Obstetrics and Gynecology Resident Handbook

2011-2012

Table of Contents: Residency Curriculum

Section 1 General Information Statement of Patient Care Supervision of Residents Duty Hours and Working Environment Selection of Residents General House Staff Information and Sample Work Agreement Promotion/Graduation Evaluation and Standards Specific to OBGYN Remediation/Probation Policy Specific to OBGYN

Section 2 Section 3

Residency Program Office Goal Core Competencies Patient Care Medical Knowledge Practice Based Learning and Improvement Communication and Interpersonal Skills Professionalism Systems Based Practice Structure of the Houseofficers Year General Information Call Schedule Obstetrics Gynecology Gynecologic Oncology Reproductive Endocrinology and Infertility Pediatric and Adolescent Gynecology Emergency Department Surgical Intensive Care Unit Primary Care Methodist Rotation Corpus Christi Rotation

Section 4

Section 5

Educational Goals and Objectives Obstetrics Gynecology Gynecologic Oncology Page 2 of 185

Reproductive Endocrinology and Infertility Pediatric and Adolescent Gynecology Primary Care

Section 6

Admitting Policies and Procedures General Information Transfers In House Transfers from Outside UTMB Housestaff Duties Outside of Routine Patient Care Teaching Resident Research Procedural Tracking Medical Record Keeping Circumcisions Declaration of Death/Death Notes/Autopsies Directives to Physicians/Do Not Resuscitate Consultations Sponsored Educational Programs General Discretionary Fund Complimentary Medical Literature Medical Organizations Educational Conferences and Examinations General Grand Rounds Morbidity and Mortality Conference Faculty Lectures PGY 4 Resident Lectures Intern Lecture Series Journal Club Small Group Sessions In-Service Examination (CREOG) Oral Examination Vacation/Leave Policies General ABOG Vacation/Leave Requirements Total Leave Time Vacation Time Educational Meeting Time Personal Leave Maternity Leave Page 3 of 185

Section 7

Section 8

Section 9

Section 10

Paternity Leave Fellowship/Job Interview & Examination Leave Holiday Vacation Section 11 Miscellaneous Policies Licensure (Step 3/State/DPS/DEA) ABOG Certification Procedure Certification Requirements (BLS/ACLS/NALS) Evaluations Moonlighting Administrative and Family Planning Chiefs UTMB Employee Requirements (Compliance/Risk Management/POCT) Sexual Assault Evaluations Procedure for Obtaining Order Entry Access at Home Grievance Procedures Professional Standards and Professionalism Attitude and Behavior Competence Demeanor Appearance Sexual Harassment Special Need Services Counseling Services Risk Management Employee Health (Bloodborne Exposure/PPD/Vaccinations) Hurricane Policy Appendix Procedural Tracking Decedent Affairs Paperwork Vacation and Leave Request Form Decedent Affairs Paperwork TSBME Checklist and Jurisprudence Study Guide Evaluation Form On-Line Compliance Test POCT Validation Process Statement of Acknowledgements (signed upon entry and yearly at resident retreat)

Section 12 Section 13

Section 14

Section 15 Section 16

Page 4 of 185

1
Section

General Information
Statement of Patient Care
The Obstetrics and Gynecology Department accepts responsibility for: Evaluation of Texas Department of Criminal Justice (TDCJ) patients. Evaluation of Richmond State School and Rusk State School residents. Patients who are of educational value to the housestaff. Patients who need seconda ry or tertiary care, which is not available in their home area. Patients who would receive better care if transferred to UTMB. In the clinical learning environment, each patient must have an identifiable, appropriatelycredentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patients care. The clinical responsibilities for each resident must be based on PGY -level, patient safety, resident education, se verity and complexity of patient illness/condition and available support services.

Supervision of Residents
Qualified faculty supervises all patient care. The program director ensures, directs, and documents adequate supervision of residents at all times. Residents are provided with rapid, reliable systems for communicating with supervising faculty. Faculty schedules are structured to provide residents with continuous supervision and consultation. Faculty and residents are educated to recognize the signs o f fatigue and adopt and apply policies to prevent and counteract the potential negative effects. Supervision of Residents: In particular, PGY -1 residents should be supervised either directly or indirectly with direct supervision immediately available. Any health professional with appropriate certification, e.g., Certified Nurse Midwife, Nurse Practitioner, Physician Assistant, can be listed as faculty. R1 and R2 residents and all rotating residents (e.g., family medicine residents) may be supervised by lic ensed allied health professionals who are listed as faculty provided that: ? the clinical care is within their scope of practice expertise; ? the level of clinical care is low risk; Page 5 of 185

? physician faculty members are available by telephone; and, ? the program director has approved the supervision with respect to the educational expe rience. Allied Health Professionals cannot substitute for physician faculty members to meet 24 hour requirement for on-site supervision of resident s (care).

Duty Hours and Working Environment

The residency program follows the ACGME Duty Hour Requirements. Duty hours are monitored by the residents logging on daily to New Innovations. This is mandatory by the GME office and will be strictly enforced. Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patie nt care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.

Maximum Duty Period Length Residents are provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. Duty periods of PGY-1 residents must not exceed 16 hours in duration. Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patie nt care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested. It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours. Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. o In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. o Under those circumstances, the resident must: appropriately hand over the care of all other patients to the team responsible for their continuing care; and, document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. o The program director must review each submis sion of additional service, and track both individual resident and program-wide episodes of additional duty.

Page 6 of 185

Minimum Time Off between Scheduled Duty Periods PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled dut y periods. Intermediate-level (PGY-2) should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty. Residents in the final years (PGY 3 & 4) of must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. This preparation must occur within the context of the 80-hour, maximum duty period length, and one -day-offin seven standards. While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. Circumstances of return -to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.
Maximum Frequency of In-House Night F loat

Residents must not be scheduled for more than six consecutive nights of night float

Maximum In-House On-Call Frequency PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).
At-Home Call

Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-thirdnight limitation, but must satisfy the requireme nt for one -day-in-seven free of duty, when averaged over four weeks. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident. Residents are permitted to return to the hospital while on at-home call t o care for new or established patients. Each episode of this type of care, while it must be included in the 80hour weekly maximum, will not initiate a new off-duty period. The Residency Program Director and Administrative Chief Resident(s) will be monitoring the duty hours of each resident in order to ensure an appropriate balance between education and service. Back-up support systems are provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.

SELECTION/RECRUITMENT POLICY
Minimum Standards for Selection as a University of Texas Medical Branch Obstetrics and Gynecology Resident

Page 7 of 185

UTMB accepts eight first year Obstetrics and Gynecology Residents through the National Residency Matching Program (NRMP). The following criteria apply to resident selection for NRMP match listing, program transfers and scramble match.

Requirements for Interview Acceptance 1. A completed ERAS application is on file or available. 2. Resident applicants must have successfully passed the USMLE Step 1. 3. If taken, resident applicant must have successfully passed the USMLE Step II. 4. US graduate resident applicants must a. Have graduated from or will graduate from an LCME approved US allopathic medical or osteopathic school by June 30th of the applicable year, or b. Applicant must have graduated from an LCME approved medical school within 3 years of application for residency UNLESS enrolled in an ACGME accredited trainin g program or in the US military. 5. If an International Medical Graduate, the resident applicant must: a. Have or will have by June 15th of the applicable year, a completed ECFMG certificate and a CSA certificate where appropriate, b. Must have graduated from medical school within 3 years of application for residency UNLESS enrolled in an ACGME accredited training program or in the US military, and c. If applicable, a valid J-1 visa. 6. All resident applicants must have appropriate references as to potential, acceptable proficiency in the six ACGME defined competencies. 7. Resident applicants must display the professional characteristics and behaviors expected of a physician including, but not limited to: a. A positive attitude towards medical students/residents in training and other health care professionals and to medicine in general, b. Adaptability to new situations and a flexible work schedule, c. Ability to learn quickly and follow directions, d. Accountability and dependability, e. Appropriate work habits and personal hygiene.

Page 8 of 185

8. Resident applicants must be able to carry out the duties and responsibilities of their appointed position. 9. The recruitment Committee may, by a substantial (two-thirds) majority of all its members, supersede the above requirements for interview acceptance and invite a candidate to interview for the residency training program. 10. The deadline for applications is December 1st.

Application Deadlines: Applications for PGY-1 positions are accepted from Sept. 1st to Dec 1st for appointment beginning the last week of June. Interviews are scheduled from Nov. through Jan.

OBGYN POLICY ON PROMOTION/GRADUATION

Residents must achieve satisfactory performance in all ACGME competencies for promotion and graduation. Resident performance will be reviewed by the PD or designee and residents who do not achieve satisfactory performance will not be promoted to the next level or may not graduate. PGY 1-3 residents will be evaluated for promotion to the next level by the program director prior to March 1 of a given year. The approval of the faculty members on the department education committee is required for withholding promotion or graduation. Notification of non-promotion will be made in accordance with the UTMB inistutional GME policy.

GRADUATE MEDICAL EDUCATION INFORMATION (GENERAL INFORMATION PACKET AND SAMPLE CONTRACT)
INTRODUCTION The following information has been compiled by The University of Texas Medical Branch (UTMB) Graduate Medical Education Office for use by House Staff, Program Directors, and Clinical Chairs/Division Chiefs of UTMB. UTMB is committed to offering residency programs as a part of its educational mission and has established mechanisms to ensure that its various residency programs are in compliance with the Institutional and Program Requirements for Residency Training as promulgated by the Accreditation Council for Graduate Medical Education (ACGME) including house staff duty hours and the notification of house staff of any adverse accreditation action related to their specific reside ncy programs. SECTION I - APPOINTMENT INFORMATION

Page 9 of 185

A. APPOINTMENT/REAPPOINTMENT House staff and advanced subspecialty house staff (fellowship) appointments are assigned at a postgraduate year (PGY) level commensurate with the ACGME (see APPENDICIES 1A & 1B of this document) and American Board of Medical Specialties (ABMS) guidelines. House staff appointments are recommended by the Program Director and are subject to review and acceptance by the Associate Dean for Graduate Medical Education. All appointments are one year in length and are renewable annually on the recommendation of the Program Director and with the concurrence of the Associate Dean for Graduate Medical Education. Failure to reappoint may be grieved by the house staff as per Section III of this document. B. ORIENTATION The UTMB Graduate Medical Education Office holds an orientation program for all house staff newly appointed to UTMB Hospital's residency programs regardless of the training level to which they are appointed. Attendance is mandatory and the house staff is paid for those days as ordinary workdays. The intent of the orientation is to provide general and specific information about the institution which will facilitate the new house staffs entry into UTMB's residency programs, allow completion of required Human Resources processing as a new employee, comply with health service requirements including immunization and TB testing, allow an opportunity for the new house staff to meet each other socially, and to get to know the house staff already at UTMB. The UTMB Graduate Medical Education Office provides specific details about the orientation to new house staff before their arrival. C. HOUSE STAFF WORKSHOPS All new house staff are required to attend mandatory annual house staff Risk Management and Medical Economics workshops. The workshops are held to respond to requirements of the Accreditation Council for Graduate Medical Education. Risk Management All physicians covered by the UT System Professional Medical Liability Plan (Plan) are required to participate in risk management education. An online course called the CCC (Clincolegal Correlations Course) is the tool used for the risk education requirements. Physicians will receive 3.5 risk management credits and 3.5 Category 1 (formal) continuing medical education credits for each unit completed, with the exception of the specialtyspecific standards of care unit. Risk management courses are approved for ethics training by the Texas Medical Board. The Standards of Care unit will provide one hour of risk management education. It is shorter than the others and does not qualify for continuing medical education credits.

Page 10 of 185

The course can be found at http://ut.elmexchange.com/ccc. Select UT Medical Branch Fellows or UT Medical Branch House staffs as appropriate from the drop-down box labeled New Users. Click Submit and follow the instructions to select a username and password and proceed with the course. Returning users may sign in directly under Returning Users at the same URL. The mandatory Risk Management Workshops focus on medico/legal aspects of practicing medicine including laws that physicians need to know related to risk prevention. Requirements of faculty supervision, drug prescribing, and sexual misconduct guidelines within UTMB are also discussed. A consultant teaches communication skills, particularly communicating with patients. Attorneys from UTMB and the UT System Office of General Counsel review the UT Systems Medical Liability Plan and National Practitioner Data Bank. Local private attorneys present an advanced legal didactic for the senior house staff including case playing. Each house staff is required to obtain 15 hours of risk education within the first eight months of employment at UTMB to meet requirements of the University of Texas System Professional Medical Liability Benefit Plan. Section II.G below contains additional information regarding coverage under the Plan. Attendance at the House Staff Risk Management Workshops provides additional hours of risk education credits. Any remaining hours can be obtained with documentation of attendance at risk education conferences/seminars such as M&M Conferences, Grand Rounds, or other CME courses offered at UTMB. The credits are maintained by the Risk Management Department. The 15hour credit covers the first three years of training. If the program is longer than three years, fifteen credits will be needed for each three-year period. If house staff are here for only one year past the first three years, then only five additional credits are needed. Medical Economics - The Medical Economics Workshops provide training to house staff physicians regarding managed care systems to enhance quality, accessible, and efficient health care. Upon completion of the program, the house staff physician should be able to identify and understand managed care concepts, understand how managed care impacts clinical practice at UTMB, understand the financial impact of clinical decisions as related to managed care companies, understand the managed care system in order to secure house staffs own health care and assist patients with their health coverage. The presentations include an ethics didactic and socioeconomic discussion. D. EMPLOYM ENT CERTIFICATION House staff applying for mortgage loans, student loan deferments, etc., may instruct the lender to direct requests for information or certification to the UTMB Graduate Medical Education Office, Room 417, Jennie Sealy Hospital, campus route 0462. E. VETERANS ADMINISTRATION EDUCATION BENEFITS UTMB is fully approved by the Texas Education Agency to provide education and training to eligible persons. If house staff are a veterans currently enrolled or anticipating enrollment in any of the graduate medical education programs offered by UTMB and are eligible to receive veterans benefits, contact the UTMB Graduate Medical Education Office for any assistance needed in the

Page 11 of 185

application process. F. TEXAS MEDICAL BOARD (TMB) PERMITS The Texas Medical Board (the Board) requires an individually held Physician in Training Permit. Information about this permit is sent to all applicants of GME programs. All house staff at UTMB will be required to have an appropriate Board issued Physician in Training Permit or a permanent Texas Medical license as a condition of appointment by the first day of employment. If the training permit is not received within 30 days of initial work agreement date, the program director may void the work agreement. To expedite the Physician in Training Permit and to ensure that all house staff hold a valid permit, UTMB requests that all information pertaining to the permits be sent to the UTMB Associate Dean for Graduate Medical Education Office. The house staffs signature on the UTMB House Staff Work Agreement gives his/her approval to use the UTMB Associate Dean for Graduate Medical Education Offices address. Annual Physician in Training Reports UTMB Program Directors must ensure that the Board receives certain information annually in order to keep the Board informed on a permit holders progress while in the approved training program. The Office of the Associate Dean for Graduate Medical Education will support the House Staff and Program Directors in providing the required infor mation on forms provided by the Board. The required information shall include: a) Information regarding the permit holders criminal and disciplinary history, professional character, mailing address, and place where engaged in training since the Program Directors last report; b) Certification of the permit holders training; c) Such other information or documentation the Board and/or the Executive Director deem necessary to ensure compliance with Chapter 171 of the Texas Medical Board Rules, all other Board Rules, and the Texas Medical Practice Act (Tex. Occ. Code 161, et seq. (Vernon 2006). The permits are valid in Texas training programs only. If house staff do an elective rotation outside of Texas, they must obtain a permit to practice medicine from the appropriate State Medical Board. Additional information can be obtained from house staffs residency program coordinator. It is imperative for house staff to be aware of the proper procedures and entities to contact when they are named in a claim or lawsuit and are completing an application for a license or permit. The TMB verifies every Physician in Training permit and license renewal for the correctness of these verifications of coverage with UT System insurance carriers. Erroneously answering this question is viewed as fraud by the TMB and results severe difficulties in obtaining a permit to practice medicine. The house staffs Program Coordinator will maintain a list of house staff named in a malpractice lawsuit for their future reference in completing licensure applications. G. LICENSURE

Page 12 of 185

All eligible house staff are encouraged to obtain valid medical licensure from the Texas Medical Board. It is the personal financial responsibility of the house staffhouse staff to obtain or renew his/her medical license. The UTMB Graduate Medical Education Office should be notified immediately upon medical licensure/relicensure in Texas and a copy of the physician permit portion of the license should be submitted to this office. The Texas Medical Board's address is: P. O. Box 2018, Austin, TX 78768-2018. H. LICENSURE EXAM REQUIREMENTS To ensure that house staff complete the three steps of exams required for licensure, the UTMB Graduate Medical Education Committee adopted a policy regarding time lines to pass the three USMLE steps (APPENDIX 3). It is beneficial to the house staff if the exams are completed within the first two years of residency because the exams cover multiple disciplines. It ensures that house staff meet the exam requirements of USMLE before completion of training regardless if they remain in Texas or practice medicine in other states. I. INSTITUTIONAL DEA NUMBER Those house staff covered under a Physician in Training Permit will be assigned an Institutional DEA Number. This is a one to three-digit suffix number to be used in conjunction with the DEA institutional number of the UTMB. This number will be assigned through the Outpatient Pharmacy and will provide the house staff prescription writing privileges in the UTMB Hospitals. IMPORTANT NOTE: Prescription order forms should show in addition to a legal signature: 1) prescribing physician's name printed in full and legally; 2) DEA number for controlled drugs; and 3) patient's name and address. Do this for the patients. Many pharmacists will not fill prescriptions if this information is missing. J. DEA NUMBER Since the UTMB Institutional DEA number cannot be used once individual medical licensure is obtained, all eligible house staff are responsible for obtaining their individual Texas Department of Public Safety (DPS) number and Federal Drug Enforcement Agency (DEA) number once licensed in Texas. The Federal DEA and the Texas DPS charge a fee for each of these numbers. The UTMB Graduate Medical Education Office should be provided copies of these documents when obtained. K. LEAVES OF ABSENCE In the event of a house staffs absence from a training assignment, other than on vacation or sick leave, a formal leave of absence (with or without pay, depending on the circumstances and at the discretion of the Program Director, under institutional guidelines) will be recognized by the UTMB Graduate Medical Education Office. The Program Director must notify the UTMB Graduate Medical Education Office of leaves of absence and conditions relative thereto. house staff should be aware Page 13 of 185

completion of residency training and eligibility for Board certification depend on the completion of certain time in training requirements specific to the medical specialty. Extended absences from the program may require additional time and training. This can be best clarified by discussion with the Program Director. L. MOONLIGHTING PGY 1 residents are not permitted to moonlight. Professional and patient care activities that are external to the educational program are called moonlighting. Moonlighting activities, whether internal or external, may be inconsistent with sufficient time for rest and restoration to promote the house staffs educational experience and safe patient care. Therefore, institutions and program directors must cl osely monitor all Moonlighting activities. This includes moonlighting within UTMB. When house staff "moonlight," it should be with the knowledge that: 1. Independent licensure by the State of Texas for the practice of medicine is mandatory; 2. Within UTMB,the department to which the house staff is assigned will assure that appropriate levels of malpractice coverage retained through The University of Texas Professional Liability Plan is in place. Outside UTMB, no malpractice insurance is provided nor will any other fringe benefits ordinarily afforded to the house staff be in effect. 3. No house staff may "moonlight" during assigned duty time; 4. Permission of the residency Program Director must be obtained in writing before arranging to "moonlight." Individual Program Directors may forbid moonlighting. The Program Director shall monitor the number of moonlighting hours as required by an ACGME Institutional Requirements to ensure compliance with duty hours. The Program Director shall acknowledge in writing that she/he is aware that the house staff is moonlighting, and this information should be part of the house staffs folder. The house staffs performance will be monitored for the effect of these activities upon performance and that adverse effects may lead to withdrawal of permission. 5. House Staff are required to notify the Program Director of their participation/involvement in other committees outside the institution or any involvement in the community that would

Page 14 of 185

impact duty hours. 6. House Staff are not required to engage in moonlighting. 7. The U.S. Code of Federal Regulations clearly prohibits exchange visitors (J1 visa holders) participating in programs of graduate medical education from pursuing work outside of their training programs. Therefore, any Graduate Medical Education Officer holding a J1 visa may not moonlight or earn extra income under any circumstances. M. HEALTH INFORMATION MANAGEMENT Dictation and timely completion of medical charts, signing patient orders, and general complianc e with the rules and regulations of the UTMB Health Information Management Department is considered an integral component of graduate medical education. House staffHouse staffs will complete all medical record assignments in a timely manner and accept responsibility for familiarizing themselves with hospital medical records policy. Failure to complete medical records, as prescribed by applicable Medical Staff Bylaws, hospital rules and regulations, clinic rules and regulations, and/or departmental policy, may result in corrective action, which may include suspension without pay. A Certificate of Completion of residency training will not be issued until all medical record assignments are completed at the end of the training period. N. DISASTER PLAN House staff should be familiar with the Institutional (http://www.utmb.edu/policy/emergncy/emrplnm.pdf) and Departmental Disaster Plans and understand their role and responsibilities if such an event occurs. House Staff are designated by their department as essential employees during a disaster and required to remain in the hospital until formally released at the conclusion of the disaster period. O. HOUSE STAFF DIRECTORY It is essential that the UTMB Graduate Medical Education Office maintain accurate and up-to-date information on House Staff including home address, telephone number, etc. Any change in this data should be reported promptly to the UTMB Graduate Medical Education Office and the Human Resources Department. P. INTERNATIONAL MEDICAL GRADUATES Individuals who received their medical education outside the United States must be sponsored through the Educational Commission for Foreign Medical Graduates. Any unique circumstances requiring visa definition should be brought to the attention of the UTMB Graduate Medical Education Office well in advance of arrival on campus. UTMB accepts the J-1 visa, and although uncommon, the H1-B visa is acceptable on an individual basis with approval of the Associate Dean for Graduate Medical Education through the Office of International Affairs. For UTMB ID badge, the International Medical Graduate who receives an MBBS may choose to use Dr. or have their name listed only with no medical degree.

Page 15 of 185

Q. SHRINERS BURNS INSTITUTE RELATIONS House Staff from a number of the UTMB residency programs have required rotations to the Shriners Burns Institute in Galveston for portions of their educational and clinical experience. Supervision is provided by UTMB faculty who are also members of the Shriners Burns Institute Medical Staff. Although formally affiliated with UTMB, the Shriners Burns Institute is administratively independent and establishes its own rules and regulations for its medical staff and employees. R. OFF-CAMPUS ELECTIVES The Program Director and the Associate Dean for Graduate Medical Education must approve offcampus electives in advance. An affiliation letter must be fully processed before the elective begins to ensure that appropriate criteria are met. Electives must be in an ACGME accredited program and/or count toward residency and/or specialty board requirements. Electives outside the U.S. will generally not be allowed because of licensure and liability coverage issues. Further, the Associate Dean for Graduate Medical Education must approve them before scheduling with an off-campus facility. Procedures for off-campus electives are available in the UTMB Graduate Medical Education Office. S. HARASSMENT (INCLUDING SEXUAL HARASSMENT) House Staff are subject to the provisions and protection of the Institutional Handbook of Policies and Procedures related to this issue (www.utmb.edu/policy/ihop, Policy 3.2.4). T. PHYSICIAN IMPAIRMENT House staff physicians are subject to the provisions of the Institutional Handbook of Policies and Procedures related to this issue under the UTMB policy entitled Evaluation and Treatment of Impaired Physicians (www.utmb.edu/policy/ihop, Policy 8.1.7). U. RESIDENCY CLOSURE/HOUSE STAFF COMPLEMENT REDUCTION In the event that UTMB reaches a decision to reduce the size of a residency or to close a residency or fellowship program, all house staff in training, or applying for such programs, will be informed as soon as possible. In the event of such a reduction or closure, all house staff already in the program will be allowed to complete their GME educational program at UTMB or, where this is impossible, will be assisted in enrolling in an ACGME accredited program in which they can continue their GME educational program. V. NOTIFICATION OF CHANGES IN THIS DOCUMENT In the event of change in this document entitled "UTMB General Information for House Staff," efforts will be made to notify members of the UTMB House Staff, in writing, at least six weeks prior to such a change becoming effective; however, changes may be made and become effective without notice. SECTION II - SALARY AND FRINGE BENEFITS; VACATION AND LEAVE

Page 16 of 185

A. SALARIES AND PAYROLL POLICIES House Staff salaries are paid by UTMB on a monthly basis. The current salary schedule for various house staff appointment levels is listed in APPENDIX 2. Checks are issued once a month for a total of twelve checks per year. Payment is inclusive from the first to the last day of the current month. Checks are issued on the first working day of the following month. House staff should check with their department regarding distribution of paychecks. House staff may elect to have thei r paychecks automatically deposited directly to their bank using a Direct Deposit Form. B. FRINGE BENEFITS - GENERAL As employees of UTMB, house staff participate in the premium sharing benefit. Several excellent insurance programs are available to the house staff as a UTMB employee including health, dental, accidental death and dismemberment, and life insurance. All house staff are covered under the UTMB House staff & Fellow Long Term Disability Insurance Program. It is designed to provide comprehensive coverage that is uniquely tailored to house staff physicians needs. A permanent salary increase is provided to allow House Staff to pay for this program themselves to achieve a significant IRS advantage. Specifics of each of the insurance programs can be found in the booklets provided by the Benefits Center. C. HEALTH AND DENTAL INSURANCE The State of Texas, through its premium-sharing program, will pay for house staffs medical insurance coverage. The University of Texas Medical Branch will pay for house staffs dependent coverage through a salary adjustment. Premiums for dental coverage will also be paid through this salary adjustment. However, house staff will pay the premiums for their dependents dental coverage through payroll deduction. There is an annual open enrollment period in the summer for employees to make changes in insurance benefits that become effective on September 1, which is the beginning of the fiscal year. If house staff has a qualified family status change, such as a marriage, divorce, or a newborn, they can make changes within 31 days of the change. However, if house staff add previously eligible dependents sometime after their initial enrollment as a new hire, their dependents who are required to complete an evidence of insurability form may be subject to a temporary reduction of benefits due to a pre-existing condition. D. WORKER'S COMPENSATION Workers Compensation Insurance covers all house staff. Any on-the -job injury must be reported immediately to the house staffs supervisor. The supervisor must complete the necessary forms and forward them to the Capability Management Office. If the on-the-job injury is such that house staff needs to report to the Hospital Emergency Room, advise the Hospital that the injury was received on the job. Reimbursement for on-the-job injury cannot be considered unless an appropriate report has been filed. This should be done immediately following the incident. E. COUNSELING, PSYCHOLOGICAL, AND OTHER SUPPORT SERVICES

Page 17 of 185

House staff as both employees and students in a particularly stressful assignment are eligible for the counseling and support services provided by the Employee Assistance Program http://www.utmb.edu/poem/EAP/EAP.htm. F. RETIREMENT BENEFITS Each house staff, as an employee of UTMB and the State of Texas, is provided retirement benefits under either the Teacher's Retirement or an Optional Retirement Program. Specifics of these programs are provided to each employee by the Benefits Center. G. PROFESSIONAL LIABILITY INSURANCE Professional liability coverage for UTMB house staff is provided under the University of Texas System Professional Medical Liability Benefit Plan at the level of $100,000 per claim. In addition, UTMB house staffs continue to have indemnity protection up to $100,000 per claim provided by Chapter 104 of the Texas Civil Practice and Remedies Code. Any house staff who even suspects the possibility of an incident which might provoke a malpractice suit is required to simultaneously: 1) call the Risk Management Department at (409)772-4775 so that the occurrence can be reported to the U.T. System and a decision may be made regarding an investigation, and; 2) notify the department in which appointed. Coverage as stated above shall commence on the effective date of residency training and shall be renewed annually or cease on the date that employment with or assignment to The University of Texas System is terminated, whichever occurs first. Causes of action that occur during official University of Texas System employment are covered, even though a claim or lawsuit is filed subsequent to cessation of employment (liability protection tail). H. VACATION LEAVE Vacations are to be arranged with the house staffs department of appointment. Advance notification guidelines will be determined by the Program Director. The amount of vacation allowed at any one time will be the decision of the Program Director. Any changes to the vacation schedule require written approval from the Program Director. General policies and procedures related to house staff vacations are the same as for other UTMB employees and can be found in the "UTMB Institutional Handbook of Operating Procedures" (www.utmb.edu/policy/ihop). House Staff shall be granted vacation as per institutional policies related to faculty and employees and are encouraged to use vacation during the fiscal year in which it was earned. I. SICK LEAVE The house staff sh all be entitled to sick leave subject to the following conditions: The house staff shall earn sick leave entitlement beginning on the first day of employment and terminating on the last day of duty (last day of duty defined as termination of contract or completion of residency program.) Sick leave entitlement shall be earned by a full-time house staff at the rate of eight hours for each month or fraction of a month of employment, and shall accumulate with the unused amount of such leave carried forward eac h month. Sick leave accrual shall terminate on the

Page 18 of 185

last day of continuous duty. Sick leave may be taken when sickness, injury, or pregnancy and confinement prevent the house staffs performance of duty or when a member of his/her immediate family is ill and requires the house staffs attention. A house staff who must be absent from duty because of illness shall notify his/her Program Director of that fact at the earliest practical time. J. MATERNITY/PATERNITY LEAVE There is no separate policy or benefit for maternity and/or paternity leave. Please see Section II, paragraph K - Family and Medical Leave Act. Maternity and paternity leave are discussed in this section. K. FAMILY AND MEDICAL LEAVE ACT Eligible UTMB employees may take up to 12 weeks paid or unpaid leave under certain qualifying conditions based on the terms of the Family and Medical Leave Act of 1993 (FMLA). Eligible employees are entitled to a total of 12 weeks of leave time during any 12-month period for any one or more of the following qualifying reasons: birth or adoption of a child; placement of a foster child; or a serious health condition of an employee or an employee's dependent, defined as a child, parent or spouse (excluding parent-in-law). Employees must exhaust all sick and vacation accruals before going out on leave without pay. During pregnancy, a female house staff may be able to continue to work as long as she is able to carry a regular schedule and fulfill the duties and responsibilities of the position in the judgment of her Program Director. The Program Director may not require that a pregnant house staff take the full six weeks of postpartum leave as long as a doctors release is provided. Additional time may be authorized by the program director if needed. The amount of time to be made up will be determined by the Program Director, subject to residency program and specialty board requirements. NOTE: House Staff should be aware that graduation from residency and Board certification depends on the completion of certain time in training requirements. Extended absences from the program may require additional time and training. For more information, employees should contact and discuss their FMLA options with their supervisor. FMLA References: 29 U.S.C. 2601, et seq. IHOP Policy Family and Medical Leave 3.9.10 IHOP Policy Sick Leave 3.9.8 IHOP Policy Parental Leave 3.9.7

Page 19 of 185

SAO Leave Interpretations 97-01, 00-01 L. EDUCATIONAL LEAVES Absence from training to attend educational conferences must be approved by the house staffs department, and the departments administrative officer must execute an official travel request form. Failure to do so may jeopardize certain survivor and other benefits, which may be forfeited if the house staff is not on an official leave of absence. Subject to residency program requirements, such leave is granted with pay and not charged to vacation time. Travel time must not extend beyond the dates of the meeting plus the time necessary to travel (based on direct air route), usually one day to go, and one day to return. Additional days will be considered as vacation time. M. EMPLOYEE IDENTIFICATION BADGE Employee identification badges are provided at no charge to the house staff and are to be worn while on duty. Increasingly, these ID badges are being used to control various house staff benefits such as meals when on-call, security access, etc. N. UNIFORMS AND LAUNDRY SERVICE All House Staff are initially furnished three lab coats. Three additional lab coats are provided each year. The institution does not provide laundry services. O. MEALS ON-CALL Meals are not provided at institutional expense except for House Staff who are officially on-call inhouse. They will be provided one free meal a day. Please check with the Program Coordinator as to the specific mechanics which operates on a voucher system currently utilizing the House Staffs employee ID #. P. FIELD HOUSE MEMBERSHIP Arrangements have been made for a discounted rate for UTMB Field House membership for house staff and their families. For further information about this, contact the Field House at (409) 7721304. This arrangement applies to House Staff located at the UTMB-Galveston campus only. Q. PARKING Parking information and permits may be obtained from the Parking Facilities Office located in Room 1.104 of Levin Hall, ext. 24786. The house staff pays a minimal amount for parking spaces during regular work hours. Fee for the garages is $12.00 per month and surface lots are $7.50 per month. After-hours parking access can be obtained at no charge to house staff in the Parking Facilities Office. These are institutionally subsidized rates. R. HOUSING Housing is not provided as an institutional benefit.

Page 20 of 185

SECTION III - DUE PROCESS; GRIEVANCE A. GENERAL PRINCIPLES Although UTMB's house staff are UTMB employees and do render professional medical services to UTMB patients, UTMB's residency training programs are primarily educational. The entire accreditation process under the auspices of the ACGME acknowledges this academic focus, and the standards for accreditation require that: academic goals be set by the residency training programs; academic resources including appropriate faculty, facilities, equipment and clinical material be provided; and regular evaluation of the trainees related to academic achievement occu r and be documented. Appropriate policies and procedures for due process also are required for ACGME accreditation, but such policies and procedures are in the context of a primarily academic educational process. In fact, the ACGME accreditation standards explicitly protect the house staff against excess service employment obligations that interfere with their training programs. Since the UTMB residency training programs are primarily educational programs, the institution vests responsibility and authority for conducting the programs and determining the success of academic achievement of the individual trainee in the program faculty and the Program Directors with the departmental Chairs ultimately responsible for process management. The Program Directors and faculty responsible for the training of house staff have an obligation to: provide appropriately organized educational opportunities to the trainees; convey clearly the educational objectives of the program and the performance required by the trainees for academic success (including those patterns of individual personal behavior that reasonably should positively impact patients, institutional employees and/or other trainees); and develop a regular evaluation process that alerts trainees to academic and performance deficiencies and provides direction in their correction. These requirements are integral elements of the ACGME accreditation standards. The Program Directors and faculty responsible for training house staff additionally are obligated to apply these academic standards to each individual trainee in the program to protect both the individual patients who are the source of the trainees' opportunities to learn in a practical way and the public at large who rely on the process to protect them against unqualified practitioners claiming expertise of a specific type. This obligation includes removal from the program of (or a decision not to reappoint) those trainees who are academically unsuccessful or whose behavior creates a risk for patients, disrupts the multidisciplinary health care team, or interferes with the educational program of other trainees. Finally, the Program Directors and faculty must attest to the satisfactory completion of the academic training program for each trainee seeking certification from the involved board to acknowledge the trainee's qualifications as a specialist or subspecialist. In conclusion, residency training is primarily an academic and educational process and the development of institutional policies and procedures for due process and oversight of those policies must be based on this guiding principle. B. APPOINTMENT OF HOUSE STAFF Initial appointments of House Staff are in general through the applicable matching program.

