate abnormalities.(PC)

F. Labor and delivery1. Obtain an accurate history, describing onset of uterine contractions and ruptured membranes. (PC)2. Describe appropriate indications for induction of labor. (MK)3. Perform a pertinent physical examination to assess: (PC)

a. Status of membranesb. Presence of vaginal bleedingc. Fetal presentationd. Fetal positione. Fetal weightf. Cervical effacementg. Cervical dilatationh. Station of the presenting parti. Clinical pelvimetryj. Uterine contractility

4. Describe appropriate indications for, and complications of, cervical ripening agents. (MK)5. Describe appropriate indications for, and complications of, labor-inducing agents. (MK)6. Describe the normal course of labor. (MK)7. Assess the progress of labor. (PC)8. Describe the risk factors for abnormal labor. (MK)9. Identify abnormalities of labor. (MK)

a. Failed inductionb. Prolonged latent phasec. Protracted active phased. Arrest of dilatatione. Protracted descentf. Arrest of descent

10. Describe the appropriate role for, and complications of, the following interventions for abnormal labor: (MK)

a. Analgesia/anesthesiab. Amniotomyc. Augmentation of labord. Uterine contraction monitoringe. Episiotomyf. Operative vaginal forceps/vacuum deliveryg. Cesarean delivery

45

11. Recognize and appropriately evaluate abnormal fetal presentations and positions. (PC)12. Select and perform the most appropriate procedure for delivery. (PC)13. Counsel patients about the prognosis for abdominal versus vaginal delivery in a subsequent pregnancy. (ICS, P)

G. Postpartum Care- Evaluation of the newborn1. Perform an immediate assessment of the newborn infant and determine if resuscitative measures are indicated. (MK, PC)2. Resuscitate a depressed neonate: (PC)

a. Properly position the baby in the radiant warmer.b. Suction the mouth and nose.c. Provide tactile stimulation.d. Administer positive pressure ventilation with bag and mask.e. Administer chest compressions.

3. Assign Apgar scores. (PC)4. Describe the indications for cord blood gas analysis and interpret the test results. (MK)5. Obtain cord blood for the following purposes: (PC)

a. Blood gas analysisb. Determination of fetal blood typec. Cord blood storage

6. Describe the rationale for administration of topical antibiotics to prevent neonatal ophthalmic infection. (MK)7. Counsel parents about the advantages and disadvantages of circumcision. (ICS, P)

H. The puerperium1. Perform a focused physical examination in postpartum patients. (PC)2. Identify and treat the most common maternal complications that occur in the puerperium: (MK, PC)

a. Uterine hemorrhageb. Infectionc. Wound dehiscence (abdominal incision and episiotomy)d. Bladder instabilitye. Postoperative ileusf. Injury to the urinary tractg. Breast engorgement and mastitish. Pulmonary embolism (including amnionic fluid)i. Deep vein thrombosis

3. Recognize, treat, and refer as appropriate, postpartum affective disorders. (PC, ICS, SBP, P)4. Prescribe methods of reversible contraception. (MK)5. Counsel patients about permanent sterilization. (ICS, P)6. Perform postpartum surgical sterilization. (PC)7. Counsel patients about the advantages of and answer questions related to breast feeding. (ICS, P)8. Counsel patients regarding future pregnancies. (ICS, P)

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OBSTETRICS 1 ROTATIONWEEKLY SCHEDULE

Monday Tuesday Wednesday Thursday FridayAM L &D AM L &D AM L &D AM L &D AM L &DPM L &D PM L &D PM L &D PM L &D PM L &D

OBSTETRICS 1 READING SCHEDULE:

Obstetrics Normal and problem Pregnancies 5th editionChapters 1, 2, 5, 6, 7, 8, 11, 12, 13, 16, 17, 19, 20, 21, 22, 23, 24, 26, 31, 23, 33Or

Williams 23 edition (Chapters are same as in 22 edition)Chapters1,2,3,6,7,8,12,13,14,15,16,17,18,19,20,21,22,25,26,28,29,30,31,32,33

47

OBSTETRICS 2 ROTATION

Goals and Objectives;The PGY 2 rotation is four months in length, divided over the year. The resident is assigned to Seton Center Clinic, and makes postpartum rounds on the floor. Additionally, this rotation covers night float. The resident will be assigned schedule A or B based on elected vacation time. Vacation time will not be allowed while on a night float rotation to assure equal distribution of call.

A. Physiology1. Describe the major physiologic changes in each organ system during pregnancy. (MK)2. Evaluate symptoms and physical findings in a pregnant patient to distinguish physiologic from pathologic findings. (MK)3. Interpret common diagnostic tests in the context of the normal physiologic changes of pregnancy. (MK, PC, SBP)

B Preconception care 1. Perform a thorough history, assessing historical and ongoing risks that may affect future pregnancy. (PC, ICS)2. Counsel a patient regarding the impact of pregnancy on maternal medical conditions. (PC, MK, ICS, P)3. Counsel a patient regarding the impact of maternal medical conditions on pregnancy. (PC, MK, ICS, P)4. Counsel a patient regarding appropriate lifestyle modifications conducive to favorable pregnancy outcome. (PC,MK, ICS, P)5. Counsel a patient regarding appropriate preconception testing. (SBP)6. Counsel a patient regarding pregnancy-associated risks and conditions, such as: (MK, ICS, PC, P)

a. Advanced ageb. Hypertensionc. Diabetesd. Genetic disordere. Prior aneuploid or anomalous fetus/newborn

C. Preterm labor 1. Describe the multifactorial etiology of preterm labor. (MK)2. Obtain a complete obstetric history in patients with pretermlabor. (PC)3. Perform a thorough physical examination to determine uterine size, fetal presentation and fetal heart rate, and to assess cervical effacement and dilatation. (PC)4. Perform and interpret biophysical, biochemical, and microbiologic tests to assess patients with suspected preterm labor.(PC)5. Recognize the indications for, and complications of, interventions for preterm labor, such as: (MK, PC)

a. Antibiotics

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b. Tocolyticsc. Corticosteroidsd. Amniocentesise. Cerclagef. Bed rest

6. Describe the expected frequency and severity of neonatal complications resulting from preterm delivery, and describe the survival rates for preterm neonates based on age and weight. (MK)7. Appropriately counsel patients about management options for the extremely premature fetus. (ICS, P)8. Counsel patients about recurrence risk and preventive measures for preterm delivery. (ICS, P)

C. Bleeding in late pregnancy1. Describe the etiology of bleeding in late pregnancy. (MK)2. Describe the factors that predispose to placenta previa and abruptio placentae. (MK)3. Perform a focused physical examination in patients with bleeding in late pregnancy. (PC)4. Interpret diagnostic tests, such as: (MK)

a. Hematocritb. Platelet countc. Coagulation profiled. Kleihauer-Betke test

5. Perform the following diagnostic tests: (PC)a. Abdominal ultrasonography to localize the placenta and evaluate for possible placental separation.b. Endovaginal or transperineal ultrasonography to localize the placenta.

6. Determine the appropriate timing and method of delivery in patients with bleeding in late pregnancy. (MK, PC)7. Manage serious complications of abruptio placentae and placenta previa, such as hypovolemic shock and coagulopathy. (PC)8. Counsel patients about the recurrence risk for placenta previa and abruptio placentae. (MK, ICS, P)

D. Hypertension in pregnancy1. Describe the possible causes of hypertension in pregnancy.(MK)2. Describe the usual clinical manifestations of chronic hypertension, gestational hypertension, and preeclampsia. (MK)3. Perform a physical examination pertinent to patients with hypertension. (PC)4. Perform tests to: (MK, PC)

a. Determine the etiology of chronic hypertension.b. Differentiate chronic hypertension from preeclampsia and gestational hypertension.c. Assess the severity of chronic hypertension, gestational hypertension, and preeclampsia.

5. Assess fetal well-being in patients with hypertension in pregnancy (see Antepartum Fetal Monitoring). (PC)

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6. Treat hypertensive disorders of pregnancy. (PC)7. Recognize and treat possible maternal complications of hypertensionin pregnancy, such as: (PC)

a. Cerebrovascular accidentb. Seizurec. Renal failured. Pulmonary edemae. HELLP (hemolysis, elevated liver enzymes, and low plateletcount) syndromef. Abruptio placentae

8. Counsel patients about recurrence risk for gestational hypertension and preeclampsia in a subsequent pregnancy.(MK, ICS, P)

E. Postterm pregnancy1. Determine gestational age using a combination of menstrual history, physical examination, and ultrasound examination.(MK)2. Recognize unusual causes of postterm pregnancy, such as: (MK)

a. Lethal fetal anomaly (e.g., anencephaly)b. Placental sulfatase deficiency

3. Describe the potential fetal and neonatal complications ofpostterm pregnancy, such as: (MK)

a. Macrosomiab. Meconium aspiration syndromec. Oligohydramniosd. Hypoxiae. Dysmaturity syndromef. Fetal demise

4. Perform and interpret surveillance tests for the postterm fetus: (PC)a. Antepartum fetal heart rate testingb. Ultrasound examination

5. Describe appropriate indications for delivery in the postterm pregnancy. (MK)F. Premature rupture of membranes

1. Describe the possible causes of premature rupture of membranes (PROM) in preterm and term patients. (MK)2. Perform diagnostic tests to confirm rupture of membranes.(PC)3. Assess patients with PROM for lower and upper genital tractinfection. (PC)4. Describe the indications for, and complications of, expectant management in preterm and term patients with PROM. (MK)5. Describe the indications for, and complications of, induction of labor in preterm and term patients with PROM. (MK)6. Describe the role and possible complications of the following interventions in patients with preterm PROM: (MK)

a. Tocolyticsb. Corticosteroidsc. Antibiotics

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d. AmniocentesisG. Vaginal birth after cesarean delivery

1. Document an accurate history of a patient’s previous operative delivery. (PC)2. Counsel a patient about risks and benefits of vaginal birth after cesarean delivery (VBAC). (ICS, P)3. Describe the appropriate criteria for, and contraindications toVBAC, including criteria for anesthesia and hospital policies. (MK, PC, PBLI, SBP)4. Recognize and treat possible complications of VBAC, such as scar dehiscence, hemorrhage, fetal compromise, and infection. (PC)

OBSTETRICS 2 ROTATIONWEEKLY SCHEDULE

Schedule ASunday Monday Tuesday Wednesday Thursday Friday

Weeks 1 and 2

Night float 7am-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Lecture AM

Weeks 3 and 4

Off US Clinic/US Clinic/US Continuity Clinic

Ultrasound at Seton Center

Schedule BSunday Monday Tuesday Wednesday Thursday Friday

Weeks 1 and 2

Off US Clinic/US Clinic/US Continuity Clinic

Lecture/Clinic

Weeks 3 and 4

Night float 7am-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Night float 5pm-7am

Lecture AM

OBSTETRICS 2 READING SCHEDULE:

Obstetrics Normal and problem Pregnancies 5th editionChapters 3, 4, 9, 10, 14, 15, 18, 22, 25, 26, 28, 29, 30, 31, 32, 33, 37, orWilliams 23 edition (chapters same as in 22 edition)Chapters 4,5,6,10,16,23,24,27,34,35,36,37,38,39,40,52

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OBSTETRICS 3 ROTATION

Goals and Objectives:The PGY 3 rotation is four blocks in length divided over the year. The third year resident is assigned to the clinic, as well as is responsible for care of in patient ante partum patients.

A. Pathology and neoplasia 1. Describe symptoms and physical findings suggestive of malignancy in the pregnant patient. (MK)2. In consultation with a medical or gynecologic oncologist, counsel a patient about treatment options and their impact on pregnancy and the timing of delivery. (PC, ICS,P)

B. Microbiology and immunology 1. Describe the principal features of the host immunologic response. (MK)2. Describe how the maternal immune response is altered by pregnancy. (MK)3. Describe the basic features and timing of development of the fetal immunologic response. (MK)4. Describe the association between genital tract infection and adverse perinatal outcomes, such as: (MK)

a. Preterm laborb. Preterm premature rupture of membranesc. Neonatal infectiond. Maternal infection

C. Diabetes mellitus1. Classify diabetes mellitus in pregnancy. (MK)2. Interpret screening tests for gestational diabetes. (MK, PC,SBP)3. Monitor and control blood sugar in the pregnant patient with diabetes mellitus. (PC)4. Assess, recognize, and manage fetal and maternal complications such as: (MK, PC)

a. Fetal malformationsb. Disturbances in fetal growthc. Diabetic ketoacidosis

5. Counsel patients with diabetes regarding future reproduction and the long-term health implications of their medical condition. (ICS, P, SBP)

D. Diseases of the urinary system1. Evaluate signs and symptoms of urinary tract pathology in pregnant patients. (PC)2. Describe the indications for the common diagnostic tests for renal disease in pregnancy. (PC)3. Interpret the results of common diagnostic tests for renal disease in pregnancy. (MK, PC, SBP)4. Counsel patients about the possible adverse effects of diseases of the urinary tract on fetal and maternal outcome, such as: (ICS, P, SBP)

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a. Intrauterine growth restrictionb. Prematurityc. Perinatal mortalityd. Hypertension

5. Develop, in consultation with other specialists, a comprehensiveplan for the perinatal management of a patient with renal disease. (ICS, P, SBP, PBLI)

E. Infectious diseases 1. Perform a focused history and physical examination in pregnant patients who have known or suspected infectious diseases. (PC)2. Choose and perform laboratory tests to confirm the diagnosis of infection. (MK, PC, SBP)3. Assess the severity of a specific infection and its potential maternal, fetal, and neonatal impact. (PC)4. Describe the possible adverse maternal and fetal effects of antibiotics administered during pregnancy. (MK, PC, ICS)5. Manage specific infections in consultation with other specialists, as indicated. (ICS, P, SBP)

F. Hematologic disorders1. Evaluate possible causes of anemia, thrombocytopenia, deep vein thrombosis, and coagulopathy in pregnancy.(MK)2. Institute appropriate acute and chronic management plans for these conditions, including prophylaxis to minimize recurrence risk. (PC, SBP)3. Counsel patients about the fetal and maternal impact of hematologic disorders in pregnancy. (ICS, P)

E. Cardiopulmonary disease1. Describe symptoms and physical findings suggestive of cardiopulmonary disease in pregnancy. (MK)2. Describe the indications for and interpret the results of common diagnostic tests for cardiopulmonary disease in pregnancy. (MK, PC)3. Classify maternal cardiac disease in pregnancy and describe the associated maternal and fetal risks. (MK)4. Order appropriate fetal evaluation in patients with congenital heart disease.5. Counsel patients about the impact of pregnancy on cardiopulmonary disease and the impact of these diseases on pregnancy. (ISC, P)6. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with cardiopulmonary disease. (P, SBP)

F. Gastrointestinal disease1. Perform a history and physical examination for the diagnosis of gastrointestinal disease in pregnancy. (PC)2. Describe the indications for and interpret the results of common diagnostic tests for gastrointestinal disease in pregnancy. (MK, PC)3. Diagnose and provide initial management of common gastrointestinal diseases in pregnancy. (MK, PC)4. Counsel patients about the impact of gastrointestinal disease on pregnancy and the impact of pregnancy on gastrointestinal disease. (ICS, P)

53

5. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with gastrointestinal disease. (P, SBP)

G. Neurologic disease1. Perform a focused history and neurologic examination in pregnant patients with a known or suspected neurologic disorder. (PC)2. Describe the indications for and interpret the results of common diagnostic tests for neurologic disease in pregnancy. (MK, PC)3. Counsel pregnant patients regarding the impact of pregnancy on neurologic disease and the impact of the diseas on pregnancy. (ICS, P)4. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with neurologic disease. (P, SBP)

H. Endocrine disorders (excluding diabetes mellitus)1. Perform a focused history and physical examination in pregnant patients with a known or suspected endocrine disease. (PC)2. Describe the indications for and interpret the results of common diagnostic tests for endocrine disease, such as:(MK, PC)

a. Thyroid function testsb. Adrenal function testsc. Pituitary function testsd. Imaging studies

3. Counsel patients about the impact of an endocrine disease and its treatment on pregnancy and the impact of pregnancy on the endocrine disorder. (ICS, P)4. In consultation with other specialists, develop a comprehensive plan for the perinatal management of patients with an endocrine disorder. (P, SBP)

I. Collagen vascular disorders1. Perform a focused history and physical examination in pregnant patients with known or suspected collagen vascular disease. (PC)2. Describe the indications for and interpret the results of common diagnostic tests for collagen vascular disease in pregnancy, such as: (MK, PC)

a. Serologic tests for rheumatoid factorb. Anti-DNA antibodiesc. Antinuclear antibodiesd. Lupus anticoagulante. Anticardiolipin (antiphospholipid) antibodiesf. Anti-Ro, Anti-La

3. Counsel patients regarding the impact of collagen vascular disease and its treatment on pregnancy and the impact of pregnancy on collagen vascular disease. (ICS, P)4. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with collagen vascular disease. (P, SBP)

J. Psychiatric disorders1. Perform a mental status examination. (PC)2. Describe the symptoms of common psychiatric disorders in pregnancy. (MK)3. Assess the risk of psychiatric disorders such as bipolar disorder, schizophrenia, depression, and the safety of psychiatric medications in the patient and her fetus. (PC,ICS)

54

4. Identify patients who require referral for psychiatric consultation.(P, SBP)

K. Emergency care during pregnancy1. Perform a diagnostic history and physical examination in pregnant patients with a medical or surgical emergency.(PC)2. Order and interpret diagnostic tests, such as CT or MRI scan, lumbar puncture, and x-rays, to assess for adverse effects of emergency conditions on the developing pregnancy.(MK, PC)3. Initiate therapy, in consultation as necessary, and describe the impact of the condition on the pregnancy as well as the impact of the pregnancy on the emergent condition. (ICS, P)4. Describe the timing of delivery in obstetric patients with emergent conditions. (MK)

L. Substance abuse in pregnancy1. Describe behavior patterns suggestive of substance abuse.(MK)2. Perform a thorough history and physical examination in patients suspected of substance abuse in pregnancy. (PC)3. Counsel patients about the impact of substance abuse on the fetus/neonate. (ICS, P)4. Assess the fetus for adverse effects of substance abuse, such as congenital anomalies or growth restriction. (MK)5. Refer patients with known or suspected substance abuse for counseling and follow-up. (P, SBP)

M. Second-trimester pregnancy loss1. Describe the usual symptoms and clinical manifestations of a second-trimester abortion. (MK)2. Describe the risk factors for, and etiologies of, second-trimester pregnancy loss. (MK)3. Perform a physical examination and order diagnostic tests to identify the site of genital tract bleeding, assess cervical effacement and dilatation, and evaluate uterine contractions. (PC)4. Perform diagnostic tests to assess patients with threatened second-trimester pregnancy loss, such as: (PC)

a. Ultrasonographyb. Genital tract cultures

5. Implement appropriate medical and surgical management (including cervical cerclage) for patients with threatened second-trimester abortion. (PC)6. Manage the complications of second-trimester pregnancy loss, such as: (MK, PC)

a. Chorioamnionitisb. Retained placentac. Uterine hemorrhage

7. Counsel patients who have experienced second-trimester pregnancy loss about recurrence risk. (ICS, P)

N. Multiple gestation1. Describe the factors that predispose to multiple gestation.(MK)

55

2. Describe the physical findings suggestive of multiple gestation.(MK)3. Confirm the diagnosis of multiple gestation by performingan endovaginal or abdominal ultrasound examination. (PC)4. Describe the medical rationale for selective fetal reductionin higher order multiple gestation. (MK)5. Describe, diagnose, and manage the maternal and fetal complications associated with multiple gestation. (PC)6. Perform tests to assess the general well-being of the fetuses of a multiple gestation. (PC)7. Counsel patients as to the antenatal testing and delivery plans for multiple gestations. (ICS, P, PC)

O. Fetal death1. Describe the clinical history indicative of fetal death. (MK)2. Describe the possible causes of fetal death. (MK)3. Confirm the diagnosis of fetal death by ultrasound examination.(PC)4. Interpret the results of diagnostic tests to determine the etiology of fetal death. (PC)5. Select and perform the most appropriate procedure for uterine evacuation based on considerations of gestational age and maternal history. (PC)6. Describe and treat the principal complications of a retained dead fetus. (MK)7. Describe and treat the major complications of surgical and medical uterine evacuation. (PC)8. Describe the grieving process associated with pregnancy loss and refer patients for counseling as appropriate. (PC)9. Counsel patients about recurrence risk for fetal death. (ICS, P)

P. Intrauterine growth restriction1. Describe the factors that predispose to fetal growth restriction.(MK)2. Assess uterine size by physical examination and identify size/date discrepancies. (PC)3. Evaluate the patient for causes of intrauterine growth restriction. (PC)4. Perform an accurate ultrasound examination to assess fetal growth. (PC)5. Monitor a fetus with suspected growth restriction (e.g., with antepartum heart rate tests, ultrasonography, and Doppler velocimetry) to determine the appropriate time and method of delivery. (PC)6. Counsel patients about the recurrence risk for intrauterine growth restriction. (ISC, P)

Q. Isoimmunization and alloimmune thrombocytopenia1. Describe the major antigen–antibody reactions that result in red cell isoimmunization or thrombocytopenia. (MK)2. Interpret serologic assays that quantify antibody titers. (PC)3. Describe the appropriate indications for determination of paternal antigen status. (MK)4. Describe the major fetal complications of isoimmunization and alloimmune thrombocytopenia. (MK)

56

5. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with isoimmunization and alloimmune thrombocytopenia. (P, SBP)

OBSTETRICS 3WEEKLY SCHEDULE

Monday Tuesday Wednesday Thursday FridayAM L&D Continuity

ClinicL &D Clinic Lecture

PM L&D ContinuityClinic

L &D Clinic Clinic

OBSTETRICS 3 READING SCHEDULE

Obstetrics Normal and Problem Pregnancies 5th edition Gabbe, Niebyl and SimpsonChapters 28 – 40

Williams Obstetrics 23 editionChapters 41-59

Creasy and Resnik Maternal Fetal Medicine 5th editionSelected Chapters

57

OBSTETRICS 4/MATERNAL FETAL MEDICINE

Goals and Objectives:The PGY 4 rotation in Maternal Fetal Medicine and Obstetrics is four months in length divided over the year. The chief resident manages the entire service, gaining in the administrative aspect of the obstetric care, including risk management, case presentation and teaching responsibilities of the lower level residents. The chief resident is ultimately responsible for the lower level residents seeing patients in clinic, Labor and Delivery, the ante partum and postpartum wards. The goals and objective for this rotation include those as listed in the Obstetrics 3 rotation, with the addition of the following.

A. Describe the general indications for genetically based diagnostics.(PC)

B. Perform or interpret genetic risk assessment through: (PC)1. Pedigree analysis2. Gene testing

a. Antenatalb. Adult

C. Describe the sensitivity and specificity of various genetic tests and the implication of these parameters in clinicalpractice. (PC)

D. Describe the role of genetics in drug metabolism and individual variation in drug effi cacy. (PC)

E. Discuss the factors involved in the development of and recommendations for genetic testing. (PC)

1. Frequency of the condition in the population.2. Nature and range of severity of the condition.3. Treatment, intervention, and/or prevention.4. Reproductive options to avoid or reduce risk.5. Test availability including prenatal screening and/or diagnostictesting.6. Sensitivity, specifi city, and positive predictive value of thetest.7. Genotype-phenotype correlation.8. Frequency of gene mutation in general population or selective sub-groups based on ethnicity/race.9. Cost and cost-effectiveness of screening.10. Usefulness of test information to individual, to family andto society.11. Availability of public and professional educational material/programs.12. Availability of adequate genetic counseling services forfollow-up.13. Potential for uncertainty of tests results.

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14. Potential for psychological, emotional, or physical harmto patient.15. Potential for misuse of information and genetic discrimination.