Page 21 of 185

Appointments at UTMB are formalized through a UTMB House Staff Work Agreement and generally are for one (1) year. Annual reappointment through the conclusion of the particular house staffs program will be based on the house staffs acceptable academic and professional performance. Exceptions to the one year appointment include a three (3) month trial appointment and the institutional permit program as worked out with the Texas Medical Board for selected International Medical Graduates being considered for regular one year appointments by UTMB's residency programs, and occasional appointments for less than one year required to address unique circumstances created by house staff illness or the need for remediation. C. TRAINING PROGRAM OVERSIGHT A process of regular institutional oversight and periodic internal review of each residency training program is in place through the Graduate Medical Education Committee as required by the ACGMEs Institutional Requirements. It is through this process that the institution monitors training program compliance with the accreditation standards including those related to the development of educational objectives, appropriate academic structure and function, and regular evaluation of trainees. D. HOUSE STAFF EVALUATION An institutional electronic evaluation system in MyUTMB is used at UTMB and is mandatory for all residency programs including faculty and house staff. Each UTMB residency training program is to have a written procedure approved by the institution for regularly scheduled electronic evaluations of the performance of each house staff by such program's Program Director as required by the ACGME's Institutional Requirements. The fact that these evaluations have been reviewed with the house staff will be documented in the individuals electronic file. House Staff will be notified by email when their evaluation is completed. A log of the house staff viewing the evaluation will be maintained. These electronic evaluations are intended to document the strengths and weaknesses of the house staffs knowledge and/or performanc e including the core competencies required by the ACGME. The training program is expected to notify the house staff at the earliest time possible of significant deficiencies in knowledge or performance, document plans for correction or improvement, and monitor success or lack thereof in doing so. Evaluations completed on each house staff will be retained in the electronic evaluation system permanently. Each house staff will be required to evaluate his/her residency program and faculty annually using the el ectronic evaluation system in MyUTMB. Training is provided for MyUTMB through Information Services during house staff orientation. Additional training is offered by Information Services. E. UNSATISFACTORY PERFORMANCE 1. All house staff are subject to the UTMB Institutional Policies and Procedures related to discipline and discharge (www.utmb.edu/ihop, policy 3.10). If according to the guidelines established by the individual training program, a house staffs academic performance (including patterns of personal behavior that may or do negatively impact patients, institutional or affiliates' employees and/or other trainees) and overall progress in the training program is deemed unsatisfactory, a consultation shall be held between the house staff and the applicable Program Director or his/her designee to discuss all

Page 22 of 185

aspects of the problem and to develop appropriate remedial actions on the part of the house staff. This consultation shall not of itself constitute a Corrective Action and shall not preclude the Program Director from also recommending simultaneously a formal Corrective Action. The consultation shall be documented in the house staffs file and the expected efforts at correction and timelines for carrying them out sufficiently detailed as to allow periodic assessment of the house staffs success or lack thereof. 2. A consultation is not a prerequisite for Corrective Action when, in the opinion of the Program Director or his/her designee, a determination is made that a house staffs discharge of clinical responsibilities would expose patients to unnecessary medical risks and the hospital to unnecessary liability. In this case, a house staff may be temporarily relieved of his/her clinical responsibilities, with pay, reassigned to other duties with pay or suspended with pay pending the outcome of an investigation by the Program Director. A house staff who has been so relieved/reassigned with pay or suspended with pay pending the outcome of an investigation, shall receive, within a reasonable length of time, not to exceed ten (10) working days, a written statement from the Program Director or designee containing a description of the deficiencies in the performance of the house staff. Expected corrections and time lines for achieving them also should be sufficiently detailed in this statement and the house staffs file as to allow periodic assessment of the house staffs success or lack thereof. Action taken pursuant to this paragraph shall be deemed a Corrective Action, subject to the ten-day notice specified above and the other requirements set forth in Section III. G., and shall not preclude further action being taken. F. PROBATION 1. The Associate Dean for Graduate Medical Education must be notified in advance and approve the placement of a house staff on probation. 2. The decision to place a house staff on probation for educational reasons such as inadequate reading or lack of adequate knowledge base generally evolves over time and is supported by evaluations of the house staff which reflect inadequate performance. Interactions between the Program Director and the house staff concerning inadequate performance should be documented and reflect that lack of improvement led to the decision for probation. 3. The decision to place a house staff on probation may occur abruptly because of problems in the delivery of clinical care. These problems may be of such acuity as to require modification of clinical assignment along with probation. In such cases, it is possible that previous documentation of inadequate performance may not exist. 4. After appropriate discussion, advice, and recommendation by the Department's Residency Advisory Committee, if such a committee exists, the recommendation to place a house staff on probation may be made by the Program Director or Chairman of the department. The ultimate responsibility for the decision to place a house staff on probation rests with the Chairman of the department. 5. The nature of the deficiencies of the house staff should be listed and it should be stated whether these deficiencies might impact clinical performance. The terms of the probation must be delineated in writing by the Program Director based on identified problems. If a limitation of clinical duties is deemed necessary or if there is any obligation of the house staff to obtain extra supervision during

Page 23 of 185

clinical duties, these terms must be delineated. 6. The Program Director must notify the Office of Associate Dean for Graduate Medical Education of the probationary status of a house staff. 7. The Program Director must notify all faculty who will be working in a clinical setting with the house staff of the probation status of a house staff. The decision to inform other personnel who have a need to know will be at t he discretion of the Program Director. 8. The house staff may challenge the decision for probation using the standard policies for grievance for house staff. If a house staff appeals probation, probation will be delayed until the final appeal decision is reached. Any modification in clinical assignment or privileges that was instituted in the probation will remain in effect until final disposition of the appeal. If the probation is upheld after appeal, the Texas Medical Board will be notified of the probationary status (TMB Rule 171.1.(e).) 9. At the end of the probationary period, documentation should be made of satisfactory or unsatisfactory remediation by the house staff. The Institutional Graduate Medical Education Committee and all faculty working with the house staff should be informed of his/her return to regular working status. G. CORRECTIVE ACTIONS IN GENERAL 1. If the time periods specified in a consultation or a Corrective Action have lapsed without correction of the house staffs performance deficiencies, he or she will be subject to initial or further Corrective Action, as the case may be, including without limitation reprimand, probation, suspension or termination for insufficient/unsatisfactory knowledge and/or performance by recommendation of the Program Director. Any recommendation for Corrective Action shall be in writing, delivered to the house staff by certified mail, (return receipt requested); shall describe the deficiencies in performance and/or knowledge; the reasons why the specific Corrective Action is being taken; and (unless the Corrective Action is termination), expected corrections and timelines for achieving them. 2. Corrective Actions, except termination, will be final on receipt of the Program Director's written notice unless the house staff successfully grieves the action. The Corrective Action of termination will be final on receipt of the Program Director's written notice unless the house staff successfully appeals the action pursuant to Section III.H. H. APPEAL RIGHTS AND PROCEDURES FOR TERMINATION 1. The house staff subject to the Corrective Action of termination shall have the option to appeal the action in writing to the Associate Dean for Graduate Medical Education (Associate Dean) within ten (10) working days of receiving notice of the action. Failure to appeal within the prescribed ten working days shall constitute waiver of the option of appeal. 2. Upon timely receipt of the house staffs written appeal of termination, the house staff may elect to meet personally with the Associate Dean to discuss the reasons for the recommended termination and to present the house staffs response. Regardless whether the house staff elects to meet with the Page 24 of 185

Associate Dean, the Associate Dean shall, within ten (10) working days of receiving the appeal, conduct a thorough review of the process that led to the recommended termination, including the documentation in the house staff's file. 3. After such review, the Associate Dean shall notify the house staff in writing by certified mail, return receipt requested, whether he/she shall either uphold or rescind the termination, with a copy to the applicable Program Director and Chair/Division Chief. 4. The house staff may appeal further in writing to the Dean of the School of Medicine (Dean) and finally to the house staff if not satisfied at the Associate Dean. The timelines to initiate a written appeal and to deliver written decisions by certified mail, return receipt requested, at the next two (2) steps of an appeal are the same as listed above in Section III.H1. 5. No compensation, whether salary or other benefit, may be withheld from a house staff appealing his/her termination in accordance with this Section III.H., until a written decision at the final level appealed to is rendered upholding the termination. A final decision to uphold a house staffs termination shall also preclude any reappointment of the house staff to any subsequent year of training at UTMB. 6. No specialty or sub-specialty certifying board or national state or local medical organization shall be notified of a Corrective Action until a final determination has been made. I. GRIEVANCE PROCEDURE FOR CORRECTIVE ACTIONS OTHER THAN TERMINATION 1. If a house staff has a grievance related to his/her training program or has been subject to any Corrective Action other than termination, the house staff should first attempt to resolve the matter informally by consulting with the applicable Chief House Staff, Program Director, and/or Chair/Division Chief. 2. If the house staff is unable to resolve the matter informally or wishes to grieve a Corrective Action other than termination, he/she should present his/her grievance in writing to the Associate Dean within 10 (ten) working days of the date the matter arose or recommendation for Corrective Action other than termination was made. The Associate Dean shall notify the house staff in writing of his decision regarding the matter, or to uphold or rescind the Corrective Action, other than termination, within 20 (twenty) working days of receiving the written grievance, unless extended by the Associate Dean's and house staffs mutual agreement. 3. Subject to the UTMB Grievance Policy (Institutional Handbook of Policies 3.10.3, the Associate Dean level shall be the final level of grievance. J. REAPPOINTMENT 1. A decision not to reappoint a house staff does not constitute Corrective Action. If a house staff is not to be reappointed to the next year of training, he/she should receive written notice (by certified mail, return receipt requested, or hand delivered with written acknowledgment of receipt) from the Program Director by March 1 of the current contract year, or four (4) months prior to the last date of the current contract if the house staff was appointed other than in the late June or early July time

Page 25 of 185

frame. 2. House Staff who plan not to continue in the succeeding year of their training program should notify the Program Director in writing by March 1 of the current year, or four (4) months prior to the last date of the current contract. 3. The Associate Dean is to be copied on the notifications of intent not to reappoint or intent not to accept reappointment referenced above. 4. If grieved in writing by the house staff, the Associate Dean will review a decision not to reappoint a house staff. Such grievance will be subject to the grievance procedures stated in Section III.I., except that the Associate Dean level shall be sole and final level of grievance. APPENDIX 1A POSITION DESCRIPTION OF HOUSE STAFF (As required by the JCAHO and wording suggested by the AAMC) 1. The house staff meets the qualifications for house staff eligibility outlined in the Essentials of Accredited Residencies in Graduate Medical Education in the AMA Graduate Medical Education Directory. 2. As the position of the hous e staff involves a combination of supervised, progressively more complex and independent patient evaluation and management functions and formal educational activities, the competence of the house staff is evaluated on a regular basis. The program maintains a confidential record of the evaluations. 3. The position of the house staff entails provision of care commensurate with the house staffs level of advancement and competence, under the general supervision of appropriately privileged attending teaching staff. This includes: participation in safe, effective, and compassionate patient care; developing an understanding of ethical, socioeconomic and medical/legal issues that affect graduate medical education and of how to apply cost containment measures in the provision of patient care; participation in the educational activities of the training program and, as appropriate, assumption of responsibility for teaching and supervising other house staff and students, and participation in institutional orientation and education programs and other activities involving the clinical staff; participation in institutional committees and councils to which the house staff is appointed or invited; and performance of these duties in accordance with the established pr actices, procedures and policies of the institution, and those of its programs, clinical departments and other institutions to which the house staff is assigned; including among others, state licensure requirements for physicians in

Page 26 of 185

training, where these exist. APPENDIX 1B (ACGME Institutional Requirements Section III.E.) House staff Participation in Educational and Professional Activities 1. The Sponsoring Institution must ensure that each ACGME-accredited program defines, in accordance with its Program Requirements, the specific knowledge, skills, attitudes, and educational experiences required in order for their House Staff to demonstrate the following: a. Patient care that is compassionate, appropriate, and effective for the treatment of health proble ms and the promotion of health b. Medical knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiological and social-behavioral) sciences and the application of this knowledge to patient care c. Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care d. Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals e. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population f. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value. 2. In addition, the Sponsoring Institution must ensure that House Staff a. develop a personal program of learning to foster continued professional growth with guidance from the teaching staff; b. participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other House Staff and students; c. have the opportunity to participate on appropriate institutional and departmental committees and councils whose actions affect their education and /or patient care; d. participate in an educational program regarding physician impairment, including substance abuse. 3. The Sponsoring Institution must ensure that House Staff submit to the program director or to the DIO at least annually confidential written evaluations of the faculty and of the educational experiences.

Page 27 of 185

APPENDIX 1C ACGME House staff Duty Hours and the Working Environment Providing house staff with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and house staff well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on house staff to fulfill service obligations. Didactic and clinical education must have priority in the allotment of house staff time and energies. Duty hour assignments must recognize that faculty and house staff collectively have responsibility for the safety and welfare of patients. Supervision of House Staff B. Qualified faculty must supervise all patient care. The program director must ensure, direct, and document adequate supervision of house staff at all times. House staff must be provided with rapid, reliable systems for communicating with supervising faculty. C. Faculty schedules must be structured to provide house staff with continuous supervision and consultation. D. Faculty and house staff must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects. II. Duty Hours A. 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 related to patient care, the provision for transfer of pa tient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. B. Duty hours must be limited to 80 hours per week, averaged over a four -week period, inclusive of all in-house call activities. C. House staff 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 as one continuous 24-hour period free from all clinical, educational, and administrative activities. D. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour period provided between all daily duty periods and after in-house call. III. On-Call Activities The objective of on-call activities is to provide house staff with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal workday when house staff are required to be immediately available in the assigned institution. A. In-house call must occur no more frequently than every third night, averaged over a four -week Page 28 of 185

period. B. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. House staff may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subs pecialty Program Requirements. C. No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted after 24 hours of continuous duty D. At-home call (pager call) is defined as call taken from outside the assigned institution. 1. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each house staff. House Staff taking at-home call must be provided wit h 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. 2. When house staff are called into the hospital from home, the hours house staff spend in-house are counted toward the 80-hour limit. 3. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. APPENDIX 2 THE UNIVERSITY OF TEXAS MEDICAL BRANCH GRADUATE MEDICAL EDUCATION Policy on Passage of United States Medical Licensing Exams (USMLE) Approved by: UTMB Graduate Medical Education Committee Approval Date : February 3, 2004 Effective Date : July 1, 2004 Revised Date: January 25, 2006 Purpose: To ensure that house staff and fellows complete the three steps of exams required for licensure by the Texas State Board of Medical Examiners. It is beneficial to the house staff if the exams are completed within the first two years of residency because the exams cover multiple disciplines. It ensures that house staff meet the exam requirements of USMLE before completion of training regardless if they remain in Texas or practice medicine in other states. This policy does not apply to house staff and fellows who hold an unrestricted Texas medical license. They have met all exam requirements.

Page 29 of 185

Guidelines for House staff/Fellows: Prior to acceptance of a residency/fellowship applicant, the Program Director shall assure that the applicant has passed USMLE Step 1, or its equivalent, within the number of attempts required for Texas licensure. If House staff/Fellows lack USMLE Step 2 and Step 3 at the time of employment : 1. At the end of the first year of residency/fellowship training, each house staff/fellow will be required to present proof to the GME Office of passage of Step 2 Clinical Knowledge and Clinical Skills, or its equivalent, within the number of attempts required for Texas licensure. 2. At the end of the second year of residency/fellowship training, each house staff/fellow will be required to present proof to the GME Office of passage of USMLE Step 3, or its equivalent, within the number of attempts required for Texas licensure. If House staff/Fellows lack USMLE Step 3 at the time of employment: At the end of the second year of residency/fellowship training, each house staff/fellow will be required to present proof to the GME Office of passage of Step 3, or its equivalent, within the number of attempts required for Texas licensure. Educational Leave will be granted during the time required to take the exams. House staff/Fellows who do not complete the Steps in accordance with the above time frames will not proceed to the next postgraduate year until the applicable step exam is successfully completed. Following completion of the first two years of employment, such house staff/fellows will have leave without pay not to exceed three months after which they will be dismissed from the program if the step exams are not successfully completed. House staff/Fellows who are dismissed are eligible to appeal the dismissal. THE USMLE WEB SITE PROVIDES TUTORIAL AND SAMPLE TEST MATERIALS AT http://www.usmle.org/applicationmaterials/default.htm#usmlecd. Sources: //www.tmb.state.tx.us/apps/physician_eligibility.php

SAMPLE - HOUSE STAFF AGREEMENT (CONTRACT)

Page 30 of 185

Page 31 of 185

OBGYN Policy on Evaluation and Minimum Standards that Must be Met

Residents are evaluated by faculty and their peers at the conclusion of each rotation. Residents are also evaluated periodically by nursing staff, patients and medical students in a 360 degree fashion. Evaluation of specific procedural competency is done on an annual basis (see prcedural evaluation form). Satisfactory performance in all ACGME compentencies is required for promotion to the next PGY level and for graduation. All procedural evaluations appropriate for the PGY level must be satisfactorily completed for promotion and graduation. Evidence of inadequa te performance may include any of the following: 1. Persistently low CREOG scores as defined in this handbook 2. A pattern of low scores on global 360 degree evaluations (from faculty, peers, professional associates, students) 3. Evidence of unprofessional behavior 4. Non compliance with institutional, departmental or residency policies 5. Failure to achieve satisfactory evaluations of specific procedural competencies (see procedural evaluation form) 6. Persistent failure to perform satisfactorily in any required duties of the residency program

OBGYN POLICY ON REMEDIATION/PROBATION

Residents may be placed on probation for failure to meet minimum standards as defined in the policy above or for critical lapses in patient care. A recommendation to place a resident on probation will be made by the program director to the department chair. If the department chair approves the recommendation, then the approval of the faculty members on the departmental education committee will be obtained before proceeding with placement of a resident on probation.

Page 32 of 185

2
Section

Residency Program Office

Primarily the program director, the chief residents, and the program coordinator supervise the housestaff. For the academic year 2008 - 2009 the persons to contact will be as follows: Program Director Dr. Tony Wen 772-2898 office 643-2688 pager 643-2288 pager 643-2024 pager 772-2999 office 645-5882 pager

Chief Residents Program Coordinator

Dr. Erin Beltramini Dr. Gradie Moore Mrs. Sherry Bastien

All scheduling, evaluations and other personnel management issues are handled by this office. The people listed above are your advocates; feel free to contact them when any problems or questions arise. At least one of the chief residents is available by beeper at all times.

Goal
The primary goal of UTMB's Obstetrics & Gynecology Residency Training Program is to offer residents a broad experience that will prepare them to function as independent practitioners or to enter academic fellowship programs. To achieve th is, the faculties have established a balanced schedule offering organized teaching and learning activities, clinical experience, and research opportunities. Educational goals in resident training are facilitated by the following:

Residents actively interact with a 24-hour-a-day in-house faculty supervisor;

Page 33 of 185

Full-time supervising faculty have offices adjacent to the Ob/Gyn area within the UTMB Hospitals;

Ob/Gyn faculty and residents work closely with other clinical and basic science faculty;

The Department houses a Labor & Delivery suite and provides extensive services in the University Hospital Clinics;

Patient referrals from across the state provide challenging clinical experienc es in a strong academic environment.

The Department provides opportunities for extensive experience in primary care.

Graduates of our residency program engage in academic endeavors, fellowship training, and private practice throughout the United States.

Page 34 of 185

3
Section

Core Competencies
At the completion of your residency, you must be proficient in the following six core competency areas:

Patient Care
Residents are expected to provide patient care that is compassionate, appropriate and effectiv e for the promotion of health, prevention of illness, treatment of disease and end of life care. Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures. Make informed recommendations about preventive, diagnostic and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preference. Develop, negotiate and implement effective patient management plan s and integration of patient care. Perform competently the diagnostic and therapeutic procedures considered essential to the practice of Obstetrics and Gynecology. Inform patient and family of end of life concerns, issues, and rights. Work with ancillary services to help with these issues.

Medical Knowledge
Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others. Apply an open-minded and analytical approach to acquiring new knowledge. Access and critically evaluate current medical information and scientific evidence. Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of Obstetrics and Gynecology. Apply this knowledge to clinical problem solving, clinical decision-making, and critical thinking in patient care.

Page 35 of 185

Practice Based Learning and Improvement

Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care. Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice. Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care. Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education.

Communication and Interpersonal Skills

Residents are expected to demonstrate interpersonal communication skills that enable them to establish and maintain professio nal relationships with patients, families, and other members of health care teams. Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues. Use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families. Interact with consultants in a respectful, appropriate manner. Maintain comprehensive, timely, and legible medical records. Work effectively as a member of the ward team and the clinic form. Teamwork: Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty.

Professionalism
Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society. Demonstrate respect, compassion, integrity, and altruism in relationships with patients families, and colleagues. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues. Adhere to principles of confidentiality, scientific/academic integrity, and informed consent. Recognize and identify deficiencies in peer performance. Remain professional in appearance and behavior in the performance of all duties.

Page 36 of 185

Systems Based Practice

Residents are expected to demonstrate both understanding of the contexts and systems n i which health care is provided, and the ability to apply this knowledge to improve and optimize health care. Understand, access, and utilize the resources, providers and systems necessary to provide optimal care. Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient. Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management. Collaborate with other member s of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care.

The Faculty of the Department of Obstetrics and Gynecology is dedicated to providing the education and leadership necessary to aid the house staff in achieving and possibly surpassing these competency goals. The residents are also to develop a personal program of learning to foster continued professional growth with guidance from the teaching staff. In addition, they should participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students.

Page 37 of 185

4
Section

Structure of the Houseofficers Year

General Information
Rotations change every four to six weeks for residents. Faculty physicians follow calendar months. Rotations are divided into direct patient care months and electives. Direct patient care rotations include Obstetrics, Gynecology, Gynecologic Oncology, Reproductive Endocrinology and Infertility, Pediatric and Adolescent Gynecology, Night Float, and Family Medicine rotations. Electives are requested by the residents and may consist of subspecialty endeavors, gynecologic surgical experiences, research, or other electives that may be approved. All electives must be approved by the program director. Requests should be submitted to the program coordinator as a proposal explaining the elective. The requests must be submitted three months in advance of the propos ed elective.

Obstetrics and Gynecology Rotation by PGY levels

PGY1 GYN day- 6 wks x2 OB day- 4 wks x 3; OB night- 2 wks x3 Ward night- 2 wks x3; REI- 6 wks US-Genetics 2 wks Family Med- 4 wks PGY2 GYN day- 6 wks Memorial SE GYN - 6 wks OB day- 4 wks x3 OB night- 2 wks x3; Triage- 2 wks x3 Onco- 6 wks Research- 6 wks PGY4 GYN day- 6 wks 1 Beaumont GYN- 6 wks OB day- 4 wks x3 OB night- 2 wks x3; Urogyn- 4 wks REI- 3 wks Consult/US - 4wks ROBOT - 2wks

PGY3 GYN day- 6wks Corpus GYN- 6 wks OB day- 4 wks x3 OB night- 2 wks x3 Antepartum- 2 wks x3 Onco- 3 wks MDA ONC-6 wks REI-3 wks RSCH-2 wks

Page 38 of 185

Call Schedule
The call schedule is designed to provide in-house coverage for the Wards, Emergency Room and Labor and Delivery over the weekend allowing every resident to have at least one day off per week. There is also a daily home call for PGY3 and PGY 4 residents providing coverage for the Operating Room (gyn cases only) for any emergent cases. PGY 1 and PGY 2 residents average one call per week. PGY 3 and PGY 4 residents have approximately 1 home call per week and 6 in -house calls per year. Changes to the call schedule for each month is due to Sherry Bastien by the 15th day of the prior month and must be approved by the Administrative Chief residents. Saturday GYN 1a GYN 1b Normal Nights Research Antepartum Consult Sunday GYN 2 FAM/USG REI 1 Research Antepartum Consult Monday Normal Coverage

ER CALL/Ward (am) ER CALL/Ward (pm) L&D PGY 1 PGY 2 PGY 3 PGY 4

7am to 7pm

7pm to 7:30am Normal Coverage REI 1 Normal Coverage Normal Coverage Normal Coverage

Obstetrics
The Obstetric rotations are designed to teach the resident the skill of managing a pregnancy from conception to delivery. Prenatal care, of high and low risk pregnancies, is performed weekly during the continuity of care clinics. The skills involved in the management of labor and the performance of vaginal, operative vaginal and operative deliveries occurs in the Labor and Delivery Unit. The diagnosis and management of antenatal medical complications occurs in the continuity clinic as well as in caring for these patients on the antepartum ward service. Routine as well as complicated postpartum care is learned in the continuity clinic as well as on the postpartum ward. The Labor and Delivery Unit is staffed on weekdays by 6-8 residents, primarily two residents from each PGY level. There is one team of residents (PGY 1-4) in charge of the evaluation, admission, management and discharge of all pregnant women that present to L&D. The other team (PGY 1-4) performs all operative procedures. These two teams are labeled OB-A and OB-B. Each team alternates, on an every other day basis, the coverage of the L+D Unit and the OR. Each team is also assigned a panel of postpartum and antepartum patients. The PGY 1 and PGY 2 residents manage the uncomplicated postpartum patients. Complicated postpartum patients are managed by the lower level residents with the supervision of the PGY 4 resident and faculty. Antepartum patients are managed by the PGY 3 and PGY 4 residents. A Maternal Fetal Medicine Faculty is assigned to a specific team (OB-A or OB-B) and is responsible for rounding on antepartum patients on a daily basis. This faculty is also available for consultation at all times and is responsible for evaluating the residents. A night float team (OB-Nights) exists to cover the Labor and Delivery unit on weeknights and weekends. This team consists of one resident from each PGY level. Additionally the two lower level residents on night float covering the wards and ER are available, if needed. The OB-Nights team is responsible for the evaluation and management of all patients in Labor and Delivery. Additionally the PGY3 and PGY 4 residents serve as consultants to the midwives and lower level Page 39 of 185

residents covering the wards and ER. Faculty take in-house call to cover Labor and Delivery and are available for consultation at all times.

Gynecology
The gynecology rotation exists to provide the residents with basic gynecologic operative experienc e, postoperative patient management, preoperative evaluation and primary office care. The Gyn team consists of one resident from each PGY level with the addition of an extra PGY 2 and 3 for a total of 6 residents. The PGY 4 resident assigns operative cases based upon PGY level and skill. All residents perform preoperative evaluations appropriate for their level of training through their continuity clinics. The Gynecology service is responsible for the care of all postoperative patients and non-operative admissions. There is a same day/walk -in clinic for emergencies. These patients are seen by the residents of the Gynecology team that are not in the O.R. Rounds on these patients are to be performed in the morning before all OR and clinic responsibilities begin. All of the following clinic patients must be presented to a faculty member: preoperative patients, private insurance patients, potential admissions to the inpatient ward, Medicare patients and inpatient consultations. Additionally, Medicare patie nts must be seen and examined in the presence of a faculty member.

Gynecologic Oncology
Although most Obstetrics and Gynecology residents will not proceed on to a fellowship in gynecologic oncology, exposure to this subspecialty is essential. The general OB/Gyn must be able to identify patients who are at risk for, or who already have, malignancies of the pelvic organs and/or breast. The expectations for the resident is to learn how to provide education, counseling and followup care for patients with pelvic/breast malignancies as well as understanding the therapeutic options. The gynecologic oncology service consists of a PGY 2 and PGY 3 resident. The residents on the rotation acquire the above mentioned skills by managing the inpatient service (cons isting of postoperative, radiation/chemotherapy complication and breast cancer chemotherapy patients), dysplasia clinic, oncology clinic, chemotherapy clinic, breast clinic, preoperative clinic and operative cases. The residents on the oncology team are exempt from the general OB/GYN call schedule for the duration of the rotation and take home call on a rotating basis. The in-house ward call/night float resident initially evaluates the patient and then addresses any issues to the oncology home call resident. (The PGY 3 and PGY 4 on OB-Nights do not serve as consultants for oncology patients. Ward call is to address all issues with the oncology home call resident directly). The faculty on service will make daily rounds on the inpatients

Reproductive Endocrinology and Infertility

This rotation is designed to expose the resident to the basic science knowledge behind human development, assisted reproductive techniques and the physiology of the hypothalamic -pituitaryovarian axis. The service is composed of a PGY 1 resident. There are conferences addressing infertility, reproductive endocrinology and menopause three times weekly. The REI faculty are present at each conference and discuss diagnosis as well as management issues. Additionally the residents staff REI clinic twice weekly, menopause clinic weekly and operative cases once a week.

Page 40 of 185

Faculty members and/or fellows supervise all clinical activities in the operating room, clinic and ward. The faculty and/or fellow are available for consultation 24-hours a day, seven days a week.

Houston Infertility Center

This rotation is designed to expose the resident to the private practice setting for assisted reproductive medicine and services. The service is composed of a PGY 4 resident. Faculty members supervise all clinical activities in the operating room, clinic and lab. In the fourth year, residents will rotate with the physicians of Houston Fertility institute (HFI). Dr. Craig Witz will be the principal mentor for this experience. Residents will primarily see patients with Dr. Witz at HFIs Webster and Fondren offices*. The schedule is listed below. Variations will be dictated by patient care requirements.

AM PM

Monday Tuesday Wednesday Thursday Friday Fondren Webster Fondren Webster Continuity Clinic Fondren Webster Webster Webster Webster

Office hours begin at 8 am. There are no weekend assignments. Residents will see patients with a vast array of problems related to infertility and recurrent pregnancy loss. As a result of these patient encounters, it is expected that the resident will become proficient in the evaluation and management of ovulatory dysfunction including polycystic ovarian syndrome. In addition, residents will become familiar with the evaluation and management of patients with amenorrhea, hyperandrogenism, hyperprolactinemia, endometriosis, and thyroid disorders. The resident will also become familiar with methods of achieving controlled ovarian hyperstimulation as well as the process of in vitro fertilization. As wel l, they will demonstrate an understanding of the diagnosis and treatment of mullerian anomalies, certain genetic abnormalities, and thrombophilia. Residents will have the opportunity to hone their skills performing vaginal sonography and will participate in sonohysterography. They will also learn to perform and interpret hysterosalpingograms. They will scrub for outpatient surgical procedures including transvaginal retrieval of oocytes, hyseteroscopy, laparoscopy, and myomectomies. As time permits, residents will be engaged in didactics given by the attending physicians covering subjects such as: embryology of the reproductive system, steroidogenesis, mechanisms of hormone action, abnormal pubertal development, disorders of ovulation, PCOS, endometriosis, hyperprolactinemia, premature ovarian failure, and hirsutism. To prepare for these discussions, it is recommended that residents read relevant chapters in Clinical Gynecologic Endocrinology and Infertility by Marc A Fritz, and Leon Speroff.
*Fondren Office:

2500 Fondren, Suite 350 Houston, Texas 77063 Ph: 713-490-2527 Fax: 713-334-5547

Webster Office: 251 Medical Center Blvd, Suite 125 Webster, Texas 77598 Ph: 281-286-4434 Fax: 281-554-5115

Page 41 of 185

Pediatric and Adolescent Gynecology

Pediatric and Adolescent gynecology is designed to teach the resident how to interact with children and understand the diagnosis and management of gynecologic problems specific to children. A PGY 1 resident is assigned to this service and spends one day a week for 6 -7 weeks in the pediatric & adolescent gynecology clinic. While on service the resident learns interviewing skills, age specific modifications for physical examination, evaluation and management of the prepubertal child and adolescent and contraceptive counseling for teenagers.

Emergency Department
All residents will spend one rotation in the Emergency Department. The ER operates with a partial triage system. On arrival, the triage nurse assigns patients to either the West Side (minor side) or East Side (major side). PGY-1's are assigned to both the Major and Minor sides and evaluate all types of patients. They will be working in conjunction with other interns assigned to the ER service including Anesthesiology, Psychiatry, Surgery, Internal Medicine and/or Family Medicine. The rotation will be in 12-hour shifts with days off interspersed. Faculty are available to review work done and assist in the management of these patients. All charts must be reviewed and signed by Faculty before a patient is discharged. Any changes in the ER schedule must be confirmed with the Chief Residents. If you are scheduled to be on the ER rotation but are not working an ER shift, you are still expected to be in town and available if needed.

Primary Care/Continuity Clinic

Each resident at the R1-R4 levels attends his or her primary care continuity session 1/2 day each week. This experience gives the resident an opportunity to provide outpatient care to the same group of patients over an extended period of time. All patients are assigned to a specific residents continuity clinic and become part of the residents panel of patients to be followed for the entire four years of training. Per ACGME: The clinical responsibilities for each resident must be based on PGYlevel, patient safety, resident education, severity and complexity of patient illness/condition and available support services. One full-time physician is assigned as preceptor for each session with the exclusive role of providing supervisory guidance, support and teaching for residents and students. This is in line with the ACGME Rule: each patient must have an identifiable, appropriatelycredentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patients care. Residents thus have the advantage of long-term management of a large number of patients with a wide range of problems. Primary care topics are included in didactic presentations and reading assignments. Residents are supervised in continuity clinic by faculty members who have extensive experience in ambulatory care of the obstetrics and gynecologic patient.