F. List the types of genetic abnormalities that may result inclinically signifi cant abnormalities. (MK)

1. Deletions2. Additions3. Trinucleotide repeats4. Microsatellite instability5. Mitochondrial DNA abnormalities

G. Describe stem cells and potential uses of stem celltechnology.

H. Basic mechanism of genetic inheritance1. Describe the basic structure and replication of DNA. (MK)2. Describe the processes of mitosis and meiosis. (MK)3. Describe common terms associated with genetic expression.(MK)

a. Exonb. Intronc. Codond. Transcriptione. Translation

4. Describe the clinical significance of karyotype abnormalities,such as: (PC)a. Trisomy

i. 13ii. 18iii. 21

b. Polyploidyc. Monosomyd. Sex chromosome abnormalitiese. Deletionsf. Inversionsg. Translocationsh. Mosaicismi. Chimeras

5. Describe the normal process of gametogenesis. (MK)6. Describe the normal process of fertilization and the combination of genetic information. (MK)

I. Clinical implications of heritable disease1. Describe the clinical significance of heritable diseases, such as cystic fibrosis, Tay-Sachs disease, and hemophilia.(PC)2. Counsel patients about the techniques for and implications of testing for heritable diseases. (PC, ICS)

59

3. Discuss treatment and surveillance options for patients or newborns with genetically derived disease. (PC)

J. Genetic counseling1. Elicit a history for inherited disorders, ethnic- or racespecific risks, and teratogen exposure. (PC)2. Describe the concepts of penetrance and variable expression and their impact on prognosis for a given genetic disorder. (MK, PC)3. Distinguish between various forms of genetic inheritance: (MK)

a. Autosomal dominantb. Autosomal recessivec. X-linkedd. Mitochondriale. Genomic imprinting

4. Counsel patients about the manifestations of common genetic disorders. (PC, ICS)5. Describe the indications for, and limitations of, noninvasive diagnostic tests for fetal aneuploidy and structural malformations (e.g., ultrasonography, serum analytes).(PC, SBP)6. List ultrasonography fi ndings that are often associated with genetic disorders for: (PC)

a. Duodenal atresiab. Omphalocelec. Nuchal translucency/nuchal skin foldd. Echogenic bowele. Heart defectsf. Diaphragmatic herniag. Ventriculomegaly

7. Counsel patients about the risks and benefi ts of various methods of invasive fetal testing, such as: (PC, ICS)

a. Chorionic villus samplingb. Amniocentesisc. Cordocentesisd. Pre-implantation genetic testing

8. Order and interpret appropriate maternal and fetal/neonatal tests to evaluate possible causes of fetal demise. (PC)9. Counsel a patient with an abnormal fetus regarding management options. (PC, SBP, ICS)10. Counsel a patient and her family after adverse pregnancy outcome about such factors as recurrence, future care, and possible interventions. (PC, SBP, ICS)11. Counsel a patient and other health care professionals about fetal effects from exposure to various pharmacologic agents or to indicated diagnostic studies utilizing ionizing radiation. (PC, ICS)12. Counsel a patient about the genetic implications of advancing maternal and paternal age. (PC, ICS)

60

K. Describe the indications and uses for umbilical cord stem cells and counsel patients on the advantages and disadvantages of umbilical cord blood banking. (PC, MK, ICS

OBSTETRICS 4/MATERNAL FETAL MEDICINEMFM WEEKLY SCHEDULE**

Monday Tuesday Wednesday Thursday FridayRPC L & D Continuity

ClinicL&D Lecture/L & D

RPC L &D Continuity Clinic

L&D L&D

The Obstetrics 4/MFM rotation resident will be assigned additional days in the RPC by the program Director and/or assistant program director.

OBSTETRICS 4/MFM RotationREADING SCHEDULE

Obstetrics Normal and Problem Pregnancies 5th edition Gabbe, Niebyl and SimpsonChapters 28 – 40

Williams Obstetrics 23 editionChapters 41-59

TeLinds Operative Gynecology 10th editionRock and JonesChapter 35

Creasy and Resnik Maternal Fetal Medicine 5th editionSelected Chapters

61

OBSTERICAL PROCEDUARAL COMPETENCIESProcedure Level of Training Understanding Understanding

and PerformAntepartumAmniocentesis

2nd trimester-genetic dx R2 X3rd trimester-asst. of fetal lung maturity R2 X

Cervical cerclageTransabdominal R4 XTransvaginal R3 X

Chorionic villus sampling R3 XCordocentesis R3 XFetal assessment, antepartum

Biophysical profile R1 XContraction stress test R1

XNonstress test R1 XVibroacoustic stimulation R1 X

Intrauterine transfusion R3 XUltrasound examination

Abdominal and endovaginal R1 XAbdominal ultrasonography,

targeted examination R2 XColor Doppler ultrasonography R3 XThree-dimensional ultrasonography R4 X

Doppler velocimetry R4 XVersion of breech, external R3 XIntrapartumAmnioinfusion R1 XAmniotomy R1Anesthetic/analgesic procedures

Administration of parenteralAnalgesics/sedatives R1 X

Administration of narcotics R1 XEpidural anesthesia R1 XGeneral anesthesia R1 XSpinal anesthesia R1 X

Cesarean delivery XClassical R2 XLow transverse R1 XLow vertical R1 X

Cesarean hysterectomy R3 XCurettage for adherent placenta R2 XDilation and evacuation for second-

trimester fetal death R3 XEpisiotomy and repair R1 X

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Fetal assessment, intrapartumFetal heart rate monitoring R1 X

Procedure Level of Training Understanding Understandingand Perform

Fetal scalp pH determination R1 XFetal scalp stimulation test R1 XVibroacoustic stimulation test R1 X

Forceps deliveryOutlet R3 XLow R3 X

Hypogastric artery ligation R3 XInduction of labor with prostaglan-

Dins or oxytocin R1 XManual removal of the placenta R1 XSkin incision

Vertical R2 XTransverse R1 X

Suction evacuation for the first-trimester fetal death R1 X

Uterine artery ligation R3 XVacum extraction

Outlet R1 XLow R2 X

Vaginal delivery, breech R3 XVaginal delivery, spontaneous R1 XPostpartumCircumcision, neonatal (with

anesthesia) R1 XHematoma evacuation

Intraabdominal R2 XVulvar R3 XVaginal R3 X

Neonatal resuscitation, immediate R1 XRepair of genital tract laceration

Cervical R3 XPerineal (second, third, and

fourth degree lacerations)R3 XVaginal R1 X

Sterilization R2 XWound Care

Debridement R2 XIncision and drainage of

abscess or hematoma R3 XRepair of dehiscence R3 XSecondary closure R3 X

63

GYNECOLOGY ROTATION

The practice of gynecology includes both surgical and nonsurgical treatment of disorders of the female reproductive tract. Once primarily a surgical specialty, as a result of advances in therapeutic and diagnostic techniques, gynecology has increasingly become more offi ce-based. In addition to primary office care, the gynecologist often cares for patients with more specialized needs, including those of patients with endocrinologic disorders, infertility and pregnancy loss, urologic disorders, cancer of the reproductive tract, and conditions requiring acute and critical care. In acquiring skills andknowledge in the general discipline of obstetrics and gynecology, residents should assimilate diagnostic and therapeutic principles underlying a broader spectrum of medical and surgical disorders. Once in clinical practice, the gynecologist often remains the primary health care provider for patients who have been treated by subspecialists or by physicians outside the specialty of obstetrics and gynecology.

64

GYNECOLOGY 1 ROTATION

Goals and Objectives:The PGY 1 rotation is four blocks divided over the year. Under the supervision of a chief resident and faculty, the PGY 1 resident evaluates patients preoperatively and postoperatively for basic, primarily out patient or minor surgical procedures.

A .Physiology (MK)1. Describe the hemodynamic changes associated with blood loss.2. Summarize the changes that occur in the cardiopulmonary function of an anesthetized and postanesthetic patient.3. Describe the physiology of wound healing.4. Describe the physiology of blood pressure maintenance and abnormalities of blood pressure.5. Describe the physiologic changes related to the maintenance of adequate urine output.6. Describe the physiology of thermoregulation in the anesthetizedand postanesthetic patient.

B. Pathology and neoplasia (MK)1. Summarize the pathogenesis and epidemiology of the common nonmalignant neoplasms that affect the external and internal genitalia.2. Describe the histology of the common non-malignant neoplasms that affect the external and internal genitalia.

C. Microbiology and immunology (MK)1. Describe the normal bacteriologic flora of the lower genital tract.2. Describe the microbiologic principles germane to the diagnosis and treatment of gynecologic infectious diseases.3. Describe the epidemiologic principles involved in the spread of infectious diseases in both patients and health care workers, including transmission and prevention of human immunodeficiency virus (HIV) and hepatitis.4. Discuss the immunologic response to infection.

D. Abnormal/Dysfunctional uterine bleeding1. Describe the principal causes of abnormal uterine bleeding and distinguish abnormal uterine bleeding from dysfunctional uterine bleeding. (MK)2. Elicit a pertinent history to evaluate abnormal uterine bleeding. (PC)3. Perform a focused physical examination to investigate the etiology of abnormal uterine bleeding.4. Perform and interpret the results of selected diagnostic tests to determine the cause of abnormal uterine bleeding, such as: (PC)

a. Endometrial biopsyb. Pelvic ultrasonography/saline infusion ultrasonography

65

c. Hysteroscopyd. Laparoscopy

5. Interpret the results of other diagnostic tests, such as:(PC)a. Serum/urine human chorionic gonadotropin (hCG)assayb. Endocrinologic assaysc. Microbiologic cultures of the genital tractd. Complete blood counte. Coagulation profile

6. Treat abnormal uterine bleeding using both nonsurgical and surgical methods. (PC)7. Recommend appropriate follow-up that is necessary for a patient with abnormal uterine bleeding. (PC)

E. Vaginal and vulvar infections1. Describe the principal infections that affect the vulva and vagina. (MK)2. Elicit a pertinent history in a patient with a possible infection of the vulva or vagina. (PC)3. Perform a focused physical examination. (PC)4. Perform and interpret the results of selected tests to confirm the diagnosis of vulvar or vaginal infection, such as:(PC, MK)

a. Vaginal pHb. Saline microscopyc. Potassium hydroxide microscopyd. Bacterial, fungal and viral culturee. Colposcopic examinationf. Vulvar or vaginal biopsy

5. Treat vulvar and vaginal infections. (PC)6. Describe the follow-up that is necessary for a patient witha vulvar or vaginal infection, for example: (PC, P, SBP,ICS).

a. Assessing and treating sexual partner(s)b. Requirements for reporting a communicable diseasec. Assessing the patient for other possible genital tractinfectionsd. Counseling the patient with respect to measures that prevent reinfection

F. Sexually transmitted diseases1. Describe the most common STIs, including causes, symptoms, and risk of transmission, such as: (MK)

a. Chlamydiab. Gonorrheac. Syphilisd. Hepatitis B and hepatitis Ce. Human immunodeficiency virus (HIV)f. Herpes simplexg. Human papillomavirus

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h. Chancroid2. Elicit a pertinent history in a patient with a suspected STI. (PC)3. Perform a focused physical examination in a patient with a suspected STI. (PC)4. Perform and/or interpret results of specific tests to confirm the diagnosis of an STI, such as: (PC)

a. Bacterial and/or viral cultureb. Endocervical aspirate for Gram stainc. Endocervical swab for nucleic acid probed. Endocervical culturee. Cervical or vaginal cytologic screening (Pap test) and HPV testingf. Scraping of an ulcer or chancreg. Serologic assaysh. Tzanck smear

5. Treat STIs with appropriate antimicrobial agents. (PC)6. Describe the long-term follow-up for patients with a STI, including assessment of the patient’s sexual partner, discussion of preventive measures, and review of serious sequelae, such as: (PC, ICS, P, SBP)

a. Infertilityb. Ectopic pregnancc. Chronic pelvic paind. Pelvic infl ammatory disease (PID)e. Cervical dysplasia, neoplasia

G. Spontaneous abortion1. Describe the principal causes of, or predisposing factors for, spontaneous first-trimester abortion. (MK)2. Describe the differential diagnosis of early spontaneous abortion.(MK)3. Describe the usual symptoms and findings experienced by a patient with an early pregnancy loss. (MK)4. Perform a focused physical examination to confirm the diagnosis of spontaneous abortion. (PC)5. Perform and/or interpret the results of selected tests used in the diagnosis and management of early pregnancy loss: (PC)

a. Quantitative serum hCG titerb. Ultrasonography (abdominal and endovaginal)c. Serum progesteroned. Complete blood count

6. Treat a patient with an early spontaneous abortion, using nonsurgical or surgical methods. (PC)7. Describe and treat the complications that may develop as a result of treatment of a spontaneous abortion, for example:(PC)

a. Genital tract infectionb. Uterine perforationc. Retained products of conception

8. Describe the indications for anti-D immune globulin in patients experiencing a spontaneous abortion. (MK)

67

9. Counsel patients regarding future fertility issues and risk of recurrent pregnancy losses depending on the etiology (PC,ICS, P)10. Summarize signs and symptoms, diagnosis, treatment, and potential sequelae for septic abortion. (MK)

GYNECOLOGY I ROTATION

WEEKLY SCHEDULE*

Monday Tuesday Wednesday Thursday Friday

AM OR OR OR Continuity Clinic

Lecture

PM OR OR OR ContinuityClinic

Pre Op Conference and Post op Clinic

GYNECOLOGY 1 READING SCHEDULE

Comprehensive Gynecology 5th editionStenchever, Droegemeuller, Herbst & MishellChapters 1 – 19, 22,23, 24, 25

68

GYNECOLOGY 2 ROTATION

Goals and Objectives:This PGY II rotation is four months divided over the year. Under the supervision of the chief resident and the faculty the PGY II resident begins to evaluate surgical canidates patients pre-operatively, and learn post-operative care.

A. Pharmacology (MK)1. Describe the general principles of drug delivery, distribution, metabolism, and excretion.2. Summarize the pharmacology of medications used in the treatment of common gynecologic disorders.3. Explain the pharmacologic principles of drug therapy in prepubertal girls, women of reproductive age, and elderly patients.4. Describe the components of commonly used contraceptive agents and their mechanism of action.

B. Vulvar dystrophies, dermatoses and vulvar pain syndromes1. Describe the principal types of vulvar dystrophies and dermatoses, such as: (MK)

a. Squamous cell hyperplasiab. Lichen sclerosusc. Lichen planusd. Lichen simplex chronicuse. Atrophic dermatitisf. Vulvar vestibulitis and vulvodynia

2. Elicit a pertinent history in a patient with a suspected vulvar dystrophy, dermatosis or vulvar pain syndrome. (PC)3. Perform a focused physical examination in a patient with a suspected vulvar dystrophy, dermatosis or vulvar pain syndrome. (PC)4. Perform and/or interpret the results of selected diagnostic tests to confirm the diagnosis of a vulvar dystrophy or dermatosis, for example: (PC, MK)

a. Colposcopyb. Staining with dyes to localize the affected areac. Vulvar biopsy

5. Treat common vulvar dystrophies dermatoses and vulvar pair syndromes medically and surgically. (PC)6. Describe follow-up for a patient with a vulvar dystrophy or dermatosis, including the risk, if present, for malignant change. (PC)

C. Urinary tract disorders (infection, nephrolithiasis)1. Distinguish the types of urinary tract infection, including bacteruria, urethritis, cystitis, and pyelonephritis. (MK)

69

2. Describe the pathophysiology related to urinary tract infection, including the organisms commonly implicated in lower and upper urinary tract disorders, and host factors, such as urinary retention, age, and pregnancy. (MK)3. Describe the pathophysiology of the common forms of nephrolithiasis, including patient risk factors for the development of nephrolithiasis. (MK)4. Describe typical clinical presentations, and elicit a pertinent history, in a patient with a possible urinary tract infection or nephrolithiasis. (PC)5. Describe the diagnostic methods and diagnostic criteria for the various types of urinary tract infections. (MK)6. Summarize the methods used for the diagnosis of nephrolithiasis.(MK)7. Describe modes of therapy for acute, chronic, and complicated urinary tract infections, including prophylaxis for recurrent infection. (MK, PC)8. Summarize therapeutic options for nephrolithiasis, and strategies to prevent recurrence. (MK, PC)

D. Chronic pelvic pain1. Define chronic pelvic pain. (MK)2. Outline the principal gynecologic and nongynecologic causes of chronic pelvic pain, and describe the pathophysiology of each cause. (MK)3. Elicit a pertinent, detailed medical, menstrual, and sexual history to characterize the patient’s chronic pelvic pain, including signs/symptoms emanating from non-reproductive organs. (PC)4. Elicit an appropriate social and mental health history in a patient with chronic pelvic pain. (PC)5. Perform a focused physical examination, including attempts to localize the pain and an evaluation of neurologic and musculoskeletalcomponents. (PC)6. Perform and/or interpret the results of the following selected diagnostic tests to determine the cause of chronic pelvic pain:(PC, ICS)

a. Microbiologic cultures of the genitourinary tractb. Radiologic imaging studiesc. Hysteroscopyd. Laparoscopye. Injection of anesthetic agent at a specifi c trigger point.f. Mental health examination, including screening for depressionor dysphoria.

7. Treat patients with chronic pelvic pain, using nonsurgicaland surgical methods. (PC)8. Summarize indications and approximate success rates forinterventions for chronic pelvic pain, such as laparoscopy,presacral neurectomy, uterosacral nerve ablation, adhesiolysis,and extirpative procedures. (MK, PC)9. Describe the indications for referral of a patient to a specialistin urology or gastroenterology. (PC, SBP)10. Describe the indications for referral to a multidisciplinary group, including pain management specialists and behavioraland/or mental health. (PC, SBP)

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11. Describe the appropriate long-term goals and follow-up for a patient with chronic pelvic pain. (PC, SBP, P)

J. Endometriosis1. Summarize the theories of the pathogenesis of endometriosis.(MK)2. Describe the typical history of a patient with endometriosis.(MK)3. Perform a focused physical examination in a patient with suspected endometriosis and identify the principal abnormal clinical findings. (PC)4. Perform and interpret the results of selected tests to confi rm the diagnosis of endometriosis, for example: (PC)

a. Endovaginal ultrasonographyb. Laparoscopy with/without biopsy

5. Describe various features of endometriosis on visual inspection with laparoscopy or laparotomy. Compare the sensitivity of visual inspection with biopsy in diagnosing endometriosis.(MK)6. Describe the staging system for endometriosis according to the American Society for Reproductive Medicine Classifi cation of Endometriosis. (MK)7. Treat endometriosis medically and surgically. (PC)8. Describe the appropriate long-term follow-up and outcome in patients who have endometriosis, including infertility. (MK, PC)

K. Ectopic pregnancy1. Describe the major factors that predispose to ectopic pregnancy. (MK)2. Elicit a pertinent history in a patient with a suspected ectopic pregnancy. (PC)3. Perform a focused physical examination in a patient with suspected ectopic pregnancy. (PC)4. Describe the differential diagnosis of ectopic pregnancy. (MK)5. Perform and interpret the results of tests to confirm the diagnosis of ectopic pregnancy, such as: (PC)

a. Endovaginal ultrasonographyb. Uterine curettage or aspirationc. Laparoscopy

6. Interpret the results of other diagnostic tests, such as: (PC)a. Quantitative serum hCG titerb. Complete blood count

7. Describe the indications and contraindications for, and complications of, medical and surgical management of an ectopic pregnancy. (PC)8. Counsel a patient about the risks and effectiveness of medical and surgical ttherapy for ectopic pregnancy.9. Treat an affected patient using appropriate nonsurgical or surgical methods. (PC)10. Describe the indications for anti-D immune globulin in patients with an ectopic pregnancy. (MK)11. Describe the follow-up that is indicated for a patient treatedfor an ectopic pregnancy. (PC, ICS)

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12. Counsel patients about the recurrence risk for an ectopic pregnancy and prognosis for a normal intrauterine pregnancy. (PC, ICS, P)

GYNECOLOGY 2 ROTATION

WEEKLY SCHEDULE*

Monday Tuesday Wednesday Thursday Friday

AM OR Continuity Clinic

OR OR Lecture

PM OR ContinuityClinic

OR OR Pre Op Conference/Post

Op Clinic

GYNECOLOGY 2 READING SCHEDULE

Comprehensive Gynecology 5th editionStenchever, Droegemeuller, Herbst & Mishell Chapters 20,21,24

TeLinds Operative Gynecology 10th editionRock and JonesChapters 7,10,14,15,16,17,18,19, 32,33,34

72

GYNECOLOGY 3 ROTATION

Goals and Objectives:This PGY III rotation is four months divided over the year. This PGY-3 is assigned primarily to the OR, and develops greater experience in the running and operations of the gynecologic service. Under the supervision of the Chief Resident and the Faculty they will refine their learning the principles of abdominal and vaginal surgery.

A. Basic mechanism of genetic inheritance1. Describe the inheritance of hemoglobinopathies. (MK)2. Summarize the genetic basis for hereditary cancer syndromes in women such as: (MK)

a. Breast cancerb. Colon cancerc. Ovarian cancerd. Endometrial cancer

3. Describe the implications of the integration of viral genetic information into normal cervical cells. (MK)

B. Clinical implications of genetic inheritance1. Describe the role of genetics in the following: (MK)

a. Spontaneous abortionb. Recurrent abortionc. Uterine leiomyomata

C. Urogynecology (urinary incontinence and pelvic support defects)1. Explain the normal anatomic supports of the vagina, rectum, bladder, urethra, and uterus (or vaginal cuff in the setting of prior hysterectomy), including the bony pelvis, pelvic floor nerves and musculature, and connective tissue. (MK)2. Describe the static and dynamic interrelationships and function of the pelvic organs and support mechanisms.(MK)3. Summarize the normal function of the lower urinary tract during the filling and voiding phases, and the mechanisms responsible for urinary continence. (MK)4. Summarize the potential psychological, social, and sexual consequences of urogynecologic disorders. (MK)5. Describe the principal etiologies of pelvic support defects, urinary incontinence, and fecal incontinence, including effects of pregnancy and delivery. (MK)

73

6. Identify the anatomic defects associated with various aspects of pelvic support disorders. (MK)7. Characterize the major types of urinary incontinence.(MK)8. Describe abnormal urethral conditions, including urethral syndrome, urethritis, and diverticuli. (MK)9. Describe the possible etiologies, diagnostic strategies, and treatment approaches for interstitial cystitis. (MK, SBP)10. Describe the various types of urinary voiding disorders and their possible etiologies, including medical and surgicalcauses. (MK)11. Describe the etiologies, prevention, diagnostic techniques, and approaches to repairing various fistulae that may involve the pelvic organs. (MK)12. Describe the symptoms that may be experienced by a patient with pelvic support defects, urinary incontinence, or fecal incontinence. (MK)13. Elicit a pertinent history in a patient with a suspected pelvic support defect, urinary incontinence, or fecal incontinence.(PC)14. Perform a focused physical examination to identify and characterize specific pelvic support defects, including:(PC)

a. Anterior compartmentb. Urethral hypermobilityc. Posterior compartmentd. Apical compartment (cervix/uterus or vaginal cuff)

15. Perform a focused physical exam in a patient with urinary and/or fecal incontinence, including assessment of: (PC)

a. Bladder and urethral supportb. Perineal, levator, and anal sphincter strengthc. Neurologic status

16. Perform and interpret the results of selected tests to characterize urinary incontinence disorders, including: (PC)

a. Assessment of residual urine volumeb. Simple cystometryc. Q-tip test

17. Describe the indication for, and interpret the results of other diagnostic tests, such as: (PC)

a. Urinalysisb. Urine culturec. Cystourethroscopyd. Multichannel cystometrye. Urethral profi lometryf. Urofl owmetryg. Radiologic testsh. Electromyographyi. Assessment of anal sphincter integrity (e.g., manometry, radiologic imaging studies, neurologic testing)

18. Treat urogynecologic disorders by both nonsurgical (e.g., pelvic fl oor exercise regimens, physical therapy, pessary)and surgical methods. (PC)

74

19. Describe the types of injuries or complications that may occur related to medical and surgical treatments of urogynecologic disorders, and the approaches to managing them. (PC)20. Describe appropriate follow-up for a patient who has been treated for a urogynecologic disorder. (PC, SBP, ICS)21. Summarize and counsel patients regarding risks, benefits, and expected outcomes of surgical and non-surgical approaches to management of pelvic support and incontinencedisorders. (PC, ICS, P)

H. Pelvic masses1. Describe the major causes of pelvic masses, including nongynecologic sources and those arising from the female genital tract, such as: (MK)

a. Uterine fibroidsb. Adnexal cystic and solid massesc. Tuboovarian abscessd. Adnexal torsione. Ovarian cysts/benign neoplasmsf. Diverticulitisg. Appendicitis

2. Elicit a pertinent history suggestive of a pelvic mass, such as: (PC)a. Weight loss or weight gainb. Gastrointestinal symptomsc. Menstrual abnormalitiesd. Pelvic pain or pressure

3. Perform a focused physical examination to confirm the diagnosis of a pelvic mass. (MK)4. Perform and/or interpret tests such as endovaginal or abdominal ultrasonography to confirm the diagnosis of apelvic mass. (PC)5. Interpret the results of other tests, such as MRI or tomographic imaging, in the evaluation of a pelvic mass. (PC,SBP)6. Discuss the role of serum markers in the evaluation and monitoring of a patient with a pelvic mass. (MK)7. Treat benign pelvic masses, using nonsurgical or surgical methods, considering such factors as the patient’s: (MK)

a. Ageb. General healthc. Treatment preferenced. Desire for future childbearinge. Symptom complex

8. Describe the appropriate follow-up for patients who have been treated for a benign pelvic mass. (PC, SBP

K. Benign disorders of the breast1. Describe the clinical history and principal pathophysiologic conditions that affect the breast, such as: (MK, PC)

a. Breast massb. Nipple discharge

75

c. Paind. Infection (mastitis)e. Asymmetryf. Excessive sizeg. Underdevelopment

2. Perform a focused physical examination to evaluate for an abnormality of the breast. (PC)3. Describe the indications for the following procedures to assess breast disorders. Be able to perform and/or interpret the indications for and results of each of them: (PC)

a. Needle aspiration of a cyst or abscessb. Collection of nipple discharge for cytologic examination and/or culturec. Fine needle aspiration of a massd. Needle localization biopsye. Excisional biopsyf. Mammographyg. Ultrasonographyh. MRI

L.Preoperative care1. Conduct detailed preoperative assessment with consideration given to the needs of special patient groups, such as: (PC,ICS, P, SBP)

a. Children and adolescentsb. The elderlyc. Patients with coexisting medical conditions, such as cardiopulmonarydisease or coagulation disordersd. Non-English speaking patients

2. Describe indications for and perform appropriate preoperative evaluation and/or referral, including laboratory tests,radiographic imaging, and EKG. (PC, SBP)3. Be able to obtain informed consent, with special regard to:(PC, ICS, P)

a. Alternatives to surgeryb. Alternative surgical proceduresc. Interopartive complicationsd. Indications for transfusion

4. Compose appropriate preoperative preparation plans for patients undergoing gynecologic surgery, including: (MK, PC)

a. Mechanical bowel preparationb. Antibiotic usec. Thromboembolism prophylaxisd. Preoperative anesthesia consultation

C. Postoperative care1. Choose appropriate pain control based on the surgical procedure, degree of patient discomfort, and patient characteristics,including age and presence of coexisting morbidities.(MK, PC)

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2. Elicit appropriate history, perform a physical examination, perform and/or interpret appropriate tests, and manage common postoperative complications, such as: (PC)

a. Feverb. Gastrointestinal ileus/obstructionc. Infectiond. Wound complicationse. Fluid or electrolyte imbalances, including abnormalities ofurinary outputf. Respiratory problemsg. Thromboembolism

3. Manage and counsel patients about normal postoperative recovery. Include the following topics: (PC, ICS, SBP)

a. Advancement of diet and return to normal dietary and bowel functionb. Ambulationc. Management of urethral catheterization and return tonormal urinary functiond. Thromboembolism prophylaxise. Wound caref. Return to normal activity levels and/or appropriate restrictions, including sexual activityg. Surgical menopause

4. Arrange for appropriate posthospitalization care, including visiting nurse, physical therapy, social services, and other resources to optimize patient outcomes. (SBP)

.

GYNECOLOGY III ROTATION

WEEKLY SCHEDULE

Monday Tuesday Wednesday Thursday Friday

AM OR OR OR OR Lecture

PM OR OR OR OR Pre Op Conference

H&P’s Continuity

Clinic

77

GYNECOLOGY III READING SCHEDULE

TeLinds Operative Gynecology 10th editionRock and JonesChapters 7,8,9,23-32,35,36-40

GYNECOLOGY IV ROTATION

Goals and Objectives: This rotation occurs in the fourth year, and is 4 months in length. This PGY-3 is assigned primarily to the OR, and develops greater experience in the running and operations of the gynecologic service.

A. Intraoperative care

1. Discuss the surgical plan with the operating room team. (ICS,SBP)2. Choose appropriate suture and surgical instruments as dictated by the procedure. (MK, PC)3. Be able to properly position the patient for the procedure and understand the consequences of improper use of stirrups.(PC)4. Understand and demonstrate the incisions used and instruments for abdominal entry for laparoscopy and laparotomy,including Cherney, Maylard, Midline, Paramedian and Pfannenstiel.(MK, PC)5. Demonstrate the proper use of retractors. (MK, PC)6. Name and be able to properly use surgical instruments. (MK,PC)7. Discuss the various surgical power sources (electrocautery, laser, and so forth), indications for each, alternatives, and complications. (MK, PC)8. Describe the options for intraoperative pain control. (MK)

B. Critical Care- Toxic shock syndrome1. Describe the pathogenesis and microbiology of toxic shock syndrome (TSS). (MK)2. Describe the typical signs and symptoms of a patient with TSS and distinguish signs/symptoms according to the infectious agent. (PC)3. Perform a focused physical examination to confi rm the diagnosis of TSS, and assess the severity of the patient’s illness.(PC)4. Interpret the results of diagnostic tests to evaluate TSS. (PC)5. Describe the principles of treatment of TSS, and the possible need for consultation with a critical care or infectious disease specialist. (PC, SBP)6. Counsel affected patients about the risk of recurrence and the value of preventive measures. (PC)

78

C. Septic shock1. Explain the pathophysiology of septic shock. (MK)2. Describe the usual causes of septic shock in obstetric and gynecologic patients. (MK)3. Describe the typical symptoms experienced by a patient with septic shock. (MK, PC)4. Perform a focused physical examination to confirm the diagnosis of septic shock, attempt to determine the etiology of the disorder, and assess the severity of the patient’s illness. (PC)5. Describe indications for, and interpret the results of, the followingdiagnostic tests: (MK, PC)

a. Microbiologic culturesb. Complete blood count and white cell differentialc. Liver function testsd. Renal function testse. Coagulation profi lef. Chest x-rayg. MRI and CT scan of the abdomen and pelvish. Ultrasonography of the pelvisi. Arterial blood gasesj. Central hemodynamic monitoring

6. Describe the principles of management of septic shock, including antimicrobial and supportive therapy. (MK, PC)7. Manage a patient with septic shock, consulting an appropriate specialist as needed. (PC, SBP)

C. Adult respiratory distress syndrome1. Identify the principal causes of adult respiratory distress syndrome (ARDS). (MK)2. Explain the pathophysiology of ARDS depending on the etiology. (MK)3. Describe the usual signs and symptoms manifested by a patient

D. Adult respiratory distress syndrome1. Identify the principal causes of adult respiratory distress syndrome (ARDS). (MK)2. Explain the pathophysiology of ARDS depending on the etiology.(MK)3. Describe the usual signs and symptoms manifested by a patient with ARDS. (MK, PC)4. Perform a focused physical examination to aid in the diagnosis of ARDS and assess the severity of the condition. (PC)5. Interpret the results of diagnostic tests such as: (PC)

a. Chest x-rayb. Pulse oximetryc. Arterial blood gasesd. Pulmonary function tests

79

e. Central hemodynamic monitoring6. Describe the principles of treatment of ARDS. (PC)7. Manage a patient with ARDS, consulting an appropriate specialist as needed. (PC, SBP, ICS)

E. Hemodynamic assessment1. Describe the conditions most likely to cause cardiovascular dysfunction in obstetric and gynecologic patients. (MK)2. Perform a focused physical examination to detect signs of hemodynamic derangements, such as: (PC)

a. Hypotension or hypertensionb. Bradycardia or tachycardiac. Apnea or tachypnead. Signs of poor tissue perfusion (e.g., oliguria, delayed capillary refill)e. ARDSf. Myocardial failureg. Altered mental status

3. Explain the indications for central hemodynamic monitoring (right heart catheterization). (MK, PC)4. Interpret the results of central hemodynamic monitoring and describe management of patients in whom central monitoring is being performed based on hemodynamic parameter obtained. (MK, PC)5. Describe the complications of central hemodynamic monitoring and consult with an appropriate specialist, as needed, when managing those complications. (MK, PC, SBP)

E. Cardiopulmonary resuscitation1. Perform a rapid, focused physical examination to identify the patient who requires cardiopulmonary resuscitation and attempt to determine the cause of the patient’s decompensation.(MK, PC)2. Perform basic cardiac life support as per American Heart Association guidelines. (MK, PC)3. Describe the principles of Advanced Cardiac Life Support (ACLS), and in cconjunction with an ACLS team, participate in the performance of ACLS according to American Heart Association guidelines. (MK)

F. Allergic drug reactions1. List the drugs most likely to produce allergic reactions in obstetric and gynecologic patients. (MK)2. Describe the typical symptoms associated with a drug reaction.(MK)3. Describe the varying degrees of severity of a drug reaction, including anaphylaxis. (MK)4. Perform a focused physical examination to confirm the diagnosis of a drug reaction and assess the severity of the reaction.(PC)5. Describe the differential diagnosis of a drug reaction. (MK)

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6. Describe the principles of treatment of a drug reaction. Manage a patient with a drug reaction, in consultation with an appropriate specialist, as needed. (MK, PC, SBP)

G. Acute blood loss1. Describe the pathophysiology of acute blood loss.2. Describe the laboratory evaluation of acute blood loss, including:

a. Complete blood countb. Evaluation of coagulopathyc. Electrolyte evaluationd. Evaluation of acute renal failure

3. Describe the treatment of acute blood loss, including:a. Fluid and electrolyte replacementb. Blood transfusionc. Correction of coagulopathies

H. Surgical Care of the Geriatric Patient1. Explain surgical options for a given indication in a geriatric patient, accounting for the patient’s medical condition and functional status. (MK, PC, ICS)2. Assess the impact of the proposed surgical intervention on a patient’s capacity for independent living, including assessment of availability of assistance, or need for assistance during treatment or the recovery period. (PC, ICS)3. Summarize complications of anesthesia that are more common in the elderly patient. (MK)4. Assess the geriatric patient’s capacity for independent decision making related to surgical consent. (PC, ICS, P)5. Counsel patients and family members about advance directives, living wills, DNR orders, power of attorney, and surrogate decision-making. (PC, ICS, P, SBP)6. Describe the appropriate preoperative evaluation for a geriatric patient, including consultation with other medical disciplines as indicated. (PC, SBP)7. Describe the unique considerations related to preoperative, intraoperative, and postoperative care of the geriatric patient, such as: (PC, ICS, SBP)

a. Entrapment (pressure) neuropathiesb. Hypothermiac. Fluid and electrolyte imbalancesd. Thromboembolisme. Pain managementf. Adverse drug eventsg. Mental status changesh. Incontinencei. Infectionj. Nutritionk. Stress-induced gastrointestinal ulcerationl. Pressure ulcersm. Ambulation diffi culties

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n. Prevention of fallso. Functional declinep. Possible referral to an assisted-living facility or possibleneed for assistance within the home.

GYNECOLOGY IV ROTATION

WEEKLY SCHEDULE*

Monday Tuesday Wednesday Thursday Friday

AM OR OR OR OR Lecture

PM OR OR OR OR Pre Op conference

H&P’s/Contunity Clinic

GYNECOLOGY IV READING SCHEDULE

TeLinds Operative Gynecology 10th editionRock and Jones Chapters 23-32,41,42,43,44

Urogynecology and Urodynamics Theory and PracticeOstergard and BentSelected Chapters

82

GYNECOLOGY PROCEDURAL COMPETENCIESProcedure Level of Training Understanding Understanding

and PerformAbdominal sacrocolpopexy R4 XAblation and excision of

endometriosis implants R2 XAblative procedure (cervix,

endometruim, vagina, vulva) R2 XAnti-incontinence (urinary) proceduresR3 XAnoscopy R2 XAppendectomy R2 XBiopsy

Cervix R1 XEndocervix R1 XEndometrium R1 XSkin R1 XVagina R1 XVulva R1 XPeritoneum R1 X

Breast, cyst aspiration R3 XCervical Conization R1 XColonic endosopy R1 XColpocleisis R4 XColporrhapy

Anterior (including urethropexy)R3 XPosterior R3 X

Colposcopy, with directed biopsy of cervix,Vagina or vulva R1 X

Colposuspension R3 XCuldoplasty R3 XCystometrography

Simple R2 X Complex (mutichannel) R3 X

Cystotomy repair R3 XCystourethroscopy R2 XDilation and curettage R1 XEnterocele repair R3 XEnterotomy repair R3 XExcision of cyst R1 X

(ovarian, tubal, vaginal, vulvar) X

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Excision of Bartholin’s gland R1 XFistula repair

Rectovaginal R3 XVesicovaginal R4 XUreterovaginal R4 XUrethrovaginal R4 X

Herinaepair (incisional) R3 XProcedure Level of Training Understanding Understanding

and Perform

Hysterectomy XLaparoscopic, total or supracervical R4 XAbdominal, total or supacervical R3 XVaginal R3 XVaginal, laparoscopically assisted R3 X

HysterosalpingographyHysteroscopy

Diagnostic R1 XOperative R2 X

Incision and drainage of an R1abscess or hematoma

Laparoscopy, diagnostic R2and/or operative X

Laparotomy incisions, abdominal R2Lysis of adhesions

Abdominal R3 XLaparoscopic R3 X

Marsupialization of Bartholin’s cyst R1 XMyomectomy R2 XOmentectomy, infracolic R3 XOopphorectomy R2 XOvarian biopsy R1 XOvarian or paraovarian cystectomy R1 XOvarian drilling, laparoscopic R1 XOvarian transposition R2 XParavaginal repair R3 XPerineothaphy R3 XPerineoplasty R3 XPolypectomy R2 XPresacral neurectomy R4 XPressure-flow study (urodynamics) R3 XQ-tip test R1 XSalpingectomy and/or oophorectomy R1Salpingostomy R1 XSalpingotomy R1 XSterilization

Abdominal R2 X

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Laparoscopic R2 XHysteroscopic R2 X

Trachelectomy R4 XTrigger point injection R2 XUltrasonography

Abdominal R1 XEndovagnial R1 X

Procedure Level of Training Understanding Understandingand Perform

Saline infusion ultrasonography R1 XUrethral bulking procedures R3 XUrethral diverticulum repair R3 XUrethral pressure profilometry R3 XUreteroureterostomy R4 XUreteral reimplantation R4 XUterine evacuation (for pregnancy R1

termination, incompleteabortion, fetal death)Dilation and evacuation R1 XSuction curettage R1 X

Mechanical or osmoticpreprocedural cervical preparation R1 X

Vulvectomy, simple R3 XWide local excision (vulva) R2 XWound care

Debridement R2 XIncision and drainage R2 XPlacement of fascial or skin graft R4 XRepair of dehiscence R3 XSecondary closure R3 X

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REPRODUCTIVE ENDOCRINOLOGY AND FERTILITY ROTATION I

The practice of reproductive endocrinology requires a thorough knowledge of disorders of development as well as disorders associated with infertility or failure in human reproduction. Manifestations of disorders that become evident at the time of sexual maturation may have their beginnings as developmental or genetic abnormalities. An understanding of the association between early developmental and genetic problems and their later manifestations is important to appreciate the hormonal interactions that occur within the female reproductive tract. Likewise, the metabolic implications of disorders should be recognized.

For many gynecologists, evaluating and treating fertility disorders constitute their entire practice. This area of the specialty includes identifying disorders related to pregnancy loss as well as causes of infertility. Although the resident in obstetrics and gynecology is not expected to master the actual techniques of assisted reproduction, knowledge of the scientific basis for these procedures, including a thorough knowledge of gamete development, embryology, and physiology of the hypothalamic–pituitary–ovarian axis, is imperative. The science underlying these techniques represents the cognitive information important to the application of these technologic skills.

Women today spend more than one-third of their lifetimes in thepostreproductive years. This area of medicine is becoming increasingly important as the life expectancy of U.S. women increases. The medical management of postreproductive women usually falls to the obstetrician– gynecologist specialist rather than the subspecialist. Therefore, the resident should have a thorough understanding of the changes that occur in the hypothalamic–pituitary–ovarian axis at the time of menopause and the importanceof these changes as they relate to alteration in other body systems,particularly the cardiovascular and skeletal systems. In addition, the residentshould understand the appropriate use of hormone therapy

Goals and Objectives:This three month rotation occurs during the second year. The resident is expected to be in frequent contact with Dr. Ripps, and as such obtain a weekly schedule of office patients and surgery

A. Genetics-Basic mechanism of genetic inheritance

1. Describe the genetic basis of the following conditions:(MK)

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a. Normal and abnormal Müllerian developmentb. Disorders of androgen excessc. Repetitive pregnancy lossd. Ambiguous genitalia

2. Describe the principles of preimplantation genetic diagnosis.(MK)3. Discuss Mendelian and non-Mendelian patterns of inheritance.(MK)

a. X-linked conditionsb. Autosomal recessive and dominant conditionsc. Imprintingd. Trinucleotine repeat expansionse. Mitochondrial

B. List the role of genetics in the development and evaluationof infertility. (MK)

1. Malea. Klinefelter’s syndromeb. Congenital vas deferens absence and azoospermiac. Y-chromosome deletions

2. Femalea. Age-related aneuploidyb. Diminished ovarian reserve/premature ovarian failure

C. Discuss the role of genetics in the timing of both normaland abnormal menopause. (MK) D. Physiology

1. Describe the physiology of: (MK)a. The hypothalamic–pituitary–ovarian axisb. Adrenal steroid and catecholamine synthesisc. The thyroid gland and thyroid hormone synthesisd. Female and male gametogenesise. Hormonally regulated tissue receptorsf. Bone formation/resorption

2. Describe the normal process of steroid hormone biosynthesis.(MK)3. Describe the relationship between ovarian and adrenalandrogen production and hyperinsulinemia. (MK)4. Describe the physiology of the normal menstrual cycle.(MK)5. Describe physiologic changes that occur at the time of puberty and menopause. (MK)

E. Embryology and developmental biology1. Describe the normal embryology of Müllerian and ovarian development. (MK)2. Describe the pathogenesis of abnormal Müllerian development. (MK)3. Describe the pathogenesis of disorders of sexual differentiation.(MK)

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F. Anatomy1. Describe and interpret normal and abnormal reproductive tract anatomy visualized by imaging procedures, such as: (MK, PC)

a. Hysterosalpingography (HSG)b. Pelvic ultrasonography/saline infusion ultrasonographyc. CTd. MRI

2. Describe normal and abnormal reproductive tract anatomy visualized grossly, hysteroscopically and laparoscopically. (PC)3. Describe the anatomic appearance of Müllerian abnormalities (MK)4. Describe the anatomic abnormalities that occur in patients with disorders of sexual differentiation. (MK)5. Describe the anatomy of the central nervous system as it relates to menstrual function. (MK)6. Describe the anatomic changes that occur to the reproductive organs and breasts at the time of puberty and menopause. (MK)

G. Pharmacology1. Describe the pharmacology of medications used to(MK)

a. Induce ovulationb. Inhibit ovulation (e.g., gonadotropin-releasing hormone agonists and antagonists, steroid contraceptives)c. Inhibit the effects of prostaglandinsd. Inhibit the effects of progesterones (mifepristone)e. Treat hyperprolactinemia

2. Describe the pharmacology of hormone therapy and selective estrogen and progesterone receptor modulators (MK)3. Describe the pharmacology of medications used to inhibit bone resorption and stimulate bone formation. (MK)

H. Pathology and neoplasia1. Describe the histologic appearance of endometriosis.(MK)2. Describe the histologic changes of the endometrium associated with: (MK)

a. The normal menstrual cycleb. Ovulation-inducing or ovulation-inhibiting agentsc. Chronic anovulation

3. Describe the histologic appearance of the ovary: (MK)a. In its normal stateb. In androgen-excess disorders, such as polycystic ovary syndrome and hyperthecosis

I. Microbiology and immunology1. Describe histologic alterations in the endometrium andfallopian tubes associated with infection and their effect on fertility. (MK)2. Describe immunologic causes of infertility. (MK)

88

J. Pediatric gynecology (birth to menarche)1. Describe gynecologic problems experienced by pediatricpatients, such as: (MK)

a. Vulvovaginitisb. Vulvar diseasec. Prepubertal vaginal bleedingd. Traumae. Foreign body in the vaginaf. Sexual abuseg. Abnormal pubertal developmenth. Ambiguous genitalia

2. Elicit a pertinent history and a focused physical examination appropriate for the patient’s age, including: (PC, ICS, P)

a. Demonstration of correct use of equipmentb. Positioningc. Adjuncts to examination

3. Perform and/or interpret selected tests to diagnose a specifc gynecologic disorder in a pediatric patient: (PC)

a. Microbiologic cultures of the lower genital tractb. Vaginoscopyc. Vaginal lavaged. Ultrasonographye. MRI

4. Understand the medical and surgical treatment of pediatric gynecologic disorders. (MK, PC)5. Understand the indications for referral to a sub-specialist. (PC, SBP)6. Counsel the patient and her family about long-term prognosis and the effect of specific conditions on reproduction (ICS)7. Perform a forensic examination (including appropriate laboratory tests) to evaluate sexual abuse. (PC, SBP)

a. Describe the standards for diagnosis of sexual abuse and for maintenance of the chain of evidence.b. Describe the mandated reporting law for sexual abuse in the physician’s practice location.c. Collaborate with appropriate health professionals regarding the follow-up of pediatric patients evaluated for sexual abuse.

K. Precocious puberty1. Define precocious puberty. (MK)2. Describe the principal causes of precocious puberty. (MK)3. Perform a history and a focused physical examination to evaluate the diagnosis of precocious puberty. (PC, ICS)4. Interpret the results of selected tests to evaluate precocious puberty, such as:(PC)

a. Ultrasonography

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b. Gonadotropin assaysc. X-ray studies to determine bone aged. CT or MRI scans

5. Describe the treatment and long-term prognosis for patients with precocious puberty. (PC)

L. Developmental anomalies of the urogenital tract1. Describe the major developmental anomalies and their implications for sexual function, menstruation, fertility, and reproductive outcome, including: (MK)

a. Hymenal abnormalitiesb. Vaginal agenesis with or without a uterusc. Vaginal septumd. Uterine septume. Unicornuate or bicornuate uterus

2. Describe the features of a patient’s history suggestive of a developmental anomaly of the urogenital tract. (MK)3. Perform a focused physical examination to identify developmental anomalies of the urogenital tract and associated somatic anomalies. (PC)4. Interpret the following tests to confi rm the diagnosis of a developmental anomaly, its etiology, and its potential clinical implications: (MK, PC)

a. Ultrasonography, sonohysterography, hysterosalpingography,hysteroscopy, laparoscopyb. Endocrinologic assaysc. Microbiologic testsd. Peripheral blood karyotype assessmente. CT or MRIf. Examination under anesthesia

5. Describe appropriate medical and surgical treatments for patients with developmental anomalies. (PC)6. Counsel patients and their families about the impact of genital tract anomalies on reproduction. (ICS)7. Describe the indications for referral. (SBP)

M. Adolescent gynecology1. Discuss the diagnosis and management of gynecologic issues often experienced by adolescent women, such as:(MK, PC)

a. Normal and abnormal pubertal developmentb. Normal psychosocial developmentc. Pituitary disordersd. Primary amenorrheae. Breast massf. Menstrual irregularitiesg. Dysmenorrheah. Vulvovaginitisi. Sexualityj. Contraceptive needs

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k. Sexually transmitted diseasesl. Pregnancym. Sexual abusen. Ovarian diseases and masseso. Endometriosisp. Chronic pelvic pain

2. Elicit a pertinent medical and sexual history from an adolescent patient. (ICS)3. Perform a physical examination with special attention to the needs of an adolescent patient. (PC, P)4. Provide for the primary care needs of the adolescent, demonstrating knowledge in areas, such as:

a. Psychological health (PC)b. Immunizations (PC)c. Confidentiality issues (P)d. Facilitation of parent-child communication (ICS)e. Safety and prevention of morbidity and mortality (PC)f. Substance abuse (PC)g. Nutrition and dietary management (PC)

5. Provide patient and parent education in the following areas: (ICS) a. Normal anatomic and psychosocial developmentb. Personal hygienec. Mensesd. Sexualitye. Prevention of pregnancy and STDsf. Psychosocial concerns

6. Perform or interpret selected tests to confirm the diagnosis of specific gynecologic disorders in an adolescent patient, such as: (MK, PC)

a. Microbiologic testsb. Endocrinologic assaysc. Ultrasonography, sonohysterography, hysterosalpingography,hysteroscopy, laparoscopyd. CT or MRI

7. Treat adolescent gynecologic disorders medically or surgically.(PC)8. Describe the indications for referral. (SBP)9. Counsel the patient and her family about the long-term prognosis of her condition. (ICS)

N. Delayed puberty1. Understand the principal causes of delayed puberty. (MK)2. Describe the history of a patient with delayed puberty.(MK)3. Perform a physical examination and interpret tests toevaluate the etiology of delayed puberty, such as: (PC)

a. Vaginal cytologyb. X-rays for bone agec. Endocrinologic assaysd. Peripheral blood karyotype

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e. CT scan or MRI of the head4. Describe the treatment of a patient with delayed puberty.(PC)5. Describe the indications for referral. (SBP)6. Counsel a patient and her family about her long-term follow-up and prognosis and the effect of her condition on reproduction. (ICS)

WEEKLY SCHEDULE*

Monday Tuesday Wednesday Thursday Friday

AM REI/OFFICE

REI/OR Continuity Clinic

Tubals/REI office

Lecture

PM REI/OFFICE

REI/OR Continuity Clinic

Essures/TubalsTubal H&P

Clinic

ENDOCRINE ROTATION READING SCHEDULE

Precis: Reproductive Endocrinology and Infertility 3rd Edition Required entire text

Clinical Gynecology, Endocrinology and Infertility 7th editionSperoff, Glass, KaseSupplemental reading

REI PROCEDURAL COMPETENCIESProcedure Level of Training Understanding Understanding

and Perform

Assisted reproductive technologiesIVF R2 XICSI R2 XGamete donation R2 XPreimplantation genetic

Diagnosis R2 XGIFT R2 X

Hysterosalpingography R2 XHysterosongraphy R2 XHysteroscopy

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Diagnostic R2 XOperative

Submuscosal Fibroid Resection R2 XPolyp Resection R2 X

Incision of vaginal septum R2 XLaparoscopy R2

Diagnostic R2 XOperative

Chromopertubation R2 XLysis of adhesions R2 XFimbrioplasty R2 XSalpringostomy R2 X

MetroplastyAbdominal R2 X

Hysteroscopic resection of uterineseptum R2 X

Tubal anastomosis R2 XVaginal reconstruction R2

GYNECOLOGIC ONCOLOGY 3/NIGHT FLOAT

Goals and Objectives:The third year resident is responsible, under the guidance of the chief year resident and the attending gyn oncologist over this four month rotation.