Page 42 of 185

Inpatient/Ward Responsibilities
This section covers the responsibilities of all members of the patient care team for any given OB/GYN service that manages patients admitted to the hospital A. Responsibilities of Team Members 1. Service Faculty: -Oversees team function and overall patient care -Teaches housestaff and medical students -Monitors discharge planning and expeditious care of patient -Accepts ultimate legal responsibility f or patient's welfare -Learns from other team members -Assures attendance of team members at all required conferences. 2. PGY 4 Resident : -These responsibilities apply to the PGY 3 resident if there is not a PGY 4 resident present -Is directly accountable to the attending for the entire service -Assures that an upper level evaluation and note is written on each admission -Leads morning rounds by evaluating the lower level treatment plan -Plans discharges and coordinates patient follow-up -Teaches inter ns and students, and sometimes faculty -Is directly responsible for the weekly M+M list composition and submission -assures that the team is not delinquent in medical record keeping responsibilities -Assures attendance of self and team members to all required conferences Faculty Notification : It is the responsibility of the resident to contact faculty immediately for the following issues: -All admissions within 3 hours of admission to the hospital -Potentially unstable patients -Transfers to intensive care -Deaths (expected and unexpected) -Changes in patient status -Procedures -Risk management issues -Patients leaving or declining urgent treatment AMA (against medical advice) -Restricted drug/treatment approval 3. PGY 1, PGY 2 and PGY 3: -Evaluate s patients prior to morning rounds in order to develop a treatment plan for each patient -Writes orders and daily notes -Calls consultants -"Checks out" the patients to the ward call/night float resident -Teaches students, sometimes teaches PGY 4 reside nt and faculty B. Afternoon Rounds Review of patient status and morning round decisions are done each afternoon, prior to departing for

Page 43 of 185

the day. Tenuous patients are re-examined and pending discharges designated at this time. Such review ensures that all duties have been accomplished and that hospitalization is progressing efficiently. C. Check Out Once patients have been stabilized and work has been completed, the team will make a list of all patients outlining their status, potential on call problems, and suggestions for intervention. This list will be given in person to the ward call/night float resident to facilitate the cross-coverage of those patients overnight. Particularly ill patients must be checked-out by the primary teams PGY 3 or PGY 4 to the OB-Nights PGY 3 or PGY 4 resident. D. Daily Progress Notes Notes should be completed daily and outline the patient's status, progress, and subsequent plan of care (POC). The daily notes should generally be in a problem-oriented format (SOAP no te). It is very important that issues that arise during the hospitalization are addressed and the POC for these issues outlined. They should include a focused physical exam, outline estimated length of stay, and document the need for continued hospitalization. All laboratories and radiographic studies should be included daily. All notes should be dated and timed and signed by the individuals completing them. Signatures should be legible or accompanied by a legible printed name, and beeper number . Medical students may also write daily notes on patients they follow, in addition to the housestaff daily note. The medical student note may not substitute for the housestaff daily note. Any notes written by the medical students will be reviewed, corrected, and signed by the resident or faculty, who will be ultimately responsible for their content. E. Discharges Discharge planning should begin at admission. To facilitate incoming admissions, discharges should be arranged as early in the day as possible. A written discharge summary (yellow border sheet) and necessary paperwork should be completed the evening prior to any anticipated discharge. Discharge summaries should be dictated on the day of discharge.
NOTE: The hospital administration is looking into the time it takes to discharge the patients. As you can appreciate, the longer the patient stays in the hospital after she is ready for discharge, the more it would cost. I know that there are several issues that may delay discharge of the patient, many of which not under our direct control. However, the initiating event for any discharge is the physician order, including the approval by the faculty. Without completing this initiating event, all other services that may be at more fault than us in the delay will automatically point the finger at us. Therefore, it is imperative that discharge order be finalized first thing in the morning. The policy is that all discharge order should be finalized by 9 am on business days and 9:30 am on weekends/holidays. In order to accomplish this, I suggest the following. Checking with the resident who is doing the po stpartum discharges first thing in the morning (it is usually a second year resident on labor and delivery). The resident will have a list of all pending discharges to review with the faculty. All straightforward discharges can be approved right there, and those that require individual attention can then be seen (either with or without the resident) and approved. After completing the postpartum discharges, I ask you to then round on the antepartum service, starting with the patients who are likely for discharge. After completing the rounds on the antepartum service, then you should resume the rounds on the remaining postpartum patients. I anticipate that in order to complete the discharges by the required time, we will need to start

Page 44 of 185

with the postpartum resident at 8 am . Dr. Wen will notify the resident to be ready on labor and delivery at 8 am, along with a list of the postpartum discharges. Dr. Wen will also notify the antepartum resident to start with the discharges too. Both residents should complete the discharge orders as soon as possible.

Page 45 of 185

5
Section

Educational Goals and Objectives

General
Each resident and faculty is provided with the educational goals and objectives at the start of each academic year and at the start of each rotation. Confirmation of receipt and review of these objectives is obtained in the form of a written and signed statement on behalf of each resident. The educational goals and objectives are based upon the CREOG Educational Objectives for Residents in Obstetrics and Gynecology. Multiple educational opportunities exist; including, faculty didactic lectures, Grand Rounds, Morbidity and Mortality conference, REI conferences, Minor and Major Operative Procedures, Faculty Ward Rounds and Journal club. The Program Director uses the residents performance on the CREOG in -service examination, individual faculty evaluations and performance on the Oral examination to ascertain whether each resident is meeting their PGY level specific educational goals and objectives. Procedural skills are taught by upper level residents and faculty. Each resident is formally evaluated by the assigned service faculty and chief resident. These evaluations include procedural competency. If any deficits exist in knowledge base or procedural skills, as reflected by the above mechanisms, the program director and chairman determine the appropriate course of remediation. Appendix I contains specific questions which elaborate on the educational goals and objectives assigned per PGY level. Procedural skills and knowledge are referenced per PGY level as well.

Antepartum Rotation
Goals: -to allow 3rd year residents improved learning opportunities in complicated postpartum and antepartum care, especially with regards to high risk pregnancies, e.g. pre-eclampsia, chronic hypertension, oligohydramnios, placenta previa, diabetes, etc. -improve continuity of care and management on antepartum patients Learning Objectives See resident handbook learning objectives for the PGY-3 Obstetrics resident.

Page 46 of 185

Description: -3 rd year resident who manages, rounds with faculty on all antepartum patients and complicated postpartum patients. This rotation will alternate in 2 week increments with nights blocks. -Antepartum resident hours 0730-1630 Tues-Friday, Nights on Sat/Sun 1800-0800. Post call on Mondays. (Total hours= 64) -Ob Day team will be responsible for rounds /management on Mondays Duties: -admit antepartum patients sent for direct admissions -management of all antepartum patients and complicated postpartum patients -round daily with antepartum MFM faculty at time designated by faculty -Ob day team will help with rounds in AM as needed. All antepartum patients must have been seen and evaluated prior to rounds with faculty. -maintain current list of all antepartum and complicated postpartum patients for view by fellow residents and faculty -be familiar with all antepartum patients -answer floor questions during day regarding antepartum patients and be available to evaluate complications during day that arise on postpartum patients -help facilitate follow up and ensure that all appropriate labs, ultrasounds, procedures, consents, etc are obtained on patients -help in L&D when not busy with floor duties -attend and present patients at weekly MFM conferences -present antepartum patients at M&M -check out daily with upper levels about antepartum patients and discuss postpartum patients with lower levels -make sure night team/day team are aware of high risks patients on floor
The hospital administration is looking into the time it takes to discharge the patients. As you can appreciate, the longer the patient stays in the hospital after she is ready for discharge, the more it would cost. I know that there are several issues that may delay discharge of the patient, many of which not under our direct control. However, the initiating event for any discharge is the physician order, including the approval by the faculty. Without completing this initiating event, all other services that may be at more fault than us in the delay will automatically point the finger at us. Therefore, it is imperative that discharge order be finalized first thing in the morning. The policy is that all discharge order should be finalized by 9 am on business days and 9:30 am on weekends/holidays. In order to accomplish this, I suggest the following. Checking with the resident who is doing the postpartum discharges first thing in the morning (it is usually a second year resident on labor and delivery). The resident will have a list of all pending discharges to review with the faculty. All straightforward discharges can be approved right there, and those that require individual attention can then be seen (either with or without the resident) and approved. After completing the postpartum discharges, I ask you to then round on the antepartum service, starting with the patients who are likely for discharge. After completing the rounds on the antepartum service, then you should resume the rounds on the remaining postpartum patients. I anticipate that in order to complete the discharges by the required time, we will need to start with the postpartum resident at 8 am . Dr. Wen will notify the resident to be ready on labor and delivery at 8 am, along with a list of the postpartum discharges. Dr. Wen will also notify the antepartum resident to start with the discharges too. Both residents should complete the discharge orders as soon as possible. Another issue to keep in mind is that the MFM-NPs round on the postpartum patients on certain days (weekends/holidays, Wednesdays, and Mondays). If the NP is rounding, then proceed directly to the

Page 47 of 185

antepartum discharges. On occasions when we are short staffed, the NPs may not round on Wednesdays or Mondays, so please check (we will also do our best to notify you). I apologize for the long email, but this is a very important issue and I ask for your utmost cooperation. We are under the microscope. Thank you George
There will be monitoring on getting the patient discharge in timely manner. 1) PGY2 on postpartum round with faculty CANNOT be in OR at 8:00 am and MUST be available in L&D. She/he MUST be prepare to check out with faculty on the postpartum patients for sure discharge and those for possible discharge. 2) PGY1 and PGY2 Residents rounding on the postpartum patients in the morning- MUST check out to the Ro unding PGY2 on the potential discharges (and complicated cases), so she/he can place or pend discharge orders ahead of time. Again, to expedite this process, both PGY1 and PGY2 on service must divide the patients evenly and complete the rounds in timely manner. 3) PGY3- antepartum MUST complete round and be prepare to start round on potential discharge patients first by 8:10 am and be prepare to discharge them by (9:00 am / 9:30 am). 4) PGY3- OB service MUST complete round on the antepartum patients in L&D and triage settings by 8:00 am and notify faculty of potential discharges 5) On both ante / postpartum services, please remind our stable patients who will be discharge next morning to make arrangement for their ride home ahead of time. 6) On both ante / postpartum services, please try to assign only patients who will not be discharge that day to the medical students. We will focus on those patients as teaching cases on rounds.

Obstetrics
A. PGY 1 Medical Knowledge

Develop a core knowledge of: o The components of prenatal care o Prenatal labs o Normal and abnormal labor o Antepartum and intrapartum fetal monitoring o Normal physiological changes of pregnancy o Obstetrical lacerations o Routine postpartum care o Circumcision o Indications for operative vaginal deliveries o Indications for cesarean delivery

Page 48 of 185

Patient Care

Recognize common abnormalities in the obstetrical exam such as abnormal fundal height, abnormal blood pressure Perform: o Appropriate prenatal labs for uncomplicated patients o Obstetrical dating o Fundal height o Fetal heart tones o Leopolds maneuver for presentation and estimated fetal weight o Cervical dilation, effacement, station and position o Spontaneous vaginal delivery o Midline episiotomy and repair o Repair first and second degree lacerations o Primary low transverse cesarean delivery o Fetal scalp electrode placement o Artificial rupture of membranes o Intrauterine pressure catheter placement o Amnioinfusion o Sterile speculum exam to diagnose ruptured membranes o Post partum tubal ligation Prescribe: o RhoGAM o Antibiotics o Pitocin o Cervical ripening agents o Postpartum contraception o Postpartum analgesia Interpret a reactive nonstress test Recognize factors in the history or physical that indicate possible medical, genetic or obstetrical complications Recognize postpartum complications such as: o Endometritis o Postpartum hemorrhage o Deep venous thrombosis

Interpersonal and Communication Skills

Provide patients with an explanation of pain control options in labor Provide patients with an explanation of routine procedures such as intrauterine pressure catheter placement, artificial rupture of membranes and fetal scalp electrode placement Communicate a thorough sign-out on patients to improve continuity of care

Professionalism

List the components of informed consent Demonstrate a commitment to patient confidentiality Incorporate the team concept in taking care of patients which includes the attending, students and nurses

Page 49 of 185

Increase awareness of the patients expectation of her birthing experience

Practice Based Learning

Dictate intraoperative notes and discharge summaries in a timely fashion Concentrate on using only hospital approved abbreviations Write orders based on the pharmacy protocol to prevent medical errors Understand and comply with teaching physician regulations

System Based Practice

Offer patients who are breast feeding the option of a lactation consultant if necessary Understand the criteria that necessitates neonatal physician presence at a delivery Understand patient, family and neonatal issues that require social work intervention

Learning Resources

The Resident Lounges have major obstetrics textbooks, instructional videos/CDs and access to computers. Residents will review fetal monitoring tracings throughout the rotation. Residents attend Wednesday morning Morbidity and Mortality Conference, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am. (Night Float residents usually conclude at 8am per work hour rules.) Daily sign-outs at 7:00AM and 5:30 PM.

Reading Assignment: Williams Obstetrics by Cunningham, 22nd Edition. Chapters: 1-6, 8, 12, 15, 17, 18, 20, 23, 26, 27, 30 & 48-50. Operative Obstetrics by Gilstrap, 2nd edition. Chapters: 1-7, 12, 13, 15, 17 and 37 ACOG Practice Bulletin: #4, #9

B. PGY 2 Medic al Knowledge

Develop a core knowledge of: o Disease processes that adversely affect pregnancy o Disease processes that pregnancy adversely affects o Management of multiple gestations o Intrapartum complications Build on core knowledge of: o Normal and abnormal labor o Medical complications of pregnancy

Page 50 of 185

o o o o

Antenatal testing modalities for fetal well-being Intraoperative techniques and core knowledge of pelvic anatomy Types of anesthesia appropriate for pain control Postpartum care

Patient Care

Take a targeted history and perform a relevant physical on the obstetrical patient who presents to triage Appropriately triage patients who present for urgent evaluation and labor checks Identify and manage these obstetrical complications: o Hypertension and preeclampsia o Intrauterine growth restriction o Third trimester bleeding o Postdates pregnancy o Oligohydramnios o Polyhydramnios o Incompetent cervix o Nonvertex presentation at term o Nonreactive nonstress test o Abnormal biophysical profile o Positive contraction stress test o Abnormal Doppler velocimetry Perform: o External cephalic version o Delivery of multiple gestations by cesarean section or vaginal delivery o Vacuum delivery o Repeat low transverse cesarean delivery o Classical cesarean delivery o Neonatal resuscitation o Appropriate interventions for an abnormal fetal heart rate pattern o Appropriate labs and diagnostic tests for complicated patients Prescribe o Tocolytics o Postpartum analgesia

Interpersonal and Communication Skills

Communicate with attendings and the team regarding patient status and plan for patients evaluated in triage Provide patients and their families regarding management in the triage setting Counsel patients in regards to: o Prolonged bed rest o Common antepartum conditions such as preeclampsia and PPROM o Normal physiological changes after a vaginal birth o Normal hospital course after a cesarean section o Use of vacuum at the time of delivery

Page 51 of 185

Professionalism

Deliver the diagnosis of fetal demise or fetal distress in an understandable manner Demonstrate sensitivity to the patients needs during a prolonged hospitalization Assess the social situation and needs of a patient preparing for discharge

Practice Based Learning

Increase awareness of preauthorization for medical services provided Understand appropriate use of new technology in the treatment and management of preterm labor Enhance student involvement in patient care Become more aware of ACOG resources that outline acceptable medical practices Use consultative services to improve patient care

System Based Practice

Increase awareness of the supportive services for patients who have experienced a perinatal loss Understand the admission criteria for Level I, II, and III nursery Understand the difference between a Level I, II and III hospital facility Increase awareness the cost of maternal care versus neonatal care Understand the cost of a cesarean section versus a vaginal delivery to the patient and society

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to c omputers in addition to the major text books that are given to the residents at the start of their residency. Fetal heart rate monitoring strips are reviewed throughout the rotation. Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am. (Night Float residents usually conclude at 8am per work hour rules.) Daily sign-outs at 7AM and 5:30PM.

Reading Assignment: Williams Obstetrics by Cunningham, 22nd Edition. Cha pters: 11, 14, 16, 19, 22, 26, 29, 3441, 43 Operative Obstetrics by Gilstrap, 2nd edition. Chapters: 9, 14-17, 22-26, 34-36 ACOG Committee Opinion: #6, 8, 13, 17, 29, 37

Page 52 of 185

C. PGY 3 The PGY 3 oversees the obstetrical service in consultation with the 4th year and attendings. The 3rd year performs complex cesarean sections and appropriate operative vaginal deliveries. During the Night Float portion of the rotation, the 3 rd year works with the intern to complete ED consults and management the gynecology floors. The 3rd year is responsible for the weekly case list of patients presented to faculty for weekly Morbid and Mortality conference. Medical Knowledge

Build on core knowledge of: o Normal obstetrics o Disease processes that adversely affect pregnancy o Disease processes that pregnancy adversely affects o Methods of antenatal testing of fetal well-being o Obstetrical complications of pregnancy

Patient Care

Provide risk appropriate care for patients with medical conditions including: o Cardiovascular disease o Collagen vascular disease o Neurological conditions o Diabetes o Antiphospholipid syndrome o Thrombotic events Provide appropriate antepartum care for pregnancies complicated by fetal anomalies such as: o Fetal arrhythmias o Intrauterine growth restriction o Twin-twin transfusion syndrome o Isoimmunization o Hydrops immune and non-immune o Poly- and oligohydramnios Identify and manage these obstetrical complications: o Umbilical cord prolapse o Vasa previa o Placenta previa o Placenta accreta o Fetal death in utero o Wound dehiscence Perform o Outlet forceps delivery o Complicated cesarean delivery Prescribe: o Tocolytics o Insulin

Page 53 of 185

Interpersonal and Communication Skills

Counsel patients in regard to: o Management options for parents with a periviable fetus o Initial grief counseling for a fetal loss o Management plans for their pregnancy o Diabetic diet education o Insulin injection o Hypoglycemic reaction o Management of hyperemesis o How a specific disease state impacts pregnancy Continue to improve communications with anesthesia, neonatology, and the charge nurse

Professionalism

Increase awareness of racial disparities in obstetrical outcomes Coordinate transfers from other hospitals to UTMB

Practice Based Learning

Continue to use online services to research clinical questions Critique a research article Access the CDCs website regarding womens health care policies, such as guidelines for treating GBS, hepatitis B prophylaxis, etc Increase awareness of patients rights as a research subject

System Based Practice

Understand the role of the quality assurance committee Identify discharge coordinator and work with the individual to assure patient has appropriate needs at home Become aware of the hospital utilization review process and how it impacts patient care.

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major textbooks that are given to the residents at the start of their residency. Fetal heart rate monitoring strips are reviewed throughout the rotation. Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am. (Night Float residents usually conclude at 8am per work hour rules.) Daily sign-outs at 7AM and 5:30PM.

Reading Assignment: Williams Obstetrics by Cunningham, 22nd Edition. Chapters: 3, 9, 20, 21, 27, 28, 38, 44, 47, 51-55.

Page 54 of 185

Operative Obstetrics by Gilstrap, 2nd edition. Chapters: 6, 16-18 ACOG Practice Bulletin: #12, 30, 31, 33

D. PGY 4 The PGY 4 is responsible for overseeing the antepartum, postpartum and intrapartum services. The 4th year instructs lower levels in staff cases and provides education of junior residents in the operating room. During the Night Float portion of the rotation, the 4th year oversees any gynecology issues that arise. Medical Knowledge:

Develop a core knowledge of critical care in obstetrics Build on core knowledge of: o Normal obstetrics o Disease processes that adversely affect pregnancy o Disease processes that pregnancy adversely affe cts o Antenatal testing of fetal well-being o Obstetrical complications of pregnancy o Basic ultrasound skills

Patient Care:

Perform: o Forceps assisted vaginal deliveries o Repair of third and fourth degree perineal tears o Amniocentesis for fetal lung maturity o Cesarean hysterectomy o Cervical cerclage Demonstrate and refine the skills learned during previous years Manage the high risk obstetrical service in an organized and efficient manner Coordinate the care for all patients on the antepartum service with the appropriate junior resident Coordinate the care for all patients on the postpartum service with the appropriate junior resident Demonstrate leadership skills with the junior level residents and medical students Coordinate care for any patient in the intensive care unit Identify and manage these postpartum complications: o Septic pelvic thrombophlebitis o Episiotomy infection and/or breakdown o Eclampsia o Pulmonary or cardiovascular compromise

Interpersonal and Communication Skills:

Refine communication skills with the patient and her family

Page 55 of 185

Refine communication skills with the medical staff Develop leadership skills in patient management Take a leadership role in medical student and junior resident education Assure a complete sign-out to the covering team to provide excellent continuity of care

Professionalism:

Demonstrate a commitment to excellent patient care Demonstrate passion for the practice of medicine and patient care Refine ethical principles in patient care

Practice Based Learning:

Understand the role of university risk management Acquire basic knowledge of medical malpractice and the components of a lawsuit Identify patients with an untoward outcome and review their care Prepare discussion of untoward outcomes at mortality and morbidity conference Continue to use resources to improve self directed learning

System Based Practice:

Become familiar with home health care agencies and the services they can provide for patients at home Review antenatal nursing protocols and understand the impact these protocols have on your clinical practice. Familiarize yourself with treatment options in the community for patients who are dependant on drugs

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency. Fetal heart rate monitoring strips are reviewed throughout the rotation. Residents attend Wednesday morning Morbidity and Mortality Conference, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am. (Night Float residents usually conclude at 8am per work hour rules.) Daily sign-outs at 7AM and 5:30PM.

Reading Assignment: Williams Obstetrics by Cunningham, 22nd Edition. Chapters: 7, 10, 11, 13, 24, 25, 31, 42, 44, 46, 56-59. Operative Obstetrics by Gilstrap, 2nd edition. Chapters: 10, 12, 14, 18-20, 24, 25, 27-28 ACOG Practice Bulletin: #38

Page 56 of 185

Obstetrical Service Policies ________________________________________________________________________ Policy A: Post Partum Tubal Ligations, effective 5/1/2005 1. First and second year residents will be allowed to perform tubal ligations unassisted at such time as they are deemed to possess appropriate skill level to do the operation. It is mandatory that the faculty staffing the case be present from incision until both tubes have been identified and segments removed and hemostasis assured. Only third year residents and higher are credentialed to operate on women at high risk for complic ations from postpartum tubal ligations. Specifically, the following patients require a third year resident or higher to be scrubbed for the entirety of the case: a. Women weighing greater than 200 pounds. b. Women who have had any prior intraabdominal surgery to include open surgery or laparoscopic surgery.

2.

The authority to override this policy resides only with the Chief of the Obstetrical Service or the Chairman of the Department of Obstetrics and Gynecology. The policy is expected to be followed absolutely and with no deviation. Policy B:, Use of the Domicile and performance of ultrasound examinations, effective 5/3/2006 1. When performing a sonosite (in clinic or in L&D setting), you need to type the patient's name in the USG machine and be sure there is a patient sticker on the report. This is a medical document needs to be accurate for potential legal issues. In patients who are admitted to the Domicile, please be sure the computer admission orders include medication (dose and frequency), clinic follow-up [(specify within what time period (should be 1 week)]. These patients should be followed -up by the antepartum upper -level residents or Maria Patawaran. The Domicile is currently staffed by nurses' aids and an RN on a part -time basis, so do not expect complicated medication management in this setting.

2.

Policy C: Faculty Presence in OB Surgical Procedures, Effective 7/12/06 Faculty must be in the room for the critical parts of all obstetrical operative procedures, as well as at the time of initial surgical incision. In life threatening emergencies the resident may proceed, but the faculty should be summoned stat. When general anesthesia is anticipated the faculty must be present when the anesthesia is being induced. ________________________________________________________________________ Policy D: Cleanliness and Professionalism, Effective 2/7/2007 Please help me make our unit and our behavior more professional via the following: 1) No eating or drinking on the L&D unit outside of the resident lounge or the break room. 2) No coats, jackets, books, etc. out on the L&D unit. Leave them in the lounge please. 3) If you see trash, please pick it up. If you see someone drop trash, ask them not to! 4) Enforce the above rules with our students.

Page 57 of 185

5) Keep your lounge clean and neat! Policy E: Consultations to other services, effective 4/18/2007 No consultations to other services are to be placed until such time as the responsible faculty writes a note approving the consultation. Additionally, the consultations will be tracked by individual faculty/fellow and the necessity for consultations will be evaluated to insure the utilization is proper. The exception to obtaining consultations would of course be in emergency circumstances when consultation can be done immediately and doe s not need to be delayed if it is in fact, a legitimate emergency. UTMB Protocol for Management of HIV-infected (confirmed) pregnant womEn and Newbons (VERSION 5/11/2010) (FOR MANAGEMENT OF IN DETERMINATE WOMAN/INFANT, SEE SECTION I.) A. Identification/Re ferral by Obstetrics Providers: As per the Texas Department of Health guidelines, all pregnant women will be counseled and offered testing for HIV at the very first contact with a clinician (inpatient or outpatient), and at delivery. For additional information on HIV testing at delivery see Section G. Review HIV results in a timely fashion. Review positive results with the patient. Refer all women to Maternal Child HIV Clinic (Childrens Hospital): Call 409-772-1459 or 409772-2798 for appointment, and FAX clinical and laboratory information to 409-747-1753. If women are hospitalized during pregnancy or labor, please call the Pediatric Infectious Disease Faculty On-Call through UTMB page operator: 409-772-1011 for inpatient consult. Refer all women to one of the following UTMB Maternal Fetal Medicine service clinics listed below: rd a. Galveston: Complicated Ob Consult Clinic in the UHC building, 3 floor on Wednesdays and Thursdays. An appointment can be made by calling 409-772-9507 or by faxing a consult to 409-747-6555. b. Regional Maternal Child Clinics in Pasadena (phone 713-473-5180), Texas City (409643-8359) and Stafford (281-499-3004) have High Risk Ob Clinics. As with any other abnormal critical lab test, the follow up of patients with positive results must be confirmed and documented. B. Evaluation by Maternal Fetal Medicine OBGYN during pregnancy: Discuss and begin treatment (see treatment options in Section D) Discuss delivery options: Discuss risks and benefits of c-section: (current published data suggests reduction of transmission from 3%-8% without c-section (antiretroviral treatment with zidovudine) to 2%-3% if combined with elective (non-urgent) c-section. At UTMB, the rate of transmission is less than 1% even without routine c-section when two or more medications rather than zidovudine (ZDV, also known as AZT) alone are used. Other recent studies have shown similar results, ie. women on combination antiretroviral medications have no added advantage of c-section.

Page 58 of 185

Discussions and informed consent regarding delivery route are discussed and documented. Some authorities suggest neonatal benefit from C -section delivery of women with HIV whose viral loads are greater than 1,000 copies per milliliter. This issue should be included in the discussions re garding route of delivery. The benefit of elective C -section in patients who have recent (within the last month) viral loads of less than 1,000 copies per milliliter is not currently demonstrated. Any final decision regarding recommended route of delivery should take into consideration patient choice, obstetric considerations, and available data and research regarding viral load and HIV disease state as they relate to perinatal viral transmission risk. At this time, it is reasonable to offer scheduled c-section at term as a delivery option for patients with a HIV-1 RNA viral load (near term) of >1,000 copies/mL. Amniocentesis may increase the risk HIV transmission. This risk should be discussed if amniocentesis is possibly indicated. If possible, amniocentesis should be done while the woman is on effective anti-HIV treatment. Evaluation for cervical dysplasia (if appropriate) Serologic evaluation - RPR, hepatitis B and C. Obtain consent for tubal ligation for family planning, if desired All pregnant women should be referred to the Maternal Child HIV Clinic (Pediatrics). Subsequent referral to the AIDS Care and Clinical Research Program (Internal Medicine), formerly known as Adult Virology Clinic, will be coordinated by the Maternal Child HIV Clinic.

C. Evaluation by Maternal Child HIV Clinic (Pediatrics): The Maternal Child HIV Clinic is staffed by specialists from the Division of Pediatric Infectious Diseases. The clinic is held Monday and Thursday mornings (currently in Texas City). On an individual basis, women may also be evaluated on other days when they have appointments with other specialists. Appointments can be made by calling 409-772-1459 or 409-772-2798. Obtain history, including risk factors, treatment history, and perform psychosocial evaluation. Counsel women regarding treatment efficacy, and diagnostic and therapeutic issues of the newborn. Ensure adherence to the principles of treatment (Section D). Discuss future fertility options. Assist in tubal ligation if desired by women. Assist women in TDC with child placement and future evaluation in conjunction with social workers and mothers. Refer all virological/immunologically complicated pregnant women to the Adult AIDS Care and Clinical Research Program (ACCRP) at UTMB for additional evaluation during pregnancy, or if uncomplicated, refer all women after delivery to ACCRP or other HIV clinics. Counsel each patient regarding the risks and benefits of anti-HIV prophylactic therapy to prevent perinatal HIV transmission. Also, counsel each patient regarding issues relating to long-term antiviral therapy of HIV. Prescriptions for the medications will be given as per treatment options in Section D. Vaccination for influenza, Hepatitis B and Pneumococcus should be considered during pregnancy for all HIV positive patients. Obtain additional serologies such as toxoplasma (IgG/IgM), CMV (IgG) on a case-by-case basis. Depending on the complexity of the HIV disease and the ability of the women to handle multiple visits with many specialists, the women will be referred to AARCP to see the adult HIV specialist during pregnancy. After delivery, all women will be referred to AARCP for their longterm care. For women who reside in distant communities, the clinic social worker will make arrangements for housing at the UTMB Domicile to facilitate delivery at UTMB if allowed by the patient

Page 59 of 185

See all newborns at birth, obtain diagnostic blood samples, initiate treatment, and arrange outpatient follow-up.

D. Principles of treatment during pregnancy: MATERNAL FETAL MEDIC INE AND/OR HIV SPECIALIST SHOULD CONSIDER TREATMENT OPTIONS AT THE FIRST VISIT WITH HIV-POSITIVE RESULTS. OUTSIDE PROVIDERS REFERRING PATIENTS SHOULD DISCUSS PRECONSULTATION TREATMENT WITH MATERNAL FETAL MEDICINE (409/7722222) AND/OR MATERNAL CHILD HIV PROGRAM (409/772 -2798) IF IT IS FELT THAT TREATMENT INITIATION WOULD OTHERWISE BE APPRECIABLY DELAYED. TREATMENT OPTIONS GENERALLY INC LUDE: Treatment decisions should be made through patient consultation with the Maternal Child HIV Program and/or Maternal Feta l Medicine Standard treatment in pregnancy includes combination of three antiretroviral agents. Generally, ZDV should be included as a component of treatment, unless medically or virologically contraindicated. All patients will be evaluated insofar as suitability for multi-drug highly active anti-retroviral therapy (HAART). Multi-drug treatment may include combinations of two reverse transcriptase inhibitors such as ZDV/lamivudine (300 mg/150 mg, also known as Combivir) and a protease inhibitor. o At UTMB, typically Combivir (ZDV + 3TC) dose of one tablet PO BID is combined with Kaletra (lopinavir 200 mg + lopinavir 50 mg), a protease inhibitor at dose of 2 tablets PO twice daily. In third trimester, if viral load is still detectable, the dose can be increased to 3 tablets twice daily. o Nelfinavir, a protease inhibitor, is an option for women who cannot tolerate Kaletra. Non-nucleoside reverse transcriptase inhibitors, such as nevirapine and efavirenz, should be avoided in pregnancy. Treatment options for any given patient are based upon: o Virologic consideration o Patient choice and treatment expectations o Consideration of complications and side-effects The goals of therapy are: o To minimize the risk of perinatal transmission of HIV o To limit pregnancy-associated co-morbidity from HIV infection and sequelae o To provide the best effective regimen for a particular patient o To lower maternal viral load as effectively as practicable Obtain maternal blood sample for antiretroviral resistance by phenotypic assay at the first visit. Treatment may begin with the above standard agents prior to the results of resistance testing. Treatment may be later modified based on test results. Monitor viral load and CD4: o Prior to initiation of therapy o Repeat at 28 weeks gestation and at 36 weeks gestation. Viral load results to be included in a given patient's consideration of route of delivery. o Consider viral load evaluation for admissions between 20-28 weeks gestation for which preterm delivery is likely o Viral load and CD4 testing should generally NOT be obtained if within 4 weeks of immunization

Page 60 of 185

E. Principles of treatment during Labor: For women at term, delivery prior to onset of labor by c-section is to be considered (see section B): o Some authorities recommend that elective c-section delivery be offered to HIV positive pregnant patients at 38 weeks gestation. This recommendation should be discussed with the patient and taken in overall context when planning an elective delivery (see Section B, second item). If elective c-section is performed, ZDV is generally used for reduction of intrapartum transmission 2 mg/kg/IV load over one hour - followed by continuous infusion of 1 mg/kg/hr IV. Infusion should begin 3 hours prior to planned delivery if obstetrically feasible. If vaginal delivery is attempted (or if obstetric considerations dictate c-section of patient in labor), ZDV to be initiated (as described for elective c-section) as soon as practicable after patient is diagnosed in active labor or felt to be near delivery Patients admitted and treated for preterm labor should generally receive IV ZDV treatment concomitant with any decision to begin active pharmacologic tocolysis. If tocolysis is successful and delivery is not deemed imminent, IV ZDV can be discontinued and oral therapy can be resumed. Unless medically necessary to discontinue it, other anti-HIV therapy should NOT be discontinued while the patient is in labor or is admitted for delivery. As a general rule, oral therapy is to be continued. If oral ZDV is part of a particular patients regimen, then it may be held during IV ZDV therapy. Other medications are to be continued unless particular contraindications exist. Premature rupture of amniotic membranes may negate the reduction of vertical transmission noted with intrapartum ZDV use. Preterm patients who present with ruptured amniotic membranes (PPROM) should be counseled on an individual basis regarding treatment without delivery, preterm delivery, and route of delivery. Data are not presently clear regarding best management in such patients. IV ZDV will generally be used as the intrapartum prophylactic treatment of choice. Individual patients may, in certain cases (hypersensitivity to ZDV, virologic sensitivity, drug history, availability of new scientific evidence, etc), may be candidates to alternative therapy. If alternative intrapartum therapy is used, documentation and delineation of rationale for use is advisable. In term patients in labor, the effects of length of labor, the presence and length of rupture of amniotic membranes, and the effect of number of vaginal digital examinations is not presently clear. However, as obstetrically feasible, the following should be considered in patients attempting vaginal delivery: o Labor should receive active management o The interval between rupture of amniotic membranes and delivery should be as short as safely possible o Delivery route (vaginal vs. elective c -section) as discussed and planned with patient (see Section B) o Avoid fetal scalp electrodes and any procedure that might expose fetus to maternal blood (or might result in skin trauma to the fetus) Postpartum tubal ligation or cogent family planning method. Refer women to the AIDS Care and Clinical Research Program (Adult Virology/HIV Clinic) for follow-up. Notification of Pediatric HIV Infectious Disease Service (via formal consult) is to be performed on any HIV patient admitted for antepartum or delivery care. Consultation with the Pediatric HIV

Page 61 of 185

Infectious Disease Service will facilitate optimal interaction and follow -up of the mother-infant pair post delivery. F. The AIDS Care and Clinical Research Program (ACCRP) at UTMB: During pregnancy, the Maternal Child HIV Clinic will refer all virologically/ immunologically complicated women to ACCRP. All women will be referred to ACCRP or other HIV clinics for HIV care after delivery G. INTRAPARTUM TESTING FOR HIV: INTRAPARTUM HIV TESTING IS TO BE OFFERED TO EVERY PREGNANT PATIENT ADMITTED FOR DELIVERY IF TEST RESULT FROM THIRD TRIMESTER UNAVAILABLE FOR REVIEW (VERBAL RESULT IS NOT ADEQUATE). NO WRITTEN CONSENT IS NECESSARY. MEDICAL RECORDS WILL DOCUMENT THE REASONS FOR REFUSAL OF TEST WHEN APPLICABLE. MEDICAL RECORDS WILL DISCUSS THAT PRELIMINARY RESULTS OF POSITIVE TEST HAS BEEN PROVIDED. HIV ELISA TEST WILL BE PERFORMED ON 24 HR/7DAYS BASIS FOR SAMPLES ORDERED FROM LABOR AND DELIVERY AND REPORTED WITHIN 6 HOURS. HIV ELISA WILL BE CONFIR MED BY WESTERN BLOT OVER THE COURSE OF A PROCESS THAT TAKES AN ADDITIONAL 24-72 HOURS. ALL POSITIVE HIV ELISA TEST RESULTS WITHOUT CONFIRMATORY TESTS WIL L BE LABELED PRELIMINARY POSITIVE AND WILL BE ENTERED INTO THE ELECTRONIC MEDICAL RECORDS. THE LABORATORY WILL ALSO REPORT THE SIGNAL/CUT-OFF (SC) RATIO FOR THE CURRENT VITROS ASSAY PLATFORM. A VALUE OF 30 OR ABOVE WILL BE CONSIDERED STRONGLY SUGGESTIVE OF HIV INFECTION, WHILE A VALUE OF 10 OR LESS IS SUGGESTIVE OF INDETERMINATE TEST. A VALUE OF BETWEEN 10-30 COULD BE CONSIDER ED HIGH RISK FOR HIV, ALTHOUGH THERE IS INSUFFICIENT DATA. THIS SC VALUE CAN ASSIST IN DETERMINATION FOR HIV TREATMENT OF THE MOTHER AND THE CHILD, C-SECTION DELIVERY, AND BREASTFEEDING OF THE INFANT. FALSE POSITIVE ELISA RESULTS SEEN WITH LOW SC VALUES MAY EVENTUALLY BE FOUND TO BE TRUE POSITIVE, OR AFTER REPEATED TESTING TO BE FALSE POSITIVE. PRELIMINARY POSITIVE HIV ELISA TESTING WILL BE REPORTED BY PHONE BY THE LABORATORY STAFF TO THE APPLICABLE OBGYN FACULTY-ON-DUTY IN LABOR AND DELIVERY (409/643-9902) AND THE PG4 RESIDENT-ON-DUTY IN LABOR AND DELIVERY (409/645-5064) AT THE TIME THE REPORT IS AVAILABLE. AS A BACKUP, THE LAB WILL BE GIVEN THE LABOR A ND DELIVERY MAIN NUMBER (409/772-2891) WITH INSTRUCTIONS TO RELAY INFORMATION TO THE OBGYN CHIEF RESIDENT ON-CALL AT THIS TIME. THE OBGYN FACULTY RE CEIVING THE INFORMATION WILL INSTRUCT THE OB CARE TEAM ON-DUTY TO UNDERTAKE THE FOLLOWING STEPS: THE REFERENCED PATIE NT IS NOTIFIED OF THE PRELIMINARY NATURE OF HER POSITIVE RESU LT

Page 62 of 185

 IF THE PATIENT IS UNDELIVERED, THE PRELIMINARY RESULT, THE AVAILABILITY OF THE FINAL RESULT, AND THE OBSTETRIC MANAGEMENT ISSUES GERMANE TO HIV TESTING WILL BE DISCUSSED BY THE OB CARE TEAM TREATING THE REFERENCED PATIENT. ANY ALTERATIONS IN MANAGEMENT WILL BE DOCUMENTED AND DISCUSSED. THE NEONATAL NURSERY CHARGE NURSE WILL BE NOTIFIED (409/7722025) OF THE PRELIMINARY POSITIVE RESULT THE PEDIATRIC INFECTIOUS DISEASE TEAM WILL BE FORMALLY CONSULTED ON A 7-DAY BASIS: ON WEEKDA Y WORKING HOURS, CALL THE OFFICE AT 409/772-2798; AT OTHER TIMES CALL THE UTMB PAGE OPERATOR AT 409/772-1011 TO CONTACT THE ON-CALL FACULTY. THE TEAM WILL PROPERLY COUNSEL THE MOTHERS REGARDING THE IMPLICATIONS OF THE PRELIMINARY POSITIVE RESULTS, POSSIBLE TREATMENT OPTIONS, A ND SUBSEQUENT CLINIC FOLLOW-UP OF THE MOTHER AND HER NEWBORN. H. NEWBORN NURSERY/ISCU: See Section K for management algorithm Consultation: All newborns of HIV-positive mothers (true, indeterminate, or preliminary positive) will be referred to the Pediatric Infectious Disease team by the newborn nursery within 6 hours of delivery on a 7-day basis: o During weekday working weekday hours, fax the consult to the division office (x71753) o At other times, contact the on-call faculty by pager. Laboratory tests: The following blood samples will be collected after the Pedi ID team has been notified and is available to pick up the samples: o 1 pearl top or purple top 1.5 ml (for HIV viral load assay). Pearl white top tube is preferred, if available. Purple top tube can be used if pearl white tube is not available, however, it must be received by the laboratory within 1 hour of blood draw. If possible, do not draw this sample on the weekend. o 1 purple top - 0.3 ml for CBC (to check for anemia secondary to zidovudine) o 1 red top - 0.5 ml (for HIV ELISA antibody)- this is an optional test and can be omitted if the blood sample is insufficient. During weekdays, the Pedi HIV team will deliver the HIV viral load sample to the laboratory. On long weekends and holidays, the Pedi HIV team may decide to forgo HIV testing altogether in the nursery, and obtain them within 2 weeks of birth in the clinic Treatment: Zidovudine (ZDV or AZT): o Full term b abies: Begin oral ZDV at 2 mg/kg/dose q 6 h within 8 hours of birth for six weeks. IV dose is 1.5 mg/kg/dose q 6 h. o Premature babies: ZDV dosing for infants < 35 weeks gestation at birth is 1.5 mg/kg/dose IV, or 2.0 mg/kg/dose PO, every 12 hours, advancing to every 8 hours at 2 weeks of age if > 30 weeks gestation at birth or at 4 weeks of age if < 30 weeks gestation at birth. o HIV medications can be given before the collection of HIV test samples.

Page 63 of 185

Additional HIV medications: Some babies may require medications other than or in addition to ZDV. Circumstances requiring the second agent include inadequate or no treatment, advanced maternal AIDS, poor virologic control, complicated obstetric course, etc. o The usual second agent is nevirapine (also know as Viramune) at 2 mg/kg single oral dose. An alternative is lamivudine (also known as Epivir or 3TC) at dose of 2 mg/kg/dose BID or q 12 h x 4 weeks. o In case of suspicion for multidrug-resistant HIV in the mother, Kaletra (combination of lopinavir 80 mg & ritonavir 20 mg/ml) may be used in place of nevirapine. The dose of Kaletra is 300 mg lopinavir per m2 of body surface area PO twice daily x 4 weeks. Discharge: The nursery staff will ensure that the babies are discharged home with a full 6 -week supply of zidovudine from the UTMB pharmacy (as already agreed upon by the pharmacy). Do not give prescriptions to purchase zidovudine at outside pharmacies. The Pediatric HIV team will give the follow -up appointment prior to discharge. It will also coordinate referrals to other clinics, if necessary. A discharge instruction sheet will be given to the family by the Pedi ID team regarding the duration of zidovudine treatment (6 weeks), CBC testing at 2-3 weeks, and follow -up clinic appointment (usually 2 months). I. MANAGEMENT OF PREGNANT WOMEN AND NEONATE WITH INDETERMINATE HIV TESTS aN indeterminate HIV test is a fully completed HIV profile in which the final result is reported as indeterminate.

In general, HIV Elisa test can produce false positive results due to pregnancy and other disease conditions. It occurs at 1-2% of all tests conducted. However, 1% of women with such results may belong to women who have been recently infected with HIV- such women will eventually fully convert to positive HIV test. In order not miss women with indeterminate test who may be actually infected (converting to fully positive), proper evaluation needs to take place. Furthermore, even if the women have false positive test (no HIV), this needs to be ascertained by careful follow-up because similar results could occur in future pregnancies. The following general schema of management is recommended.

Page 64 of 185

CHECK LIST Mother (pregnant woman): Current gestation: ___________________ Dates of all HIV tests and results in this pregnancy: __________________________________________ _________________________________________________ _________________________________________________ __ Dates and results of HIV tests before current pregnancy: _______________________________________

__________________________________________________ Social history: HIV + partner: Yes / No / Unknown Ongoing substance abuse: Yes / No / Unknown Multiple or new sexual partners in pregnancy: Yes / No / Unknown Adequate prenatal care: Yes / No / Unknown Other high risk social behavior: ________________________

After completing the above checklist, please apply the algorithm on the next page.

Page 65 of 185

J. PREGNANCY: Indeterminate HIV test in pregnancy (Positive HIV ELISA but W. blot indeterminate)

Partner known HIV positive

No or unknown

Yes
Indeterminate test in prior pregnancy Yes

No

< 24 weeks gestation

> 24 weeks gestation

Repeat HIV ELISA in 2 months

Repeat in 2 months or at 28 weeks gestation, whichever earlier

Indeterminate or negative

Negative

Indeterminate

Positive test (confirmed W. blot)

High risk behavior - Multiple sexual partner in pregnancy - History of substance abuse - Poor prenatal care

No

Yes Consult Maternal-Child HIV Clinic (Pediatric) Phone: 409 -772-2798 FAX: 409-747 -1753

No HIV treatment Repeat test in third trimester and at delivery Refer to Protocol for test at delivery

Page 66 of 185

K. HIV MANAGEMENT ALGORITH FOR NEWBORNS Positive Maternal HIV ELISA at Delivery Preliminary result available within 6 hrs Previous confirmed positive HIV test

No Previous indeterminate test in current or prior Yes No

Yes

Yes

Prior negative HIV test in current pregnancy; AND HIV ELISA SC value < No

Lack of multiple sexual partners in current pregnancy

Yes

No Neonate: HIV test and treatment to be considered Treatment to begin within 12 hours of life Avoid breastfeeding Consult Pediatric ID/HIV team within 12 hours Office Phone: 409-772-2798 Pager: Call operator (nights and weekends) FAX: 409-747-1753

Neonate: No further test or treatment No further HIV follow -up May breastfeed Mother (contact Obstetric team): Order HIV viral load test Counsel and reassure mother about the likely false positive test Repeat HIV ELISA within 1

Follow -up maternal W. blot result when available. If positive, refer to Pedi ID/HIV Team

Page 67 of 185

L. Key Contacts:
MATERNAL CHILD HIV PROGRAM PEDIATRICS JANAK A. PATEL, M.D. ; PROGRAM DIRECTOR - MAIN CONTACT PHONE: (409) 772-2798; PAGER: 409-643-3063; FAX: (409) 747-1753 HIV PROGRAM COORDINATOR: PHONE: (409) 77 2-1459 OBSTETRICS TONY WEN, M.D.; PROGRAM FACULTY - MAIN CONTACT PHONE: (409) 772-2898; FAX: (409) 772-5297 MATERNAL FETAL MEDIC INE: (409) 772-2222 AIDS CARE AND CLINICAL RESEARCH PROGRAM (UTMB ADULT VIROLOGY/HIV CLINIC) PHONE: (409) 747-8769 FAX: (409) 7 72-6527

Gynecology
A. PGY 1 The gynecology rotation is a six to seven week block. Interns provide coverage of the gynecology floors, take consultations from the emergency room and assist on appropriate cases in the operating room. The Intern takes Saturday ER call.

Medical Knowledge

Develop a core knowledge of: o Contraceptive options o Gynecological emergencies o Infections that primarily affect the vagina and vulva o Physiology of a normal menstrual cycle o Pelvic anatomy o Types of abortion o Sterile technique o Informed consent process o Normal postoperative care o Postoperative pain management Differentiate between types of abortions o Threatened o Incomplete o Complete o Inevitable o Septic Recognize an intrauterine pregnancy, an ectopic pregnancy and adnexal mass on ultrasound Interpret BHCG results in normal and abnormal pregnancy

Page 68 of 185

Patient Care

Perform: o Pelvic exams o Pap smear o Wet prep o pH of the vagina o Suction Dilation and curettage o Insertion of Ward catheter o Diagnostic hysteroscopy o Diagnostic laparoscopy o Laparoscopic bilateral tubal ligation o Cervical conization (LEEP) Prescribe: o Medical contraception o Patient controlled analgesia o Medical therapy for an ectopic pregnancy

Interpersonal and Communication Skills

Counsel patients regarding: o Safe sex o Sexually transmitted disease o Family planning o HIV testing Provide an adequate check out to the on call team to ensure excellent patient care Provide care to the sexually assault patient in a emotionally sensitive manner

Professionalism

Demonstrate sensitivity to patients anxiety regarding a pelvic exam Become tolerant of value systems different than your own

Practice Based Learning

Obtain an informed consent Dictate operative notes and discharge summaries Practice proper sterile technique

System Based Practice

Become familiar with the criteria for inpatient versus outpatient surgery Increase awareness of the cost of surgical versus medical options for treating a disease such as fibroids and ectopic pregnancies Understand the legal issues involved in gathering evidence after sexual assult

Page 69 of 185

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency. Residents attend Wednesday morning Morbidity and Mortality Conference, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am.

Reading assignments Comprehensive Gynecology, 5th edition: Chapters 14, 16-17,22 ,24 ,25 Te Lindes Operative Gyneco logy, 9th edition: Chapters 5, 21, 23, 45 ACOG Committee Opinion #357 ACOG Practice Bulletin #45 B. PGY 2 The gynecology rotation is a six to seven week block. The PGY-2 assists the intern with floor calls and Emergency Department consultations. The 2nd year takes Sunday ER/Ward call. Medical Knowledge

Develop a core knowledge of: o Premalignant lesions of the female reproductive tract o Abdominal surgery principles o Operative hysteroscopic procedures o Laser principles o Operative laparoscopic surgery principles o Preoperative evaluation of healthy patients Build upon core knowledge of: o Gynecological emergencies o Normal and abnormal pelvic anatomy o Postoperative management

Patient Care

Perform: o Laser surgery of the external genitalia o Abdominal hysterecto my and bilateral salpingo-oophorectomy o Laparotomy o Operative Laparoscopic procedures o Perform colposcopy in the patient with vulvovaginal or cervical dysplasia o Transvaginal sonography

Page 70 of 185

Interpersonal and Communication Skills

Provide adequate sign-out for gynecology patients to the cross covering team at night Communicate with referring physicians Communicate with consulting services

Professionalism

Understand the anxiety of a patient with a prior poor obstetrical outcome Refine your skills in dealing with difficult patients

Practice Based Learning

Increase awareness of the hospital formulary drugs Demonstrate an understanding how to schedule patients for surgery Dictate operative notes and discharge summaries in a timely fashion

System Based Practic e

Recognize insurance requirements for elective and emergency hospitalizations Understand goals of utilization review

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that a re given to the residents at the start of their residency. Residents attend Wednesday morning Morbidity and Mortality Conference, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am

Reading assignments Te Lindes Operative Gynecology, 9th edition: Chapters 15-17, 26, 28, 31 ACOG Technology Assessment #4 ACOG Practice Bulletin #3, 11, 14, 15, 67, 72

C. PGY 3 The gynecology rotation is six to seven weeks in length. The PGY 3 supervises the lower levels and together they cover the floors. The 3 rd year completes floor consultations. The 3rd year first assists on appropriate OR cases. The 3rd year is responsible for the weekly case list of patients presented to faculty for weekly Morbid and Mortality conference. Medical Knowledge

Expand on a core knowledge of: o Surgical management of chronic pelvic pain Page 71 of 185

o o o o o o o

Surgical management of abnormal uterine bleeding Premalignant lesions of the female reproductive tract Laser principles Laparoscopic surgery principles Preoperative preparation for surgery Common postoperative complications Pelvic anatomy

Patient Care

Perform: o Operative hysteroscopy o Complex total abdominal hysterectomy o Complex laparotomy for adnexal masses and endometriosis o Laparoscopic management of ectopic pregnancy o Endometrial ablation o Vaginal hysterectomy o Transvaginal sonography

Interpersonal and Communication Skills

Communicate effectively with services requesting gynecology consult Provide an adequate check out to the on call team to ensure excellent patient care and adequate continuity of care

Professionalism

Accept teaching responsibility of the junior members of the team Accept teaching responsibility of third year students Accept constructive criticism to improve surgical skills

Practice Based Learning

Increase awareness of ACOG resources regarding standards of practice Use online services to research clinical questions Teach junior residents and medical students

System Based Practice

Increase awareness of national health initiatives Increase awareness of hos pital utilization Demonstrate an understanding between costs of inpatient versus outpatient procedures

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency.

Page 72 of 185

Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am

Reading assignments Comprehensive Gynecology, 5th edition: Chapter 19 Te Lindes Operative Gynecology, 9th edition: Chapter 20, 27 ACOG Committee Opinion #243, 278, 293, 311, 323, 334, 337, 345 ACOG Practice Bulletin #7, 16, 21, 51, 63, 66, 69, 74 D. PGY 4 LOCATION: ROBOTICS -SAN ANTONIO This rotation is currently being developed and will be updated as more information becomes available. The main purpose is to educate and train residents in the use of robotic assisted surgeries. LOCATION: UTMB AND BEAUMONT (CHRISTUS ST. ELIZABETH/ST. MARY) The gynecology rotation is a six to seven week block. The PGY 4 assumes responsibility for the team and coordination of care for all of the patients on the service. The 4 th year first assists on vaginal cases as well as other complex procedures. The 4th year instructs lower levels in staff cases, which provides an opportunity for teaching junior residents in the operating room. Medical Knowledge

Develop core knowledge of o Critical care for the gynecological patient o Vaginal surgery procedures o Pelvic floor defects Build upon core knowledge o Laparoscopic surgery principles o Hysteroscopic surgery principles o Abdominal surgery principles

Patient Care

Perform: o Complex operative laparoscopy o Laparoscopic total hysterectomy o Laparoscopic assisted vaginal hysterectomy o Vaginal hysterectomy o Complex operative hysteroscopic procedures such as uterine septum resection o Endomyometrial resection o Anterior colporrhaphy o Posterior colporrhaphy o Enterocele repair

Page 73 of 185

o Surgical management of stress incontinence Refine skills from surgeries learned as a first, second, and third year

Interpersonal and Communication Skills

Coordinate the care for all patients on the gynecology service with the appropriate junior resident Demonstrate leadership skills with the junior residents and medical students Identify and present complications at the monthly morbidity and mortality conference Elicit support from nursing, social work and ancillary services to provide comprehensive care of patients Assign appropriate surgeries to the lower level residents

Professionalism

Become aware of the differences in teaching techniques and use the ones most effective for your team Improve conflict resolution skills Refine your skills dealing with difficult patients Accept primary responsibility of management of staff patients

Practice Based Learning

Identify essential books for your practice Identify essential web based programs to enhance knowledge Prepare for written OB/Gyn Boards Improve your knowledge of CPT and ICD-9 codes

System Based Practice

Increase awareness in the different cost of malpractice

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency. Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am

Reading assignments Comprehensive Gynecology, 5th edition: Chapter 20-21 Te Lindes Operative Gynecology, 9th edition: Chapter 35-39

Page 74 of 185

Gynecologic Oncology
A. PGY 2 The oncology rotation is six to seven weeks in length. The PGY 2 provides coverage of the floors and admits oncology patients. The 2 nd year second assists on appropriate cases. During this rotation the 2 nd year takes home call every third night. Medical Knowledge

Develop a core knowledge of: o Risk factors associated with gynecological malignancies o Historical and physical findings associated with a gynecological malignancy o Screening tests for gynecological malignancies o Chemotherapeutic agents used to treat gynecological malignancies, the major side effects, and management of these side effects o General radiation principles and the most common complications o Management of the abnormal pap smear o Vulvovaginal dysplasia o Pain control in the patient with cancer o Postoperative care o Laser principles o Pelvic anatomy

Patient Care

Obtain a targeted history in patients with a suspected gynecological malignancy Order and interpret appropriate screening tests Order and interpret appropriate labs for patients receiving chemotherapy Evaluate patients for side effects from chemotherapy Prescribe treatment for common side problems such as nausea/vomiting and pain control Perform routine postoperative care Diagnose post-operative complications: o Wound infection o Ileus o Bowel obstruction o Fluid overload o DVT and PE Describe the indications and components of bowel prep Perform colposcopy in the patient with vulvovaginal or cervical dysplasia Obtain informed consent for transfusions

Interpersonal and Communication Skills

Counsel patients in regard to: o Pain control options o Postoperative expectations o Transfusion of blood products

Page 75 of 185

Communicate effectively with other members of the team, nursing staff and ancillary services Work with consult services to provide comprehensive care

Professionalism

Demonstrate sensitivity to a terminally ill patient and her family Demonstrate an understanding of the stages of grief and how it impacts a patient diagnosed with cancer. Demonstrate an understanding of patients different religious preference and understand how it impacts patients decisions and desires

Practice Based Learning

Assist the team in counseling families regarding code status Understand the resources available in the chaplains office for families Work with social work to provide necessary services for patients after discharge

System Based Practice

Describe how cancer screening can prevent malignancies Explore how outpatient chemotherapy versus inpatient chemotherapy im pacts health care costs

Learning Resources

The team rounds with the oncology attending on a daily basis for bedside teaching and directed patient care Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am Residents, Fellows and Faculty attend Thursday afternoon book review, chemotherapy meeting, Tumor Treatment Planning Conference, and Journal Club The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency

Reading assignments Clinical Gynecologic Oncology by Disaia. Chapters 1, 2, 4, 7, 10, 14, 18 ACOG Practice Bulletin: #45, #66

B. PGY 3 (Galveston ONC and M.D. Anderson Rotation) The oncology rotation is six to seven weeks in length. The PGY3 first or second assists on appropriate cases. During this rotation the 3rd year takes home call every third night.. The 3rd year is responsible for the weekly case list of patients presented to faculty for weekly Morbid and Mortality conference.

Page 76 of 185

Medical Knowledge

Develop a core knowledge: o Vascular, lymphatic and nerve supply to the pelvic organs o Gynecological cancer staging o Surgical treatment for gynecological cancer o Alterations in immune mechanisms that result from cancer and chemotherapy o Genetics of cancer o Intraoperative complications in the oncology patient Expand core knowledge of: o Risk factors associated with gynecological malignancies o Historical and physical findings associated with a gynecological malignancy o Screening tests for gynecological malignancies o Abdominal surgery principles o Preoperative evaluation to patients with operative risk factors o Postoperative management of complications

Patient Care

Determine the gynecological cancer stage of cervical, ovarian, and endometrial cancer and correlate stage with prognosis Describe the histology of gynecologic malignancies and how the histological features relate to prognosis Be familiar with pelvic side wall anatomy including opening the sidewall to identify the ureter and its course Perform: o TAH/BSO for endometrial cancer o Appropriate ovarian staging cases o Assist on radical hysterectomy, radical vulvectomy and pelvic lymph node sampling Coordinate critical care for the patient with cancer

Interpersonal and Communication Skills

Counsel patients in regard to: o Palliative care o Quality of life issues o Sexual function after cancer surgery o Options for patients who desire to die at home

Professionalism

Increase sensitivity and awareness to patients who have limited income and resources for home health care Increase awareness how to incorporate medical students into the health care team of an individual with a chronic and terminal illness Refine ethical principles in patient care

Page 77 of 185

Practice Based Learning

Develop an understanding of how to fill out and sign a death certificate Recognize untoward complications in the treatment of cancer Describe the hospital policy for restraints for the patient with confusion

System Based Practice

Describe how a living will works and understand how to implement one Describe how a do not resuscitate order works and how to implement one

Learning Resources

The team rounds with the oncology attending on a daily basis for bedside teaching and directed patient care Residents attend Wednesday morning Morbidity and Mortality Conference, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am Residents, Fellows and Faculty attend Thursday afternoon b ook review, chemotherapy meeting, Tumor Treatment Planning Conference, and Journal Club The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency

Reading assignments Clinical Gynecologic Oncology by Disaia. Chapters 3, 5, 6, 8, 9, 11, 12, 13 & Appendix A ACOG Practice Bulletin: #65, 74

Reproductive Endocrinology and Infertility

A. PGY 1 The REI rotation is six to seven weeks in length. The intern works with the REI faculty, evaluating patient with infertility and other endocrinologic pathology. The intern first assists on surgeries performed on REI patients and observes IVF procedures. The rotation allows the intern to have further vaginal ultrasound experience. The intern will take call every Saturday to work an L&D night call. Medical Knowledge

Develop a core knowledge of: o Primary and secondary infertility o Physiology or reproduction including the hypothalamic -pituitary-ovarian axis, adrenal steroidogenesis and thyroid gland o Female and male gametogenesis o Preimplantation genetic diagnosis o Hyperprolactinemia o Hirsutism o Endometriosis

Page 78 of 185

Polycystic ovarian disease Premature ovarian failure Galactorrhea Build upon core knowledge of: o Laparoscopic surgery o Operative hysteroscopy o Transvaginal ultrasound
o o o

Patient Care

Perform: o History and physical exam to assess the cause of infertility o Selected diagnostic tests to assess the cause of infertility o Hysterosalpingogram o Ovulation induction with clomid citrate o Medical and surgical treatment for endometriosis o Myomectomy o Vaginal ultrasound Diagnose and manage: o Hyperprolactinemia o Hirsutism o Endometriosis o Polycystic ovarian disease o Premature ovarian failure o Galactorrhea o Amenorrhea o Delayed puberty o Uterine bleeding o Menopause o Nipple discharge o Premenstrual syndrome. Describe the indications, prognosis, and complications of artificial reproductive technology Improve intraoperative laparoscopy skills Improve operative hysteroscopy skills

Interpersonal and Communication Skills

Counsel patients regarding aspects of assisted reproductive technologies including IUI, ovarian stimulation, egg retrieval, and transfer of the embryo. Gain an awareness of the personnel in an IVF office and their roles Understand the psychological impact that infertility has on a couple and the community resources to offer them support.

Professionalism

Demonstrate sensitivity to couples undergoing infertility treatment and appreciate the impact this has on their personal lives Increase awareness of the difference between health coverage in females and males.

Page 79 of 185

Gain exposure to some of the ethical dilemmas in assisted reproductive technology

Practice Based Learning

Become aware of how successful IVF cycles are defined Understand what aspects of infertility are covered by insurance Become familiar with the quality control used in an IVF lab

System Based Practice

Become aware of adoption agencies and how they assist couples Increase awareness of egg and sperm donors

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency. Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am The resident attends weekly Tues and Thurs morning REI conference.

Reading assignments Clinical Gynecologic Endocrinology by Speroff. Chapters 3, 7, 12, 13, 16, 20, 27, 29 ACOG Practice Bulletin: #11, 14, 51 B. PGY 4

Reproductive Endocrinology and Infertility Educational Objectives HOUSTON FERTILITY INSTITUTE ROTATION
The REI rotation is six to seven weeks in length. The 4th year works with the REI faculty, evaluating patient with infertility and other endocrinologic pathology. The 4 th year first assists on surgeries performed on REI patients and observes IVF procedures. The rotation allows the 4th year to have further vaginal ultrasound experience. In the fourth year, residents will rotate with the physicians of Houston Fertility institute (HFI). Dr. Craig Witz will be the principal mentor for this experience. Residents will primarily see patients with Dr. Witz at HFIs Webster and Fondren offices*. The schedule is listed below. Variations will be dictated by patient care requirements. Monday Tuesday Wednesday Thursday Friday AM Fondren Webster Fondren Webster Webster PM Fondren Webster Webster Webster Webster Office hours begin at 8 am. There are no weekend assignments.

Page 80 of 185

Residents will see patients with a vast array of problems related to infertility and recurrent pregnancy loss. As a result of these patient encounters, it is expected that the resident will become proficient in the evaluation and management of ovulatory dysfunction including polycystic ovarian syndrome. In addition, residents will become familiar with the evaluation and management of patients with amenorrhea, hyperandrogenism, hyperprolactinemia, endometriosis, and thyroid disorders. The resident will also become familiar with methods of achieving controlled ovarian hyperstimulation as well as the process of in vitro fertilization. As well, they will demonstrate an understanding of the diagnosis and treatment of mullerian anomalies, certain genetic abnormalities, and thrombophilia. Residents will have the opportunity to hone their skills performing vaginal sonography and will participate in sonohysterography. They will also learn to perform and interpret hysterosalpingograms. They will scrub for outpatient surgical procedures including transvaginal retrieval of oocytes, hyseteroscopy, laparoscopy, and myomectomies. As time permits, residents will be engaged in didactics given by the attending physicians covering subjects such as: embryology of the reproductive system, steroidogenesis, mechanisms of hormone action, abnormal pubertal development, disorders of ovulation, PCOS, endometriosis, hyperprolactinemia, premature ovarian failure, and hirsutism. To prepare for these discussions, it is recommended that residents read relevant chapters in Clinical Gynecologic Endocrinology and Infertility by Marc A Fritz, and Leon Speroff. *Fondren Office: 2500 Fondren, Suite 350 Houston, Texas 77063 Ph: 713-490-2527 Fax: 713-334-5547
EducationalGoalsandObjectives: 1. Medical Knowledge : Primary and secondary infertility, Physiology of reproduction, Female and male gametogenesis, Preimplantation genetic diagnosis, Hyperprolactinemia, Endometriosis, Polycystic ovarian disease and Premature ovarian failure 2. Patient Care: Perform: History and physical exam, select diagnostic tests to assess the cause of infertility. Initiate ovulation induction with clomid citrate and medical and surgical treatment for endometriosis. Diagnose and manage: Hyperprolactinemia, Hirsutism, Endometriosis, Polycystic ovarian disease, and Premature ovarian failure. Improve operative skills listed below and transvaginal ultrasound. 3. Interpersonal and Communication Skills: Counsel patients regarding aspects of assisted reproductive technologies including IUI, ovarian stimulation, egg retrieval, and transfer of the embryo. 4. Professionalism: Demonstrate sensitivity to couples undergoing infertility treatment and appreciate the impact this has on their personal lives and address some of the ethical dilemmas in assisted reproductive technology. 5. Practice Based Learning: Become aware of how successful IVF cycles are defined and become familiar with the quality control used in an IVF lab. 6. System Based Practice: Increase awareness of egg and sperm donors. Procedure Understand UnderstandandPerform Assisted reproductive technologies IVF X

Webster Office: 251 Medical Center Blvd, Suite 125 Webster, Texas 77598 Ph: 281-286-4434 Fax: 281-554-5115

Page 81 of 185

ICSI X Gamete donation X Preimplantion genetic Diagnosis X GIFT X Hysterosalpingography Hysterosonography Hysteroscopy Diagnostic Operative Submucosal fibroid resection Polyp resection Incision of vaginal septum X Laparoscopy Diagnostic Operative Chromopertubation Lysis of adhesion Fimbrioplasty X Salpingostomy Metroplasty Abdominal X Hysteroscopic resection of uterine Septum X Tubal anastomosis X Vaginal reconstruction X

X X X X X X X X X

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency. Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am The resident attends weekly Tues and Thurs morning REI conference.

Reading assignments Clinical Gynecologic Endocrinology by Speroff. Chapters 9, 10, 14, 15, 17, 18, 28, 32, ACOG Practice Bulletin: #16, 34

Pediatric and Adolescent Gynecology

A. PGY 1 At the conclusion of the PGY 1 year, the resident should have developed competency in the following objectives:

Page 82 of 185

Medical Knowledge

Develop a core knowledge of: o Gynecologic disorders experienced by children and adolescents and special implication for diagnosis and management.. Build on a core knowledge of: o Contraceptive options and counseling o Options for elective termination of pregnancy o Describe the anatomical changes of the genital tract related to different ages (newborn, child and adolescent. o Describe the sex hormonal changes that occur in the first two years of life and as part of normal puberty.

Patient Care

Perform: o IUD placement and removal o Elicit a medical and sexual history from an adolescent. o Provide the primary health care needs of an adolescent o Provide patient and parent education regarding normal development, menses, sexuality, prevention of STDs and pregnancy. o Perform a gynecologic exam on children and adolescents.

Interpersonal and Communication Skills

Coordinate comprehensive care for patients including social work, psychiatric, and nutrition services Counsel patients regarding termination of pregnancy

Professionalism

Deliver bad news such as fetal demise in a sensitive and empathetic manner Respond to constructive criticism Increase sensitivity and awareness to patients who have limited income and resources for home health care

Practice Based Learning

Provide appropriate follow-up for patient undergoing colposcopy Improve your knowledge of ICD-9 and CPT codes

System Based Practice

Become familiar with home health care agencies and the services they can provide for patients at home Increase awareness of a financial counselors role in a practice Become aware of state and federal regulations regarding termination of pregnancy

Page 83 of 185

Learning Resources

The Resident Lounges have major obstetrics textbooks, access to computers in addition to the major text books that are given to the residents at the start of their residency. Residents attend Wednesday morning Morbidity and Mortality Conferences, Grand Rounds and Didactic Lecture with protected teaching time from 7 -10am

Reading assignments and Questions for each week of the rotation. Clinical Gynecologic Endocrinology by Speroff. Chapters 9, 10, 21-26 Precis Gynecology third edition, Pediatric Gynecology Chapter, authored by A Berenson, pp 180185 Questions:

1. Describe 2 positions that you could use to examine a child under 4 yo. 2. Describe labial agglutination, including its symptoms and treatment. 3. Discuss the occurrence of condyloma accuminata in children, including possible etiologies, natural history and treatment. 4. Discuss the treatment of lichen sclerosis. 5. Discuss the presentation and treatment of urethral prolapse.

Clinical endocrinology and infertility, Speroff and Fritz, chapter 11, Amenorrrhea, pp 401-64 Questions:
1. What is the definition of primary amenorrhea? 2. Name the components of the 4 compartments that you consider in the evaluation of amenorrhea and 2 disorders associated with each compartment. 3. What is the first step in the evaluation of the amenorrheic patient? 4. What do you do if the patient does not have a withdrawal bleed after a progestin challenge? 5. Discuss the differences between Mullerian Agenesis and Androgen Insensitivity.

Clinical endocrinology and infertility, Speroff and Fritz, chapter 24, Long acting methods of contraception, pp 949-974 Questions:
1. 2. 3. 4. 5. What are the absolute contraindications for implants? For Depo Provera? Describe Implanon how many rods, how long effective, and hormone it contains. How can you treat breakthrough bleeding when it occurs with use of Depo Provera? Discuss the effects of Depo Provera on bone mineral density. How long does it take for fertility to return after discontinuing DMPA?

Clinical endocrinology and infertility, Speroff and Fritz, chapter 13, Hirsutism, pp 499-530. Questions:

1. What is the most common source of increased testosterone in hirsute women? 2. What are some important questions to ask in the history of a woman with hirsutism? What should you look for on the physical exam? 3. What 2 laboratory tests should initially be done on the hirsute woman? What do they tell you? 4. How do you screen for Cushings syndrome? 5. What is the most common treatment for hirsutism? Why is it effective?