A. Endometrial hyperplasia1. Obtain a targeted history in patients who have abnormal uterine bleeding, including an assessment of risk factors, such as: (PC, ICS)

a. Obesityb. Anovulationc. Polycystic ovary syndrome

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d. Glucose intolerancee. Estrogen or antiestrogen exposuref. Family history

2. Perform a focused physical examination in women who have abnormal bleeding and risk factors for endometrial hyperplasia. (PC)3. Describe factors that influence the treatment of hyperplasia,such as: (MK)

a. Classification and histologyb. Age of patientc. Reproduction goalsd. Risk of malignancy

4. Treat endometrial hyperplasia medically and surgically.(PC)5. Describe and manage the potential complications

B. Genetics (MK)1. Describe the clinical relevance of oncogenes and tumor suppressor genes.2. Describe the inheritance patterns for malignancies of the pelvic organs and breast.3. Describe the current indications for screening for BRCA1, BRCA2 and HNPCC.4. Describe the cell replication cycle and identify the phases of the cycle most sensitive to radiation and chemotherapy.

C. Physiology (MK)1. Describe the ability of vital organ systems to tolerate cancer therapy and define the concept of therapeutic index.2. Describe the changes in cell and organ physiology that result from injury due to radiation and chemotherapy.

D. Embryology and developmental biology (MK)1. Describe the embryology of gonadal migration and its role in the pathogenesis of epithelial and germ cell neoplasms.2. Describe the embryologic origins of cell types found in benign and malignant germ cell tumors.

E. Anatomy (MK)1. Describe the anatomy of the anterior and posterior abdominal wall.2. Describe the anatomy of the pelvic fl oor retroperitoneal and paraaortic spaces.3. Describe the gross and histologic anatomy of the external genitalia pelvic organs and the breast.4. Describe the vascular, lymphatic, and nerve supply to the breast, external genitalia and each of the pelvic organs.5. Describe the anatomic relationship between the reproductive organs and the non-gynecologic abdominal and pelvic viscera, i.e., bladder, ureters, and bowel.6. Describe the likely changes in the anatomic relationships of the pelvic and abdominal viscera created by surgical or radiation treatment for a malignancy of the pelvic organs.

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F. Pharmacology (MK)1. List the major chemotherapeutic agents used for treatment of malignancies of the reproductive organs and breast.2. Describe the principal adverse effects of these major chemotherapeutic agents.3. List supportive care methods/medications which can be used to ameliorate the following treatment complications:

a. Marrow suppressionb. Nausea and vomitingc. Hemorrhagic cystitisd. Peripheral neuropathye. Renal toxicityf. Cardiac toxicity

G. Pathology and neoplasia (MK)1. Describe the histology of malignant and pre-malignant conditions of the pelvic organs and breast.2. Describe risk factors contributing to the pathogenesis of malignancies of the pelvic organs and breast.3. Describe the prognosis for the major malignancies of the breast and pelvic organs.

H. Microbiology and immunology (MK)1. Describe the role of viruses in the pathogenesis of gynecologic tumors.2. Describe the infl uence of immunosuppression on the risk of acquiring gynecologic cancers.3. Describe the impact of cancer and its therapies on the immunesystem.4. List the principal consequences of immunosuppression in the cancer patient (e.g., increased susceptibility to infectionand poor wound healing).

I. Carcinoma of the Breast- Epidemiology and risk assessment of breast cancer1. Evaluate a patient’s personal or family history of breast cancer, including the risk associated with BRCA1 or BRCA2. (PC)2. Evaluate other epidemiologic factors to assess a woman’s risk for developing breast cancer, such as: (PC)

a. Patient ageb. Parityc. Ethnicityd. Lactatione. Hormone replacementf. Alcohol consumption

3. Counsel patients regarding breast cancer prevention strategies. (ICS)4. Counsel patients regarding the use of screening methods, such as mammography. (ICS)5. Refer patients appropriately for genetic counseling and testing. (PC, SBP)

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J. Diagnosis of invasive carcinoma of the breast1. Perform a focused history and physical examination in women with signs or symptoms of breast cancer. (PC,ICS)2. Order and explain to the patient appropriate diagnostic tests for evaluating a suspicious breast lesion. (PC, ICS)3. Describe the indications for and interpret for the patient the results of needle aspiration of a breast cyst and fine needle biopsy of a solid lesion. (PC, ICS)4. Describe the indications for and interpret for the patient the results of other diagnostic studies, such as: (PC)

a. Mammographyb. Ultrasonographyc. Core-needle biopsyd. Excisional biopsy

K. Management of invasive breast cancer (MK)1. Describe the staging of breast cancer and the prognostic significance of histologic type, regional lymph node metastasis, distant metastasis, and hormone receptor status.2. Describe the indications for lumpectomy vs. mastectomy.3. Describe the indications for adjuvant therapy with hormonal treatment, chemotherapy, or radiation therapy.4. Describe the impact of pregnancy on the treatment and prognosis of breast cancer.

L. Breast cancer survivorship1. Describe the psychosocial impact of breast cancer on family dynamics, sexuality, and stress management and make appropriate referral to support groups and healthcare professionals. (PC, SBP)2. Manage the adverse effects of antiestrogen medications, such as tamoxifen and aromatase inhibitors. (PC)

M. Vulvar and Vaginal Malignancies- Pre-invasive lesions1. Describe the epidemiology of vulvar intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VAIN).(MK)2. Describe the clinical manifestations of VIN and VAIN. (MK)3. Describe the differential diagnosis of pigmented and nonpigmented vulvar and vaginal lesions. (MK)4. Perform and interpret the results of diagnostic procedures for VIN and VAIN. (PC)5. Perform surgical and/or medical treatment for patients with VIN and VAIN. (PC)6. Establish a post-treatment follow-up plan for patients with VIN and VAIN. (SBP)7. Describe the structural and histologic changes in the vagina characteristic of in utero exposure to diethylstilbestrol(DES). (MK)

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N. Invasive vulvar carcinoma1. Describe the epidemiology of invasive vulvar lesions, such as: (MK)

a. Melanomab. Squamous cell carcinomac. Basal cell carcinomad. Paget’s diseasee. Sarcomaf. Verrucous carcinomag. Bartholin’s gland carcinoma

2. Describe the clinical manifestations of invasive vulvar malignancies. (MK)3. Describe the differential diagnosis of vulvar cancer.(MK)4. Perform appropriate biopsies to diagnose vulvar carcinoma.(PC)5. Describe the staging of invasive vulvar cancers using thesystem adopted by the International Federation of Gynecology and Obstetrics (FIGO). (MK)6. In consultation with a gynecologic oncologist, counsel a patient about the evaluation and treatment (indications, complications) of vulvar cancer. (PC, ICS)7. Describe the prognosis for invasive vulvar malignancies. (MK)8. Describe the impact of treatment of vulvar cancer on sexual function and manage/refer the patient appropriately.(MK, PC, SBP)9. Provide psychosocial support and long-term follow-up for patients with vulvar cancer. (PC, ICS, SBP)

D. Invasive carcinoma of the vagina1. Describe the epidemiology of invasive vaginal cancer such as:

a. Squamous cell carcinomab. Clear cell adenocarcinoma (MK)

2. Describe the clinical manifestations of invasive vaginal cancer. (MK)3. Describe the differential diagnosis of invasive vaginal cancer. (MK)4. Perform appropriate biopsies to diagnose vaginal cancer.(PC)5. Describe the FIGO staging of invasive vaginal cancer.(MK)6. In consultation with a gynecologic oncologist, counsel the patient regarding the evaluation and treatment (indications, complications) of vaginal cancer. (PC, ICS)7. Describe the prognosis for invasive vaginal cancer.(MK)8. Describe the impact of treatment of vaginal cancer on sexual function and manage/refer patients appropriately. (MK, PC, SBP)9. Provide psychosocial support and long-term follow-up for patients with vaginal cancer. (PC, ICS, SBP)

E. Cervical Disorders- Pre-invasive cervical disease1. Describe the epidemiology of cervical dysplasia. (MK)2. Elicit a pertinent history in a woman with an abnormal Pap test. (PC)3. Interpret Pap test reports using the Bethesda classifi cation system and determine appropriate follow-up. (PC)

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4. Perform and interpret the results of diagnostic procedures for cervical dysplasia. (PC)5. Treat cervical dysplasia with modalities, such as: (PC)

a. Cryosurgeryb. Laser ablationc. Loop electrical excisiond. Cold knife conization

6. Manage the complications resulting from treatment of cervical dysplasia. (PC)7. Establish an appropriate follow-up plan for a woman who has been treated for cervical dysplasia. (PC)8. Describe the structural changes in the cervix that are characteristic of in utero DES exposure.9. Counsel patients regarding the use of vaccinations for the prevention of HPV related diseases. (MK)

F. Invasive cervical cancer1. Describe the epidemiology of cervical cancer.(MK)2. Describe the typical clinical manifestations of cervical cancer. (MK)3. Describe the differential diagnosis of cervical cancer. (MK)4. Perform appropriate biopsies to diagnose invasive cervical cancer. (PC)5. Describe the FIGO staging of cervical cancer. (MK)6. In consultation with a gynecologic oncologist, counsel the patient about the evaluation and treatment (indications,complications) of cervical cancer. (PC, ICS)7. Describe the prognosis for cervical cancer. (MK)8. Describe the impact of treatment of cervical cancer on sexual function and manage/refer patient appropriately. (MK, PC, SBP)9. Provide psychosocial support and long-term follow-up for patients with cervical cancer. (PC, ICS, SBP)

G. Carcinoma of the Uterus1. Describe the epidemiology of endometrial cancer such as: (MK)

a. Uterine adenocarcinomab. Uterine sarcoma

2. Describe the clinical manifestations of endometrial cancer. (MK)3. Describe the differential diagnosis of invasive endometrial cancer. (MK)4. Perform biopsies to diagnose endometrial cancer. (PC)5. Describe the FIGO staging of invasive endometrial cancer. (MK)6. In consultation with a gynecologic oncologist, counsel the patient about the evaluation and treatment (indications, complications) of endometrial cancer. (PC, ICS)7. Describe the prognosis for invasive endometrial cancer. (MK)8. Provide psychosocial support and long-term follow-up for women with endometrial cancer. (PC, ICS, SBP)

H. Carcinoma of the ovary1. Describe the epidemiology of ovarian cancer. (MK)

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2. Describe the inherited syndromes that increase a woman’s likelihood of developing ovarian cancer. (MK)3. Describe the screening protocols that may identify patients who have an inherited form of ovarian cancer. (MK)4. Describe the clinical manifestations of ovarian cancer. (MK)5. Describe the histology, staging and prognosis for: (MK)

a. Epithelial tumorsb. Germ cell tumorsc. Stromal tumorsd. Sarcomase. Metastatic tumorsf. Tumors of low malignant potential

6. Interpret for the patient the following tests to diagnose ovarian cancer: (PC, ICS)

a. Ultrasonographyb. Serum tumor markersc. Cytology from thoracentesis or paracentesisd. CT scan

7. In consultation with a gynecologic oncologist, counsel the patient about the evaluation and treatment (indications, complications) of ovarian cancer. (PC, ICS)8. Provide psychosocial support and long-term follow-up for women with ovarian cancer: (PC, ICS, SBP)

I. Carcinoma of the fallopian tube

1. Describe the epidemiology of fallopian tube cancer. (MK)2. Describe the typical clinical manifestations of fallopian tube cancer. (MK)3. Describe the FIGO staging and prognosis of fallopian tube tumors. (MK)4. In consultation with a gynecologic oncologist, counsel the patient about the evaluation and treatment (indications, complications)of fallopian tube cancer. (PC, ICS)5. Discuss the prognosis of fallopian tube cancer. (MK)6. Provide psychosocial support and long-term follow-up for women with fallopian tube cancer. (PC, ICS, SBP)

J. Gestational Trophoblastic Disease- Hydatidiform mole1. Describe the epidemiology and genetics of hydatidiform mole. (MK)2. Describe the clinical manifestations of gestational trophoblastic disease (GTD) (MK)3. Diagnose GTD and its manifestations using tests, such as: (PC)

a. Ultrasonographyb. Quantitative b-hCG titerc. Chest x-rayd. Thyroid function tests

4. Distinguish between a complete and partial hydatidiform mole using histologic and cytogenetic findings. (MK)

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5. Provide surgical treatment for a patient with GTD. (PC)6. Provide the appropriate follow-up for a patient who has had suction evacuation of a molar pregnancy. (PC)7. Counsel the patient regarding recurrence risk for GTD. (PC, ICS)

K. Malignant gestational trophoblastic disease1. Describe the conditions that may precede malignant GTD. (MK)2. Describe the histologic appearance of invasive mole versus choriocarcinoma versus placental site trophoblastic tumor. (MK)3. Describe the diagnosis of malignant GTD using a combination of physical examination, b-hCG, chest x-ray, CT scan and ultrasonography. (MK)4. Classify metastatic GTD into good prognosis (low risk) versus poor prognosis (high risk). (MK)5. Describe referral to a gynecologic oncologist for surgical and medical treatment of GTD. (MK)6. Counsel patients regarding risk of recurrence and prognosis for future pregnancies. (PC, ICS)7. Provide psychosocial support and long-term follow-up of patients with GTD. (PC, ICS, SBP)

L. Therapy- Radiation therapy1. Describe the general principles of radiation therapy. (MK)2. Describe the indications for radiation therapy in the treatment of gynecologic neoplasms and the factors that influence decisions regarding intervention, such as: (MK)

a. Classification and FIGO staging of disease and histologyb. Age of patientc. Underlying medical conditionsd. Implications for future fertilitye. Concomitant therapy with radiosensitizers or chemotherapyf. Previous abdominal proceduresg. Need for palliative management

3. Describe the potential complications of radiation therapy.(MK)

M. Chemotherapy1. Describe the general mechanisms of action of chemotherapy. (MK)2. Describe the general indications for chemotherapy in the treatment of gynecologic neoplasms. (MK)3. Describe the most appropriate indication for chemotherapeutic agents, such as: (MK)

a. Alkylating agentsb. Antimetabolitesc. Vinca alkaloidsd. Antibioticse. Hormonal agentsf. Heavy metals

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g. Immunotherapy4. Describe the potential complications of chemotherapy. (MK)5. Describe the long-term effects of chemotherapy on fertility. (MK)

N. Terminal care1. Describe the basic principles of palliative care. (MK)2. Describe medical, radiation and operative modalities for palliation of symptoms in terminally ill patients. (MK)3. Describe the appropriate indications for a “do not resuscitate” (DNR) order. ((MK)4. Describe the medical, ethical, and legal implications of a DNR order. (MK)5. Describe the concept of therapeutic index when considering medical or operative intervention to improve patients’ quality of life. (MK)6. Describe the basic principles of pain management and provide appropriate pain control for terminal patient

GYNECOLOGY ONCOLOGY 3

WEEKLY SCHEDULE*

Weeks 1 and 2Monday Tuesday Wednesday Thursday Friday

OR/Office OR Office OR Lecture

OR/Office OR Office OR Office

Weeks 3 and 4Monday Tuesday Wednesday Thursday Friday

Night Float Night Float Night Float Night Float Night Float

Night Float Night Float Night Float Night Float Night Float

GYNECOLOGY ONCOLOGY III READING SCHEDULE

Clinical Gynecologic Oncology 7th editionDisaia and CressmanChapters 1 – 21

GabbeChapter 36

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GYNECOLOGIC ONCOLOGY 4

Goals and Objectives:The chief resident is responsible, under the guidance of the attending gyn oncologist for the running of the gyn oncology service over this four month rotation.

The goals and objectives are the same as in the gynecology oncology 3 rotation.

GYNECOLOGY ONCOLOGY 4

Weeks 1 and 2Monday Tuesday Wednesday Thursday Friday

102

Night Float Night Float Night Float Night Float Night Float

Night Float Night Float Night Float Night Float Night Float

Weeks 3 and 4Monday Tuesday Wednesday Thursday Friday

OR/Office OR Office OR Lecture

OR/Office OR Office OR Office

GYNECOLOGY ONCOLOGY IV READING SCHEDULEClinical Gynecologic Oncology 6th editionDisaia and Cressman Chapters 1 – 21

Gynecologic Oncology Procedural Competencies

Procedure Level of Training Understanding Understandingand Perform

Colectomy (partial or total) R3 XColostomy R3 XFistula repair

Enterocutaneous R4 XUreterovaginal R4 X

HysterectomyExtrafascial (with or without bilat-

eral salpingo-oophorectomy) R3 XRadical (with or without bilateral

salpingo-oophorectomy) R4 XLumpectomy of breast R4 XLymph node biopsy/dissection

Axillary R4 XInguinal R3 XParaaortic R3 XPelvic R3 XSentinel R3 X

MastectomySimple R3 XRadical R4 X

Paracentesis R3 XPelvic exenteration with or without

reconstruction R3 XPort placement, intraperitoneal R3 XRadiation therapy

Brachytherapy R3 X

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External beam R3 XInterstitial R3 XResection of large and small bowel R3 XStaging laparotomy R3

Biopsy of pelvic lymph nodes R3 XBiopsy of peritoneal implants

and cytologic washing of theperitoneal cavity R3 X

Exploration of abdomen R3 XInfracolic omentectomy R3 X

Suction evacuation of molar pregnancy R3 XVaginal reconstruction

Gracilis flap R4 XMartius flap R4 XSkin graft R4 X

Transverse rectus abdominis myo-cutaneous flap R4 X

Venou access device placement R3 XVulvectomy, radical R3 X

CRITICAL CARE MEDICINE ROTATION

Goals and Objectives;The PGY 2 rotation is one rotation block. The resident is assigned to the critical care medicine faculty, and is responsible for all critical care consults/ICU patients. This rotation occurs in the latter part of the second year, to prepare the resident for the responsibilities of caring for critically sick antepartum patients, and gynecologic oncology patients, which occurs in PGY3.

Patient Care:1. Under the supervision of the faculty, the resident will become familiar with ICU medicine, and understand the basic path physiology of critical ill patients.2. Recognize and be able to manage critically ill postoperative patients..

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Medical Knowledge:1. Understand the patholophysiology of the following; toxic shock syndrome, Septic shock, ARDS, Hemodynamic assessment of the critically ill patients, and cardiopulmonary resuscitation.

Practice-based Learning and Improvement:1. Learn to identify strengths, deficiencies, and limits in one’s knowledge and expertise.2. Set learning and improvement goals.3. Identify and perform appropriate learning activities. 4. Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; 5. Incorporate formative evaluation feedback into daily practice;6. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.7. Use information technology to optimize learning.8. Participate in the education of patients, families, students, residents and other health professionals. 9. Understand the basics of epidemiology, statistics, data collection, management and its use of medical literature and assessment of it value.

Interpersonal and Communication Skills: 1. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds.2. Communicate effectively with physicians, other health professionals, and health related agencies. 3. To work effectively as a member or leader of a health care team or other professional group; 4. To act in a consultative role to other physicians and health professionals.5. To maintain comprehensive, timely, and legible medical records, if applicable. 6. To have the fundamentals of good medical history taking and thoughtful, meticulous physical examination. Information gained by these procedures must be carefully recorded in the medical record. A reliable measure of the quality of a program is the quality of hospital records. These records should include daily appropriate progress notes by residents, together with a discharge summary.

Professionalism1. Residents must demonstrate compassion, integrity, and respect for others. 2. Demonstrate responsiveness to patient needs that supersedes self-interest. 3. Develop respect for patient privacy and autonomy.4. Demonstrate accountability to patients, society and the profession.5. Demonstrate sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.6. Construct a framework for ethical decision making, and medical jurisprudence.

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Systems-based Practice 1. Work effectively in various health care delivery settings and systems relevant to their clinical specialty; 2. Coordinate patient care within the health care system relevant to their clinical specialty; 3. Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate; 4. Advocate for quality patient care and optimal patient care systems; 5. Work in interprofessional teams to enhance patient safety and improve patient care quality. 6. Participate in identifying system errors and implementing potential systems solutions.

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FACULTY EVALUATION (See Evaluation Policy) Residents are required to complete an anonymous evaluation of each faculty member and an overall written assessment of the residency education program at the end of the academic year. These assessments will be reviewed by the Program Director and used in making decisions about possible promotion(s) for individual faculty members.

EVALUATION POLICY:

METHOD OF EVALUATION/COMP MATRIXCompe-tency

Global Assess.

CREOG Exam.

Read.Quiz.

Oral Exam.June

Surg.ScoreCard

Journal.Club

Formal Present.

ResearchProject

360Eval.

Preop Confer-ence

ClinicalTopicReview Log

Praise/ConcernCards

MedicalRecordChart Review

OSCE System Based Practice/M&M Conf.

HospCommPart

Profess-ionalism

Medical Know-ledge

Patient Care

Commun-ication

Practice-Based Learning

Systems-Based Practice

Evaluation Monthly Schedule

1. Global Evaluations sent out last day of rotation. These will be reviewed twice a year at evaluation day with the resident and their mentor.

2. Stats turned into report run and the first Monday of the month. Drs. DeCesare/Dorr/Peterson/Holly notified with incomplete stats.

3. GME one will be checked the first Monday of the month. Drs. DeCesare/Dorr notified with incomplete hours.

4. Medical records will be complete every Tuesday. Dr. Dorr/DeCesare notified with incomplete medical records.

5. 360 evaluations will be given to patients in May and December. Staff 360 evaluations will sent the same time. The goal is ten evaluations per resident per month.

6. Peer/Self 360 evaluations will be completed in May, yearly.7. Program/Faculty Evaluations will be filled out yearly.8. Surgical score cards will be placed in the box in am report room, or to Holly for

each surgery resident performs. Holly will input into spreadsheet. Scores will be reset yearly. New Innovations will send copy of this to each resident with the gyn and gyn onc objectives.

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9. Praise/concern cards will be filled out by faculty and or residents regarding their performance. Concern cards will be reviewed by the resident and the PD at the time the concern card is received. Praise cards will be reviewed twice a year.

10. All oral presentations/Grand rounds will be evaluated by the attending physicians present. A copy of the presentation should be emailed to Holly. This information will be reviewed twice a year.

11. Medical records (clinic charts) will be reviewed by nurses/billing. This information will be reviewed with the residents twice a year.

12. Journal club will be every month. EBM format, as well as traditional presentation methods will be used. Faculty will evaluate resident on the presentations.

Competency Matrix

Medical KnowledgeGlobal evaluation monthlyOral exams, yearly (June)Standardized Patients (yearly, July)

Patient CareSurgical Score CardsOral exam, yearly (June)Standardized Patients (yearly, July)Written Communication (Wanda Brown, Seton Center Nurse Manager)

Practice Based Learning and ImprovementPBLI case presentations, M-Thursday am report (topic lists)*M and M/Quality risk Improvement Conference (4 times year)

Systems Based Practice All residents (except interns) will participate in hospital quality improvement/pt safety committeesFSU seminars Business of MedicineTeam Building activities-Bill Dee weekly; entire group yearlyM and M/Quality risk Improvement Conference (4 times year)

ProfessionalismGlobal evaluations, monthly360 (Patient – May/December, Staff-May/December, Self/Peer-May)Standardized Patients (yearly, July)Praise/Concern Cards (prn by staff and residents)Medical Records (List emailed weekly)

Interpersonal Relationships/Communication SkillsStandardized Patients (yearly, July)Grand Rounds (Attending evaluations, copy presentation to Holly)*

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Chart Review/Written Communication (Wanda Brown, Seton Center Nurse Manager)*Grand Round EvaluationM&M EvaluationProgram Evaluation

Journal Club First Thursday of every month

RESIDENT TEACHING RESPONSIBILITIES:Teaching resident’s who are junior to you is one of the most important resident activities. Residents’ responsibilities will vary with the service.

Because of the leadership qualities this residency is designed to foster, teaching will continue to be expected, and excellence in this area will be formally recognized. The opposite is also true. Those who fail to use common courtesy in dealing with other residents, who neglect their role as leaders and who deal with other residents in an antagonistic, counterproductive manner will be subject to disciplinary action. Chronic behavior of this nature may be grounds for probation or termination.

At the end of each third year medical rotation, you may be expected to complete a resident evaluation form and make comments on the resident’s progress. These forms are a vital part of your duties and must be completed in a thorough, candid, and constructive manner as promptly as possible.

DOCUMENTATION OF CLINICAL AND SURGICAL EXPERIENCE:Throughout the four years of training, residents are expected to keep an accurate record of their clinical experience. Vaginal deliveries, cesareans, surgical procedures, and primary care encounters must be documented. Residents are to enter their surgical statistics directly into the ACGME database via the Internet at http://www.acgme.org/residentdatacollection/. Statistics will be entered into the computer daily, and will be printed and turned into the Program Director weekly for verification. Failure to comply will result in warning (1st offense), suspension (2nd offense) and probation (3rd offense).

Additionally, as approved by the GMEC, residents who scrub in on cases that are not in the division they are assigned to, but who desire to gain the learning experience from assisting in such cases, must follow all required hospital procedure and document such.