Page 84 of 185

Genetics Rotation
The Genetics Rotation occurs during the Breast/ultrasound/genetics block. The PGY1 rotates in the division of Pediatric Genetics with Dr. Lillian Lockhart. Childrens Hospital, Room 350, ext. 23466. The following schedule is expected: Monday post call (off) Tuesday report to Dr. Lockhart 8am-4pm Wed 7am 10:00 Resident Lecture (CSA Auditorium) 11:00 1:00 MFM/Perinatal Conf 1:00-Continuity Clinic Thursday report to Dr. Lockart 8am 4pm Friday report to Dr. Lockhart 8am -4pm Saturday Off Sunday L&D Night call Medical Knowledge Develop a core knowledge of o Basic structure and replication of DNA o Process of mitosis and meiosis o Describe the clinical significance of karyotype abnormalities Trisomy Monosomy Deletions Inversions o Describe clinical significance of heritable diseases, such as cystic fibrosis, Tay -Sachs disease, and hemophilia o Inheritance of hemoglobinopathies o Genetic basis of hereditary cancer syndromes in women o Describe the genetic basis of normal and abnormal Mullerian development o Disorders of androgen excess o Recurrent pregnancy loss o Ambiguous genitalia Describe principles of preimplantation genetic diagnosis

Patient Care Perform o History and Pedigree as indicated o Physical exam be able to recognize normal and abnormal genitalia o Provide counseling to patients with genetic disorders Assist MFM physicians with genetic amniocentesis Professionalism Deliver difficult news such as fetal chromosomal abnormalities in a sensitive and empathetic manner Recognize and respect cultural differences regarding termination of pregnancy

Page 85 of 185

Practice Based Learning Understand what aspects of genetic diagnosis are covered by insurance Review the cost and indications of the different forms of pregnancy termination Increase awareness of preauthorization for medical services provided Systems Based Practice Become familiar with the legal limits of pregnancy termination in your state and the rules and regulations of your institution Understand the cost and social services available to a child born with a chromosomal abnormality Learning Resources The Resident Lounges have major textbooks, and access to computers and the internet. Residents attend Wednesday morning Morbidity and Mortality Conference, Grand Rounds, Journal Club, and Didactic Lecture with protected teaching time from 7 10 am. The resident attends the weekly perinatal conference held at 3.400 JSA (Chairmans Conference Room) Reading Assignments Clinical Gynecologic Endocrinology by Speroff, 7 th Edition, 2005 Chaper 9 Williams Obstetrics by Cunningham, 22 nd Edition, 2005, Chapter 12

Primary Care
By the completion of the PGY 1 year, each resident should have developed competency in the following categories listed below. In addition, these learning topics are reinforced throughout the four years during the inpatient and outpatient management of Obstetric and Gynecologic patients. 1. Performance of routine health maintenance and screening history and physical examination. 2. Provide immunizations 3. Manage the following medical conditions: I. Preventive Medicine 1. Patient safety 2. Substance abuse 3. Smoking cessation 4. Nutritional counsel 5. Lipid disorders 6. Immunizations 7. Fitness counseling 8. Domestic violence 9. Common pediatric and adolescent disorders 10. Common medical emergencies 11. Sigmoidoscopy II Infectious Diseases Page 86 of 185

1. ENT disorders 2. HIV infection 3. Sexually transmitted diseases 4. Urinary tract 5. Respiratory infections III. Chronic Medical Diseases 1. Arthritis (other rheumatologic and autoimmune diseases) 2. Thyroid diseases 3. Asthma (and other respiratory disorders) 4. Cardiovascular disease and hypertension 5. Dermatologic disorders 6. Diabetes mellitus 7. Gastrointestinal disorders: 8. Irritable bowel syndrome 9. Gastroesophageal reflux disease 10. Inflammatory bowel disease 11. Neurological disorders and headaches 12. Hematological disorders 13. Low back pain and musculoskeletal disorders 14. Renal disorders IV. Behavioral Medicine 1. Anxiety 2. Depression 3. Eating disorders 4. Obesity 5. Substance abuse Reading assignments Womens Primary Health Care by Carlson - Whole Book

GYNECOLOGY SONOGRAPHY ROTATION OBJECTIVES

1st year resident on Ultrasound Rotation Learning Objectives : By the end of the rotation the resident should be able to: 1. 2. 3. 4. 5. Image the normal uterus Identify normal ovaries in at least 25% of the cases attempted Describe the procedure for sonohysterography Describe the common indications for ordering a pelvic ultrasound and sonohysterogram Describe the role for sonography in the evaluation of abnormal uterine bleeding

Reading assignment: Callen, Ultrasonography in Obstetrics and Gynecology, 4th edition, Chapters 28, 29, 31, 33. Clinical responsibilities: Perform transvaginal ultrasound examinations with direct faculty supervision

Page 87 of 185

Evaluation: Direct observation by faculty on clinical rotation. Schedule : Wednesday mornings 3rd year resident on Reproductive En docrine and Infertility AND 4th year resident on consult service Learning Objectives : In addition to the 1st year objectives, by the end of the 4th year rotation the resident should be able to: 1. Perform a complete transvaginal sonogram, including identification and measurement of relevant pelvic organs. 2. Interpret abnormal sonographic findings commonly encountered during a pelvic sonogram. 3. Independently perform a sonohysterogram. Clinical responsibilities: 1. Perform transvaginal ultrasound examinations and sonohysterograms with direct faculty supervision. 2. Prepare preliminary ultrasound reports including interpretation of findings. 3. Counsel patients on the sonographic findings. Evaluation: Direct observation by faculty on clinical rotation Schedule : 3rd year REI resident: Wednesday afternoons 4th year resident: All day Tuesdays at Bay Colony UTMB Womens Health Center

CONSULT/ULTRASOUND ROTATIONS (PGY 1 &4)

2010 Resident Consult & Ultrasound/Genetics Service
RESIDENT LEVEL MON TUES 8-5
Pearland

WED 7-5
Attend Lecture & go to designated TDCJ Clinic (Gatesville/TX City)

THURS 8-5
MFM USG (Galveston)

FRI 8-5
Pearland

PGY 4 Consult

Post Call

8-5 PGY 1 Combined Ultrasound & Genetics Pasadena NP sonosite clinic 1-5

7-10 M&M Grand Rnds Didactics

8-12 Ultrasound Clinic (3rd Floor UHC)

8-12 Genetics (3rd Floor UHC)

Post Call

1-5 1-5 1-5 MFM Lectures Pasadena and GYN Ultrasound Continuity NP sonosite ULTRASOUND Clinic (3rd Clinic (am) clinic WITH DR. Floor UHC) VINCENT The genetics and ultrasound clinics are located on the 3rd floor university hospital clinic bldg.

Page 88 of 185

Pasadena: Mornings beginning at 8:00am Pasadena Clinic 3737 Red Bluff Rd suite 150 Pasadena TX 77502 713-473-5180 or 713-475-4201 Pearland Address: 2750 East Broadway, Pearland, TX 77581 281-485-0865

1.

PGY 4 Resident vacation will result in a cancellation of the resident consult service for that day. Please plan in advance.

2.

For the chief resident USG service, appointments will be scheduled through MFM USG.

3.

OB consults will be reviewed and approved by Drs. Snyder/ and Olson prior to scheduling. OB consults will be scheduled through OB/GYN clinics.

Resident Ultrasound Rotation The ultrasound rotation is designed to provide progressive learning for the PGY1 and PGY 4 resident levels PGY 1 At the end of this block the PGY 1 resident will be able to: 1. Understand the components of an ultrasound exam 2. Be able to interpret a first trimester ultrasound exam and note fetal viability 3. Be able to perform basic measurements of bio metry to determine menstrual age 4. Understand and gain some proficiency at obtaining the essential elements of a normal fetal anatomic survey. To accomplish the above, the PGY1 resident will in sequential fashion obtain proficiency in identifying and measuring the following fetal anatomy. Try to complete at least one module each day you are on the MFM unit Module 1 Module 2 Module 3 Module 4 Fetal cranium/ face, abdomen, stomach, situs Fetal spine in longitudinal and transverse views and extremities Fetal heart, cord insertion, bladder, kidneys and adrenals Complete biometry and AFI

A copy of Chapter 6 from Callen has been provided for your reading pleasure. Standard texts are available in the ultrasound unit for you to use during the block. Pre and post tests will be administered. A schedule for the block as been provided PGY 4 At the end of the block the PGY4 resident will be able to: 1. Perform and interpret fetal biometry

Page 89 of 185

2. Be able to counsel patients about findings related to a n ultrasound exam 3. Understand the use of Doppler ultrasound during pregnancy 4. Be able to identify selected fetal anomalies During each ultrasound exam, unless technically impossible, the following should be imaged and documented: Fetal number and presentation (second and third trimester) Location and grade of the placenta Cardiac activity AFI Biometry (BPD,HC,FL,AC, HL) Interpretation of the biometry Documentation of anomalies or additional anatomy that is visualized. A formal report will be generated and signed with the MFM doctor in attendance and the images will be archived.

Module 1: Cranium Biparietal Diameter (BPD) Obtain an axial view showing the thalami, third ventricle, cavum septi pellucidi, and midline falx.
XX

XX

Place ultrasound cursors upper-outer and lower-inner for measurement. Head Circumference (HC) Use same image as above and measure the circumference by placing the cursors outer to outer: a. The shape of the head should be oval. When the oval shape is exaggerated = dolichocephaly. The shape is very round = brachycephaly. b. Cephalic Index (CI) normal 79 + 8. CI = BPD/fronto-occipital diameter (FOD) CI < 70 = dolichocephalic; CI > 88 = brachycephaly c. Abnormal shapes should be identified: Cloverleaf (thanatophoric dysplasia, aneuploidy)

Page 90 of 185

 Lemon-shaped (spina bifida) Large eye sockets, hard to get BPD (anencephaly) Intracranial Structures Remember with your BPD view you have already noted the midline (absent = holoprosencephaly), cavum septi pellucidi (absent = agenesis corpus callosum), third ventricle (if dilated = hydrocephalus)

Page 91 of 185

Now examine: a. Cerebellum b. Cisterna magna (normal < 1.0 cm) c. Nuchal fold (N < 0.5 cm at < 20 wks) d. Lateral ventricle (normal < 1.0 cm) e. Choroid plexus fills the body of the lateral ventricle but does not extend to the frontal horns. Evaluate for cysts. Face A frontal view of the face is obtained. The nose and lips should be clearly observed. The size of the tongue should be noted. Frontal bossing may be noted when the forehead can be clearly seen in a frontal face view. A profile should also be obtained noting the shape of the profile, nasal bone, and chin.

Abdomen The abdominal circumference (AC) should be determined at the level of the junction of the umbilical vein and portal sinus. These form a J with the most anterior portion of the ascending left portal vein not extending to the anterior abdominal wall.
Spine

Stomach Right portal vein

Pars transverse

Ascending left portal vein

The stomach (visualized by 14 wks) should be noted on the left and below the diaphragm.

Page 92 of 185

Module 2: Spine There are typically three ossification centers recognizable by ultrasound. One is the vertebral body. Two are ossification centers of the posterior lamina.

These three ossification centers form a triangle with the tip pointing to the center of the fetus.
Skin Post lamina Vertebral body

In a coronal view a railroad track image will be depicted. The external echoes are the posterior lamina and the middle echoes are the vertebral bodies.

Extremities Identify long bones of the upper and lower extremities. Also note fingers and toes.

Measureme nt of the femur length includes only the ossified diaphysis and excludes the cartilaginous epiphyses.

Module 3: Heart In a typical four-chamber view, the apex of the heart should be on the left side of the chest; the descending aorta also should be visible on the left side of the chest. The heart itself shows the four chambers, with the right ventricle anterior and closest to the chest wall, and the left ventricle more posterior and more to the left. The right ventricle is also identifiable by the presence of the moderator band, which is a portion of muscle visible at the apex of the right ventricle. The two atria are visible, as well as the anterior atrial septum. The foramen ovale should be identifiable and its flap seen to move under real-time sonogr aphy to and from the anterior atrial septum toward the left

Page 93 of 185

atrium. Easily seen findings consistent with normal fetal R L flow and correct hemodynamic and anatomical orientation would therefore be: 1. 2. 3. Heart on left side of chest (stomach). Ventricle with moderator band on right side of heart (anterior). Foramen ovale opens into left atrium.

The mitral and the cuspid valves are also visible. The papillary muscles and chorda tendineae can usually be depicted within the lumen of the left ventricle.

By angling the transducer alongside the left ventricle, one can demonstrate the left ventricle and the outflow tract going into the ascending aorta. The coronary arteries are sometimes visible by identifying the coronary ostium at the root of the aorta. In a basal section through the aortic cusps, the two atria will appear posterior and a small portion of the two ventricles will be seen anteriorly. The right coronary artery arises in front of the anterior semilunar valve. The left coronary arises in front of the left posterior semilunar valve. The coronary arteries appear as well-delineated vessels. The ductus arteriosus can be differentiated from the aortic arch by its much more abrupt bend and, of course, by the fact that the major cervical vessels do not o riginate from it. The superior vena cava is visible as it enters the right atrium. In many views of normal heart, left and right outflow tracts appear to cross.

Identify the umbilical cord insertion. The umbilical cord should be noted to have three ve ssels in a free segment and two umbilical arteries are noted alongside the bladder. The bladder should be visualized by 14 weeks.
Umbilical artery Bladder

The kidneys are visible after 16 weeks but become more obvious after 20 weeks. Note any dilatation of the renal pelves. Renal pelves dilatation should be < 4 mm.
Kidney

Page 94 of 185

Module 4: Full ultrasound exam

Page 95 of 185

Ultrasound Checklist Date Placental location Cervix BPD/HC Lateral ventricle Cerebellum Cysterna magna Nose/lips Profile Four chamber heart Diaphragm Stomach Kidneys Umbilical cord insertion Umbilical cord Bladder Spine Extremities AFI Interpretation of biometry Femur Humerus AC

Competence

Structure

Page 96 of 185

References 1. 2. 3. 4. Fleischer et al: The principles and practice of ultrasonography in obstetrics and gynecology. Norwalk, Connecticut: Appleton & Lange, 1991:1-668. Nyberg et al: Diagnostic ultrasound of fetal anomalies. Boston, Massachusetts: Mosby - Year Book, Inc., 1990:1 -778. Callen et al: Ultrasonography in obstetrics and gynecology. Saunders Publishing, 4th edition, 2000. Ultrasonography in pregnancy, ACOG Practice Bulletin No. 58, American College of Obstetricians and Gynecologists. Obstet Gynecol 2004; 104: 1449-58

Sono Pearls
Yolk Sac Range 3 6 mm > 6 mm Abnormal Not seen after 10 12 wks Amnion Fuses with Cheron 8-16 wks Embryo Day 36 70 (5.1 10 wks) Grows .8mm/Day MSD > 18 mm Should see a FHR CRL > 5 mm ? FHR 5.1 wks (36 D) FHR begins to beat 5.7 wks ? FHR by TVS definitely by 6.5 wks Sac grows 1 3 mm / Day STATISTICS 5% Loss at 7 12 wks M.A. if new spotting 2% Loss > 8 wks M.A. ? FHR on TAS 31 40% Loss rate after implantation/fertilization 2 3% rate in 2 3 Trimester 24% Loss rate <5 mm GRL + FHR on T VS

Page 97 of 185

4 Signs of Pregnancy Failure 1. 2. 3. 4. No HB with CRL > 5 mm No embryo with MSD > 25 mm No yolk sac with MSD > 10 mm No growth or Neg growth of embryo or sac on serial scan PGY-1 Ultrasound Test 1. Potential pitfalls of ultrasound done in the first trimester include a. normal extra-abdominal position of the embryonic intestine simulating an abdominal wall defect. b. the prominence of integument simulating skin edema. c. potential for false-negative diagnosis of anencephaly d. inaccuracy of crown/rump length for gestationa l age. e. none of the above f. a, c g. a, b, c 2. The diagnosis of fetal death ideally should be made by a. abdominal and vaginal scanning b. absence of cardiac motion for 3 minutes confirmed by more than one examiner c. lack of doubling of BHCG in 48 hours d. color Doppler e. a perinatologist 3. Patients who are obese appear to have ________ amounts of fluid due to ________ a. increased, water content of adipose b. increased, refraction of sound waves c. decreased, macrosomic infants d. decreased, scattering of sound 4. The percentage of chromoso mal abnormalities in pregnancies that abort before 6 weeks is a. 10% b. 20% c. 50% d. 70% 5. Cleavage of the zygote normally begins in a. fallopian tube b. uterus c. peritoneal cavity 6. The embryo officially becomes a fetus at a. 8 menstrual weeks b. 10 menstrual weeks c. 12 menstrual weeks d. 14 menstrual weeks

Page 98 of 185

7. Ultrasound is high frequency sound waves exceeding _________ cycles/second. a. 5,000 b. 10,000 c. 20,000 d. 50,000

8. A safe level of ultrasound exposure to tissue has been defined as a. 50 mW/cm2 b. 100 mW/cm2 c. 200 mW/cm2 d. 300 mW/cm2 9. Ultrasounds done in the first trimester should include the following except e. fetal number f. crown -rump length g. evaluation of adnexa h. 4 chambered view of heart 10. The uterus is derived from the a. Gubernaculum b. urogenital sinus c. mesonephric duct d. Mullerian ducts 11. The double decidual sac sign is a. a sign of an extopic pregnancy b. a finding consistent with an intrauterine pregnancy that is very early c. a sign of a nonviable pregnancy d. a sign of trophoblastic neoplasia 12. Draw an arrow where the cursor belongs to measure this femur

13. Flexion refers to the _________ in relationship to the _________. Version refers to the ________ to the __________. a. axis of the cervix, vagina; cervix, axis of the body of the uterus b. axis of the cervix, axis of the body of the uterus; cervix, vagina c. axis of the body of the uterus, cervix; axis of the cervix, vagina d. vagina, cervix; axis of the body of the uterus, axis of the cervix 14. The most common transducers used in obstetrics and gynecology are the a. 2 MHZ b. 3 5 MHZ, and 5 10 MHZ

Page 99 of 185

c. 40 MHZ 15. The fetal loss rate for a genetic amniocentesis is a. .1% b. .5% c. 1% d. 5% 16. The needle used for an amniocentesis is a a. 22 gauge 3.5 inch spinal needle b. 18 gauge 5 inch spinal needle c. 24 gauge 7 inch spinal needle d. 16 gauge, 3.5 inch spinal needle 17. In the fetal leg, the medial bone is the _______ and the lateral bone is the _______. a. radius, ulna b. ulna, radius c. tibia, fibula d. fibula, tibia 18. In the fetal forearm, proximally the ________ is longer than the ____________. a. radius, ulna b. ulna, radius c. tibia, fibula d. fibula, tibia 19. The normal umbilical cord is composed of a. 2 arteries, 1 vein b. 2 veins, 1 artery c. 1 artery, 1 vein d. 2 arteries, 2 veins 20. Fetal kidneys are usually identified as early as a. 0 8 weeks b. 10 12 weeks c. 15 16 weeks d. 24 26 weeks 21. In the second trimester, the fetal measurements most commonly used to establish gestational age are ___________, __________, and _________. 22. The critical landmarks for measuring the BPD or HC include a. falx, thalami cavum septum pellucidi, atria of ventricles b. cerebellum, third ventricle, cerebral peduncles c. lateral horn of ventricles, cavum septum pellucidum d. cerebal peduncles, falx, cisterna magna

Page 100 of 185

23. The BPD should be measured from the ________ surface of the skull table nearest the transducer to the __________ margin of the opposite skull table. a. inner, outer b. outer, outer c. inner, inner d. outer, inner 24. Landmarks for the measurement of the abdominal circumference are a. portal vein in liver and fetal stomach b. bladder and spine c. kidneys and cord insert d. aorta and spine 25. Femoral diaphysis length can be reliably used after __________ weeks. a. 12 b. 13 c. 14 d. 15 26. Which ultrasound examination is defined by the indications for the exam? a. limited b. standard c. specialized d. first trimester 27. Name the 6 components of a standard ultrasound examination. 1. 2. 3. 4. 5. 6.

Page 101 of 185

PGY-4 Ultrasound Test 9. In order to accurately assess growth, interval growth should be assessed no more frequently than a. 10 days b. 4 weeks c. 2 weeks d. 1 week 10. A false positive diagnosis of placenta previa can be made due to a. over distended bladder b. breech fetus c. polyhydramnios d. under filled bladder 11. What percentage of blastocysts that implant in the uterus and result in detectable levels of hCG abort near the next expected menses? a. 10% b. 20% c. 40% d. 80% 12. Of clinically recognized pregnancies, what percent will threaten to abort? a. 1% b. 10% c. 25% d. 80% 13. Of those pregnancies that threaten to abort, what percentage are lost? a. 1% b. 25% c. 50% d. 90% 14. A diagnosis of hydrocephalus is suggested by a lateral ventricular measurement greater than a. .5 cm b. 1.0 cm c. 1.5 cm d. 2.0 cm 15. The incidence of choroid plexus cysts in second trimester fetuses is . a. 0.001 - .003% b. .2 4% c. 5 10% d. 10 15%

Page 102 of 185

16. The most common noted abnormality with choroid plexus cysts is __________ which occurs in _________% of second trimester fetuses with cysts a. clubbed feet, 5% b. trisomy 13, 3% c. trisomy 16, 5% d. trisomy 18, 1% 9. The most common chromosomal abnormality associated with cystic hygromas are a. monosomy XO (Turners syndrome) b. trisomy 13 c. trisomy 18 d. trisomy 21 28. A femur length/abdominal ratio of greater than ________ suggests asymmetrical IUGR a. .10 b. .20 c. .24 d. .3 29. A systolic to diastolic ratio of greater than _______ any time after 30 weeks is abnormal at the umbilical artery. a. 1 b. 2 c. 3 d. 4 30. The average weight of a non pregnant uterus is a. 20 grams b. 40 grams c. 80 grams d. 120 grams 31. The uterus usually assumes a position that is a. anteverted and anteflexed b. retroverted and retroflexed c. retro vertical and anteflexed d. ante vertical and retroflexed 32. List the components of a biophysical profile 1. 2. 3. 4. 5. 33. List the components of the biophysical profile in order of which is lost first to last with acute hypoxia 1. 2. 3. 4.

Page 103 of 185

34. T/F Abnormal biophysical profile is associated with the development of intrauterine infection. 35. T/F Abnormal Doppler waveforms have proven to have a high positive predictive value for IUGR in low risk populations.

36. T/F Doppler waveforms have value in evaluation of fetuses known to be at increased risk for perinatal morbidity and mortality (IUGR, HTN, PE) 37. The best place to sample the umbilical cord for an S/D ratio is a. Cord insert into placenta b. free loop c. cord insert into fetus d. fetal abdomen 38. The endometrial thickness on ultrasound should not be greater than ________ in a post menopausal woman a. .5 cm b. .8 cm c. 1.5 cm d. 2.0 cm 39. A gestational sac can consistently be detected by endo vaginal sonography at an HCG level of a. 200 500 IU/L b. 500 1500 IU/L c. 1500 2000 IU/L d. 2000 2500 IU/L 22. T/F All embryos with a heart rate less than 85 BPM will be lost. 23. Almost all viable embryos will have evidence of cardiac activity if the CRL is greater than e. 3 m f. 5 mm g. 8 mm h. 10 mm 24. Failure to visualize an embryo on transabdominal ultrasound at a sac size of _______ mm means the pregnancy is probably an embryonic (blighted ovum). a. 10 mm b. 15 mm c. 20 mm d. 25 mm 25. Visualization of the atria, ventricles, cardiac septa, and outflow tracts detects what % of structural cardiac anomalies a. 20 30%

Page 104 of 185

b. 30 50% c. 50 70% d. 80 90% 26. Hyperechoic bowel has been observed with a. normal pregnancies b. cystic fibrosis c. Downs syndrome d. All of the above e. b, c

GENETICS

PGY-1
Genetics 2 week rotation Time 8:00 AM 4:00 PM Page 105 of 185

Report to Dr. Lockhart, Childrens Hospital, Room 3.350, ext. 23466 Objectives

A. Basic Genetics 1) Describe the basic structure and replication of DNA, Mitosis and Meiosis 2) Describe the clinical significance of Karyo type abnormalities, provide an example of each; Trisomy Monosomy Deletions Inversions 3) Describe the clinical significance of Cystic Fibrosis, Tay-Sachs, hemophilia, sickle disease, Thalassemia B. Genetic Counseling 1) Elicit a history focused on an inheritable disorder listed above 2) Understand genetic inheritance, dominate, recessive, x-linked, penetrance and variable expression 3) Describe non-invasive antenatal testing Serum screening Ultrasound 4) Be able to counsel patients about invasive testing a) Chorionic villus sampling b) Amniocentesis c) Cordiocentesis 5) Be able to order and interpret tests appropriate for indicating a fetal demise. 6) Counsel a patient about management options with an abnormal fetus. 7) Counsel a patient and her family about pregnancy outcome, recurrence, future care and possible interventions. 8) Newborn Nursing (NBN)/NICU 2 wk rotation 9) Be able to counsel a patient regarding pregnancy associated with risks of: a) AMA b) Diabetes c) Genetic Disorders d) Aneuploid/anomalous fetus Monday Post Call, No Clinical Assignment Attend your Continuity Clinic Friday AM Attend Wednesday OB Conferences 7 10 AM Attend combined MFM/Neonatal/Genetics Conference Wednesday 12 2 in the Chairmans Conference Room

Urogynecology Rotation Monday- Post Call for interns/Research/Antepartum Tuesday- Clinic with Muir or OR with Jurnalov Wednesday Clinic with Jurnalov or OR with Muir Thursday- Clinic with Jurnalov Friday- Clinic with Jurnalov

Page 106 of 185

Educational goals: 1. Office evaluation of pelvic organ prolapse a. History b. POPQ c. Vaginal skin evaluation (premenopausal Vs atrophy) d. What lies behind the bulge e. Associated medical problems (urinary, bowel, sexual function; depression and pain) 2. Office evaluation of urinary incontinence a. History b. Evaluation for fistula, diverticulum, urethral mobility, c. Multi-channel urodynamics (how to perform and interpret) d. Associated medical problems (prolapse, sexual function, depression, infection (UTI) and painful bladder syndrome) 3. Office evaluation of fecal incontinence a. History b. Evaluation for anal sphincter defects/ posterior wall support/ rectal prolapse c. Associated medical problems (depression/isolation; IBS; urinary incontinence and prolapse d. Imaging (endoanal ultrasound) 4. Conservative/ Medical management of the prolapse and incontinence a. Bladder/ bowel training b. Pelvic floor muscle training c. Pessary fitting d. Catheter use (in-office procedure and patient education) e. Medical management (drugs) 5. Discussion/ involvement with the surgical management of prolapse and incontinence (discussion Vs involvement dependent upon the year of resident in the rotation) Educational Materials: Walters and Karram: Urogynecology text book- anticipate that the resident on the rotation will be expected to read majority of textbook Surgical videos (anatomy, surgical procedures and POPQ evaluation)

Page 107 of 185

Corpus Christi Rotations

The Corpus Christi rotations are designed to expose the resident to private practice and to supplement the operative gynecologic experience. The goals and learning objectives are the same as those outlined in the gynecology section.

Overall Educational Objectives : (1) To learn basics of pre-operative and post -operative care (2) To learn and improve gynecologic surgical technique (3) To expand knowledge of diseases of the lower genital tract

Specific Educational Objectives for PGY III (1) To improve vaginal surgery skills (2) To learn advance laparoscopic techniques (3) To learn advanced techniques for pelvic floor support (4) To improve overall surgical skills (5) To improve pre and post operative care skills (6) To become familiar with conduct of private practice Overview of the Rotation: The gynecologic surgery rotation at Corpus Christi provides residents with exposure to a variety of gynecologic surgeons and a variety of procedures in a setting of private practice. This rotation is designed to provide extensive operating room experience. The level of pre operative and post operative resident involvement is at the discretion of the attending physician and with permission of the patient. Educational Didac tics: UTMB residents rotating at Corpus are expected participate in conferences or other didactic offerings. (See instructions on Blackboard) Apartments in gated community, 2 pools, near CHRISTUS South Residents will need to bring UTMB pagers for use at CC Structure of rotation: 2 hospitals in the CHRISTUS Spohn system o CHRISTUS Memorial Gyn team will consist of FP PGY3 and UTMB PGY3. The call responsibility will alternate from the UTMB PGY 3 and 4 for a week at a time. It will be home call and our assistance will be utilized if needed in the following chain: FP intern > FP PGY 3 > Gyn faculty. Rounding will primarily be at Memorial There is an OB fellow (4th year FP) who does C -hysts, etc. Residents may assist if time allows. There is no routine OB work on this rotation. Resident discipline will come under the UTMB House Staff Contract, and residents may be pulled from rotation if requested by CHRISTUS faculty. Page 108 of 185

CHRISTUS is a faith-based system and residents must agree to abide by its ethical standards while on the rotation.

TIPS FROM DR. CHILVERS

J Tips for Corpus Christi Gynecology Rotation J

What needs to be clear to us residents is that Memorial is to be the residents TOP PRIORITY, meaning that, if one of you is away (for an interview or something, like missed a plane ride and could not be available to round at Memorial), the other resident is expected to be at Memorial to round, etc. This has been discussed because, if the 3 rd year is gone and the 4th year goes to Memorial, then they could leave a private high-and-dry without a primary assistant, which is bad for them and for our program over there. So, knowing about absences/interviews ahead of time is key. So you can let the private MD know ahead of time and he can obtain another assistant (this did not happen on my rotation, but it is quite possible the way things are set up). There are unforeseen emergencies that could happen the day before, but in those cases one of the gyn residents (family practice) who is on rotation should be called along with a faculty Dr. Elmilady in particular would like to be kept informed of every case scheduled for the OR at Memorial as well as any unforeseen or foreseen absences from Memorial. Call him anytime, even during the middle of the night, even i f he is not the one on call (except for an emergent case to be done that same night when he is not on call), as he is mainly in charge of the residents at Memorial. This will keep things running smoother between faculty and between residents and faculty. Overall, they are very understanding and admit that the tasks and duties and procedures are still being worked out. Communication is key, I say. So make effort to talk to them about your schedules any time there is a change. 3rd year: Primarily at Memorial, will go to Spohn South some days to watch urodynamics and may occ. be sent to Spohn South if schedule is light at Memorial (usu. not a problem). Will round at Memorial every day except on weekends when not on call. Has a closer working relationship with the family practice residents because works more with them in Memorial than the 4 th year. Other tidbits: No OB requirements for either UTMB resident. J Spohn South pagers to be obtained by second group. There are cards for parking and keys for the apartment that need to be handed off each rotation. UTMB residents still need their own code/Dr. number to dictate and print censuses. Residency coordinator: Belinda (Bel) Flores, tel. 361-902-6570 . She also has a cell phone #, but each resident can ask her for this. The other private MDs are good about giving cell phone/ contact #s if needed. The Corpus Spohn Memorial Hospital Address is 2606 Hospital Blvd. Corpus Christi, Texas 78405.

Page 109 of 185

The apartment address is 1802 Ennis Joslin Corpus Christi, Texas 78412, Apt 736. Bring bath towels, pillows, and sheets for twin beds. There is not yet cable or a TV, but Michelle Andre and Jeff Sandate will probably see to it that this is changed by the 3 rd block by speaking with Sherry about this. The item s from Harlingen that are ours should be brought down there. Also, there is FREE food at ALL the hospitals in which you will work. Yea!, so good for the morale. There are computers in the Memorial library or the Spohn South doctors lounge which can be used without passwords. Also, the hotel has a work out place and a Free monthly massage for residents of the complex (cant say that I set up a time for this but it is worth checking out for a stress reliever; of course an alternative is the Corpus beach huge step up from the Galveston beaches). Also note that Ennis Joslin and Ocean drive are the best streets on which to run, as they are safe and scenic and close to the apartments.

Memorial Southeast Hospital Rotation

2nd year residents
On-site supe rvision: When/where to report on the first day: To Dr. Salinas's office at 8:30 a.m. 1650 Winding Way Drive, Suite 100, Friendswood, TX Check with Melissa at her office 281-996-7788. Dr. Asumugha office is 1103 Resource Pkwy #104, Houston 77089 called the AFina Womens Center - - He has in office procedures on Thursday -so try to go to this location by 8:30am . call the office to let them know about you 281-464-9100.

Schedule: The gynecology rotation at Memorial Southeast Hospital is a six to seven week block. The 2nd year at Memorial Southeast takes Sunday ER/Ward call in Galveston from 7:00am to 7:00pm. There is no overnight call at Memorial Southeast. The Memorial Southeast resident will return to Galveston on Friday mornings for continuity clinic. Dr. Salinas will assign your specific schedule at Memorial Southeast and be your primary point of contact during your rotation. Directions: Travel IH 45 north. Exit Dixie Farm Road, go west over IH 45 to Beamer Road. Turn right onto Beamer and go approximately 1.5 miles. Turn right on Astoria. Memorial Hermann Southeast Hospital will be on your right. It is approximately 37 miles from UTMB. Tips:

Page 110 of 185

Check the OR schedule for the entire week, get permission and scrub into as many cases as possible. Thursdays are Dr. Asumugha gyn procedures days: (IUDs, Colpos, biopsies, etc.. at his office) Dr. Dafashey and Dr. Tawadras do the majority of the laprascopic cases. OR is on the 3rd floor GYN pts are usually on 4B

Educational objectives: Medical Knowledge

Develop a core knowledge of: o Premalignant lesions of the female reproductive tract o Abdominal surgery principles o Operative hysteroscopic procedures o Laser principles o Operative laparoscopic surgery principles o Preoperative evaluation of healthy patients Build upon core knowledge of: o Gynecological emergencies o Normal and abnormal pelvic anatomy o Postoperative management

Patient Care

Perform: o Laser surgery of the external genitalia o Abdominal hysterectomy and bilateral salpingo-oophorectomy o Laparotomy o Operative Laparoscopic procedures

Interpersonal and Communication Skills

Provide adequate sign-out for gynecology patients to the cross covering team at night Communicate with referring physicians Communicate with consulting services

Professiona lism

Understand the anxiety of a patient with a prior poor obstetrical outcome

Page 111 of 185

Refine your skills in dealing with difficult patients

Practice Based Learning

Increase awareness of the hospital formulary drugs Demonstrate an understanding how to schedule patients for surgery Dictate operative notes and discharge summaries in a timely fashion

System Based Practice

Recognize insurance requirements for elective and emergency hospitalizations Understand goals of utilization review

Reading assignments Te Lindes Operative Gynecology, 9th edition: Chapters 15-17, 26, 28, 31 ACOG Technology Assessment #4 ACOG Practice Bulletin #3, 11, 14, 15, 67, 72

Page 112 of 185

6
Section

Admitting Policies and Procedures

General Information
All housestaff have admitting privileges to John Sealy Hospital. All admissions including TDC should be called to the Admitting Office at extension 73600. An upper level resident MUST approve all admissions. Obstetric admissions of stable patients with nonviable pregnancies should be done directly to the antepartum unit. These patients are not to go through Labor and Delivery. Gynecologic admissions require pre-approval by the admitting gynecology faculty with formal evaluation by an upper level resident.

Transfers In House
All transfers should be called to admitting services at extension 73600 as above. If the patient is to be transferred from ANOTHER SERVICE the following information is needed: Patient's Name. Unit History Number. Diagnosis. What service the patient is currently on. Special needs. Reason for transfer. The resident of the transferring service must contact the resident of the accepting service to provide pertinent case information.

Transfers from Outside UTMB

MUST BE ACCEPTED BY A FACULTY MEMBER. There are no exceptions to this rule. Refer all requests to the transfer center at 1-800-FACULTY.

Page 113 of 185

7
Section

Housestaff Duties Outside of Routine Patient Care

Teaching
The Obstetrics and Gynecology housestaff play a critical role in the education of the third and fourth year medica l students. The students rely on the expertise of housestaff for decision-making, and look to you as their model for professional behavior. Students at the University of Texas Medical Branch spend six weeks on the Obstetrics and Gynecology clerkship. The re is also four-week Acting Internship Obstetrics and Gynecology rotation. The appointed resident for the service should make a point of sitting down with the students on the FIRST day of the rotation to explain his/her expectations. Students are given ba sic guidelines for the clerkship in orientation. Individual residents need to explain their team management style and expectations to the students clearly so that everyone can work well together. Encourage the student to interview and examine the patient first when possible. The student should be informed of the presenting complaint (not the presumptive diagnosis) and the student should see the patient before reviewing the chart. After seeing the patient the student should review the chart and write-up the history and physical examination. A problem list should be developed. Discuss the students findings and facilitate their working through the patients problems. The student should be given time to read about the patient and write a thorough assessment and plan. Students should be prepared to present each of their patients on morning rounds. Give feedback to the student on presentations, both content and style. Incorporate bedside teaching for interview and physical examination technique. Review the b asics of laboratory findings with the students to insure that they understand both why a test was ordered and how to appropriately interpret the results. In addition to ward/clinic/OR work, students are expected to attend lectures and small group meetings. Student didactic sessions are given priority over other responsibilities including ward/clinic/OR activities. A critical role in teaching students is feedback and evaluation. Please give the students feedback as often as possible. At mid-rotation and at the end of the rotation you should sit down with each student individually and discuss his/her performance. Student evaluation should be completed and turned in on the last day of the rotation. Housestaff evaluations of

Page 114 of 185

the students are critical in the as signment of a students grade so please provide objective comments that are representative of the students performance for the entire rotation. Students play an important role in the workings of a ward team, but please remember that they are also in school and that the experience should enhance their education. It is reasonable for a student to gather data relevant to the patients that they are following and to help the team out as much as possible. However, asking a student to leave attending rounds to do scut work does not support the educational mission of the department. Students are held to the highest standards of professional behavior. Please model the behavior that falls within the appropriate guidelines for our profession. If the students obse rve you consistently behaving in a professional manner, they will adapt their behavior accordingly.

The clerkship office welcomes housestaff at any time to discuss questions or concerns regarding students. You can call (772-2897) or email Brandie Davis, student coordinator (bmdavis@utmb.edu) at any time.

Residents are also actively involved in teaching other residents. Lower level residents (PGY1&2) are expected to evaluate patients and then present the patient along with their diagnosis and management plans to an upper level resident (PGY3&4). All residents serve as a role model, either to a student or other resident, thus professional behavior is expected at all times.

Resident Research
Resident participation in scholarly activities is mandatory. (Further updates will be added) I. All residents are required to participate in scholarly activities. This requirement may be fulfilled in one of three ways: A. Completion of an original basic or clinical science investigation. The data collected must be submitted for presentation at a regional or national meeting. The resident will also present the research findings at departmental Grand Rounds. B. Preparation of a review article summarizing current topics of clinical interest to obstetricians and gynecologists. This review article must include a thorough summary of the published literature on the topic. A manuscript must be prepared that is of publishable quality. For examples, see review articles in the Obstetrical and Gynecological Survey. At least 20 references must be included. The length should be from 20-30 manuscript pages (including tables, references, and figures). The resident will also be expected to present the topic orally at a Grand Rounds during the PGY-4 year. C. Preparation of a case report or case series. The Green Journals format should be used unless the report is submitted to another journal. See http://www.greenjournal.org/misc/authors.pdf for details. D. Completion of a quality impr ovement project II. Prior to commencing the project or review article, the resident must: A. Have the project/review article proposal approved by the director of resident research B. Have identified a faculty member to mentor the resident for the scholarly activity III. Timeline for all scholarly activities:
1) PGY-1: March- complete Citiprogram on line training and identify a mentor or project May- complete IRB submission (literature search and discuss with faculty on the feasibility of study question and write background / introduction and hypothesis section)

Page 115 of 185

2) PGY-2: Aug- complete Method section and review with mentor 4-6 weeks of protected research- lab or data collection 3) PGY-3: Nov-Feb- data analysis. If complete early enough can present at SGI, SGO, SMFM, ASRM, ACOG or other meetings. Available for fellowship application. June- research day- presentation research or review or case-report or QI projects 4) PGY-4: Manuscript for publication (research studies or review or case report or QI). (PGY-4 will have more time to interview for job/fellowship, prepare for ABOG and to look for new giant house and to prepare for the move).

IV. Residents who elect to fulfill the scholarly activity requirement by completion of an original basic or clinical science investigation are eligible for the UTMB OB/GYN Resident Research Award. A. The award will be $500 for 1st place, $250 for 2nd place, and $100 for 3rd place. B. Only research performed during residency will be considered. Projects must be completed by September 1 of the PGY-4 year to be eligible. C. Only PGY-4 residents are eligible for this prize. D. If there is not research of sufficient quality, prizes may not be awarded in any given year. E. Awards will be determined by a committee of faculty, chosen by the residency program coordinator. Faculty mentors of residents under consideration for the award may not serve on the committee. V. This policy applies to residents entering the program in 2007, the PGY -1 class that began training in 2006, and all subsequent entering residents.

4/19/07 DMB Edited 6/1/2011 TW

Procedural Tracking
The ACGME requires residency programs to provide a minimum number of Obstetric, Gynecologic and Surgical Cases in order to continue accreditation. Each resident is responsible for keeping track of every case/procedure performed. Please remember that your primary care, elective experience, transvaginal ultrasounds, amnios, and LEEPS and are just as important to keep track of as your operative cases.

Medical Record Keeping

A. Operative Reports Dictations must be done in the recovery room after completing the surgery. Dictations are considered LATE if not completed by the morning after the surgery was performed. The following people receive notification of delinquent dictations daily, the Chairman, Dr. Hankins, the program director, Dr. Breitkopf, the assistant program director, Dr. Haver, the Chief Residents and the Program Coordinator, Sherry Bastien. Policy on Delinquent Charts The following policy will be implemented Monday Ja nuary 16, 2007.

Page 116 of 185

If any ob/gyn resident has more than 10 delinquent charts (aged greater than 30 days), he or she will automatically be placed on vacation until the charts are completed. This number will represent the combination of both paper charts, and the electronic medical record. The vacation days will come out of each residents current vacation balance. If the residents vacation balance is depleted, they will be placed on temporary suspension until the charts or ACGME entries are completed. Any days spent on suspension will be made up at the end of the residency. Coverage for unscheduled vacations will be provided by fellow residents as needed

B. Inpatient Discharges Residents are responsible for completing the Yellow Border discharge form and the discharge summary dictation within 28 days from the discharge date (additionally on OB postpartum services the Purple Border sheet is required). The Chief resident of the service is responsible for assigning each team member specific dictation requirements. Process for Assurance of Medical Record Completion: Upon discharge, the record will be brought to Record Processing and rechecked for completeness. If the required dictation/documentation has not been done, the OB/GYN MRT will place the chart in the residents MRT chart slot. The chart will remain there for 9 days and then will be sent to the main medical records department. Note: if there are no charts in the OB/GYN MRT slot, check your list of dictations or the main medical records. Just because the MRT slot is empty do not assume all dictations have been completed. Every two weeks a letter is generated listing all assigned dictations/documentation, including those designated as delinquent. These letters are sent to each individual resident and faculty. If any record remains incomplete at the 28th day, the physician has violated Medical Staff Bylaws, which will result in suspension from the Medical Staff or Residency Program. This 28th-day incomplete status will be verified and the Clinical Chairman, Vice President for Hospital Affairs, Vice President for Administration and Business Affairs, and the President will be notified (any one or all) on the 30th day at which time the medical record will be officially declared delinquent and the p hysician will officially be suspended from the Medical Staff/Residency Program. Suspension will be lifted upon completion of any delinquent records. The Administrative Chief Residents office receives lists of those persons who have delinquent medical rec ords. Anyone who is on this list will be notified to correct this problem. If the resident remains delinquent for a period of greater than 2 weeks, the Administrative Chief Resident(s) can temporarily suspend that residents operative privileges until completion of the delinquent records. It is important to note that as long as a resident is delinquent in dictations, their supervising faculty is also classified as delinquent by the medical records department and the faculty can be suspended. Thus, this would probably be reflected in their evaluation of the resident. When you leave UTMB and apply for hospital privileges elsewhere, they request your evaluators to comment on your efficiency and delinquency of medical records.

Page 117 of 185

C. Clinic All patients seen in Gynecology clinic must have a hand written OPD note (this stays with the billing sheet) or an EMR dictation completed. EMR dictions must be signed off in Clinweb within 24 hours. HYST FORMS:
Billing will print up around 50 pre-op packets and get to Tina Fish so they are readily available for the residents Once a patient is pre -oped and her packet is complete the resident will place it in a box labeled pre op on the 7t h floor (Cathy McLean will arrange the box and let residents know where it is) 3rd floor personnel will pick up pre-op packets from the box on the 7t h floor daily 3rd floor personnel will take care of faxing the posting sheet and preanesthesia form to the appropriate office and we will arrange for the completed packet to be delivered to DSU

The residents will select the date and tell the pt..and yes all forms are included in the packets the residents need to put the entire packet in the box .. we will pick them up --

Request from Dr. Borahay: Here is the background: when we see a patient in clinic and want something done (mammogram, echo, CT scan,), we used to write the request, hand it to the patient and the patient gives it to front desk person when leaving clinic. Patient leaves with promise someone will call her with the appoin tment. Often times, nobody calls her for reasons ranging from most clinics are already on EPIC and people dont check their fax machines as before, or her phone number on record is old or they called her while she was out. This results in a group of patient waiting for a phone call that dont happen. They call the clinic nurse later frustrated and the nurse tries to hunt a resident (or faculty) to solve the issue To prevent this group of patients from forming, the front desk person (OSAs) will schedule these appointments before the patient leaves the clinic. The resident should inform the patient to have the appointment scheduled and the slip printed to her before leaving the clinic. If the patient needs follow up appointment with us, then this needs to be scheduled also before she leaves. We DONOT want patient sent home with plan that somebody will contact them later. Everything needs to be scheduled before patient leaves. Few last points: 1. Only exceptions to this rule is Cancer stop and county contract patients. These patients are essentially eligible only for mammogram as investigations. As of now, they will need to be approved by their funding resource and then called back for appointments. The patient needs to get a reliable phone number to call for follow up once their service is approved. 2. Residents should completely refrain from requesting an investigation/consult/imaging for a patient without funding. Make sure she understands that unfunded investigation will cost and she is aware and ready for it. Requests for other service consult, imaging for unfunded patient will give the patient the impression that it will be done, she will be later frustrated when knowing the case, will waste time of our clinic personnel and most importantly, will not be done. Patients can be referred to appropriate community resources, e.g. 4cs clinic, Rose clinic for mammograms, and so on. Page 118 of 185

3. We will keep gyn team clinic in the morning. Erin and Gradie promised there will be a difference in presence of upper level residents. We will re-evaluate situation in August.

All patients seen in L&D triage and any prenatal clinics must have an EMR note done under the appropriate covering Faculty. The EMR note must be electronically signed by the completion of the clinic or shift. D. Birth Certificates By Texas state statute, birth certificates must to be signed by 5 days from delivery. They are located in a file in the OB/GYN MRT next to the resident mailboxes. When on an Obstetric rotation or just having completed an obstetric rota tion, make it a habit to go by the MRT and sign the birth certificates daily.

Circumcisions
Circumcisions are performed by the Pediatric Department. Any resident interested in learning how to perform circumcisions may contact the Pediatric Department to arrange for training.

Declaration of Death / Death Notes / Autopsies

At the conclusion of an unsuccessful code, or in the event of the expiration of a patient who did not wish to be resuscitated, the primary team physician or the on-call physician will be required to pronounce the patient dead. The pronouncing physician will have the following responsibilities: Examination of the patient and confirmation of death. Notification of the attending physician and the patients family. Completion of a Death Note in the chart, dated, timed and signed by the physician pronouncing death (example below). Inform the Charge Nurse of the death. Request autopsy from patients family. Completion of paperwork (Authorization for Postmortem Procedures Form, Cause of Death Worksheet). These forms will be available from the unit clerk and can also be found at <http://clinweb.utmb.edu/dap/>. This paperwork must accompany the body to the morgue and should be as complete as possible pending availability of more information. See Appendix B for further details on decedent affairs paperwork. Make arrangements to meet patients family if arriving later that day. Sign official death certificate. Medical records prepare this and the physician will be contacted 2-5 days later to sign this form. This should be done as promptly as possible.

EXAMPLE OF DEATH NOTE: "Called by nursing staff to see patient for lack of respiration and pulse. On examination, patient was found to have no spontan eous respirations. No pulse could be palpated or auscultated. Pupils were fixed mid-position, and there was no pupillary reaction to light. There was no response to deep pain stimuli. Patient had requested that no resuscitation efforts be undertaken given the terminal nature of his/her disease. We have complied with these wishes. Patient was pronounced dead at 0519 today,

Page 119 of 185

June 6, 1992. Patient's family and Attending Physician, Dr. Blackwell, were notified." Signature of pronouncing physician must follow death note, and must be legible. Beeper number should also be included with the signature. TDCJ Deaths The physician confirms death and writes the death note in the chart. The resident notifies the attending physician of the patients death. The TDCJ Chaplain will notify the family regarding a patients death. A TDCJ Official will contact the next-of-kin regarding autopsy and funeral home arrangements. A TDCJ Official will communicate the funeral home arrangements to Autopsy Service. TDCJ will notify the Medical Examiner. Transportation will assist with moving the body to the morgue. If death is not medico-legal, the physician will complete and sign the death certificate.

Directives to Physicians / Do Not Resuscitate

In Texas there are three forms that document a patients wishes concerning the provision of future life -sustaining treatment (CPR, medications, ventilators, dialysis, artificial fluid and nutrition, etc). 1. Directive to Physicians and Family or Surrogates - The patient states their preferences and may appoint a proxy. - Becomes effective when the individual is determined to have an irreversible (incurable) or terminal (death predicted within six months) condition and the individual is unable to express their wishes (incapacitated, comatose, etc). 2. Medical Power of Attorney - The patient appoints an agent to make health care decisions in the event that the patient becomes incapacitated. 3. Out of Hospital DNR - Directs that CPR not be performed in settings outside the hospital (includes ER, Clinics). - An identifying bracelet is sufficient evidence not to provide resuscitation. - It is not necessary that patient be terminal or has an irreversible condition. - It can be completed by a surrogate on behalf of the patient. By federal law, all patients admitted to the hospital should be asked if they have an advance directive and if not, whether they would like information about them. Additionally, it is good practice to discuss these issues with both inpatients and outpatients so that their wishes are known and can be honored. Further information is available in UTMB IHOP Policy 9.15.5, 9.15.6, 9.15.8 or from the Ethics Service (x71230) or Legal Affairs (24818). Any of these documents may be revoked at any time by the patient (or their surrogate in the case of an OOHDNR). DO NOT RESUSCITATE ORDERS/WITHHOLDING/WITHDRAWAL OF LIFE SUSTAINING TREATMENT Treatment decisions concerning CPR or life -sustaining treatment can by made by: The informed choice of a patient that in the physicians judgment is capable of making medical decisions. Page 120 of 185

If the patient has been determined by the attending physician to be incapable of expressing his wishes and in a terminal or irreversible condition: o On the basis of a patients directive. o By the legal guardian. o By the Medical Power of Attorney or proxy appointed in patients directive. o By an appropriate surrogate decision maker (next of kin) in the following order: Spouse, Adult child, Parent, Nearest living relative. If there is not a legal guardian or medical power of attorney and none of the above surrogates are available, the attending physician may make a treatment decision and request that a physician from the Ethics Committee concur with that decision. All surrogate decision makers should make treatment choices based first on their knowledge of the patients wishes and if that is unknown based on the patients best interest. Note: 1. A faculty physician must write DNR or other orders concerning the withholding or withdrawing of life sustaining treatment. 2. The Treatment Support Level form is a guide for discussion and for physician orders and is not to be completed or signed by patient or surrogate. 3. DNR or other orders concerning the withholding or withdrawing of life sustaining treatment must be re-written after transfer between units. 4. In the case of perceived medical futility by the healthcare team in which a DNR or Withdrawal of Support orders are desired by the team without the agreement of the patient or patients surrogate, an Ethics consult should be obtained. The Ethics Service w ill then evaluate the case and advise the team how to proceed. 5. If questions or disagreements occur, consult the Ethics Service for assistance (x71230).

Consultations
In-hospital consults between Obstetrics and Gynecology and any other service should occ ur on a physician-to-physician level, despite the computerized consult format, with verbal contact made by the consulting physician. During the weekends and holidays only urgent consults should be requested. Routine consults should not be entered until the next regular working day. Urgent consults must be called directly to the consulting physician. All consults performed by the Obstetric and Gynecology service must be completed within the same day of receiving the request and must be staffed by the appropriate Faculty. Gynecology consults will be assigned to the team in the Gynecology clinic on the day the consult was received, unless the patient was previously known by a specific Gyn service. Consultation requests for Obstetrics or Gynecology needing to be performed over the weekend are to be completed by the Ward Call resident (with consultation by an upper level resident). If a weekend consult is performed and requires the Obstetric or Gynecologic services to continue to follow the patient, the Ward Call Resident staffing the consult must notify the chief resident of the appropriate team.

Page 121 of 185

8
Section

Sponsored Educational Programs

General
The Department of Obstetrics and Gynecology, the Graduate of Medical Education Office and certain pharmaceutical companies provide each resident with certain complimentary items relevant to medical education. These items include; three white non-monogrammed lab coats per year, Medical Textbooks, membership to ACOG (monthly Obstetrics and Gynecology green Journal), Monetary Discretionary Fund, Long Distance Telephone Code, Reduced Rate Parking, Reduced Rate Field House Membership, Reimbursement for educational meetings/travel.

Discretionary Fund
Over the four years of residency, each resident will receive a complimentary allocation account consisting of a total of $2,400.00. This money may be used for reimbursement of licensing fees (for Texas, American Board Written exam, etc), purchase of books, office equipment, etc. There is a caveat, any item that is purchased must be less than $500.00 otherwise it will be UTMB property when the individual leaves the institution. Any unspent money at the end of the four years will belong to UTMB so use as much of it as you can. PGY-1s Complimentary Textbooks PGY-2s Allocation amount is $900 PGY-3s Allocation amount is $1500 PGY-4s No additional allocation or textbooks

Medical Literature
The Department of Obstetrics and Gynecology provides each resident with several pertinent medical textbooks. These books are distributed during the PGY1 years. See below for a list of complimentary textbooks.

Page 122 of 185

PGY -1 Williams' Obstetrics Williams Gynecology Clinical Gynecologic Endocrinology and Infertility (Speroff) Principles and Practice of Gynecologic Oncology

Medical Organizations
In order to preserve power and quality in health care, physicians must be actively involved in professional organizations. Obstetrics and Gynecology Housestaff are encouraged to join the following organizations. American College of Obstetrics and Gynecology (ACOG) membership, as a Junior Fellow, is automatically provided by the Department of Obstetrics and Gynecology. for the duration of the residency. After graduation, ACOG automatically converts you to a Junior Fellow in Practice and will bill you in November. Once you obtain ABOG certification you will become a full Fellow. For reference the ACOG website is <http://www.acog.org> American Medical Association (AMA) can be joined through the state or directly. Dues for residents are approximately $45.00 per year or $120 for three year membership and include subscriptions to the Medical News and JAMA. Membership application information is available on their website <http://www.ama -assn.org>. Texas Medical Association (TMA) through the Galveston County Medical Society. Dues are approximately $25.00 per year. The benefits include low cost life insurance, practice management seminars, and the opportunity of political participation in the future of medicine. Membership application information is available on their website < http://www.texmed.org >.

Page 123 of 185

9
Section

Educational Conferences and Examinations

General
These conferences are designed to provide a didactic educational experience for the residents. Although unforeseen circumstances may occur, attendance is considered mandatory. As referenced in further detail in section 13 Professional Standards and Professionalism, it is unacceptable when a resident fails to comply with the educational requirements of this training program. Educational requirements for conferences and lectures are all lectures will have a reading assignment and questions/quiz. The residents use Blackboard to review their reading assignment and take their quiz. Tegrity will be used when available to record the lectures and slide presentations. The residents will have 10 days from the date the lecture was presented to take the quiz. The residents will have two chances to take the quiz for a passing score. The quiz is timed about 2 minutes per short questions (adjustments will be made for paragraph questions). If the quiz is not completed by the 11th day, then a 0 is recorded as the score. 3 or more quizzes resulting in non-passing grades (below a 70) will result in the resident to be reviewed by the education committee for decisive action. Didactic policya) I have calculated- The Total hours of lectures per year will be 75 hours (52 weeks x 3 = 156 h) (Dec-Jan CREOG prep & holidays= 22 h) (grand rounds= 8 h) (M&M= 22 h) (J club= 8 h) (7 simulation lab= 21 h) =75 hours. b) You will be excused for 3 weeks of vacation + 1 week of illness= 10 quizzes c) Youwill be responsible for 65 quizzes per year or 5.4 per month. Maximum time to review 2-3 lectures on Tegrity + 2-3 Quizzes= 5 hours/week. d) You will be given 11 days to complete the weekly quizzes (deadline is 2nd Sunday after the lecture). e) You will have 2 trials at each quiz and maximum time of 30 min per attempt. f) Passing score is overall 70% of the 65 quizzes. (So 1 correct answer is better than 0%). g) Special circumstances require PD assessment: (1) Illness or family illness (maternity leav e); (2) Family Crises; (3) Extended leave- will excused at time of leave; however, the resident must make up the quizzes upon return to residency program. i.e. The quizzes given during your leave can be postpone until your return to work.

Page 124 of 185

Blackboard
Are goal for Blackboard is to give every resident an equal opportunity to learn the CREOG Educational Objectives as covered by reading assignments, lectures and quizzes. We hope to create a syllabus in which a resident may work at an advanced pace or simply follow along on a weekly schedule. Whether the resident is offsite-on vacation-on nights or providing coverage this system is intended to give everyone the same learning opportunity. BlackBoard Instructions For Residents To access the blackboard login page you will go to: https://eclass.utmb.edu/webapps/login/ -Another way you can find this is by going to the UTMB homepage and under Students on the right side of the page there is a tab that says Blackboard, you can click on this and it will also take you to the Blackboard login page. You will login using your username and password that you use to login to your computer. (Hint: your username is usually your email without the utmb.edu) After doing this you should be at the main page of Blackboard, also known as My Homepage. There are several ways to access the course (OB-GYN Resident Lectures) in which you are looking for. 1. There are three tabs on the top of the page under the UTMB logo which say My Home, Courses, and CE8. You can select the tab that says Courses. On this page you will see Course List, then you will choose the course titled OB-GYN Resident Lectures and that will take you to the page where you need to be. 2. There are three tabs on the top of the page under the UTMB logo which say My Home, Courses, and CE8. You can select the tab that says CE8. On this home page under Course list you will choose OB-GYN Resident Lectures and that will also take you to the page where you need to be. 3. Again, there are the three tabs at the top of the page. On the My Home page under Courses you will choose OB-GYN Resident lectures and that again will take you to the page where you need to be. (You May Have to Login again after sele cting the OB-GYN Resident Lectures course) OB-GYN Resident Lectures Course Your homepage will consist of your: -Tegrity Recordings (where you will watch the lectures) -The Schedule -Rotation Objectives -Clinic Schedule -And some other lectures which w ill be named in case not in Tegrity On the left hand side you will find your: -My Tools -My Grades (where you will see what you have made on your quizzes) -My Progress (where you can see when and how long you have been logged on) -Notes (where you can take notes during your sessions) -Course Tools Page 125 of 185

-Announcements (where a teacher or instructor can let you know something important. -Assessments (where you will be taking your quizez) -Calendar (where you will find the lectures dates, times, and who will be giving them or any other important dates) -Chat (where you can chat to other residents or someone whos online for help or any other reason) -Mail (where you can receive and send mail to residents or an instructor) -Syllabus (where you find what is expected of you and what the requirements are) -Whos Online (where you can see who is on Blackboard) To log out you can just hit the X at the top of the page. For more questions you can see Sherry Bastien or Tony Wen.

Grand Rounds
Grand Rounds is he ld the first Wednesday morning at 8am in the Clinical Science Auditorium on the third floor. Attendance is mandatory for all residents except for those on OB Nights, ER and Offsite Rotations. Grand Rounds are cancelled over the months of June, July and August. During those months, this time slot is used for an Intern Lecture Series.

Morbidity and Mortality Conference

Morbidity and Mortality (M+M) conference is held on Wednesday mornings from 7:00am to 8:00am in the Clinical Science Auditorium on the third floor. The format of M+M is designed to prepare residents for the ABOG oral examination. The case lists for M+M are equivalent to the ABOG oral exam case lists. Attendance is mandatory except for residents on ER and Offsite Rotations. It is the responsibility of the residents on the following teams; Obstetric A and B, Gynecology, Gynecologic Oncology and Reproductive Endocrinology and Infertility, to compose and submit the M+M list in a timely fashion. On every service except for REI, the PGY 1 and PGY 2 are responsible for collecting and submitting the data to the PGY 3 resident. The PGY 3 resident is responsible for creating (entering the data) and submitting the list following approval from the PGY 4. The list covers all patients discharged from the above inpatient services from a Saturday through Friday time span. If the resident responsible for the list is in on vacation, it is the responsibility of the PGY 4 to ensure the list is turned in and any write ups are presented. The list must be turned into Jylynn for distribution of copies no later than Tuesday at 2:00pm. NEW FORMAT Preparation of the Case List The chief resident on each service is responsible for preparing the case list each week. (We will continue to use the previously established format)

Page 126 of 185

Prioritization of Cases Case lists will be reviewed by the Program Director or the Associate Program Director two weeks prior to being discussed in M&M Conference. Cases will be prioritized in the following way: Priority 1: Cases with mortality or major complications Priority 2: Cases with minor complications or interesting cases that might be worthy of discussion. Priority 3: Routine cases that are not worthy of discussion. Case review and presentation All Priority 1 cases will be assigned by the chief resident on service for presentation. The assigned resident may or may not have participated directly in the care of the patient. The record will be reviewed and additional pertinent information can be obtained from attending physicians or residents managing the case. The following information will be included in the prepared review and presentation: Brief Clinical Summary: A one to three paragraph summation of the pertinent history, physical findings, diagnostic studies, therapeutic measures, and patient outcome. Reviewers Comments: A critical analysis of the conduct of care in the case. This should include in recognized deficiencies in patient assessment, diagnosis, or treatment and conclude with a statement or statements of if or how the morbidity or mortality could have been prevented. Quality of Care Assignment: The case will be assigned a score of 1-5 based upon the accompanying definition of scores. Justification of Quality of Care Rating: A brief statement of the critical ele ments leading to the rating of care Formal Discussant All cases that are rated 4 or 5 in quality will be formally discussed by either a chief resident not involved in the care or by a faculty member not involved in the care. Formal discussions will be limited to approximately five minutes and not to exceed seven minutes. Requests for exceptions to the time limitation should be made to the Program Director no less than two days prior to the conference. It is understood that certain cases may require addit ional time for discussion. Informal Commentary Questions and commentary will be entertained by the conference moderator according to time availability. Quality of Care Rating 1: The case represents appropriate quality of care and meets generally recognized standard in all areas. Quality of Care Rating 2: There is a different way that this case may have been managed but the difference is more a matter of style and would not constitute a breach in the generally recognized standard. Quality of Care Rating 3: Documentation is below the generally recognized standard due to deficiencies in documentation, i.e. inadequate or late history and physical examinations absent of progress notes, etc. Quality of Care Rating 4: deficiencies in treatment. The care was below the generally recognized standard for

Page 127 of 185

Quality of Care Rating 5: contributed to patient injury.

The care was below the generally recognized standard and

Faculty/Didactics Lectures
Faculty lectures are held on Wednesday mornings in the Clinical Science Auditorium on the third floor. A variety of faculty in each of the departmental divisions lecture on topics covered by the CREOG examination. Attendance is mandatory except for residents on ER and Offsite Rotations. 1st Wednesday 0700 0800 0900 M and M Grand Rounds Didactic 2nd Wednesday Didactic Didactic Didactic 3rd Wednesday M and M Journal Club Didactic 4th Wednesday Didactic Didactic Didactic

Intern Lecture Series

In place of Grand Rounds during the months of July and August, several f aculty have kindly volunteered to lecture on topics relevant to patient care from an intern point of view. Attendance is mandatory for all residents except for those on OB Nights, ER and Offsite Rotations.

Journal Club
Journal Club is usually held on the third Wednesday of the month and will replace Grand Rounds from 8am to 9am. There are eight residents (two from each PGY level) selected to present. The articles and assigned questions will be distributed by the first of the month to the assigned presenting residents. The remainder of the faculty and residents will obtain the articles one week prior to journal club. The purpose of journal club is to teach residents how to critically evaluate research, allowing continued education after residency. Attendance is mandatory for all residents/fellows that are providing coverage. If a resident is assigned to present but has a conflict, it is that residents responsibility to find a substitute. Journal club is cancelled during the months of December and June. Resident presentations should be limited to 10-15 minutes, although discussion may dictate a longer period. The resident is expected to present a brief discovery of the objectives assigned, which should include critical evaluation and analysis of the materials and methods, study population, statistical methods and conclusion. This evaluation is designed to be similar to an editorial review of a manuscript submitted to a journal for critical review.

In-Service Examination
The Council on Resident Educ ation in Obstetrics and Gynecology designs an annual CREOG InTraining Examination, fondly known as CREOGs. This examination is designed to test the residents knowledge base and prepare the resident for the American Board of Obstetrics and

Page 128 of 185

Gynecology (ABOG) written certification examination. The examination is held mid to late January of each year. The test has two three-hour segments and is administered on either a Friday or Saturday. The Administrative Chief resident(s) will determine the schedule fo r test administration and assign certain residents to cover clinical responsibilities while other residents take the examination. ACOG provides a CREOG resident quiz series composed of 52 separate learning exercises. It can be found on the ACOG website < http://www.acog.org>. Every resident has automatic physician member access to the website as a benefit of ACOG membership. The user name is your complete e-mail address (_______@utmb.edu). To access the quizzes, log onto the ACOG website, scroll to the bottom right-hand side of the page and click on CREOG. The CREOG home page will appear, access the quiz series by clicking on the menu bar on the left side of the screen. Residents are expected to make a standardized score for their postgraduate year of greater than or equal to 180. Residents scoring less than 180 standardized score for their postgraduate year will be required to attend remedial academic sessions. Residents who score less than 180 standardized score for their postgraduate year in consecutive years will be at risk for nonpromotion.

Page 129 of 185

10
Vacation / Leave Policies
General
At all times, absence begets the responsibility to arrange complete coverage with another house officer. The Chief Resident(s) and Program Director must approve all vacations and leave at a minimum of at least four weeks in advance. Submission of the vacation/leave request form does not mean that the vacation/leave has been approved. It is the responsibility of the resident to confirm that the vacation has been approved. There is an online application for leave request Log into MYUTMB click on SAS (Shared Administrative Services). Then proceed with completing a leave request. This will go through a chain of approvals including the Administrative Chiefs, the Coordinator, and the Program Director. Also, please send an email to the 4th year resident of the service, as well as the faculty of that service. This will allow each service to prepare for your absence. Housestaff absent from their duties without informing the Chief Resident(s) will be subject to disciplinary action. Note: ABOG establishes the requirements for leave/vacation time during residency. UTMB policy determines whether that leave of absence is with or without pay.

Section

ABOG Vacation/Leave Requirements

The Department of Obstetrics and Gynecologys policy regarding the various types of vacation and leave time is guided by the Bulletin of the American Board of Obstetrics and Gynecology (ABOG), which, in conjunction with the Residency Review Committee (RRC) for Obstetrics and Gynecology, is responsible for the accreditation of training programs and the certification of individual competence in Obstetrics and Gynecology. See the below excerpt from the ABOG Bulletin or refer to the ABOG website <http://www.abog.org>.
"If, within the four years of graduate medical education, the total of such leaves and vacation, for any reason, (e.g., vacation, sick leave, maternity or paternity leave, or personal leave) exceeds eight (8) weeks in any of the first three years of graduate training, or six (6) weeks during the fourth graduate year, or a total of twenty (20) weeks over the four years of residency, the required four years of graduate medical education must be extended for the duration of time the individual was absent in excess of either eight (8) weeks in years one three (1-3), or six (6) weeks in the fourth year, or a total of twenty (20) weeks for the four years of graduate medical education."

Page 130 of 185

Total Leave Time

The total of vacation, sick leave, personal leave and maternity/paternity days off cannot exceed 20 weeks during the four -year program. If the 20 weeks total is exceeded for whatever reason(s), training must be extende d accordingly into a fifth year. Such training extensions must be approved by the RRC and are not guaranteed.

Vacation Time
There are three allotted weeks of vacation per resident per year. Arrangements for vacation time are to be made according to specific established guidelines as determined by the Administrative Chief Residents and the Program Director. Please refer to these afore mentioned people for further details of these guidelines. Residents are expected to make up call nights or weekend coverage missed during vacation time so that each resident over a one year time period has the same number of calls. For clarification purposes one week of vacation means five business days.

Educational Meeting Time

Arrangements for educational leaves are to be made with the prior approval of the Administrative Chief Resident(s) and the Program Director. Request for an educational leave must be completed at a minimum of thirty days prior to the anticipated meeting. This allows for cross coverage arrangements and travel arrangements. If you desire for the Department to pay for your travel arrangements or reimburse you for travel they must have a minimum of 30 days advance notice, this can be arranged through Sherry Bastien. It is expected that any call or weekend coverage missed be made up. Unused educational meeting time cannot be used for vacation or other leave purposes. Educational Meeting time is considered a regular workday and is not deducted from the 20 week total leave over the four years of reside ncy.

Maternity Leave
If desired, a resident will be granted up to six weeks for maternity leave. It should be remembered, however, that maternity leave must be factored into the 20 weeks total leave, which obviously means that vacation, sick leave or personal leave may be lost in current or subsequent training years. It is expected that all call nights and weekend coverage missed be made up, either before or after maternity leave, such that each resident over a one year time period has the same number of calls. Also note that taking 6 weeks of maternity leave in the PGY 4 year will mean that no other leave can be taken (vacation, sick leave, holiday vacation or personal leave). If you exceed 6 weeks of leave in the PGY4 year you will be staying past graduation to make the time up.

Paternity Leave
After his wifes delivery, a resident may have a maximum of 2 weeks off during the postpartum period. Such leave must be approved by the Program Director and Administrative Chief Resident(s) and will be counted against that years UTMB vacation or sick leave time. This time will also count against the 20 week total leave time. Call and weekend coverage is expected to be made up. The

Page 131 of 185

five days allotted may begin either on the day of delivery or the day of his wifes hospital discharge (this must be previously declared with the Administrative Chief Residents).