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REQUIRED TEXT BOOKS

ObstetricsWilliams Obstetrics 23 rd edition ISBN10:  0071497013 Normal and Problem Pregnancies – 5th editionBy Steven G. Gabbe, Jennifer R. Niebyl, Mark Landon, Joe Leigh Simpson, Laura GoetzlISBN: 0443069301

Maternal-Fetal Medicine – 6th editionBy Robert K. Creasy, Robert Resnik, Jay D. IamsISBN: 0721600042

GynecologyTelinde’s Operative Gynecology – 10th edition By John Rock, Howard W. JonesISBN: 13; 9780781772341

Comprehensive Gynecology – 5th editionBy Vern L. Katz, David Gershenson, Rogerio A. Lobo, Gretchen LentzISBN: 0323029515

Ostergard’s Urogynecology and Pelvic Floor Dysfunction-6th editionBy Alfred E. Bent (Editor), Donald R. Ostergard, Geoffrey W. Cundiff, Steven E. SwiftISBN:13; 9780781770958

REIPrecis: Reproductive Endocrinology and Infertility 3rd Edition

Clinical Gynecologic Endocrinology and Infertility – 7th editionBy Leon Speroff, Marc FritzISBN: 0781747953

Gynecology OncologyClinical Gynecologic Oncology-7th editionBy Philip J. Disaia, William T. CreasmanISBN: 13; 9780323039786

Primary CarePRECIS Series Primary and Preventive Care – 3rd edition

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ADMINISTRATIVE GUIDELINES

BACKGROUND CHECKS/DRUG SCREEN:

In connection with my application for residency with FSU, I understand and agree that background and drug screen inquires are requested by Sacred Heart Health System that will seek information as to my character, work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Furthermore, I understand and agree that Sacred Heart Health System may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history, criminal record, civil matters, previous employment, educational background, and other past experiences. In addition, application to the Florida Board of Medicine as in intern/resident/fellow, as well as for unrestricted licensure, requires self-disclosure of criminal convictions and of prior substance abuse and/or treatment.

HIPAA PRIVACY AND SECURITY:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an important federal law that affects how you and the Florida State University College of Medicine must handle confidential patient health information. The fundamental premise under the Privacy Rules is to protect ‘Patient Health Information.’

‘Patient Health Information’ is broadly defined in the Privacy Rules to include any oral, written or electronic individually identifiable information relating to (a) the past, present, or future physical or mental health of an individual; (b) the provision of health care to the individual; and/or (c) the payment for health care. This means that virtually all patient related information is subject to the protections of the Privacy Rules. Consequently, it is vital that you fully comprehend your obligations to protect this information in accordance with HIPAA Policies and Procedures. The Sacred Heart Health System requires training in this area.

POLICIES AND GUIDELINES FOR PHARMACEUTICAL/VENDOR INTERACTIONS:

Purpose of Policy The purpose of this policy is to establish guidelines to ensure that patient care and medical education are not influenced by considerations other than what is in the best interests of patients and/or trainees.

Statement of Policy

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It is the policy of the FSU COM that pharmaceutical/industry access to residents is prohibited on FSU COM property, including regional medical school campuses However, discussion with representatives for the purpose of obtaining unrestricted educational grants is allowed.

This policy applies to all FSU COM residents when performing their duties on FSU COM property.

Scope of Policy

I. Accepting Offers

GiftsResidents may not solicit or accept any gifts from pharmaceutical company/industry representatives. Additionally, the use of any vendor’s material with the vendor’s name or logo is strongly discouraged in public or patient care areas. Food The direct provision of any meals, desserts, etc. by pharmaceutical/industry representatives on FSU COM property is prohibited. This includes the provision of meals during any organized, scheduled educational activity (e.g., grand rounds, journal club, faculty development, etc.) or reception. Industry representatives who wish to provide support to the FSU COM may, however, do so in the form of an unrestricted educational grant to the FSU COM. Such grants are expended for food solely at the discretion of COM departments/divisions/regional campuses/residency programs.

Entertainment Faculty members, residents, or employees of the FSU COM participating in social events, including meals, funded directly by pharmaceutical company/industry may not use their official status as FSU employees or residents. Moreover, faculty and employees of the FSU COM may not accept the use of supplier/vendor property, airplane transportation, travel packages, or similar favors from industry as FSU employees.

Compensation Residents may not accept gifts or compensation for listening to a sales talk by an industry representative, including the defraying of costs for simply attending a CME or other activity or conference.

Honoraria provided directly by pharmaceutical/other industry are not allowed if resident status with the FSU COM is acknowledged.

II. Site Access Pharmaceutical/Industry Representatives are not allowed access to residents on FSU COM property, including its regional campuses, except for the purpose of discussing/providing unrestricted educational grants.

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III. Educational Funds Industry representatives may provide support for resident educational purposes in the form of unrestricted educational grants. Initial contact with industry representatives for the purpose of discussing or obtaining unrestricted educational grants is permitted.

No educational grant, financial award, donation, or expense reimbursement may be given directly to a resident by an industry representative. Any educational grant must be provided to the College of Medicine.

Note: These provisions do not apply to meetings of professional societies that may receive partial industry support, i.e., meetings governed by ACCME Standards.

IV. Disclosure of Relationships with Industry All College, Program and Sponsoring Institution-sponsored medical education events must include full and appropriate disclosure of sponsorship and financial interests above and beyond those already governed by the Standards for Commercial Support promulgated by the Accreditation Council for Continuing Medical Education. Department Chairs, Program Directors and Faculty should disclose any financial relationships with Industry, including but not limited to ownership of practice and hospital sites at the time of appointment to these positions, annually through the FSU COM Personnel Office, and as actual, potential, or the appearance of Conflicts of Interest arise.

Faculty with supervisory responsibilities for residents should ensure that the faculty’s conflict or potential conflict of interest does not affect or appear to affect his or her supervision of the resident.

Individuals having a direct role making institutional decisions on equipment or drug procurement must disclose to the FSU COM Administration / Personnel Office, prior to making any such decision, any financial interest they or their immediate family have in companies that might substantially benefit from the decision. Such financial interests could include equity ownership, compensated positions on advisory boards, a paid consultancy, or other forms of compensated relationship. They must also disclose any research or educational interest they or their department have that might substantially benefit from the decision. The administration will decide whether the individual must remove him/herself from the purchasing decision.

Note: This provision excludes indirect ownership, such as stock held through mutual funds.

V. Training/Communication Regarding Potential Conflicts of Interest All residents shall be provided with information regarding potential conflicts of interest in interactions with industry to include:

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A copy of these guidelines on vendor interactions. Copies of the ethics statements of pertinent medical specialty societies and how to

apply those guidelines to practice. Seminars sessions describing:

o How activities can influence judgment in prescribing decisions and research activities.

o How to manage encounters with Industry representatives. o How to handle patient requests for medication, particularly regarding

direct-to-consumer advertising of drugs. o The purpose, development, and application of drug formularies and

clinical guidelines and discussing such issues as branding, generic drugs, off-label use, and use of free samples.

VI. Procedure, Monitoring and ResponsibilityWe want to ensure patients and residents know we are focusing on their welfare, not on any commercial interest and eliminate the appearance of industry’s inappropriate influence over the medical community. Therefore, all FSU COM residents will be given a copy of this Policy and Guidelines document.

The Graduate Medical Education Committee (GMEC) must ensure that the Sponsoring Institution monitors vendor interactions with residents and GME programs.

FSU COM administration, department heads, division heads, campus deans, program directors, etc. are responsible for compliance with this policy and for ensuring the personnel under their supervision understand and comply with this policy.

If FSU COM residents have any questions concerning the interpretation of this policy and guidelines, or its applicability to a particular circumstance, they should first consult with their supervisor. If their supervisor is unable to answer the question or provide appropriate guidance, or if, because of the circumstances, it would be inappropriate to discuss the matter with the supervisor, then the resident should contact the FSU COM Sr. Associate Dean’s office. If any FSU COM personnel and/or staff member is aware of any violation or threatened or potential violation of this policy, or suspects that a violation of this policy has occurred, they must also refer to the FSU COM Sr. Associate Dean’s office.

VII. Exceptions 1. This policy does not apply to part-time faculty (clerkship directors and clerkship faculty) engaged in their roles at venues other than FSU COM property; i.e., private offices, hospitals or other sites. 2. This policy does not include faculty research and related activities, which are included in the Florida State University Faculty Policies and Procedures for Dealing with Misconduct in Research and Creative Activity (http://dof.fsu.edu/facultyhandbook/Ch6/Ch6.20.html). Individuals should contact the

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FSU COM Office of Research (http://med.fsu.edu/research/office/default.asp) with regard to publishing articles under their name and FSU COM title, in disclosing their related financial interests etc.

Conflicts of Interest: Any situation in which an individual is in a position to exploit his/her professional or official capacity in some way for personal benefit.

Faculty: Physicians/Professors who possess the requisite expertise, documented educational and administrative abilities, and experience to teach residents. Meetings: Any gathering on FSU COM property involving FSU COM residents. Such gatherings would include but not be limited to resident meetings, grand rounds, or regional campus meetings.

Personnel: Faculty, staff, residents of FSU COM.

Representative: Includes any individual who is employed by or who represents any entity defined under ‘Vendor/Industry’. Sponsorship: Vendor/Supplier funding

Unrestricted Educational Grants: It is recommended that industry representatives provide financial support for FSU COM events directly to the COM in the form of an unrestricted educational grant to then be spent by the COM departments/divisions/regional campuses/residency programs for educational activities at their discretion. Appropriate recognition of the industry representative’s contribution should be given by the department/division/regional campus/residency program. Educational grants must not be made, conditioned, or related in any way to pre-existing or future business relationships with Industry. Vendors should separate their grant making functions from their sales and marketing functions. Accordingly, if vendor or patient-service representatives or other corporate representatives wish to discuss a corporate contribution of cash, equipment, supplies, or services, the employee should immediately notify the Dean or the Sr. Associate Dean for Academic Affairs/DIO. This individual, or a designee, should then become the principal point of contact with the vendor.

Vendor/Industry: Includes those businesses, corporations, or entities that supply or wish to supply equipment, goods, services, or other medical related products to physicians, administrators, residents, staff or hospitals.

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GENERAL DISASTER PLAN: Definition of Disaster: A disaster is defined herein as an event or set of events causing significant alteration to the residency experience at one or more residency programs.

Declaration of Disaster: When warranted, the Accredited Council for Graduate Medical Education (ACGME) Executive Director, with consultation of the ACGME Executive Committee and the Chair of the Institutional Review Committee, will make a declaration of a disaster. A notice of such will be posted (and periodically updated) on the ACGME website with information relating to ACGME response to the disaster.

Resident Information: All programs will maintain a roster of all residents that includes at a minimum, the following information: name, address, pager number, all available phone numbers (home, cell, etc.), all available e-mail addresses, and emergency contact individual(s) and their contact information. This information will be updated at least annually before July 31, and as appropriate to maintain accuracy. The programs will maintain this roster with internal backup, as well as external backup at the Florida State University (FSU) College of Medicine.

As possible, residents may continue their roles and participate in disaster recovery efforts. Resident reporting will continue during disaster recovery. Residents will continue to receive their salary and benefits during the disaster event recovery period, and/or accumulate salary and benefits until such time as utility restoration allows for fund transfer.

Medical-Legal Aspects: There are multiple mechanisms that may afford liability protection to FSU residents who are or will be working in the affected areas of disaster response in the State of Florida from incurring personal liabilities. In the capacity of assignment by Florida National Guard and/or Department of Homeland Security, residents may become temporary employees of Health and Human Services (HHS) and therefore are subject to and protected by the Federal Tort Claims Act. It is preferred, whenever possible, that notwithstanding other capacities in which residents may serve, they also perform within their FSU function when they participate in disaster recovery efforts. While acting within their FSU function, residents will maintain their personal immunity to civil actions via the state’s sovereign immunity and the University’s Self-Insurance Program.

Communication with ACGME: The Designated Institutional Official will call or email the Institutional Review Committee Executive Director with information and/or requests for information.

Similarly, the Program Directors will contact the appropriate Review Committee Executive Director with information and/or requests for information. Residents should call or email the appropriate Residency Director (or Residency Review Committee if unable to reach director) with information and/or requests for information.

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In the ACGME Web Accreditation Data System, ACGME will provide instructions for changing resident e-mail information as needed.

Resident Transfers / Program Reconfiguration: If, because of a disaster, at least an adequate educational experience cannot be provided for each resident the sponsoring institution will:

(a) Arrange temporary transfers to other programs/institutions until such time as the residency program can provide an adequate educational experience for each of its residents;

(b) Cooperate in and facilitate permanent transfers to other programs/institutions. If more than one program/institution is available for temporary or permanent transfer of a particular resident, the transferee preferences of each resident will be considered. Programs/institutions will make the keep/transfer decision expeditiously so as to maximize the likelihood that each resident will timely complete the resident year; and

(c) Inform each transferred resident of the minimum duration of his/her temporary transfer, and continue to keep each resident informed of the minimum duration. If and when a program decides that a temporary transfer will continue to and/or through the end of a residency year, it must so inform each such transferred resident.

Within ten days after the declaration of a disaster, the Designated Institutional Official (DIO) will contact ACGME to discuss due dates that ACGME will establish for the programs, (a) to submit program reconfigurations to ACGME; and, (b) to inform each program’s residents of resident transfer decisions. The due dates for submission shall be no later than 30 days after the disaster unless other due dates are approved by ACGME.

A form will be available on the ACGME website for institutions offering to accept temporary or permanent transfers from disaster affected institutions that must be completed. Upon request, ACGME will provide information from the form to the affected programs and residents.

ACGME will expedite the process for reviewing (and approving or not approving) submissions by programs relating to program changes to address disaster effects, including the addition or deletion of a participating institution, change in the format of the educational program, and/or change in the approved resident compliment.

HARASSMENT:

POLICY STATEMENT :

Sexual harassment is a form of discrimination based on a person's gender. Sexual harassment is contrary to the University's values and moral standards, which recognize

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the dignity and worth of each person, as well as a violation of federal and state laws and University rules and policies. Sexual harassment cannot and will not be tolerated by the Florida State University, whether by faculty, residents or staff; or by others while on property owned by or under the control of the University.

OFFICE OF AUDIT SERVICES :

The Office of Audit Services (OAS) is charged with receiving and investigating sexual harassment complaints as set forth in this policy and shall maintain the records pertaining thereto. Within the OAS, the Coordinator of Sexual Harassment Resolutions has primary responsibility for leading these investigations.

DEFINITION :

Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature directed at an employee or resident by another when:

a. submission to such conduct is made either explicitly or implicitly a term or condition of employment, academic status, receipt of University services, participation in University activities and programs, or affects the measure of a resident’s academic performance; or,

b. submission to or rejection of such conduct is used as the basis for a decision affecting employment, academic status, receipt of services, participation in University activities and programs, or the measure of a resident’s academic performance; or,

c. such conduct has the purpose or effect of unreasonably interfering with employment opportunities, work or academic performance or creating an intimidating, hostile, or offensive work or educational environment.

EXAMPLES OF SEXUAL HARASSMENT :

Incidents of sexual harassment may involve persons of different or the same gender. They may involve persons having equal or unequal power, authority or influence. Though romantic and sexual relationships between persons of unequal power do not necessarily constitute sexual harassment, there is an inherent conflict of interest between making sexual overtures and exercising supervisory, educational, or other institutional authority. Decisions affecting an employee's job responsibilities, promotion, pay, benefits, or other terms or conditions of employment, or a resident's grades, academic progress, evaluation, resident status, recommendations, references, referrals, and opportunities for further study, employment or career advancement, must be made solely on the basis of merit.

Examples of sexual harassment include, but are not limited to, the following, when they occur within the circumstances described above:

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a. use of gender-based verbal or written language, including electronic communication, offensive or degrading to a person of that gender, whether or not the content is sexual;

b. inappropriate display of gender-based pictorial images offensive or degrading to a person of that gender, including but not limited to sexual posters, photographs, cartoons, drawings, or other displays of sexually suggestive objects or pictures;

c. use of inappropriate gestures or body language of a sexual nature, including leering or staring at another;

d. unwelcome requests or demands for sexual favors or unwelcome sexual advances;

e. inappropriate nonconsensual touching of another's body, including but not limited to kissing, pinching, groping, fondling, or blocking normal movement; or

f. sexual battery. (Note: some acts of sexual harassment may also constitute violations of criminal law, e.g., sexual battery, indecent exposure, sexual abuse, etc. In such instances, please refer to the University's Sexual Battery Policy.)

DISCIPLINARY AND OTHER ACTIONS :

Sexual harassment is prohibited by the Florida State University. The University will take appropriate action against any person found to be in violation of this policy. (Note: a person who has sexually harassed another or retaliated against another may also be subject to civil or criminal liability under state or federal law.)

a. Disciplinary Actions . Any employee who has sexually harassed another employee or a resident, retaliated against such person for bringing a complaint of sexual harassment, or otherwise violated this policy shall be guilty of misconduct and subject to disciplinary action up to and including dismissal, in accordance with applicable law, rules, policies, and/or collective bargaining agreements. In addition, any resident who has sexually harassed another resident or an employee, retaliated against such person for bringing a complaint of sexual harassment, or otherwise violated this policy may be subject to disciplinary action up to and including expulsion, pursuant to the Student Code of Conduct. The term "employee" includes all persons employed by the University including faculty, residents and graduate teaching assistants.

b. Other Actions . The University will take such corrective action against any non-residents or non-employees found to have violated this policy, as may be appropriate under the circumstances.

RETALIATION :

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Retaliation against one who in good faith brings a complaint of sexual harassment or who in good faith participates in the investigation of a sexual harassment complaint is prohibited and shall be a violation of this policy and shall constitute misconduct subject to disciplinary or other action as described above.

FILING OF FALSE SEXUAL HARASSMENT COMPLAINT :

Knowingly filing a false sexual harassment complaint is prohibited and shall be a violation of this policy and shall constitute misconduct subject to disciplinary action as described above. A complaint that is investigated and deemed unsubstantiated is not necessarily a false complaint.

REPORTING REQUIRED :

Any resident or employee who has witnessed what is perceived to be a violation of this policy should promptly report that conduct to the OAS, who then will proceed as appropriate. Any supervisor who has witnessed or becomes aware of the alleged occurrence of sexual harassment by, or who receives a complaint of sexual harassment involving a person within that supervisor's purview is required to take prompt corrective action as appropriate, and to report the matter, if possible, within two work days to the OAS. Failure of the supervisor to take appropriate corrective action or to report the incident shall be a violation of this policy and shall constitute misconduct subject to disciplinary action as described above.

COMPLAINT PROCEDURE :

a. Filing of Complaint . Any resident or employee who believes that he or she is a victim of sexual harassment in violation of this policy is encouraged to promptly notify the alleged perpetrator (the "respondent") verbally or in writing that his or her conduct is unwelcome. Such action may cause the unwelcome conduct to cease as well as help to maintain an environment free from sexual harassment. Assistance and support is available from the Office of the Dean of the Faculties (for faculty), the Office of the Dean of Students (for students), or the Department of Human Resources (for non-faculty employees). Regardless of having given notice to the respondent, the resident or employee (the "complainant") may initiate a complaint under this policy by promptly bringing the matter to the attention, preferably in writing by completing the complaint form, of any of the following:

1. The Office of Audit Services; 2. The Department of Human Resources; 3. The DIO; or, 4. An employee's immediate or next immediate supervisor.

All complaints should be filed in a timely manner. Complaints filed for acts that occurred more than one year from the filing date of the

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complaint will generally not be investigated unless appropriate in the judgment of the OAS.

b. Preparing a Complaint . The complainant should provide the following information to facilitate a prompt and thorough investigation:

1. The names, addresses, telephone numbers, administrative unit, and position or status of the complainant and the respondent, if known;

2. Specific acts alleged, including dates, times, and locations; 3. Names, addresses, and phone numbers of potential witnesses;4. The effect the alleged acts have had on the complainant; 5. Actions the complainant may have taken to attempt to stop the

harassment;6. Complainant's suggestion of proposed action to address or resolve

the harassment; and7. Other information the complainant believes is relevant.

c. Transmitting a Complaint to the OAS . The complaint shall immediately be forwarded to the OAS. If the complaint is verbal, the person receiving the complaint shall make a written summary thereof on the complaint form and request the complainant to sign it.

d. Reviewing a Complaint . The OAS will make an initial determination whether the alleged perpetrator is a resident or employee. If the alleged perpetrator is identified, as one who is not a resident or employee, then the OAS will refer the matter to the Office of the General Counsel for appropriate action. If the OAS determines that the alleged perpetrator is a resident or employee, the OAS will review the complaint to determine whether the acts complained of, as stated by the complainant, constitute a violation of this policy, and if not, the complainant will be so informed. If the OAS determines the alleged acts may constitute a violation of this policy, the investigation will proceed as set forth below, unless the matter is satisfactorily resolved as in the following paragraph (e).

e. Notifying the Respondent and Supervisor; Informally Resolving a Complaint; Withdrawing a Complaint. The OAS will notify the respondent and his or her appropriate supervisor of the allegations contained in the complaint. In an effort to informally resolve the complaint, the OAS will elicit from the complainant, proposed actions the complainant believes are necessary to address or resolve the alleged harassment. The OAS will discuss these proposed actions with the respondent and with appropriate levels of management. The respective parties will also have the opportunity to propose other means of resolution. Thus, if the matter can be resolved informally, or if the complainant chooses to withdraw the complaint, the complainant will sign a statement outlining the informal resolution and releasing the University from taking any further action. If the matter is not resolved at this stage, the complaint will be investigated as set forth in below.

INVESTIGATION :

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The following procedures will govern all investigations of complaints alleging violations of this policy:

a. The OAS will thoroughly investigate complaints alleging violations of this policy with the assistance, as needed, of the following: the Office of the Dean of the Faculties, the Department of Human Resources, and/or the respondent's supervisor(s), except in cases where the respondent is a resident. If the respondent is a resident, the OAS will forward a copy of the complaint and any associated materials to the Office of the Dean of Students, which will, if appropriate, adjudicate the matter under the Code of Student Conduct. The Dean of Students shall notify the OAS of the outcome.

b. The investigation should include interviewing the complainant and witnesses suggested by the complainant who may have knowledge of the alleged offending behavior. Employees and residents shall fully cooperate in the investigation.

c. The respondent will be given an opportunity to respond to the complaint verbally and in writing and may suggest additional witnesses.

d. The investigation should also include interviewing such other witnesses as are deemed appropriate under the circumstances.

e. The investigation should include a review of any files and records of previous sexual harassment complaints against the respondent and any other documents deemed relevant.

f. All witnesses who provide relevant information should submit a written, signed statement attesting to their knowledge of the subject circumstances.

g. Confidentiality of the investigation will be maintained to the extent allowed by law.

REPORT OF OAS :

The OAS will prepare a report setting forth its findings and a determination concerning violation of this policy. The report should be completed within 120 days following the filing of the complaint, where feasible, and will be submitted to the appropriate vice president of the respondent's unit or department.

SUBSEQUENT ACTION :

The vice president will make a determination, upon review of the OAS's report, consultation with the Dean of the Faculties or the Director of Human Resources, and consideration of any other relevant information, including aggravating or mitigating circumstances, whether disciplinary action is warranted under the circumstances. If the vice president determines that disciplinary action should be initiated, then, consistent with due process requirements, the respondent will be notified in accordance with applicable Florida Board of Education and University rules and policies and collective

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bargaining agreements, and appropriate disciplinary procedures as provided for therein will be followed. Regardless of whether formal disciplinary action is initiated, the University may take such informal corrective action as may be appropriate under the circumstances. The vice president will notify the OAS of the outcome. The OAS will notify the complainant of the results of the investigation and subsequent disciplinary or other corrective action taken, if any, to the extent allowed by law. The OAS will notify the respondent of the results of the investigation when no policy violation is found and no further action planned.

DISTRIBUTION OF POLICY :

Copies of this policy are available to all current and future employees and residents at the Florida State University in hard copy (policy brochures, resident handbooks, The Bulletin, etc.), electronic format (www.auditservices.fsu.edu/sh/policy), and will be made available in alternative format upon request. Any person involved in the process under this policy needing accommodations for a disability should notify the OAS.

APPLICABILITY :

This policy supersedes any and all prior University policies regarding complaints of alleged acts of sexual harassment.

RESIDENCY CLOSURE / REDUCTION:

All program directors must report to the DIO any plans for change in residency size. Reductions should be designed to maintain a high standard of educational experience that continues to comply with ACGME standards. Significant changes in program size must be discussed at the GMEC regarding the educational impact on that program, as well as other associated programs.

In the event that the FSU COM decides to reduce the number of residency positions in and/or close any GME program, the residents will be notified as soon as possible. Should a Residency Program downsize for any reason, it will make a good faith effort to accomplish the reduction by accepting fewer residents into the entry level of the program. Any such reduction must include provision for a continued training program for existing residents/fellows. If necessary, the institution and the individual residency program will assist residents in finding another residency position in the same specialty at the appropriate PGY level; however, every effort will be made to allow residents in the program to complete their training through the FSU COM Residency Program with funding for their support remaining intact.

ACCOMMODATION OF RESIDENTS WITH DISABILITIES:

The Florida State University (FSU) embraces the value of increasing knowledge and awareness through diversity, which includes administration of the Americans with

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Disabilities Act (ADA) program. This program ensures that faculty, staff, residents and visitors with disabilities are included in the mainstream of University life.As a public entity, FSU is required by Title II of the ADA to make all of its activities, programs and services equally available to persons with disabilities. FSU has resources available for those who have disabilities, which help ensure a quality, educational and work environment.