Fellowship/Job Interviews and Examination Leave

PGY 4 residents are allotted a maximum of six days of leave for the purposes of interviewing for Fellowships and/or a Job/Practice. These six days are counted as regular workdays and are not deducted from the 20 week total leave time. This type of leave as with all others, requires preapproval from the Administrative Chief Resident(s) and Program Director. Any unused time may not be applied to any other type of leave. If additional leave is needed for these purposes it must be taken out of sick leave or vacation leave. There is an allotment of three days of leave for the purposes of taking the USMLE Step 3 examination (2 day exam) and a licensing exam (i.e., Texas Jurisprudence 1 day exam). This may be taken during any PGY year with preapproval of the Administrative Chief Resident(s) and Program Director. These three days of leave are considered regula r work days and are not counted against the 20 weeks of total leave. Note: this only applies to first time examination takers only. Leave for repeating an examination after failure would be taken out of personal leave or vacation and would be counted in the 20 week total time.

Holiday Vacation
Holiday vacation consists of a designated amount of time off encompassing either the Christmas or the New Years holiday. The amount of time off varies (roughly 5 actual days) each year and is determined by the Administrative Chief Resident(s). An actual day off is defined as including weekends and holidays. Assignment to work on either Christmas or New Years is at the discretion of the Administrative Chief Resident(s). This vacation time is counted in the 20-week total leave time. If a resident has exceeded their PGY level leave allotment or the 20-week total time this vacation may be rescinded or additional time past graduation may be due.

Page 132 of 185

11
Miscellaneous Policies
Licensure
A. Physician-i n-Training Permits During residency a Physician-in-Training permit will be obtained annually from the Texas State Board of Medical Examiners (TSBME) by the Department of Obstetrics and Gynecology on behalf of each resident. It is important to know that this permit does not authorize the performance of medical acts except as the acts are performed as part of the graduate medical education training program and under the supervision of a licensed practitioner of medicine. In other words the license does not cover the practice of medicine outside of UTMB. B. USMLE Step 3 A prerequisite to obtaining a medical license in any state is completion of the three USMLE examinations. The application for the USMLE Step 3 exam can be obtained on the website <http://www.usmle.org>. Application processing time is 2-4 weeks, after which a scheduling permit will be mailed. Upon receipt of the permit, you must call Prometrics testing center to schedule the exam within the designated 3-month win dow of test administration. (The three locations near UTMB are Webster, Sugarland and Kingwood). The fee for the examination is $705.00. The test results are available in approximately 6 weeks. Try to take your Step 3 examination as early as st possible, but it must be taken with the results in prior to June 1 of your PGY 2 year. Before submitting the application, discuss with the Administrative Chief Resident(s) the appropriate timing of the exam and your absence. Remember that although absence for the exam does not count towards the 20-week total leave, it does put a burden on the remaining residents who are at work. As soon as the scheduling permit is received call Prometrics, exam dates fill up quickly. The busiest times are May through July, November and December. Pay careful attention, there are some hefty rescheduling fees. Make sure your name on the application matches exactly the name on your Drivers License. Finally, practice using the computer software for the Clinical Case Scenarios the time to learn is not during the exam. The following insert is from the Texas State Board of Medical Examiners. There are new regulations on USMLE 3: You must have taken and passed all 3 tests within 7 years to be eligible for permanent licensure. Als o, residency programs are know required to put time frames on when residents should have taken these exams. The penalty is not progressing to the next year level. PGY 1 before progressing, must have completed USMLE step 2 PGY 2 before progressing, must have completed USMLE step 3

Section

Page 133 of 185

Exam Attempts and Eligibility

To be eligible for a postgraduate resident permit, applicants who begin postgraduate training in Texas after January 1, 2004 must not have failed a licensure examination that would prevent the applicant from obtaining an unrestricted physician license in Texas (Board Rule 171.2(e)(6)). An applicant for an unrestricted physician license must either: pass all but one part of an examination accepted for licensure within three attempts, with a fourth attempt allowed on one part only, or pass all but one part of an examination accepted for licensure within three attempts, with a fifth attempt allowed on one part only, if: o the applicant becomes specialty board certified by an A.B.M.S. or A.O.A. member board, and o completes, in Texas, an additional two years of postgraduate medical training approved by the Board (TOC 155.056. Reexamination1) Exam Part I Attempts 3 4 3 3 5 Exam Part II Attempts 3 3 4 3 3 Exam Part III Attempts 3 3 3 4 3 Eligible? Yes Yes Yes Yes Yes, if specialty board certified and additional 2 years training in Texas. Yes, if specialty board certified and additional 2 years training in Texas. Yes, if specialty board certified and additional 2 years training in Texas. No No No No

4 6 3 3
1

4 1 4 4

1 1 4 5

TOC 155.056. Reexamination

(a) An applicant must pass each part of an examination within three attempts, except that an applicant who has passed all but one part of an examination within three attempts may take the remaining part of the examination one additional time.

Page 134 of 185

(b) Notwithstanding Subsection (a), an applicant is considered to have satisfied the requirements of this section if the applicant: (1) passed all but one part of an examination approved by the board within three attempts and passed the remaining part of the examination within five attempts; (2) is specialty board certified by a specialty board that: (A) is a member of the American Board of Medical Specialties; or (B) is approved by the American Osteopathic Association; and (3) completed in this state an additional two years of postgraduate medical training approved by the board.

Transcripts of examinations taken will be required. Please request transcripts to be sent directly to this agency. NBME www.nbme.org or 215-590-9500 NBOME/COMLEX www.nbome.org or 773-714-0622 FLEX/USMLE/SPEX www.fsmb.org or 817-868-4000 LMCC www.mcc.ca or 613-521-5012 C. State Licensure If you are planning on practicing in a state other than Texas, check the website for the Federation of State Medical Boards <http://www.fsmb.org> (click on State Medical Board Information in left hand column) to obtain requirements for your state of interest. After the medical license is obtained, certain certifications are required for prescription writing. A Drug Enforcement Administration (DEA) certificate is needed regardless of the state of practice. Additionally some states, including Texas, require a Department of Public Safety certification as well. Without these certificates, you will not be able to obtain privileges at any hospital. The process to obtain a license and be able to practice in the state of Texas is long. Get started early. The instructions are listed below and a check off list of items to be included in the application packet for the TSBME is available in Appendix D. Obtain the application from the Texas State Board of Medical Examiners on the website <http://www.tsbme.state.tx.us> (click on Physician Licensure Application in left hand column). Request USMLE Transcript aka EBAHR (Fee: $50.00). o Website for request <http://www.fsmb.org> (click on Transcript Request in left hand column) o You can request for the transcript to be sent straight to the TSBME or request a copy to send along with your application, either method works Request a Self Query from the National Practitioner Data Bank (Fee: $20.00 credit card only). o Website for request <http://www.npdb-hipdb.com > (click on Perform a Self Query on the far right) o Complete the online request form, print it out, notarize it, mail it and wait for the Self Query to be mailed to you o Send the original Self Query along with the TSBME application

Page 135 of 185

Request an Official Medical School Transcript in an unopened original medical school envelope (usually requires a nominal fee). Complete Deans Certification Form D and submit to medical school Dean for return in an unopened original medical school envelope with the Deans signature across envelopes opening flap. Complete Residency Program Verification Form E and submit to program Director for return in an unopened original institutional envelope with the Program Directors signature across envelopes opening flap. Xerox Drivers License Write a check to TSBME for $805.00 Mail all of the above forms, unopened envelopes, fees, etc. along with the application to the TSBME. Application processing takes 8 weeks to 6 months and is expedited only for those practicing in underserved areas. After processing, you are notified of your eligibility to take the Medical Jurisprudence examination. It is administered in Austin during weekdays only. Recommendations are to take the Jurisprudence exam more than 30 days prior to the next Board meeting. The board meets 6 times per year (February, March, June, August, October and December). Study materials for the Jurisprudence exam are either 1) Texas Medical Jurisprudence by Fulbright & Jaworski with the Texas Medical Jurisprudence Study Guide by Lockhart available at the TMA online store < http://www.store.texmed.org/store> or 2) The Texas Medical Jurisprudence Examination: A Self-Study Guide available in the UTMB bookstore. The Jurisprudence exam is administered at 8am and if failed can be retaken later that afternoon. If the test is passed a temporary license can be issued that day for a fee of $50.00. The annual registration fee for the TSBME license is $334 and due at the time of the Board meeting immediately following the issuance of the temporary license. D. Texas Department of Public Safety After obtaining the temporary license, the Texas Department of Public Safe ty license can be applied for and issued the same day for a fee of $25.00. The DPS office is about 15 minutes North of the TSBME office. It is recommended to obtain your DPS license in this fashion. Website for reference is <http://www.txdps.state.tx.us> (click on General Information and then Controlled Substances Registration). E. Drug Enforcement Agency The final process is obtaining a DEA license. The application is available online at <http://www.deadiversion.usdoj.gov > (click on Drug Registration in the left hand column, then Registration Applications in the middle, choose DEA Form 224, Interactive Version). The fee is $210.00 for 3 years. Request all scheduled drugs. The application is sent to Washington D.C. and from there to the local office. If rushed, call the local office [Houston office (800) 743-0595] about 3-5 weeks after the application is sent and inquire about your DEA number (the number not the certificate is all that is needed for employment). The actual certificate takes about 5 -8 weeks. This must be done last because it requires a license (temporary will work) and TXDPS number.

Page 136 of 185

ABOG Certification Examinations

The American Board of Obstetrics and Gynecology (ABOG) is responsible for Board Certification. The process of certification involves a written examination and an oral examination with case list. The application for the written exam is due in November of the PGY 4 year. It can be obtained on the website <http://www.abog.org>. The application fee is $1470.00 and late fees can total up to an additional $1800.00. Notification of eligibility for the written exam will be sent in April of the PGY 4 year. If these deadlines are missed, you will have to wait another year to initiate the Board certification process. The ABOG written examination is on the last Monday of June of the PGY 4 year. Please note that you signed a contract with UTMB to wo rk until June 30th of your PGY 4 year at which time you are considered graduated. The Department typically allows for some study time just prior to the exam. This study time is to be determined by the Administrative Chief Resident(s) and the Program Director. The oral examination can be taken one year after graduation or two years after graduation. ABOG will eventually offer the oral examination during the one-year after graduation time only. It is your responsibility to apply for the oral examination. You will need to collect cases for the oral exam and if it is taken one year after graduation, cases from your PGY 4 year may be used. For this purpose it is a good idea to keep all copies of dictated operative reports. Also, during the PGY 4 year you can designate on your Palm Pilot certain cases as case list cases.

Certification Requirements
The Department of Obstetrics and Gynecology requires that all of its residents be certified in Basic Life Support, Advanced Cardiac Life Support and Neonatal Advanced Life Support. BLS and ACLS certification must be current at all times. NALS will be offered during the PGY 3 or PGY 4 year and organized by Sherry Bastien. As a UTMB employee, these courses are free of charge. Registration is available through the UTMB Education Lab for BLS and ACLS (website <http://www.utmb.edu/edlab> lists course dates and times). There is a $25.00 refundable deposit for the ACLS course. Contact the Administrative Chief Resident(s) to arrange an appropriate time to take these courses.

CHART/MEDICAL RECORDS POLICY

Policy on Delinquent Charts The following policy will be implemented Monday January 16, 2007. If any ob/gyn resident has more than 10 delinquent charts (aged greater than 30 days), he or she will automatically be placed on vacation until the charts are completed. This number will represent the combination of both paper charts, and the electronic medical record. If any resident is more than 8 weeks delinquent in entering their ACGME numbers, they will also be placed on vacation until the database is up to date. The vacation days will come out of each residents current vacation balance. If the residents vacation balance is depleted, they will be placed on temporary suspension until the charts or Page 137 of 185

ACGME entries are completed. Any days spent on suspension will be made up at the end of the residency. Coverage for unscheduled vacations will be provided by fellow residents as needed.

Evaluations
For each rotation, every resident receives evaluations from the team faculty and PGY 4 resident (and Fellow if applicable). These evaluations are done on New Innovations. Upon assignment of the evaluation by Sherry Bastien, a faculty evaluation is available to you through New Innovations as well. This evaluation from the resident is not routed to the department, but rather to the GME director whom sends out a report without identifiers during the year to the residency program director.

Moonlighting
"Moonlighting" is defined as any activity associated with the practice of medicine outside the assigned duties as a resident at UTMB for which compensation is received in cash or kind in exchange for functioning as an independent physician outside of training. This includes moonlighting within UTMB. When a resident "moonlights," it should be with the knowledge that: Outside UTMB, independent licensure by the State of Texas for the practice of medicine is mandatory. Within UTMB, the Department of Obstetrics and Gynecology will attain appropriate levels of malpractice coverage through The University of Texas Professional Liability Plan. Outside UTMB, no malpractice insurance is provided nor will any other fringe benefits ordinarily afforded to the resident be in effect. No resident may "moonlight" during assigned residency duty time. Permission of the Program Director must be obtained before arranging to "moonlight". Within UTMB, the number of hours spent moonlighting are added to the assigned residency duty time and must be in compliance with ACGME duty hours (80 hour work week and other restrictions). The Program Director should acknowledge in writing that he is aware that the resident is moonlighting, and this information should be part of the resident's folder. Since residency education is a full time endeavor, the Program Director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program. House Staff are required to notify the Program Director of their participation/involvement in other committees outside the institution or any involvement in the community that would impact duty hours. House staff are not required to engage in moonlighting. The U.S. Code of Federal Regulations clearly prohibit exchange visitors (J1 visa holders) participating in programs of graduate medical education from pursuing work outside of their training programs. Therefore, any Graduate Medical Education Officer holding a J1 visa may not moonlight or earn extra income under any circumstances.

Page 138 of 185

Administrative and Family Planning Chiefs

The Administrative Chief Residents are chosen by the Program Director in the Spring of their PGY 3 year.

UTMB Employee Requirements

A. Compliance Requirements There is a series of Institutional Compliance training modules that must be met according to the designated time frame. This requirement is met by completing a series of online quizzes determined by a profile that is selected for resident physicians. Below are the courses and the time frames in which they must be taken. Annually (every year by August 31) 1. Advanced Infection Control licensed 2. Infection Control Outpatient Clinics 3. Universal Precautions Every 2 Years (by August 31) 1. General Compliance 2. General Fire Safety Training 3. HIPPA General Awareness 4. Sexual Harassment in the Workplace Every 3 Years (by August 31) 1. Computer Ethics & Acceptable Use 2. Computer Virus Protection 3. Email Etiquette & Protection 4. Information Protection 5. Password Protection The quizzes can be accessed off of the UTMB home page. For logging on details refer to Appendix F. B. Risk Management Requirements In order to be eligible for malpractice insurance, risk management credit hours are required during all years. 5 credits each years must be recorded for malpractice guidelines. C. Point of Care Testing Requirements POCT are lab tests performed by operators at the bedside of patients. POC testing is mandated by the government and is inspected by the Joint Commission. Demonstration of operator competency is mandatory. See G for details on how to complete the online requirements or visit the website < http://www2.utmb.edu/poc>>.

Obtaining UTMB Computer Order Entry Access from Home

Physician computer order entry can be i nstalled on a home computer. For details check the UTMB website < http://www.utmb.edu/remoteaccess/>.

Page 139 of 185

12
Grievance Procedure
GRIEVANCE PROCEDURE FOR CORRECTIVE ACTIONS OTHER THAN TERMINATION 1. If a resident has a grievance related to his/her training program or has been subject to any Corrective Action other than termination, the resident should first attempt to resolve the matter informally by consulting with the following people in the sequence as written: Chief Resident on Service, Administrative Chief Resident(s), Program Director, and/or Chairman/Division Chief. 2. If the resident is unable to resolve the matter informally or wishes to grieve a Corrective Action other than termination, he/she should present his/her grievance in writing to the Associate Dean within 10 (ten) working days of the date the matter arose or recommendation for Corrective Action other than termination was made. The Associate Dean shall notify the resident in writing of his d ecision regarding the matter, or to uphold or rescind the Corrective Action other than termination, within 20 (twenty) working days of receiving the written grievance, unless extended by the Associate Dean's and resident's mutual agreement. 3. Should the resident not be satisfied with the Associate Dean's decision, the officer may present the written grievance to the Dean within ten (10) days of receiving the Associate Dean's decision. The Dean shall notify the resident in writing within twenty (20) working da ys by registered mail, return receipt requested, of the Dean's decision to uphold or rescind the Associate Dean's decision in the grievance. The Dean's decision is final.

Section

For specific policies regarding appeal rights and procedures for termination refer to the UTMB GME website at < http://www.utmb.edu/gme/general_info.htm>.

Page 140 of 185

13
Professional Standards and Professionalism
Attitude and Behavior
Acceptable professional attitude conforms to the ethical standards of the medical profession. For example, patient confidentiality is required, as is respectful behavior toward patients, colleagues, and other personnel. Appropriate behavior toward patients includes providing their care in a timely and careful manner. Appropriate behavior toward colleagues includes being on time for rounds, teaching conferences, operating room, clinic, and emergency department shifts. Unacceptable professional behavior includes treating patients without due consideration and response to their needs and concerns. Also unacceptable is being routinely late for assignments and other duties such as completing charts, returning phone calls, etc. Inappropriate dress or behavior indicates a distinct lack of respect for others. Gross misrepresentation or fraud not only represents inappropriate behavior, but also constitutes a criminal offense. It is also unacceptable when a resident fails to comply with the educational requirements of this training program. Educational requirements include attending at least 60% of the required noon conference, grand rounds, and morning report sessions.

Section

Competence
Competence is provision of what is felt to be appropriate "standard of care" for each patient. Incompetence is a gross la ck of the fund of knowledge required of a house officer's level of training. Evaluation is based on performance as well as faculty evaluations on Ward services/Labor and Delivery/Clinics/Primary Care Rotations. The Program Director, Division Heads and Faculty are responsible for identifying house officers with deficiencies in competency.

Demeanor
Residents should be courteous and respectful in all interactions with members of the health care team.

Page 141 of 185

Housestaff should be businesslike in their demeanor, and always mindful of a patient's right to privacy. Discussion of a patient's age, gender, ethnic origin, economic status, lifestyle, or disease process should occur only in appropriate areas. These discussions should never occur in public areas (i.e. hallw ays, elevators, and cafeteria). Language in patient-care areas should be appropriate, and never include the use of expletives, and/or racist or sexual remarks.

Appearance
All housestaff shall be appropriately attired at all times, including weekends, nig hts and holidays. Appropriate attire never includes jeans, tee shirts, shorts or any other informal wear. Scrubs are appropriate attire only when the house officer is working in L&D, scheduled to be in the Gyn OR, the night of call and the daytime post call. Lab coats are to be worn in-patient care areas, and should be clean. The use of cigarettes and/or smokeless tobacco is never allowed inside the hospital, clinics or on hospital property.

Sexual Harassment
Sexual Harassment is either physical or verbal conduct of a sexual nature that is unwelcome when: Submission to conduct is explicitly or implicitly a term or condition of work or academic performance, or submission to or rejection of such conduct is used as a basis for an employment decision, performance evaluation, or academic evaluation, or such conduct is known or should have been known to interfere with an individual's work or academic performance, or to create an intimidating, hostile or offensive working or educational environment. Sexual harassment, as outlined above, is unacceptable and will not be tolerated.

Page 142 of 185

14
Special Need Services
Counseling Services
In the event that a resident feels that he/she needs outside assistance, there is a counseling service available for all housestaff and their families. It is managed separately from all hospital departments. Records are confidential and not part of the hospital record. This division has drop-in as well as scheduled times available. Their extension is 23148.

Section

Risk Management
There is an office of Risk Management at UTMB to assist with problems encountered on the rotations. In the event that a legal or other potential problem arises, this office should be contacted and will review the chart and give advice to hopefully prevent or ameliorate repercussions. Their extension is 24775. All legal problems requiring a leave of absence should also be referred to the Administrative Chief Resident(s).

Employee Health
A. Occupational Exposures to Bodily Fluids If any exposure to bodily fluids (i.e. needlestick) occurs, follow the below procedures. Wash the area immediately If splashed in the eyes, mouth, or nose have them properly flooded or irrigated (minimum of 10 to 15 minutes) Notify your supervisor immediately IMMEDIATELY DO ON E OF THE FOLLOWING: o 8:00AM 4:30PM, Monday-Friday, go to Employee Health Center. o After hours, weekends, or holidays go to the Emergency Department. (Be sure to tell them youre an employee and have had a needlestick.

You MUST report the exposure and have a baseline HIV drawn within 10 calendar days to receive maximum benefits if a Workers Compensation claim were to be filed in the future. This law is documented in Texas Vernons Civil Statute, Health & Safety Code Section 85.116c.

Page 143 of 185

Post-exposure prophylaxis is offered for any percutaneous injury with blood or bodily fluids visibly contaminated with blood and unfixed tissue. The medications presently provided to you free of charge are : Zidovudine (AZT), Lamivudine (Epivir) and Indinavir (Crixivan). It is preferable that you begin this medication within the first two (2) hours after exposure but can be taken up to ninetysix (96) hours after exposure. (After 96 hours post-exposure the medications are not effective). If you go to the Emergency Department they will only provide you enough medication until the next business day when the Employee Health Center is open. It is important that you follow-up with Employee Health as they will monitor you while taking the medication. The procedure for obtaining source blood is referenced below. Obtained informed consent from source for HIV testing (Pathology/Microbiology IV form). Document in source's medical record, "source of occupational exposure" and labs were drawn for HIV, HCV, HBsAG. If source is under gene ral anesthesia or unable to respond, general hospital consent will be sufficient to obtain source blood for testing (Document in source's medical record as stated above). If source refuses testing, notify UTMB Legal Department at (409) 772-4818. Obtain two (2) serum separator tubes of blood. Use lab slip "Pathology-Bloodborne Pathogens" (MM#68693). Send blood (with informed consent if obtained) to Sample Management, 5.136 McCullough (open 24-hours/day.

B Tuberculosis Screening PPD screening is required of all Obstetrics and Gynecology residents on an annual basis during the PGY 1 through PGY 2 years. PGY 3 and PGY 4 residents require screening every six months in order to be eligible for the Harlingen rotation. C. Vaccinations Obstetrics and Gynecology residents are also required to obtain Hepatitis B, Tetanus and Rubella vaccinations or proof of immunity prior to starting their residency or immediately upon beginning residency. The University Employee Health Services will provide these vaccinations free of charge.

Page 144 of 185

15
Hurricane Policy
Given our coastal location, the threat of hurricanes remains an integral part of UTMB disaster planning. As a relative island fortress, the physical plant of UTMB is quite safe. Despite our relative secur ity, levels of hurricane readiness have been designated in an effort to efficiently cope with any threat. Should it become necessary, "essential" (E1) personnel will be required to remain, or report to campus/in hospital during an external weather emergency. UTMB chooses to wisely prepare for each hurricane season. In general, Housestaff on the Labor and Delivery, Ward Call (Ward Night Float) and ER call (ER Night Float) are designated essential. Housestaff on electives and nonessential services will be required to remain briefly to permit essential personnel to take care of property and family before "lock in" occurs. There is a Hurricane Essential Personnel Memo that lists hurricane teams included in Appendix H. In the past, in the event of a hurricane the Administrative Chief Resident(s) will comprise a list of Essential personnel based upon when the hurricane is anticipated to hit and which residents are assigned to cover L&D, Ward and ER Call at that specific time. Every time a hurricane is anticipated you must check with your Chief Resident(s) to determine your Essential status.

Section

Page 145 of 185

Appendix I Educational Goals and Objectives

Obstetrics
PGY 1 Genetics 1. Describe the organization and replication of DNA. 2. Describe the processes of cell division: mitosis and meiosis. 3. Describe the clinical significance of karyotype abnormalities, such as: a. Trisomy b. Monosomy c. Deletions d. Inversions 4. Describe the clinical significance of heritable diseases, such as cystic fibrosis, Tay-Sachs disease, and hemophilia. Pharmacology 1. Describe the role for nutritional supplementation in pregnancy (e.g., iron, folic acid). 2. Describe the impact of pregnancy on serum and tissue drug concentrations and drug efficacy. 3. Describe the factors that influence transplacental drug transfer, such as: a. Molecular size b. Lipid solubility c. Degree of ionization at physiologic pH d. Protein binding 4. Describe the possible teratogenic effects of prescription drugs in pregnancy, such as: a. Tetracycline b. Angiotensin-converting enzyme inhibitors c. Quinolone antibiotics d. Lithium e. Isotretinoin f. Seizure medications 5. Describe the possible teratogenic effects of nonprescription drugs, such as: a. Alcohol b. Heroin c. Cocaine Page 146 of 185

d. Tobacco Embryology and developmental biology 1. Describe the normal process of gametogenesis 2. Describe the normal process of fertilization. 3. Describe the normal process of embryologic development of the singleton pregnancy. 4. Describe the embryology of multiple gestations. Anatomy 1. Describe the muscular and vascular anatomy of the pelvis and vulva. 2. Describe the anatomic changes in the mother caused by normal physiologic adaptation to pregnancy. 3. Describe the anatomic changes that occur during the intrapartum period, such as cervical effacement and dilatation. 4. Describe the anatomic changes that occur during the puerperium, such as alterations in the breast and uterine involution. Microbiology and immunology 1. Describe the principal features of the host immunologic response: a. Antigen processing and recognition b. Hormonal-mediated immunity c. Cell-mediated immunity d. Phagocytosis e. Cytokine activation f. Complement activation 2. Describe how the maternal immune response is altered by pregnancy 3. Describe the basic features and timing of development of the fetal immunologic response. 4. Describe the etiology and pathophysiology of the most common genital tract infections. 5. Describe the association between genital tract infection and adverse perinatal outcomes, such as: a. Preterm labor b. Preterm premature rupture of membranes c. Neonatal infection d. Material infection Antepartum fetal monitoring 1. Describe the indications, contraindications, advantages, and disadvantages of antepartum diagnostic tests, such as: a. Nonstress test b. Contraction stress test c. Biophysical profile d. Vibroacoustic stimulation test e. Doppler velocimetry 2. Perform and interpret antepartum diagnostic tests accurately and integrate the interpretation of such tests into clinical management algorithms. Postterm pregnancy 1. Determine gestational age using a combination of menstrual history, physical examination, and ultrasound examination. 2. Recognize unusual causes of postterm pregnancy: a. Lethal fetal anomaly (e.g., anencephaly) b. Placental sulfatase deficiency 3. Describe the potential fetal and neonatal complications of postterm pregnancy, such as: a. Macrosomia b. Meconium aspiration syndrome c. Oligohydramnios Page 147 of 185

d. Hypoxia e. Dysmaturity syndrome f. Fetal demise 4. Perform and interpret surveillance tests for the postterm fetus: a. Antepartum fetal heart rate testing to detect signs of hypoxia and cord compromise b. Ultrasound examination to assess the biophysical profile score, identify oligohydramnios, and estimate fetal weight 5. Describe appropriate indications for delivery in the postterm pregnancy. 6. Determine the appropriate method of delivery in a postterm pregnancy. Intrapartum fetal assessment 1. Perform and interpret the following methods of fetal monitoring: a. Intermittent auscultation b. Electronic monitoring (1) External (2) Internal c. Fetal scalp stimulation d. Vibroacoustic stimulation e. Fetal scalp blood sampling 2. Interpret the results of Doppler velocimetry. 3. Describe the possible causes for, and clinical signif icance of, abnormal fetal heart rate patterns: a. Bradycardia b. Tachycardia c. Increased variability d. Decreased/absent variability e. Early decelerations f. Variable decelerations g. Late decelerations h. Sinusoidal waveform 4. Implement appropriate interventions, such as operative vaginal delivery and cesarean delivery (see the list of procedures at the end of this unit), for fetal heart rate abnormalities Labor and delivery 1. Obtain an accurate history describing onset of uterine contractions and ruptured membranes. 2. Describe appropriate indications for induction of labor. 3. Perform a pertinent physical examination to assess: a. Status of membranes b. Presence of vaginal bleeding c. Fetal presentation d. Fetal position e. Fetal weight f. Cervical effacement g. Cervical dilatation h. Station of the presenting part i. Clinical pelvimetry j. Uterine contractility 4. Recognize appropriate indications for, and complications of, cervical ripening agents: a. Osmotic dilators b. Prostaglandin preparations 5. Recognize appropriate indications for, and complications of, labor-inducing agents: a. Oxytocin b. Prostaglandin preparations 6. Describe the normal course of labor. 7. Assess the progress of labor. Page 148 of 185

8. Describe the risk factors for abnormal labor. 9. Recognize abnormalities of labor: a. Failed induction b. Prolonged latent phase c. Protracted active phase d. Arrest of dilatation e. Protracted descent f. Arrest of descent 10. Recognize the appropriate role and complications of the following interventions for abnormal labor: a. Analgesia/anesthesia b. Amniotomy c. Augmentation of labor d. Uterine contraction monitoring e. Episiotomy (1) Midline (2) Mediolateral (3) Episioproctotomy f. Operative vaginal delivery (1) Mid, low, and outlet forceps extraction (2) Mid, low, and outlet vacuum extraction g. Cesarean delivery 11. Recognize and appropriately evaluate abnormal presentations and positions, such as: a. Breech b. Transverse lie c. Face d. Brow e. Compound f. Occiput posterior g. Occiput transverse 12. Select and perform the most appropriate procedure for delivery (see the list of procedures at the end of this unit). 13. Counsel patients regarding the prognosis for abdominal versus vaginal delivery in a subsequent pregnancy The puerperium 1. Perform a focused physical examination in postpartum patients. 2. Identify and treat the most common maternal complications that occur in the puerperium: a. Uterine hemorrhage b. Infection (1) Endometritis (2) Urinary tract infection (3) Wound infection (4) Mastitis c. Wound dehiscence (1) Abdominal incision (2) Episiotomy d. Bladder instability e. Postoperative ileus f. Injury to the urinary tract g. Breast engorgement and abscess h. Pulmonary embolism (1) Venous (2) Amniotic fluid i. Deep vein thrombosis Page 149 of 185

3. Recognize and treat postpartum affective disorders: a. Postpartum blues b. Postpartum depression c. Postpartum psychosis 4. Prescribe methods of reversible contraception. 5. Counsel patients about permanent sterilization. 6. Perform postpartum surgical sterilization (see the list of procedures at the end of this unit). 7. Counsel patients regarding future pregnancies

PROCEDURES The following table lists the procedures pertinent to obstetrics and summarizes the level of technical proficiency that should be achieved by a PGY 1 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. PERFORM OR UNDERSTAND THE FOLLOWING: PROCEDURE Fetal Assessment Biophysical profile Contraction stress test Nonstress test Vibroactoustic stimulation Ultrasound examinations Abdominal screening Abdominal targeted Amnioinfusion Amniotomy Anesthetics/analgesics Adm. Of narcotic antagonists Adm. Of parentaeral analgesics/sedatives Epidural General Spinal Cardiopulmonary Resuscitation Airway Maintenance Bag and Mask ventilation Chest compressions Episiotomy and repair Episioproctotomy Mediolateral Midline Fetal assessment, intrapartum Heart rate monitoring Fetal Scalp Ph determination Fetal scalp stimulation test Vibroacoustic stimulation Induction of labor with prostaglandins or oxytocin Vaginal delivery, spontaneous Circumcision, neonatal Repair of genital tract lacerations Cervical UNDERSTAND PERFORM X X X X X X X X X X X X X X X X X X X X X X X X X X X

Page 150 of 185

Perineal Vaginal Sterilization

X X X

PGY 2 Preconceptional care 1. Perform a thorough history, assessing historical and ongoing risks that may affect future pregnancy. 2. Counsel a patient regarding the impact of pregnancy on maternal medical conditions. 3. Counsel a patient regarding the impact of maternal medical conditions on pregnancy. 4. Counsel a patient regarding appropriate lifestyle modifications conducive to favorable pregnancy outcome. 5. Counsel a patient regarding pregnancy-associated risks and complications, such as: a. Advanced age b. Hypertension c. Diabetes d. Genetic disorder e. Prior aneuploid or anomalous fetus/newborn Prenatal care 1. Perform a comprehensive history and physical examination. 2. Order and interpret routine laboratory tests and those required because of risk factors during pregnancy. 3. Counsel patients about lifestyle modifications that improve pregnanc y outcome, including activity, employment, nutrition, travel, and substance use/abuse. 4. Counsel patients regarding warning signs of adverse pregnancy events. 5. Schedule and perform appropriate antepartum follow -up visits for routine and high-risk obstetric care. Genetic counseling 1. Elicit a history for inherited disorders, ethnic- or race-specific risks, and teratogen exposure, and perform pedigree analysis. 2. Describe the concepts of penetrance and variable expression and their impact on prognosis for a given genetic disorder. 3. Distinguish between various forms of genetic inheritance: a. Autosomal dominant b. Autosomal recessive c. X-linked dominant d. X-linked recessive e. Multifactorial 4. Counsel patients about the manifestations of common genetic disorders. 5. Describe the indications for, and limitations of, noninvasive diagnostic tests for fetal aneuploidy and structural malformations (e.g., ultrasonography, serum analytes). 6. Counsel patients about the risks and benefits of various methods o f invasive fetal testing, such as: a. Choironic villus sampling b. Amniocentesis c. Cordocentesis 7. Order and interpret appropriate maternal and fetal/neonatal tests to evaluate possible causes of fetal demise. 8. Counsel a patient with an abnormal fetus regarding management options. 9. Counsel a patient and her family following adverse pregnancy outcome about such factors as recurrence, future care, and possible interventions Diabetes mellitus (OB) 1. Classify diabetes mellitus in pregnancy. 2. Interpret screening tests for gestational diabetes. Page 151 of 185

3. Monitor and control blood sugar in the pregnant patient with diabetes mellitus. 4. Assess, recognize, and manage fetal and maternal complications such as: a. Fetal malformations b. Disturbances in fetal growth c. Diabetic ketoacidosis 5. Counsel patients with diabetes regarding future reproduction and long-term health complications. Diseases of the urinary system 1. Evaluate signs and symptoms of urinary tract pathology in pregnant patients. 2. Describe the indications for the common diagnostic tests for renal disease in pregnancy. 3. Interpret the results of common diagnostic tests for renal disease in pregnancy. 4. Counsel patients about the possible adverse effects of diseases of the urinary tract on fetal and maternal outcome, such as: a. Intrauterine growth restriction b. Prematurity c. Perinatal mortality d. Pregnancy-induced hypertension 5. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of a patient with renal disease. Infectious diseases 1. Perform a focused history and physical examination in pregnant patients who have known or suspected infectious diseases. 2. Choose and perform laboratory tests to confirm the diagnosis of infection. 3. Assess the severity of a specific infection and its potential maternal, fetal, and neonatal impact. 4. Manage specific infections or obtain appropriate consultation for co -management. 5. Describe the possible adverse maternal and fetal effects of antibiotics administered during pregnancy, e.g., teratogenic effects of tetracycline and quinolones. Hematologic disorders 1. Evaluate possible causes of anemia, thrombocytopenia, deep vein thrombosis, and coagulopathy in pregnancy. 2. Institute appropriate acute and chronic man agement for these conditions, including prophylaxis to minimize recurrence risk. 3. Counsel patients about the fetal and maternal impact of hematologic disorders in pregnancy Cardiopulmonary disease 1. Describe symptoms and physical findings suggestive of cardiopulmonary disease in pregnancy. 2. Describe the indications for common diagnostic tests for cardiopulmonary disease in pregnancy, such as: a. Electrocardiography b. Echocardiography c. Cardiac catheterization d. Chest X-ray e. Pulmonary function tests f. Arterial blood gases 3. Interpret the results of common diagnostic tests for cardiopulmonary disease in pregnancy, such as: a. Electrocardiography b. Echocardiography c. Chest X-ray d. Pulmonary function tests e. Arterial blood gases 4. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with cardiopulmonary disease. 5. Classify maternal cardiac disease in pregnancy and describe the associated maternal and fetal risks. Page 152 of 185