If a resident wishes to request accommodation, he/she will submit the Employee Request for Accommodations Under the American with Disabilities Act (ADA), form ADA-99, to his/her residency program director, with copy to the DIO. The form is available from the FSU Office of Diversity & Compliance. The program director and DIO will review the request. If it is determined that additional medical information is needed, the resident will be provided with any forms/questionnaires necessary for his/her health care provider to complete. The Residency Coordinator will assist in the evaluation of the information to determine eligibility within the guidelines of ADA.

The program director and DIO will then coordinate with the necessary institutional staff and the resident to determine whether the requested accommodation would be effective, reasonable, and enable the resident to perform the essential functions of the position and achieve the essential educational goals and program objectives, or make a good faith effort to negotiate another accommodation. The Residency Coordinator will follow-up on employee's status/progress on annual basis, or earlier as need arises.

A request for accommodation may be made at any time during residency training. In order for the resident to receive maximum benefit from his/her residency training time, requests for accommodation should be made as early in the training process as possible.

All medical-related information will be kept confidential and maintained separately from other resident records. However, supervisors and managers may be advised of information necessary to make the determinations they are required to make in connection with a request for an accommodation. First aid and safety personnel may be informed, when appropriate, if the disability might require emergency treatment or if any specific procedures are needed in the case of fire or other evacuations. Government officials investigating compliance with the ADA may also be provided relevant information as requested. Form ADA-99 and attached documentation submitted to the Residency Coordinator will be maintained in a confidential manner in accordance with applicable federal and state mandated retention schedules.

PHYSICIAN IMPAIRMENT AND SUBSTANCE ABUSE:

The FSU COM conforms to the Florida Medical Practice Act (F.S. 458). The rule calls for all licensed practitioners to report to the appropriate authority any reasonable suspicion that a practitioner is impaired to practice. The legislation provides for

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therapeutic intervention through the Professionals Recovery Network (PRN). This organization works closely with the State Board of Medicine and is recognized as the primary method of dealing with physician impairment in the state.

1. Faculty, staff, peers, family or other individuals who suspect that a resident is suffering from a psychological or substance abuse problem are obliged to report such problems. Individuals suspecting such impairment can discuss their concerns with the Program Director and/or the DIO, or may report it directly to the Physician’s Recovery Network (PRN). It is the intent of the sponsoring institution that all appropriate rules that govern the practice of medicine be strictly enforced.

a. All referrals to the PRN are confidential and are evaluated by the professionals of the PRN. Decisions about intervention, treatment and after care are determined by the PRN.

b. As long as the practitioner satisfactorily participates in the PRN program no regulatory action would normally be anticipated by the Board of Medicine.

c. Resumption of clinical activity and residency program will be contingent upon the continued successful participation in the PRN and continuation of the resident in the program will be determined in consultation between the program director and the professionals at the PRN.

d. Information on the PRN and its program can be obtained by calling 1-800-888-8776 or by writing to the PRN at P. O. Box 1020, Fernandina Beach, FL 32035-1020.

2. Each program will provide an educational program to their residents regarding substance abuse.

3. Compliance with the above will be monitored in the internal review process.

Physicians with a past or current history of drug or alcohol addiction must contact the PRN as soon as possible on or before arriving at your training program. This is a confidential and professional organization that will help you in this regard, while maintaining your ability to practice medicine in our State.

The purpose of the PRN Program is to ensure the public health and safety by assisting the ill practitioners who may suffer from one or more of the following:

Chemical dependency Psychiatric illness Psychosexual illness, including boundary violations Neurological/cognitive impairment Physical illness HIV infections/AIDS Behavioral disorders

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By supporting ill practitioners in regaining their health, PRN attempts to maintain the integrity of the healthcare team in its role in serving the public. You are treated with respect, confidentiality, and without discrimination. Recommendations by the PRN for any type of follow-up, counseling, testing, assessment, etc. is the privacy of you and the PRN in their Advocacy/Monitoring Contract.

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RESIDENT PROMOTION, PROBATION AND TERMINATION:

1. MARCH 1st is the date by which residents will be notified of promotion or probation for the following academic year. Probation may be instituted earlier, at the discretion of the faculty and program director.

2. Promotion is dependent upon fulfillment of the following criteria to the satisfaction of the faculty:

a. Acquiring the specific cognitive, clinical, and operative skills for each level of training, as stated by the various divisions and the CREOG guidelines.

b. Appropriate moral, ethical, and professional conduct.c. Attendance and participation in teaching functions.d. Acceptable performance on the CREOG In-Service Training Examination.

“Acceptable” absolute (raw) scores and standardized scores will be determined on an individual basis, taking into account level of training, prior scores on standardized tests, and other aspects of clinical performance.

3. Failure to satisfactorily meet any of the above standards will result in the resident being placed on PROBATION.

4. Residents on probation will be given ample opportunity to correct their deficiencies.

5. Residents not fulfilling duties will be given one warning. If the offense is repeated, they will be given a suspension. The third time, they will be given probation. This is at the discretion of the faculty and the Program Director. Two suspensions in different areas (i.e. medical records and failure to complete statistics) will result in probation.

6. When such deficiencies are determined to be corrected by the faculty, the resident then will be removed from probation. Failure to correct these deficiencies within the allotted time may be grounds for TERMINATION.

7. Any major departure from the faculty’s standards of resident performance may be judged grounds for TERMINATION without a preliminary PROBATIONAL PERIOD.

8. Due process will be provided for any party potentially involved in dismissal actions and for any resident who has a grievance against the program. (See Grievances)

9. All resident evaluations will be electronic on a monthly basis through New Innovations. (See Evaluation Policy)

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Resident and Program Responsibilities:

The position of resident involves a combination of supervised, progressively more complex and independent patient evaluation and management functions, and formal educational activities.

Among a resident’s responsibilities in a training program of the University are the following:

1. to meet the qualifications for resident eligibility outlined in the Essentials of Accredited Residencies in Graduate Medical Education in the American Medical Association (AMA) Graduate Medical Education Directory

2. to develop a personal program of self-study and professional growth with guidance from the teaching staff

3. to provide safe, effective, and compassionate patient care, commensurate with the resident’s level of advancement, responsibility, and competence, under the general supervision of appropriately privileged attending teaching staff

4. to participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents

5. to participate in institutional orientation and educational programs and other activities involving the clinical staff

6. to submit to the program director confidential written evaluations of the faculty and the educational experiences

7. to participate on institutional committees and councils to which the resident is appointed or invited, especially those that relate to their education and/or patient care

8. to adhere to established practices, procedures, and policies of the University and of affiliated institutions as applicable, including among others, duty hours regulations and state licensure requirements for physicians in training

9. to develop an understanding of ethical, socioeconomic, medical/legal issues, communication skills and cost containment issues that affect graduate medical education and medical practice

10. to develop an understanding of research design, statistics, and critical review of the literature necessary for acquiring skills for lifelong learning.

Duration of Appointment and Conditions for Reappointment:

Your initial appointment will begin on June 23, 2008; however, the beginning date of the contract is contingent upon you receiving a Resident Training License. Appointments are continuously reviewed and retention in the training program depends on your satisfactory performance/training progress, including your adherence to acceptable professional behavior. A resident’s reappointment and progression to more advanced levels will be based on the results of periodic reviews of the resident’s educational and professional

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achievement, competence and progress as determined by the program director and teaching faculty. The program maintains a confidential record of the evaluations.

The primary site of your graduate medical education training will be the Sacred Heart Health System, Pensacola, and affiliates, but the location of the training for any resident may also occur at various additional sites. All assignments and call schedules are made at the discretion of the appropriate program director of the University. In addition should the residency programs be closed or downsized, the University will inform the resident as early as possible of such events. Every effort will be made to complete the resident’s course of training or to find another site for the resident to complete training.

Discipline Policies and Procedures:The position of the resident presents the dual aspect of learner in graduate training while participating in the delivery of patient care. The Florida State University College of Medicine is committed to the maintenance of a supportive educational environment in which residents are given the opportunity to learn and grow. Inappropriate behavior in any form in this professional setting is not permissible. A resident’s continuation in the training program is dependent upon satisfactory performance as a learner, including the maintenance of satisfactory professional standards in the care of patients and interactions with others on the health care team. The resident’s academic evaluation will include assessment of behavioral components, including conduct that reflects poorly on professional standards, ethics, and collegiality. Disqualification of a resident as a learner or as a member of the health care team from patient care duties disqualifies the resident from further continuation in the program.

Grievances: A grievance is defined as dissatisfaction when a resident believes that any decision, act or condition affecting his/her program of study is arbitrary, illegal, unjust or creates unnecessary hardship. Such grievance may concern, but is not limited to, the following: academic progress, mistreatment by any University employee or resident, wrongful assessment of fees, records and registration errors, discipline (other than non-renewal or dismissal) and discrimination because of race, creed, color, gender, religion, national origin, age, disability, veteran’s or marital status, or any other protected group status, subject to the exception that complaints of sexual harassment will be handled in accordance with the specific published policies of Florida State University and the College of Medicine.

A resident (employee) who has a complaint or grievance, may discuss this with the Program Director. If, after discussion, the grievances cannot be resolved, the resident may contact the Chairman of the Graduate Medical Education Committee (CGMEC). The CGMEC will meet with the resident and will review the grievance. The decision of the CGMEC will be communicated in writing to the resident.

Alternatively, the employee may utilize the University’s Mediation Program that is administered by the Employee Assistance Program (EAP) prior to the filing of a formal

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complaint or grievance. Additional information on the EAP may be obtained through the Florida Sate University.

The Office of the University’s Coordinator of Sexual Harassment Resolutions (the “Coordinator”), within the Office of Audit Services, is designated to receive and investigate sexual harassment complaints as set forth in the University’s policy and to maintain the records pertaining thereto. Additional information may be obtained through the Florida State University.

Suspension:The Chief of Staff of a participating and/or affiliated hospital where the resident is assigned, the Dean, the Chief Executive Officer (CEO) of the Hospital, or Program Director may at any time suspend a resident from patient care responsibilities. The resident will be informed of the reasons for the suspension and will be given an opportunity to provide information in response.The resident suspended from patient care may be assigned to other duties as determined and approved by the Program Director. The resident will either be reinstated (with or without the imposition of academic probation or other conditions) or dismissal proceedings will commence by the University against the resident within thirty (30) days of the date of suspension.Any suspension and reassignment of the resident to other duties may continue until final conclusion of the decision-making or appeal process. The resident may appeal to the Chair, Graduate Medical Education Committee (CGMEC), for resolution.

Non-renewal:In the event that the Program Director decides not to renew a resident’s appointment, the resident will be provided written notice no later than four months prior to the end of the resident’s contract. However, if the primary reason(s) for the non-renewal occurs within four months prior to the end of the agreement, residents will be provided with as much written notice of the intent not to renew as the circumstances will reasonably allow, prior to the end of the agreement. The notice of intent will include a statement specifying the reason(s) for non-renewal.

If requested in writing by the resident, the Program Director will meet with the resident; this meeting should occur within 10 working days of the written request. The resident may present relevant information regarding the proposed non-renewal decision. The resident may be accompanied by an advisor during any meeting held pursuant to these procedures, but the advisor may not speak on behalf of the resident. If the Program Director determines that non-renewal is appropriate, he/she will use his/her best efforts to present the decision in writing to the resident within 10 working days of the meeting; the resident will be informed of the right to appeal to the CGMEC.

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Dismissal:In the event the Program Director of a training program concludes a resident should be dismissed prior to completion of the program, the Program Director will inform the CGMEC in writing of this decision and the reason(s) for the decision. The resident will be provided previous evaluations, complaints, counseling, letters and other documents that relate to the decision to dismiss the resident.

If requested in writing by the resident, the Program Director will meet with the resident; this meeting should occur within 10 working days of the written request. The resident may present relevant information regarding the proposed dismissal. The resident may be accompanied by an advisor during any meeting held pursuant to these procedures, but the advisor may not speak on behalf of the resident. If the Program Director determines that dismissal is appropriate, he or she will use his/her best efforts to present the decision in writing to the resident within 10 working days of the meeting.

Appeal:If the resident appeals a decision for suspension, non-renewal or dismissal, this appeal must be made in writing to the CGMEC within 10 working days from the resident’s receipt of the decision of the person suspending the resident or the Program Director. Failure to file such an appeal within 10 working days will render the decision of the person suspending the resident or the Program Director the final agency action of the University.

The CGMEC will appoint an ad hoc committee to conduct a review of the action, and review the documents or any other information relevant to the decision. The resident will be notified of the date of the meeting with the CGMEC and the committee; it should occur within 15 working days of the CGMEC’s receipt of the appeal. The CGMEC, along with the committee, may conduct an investigation and uphold, modify or reverse the recommendation for suspension, non-renewal or dismissal. The CGMEC will notify the resident in writing of the decision. If the decision is to uphold a suspension, the decision of the CGMEC is the final agency action of the University. If the decision is to uphold the non-renewal or dismissal, the resident may file within 10 working days a written appeal to the Dean of the College of Medicine. Failure to file such an appeal within 10 working days will render the decision of the CGMEC the final agency action of the University.

The Dean will inform the CGMEC of the appeal. The CGMEC will provide the Dean a copy of the decision and accompanying documents and any other material submitted by the resident or considered in the appeal process. The Dean will use his/her best efforts to render a decision within 15 working days, but failure to do so is not grounds for reversal of the decision under appeal. The Dean will notify in writing the CGMEC and the Program Director and resident of the decision. The resident will then be informed of the steps necessary for the resident to further challenge the action of the University. The President of the University will be the final agency action of the University.

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RESIDENT DUTY HOURS:

Duty hours are defined as all clinical and academic activities related to the residency program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined a 1 continuous 24-hour period free from all clinical, educational, and administrative duties.

Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.

ON CALL ACTIVITIES:

The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those extra duty hours beyond the normal work day, when residents are required to be immediately available in the assigned institution.

In-house call must occur no more frequently than every third night, averaged over a 4-week period. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. No new patients may be accepted after 24 hours of continuous duty.

At-home call (or pager call) is defined as a call taken from outside the assigned institution. The frequency of at-home call is not subject to the every third-night limitation. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.

DOCUMENTATION OF RESIDENT WORK HOURS:Residents are expected to document their work hours directly into New Innovations via the Internet at www.newinnovations.com . Duty hours will be entered into the computer daily, and will be verified by the Program Director weekly. The Program Director will monitor all duty hours for verification and violations. Failure to comply will result in warning (1st offense), suspension (2nd offense) and probation (3rd offense).

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CONTINUITY CLINIC GUIDELINES: New interns will inherit schedule from outgoing chiefs. All pts scheduled in a residents cc schedule will automatically be assigned to their continuity clinic. Residents may recruit patients by checking box on the D/C instruction sheet. Attendings are the only one who may take a patient out of an assigned continuity clinic. If patients need to be seen emergently (or their schedule is full), you may schedule her with another DR. Inform her that this is just temporary, and she will not be switched to another DR’s panel unless she request to do so.

POLICIES ON SUPERVISION:Each faculty is assigned to a clinical area and is responsible for the direct supervision of such resident or teams of residents. There is in house 24 hour faculty coverage present. The lower level residents report directly to the upper level residents and the upper level residents report to the attending faculty currently in charge of that clinical area.

PROPER APPEARANCE FOR RESIDENTS:Men should wear a dress shirt with tie and a white coat with name badge. Comparable attire is expected for women. SHH and FSU name badges are mandatory at all times when engaged in patient care. Blue jeans and coveralls are unacceptable. The same is true of long hair styles for men and untrimmed beards and mustaches. The following footwear is unacceptable: tennis shoes, thongs, and heavy boots. Except in unusual circumstances, scrub suits should be worn only in the Labor and Delivery and Operating Room areas.

Two monogrammed laboratory coats will be provided to each incoming resident. One additional coat will be provided at the start of each subsequent year of training. Anyone wishing to purchase a more expensive coat may do so and be reimbursed the standard rate.

PROGRAM MEETINGS:All residents are expected to attend scheduled conferences/meetings unless specifically excused. Attendance records are maintained.

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LEGAL DOCUMENTS:If you receive legal documents, i.e., subpoenas, there are steps that must be followed. This is the resident physician’s responsibility.

1. Notify the program director.2. Notify your attending physician in the case.3. Notify Risk Management of Sacred Heart, Ext. 7864; fax – 6857 and FSU Self

Insurance Office; Phil Cox, (w) (352) 273-7006;©(352)262-17134. Notify the Designated Institutional Official (DIO) at the FSU COM

OUTSIDE PROFESSIONAL ACTIVITIES:All programs have established rules regarding active voluntary, outside and extracurricular activities that meet their RRC requirements and University’s policy. There are two categories of such activity: Programmatic moonlight and Non-Programmatic moonlighting.

CERTIFICATE OF COMPLETION:A certificate of graduate medical education training will be issued to a resident on the recommendation of the University’s appropriate Program Director only after satisfactory completion of service and educational requirements and fulfillment of all other obligations and debts, including completion of medical records and return by the resident of State of Florida property, as well as property of any affiliated institution.

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CONTINUING EDUCATION:

FLORIDA MEDICAL LICENSE:Residents who have completed PGY 1 are eligible to apply for a Florida medical license upon successful completion of Step III of the U.S. Medical Licensing Examination. The Program will pay the fee for initial licensure and one renewal. Step III must be completed at the end of the intern year for successful promotion to year two.

ACOG JUNIOR FELLOWSHIP:All residents are expected to apply for Junior Fellowship in the American College of Obstetricians and Gynecologists at the time that residency training begins. The Department will pay the residents’ dues. There are numerous advantages to membership in ACOG. Many opportunities are open only to Junior Fellows, including attendance at ACOG meetings and courses where fees are dependent on membership. As a result of membership in ACOG, residents receive a yearly subscription to OBSTETRICS AND GYNECOLOGY.

CREOG IN-SERVICE TRAINING EXAMINATION:Each year, residents will take the CREOG In-Service Training Examination. The program will pay the fees for the examination. The 2010 CREOG Examination will be given on Thursday and Friday or Friday and Saturday, January 20-22, 2011. The examination has two sections of multiple choice questions with a total of 350-400 items. The examination’s content is based on CREOG’s Educational Objectives for Residents in Obstetrics and Gynecology (9th edition). Each resident is provided with a copy of these books. The examination feedback provides a method to determine individual strengths and weaknesses in cognitive knowledge. Examination scores are one measure of the resident’s clinical performance.

RESIDENT OSCE EXAMS:Resident OSCE Exams will be in March each academic year for the 1st, 2nd, and 3rd year residents, and will assist in the criteria for promotion.

BOARD CERTIFICATION/EXAMINATIONS:Chief residents must apply for their 2010 written American Board Examination prior to November 17, 2010. Examination fees a will be provided by the program.

The American Board of Obstetrics and Gynecology (ABOG) describe its purposes as follows: “To arrange and conduct examinations and/or other procedures to test the

qualifications of voluntary candidates for certification and recertification.”

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“To issue certificates or any other evidence of competence to eligible physicians whom this Corporation considers to have demonstrated special knowledge and professional competence relating to Obstetrics and Gynecology.”

“To determine from time to time whether physicians who have been issued certificates or other evidences of competence have continued to maintain their professional qualifications, and to issue recertification certificates or other evidences of competence to those physicians who successfully demonstrate continued maintenance of such qualifications.”

Important Dates in the ABOG Certification Process:

NOT Pertaining to the Accelerated Oral ProcessI. Final year of residency (ending on or before the following September 30)A. July 1 -- CommenceB. September 1-November 16 -- Apply for basic written examinationC. Last Monday in June -- Take basic written examination

Written Examination

Between September 1 and November 16 of the final year of residency, candidates must complete the application for the written examination on-line at www.abog.org. If ruled admissible to take the examination, the candidate will do so on the last Monday in June of the final year of residency. (This paragraph applies to candidates who are due to complete their residency prior to September 30.) For candidates who will complete their residency training after September 30, application for the written examination must be delayed until the following year. If ruled admissible to take the examination, the candidate will do so in June of the following year, that is, up to 21 months aftercompletion of residency.

THE EXAMINATION PROCESS IS VOLUNTARY. THE ABOG WILL NOT CONTACT YOU. YOU ARE RESPONSIBLE FOR COMPLETING THE APPLICATION AND SUBMITTING REQUIRED MATERIALS IN A TIMELY FASHION.

RESEARCH GOALS AND OBJECTIVES:Dr. Barry Ripps-Director of Research

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The purposes of a resident research effort within our residency training program are multifaceted. Overall, these efforts will advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.

Consistent with recommendations, implementation of the program should foster an atmosphere of inquiry and scholarship within the residency program, develop skills to assess quality of published clinical research, promote confidence in the reading of medical literature, and cultivate a career-long curiosity and passion for continued exploration and learning.

Toward this mission, faculty strives for the following goals and objectives: 1. Faculty members establish and maintain an environment conductive to inquiry and scholarship with an active research component. 2. Regular clinical group discussion, rounds, journal club, and conferences. 3. Faculty members demonstrate a commitment to scholarship by one or more of the following: a. Publication of original research or review articles in peer-reviewed journals, or chapters in textbooks. b. Publication or presentation of original research, case reports, clinical series. c. Participation in national committees or educational organizations. d. Encouraging, organizing and supporting resident efforts in scholarly activities.

Resident will strive to achieve the following skills and tasks during the four year training program 1. Recognize the role of clinical research in the advancement of medicine. 2. Develop systematic and sustainable approach to reading the medical literature to keep current throughout their career with an evolving standard of practice. 3. Develop an appreciation for hierarchy of clinical study design and challenges to achieving clinically meaningful evidence; statistical power, biases, confounding variables, etc. 4. Advance a working knowledge of levels of evidence as guides to determine Research utility and incorporation into clinical practice. 5. Understand function of institutional review boards. 6. Develop/conduct a research project of publication quality: a. develop and propose test hypothesis b. design study to test hypothesis c. seek IRB review and approval as indicated d. conduct the study/enrollment e. perform data analysis f. prepare abstract/manuscript/presentation h. serve as a discussant for other projects

Time Allocation and Faculty/Facility Support

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Successful completion of item six (6) above will be best served by regular and progressive interaction with a sponsoring faculty mentor and/or coordination by a Director of Research. A general timeline for implementation and completion of the project is provided:

PGY-1Group discussions on topic of interest throughout the yearIdentification and selection of a topic by late as indicatedInitiate project by late year

PGY-2Draft of proposal for faculty review early in yearDevelop and finalize study protocolSeek review/approval by appropriate committees as indicatedInitiate project by late in the year

PGY-3Data collection/entryData and statistical analysisInterpretation of findingsPreparation of abstract/manuscriptLocal presentation and recognition at department-wide conferenceSubmission of abstract for presentation at state, regional, national meetings

PGY-4Submission of manuscript for peer-reviewed publicationServe as discussant of PGY-3 project presentations

Research Policies:

The Florida State University College of Medicine Office for Research (OFR) is responsible for all matters pertaining to research proposals developed by College of Medicine faculty members until such time as the contract, grant, or sub-contract is awarded (pre-award procedures). Post-award procedures are handled by the Financial Affairs Office. It is the responsibility of the OFR to assure compliance with college, University and grant agency requirements. The OFR must review the proposal and the Associate Dean for Research must sign approval for the College of Medicine prior to submission of the proposal to the University Office of Sponsored Research.

1. Any contract or grant proposal by a member of the COM faculty/staff must be submitted through the COM OFR if that faculty/staff member uses his or her FSU title, or the college or university name on the proposal.

2. Proposals may be submitted only if a full-time FSU faculty member is listed as Co-PI (university policy). Exceptions may be granted by the FSU Vice President for Research.

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3. Each PI should work with his/her Department Chair to determine a reasonable percent effort for the proposal and include the corresponding salary required for that percent effort, if the sponsoring agency allows PI salary.

4. The COM does not permit cost-sharing in excess of that required by the sponsoring agency. Exceptions to this policy must be approved by the Associate Dean for Research, Dean of the COM, and the FSU Vice President for Research.

5. If Recombinant DNA, Human or Animal Subjects, Radioactive/Hazardous Materials, or Workshops/Conferences are involved, the project must be approved by the appropriate FSU Compliance Officer (FSU Biohazard Committee, FSU Human Subjects Committee, Animal Use and Care Committee, Environment Health and Safety Director, Center for Professional Development Director) prior to funding.

6. All graduate resident Matriculation and Fee costs must be included in the proposal budget or paid from an alternate source.

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BENEFITS AND RESOURCES:

LIBRARIES:The Medical Library at SHH is available for use by the residents. The library is located on the first floor of the Main Hospital and has recently undergone renovation. After-hours access can be obtained by using the “88” key. Computers for literature searches are available in the library, and a librarian is available to assist you.

In addition, the FSU COM has an extensive on-line library (http://www.med.fsu.edu/library/) which is available for residents to use which also includes a number of Obstetric and Gynecology journals and books. (See Appendix VI, VII). You will be provided with a username and password. Training sessions will be held periodically throughout the year.

COMMUNICATIONS:The major means of communications within the program will be via e-mail. Residents are required to have an active e-mail address and should check their mailboxes regularly. They may use either a personal account or the College of Medicine e-mail account provided them. Computers are located in the Resident’s Report Room, Resident’s Lounge, and clinic. Resident and faculty physician e-mail addresses will be distributed to members of the program.

LEAVE FOR INTERVIEWING:It is expected that toward the end of the fourth year, residents will need to interview for a Fellowship Program or job placement. Interviews for Fellowships generally occur during the week and residents may be allowed 1-2 days at a time without being penalized for vacation. Job interviews can usually be arranged on weekends. The total number of days allowed for interviewing is at the discretion of the Program Director.

HOLIDAYS:Florida State University holidays will be observed (New Years, Martin Luther King, Memorial Day, Independence Day, Labor Day, Veteran’s Day, Thanksgiving and day after, and Christmas). If the holiday falls on the weekend, the nearest Friday or Monday will be designated. In the event a resident is unable to receive the time off while accounting for patient care, a different day off will be afforded to the resident.

RESIDENT AND FELLOW LOAN DEFERMENT REQUESTS:The Association of American Medical Colleges (AAMC) and the Council of Deans have established the policy that no loan deferment on National Direct Student Loans and Guaranteed Student Loans for any resident or fellow past PGY II will be certified. Loan deferment requests for other types of loans will be processed on an individual basis.

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MEAL VOUCHERS:Each resident will be issued meal vouchers to cover the cost of meals during days and nights of call.

MEDICAL EDUCATION ALLOWANCES:1. Third or Fourth year residents will have 5 days of administrative leave to attend a

postgraduate course. The travel allowance for the postgraduate course is $2400. Additional leave days must be taken as vacation time. Travel money can be used only to defray expenses of the postgraduate course.

2. Extramural postgraduate courses must be approved by the program director. Approval will be based upon the scientific content of the course curriculum. Residents must complete a preauthorization travel form prior to their meeting, and travel must conform to Florida State University guidelines.

3. Only one funded meeting is permitted in each academic year.4. Resident’s research selected for presentation at a National meeting will be funded

at the discretion of the chair.5. Residents may use $600 in years 1 & 2 for book allowance if they choose this

option.

FINANCIAL SUPPORT AND BENEFITS:

Stipend:

Each resident is given a stipend to pursue the resident’s graduate medical education in an amount appropriate to the resident’s level in the program. Stipend levels are reviewed annually by the Graduate Medical Education Committee of the College of Medicine and recommendations for changes are subject to approval by the Dean of the College of Medicine. Stipend levels begin on the first (worked) day of the new contract year and are paid bi-weekly.

Living quarters, meals, laundry, and other such expenses are the resident’s responsibilities. In some cases, meal tickets may be issued to the resident when the resident is assigned in-house call on nights and weekends; similarly, living quarters may be provided during some rotations outside of the primary location of the program.

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Florida State UniversityCollege of Medicine

Sacred Heart HospitalPensacola, Florida

2010-2011 RESIDENT STIPENDS

FICA Alternative Plan – BENCOR:

Level Annual Salary

Bi-weeklyRate

PGY 1 $46,244.94 $1771.84

PGY 2 $47,746.06 $1829.35

PGY 3 $49,538.11 $1889.01

PGY 4 $51,449.12 $1971.23

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The FICA Alternative Plan is a defined contribution private retirement plan authorized under Section 401 (a) of the Internal Revenue Code. Instead of paying 6.2% social security taxes post-tax, eligible Residents/Fellows contribute 7.5% of pre-tax wages into an investment account in the individual’s name. Medicare contributions at 1.45% will continue to be withheld and matched by the university. The plan is mandatory for all eligible Residents and Fellows. There are a variety of investment options for this retirement plan that include a Guaranteed Pooled Fund (an interest bearing account) and variable investment options. As a participant in the plan, you may direct the investment of your fund at any time by submitting a completed *Retirement Plan Form to BENCOR Administrative Services. If you do not submit this form to direct the investment of your funds, all of your contributions are automatically deposited into the Guaranteed Pooled Fund, an interest bearing account.

A statement of your account activity, including contributions and earnings will be mailed after the end of each calendar year to your home mailing address.

BENCOR, Inc. is the plan administrator for the Florida State University. Additional information about the plan may be found at the Florida State University’s Human Resource Service web site, www.hrfsu.eduUnder Faculty/Staff Benefits/Florida Retirement System/FICA Alternative Plan.

*First year residents receive this form during orientation.

Health, Life and Disability Insurance; Worker’s Compensation Insurance:

Health and life insurance are provided to the resident. As you begin your residency, you will receive a booklet which summarizes the benefits and limitations provided under this small group policy. Please refer to your booklet for all information and any questions you may have regarding your insurance coverage, or contact the FSU COM Coordinator.

Cobra (Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985) In the event of termination, you have the option to continue your health insurance policy at the current premium plus 2% for maximum of 18 months under COBRA. Eighteen-month continuation is also available in the event of reduction in hours or layoff. Thirty-six-month continuation is available to dependents in the event of divorce, death, Medicare entitlement or a dependent losing that status because of age. It is your responsibility to notify the Florida State university college of Medicine Graduate Medical Education personnel within 30 days of any of the above event; failure to provide notification could result in forfeiture of COBRA.

Disability insurance (DI) is offered to residents, and is provided for all who meet the provider’s qualifications. DI coverage includes compensation for an occupational injury that results in HIV infection. The approximate monthly compensation is up to $2,000.

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Note: Prior to completion of this program, you will have the opportunity to convert this group policy to an individual policy that provides compensation of up to $2,000 per month (approximately $5,000 per month for catastrophic illness or injury).If a resident suffers a work-related injury, the resident is covered under the workers’ compensation program of the University provided the resident complies with the requirements of the workers’ compensation program.

Confidential counseling and psychological support services, provided by contracted personnel, are available on an on-going basis.

Professional Liability Coverage:

As a participant in a graduate medical education program of the University, a resident is an employee of Florida State University, a public university of the State of Florida. The resident is personally immune from civil liabilities which may arise from acts or omissions committed by the resident in the course of employment. Section 768.28, Fla. Statutes, outlines the protection against claims and/or judgments extended to employees of the University under Sovereign Immunity. The Florida State University Board of Trustees is vicariously responsible for any civil claims or actions arising from the acts of its employees and agents. Pursuant to University Regulation, the University has created a program of self-insurance covering claims and actions against the University which may arise from the actions or omissions of University healthcare faculty members, residents, other professional employees or residents of the University. A resident must identify himself or herself at all times as a Florida State University employee while participating in the graduate medical education program in order to assure this coverage; a University name tag will be provided.

Medical Requirements:

Screening of the resident for infectious diseases, prophylaxis/treatment for exposure to communicable disease (including influenza), and immunizations will be provided by the University or through arrangements with Sacred Heart Hospital. The resident will have documentation of immunity to measles, mumps, and rubella (MMR), hepatitis B, polio, diphtheria, tetanus, and pertussis (DTPseries and Tdap as indicated); and varicella (chicken pox). The resident will be required to have annual tuberculosis screening an annual vaccination for influenza. The resident will comply with the infection control policies and procedures of the institutions where the resident is assigned.

Florida State University conforms to the Florida Medical Practice Act (F.S. 458). The rule calls for all licensed practitioners to report to the appropriate authority any reasonable suspicion that a practitioner is impaired to practice. The legislation provides for therapeutic intervention through the Professionals Recovery Network (PRN). This organization works closely with the State Board of Medicine and is recognized as the primary method of dealing with physician impairment in the state. Faculty, staff, peers, family or other individuals who suspect that a member of the housestaff is suffering from a psychological or substance abuse problem are obliged to report such problems.

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Reporting can be directly to the PRN or to the Program Director. All referrals are confidential and there is early involvement of the PRN. If the PRN feels intervention is necessary, they handle the situation and provide for treatment and follow-up. Residents can only return to clinical duties with the approval of the PRN. The PRN maintains contact with program directors about residents in the program of recovery.

Institutional Leave Policy:

The leave policy incorporates sick leave, vacation, uncompensated leave, temporary military duty, absences pertaining to education and training, and maternity/paternity leave. Subject to the approval of the program director and consistent with the guidelines of the appropriate specialty board, all residents receive fifteen (15) days of annual leave. Unused annual leave cannot be carried over from one year to the next and is non-transferable and non-reimbursable.A resident will accrue ten (10) days of sick leave for each full year of employment. The resident will be entitled to utilize sick leave for death, or in special cases, severe illness in the immediate family (spouse, parents, brothers, sisters, children, grandparents, and grandchildren of both resident and spouse). The number of days of sick leave allowed per illness will be determined by the program director. Unused sick leave cannot be carried over from one year to the next and is non-transferable and non-reimbursable.The total time allowed away from a graduate medical education program in any given year or for the duration of the graduate medical education program will be determined by the requirements of the specialty board involved. If leave time is taken beyond what is allowed by the University or the applicable specialty board, the resident is required to extend his or her period of activity in the graduate medical training program accordingly in order to fulfill the appropriate specialty board requirements for the particular discipline. The resident may be paid for makeup or extended time if funds are available at that time. All sick leave and annual leave form must be completed and turned into the coordinator of the program.

Vacation:

1. ALL VACATIONS MUST BE APPROVED AT LEAST 12 WEEKS IN ADVANCE OF THE START OF A NEW ROTATION BY THE ADMINISTRATIVE CHIEF RESIDENT, DIVISION DIRECTOR, AND PROGRAM DIRECTOR.

2. Only one resident from each service may be on vacation at a time.3. As a general rule, only one week of leave is permitted during a given rotation. In

addition, vacations usually should not be taken during the same rotation when a scientific meeting is scheduled. Exceptions to this policy must be approved by the program director and division director.

4. As a general rule, vacations should not be taken during the first week of a new rotation.

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5. The first year residents on the OB and Ambulatory Care services should not take leave at the same time.

6. The Night Float residents may not take vacation. The R4 and R2 may attend a meeting during this rotation if coverage can be arranged with other residents.

7. Except in unusual circumstances, vacations should not be scheduled during rotations outside of the department (i.e. Medicine, ER).

8. Vacations should be taken in one week blocks. If vacation is scheduled during a week that has a State holiday, the holiday will count as a leave day.

9. Vacation days may not be carried over from one academic year to the next.10. VACATIONS MAY NOT CONFLICT WITH THE ANNUAL CREOG

EXAMINATION OR RESIDENT RESEARCH DAY PROGRAM.11. Each resident is authorized ten days of paid sick leave annually. This type of

leave may be used for illness or unanticipated family or personal emergencies but may not be carried over from one academic year to the next. A leave form must be submitted immediately after such an excused absence.

Sick Leave/FMLAFlorida State University administers the Family and Medical Leave procedures for eligible employees in accordance with the Family and Medical Leave Act of 1993, the Federal regulations and the State University System rules. All employees are eligible for Family and Medical Leave including Other Personnel Services (OPS) employees so long as they have worked at least twelve (12) months (these need not have been consecutive) and worked at least 1250 hours in the twelve (12) months prior to the leave. OPS employees will be granted unpaid Family and Medical Leave up to a total of twelve (12) work weeks/480 hours during the twelve (12) month calendar year period.

Proper medical certification may be required to grant Family and Medical Leave for one or more of the following reasons:

For the birth and care of a newborn child (FMLA) of the employee or for placement with the employee of a child for adoption or foster care;

To care for an immediate family member (FMLA) with a serious health condition; or

To take medical leave when the employee is unable to work because of a serious health condition.

PREGNANCY / ADOPTION / PATERNITY POLICY

Internal Policy

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1. FMLA states that any person may take up to 12 weeks off after pregnancy.2. ACGME requires that a resident may not miss more than eight weeks of year

level one – three, or six weeks of year four. Additionally, ACGME guidelines state that residents may not miss more than 20 weeks over four years.

3. Prior to twenty weeks EGA (or as soon as possible in the case of adoption) the resident must meet with one of the full time faculty members (Drs. Dorr or J. DeCesare) to go over this policy.

4. Prior to twenty weeks EGA (or as soon as possible in the case of adoption), the resident must draft a letter describing how much maternity leave they wish to take, and specify if they are taking vacation days, sick days, etc.

5. Each resident receives 10 sick days per year. Unused sick leave cannot be carried over from one year to the next and is non-transferable and non-reimbursable.

6. Each resident receives 15 vacations days per year, which do not carry over year to year in the case of pregnancy, a resident may split a five day vacation, and take the days nonconsecutive.

7. It is recommended that a resident take a week of vacation alternating with a week of sick time until they have exhausted their supply of vacation and/or sick days. The resident may then take unpaid leave if they wish to take more time off. They will be limited to three months maternity leave in accordance to the FMLA.

8. Each resident is required to make up call, such that the yearly totals are equal with their classmates. Residents may not work over 80 hours/week.

9. If a resident, due to pregnancy complication or otherwise, misses more time than the ACGME mandates for training, it will be at the discretion of the full time faculty to determine appropriate make-up rotations. For example, if a resident misses eight weeks of gyn thy make-up the time doing a general surgery rotation or a gyn oncology rotation.

10. If a resident is placed on modified duty, such that they are no longer able fulfill the requirements of their rotation but they are allowed to work, then it may be at the discretion of the faculty to determine if the work that the resident is doing fulfills the requirements of the rotation. If the requirements of the rotation are not met, then the faculty will determine appropriate make-up rotations.

11. The duration of maternity leave before and/or after delivery will be determined by the resident and her physician. All available sick and vacation leave must be used to cover maternity leave. The Program Director must approve requests for leave in excess of six weeks.

12. Accrued annual leave may be used prior to the employee being placed on leave without pay. Any illness caused by or contributed to by pregnancy, miscarriage, abortion, or childbirth, shall be treated as a temporary disability, and the employee shall be allowed to use accrued sick leave when certified by the patient’s physician.

13. While on unpaid leave, the resident’s insurance benefits will be maintained by the department for up to two months. After two months, the resident will be responsible for payment of insurance premiums.

14. Changes in the rotation schedule may be made for a resident who is pregnant if these changes are approved by the Program Director.

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15. In special circumstances, leave may be granted for a resident engaged in an adoption proceeding with advance approval of the Program Director.

16. In special circumstances, paternity leave may be granted with the advance approval of the Program Director.

*for the purpose of this document, the term pregnancy will be referred to however it is implied that it refers to adoption and paternity leave time as well.

PATIENTS CHARTS / MEDICAL RECORDS:

MEDICAL RECORDS:

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The medical record is an essential ingredient for good medical care. The record serves many purposes and proper documentation, chart completion and respect for the medical record are expected of all housestaff. The medical record is, and always will be, an important part of your medical career, so the time to develop good habits is now!

DOCUMENTATION:

Indicate patient’s full name and medical record number in the upper right corner of all forms. Write your note immediately after treating the patient. The longer you wait, the less you will retain about the patient. Be specific. Sign, date and time all entries. Do not use abbreviations unless they are listed in the approved abbreviation list published by Health Information and Record Management. Abbreviations are not acceptable for diagnoses and are not to be used on informed consent forms. Choose your words carefully. The medical record is not the place to vehemently disagree with a policy or a colleague. Make alterations carefully, avoid obliterations or creating the appearance of tampering. Cross off errors with a single line, ensuring the entry is still legible. Date and initial the correction. Write in black ink. Write neatly so that another healthcare provider can read your entry in the record. Chart CompletionBy law, the medical record must be complete within twenty-three days of a patient’s discharge. In order to accomplish this, all physicians need to complete their medical records while the patient is in house or visit the Physicians’ Workroom minimally once per week. Residents should sign both the department’s sign-in sheet and the Medical Records Department register to document compliance.

Although it varies by service, most residents are responsible for signing their own progress notes, verbal orders, and dictating operative reports and discharge summaries. Chart completion will be monitored on a weekly basis, with the medical records supervisor emailing the Program Director a listing of residents not in compliance. The first time a resident is not in compliance, they will receive a warning. The second time, they will receive a suspension. The third time they will receive probation.

Your attention to the completion of medical records is reported biweekly to the Department Chairman, the Chief of Staff, and the Department Representative to Health Information and Record Management. FAILURE TO COMPLETE MEDICAL RECORDS IN A TIMELY MANNER MAY JEOPARDIZE YOUR CLINICAL PRIVILEGES.

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CODING:Definition for Reporting Diagnoses and Procedures:

Principal Diagnosis: The condition established, after study, to be chiefly responsible for the admission of the patient

to the hospital.Secondary Diagnosis: All conditions that coexist at the time of admission,

that develop subsequently, or that affect the treatment received and/or length of

stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay should be excluded.

Principal Procedure: The procedure that was performed for definitive treatment rather than one performed for

diagnostic or exploratory purposes or for management of a complication. If there appear to be two major procedures, the one most related to the principal diagnosis should be selected as the principal procedure.Secondary Procedure: These procedures are listed in order of significance

using the following criteria:1. Surgical in nature2. Carries a procedural risk3. Carries an anesthetic risk4. Requires specialized training

Coding Guidelines for Reporting Other (Additional) Diagnoses:

General Rule: For reporting purposes, the definition of “other diagnoses” is interpreted as additional

conditions that affect patient care by requiring:1. Clinical evaluation2. Therapeutic treatment3. Diagnostic procedures, or4. Extended length of hospital stay, or5. Increased nursing care and/or monitoring.

DISCHARGE SUMMARIES:

Discharge summaries must be completed before the patient is discharged from the hospital.All medical records must have a handwritten or dictated discharge summary (under 48 hours, dictated summary is not required). A final progress note may be substituted for a

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discharge summary in the case of patients with problems of a minor nature who require less than a 48-hour period of hospitalization and in the case of uncomplicated obstetric deliveries. A dictated discharge summary is required on the OB service for the following conditions:

1. All antepartum admissions (undelivered) except false labor2. All indicated abortions (termination of pregnancy)3. All deliveries by:

a. Classical cesareanb. Low vertical or low transverse cesarean with complications such as

infection, ileus, hemorrhagec. Cesarean hysterectomy

4. All patients with the following antepartum or postpartum complications:a. Severe preeclampsia and eclampsia or severe chronic hypertensionb. Diabetes mellitus – insulin dependentc. Cardiac patientsd. Isoimmunized pregnancye. Postpartum hemorrhage requiring blood transfusion

5. All fetal deaths in utero6. Any other problem or condition which the attending physician or chief resident

decides needs to have a dictated summary.

The discharge summary concisely summarizes the reason for hospitalization, significant findings, procedures performed, treatment rendered, condition of the patient upon discharge, and any specific instructions given to the patient and family. For the majority of patients, the discharge summary should be no more than 1-2 pages in length. Be sure to include the full name and address of the referring physician so a copy of the discharge summary can be sent to that individual.

CHARTING FOR PERINATAL DEATH:

A perinatal death, in addition to the usual patient care and medical record documentation, has some special requirements.

History: Include information helpful in determining the cause of death, e.g., prenatal complications, date and findings at last prenatal visit, date

of last perception of movement, history of trauma, infection, bleeding or ROM, events leading up to the diagnosis and how the diagnosis was made. Indicate the parents’ choice regarding time of delivery (i.e., immediate induction vs. expectant management.)

Delivery Note: Include parental reaction, who was present, and who saw and held the baby.All mothers of fetuses of 13 weeks or greater at time of death who deliver a recognizable fetus can choose autopsy or not and cremation or not. (Remember, if there is no cremation, parents must make arrangements for a private funeral.) Appropriate consents

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are needed. Photos will be taken automatically of all babies (no consent needed). If consent for autopsy is denied, the placenta will automatically be examined. Nonrecognizable products of conception should go to Surgical Pathology as specimens.

DISCHARGE SUMMARY FORMAT:

Dictator’s name and service Attending physician’s name and position Referring physician’s name and address Patient’s name and medical record number Date of admission Date of discharge Chief complaint History of present illness Past medical history Family history Social history Pertinent review of systems Focused physical examination Initial laboratory assessment Hospital course – include subsequent laboratory studies and diagnostic and

therapeutic procedures Final diagnoses Summary of procedures Condition on discharge Disposition and instructions to patient and family members

OPERATIVE REPORT FORMAT:

Dictator’s name and service Patient’s name and medial record number Date of surgery Pre and postoperative diagnoses. These should be as precise as possible so that

the reader can immediately determine the indication for surgery.

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Operation performed Surgeon and assistants. Always designate the attending physician as the primary

surgeon. Anesthesiologist and assistants. Always designate the attending physician as the

primary anesthesiologist. Type of anesthesia Technical procedure. You do no need to describe every specific instrument you

used and every minuscule detail of the procedure. Focus on the main points! For example, rather than describing every detail of a routine abdominal incision, you can simply indicate that “ … the peritoneal cavity was entered without complication through a vertical (or Pfannenstiel) incision.” However, items such as selection of suture material and type of fascial closure are clinically important and should be noted. Pertinent intraoperative findings (e.g., uterine leiomyoma; adnexal mass; neonate’s weight, Apgar scores, and cord blood gases) and complications (e.g., hemorrhage, bowel or bladder injury) should be described.

Specimens removed Blood loss Fluid replacement Urine output Administration of prophylactic antibiotics Administration of epidural narcotics Extubation, if general anesthesia was used – complicated vs. uncomplicated Disposition of patient (and infant, when appropriate), e.g., recovery room, SICU,

NICU If the patient had a cesarean, be certain to indicate whether she is an acceptable

candidate for VBAC.

Appendix IAppropriate Lab Ordering On Gyn Onc Service

May 5, 2008

To: Residents

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From: S. DeCesare, MD

1. Antibiotic Usage This will outline the care of the gynecologic oncology patients during the next year. According to the Medicare guidelines, which I, we will need to make substantial changes in our antibiotic usage. Given we are doing this for Medicare patients; we will do so on all patients. As such, simply refer to that bulletin for accepted drugs to use preoperatively as well as the accepted dosing patterns required. Please note that antibiotic usage needs to be discontinued within 24 hours of surgery unless it is a contaminated procedure such as gross stool spillage. If we continue antibiotics for this reason or other reasons such as pelvic abscess, this needs to be documented appropriately in the chart.

2. Lab dataI have noted a trend that the laboratory data is not being placed in the progress notes. This data needs to be part of the written record everyday. As such, if labs are not available on your first set of rounds, they need to be put into the chart later that day when they are available. The physician assisting in my office has ample time to go back and document the labs in each days note as an addendum. Similarly, the It’s and O’s need to be kept more strictly. Daily weights are not being done on a routine basis. Drain output is not being included for each individual drain as well. When the patient has multiple drains such as a urinary conduit, each drain needs to be documented separately for urine output. Additionally, all drains coming from the patient including JP drains and nasogastric drainage must be documented each day. Nighttime notes do not require this documentation to as strict of a degree.

3. Problem ListAdditionally, each medical problem needs to be listed separately in the assessment portion of the notes. For example, hypertension with documentation of blood pressures and appropriate treatment is needed in the daily notes. Similarly for diabetics, blood sugars need to be listed in the assessment as well as a comment with regards to blood sugar control and changes that are being done if control is poor.

May 5, 2008

4. Lab Data to OrgaYou are welcome to get a preprinted form with all of this data on it and get it approved by the medical records department if you wish. Please remember that the first postoperative day note should include not only the ins and outs in the first 12 hours post-op but also the ins and outs including the surgical procedure. Protonix or Nexium should

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be utilized in all postoperative patients. Surgical compression devices should also be utilized in all postoperative patients. Additionally, anticoagulants will be initiated somewhere between 24 and 72 hours post-op in all patients. However, the specifics are to be discussed with me on an individual basis.

5. Pre Op LabI would like for the residents to start using more clinical judgment with regards to the laboratory data done preoperatively. Clearly a 40 year old who is undergoing a laser of the vulva with no medical history does not require a chest x-ray, EKG, PT/PTT or type and cross prior to her laser procedure. I think we have gotten into the unfortunate habit of simply ordering every test on every patient. My goal is to train the residents to use their clinical knowledge as well as to individualize each patient. Protocols to be followed are a good idea for nurses, but as a physician, you should be thinking about the individual needs of every given patient. We want to order the appropriate tests for every patient but in clear cases where tests are not necessary preoperatively, they should not be ordered.

6. Chemo Pts.With regards to chemotherapy patients, there are several key things that the residents need to do. First the resident needs to review the medication list on each patient and make sure they are on all of their home medications as long as these are appropriate, of course. Additionally the resident should do a full physical examination upon admission except for a pelvic examination. This includes looking at intraperitoneal port sites and PICC lines to assess for infection. Electrolytes should be checked on the night prior to discharge so these can be corrected at nighttime and therefore keep from delaying the patient’s discharge the following day. Regarding chemotherapy-induced anemia, when patients are being admitted for neutropenic infection, broad spectrum antibiotic coverage plus Leukine 500 mg subcu q.24 hours should be initiated immediately.

7. Chest Pain /Hypoxemia in Gyn Onc Pts.In any patient who develops chest pain or significant hypoxemia or tachycardia, they should undergo cardiac enzyme testing, EKG and CT to evaluate for pulmonary embolus. With regards to transfusing patients with plasma or packed red blood cells, this once again needs to be individualized. Generally speaking, however, in debulkings and other high blood loss procedures, the PT/PTT should be kept near normal if active bleeding at the conclusion of the case is suspected. This should be clearly documented in the medical record. Additionally in the immediate postoperative period, hemoglobin should be kept greater than 8.5 during the first day or two postoperatively, particularly once again when small amounts of active bleeding are known to be present.

8. Wound CulturesWith regards to following cultures, all cultures need to be followed and documented in the chart until they are considered a final negative or positive. There are often multiple cultures present, and each culture needs to be followed to its completion. As part of your preoperative assessments of all patients, the patient’s labs need to be checked the day they are drawn. The patient’s medication list needs to be reviewed preoperatively to

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make sure they are not actively taking aspirin, Coumadin, high doses of ginkgo biloba, vitamin E or hormone replacement therapy. Beta blockers in patients currently on them should be continued the day of surgery. Beta blockers should only be utilized in the preoperative and postoperative setting in those patients with risk factors for myocardial infarction. Those patients who do not have risk factors for myocardial infarction can actually be harmed by perioperative beta blocker usage. I encourage you and all of the residents to read the current recommendations on perioperative beta blocker usage so you are familiar when to use this medication.

9. Pap SmearPap smears need to be current when we are pursuing a hysterectomy on a patient who has a low risk of malignancy. Those patients with obvious advanced malignancies do not necessarily require a pap smear. Also, those patients who have had prior hysterectomy do not require a current pap smear. For patients who have low risk adnexal masses, probable benign uterine fibroids, etc., it is essential to make sure we have a normal pap smear preoperatively.

10. InclosingPlease review and give copies of this entire handout with the rest of the residents. My main goal, however, is to have the incoming third-year residents learn to individualize each patient’s care and to order all of the laboratory data needed yet not order blatantly unnecessary laboratory data, particularly preoperatively. I look forward to working with you and the new third-year residents in this upcoming academic year.

Sincerely yours,

Steven L. DeCesare, M.D.Gynecologic Oncology

SLD/escCC: Clyde H. Dorr II, M.D.

MEMORANDUM

Duties and Expectations of the Gyn Oncology Service

Date: May 5, 2008

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To: All Residents

From: Steven DeCesare, M.D.

PRE-OPERATIVE DUTIES1. Pre-operative duties of the residents should include having a thorough knowledge

of the patient’s history and physical examination. This includes not only the history and present illness but also the past surgical history, obstetric and gynecologic history, medical history, family history, and social history. Additionally, the resident physician will be expected to know every medication that a given patient is taking. Not only will they be required to know the name of the medication, but what type of drug each medication is and what the relevant side effects related to surgery and post-op care are.

2. The resident physician will be questioned on various aspects of each patient’s history prior to a surgical case. If the resident physician is deemed not to have sufficient knowledge of the patient’s case, they will be dismissed from operating on that given patient. If a resident is dismissed from performing a surgical procedure, due to lack of pre-operative knowledge on a given patient, they will still be expected to follow that patient just as if they operated on said patient.

3. Additional pre-operative responsibilities will include making sure that the patient has taken all of the medications that they are supposed to take prior to their surgery. This includes taking a history of whether a bowel prep was done and how effective the bowel prep was. Additionally, this includes making sure patients that are supposed to receive SBE prophylaxis have received their antibiotic prophylaxis. This does not mean that the resident checks to see if the order was written. This means that the resident has physically ensured that the antibiotics are infusing or have infused into the patient pre-operatively.

4. Additionally the resident physician is responsible for making sure that Plavix (or other medications) are discontinued one week prior to surgery. Once again, this does not mean that the resident should assume that it has been done, but rather makes sure that this has been done with documentation in the office chart noting the date at which Plavix was discontinued. Finding out that Plavix was not discontinued on the day of surgery will be considered a major error. The same will hold true for Coumadin patients. Additionally, those Coumadin patients who are stopped from their Coumadin prior to surgery may require therapeutic Lovenox. As such, the resident physician will need to make sure that this is arranged appropriately. Coumadin should be stopped five days prior to a surgical procedure and the patient should be placed on a milligram per kilogram of Lovenox bid for those patients requiring continued anticoagulation. The last dose of Lovinox should be at 6:00 pm the night prior to surgery. The residents will be held responsible to make sure these orders are carried out appropriately. The same guidelines will hold true for any patient on Lovinox in the hospital prior to surgery. Needless to say, if the surgery is later in the day, the last dose of Lovinox can be moved up to a slightly later time in the evening prior to surgery. Never rely on anyone except yourself to make sure that anticoagulation has been

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discontinued appropriately. Lack of discontinuing anticoagulation prior to a surgical procedure will result in a lethal outcome.

5. A fourth year resident on oncology will be responsible to make sure that all pre-operative and post-operative care is being done appropriately by the third year resident. The only area that the fourth year resident will not be held responsible is for that done immediately in the pre-op area.

POST-OPERATIVE CARE1. The night call resident is responsible for writing a progress note on all oncology

patients. The post-op day zero patients and ICU patients will be seen first. Unless Labor and Delivery is markedly busy all patients however will be seen. The only acceptable excuse for not writing a note on all oncology patients every night will be that the resident did not sleep what so ever during their night shift. If you have been up all night, then I will be more than happy to provide an oncology resident to take over whatever service you were working on at 8:00 am.

2. Any nurse call which requires that an order be written, requires an additional physician’s note. This will hold true for all nursing calls except for medications that can be obtained over the counter. Failure to perform duties as the night call resident will be considered a major error.

3. A morning and a nighttime note will be written on all oncology patients on Saturdays and Sundays. Weekend notes should all be completed prior to beginning one’s obstetrical duties for that day (by 8:00am).

REMEDEATION FOR POOR PERFORMANCE

You will be notified of the specific event when you have committed a major error in writing. You may refer to this memo to review the penalties for committing a major error. Not knowing a patient sufficiently preoperatively and being dismissed from a given case, due to not knowing a history and physical adequately, will not necessarily constitute a major error; however, certainly has the potential to consist of being reported as a major error. These errors are cumulative and you do not start with a new slate on a new month long rotation on the oncology service. The errors will be recoded and kept on a record. Dr.Dorr will receive a communication each time you have committed a major infraction.

Appendix II

FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE& SACRED HEART HOSPITAL

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RESIDENT MOONLIGHTING POLICY(ACGME references are to procedural documents available on-line)

1.1 The PurposeThe Florida State University College of Medicine (FSU COM), Sacred Heart Hospital (SHH), Residency Training Program establishes this policy regarding resident moonlighting to ensure program compliance with the Accreditation Council for Graduate Medical Education (ACGME). The ACGME requires that the Sponsoring Institution have policies regarding professional activities outside the educational program. (Institutional Requirement III.D.1.k.2)

2.1 General PolicyIndividual residency programs are accredited by their Residency Review Committee (RRC) and must adhere to RRC requirements regarding moonlighting. Although RRC’s vary, the general scope is that any professional activities which are outside the established educational program must not interfere with the resident’s established educational process or the quality care of patients. Residents shall not be required to engage in professional activities outside the educational program.

3.1 Common DefinitionMoonlighting is defined as compensated clinical work performed by a resident during the time that he/she is a member of a residency program. This policy addresses two categories of moonlighting:

3.1.a Programmatic: The clinical work occurs within the specific residency program and its participating institution(s), and is simply an extension of the same type and location of clinical work performed as a requirement of the Graduate Medical Education (GME) program. Programmatic moonlighting includes internal work only.

3.1.b Non-Programmatic: The clinical work is not an extension of the residency program and its participating institution(s), and in no circumstance is the resident to hold him/herself as an employee of the University while engaged in such activities. Non-programmatic moonlighting may include internal or external work.

4.1 Primary Responsibilities 4.1.1 Institution and Program It is the responsibility of the program director to decide whether or not moonlighting will be allowed. The program director must comply with the institution’s policies and procedures. The conditions under which a resident may be allowed to participate in programmatic and/or non-programmatic moonlighting must meet ACGME requirements.

If a program director allows a resident to moonlight, a Programmatic Moonlighting Approval Form is required if the moonlighting is programmatic, and a Non-Programmatic Moonlighting Approval Form is required if the moonlighting is non-programmatic. The appropriate approval form is then made a part of the resident’s file as required by the ACGME.

Because residency education is a full-time endeavor, the Program Director must approve and monitor all moonlighting to ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program.

4.1.2 The ResidentsThe resident must be a current resident in the program, and must be in good standing.

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Residents on J-1 visas may not moonlight, as mandated by the Educational Committee for Foreign Medical Graduates (ECFMG).

A resident wishing to moonlight must obtain prior written approval from his/her program director. (Ref. Section 4.1.1 above, para. 2)

Because residency education is a full time endeavor, residents must ensure that moonlighting does not interfere with their ability to achieve the goals and objectives of their educational program. Residents are responsible for ensuring that moonlighting and other outside activities do not result in fatigue that might affect patient care or learning.

A resident’s failure to comply with the Moonlighting Policy is a breach of contract and grounds for termination.

5.1 Programmatic MoonlightingThe Program Director must ensure, direct, and document supervision and faculty support appropriate for the level of training of residents at all times. While performing these services, residents are not to act as independent practitioners. Faculty schedules must be structured to provide residents with continuous supervision and consultation.

Residents must be provided with efficient, reliable systems for communicating with supervising faculty. Faculty are also responsible to recognize the signs of fatigue and adopt and apply practices to prevent and counteract the potential negative effects.

6.1 Non-Programmatic MoonlightingResidents must be licensed for unsupervised medical practice in the state where such activity occurs, including DEA licensure as applicable and any other requirements for clinical privileging at the employment site. There must be an exchange of permission letters between the Program Director and appropriate staff at the institution where the moonlighting will occur if the moonlighting is done externally.

Residents are not covered under the University’s professional liability insurance program as the activity is outside the scope of University employment. The resident is responsible for his/her own professional liability coverage (either independently or through the entity for which the resident is moonlighting) and must provide documentation of such.

Non-programmatic moonlighting hours must be documented (including days, hours, location, and brief description of type of service[s] provided).

7.1 Work HoursAll moonlighting hours must be documented, and they must comply with the written policies regarding Duty Hours as per the training program, and the ACGME. The Program Director may not approve residents for any internal moonlighting that requires residents to exceed the 80-hour per week (on average per 4-week) rule or other provisions of the duty-hour requirements. (Not applicable to non-programmatic external moonlighting).

8.1 Maintaining Approval

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The Program Director will monitor resident performance in the Program to ensure that moonlighting activities are not adversely affecting patient care, learning or resident fatigue. The GME Committee will periodically review reports by the Program Director(s) regarding moonlighting activity.

If at any time the Program Director determines that a resident’s moonlighting schedule is adversely impacting the resident’s performance in the training program, the Program Director may withdraw the permission to moonlight.

Approved By:

___________________________ ___________________________Paul Baroco, M.D. Alma Littles, M.D.Chief Medical Officer Designated Institutional OfficialSacred Heart Health System Florida State University College of MedicinePensacola, Florida Tallahassee, Florida

___________________________ ___________________________Date Date

Appendix III

PROGRAMMATIC MOONLIGHTING APPROVAL FORM

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1115 West Call Street Phone: 850.645.6867Tallahassee, FL 32306-4300 Fax: 850.644.8924

PARTS 1 & 2 TO BE COMPLETED BY THE RESIDENT:

Name __________________________________ Date _________________________

Program _______________________ Program Location ___________________ PGY ____

All Moonlighting is voluntary, programmatic, and requires the approval of the Program Director;

Any resident who moonlights without permission will be subject to disciplinary action;

Moonlighting may not be done during duty hours and is not to interfere with my training, including my learning and/or patient care;

My total work hours including residency and all moonlighting activities will not exceed 80 hours per week, averaged over 4 weeks;

If my moonlighting activities contribute to undue fatigue, I will cease all moonlighting activities;

I am not to function as an independent practitioner during this activity. I will not function above my level of training or without my usual faculty supervision; and

There will be periodic reviews of my residency training, and if it is less than expected, permission to moonlight will be withdrawn;I acknowledge that I have carefully read and fully understand the policies regarding programmatic moonlighting as stated in this Approval Form as well as the Moonlighting Policy.

Resident Signature ___________________ Date ____________________

PART 3 TO BE COMPLETED BY THE PROGRAM DIRECTOR:

The resident is not on academic probation;

The total hours in the resident’s educational program and the moonlighting activities will not exceed the limits set forth by ACGME; and

This opportunity does not replace any part of the clinical experiences integral to the resident’s training program, and the resident will be under faculty supervision while engaging in moonlighting activities.

This approval form is valid for the current GME year only.Rev. 3/1/07

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Part 1: GENERAL INFORMATION:

Part 2: I UNDERSTAND THE FOLLOWING:

Part 3: DIRECTOR’S ATTESTATIONS:

Program Director Signature ___________________________________

Date ______________________

Appendix IV

NON-PROGRAMMATIC MOONLIGHTING APPROVAL FORM

PARTS 1 & 2 TO BE COMPLETED BY THE RESIDENT:

Name ________________________ Date _______________________________

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1115 West Call Street Phone: 850.645.6867Tallahassee, FL 32306-4300 Fax: 850.644.8924

Part 1: GENERAL INFORMATION:

Program __________________ Program Location _____________________ PGY ___

All Moonlighting is voluntary, non-programmatic, and requires the approval of the Program Director, and any resident who moonlights without permission will be subject to disciplinary action;

Moonlighting may not be done during duty hours and is not to interfere with my training, including my learning and/or patient care. My total work hours including residency and all moonlighting activities will not exceed 80 hours per week, averaged over 4 weeks (not applicable to external non-programmatic moonlighting);

I am licensed for unsupervised medical practice in the state where such activity occurs, including any other medical fees and/or requirements for clinical privileging at the employment site.

I understand I am not covered under the University’s professional liability insurance program and am responsible for my own professional liability coverage (either independently or through the entity for which I am moonlighting) and am attaching documentation of such;

If my moonlighting activities contribute to undue fatigue, I will cease all moonlighting activities; and

There will be periodic reviews of my residency training, and if it is less than expected, permission to moonlight will be withdrawn;I acknowledge that I have carefully read and fully understand the policies regarding non-programmatic moonlighting as stated in this Approval Form as well as the Moonlighting Policy. Furthermore, I clearly understand and agree that this non-programmatic activity is in no way related to my employment with the University and that the Florida State University has no obligation, responsibility, or liability whatsoever for any injury or harm which I may incur or which may befall me during my performance of or a result of this non-programmatic activity.  Accordingly, I hereby release, forever discharge, and waive any and all claims I may have now or in the future arising out of or connected with my non-programmatic activities against the Florida State University, the State of Florida, the Department of Education for the State of Florida, or the Board of Governors for the State of Florida, and any and all officers, agents, employees, underwriters, and insurers, all individually and in their respective official capacities.

Resident Signature ___________________________________

Date ____________________________

PART 3 TO BE COMPLETED BY THE PROGRAM DIRECTOR:

The resident is not on academic probation, and the total hours in the resident’s educational program and the moonlighting activities will not exceed the limits set forth by ACGME; and

This opportunity does not replace any part of the clinical experiences integral to the resident’s training program.

This approval form is valid for the current GME year only.Rev. 3/1/07

Program Director Signature ___________________________________Date ______________________

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Part 2: I UNDERSTAND THE FOLLOWING:

Part 3: DIRECTOR’S ATTESTATIONS:

Appendix V

Joseph Peterson, MD

Use of prescriptions

Junior residents should have a training license number by the time they start in the program. This license allows for the resident to prescribe all non-scheduled medications. Scheduled medications, such as narcotics and benzodiazepines, cannot be prescribed by a resident without a full medical license and DEA number and will not be filled by local pharmacies if written. The only exception is the Sacred Heart inpatient pharmacy where the prescription can be filled under the program’s hospital-wide license and DEA number.

The responsibility of providing a prescription for a scheduled drug, such as pain medication for a post-operative patient being discharged, lies with the resident performing the discharge. However,

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the prescription must be filled out completely by a resident with a full medical license and DEA number. Compliance with Florida statutes (specifically, FS Chapter 893.03 paragraph (7a)-7) must be upheld.

Residents without full licenses or DEA numbers should provide the resident from whom they are requesting a prescription with the full name of the patient, any known allergies, drug name, dose, frequency and quantity to be dispensed.

Residents, whether junior or senior, are expected to obtain their Florida licenses as soon as possible (see CONTINUING MEDICAL EDUCATION - Florida Medical License). In situations where neither the junior nor senior on call has their license, the senior resident will be expected to obtain a completed prescription from the supervising faculty or attending.

The first violation is a misdemeanor. Any resident violating this rule will be placed on probation. A second offense is a third-degree felony and will result in a report being filed with the Florida Medical Board and local or federal law enforcement agencies as indicated.

Appendix VI

Online OB/GYN Journals via the FSU College of Medicine Libraryhttp://www.med.fsu.edu/library/ejournals

     Title Date ProviderActa Obstetricia et Gynecologica Scandinavica 2001-2005 Blackwell SynergyActa Obstetricia et Gynecologica Scandinavica 1998-present InformaWorldAmerican Journal of Obstetrics and Gynecology 1995-present MDConsult JournalsAmerican Journal of Obstetrics and Gynecology 1993-April 2002 OvidAmerican Journal of Obstetrics and Gynecology 1995-present Science DirectAmerican Journal of Perinatology 1999-present ThiemeAustralian & New Zealand Journal of Obstetrics & Gynaecology. 2002-present Blackwell SynergyBirth 1998-present Blackwell SynergyBJOG: An International Journal of Obstetrics and Gynaecology 1997-present Blackwell Synergy

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BJOG: An International Journal of Obstetrics and Gynaecology (Elsevier)

2002-2003 Science Direct

Breastfeeding Medicine 2006-present Mary Ann LiebertBritish Journal of Obstetrics and Gynecology 2001 Science DirectClimacteric 2000-present InformaWorldClinical Obstetrics and Gynecology 1996-present Ovid LippincottCurrent Opinion in Obstetrics and Gynecology 1998-present Ovid LippincottEuropean Journal of Obstetrics, Gynecology, and Reproductive Biology

1995-present Science Direct

Evidence-based Obstetrics & Gynecology 1999-present MDConsult JournalsGynecologic Oncology 1995-present Science DirectGynecological Endocrinology 1999-present InformaWorldHealth Care for Women International 1998-present InformaWorldHypertension in Pregnancy 2000-present InformaWorldInfectious Diseases in Obstetrics and Gynecology 1996-2000 Wiley InterscienceInternational Journal of Gynaecology and Obstetrics 1995-present Science DirectInternational Journal of Gynecological Pathology 2000-present Ovid LippincottJournal of Mammary Gland Biology and Neoplasia 1997-January 2006 Springer LinkJournal of Maternal-Fetal & Neonatal Medicine 2001-present InformaWorldJournal of Maternal-Fetal Medicine 1997-2000 Wiley InterscienceJournal of Midwifery & Women's health 2000-present Science DirectJournal of Obstetrics and Gynaecology 1997-present InformaWorldJournal of Pediatric and Adolescent Gynecology 2002-present MDConsult JournalsJournal of Pediatric and Adolescent Gynecology 1999-present Science DirectJournal of Women's Imaging 2001-September 2005 Ovid LippincottMaternal and child health journal 1997-present Springer-VerlagMCN. The American journal of maternal child nursing 1996-present Ovid LippincottMenopause November 2000-present Ovid LippincottObstetric Anesthesia Digest 2001-present Ovid LippincottObstetrical and Gynecological Survey 1995-present Ovid LippincottObstetrics and Gynecology 1995-present HighWireObstetrics and Gynecology 1995-present Ovid LippincottObstetrics and Gynecology 1995-2003 Science DirectObstetrics and Gynecology Clinics of North America 1996-present MDConsult Clinics JournalsPlacenta 1995-present Science DirectPostgraduate Obstetrics & Gynecology 2005-present Ovid LippincottPrenatal Diagnosis 1996-present Wiley InterscienceUltrasound in Obstetrics and Gynecology 1991-present Wiley InterscienceUltrasound Quarterly 2001-present Ovid LippincottWomen and Health 1999-2005 Haworth PressWomen's Health Issues 1995-present Science Direct

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Appendix VII

Online OB/GYN Books available via the FSU College of Medicine Library

http://www.med.fsu.edu/library/Ebooks

       

Author Title Year Provider

Pernoll, Martin L.Benson and Pernoll's Handbook of Obstetrics and Gynecology 2001 NetLibrary (single user)

Novak, Emil Berek & Novak's Gynecology, 14th ed. 2007 Ovid

Solomon, DianeBethesda System for Reporting Cervical Cytology, 2nd ed. 2004 R2Library (single user)

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Bland, Kirby I.Breast: comprehensive management of benign and malignant disorders, 3rd ed. 2004 MDConsult Books

Cohen, Wayne R.Cherry and Merkatz’s Complications of Pregnancy, 5th ed. 2000 Ovid

Parker, James N.

Child Development: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References 2003 NetLibrary (single user)

Speroff, LeonClinical Gynecologic Endocrinology and Infertility, 7th ed. 2005 Ovid

DiSaia, Philip J. Clinical Gynecologic Oncology, 6th ed. 2002 MDConsult Books

Stenchever, Morton A. Comprehensive Gynecology, 4th ed. 2001 MDConsult Books

DeCherney, Alan H.Current Diagnosis & Treatment Obstetrics & Gynecology, 10th ed. 2007 AccessMedicine

Danforth, David N. Danforth's Obstetrics and Gynecology, 9th ed. 2003 Ovid

Mazur, Michael T.Diagnosis of Endometrial Biopsies and Curettings, 2nd ed. 2005 R2Library (single user)

Harris, Jay R. Diseases of the Breast, 3rd ed. 2004 Ovid

Fanaroff, Avroy A.Fanaroff and Martin's Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant, 8th ed. 2006 MDConsult Books

Bianchi, Diana W.Fetology: Diagnosis and Management of the Fetal Patient 2000 Ovid (single user)

James, David K. High Risk Pregnancy: Management Options, 3rd ed. 2006 MDConsult Books

Bankowski, Brandon J.Johns Hopkins Manual of Gynecology and Obstetrics, 3rd ed. 2007 Ovid

Craigo, Sabrina D. Medical Complications in Pregnancy 2005 R2Library (single user)

Gabbe, Steven G.Obstetrics - Normal and Problem Pregnancies, 4th ed. 2002 MDConsult Books

Wylen, MichelleObstetrics and Gynecology: PreTest (USMLE Step 2) Self-Assessment and Review, 10th ed. 2004 NetLibrary (single user)

Gershenson, David M. Operative Gynecology, 2nd ed. 2001 MDConsult Books

Sanfilippo, Joseph S. Pediatric and Adolescent Gynecology, 2nd ed. 2001 MDConsult Books

Sanders, Roger C.Structural Fetal Abnormalities: the total picture, 2nd ed. 2002 MDConsult Books

Schmidt, Guenter Ultrasound 2007 Thieme

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Cunningham, F. Gary Williams Obstetrics, 22nd ed. 2005 AccessMedicine

Appendix VIIPortfolio Basics

Julie Decesare MDSuzannne Bush MDPurposeA compilation of material that collectively suggests the SCOPE and QUALITY of a learner’s performancePurpose To stress teaching within the confines of the competencies To emphasize the academic mission of FSU Ob/Gyn residency program Encourage ACTIVE participation in learning and education To document the effectiveness of our teaching program

Mechanics of the Portfolio

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3 ring binder 8 divisions Resident Notebook is a self directed portion of the portfolio Coexists with the resident file (held in coordinators office), which will be organized by competenciesPatient Care Continuity Clinic Patient Care Logs (will be launched July 2008) Surgical Score Cards Minimum of 5 per Gyn rotation (aim for 10) Copy of OpLOG stats Summarys work fine Must include every 6 month summariesMedical Knowledge USLME results CREOG results Quizzes, Articles tests participated in Oral boards results and scores

Practice-Based Learning and Improvement Copy of am report PBLI cases and the articles referenced Copies of M and M presentations List of committee participation, and projects you have worked on

Interpersonal and Communication Skills OSCE Scores Grand Rounds lectures Copies of Self directed Didactics (am report in for that is not a PBLI case) Self Critique the following (need 5 of the following) D/C Summary OP report H and PProfessionalism Copy of at least 5 Praise cards (for the academic year) Copy of any Concern Card with action plan and follow upScholarly Activity Any presented research Resident Research ProjectOTHER CV

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Appendix VIIII

INTERN PROCEDURE COMPETENCY LISTEXAMPLE

Endometrial Biopsy1.Date____________Signature____________2.Date____________Signature____________3.Date____________Signature____________

Colposcopy1.Date____________Signature____________2.Date____________Signature____________3.Date____________Signature____________

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Vaginal/Vulvar Colposcopy1.Date____________Signature____________2.Date____________Signature____________3.Date____________Signature____________

LEEP1.Date____________Signature____________2.Date____________Signature____________3.Date____________Signature_____________

Appendix IX

Florida State University Obstetrics and Gynecology Residency ProgramResident Evaluation Policy –Mid point and End of Year EvaluationsAugust 2009

Prior to Evaluation Day1. Review Custom Evaluation Report in New Innovations

Included in the report-Global Evaluation Competency ReportDuty HoursSurgical Score CardsPrimary Care Audits360 Evaluations

Patient/staff midpoint and end of year

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Peer/Self end of year onlyPrimary Care Audits

2. Verify that the resident has 5 primary Care audits in 6 months3. Review the ACGME stat summary that Julie will email to you

Provide feed back o the resident regarding their procedural volume as compared to the national mean

On Date of Evaluation1. Have resident log into New Innovations, and make sure all of their evaluations from the previous 6 month time span have been viewed and signed electronically by the resident.2. Review the custom evaluation report with your resident.3. Review ACGME stats.

After Evaluation1. Dictate letter as per template. 2. Sign, and Holly will Upload into New Innovations.

SAMPLE EVALUATION LETTER TEMPLATE

DateDr Clyde Dorr

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