6. Order appropriate fetal evaluation in patients with congenital heart disease. 7. Counsel patients about the impact of pregnancy on cardiopulmonary disease and the impact of these diseases on pregnancy Gastrointestinal disease 1. Perform a history and physical examination for the diagnosis of gastrointestinal disease in pregnancy. 2. Describe the indications for, and advantages and disadvantages of, common diagnostic tests for gastrointestinal disease, such as: a. Stool examination for ova, parasites, bacteria, leukocytes, and occult blood b. Endoscopy c. Imaging studies d. Antibody/antigen testing e. Liver function tests 3. Interpret the results of common diagnostic tests for gastrointestinal disease in pregnancy. 4. Diagnose, and provide initial management of, common gastrointestinal diseases in pregnancy, such as: a. Hyperemesis gravidarum b. Reflux esophagitis c. Peptic ulcer disease d. Cholelithiasis e. Cholecystitis f. Pancreatitis g. Hepatitis h. Cholestasis of pregnancy i. Acute fatty liver of pregnancy 5. Counsel patients about the impact of gastrointestinal disease on pregnancy and the impact of pregnancy on gastrointestinal disease. Neurologic disease 1. Perform a focused history and neurologic examination in pregnant patients with a known or suspected neurologic disor der. 2. Describe the indications for common diagnostic tests for neurologic disease in pregnancy, such as: a. Electroencephalogram b. Lumbar puncture c. CT or MRI d. Nerve conduction studies 3. Interpret the common diagnostic tests for neurologic disease in pregnancy. 4. Counsel pregnant patients regarding the impact of pregnancy on neurologic disease and the impact of the disease on pregnancy. 5. Develop, in consultation with other specialists, a comprehensive plan for the perinatal management of patients with neurologic disease. Endocrine disorders (excluding diabetes mellitus) 1. Perform a focused history and physical examination in pregnant patients with known or suspected endocrine disease. 2. Describe the indications for common diagnostic tests for endocrine disease, such as: a. Thyroid function tests b. Adrenal function tests c. Pituitary function tests d. Parathyroid function tests e. Imaging studies 3. Interpret the results of common diagnostic tests for endocrine disease in pregnancy. 4. Counsel patients about the impact of endocrine disease and its treatment on pregnancy and the impact of pregnancy on the endocrine disorder. Page 153 of 185

5. In consultation with other specialists, develop a comprehensive plan for the perinatal management of patients with an endocrine disorder. Collagen vascular disorders 1. Perform a focused history and physical examination in pregnant patients with known or suspected collagen vascular disease.2. Describe the indications for common diagnostic tests for collagen vascular disease in pregnancy, such as: a. Serologic tests for rheumatoid factor b. Anti-DNA antibodies c. Antinuclear antibodies d. Lupus anticoagulant e. Anticardiolipin antibodies 3. Interpret the results of common diagnostic tests for collagen vascular disease in pregnancy. 4. Counsel patients about the impact of collagen vascular disease and its treatment on pregnancy and the impact of pregnancy on collagen vascular disease. 5. Develop, in consultation with other specialists, a comprehensive plan for the perinatal mana gement of patients with collagen vascular disease. Psychiatric disorders 1. Perform a mental status examination. 2. Describe the symptoms of common psychiatric disorders in pregnancy, such as: a. Affective disorders b. Anxiety disorder c. Psychosis d. Somatization disorders e. Eating disorders 3. Assess the risk of psychiatric disorders and the safety of psychiatric medications in the patient and her fetus. 4. Identify patients who require referral for psychiatric consultation. Substance abuse in pregnancy 1. describe behavior patterns suggestive of substance abuse. 2. Perform a thorough history and physical examination in patients suspected of substance abuse in pregnancy. 3. Counsel patients about the impact of substance abuse on the fetus/neonate. 4. Assess the fetus for adverse effects of substance abuse, such as congenital anomalies or growth restriction. 5. Diagnose and manage drug overdose and drug withdrawal in pregnant patients. 6. Refer patients with known or suspected substance abuse for counsel ing and follow -up Preterm labor 1. Describe the multifactorial etiology of preterm labor. 2. Obtain a complete obstetric history in patients with preterm labor. 3. Perform a thorough physical examination to determine uterine size, fetal presentation, and fetal heart rate and to assess cervical effacement and dilatation. 4. Perform and interpret biophysical, biochemical, and microbiologic tests to assess patients with suspected preterm labor. 5. Recognize the indications for, and complications of, intervent ions for preterm labor, such as: a. Antibiotics b. Tocolytics c. Corticosteroids d. Amniocentesis e. Cerclage f. Bed rest Page 154 of 185

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. 7. Appropriately counsel patients about management and intervention options for the extremely premature fetus. 8. Counsel patients about recurrence risk and preventive measures for preterm delivery Hypertension in pregnancy 1. Describe the possible causes of hypertension in pregnancy. 2. Describe the usual clinical manifestations of chronic hypertension, pregnancy-induced hypertension, and preeclampsia. 3. Perform a physical examination pertinent to patien ts with hypertension. 4. Perform tests to: a. Determine the etiology of chronic hypertension. b. Differentiate chronic hypertension from pre-eclampsia and pregnancy-induced hypertension. c. Assess the severity of chronic hypertension and pregnancy -induced hypertension. 5. Assess fetal well-being in patients with hypertension in pregnancy (see antepartum testing). 6. Treat hypertensive disorders of pregnancy: a. Describe the indications for, and complications of, antihypertensive medications. b. Describe the indications for, and complications of, antiseizure medications. c. Describe the indications for delivery in patients with a hypertensive disorder of pregnancy. 7. Recognize and treat possible maternal complications of hypertension in pregnancy, such as: a. Cerebrovascular accident b. Seizure c. Renal failure d. Pulmonary edema e. HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome 8. Counsel patients regarding recurrence risk for pregnancy-induced hypertension in a subsequent pregnancy. Premature rupture of membrane 1. Describe the possible causes of premature rupture of membranes (PROM) in preterm and term patients. 2. Perform diagnostic tests to confirm rupture of membranes: a. Observation of vaginal pooling b. Identification of a ferning pattern on microscopy c. Identification of a positive nitrazine test d. Identification of reduced amniotic fluid volume on ultrasound examination e. Instillation of dye via amniocentesis 3. Assess patients with PROM for lower and upper genital tract infection. 4. Describe the indications for, and complications of, expectant management in patients with PROM. 5. Describe the indications for, and complications of, induction of labor in patients with PROM. 6. Describe the role and complications of the f ollowing interventions in patients with preterm PROM: a. Tocolytics b. Corticosteroids c. Antibiotics d. Amniocentesis e. Amnioinfusion Fetal death 1. Describe the clinical history that characterizes fetal death. 2. Describe the possible causes of fetal death. 3. Confirm the diagnosis of fetal death by ultrasound examination.4. Perform appropriate diagnostic tests to determine the etiology of fetal death, such as: a. Postmortem examination b. Viral serologies Page 155 of 185

c. Kleihauer-Betke test d. Karyotype determination 5. Select and perform the most appropriate procedure for uterine evacuation based on considerations of gestational age and maternal history (see the list of procedures at end of this unit): a. Surgical evacuation b. Medical induction of labor 6. Describe and treat the principal complications of a retained dead fetus: a. Infection b. Hemorrhage c. Coagulopathy 7. Describe and treat the major complications of surgical and medical uterine evacuation: a. Uterine perforation or rupture b. Hemorrhage c. Infection d. Retained products of conception 8. Describe the grieving process associated with pregnancy loss and refer patients for counseling as appropriate. 9. Counsel patients regarding recurrence risk for fetal death. 10. Arrange for photographs, total body X-rays, and chromosomal analysis on tissue of the stillborn fetus to help in identifying the etiology Anesthesia 1. Understand the types of anesthesia that are appropriate for control of pain during labor and delivery: a. Epidural b. Spinal c. Pudendal d. Local infiltration e. General f. Intravenous analgesia/sedation g. Intranasal analgesia 2. Describe appropriate indications for, and contraindications to, these forms of anesthesia/analgesia. 3. Recognize and treat maternal and fetal complications of anesthesia and analgesia. 4. Perform selected procedures related to anesthesia and analgesia (see the list of procedures at the end of this unit).

PROCEDURES The following table lists the procedures pertinent to obstetrics and summarizes the level of technical proficiency that should be achieved by a PGY 2. 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 knowle dge of a procedure is implicit in the ability to perform it. PERFORM OR UNDERSTAND THE FOLLOWING: PROCEDURE Cesarean Delivery Classical Low Transverse Low Vertical Curettage for adherent placenta Manual removal of the placenta Skin incision Vertical Transverse UNDERSTAND PERFORM X X X X X X X Page 156 of 185

Uterine Artery Ligation Repair of genital tract lacerations cervical Dilation and eva cuation for second trimester Ultrasonography Endovaginal Color doppler Doppler velocimetry Power doppler Three dimensional Wound Care Debridement Incision and drainage of abscess or hematoma

X X X X X X X X X X

Page 157 of 185

PGY 3 Pathology and neoplasia (OB) 1. Describe symptoms and physical findings suggestive of malignancy in the pregnant patient. 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 Emergency care during pregnancy 1. Perform a diagnostic history and physical examination in pregnant patients with a medical or surgical emergency. 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. 3. Initiate therapy, in consultation as necessary, and describe the impact of the condition and its management on the pregnancy as well as the impact of the pregnancy on the emergent condition. 4. Describe the timing of delivery in obstetric patients with emergent conditions. Intrauterine growth restriction 1. Describe the factors that predispose to fetal growth restriction. 2. Assess uterine size by physical examination and identify size/date discrepancies. 3. Perform an accurate ultrasound examination to assess fetal growth and identify symmetric or asymmetric growth restriction. 4. 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. 5. Counsel patients about the recurrence risk for intrauterine growth restriction Multiple gestation 1. Describe the factors that predispose to multiple gestation. 2. Describe the physical findings suggestive of multiple gestation. 3. Confirm the diagnosis of multiple gestation by performing an endovaginal or abdominal ultrasound examination. 4. Understand the medical rationale for selective fetal reduction in higher order multiple gestation 5. Describe, diagnose, and manage the maternal and fetal complications associated with multiple gestation. 6. Perform tests to assess the general well-being of the fetuses of a multiple gestation Bleeding in late pregnancy 1. Describe the etiology of bleeding in late pregnancy. 2. Describe the factors that predispose to placenta previa and abruptio placentae. 3. Perform a focused physical examination in patients with bleeding in late pregnancy. 4. Interpret diagnostic tests, such as: a. Hematocrit b. Platelet count c. Coagulation profile d. Kleihauer-Betke test e. Apt test 5. Perform the following diagnostic tests: a. Abdominal ultrasonography to localize the placenta and evaluate for possible placental separation b. Endovaginal or transperineal ultrasonography to localize the placenta 6. Treat patients with bleeding in late pregnancy: a. Determine the appropriate timing of delivery. b. Determine the appropriate method of delivery. 7. Manage serious complications of abruptio placentae and placenta previa, such as hypovolemic shock and coagulopathy. 8. Counsel patients regarding the recurrence risk for placenta previa and abruptio placentae. Second-trimester pregnancy loss Page 158 of 185

1. Describe the usual symptoms and clinical manifestations of a second-trimester abortion. 2. Describe the risk factors for, and etiologies of, second-trimester pregnancy loss, such as: a. Karyotype and structural abnormalities b. Incompetent cervix c. Infection d. Uterine anomalies 3. Perform an accurate physical examination and diagnostic tests to identify the site of genital tract bleeding, assess cervical effacement and dilatation, and evaluate uterine contractions. 4. Perform diagnostic tests to assess patients with threatened second-trimester pregnancy loss, such as: a. Ultrasonography b. Genital tract cultures 5. Implement appropriate medical and surgical management (including cervical cerclage) for patients with threatened second-trimester abortion. 6. Manage the complicatio ns of second-trimester pregnancy loss, such as: a. Chorioamnionitis b. Retained placenta c. Uterine hemorrhage 7. Counsel patients who have experienced second-trimester pregnancy loss about recurrence risk. Isoimmunization and alloimmune thrombocytopenia 1. Describe the major antigen-antibody reactions that result in red cell isoimmunization or thrombocytopenia. 2. Interpret antibody titer assays. 3. Describe the appropriate indications for determination of paternal antigen status. 4. Describe the indications for amniocentesis for assessment of amniotic fluid optical density and determination of fetal blood type. 5. Describe the performance of amniocentesis at appropriate intervals to assess patients with isoimmunization. 6. Detect signs of fetal anemia on ultrasound examination. 7. Describe the indications for cordocentesis in assessment of the fetus with red cell isoimmunization or thrombocytopenia. 8. Describe the indications for, and complications of, intrauterine fetal transfusion: a. Intraperitoneal transfusion b. Intravascular transfusion 9. Determine the appropriate time and method of delivery for the isoimmunized fetus. 10. Describe the short- and long-term prognosis for infants with red cell isoimmunization or thrombocytopenia. 11. Counsel patients regarding the recurrence risk for isoimmunization and thrombocytopenia Evaluation of the newborn 1. Perform an immediate assessment of the newborn infant and determine if resuscitative measures are indicated. 2. Resuscitate a depressed neonate: a. Properly position the baby in the radiant warmer. b. Suction the nose and mouth. c. Provide tactile stimulation. d. Administer positive pressure ventilation with bag and mask. e. Administer chest compressions. f. Perform endotracheal intubation and ventilation. 3. Assign Apgar scores. 4. Describe the indications for cord blood gas analysis and interpret the test results. 5. Obtain cord blood for the following purposes: a. Blood gas analysis b. Determination of fetal blood type Page 159 of 185

6. Describe the rationale for administration of topical antibiotics to prevent neonatal ophthalmic infection. 7. Counsel parents on the advantages and disadvantages of circumcision. 8. Perform circumcision under local anesthesia. Vaginal birth after cesarean delivery 1. Obtain a history of a patients previous operative delivery. 2. Counsel a patient concerning risks and benefits of vaginal birth after cesarean delivery (VBAC). 3. Describe the appropriate criteria for, and contraindications to, VBAC. 4. Recognize and treat possible complications of VBAC, such as scar dehiscence, hemorrhage, fetal compromise, and infection (see the list of procedures at the end of this unit). PROCEDURES The following table lists the procedures pertinent to obstetrics and summarizes the level of technical proficiency that should be achieved by a PGY 3. 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. PROCEDURE Amniocentesis Genetic diagnosis Maturity Assessment Cervical cerclage Transabdominal Version of breech, external Forceps delivery Outlet Low Mid Hypogastric artery ligation Vacuum extraction Low Outlet Hematoma evacuation Intraabdominal Vaginal Vulvar Wound care Repair of dehiscence Secondary closure Neonatal resuscitation, immediate UNDERSTAND PERFORM X X X

X X X X X X X X X X X X X X

PGY 4 PROCEDURES The following table lists the procedures pertinent to obstetrics and summarizes the level of technical proficiency that should be achieved by a PGY 4. 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. PROCEDURE Cesarean hysterectomy Page 160 of 185 UNDERSTAND PERFORM X

Transvaginal Chronic villus sampling Cordocentesis Intrauterine transfusion Vaginal delivery, breech Application of forceps to the After-coming head Assisted Total Breech extraction

X X X X

X X X

Gynecology
PGY 1 Genetics 1. Describe the inheritance of coagulation disorders. 2. Describe the genetic basis for repetitive reproductive loss. Physiology 1. Describe the hemodynamic changes associated with blood loss. 2. Describe the changes that occur in the cardiopulmonary function of an anesthetized and postanesthetic patient. 3. Describe the physiology of thermoregulation in the anesthetized and postanesthetic patient. 4. Describe the physiologic changes in the urinary system related t o maintenance of adequate renal output.
Anatomy

1. Describe the anatomy of the anterior and posterior abdominal wall. 2. Describe the anatomic relationship between the reproductive organs and the nongynecologic abdominal viscera. 3. Describe the gross and histologic anatomy of the external genitalia, including arterial blood supply, venous and lymphatic drainage, and neurologic innervation. 4. Describe the gross and histologic anatomy of the pelvis and pelvic viscera, including arterial blood supply, venous and lymphatic drainage, and neurologic innervation. 5. Describe the gross and histologic anatomy of the breast, including arterial blood supply, venous and lymphatic drainage, and neurologic innervation. 6. Describe the anatomy of the central nervous system as it relates to menstrual function. Pharmacology 1. Describe the pharmacology of medications used in treatment of common gynecologic disorders. 2. Describe the pharmacologic principles of drug therapy for all age groups, including: a. Prepubertal b. Reproductive age c. Elderly Microbiology and Immunology 1. Describe the microbiologic principles germane to the diagnosis and treatment of gynecologic infectious diseases. 2.Describe the epidemiologic principles involved in the spread of infectious disea ses, including transmission and prevention of HIV (human immuno-deficiency virus), in both patients and health care workers. Vaginal and vulvar infections 1. Describe the principal infections that affect the vulva and vagina. 2. Elicit a pertinent history in a patient with a possible infection of the vulva or vagina. Page 161 of 185

3. Perform a focused physical examination in a patient with a suspected infection of the vulva or vagina. 4. Perform selected tests to confirm the diagnosis of vulvar or vaginal infection: a. Determination of vaginal pH b. Saline microscopy c. Potassium hydroxide microscopy d. Bacterial and viral culture e. Colposcopic examination 5. Interpret the results of diagnostic tests, such as: a. Gram stain of suspicious lesion of the vulva or vagina b. Bacterial and viral culture c. Vulvar or vaginal biopsy 6. Describe the long-term follow -up that is necessary for a patient with a vulvar or vaginal infection, for example: a. Assessing and treating sexual partner(s) b. Assessing the patient for other pos sible genital tract infections c. Counseling the patient with respect to measures that prevent reinfection with sexually transmitted diseases (STDs) Sexually transmitted diseases 1. Describe the most common types of STDs, such as: a. Chlamydia b. Gonorrhe a c. Syphilis d. Hepatitis B and hepatitis C e. Human immunodeficiency virus (HIV) f. Herpes simplex g. Human papillomavirus h. Chancroid 2. Elicit a pertinent history in a patient with a suspected STD. 3. Perform a focused physical examination to confirm the diagnosis and determine the specific cause of an STD. 4. Perform tests and/or interpret their results to confirm the diagnosis of an STD: a. Aspiration of vesicle b. Bacterial culture c. Endocervical aspirate for Gram stain d. Endocervical aspirate for nucleic acid probe e. Endocervical culture f. Endometrial biopsy g. Pap test h. Scraping of an ulcer or chancre i. Serologic assays j. Tzanck smear k. Viral culture 5. Treat STDs with appropriate antimicrobial agents. 6. Describe the long-term follow -up for patients with an STD, including assessment of the patients sexual partner, discussion of preventive measures, and review of serious sequelae, such as: a. Infertility b. Ectopic pregnancy c. Chronic pelvic pain Spontaneous abortion 1. Describe the principal causes of, or predisposing factors for, spontaneous first-trimester abortion. 2. Describe the usual symptoms and findings experienced by a patient with an early pregnancy loss. 3. Perform a focused physical examination to confirm the diagnosis of early spontaneous abortion. Page 162 of 185

4. Describe the differential diagnosis of early spontaneous abortion. 5. Perform selected tests to confirm the diagnosis of early spontaneous abortion: a. Endovaginal ultrasonography b. Laparoscopy 6. Perform selected tests to confirm the diagnosis of early spontaneous abortion: a. Quantitative hCG 7. Interpret other diagnostic tests, such as: a. Qualitative and quantitative serum hCG b. Serum progesterone c. Complete blood count 8. Treat a patient with an early incomplete spontane ous abortion. 9. Describe and treat the complications that may develop as a result of treatment of an incomplete spontaneous abortion, for example: a. Genital tract infection b. Uterine perforation c. Retained products of contraception 10. Describe the indications for anti-D immune globulin in patients experiencing an early spontaneous abortion. Cardiopulmonary resuscitation 1. Describe the conditions that most commonly cause cardiopulmonary failure in obstetric and gynecologic patients. 2. Perform a rapid, focused physical examination to identify the patient who requires cardiopulmonary resuscitation and to determine the cause of the patients decompensation. 3. Perform basic cardiac life support: a. Assess airway, breathing, and circulation. b. Secure the airway. c. Provide ventilation by mouth-to-mouth and bag-mask techniques. d. Perform chest compressions. Allergic drug reactions 1. Describe the drugs most likely to produce allergic reactions in obstetric and gynecologic patients. 2. Describe the typical symptoms experienced by a patient with a drug reaction. 3. Describe the varying degrees of severity of a drug reaction. 4. Perform a focused physical examination to confirm the diagnosis of a drug reaction and assess the severity of the reaction. 5. Describe the differential diagnosis of a drug reaction, such as: a. Septic shock b. Hypovolemic shock c. Cardiogenic shock d. Pulmonary embolus 6. Treat a drug reaction in consultation with a specialist in critical care medicine.

PGY1 PROCEDURES The following table lists the procedures pertinent to gynecology and summarizes the level of technical proficiency that should be achieved by a PGY 1 resident. The resident should either understand a procedure (including indications, contraindications, and principle s) 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. PROCEDURE: Biopsy - cervix Biopsy Endocervix UNDERSTAND PERFORM X X

Page 163 of 185

Biopsy - Endometrium Biopsy - Skin Biopsy - Vagina Biopsy - Vulva Breast cyst aspiration Breast, fine needle aspiration Dilation and curettage Marsupializ ation of bartholins cyst Skin incisions, abdominal - midline Skin incisions, abdominal - Pfannenstiel Sterilization, Abdominal Suction evacuation for first trimester fetal death

X X X X X X X X X X X X

PGY 2 Abnormal uterine bleeding 1. Describe the principal causes of abnormal uterine bleeding. 2. Elicit a pertinent history in a patient with abnormal uterine bleeding. 3. Perform a focused physical examination to determine the etiology of abnormal uterine bleeding. 4. Interpret the results of other diagnostic tests, such as: a. Serum human chorionic gonadotropin (hCG) titer and other endocrine assays b. Microbiologic cultures c. Complete blood count d. Coagulation profile e. Radiologic imaging studies 5. Perform selected diagnostic tests to determine the cause of abnormal uterine bleeding, such as: a. Endometrial biopsy b. Endovaginal ultrasonography c. Hysteroscopy d. Laparoscopy 6. Treat abnormal uterine bleeding medically and surgically. 7. Describe the long-term follow -up that is necessary fo r a patient with abnormal uterine bleeding. Vulvar dystrophies and dermatoses 1. Describe the principal causes of vulvar dystrophies and dermatoses, such as: a. Squamous cell hyperplasia b. Lichen sclerosus c. Lichen planus d. Atrophic dermatitis 2. Elicit a pertinent history in a patient with a suspected vulvar dystrophy or dermatosis. 3. Perform a focused physical examination in a patient with a suspected vulvar dystrophy or dermatosis. 4. Perform selected diagnostic tests to confirm the diagnosis of a vulvar dystrophy or dermatosis, such as: a. Colposcopy b. Staining with dyes to localize the affected area c. Vulvar biopsy 5. Treat the common vulvar dystrophies and dermatoses medically and surgically. 6. Describe the long-term follow -up that is essential for a patient with a vulvar dystrophy or dermatosis, including assessment of the risk for malignant change. Pelvic masses 1. Describe the major causes of pelvic masses. 2. Elicit a pertinent history suggestive of a pelvic mass, such as: Page 164 of 185

a. Weight loss or weight gain b. Gastrointestinal symptoms c. Menstrual abnormalities 3. Perform a focused physical examination to confirm the diagnosis of a pelvic mass. 4. Perform tests such as endovaginal or abdominal ultrasonography to confirm the diagnosis of a pelvic mass. 5. Interpret the results of other tests to confirm the diagnosis of a pelvic mass, for example: a. MRI or CT scan b. Serum markers, such as CA 125, alpha-fetoprotein, and human chorionic gonadotropin (hCG) 6. Treat benign pelvic masses medically and surgically, considering factors such as: a. Patient age b. General health c. Patient preference d. Desire for future childbearing e. Symptom complex 7. Describe the appropriate follow-up for patients who have been treated for a benign pelvic mass. Chronic pelvic pain 1. Describe the principal causes of chronic pelvic pain (acyclic pain >6 months in duration). 2. Elicit a pertinent medical and sexual history to determine the most likely etiology of chronic pelvic pain, including those causes ema nating from nonreproductive organs. 3. Perform a focused physical examination to determine the most likely etiology of chronic pelvic pain. 4. Perform and interpret the results of selected diagnostic tests to determine the cause of chronic pelvic pain, for example: a. Microbiologic cultures of the genitourinary tract b. Hysteroscopy c. Laparoscopy d. Injection of anesthetic agent at a specific trigger point e. Mental status examination 5. Treat medically and surgically patients with chronic pelvic pain. 6. Describe the indications for referral of a patient to a subspecialist in a different field such as psychiatry or pain management. 7. Describe the appropriate long-term follow -up for a patient with chronic pelvic pain Endometriosis 1. Describe the theories of the pathogenesis of endometriosis. 2. Describe the typical history of a patient with endometriosis. 3. Perform a focused physical examination in a patient with suspected endometriosis, and identify the principal abnormal clinical findings. 4. Perform selected tests to confirm the diagnosis of endometriosis, for example: a. Endovaginal ultrasonography b. Laparoscopy and biopsy of a suspicious lesion 5. Perform selected tests to assess the fertility status of a patient with endometriosis. 6. Describe the staging system for endometriosis according to the 1996 Revised American Society for Reproductive Medicine Classification of Endometriosis. 7. Treat endometriosis medically and surgically. 8. Describe the appropriate long-term follow -up in patients who have endometriosis. Ectopic pregnancy 1. Describe the major factors that predispose to ectopic pregnancy. 2. Elicit a pertinent history in a patient with a suspected ectopic pregnancy. 3. Perform a focused physical examination to confirm the diagnosis of ectopic pregnancy or to identify other possible causes of the patients symptoms. 4. Describe the differential diagnosis of ectopic pregnancy. Page 165 of 185

5. Perform tests to confirm the diagnosis of ectopic pregnancy, for example: a. Endovaginal ultrasonography b. Uterine curettage. c. Laparoscopy 6. Interpret the results of other diagnostic tests, such as: a. Quantitative serum hCG titer b. Serum progesterone c. Complete blood count 7. Describe the indications and contraindications for, and complications of, medical mana gement of an ectopic pregnancy. 8. Describe the indications for, and complications of, surgical management of an ectopic pregnancy. 9. Treat an affected patient medically and surgically. 10. Describe the indications for anti-D immune globulin in patients e xperiencing an ectopic pregnancy. 11. Describe the long-term follow -up that is indicated for a patient treated for an ectopic pregnancy. 12. Counsel patients regarding the recurrence risk for an ectopic pregnancy and prognosis for a normal intrauterine pregnancy Pelvic support defects 1. Describe the normal anatomic supports and dynamics of the vagina, rectum, bladder, urethra, and uterus. 2. Describe the principal etiologies of pelvic support defects. Urogynecologic disorders 1. Describe the major suspected causes of urogynecologic disorders, such as: a. Obesity b. Pulmonary disease c. Multiparity d. Medications e. Infection 2. Describe the typical symptoms experienced by a patient with a urogynecologic disorder. Toxic shock syndrome 1. Describe the pathogenesis of toxic shock syndrome (TSS). 2. Describe the typical signs and symptoms of a patient with TSS, such as: a. Myalgia b. Rash c. Fever d. Hypotension e. Tachycardia 3. Perform a focused physical examination to confirm the diagnosis of TSS, determine the etiology, and assess the severity of the patients illness. 4. Interpret the results of diagnostic tests, such as: a. Microbiologic cultures b. Complete blood count and white cell differential c. Liver function tests d. Renal function tests e. Coagulation profile f. Chest X-ray 5. Treat patients with TSS in consultation with a specialist in critical care medicine. 6. Counsel affected patients about the risk of recurrence and the value of preventive measures. Septic shock 1. Describe the usual causes of septic shock in obstetric and gynecologic patients. 2. Describe the typical symptoms experienced by a patient with septic shock. Page 166 of 185

3. Perform a focused physical examination to confirm the diagnosis of septic shock, determine the etiology of the disorder, and assess the severity of the patients illness. 4. Interpret the results of diagnostic tests, such as: a. Microbiologic cultures b. Complete blood count and white cell differential c. Liver function tests d. Renal function tests e. Coagulation profile f. Chest X-ray g. MRI and CT scan of the abdomen and pelvis h. Ultrasonography of the pelvis i. Arterial blood gases j. Central hemodynamic monitoring 5. Treat a patient with septic shock in consultation with a specialist in critical care medicine. Adult respiratory distress syndrome 1. Describe the principal causes of adult respiratory distress syndrome (ARDS). 2. Describe the usual signs and symptoms of a patient with ARDS. 3. Perform a focused physical examination to confirm the diagnosis of ARDS, determine the etiology of the disorder, and assess the severity of the condition. 4. Interpret the results of diagnostic tests, such as: a. Chest X-ray b. Pulse oximetry c. Arterial blood gases d. Pulmonary function tests e. Central hemodynamic monitoring 5. Treat a patient with ARDS in consultation with a specialist in critical care medicine Hemodynamic monitoring 1. Describe the conditions most likely to cause cardiovascular dysfunction in obstetric and gynecologic patients. 2. Perform a focused physical examination to detect hemodynamic derangements, such as: a. Hypotension or hypertension b. Bradycardia or tachycardia c. Apnea or tachypnea d. Signs of poor tissue perfusion (e.g., oliguria, delayed capillary refill) e. ARDS f. Myocardial failure g. Altered mental status 3. Describe the indications for central hemodynamic monitoring (right heart catheterization). 4. Interpret the results of central hemodynamic monitoring. 5. Describe and, in consultation with a critical care specialist, treat the complications of central hemodynamic monitoring Cardiopulmonary resuscitation 1. In consultation with a specialist in critical care medicine, perform advanced cardiac life support: a. Intubate the patient. b. Administer drugs, such as: (1) Lidocaine (2) Atropine (3) Epinephrine (4) Sodium bicarbonate 2. Describe the complications of basic and advanced cardiac life support. Page 167 of 185

PGY 2 PROCEDURES The following table lists the procedures pertinent to gynecology and summarizes the level of technical proficiency that should be achieved by a PGY 2 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. PROCEDURE UNDERSTAND Ablative procedures (cervix, endometrium, Vagina, vulva) Colposcopy with directed biopsy Cervix Vagina Vulva Conization Cold knife Laser Loop Electrical Excision Culdocentesis Excision of Bartholin's gland Excision of cyst (Bartholin's ovarian, tubal, vaginal, vulvar) Hysterosalpingography Incision or drainage of an abscess or hematoma Laparoscopy Lysis of Adhesions Abdominal Laparoscopic Marsupialization of bartholin's cyst Polypectomy Pregnancy Termination Dilation and Evacuation Medical Abortion Suction curettage Q-tip test Sterilization Laparoscopic Supracervical hysterectomy - abdominal Ultrasonography Abdominal Hysteronosonography Wound Care Debridement Incision and Drainage Placement of fascial or skin graft X Repair of Dehiscence Secondary closure PERFORM X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Page 168 of 185

PGY 3 PROCEDURES The following table lists the procedures pertinent to gynecology and summarizes the level of technical proficiency that should be achieved by a PGY 3 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. PROCEDURE Ablation and excision of endometrial implants Anoscopy Appendectomy Laparoscopy Laparotomy Colonic endoscopy Colporrhaphy Anterior Posterior Culdoplasty Abdominal Vaginal Cystometrography Cystotomy repair Cystourethroscopy Hernia repair Incisional Umbilical Hymenectomy Hypogastric artery ligation Hysterectomy Abdominal , total Vaginal Vaginal, laparoscopically assisted Hysteroscopy Diagnostic Operative Myomectomy Abdominal Hysteroscopic Laparoscopic Oophorectomy Abdominal Laparoscopic Ovarian biopsy Abdominal Laparoscopic Ovarian drilling - laparoscopy Ovarian or paraovarian cystectomy Abdominal Laparoscopic Perineorrhaphy Omentectomy - infracolic Ovarian Transposition Salpingectomy Abdominal UNDERSTAND PERFORM X X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Page 169 of 185

Laparoscopic Salpingo-oophorectomy Abdominal Laparoscopic Salpingostomy Abdominal Laparoscopic Salpingotomy Abdominal Laparoscopic Skin Incisions - abdominal Cherney Maylard Paramedian Supracervical hysterectomy - laparoscopic Trachelectomy Ultrasonography Endovaginal Urethral diverticulum repair Ureteroureterostomy Vulvectomy, simple

X X X X X X X X X X X X X X X X

PGY 4 PROCEDURES The following table lists the procedures pertinent to gynecology 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. PROCEDURE: Colposuspension Laparoscopic Retropubic Vaginal, paravaginal Enterocele repair Abdominal Laparoscopic Vaginal Fistula repair Rectovaginal Uterovaginal Vesicovaginal Presacral neurectomy Abdominal Laparoscopic Trigger Point Injection Tubal Reanastomosis Urethropexy Laparoscopy Needle assisted Retropublic Vaginal UNDERSTAND X X X X X X X X X X X X X X X X X Page 170 of 185 PERFORM

Wound Care Placement of fascial or skin graft

Gynecologic Oncology
PGY 2 Anatomy 1. Describe the gross and histologic anatomy of the pelvic organs and breast. 2. Describe the vascular, lymphatic, and nerve supply to each of the pelvic organs. 3. Describe the anatomic relationship between the reproductive organs and other viscera, such as bladder, ureters, and bowel. 4. Describe the likely changes in the anatomic relationships of the pelvic and abdominal viscera created by surgical or radiation treatment for malignancy. Microbiology and immunology 1. Describe the alterations in host immune mechanisms that occur as a result of malignancies of the reproductive tract and breast. 2. Describe the immune changes that occur as a result of treatment of malignancies of the reproductive tract and breast. 3. Describe the immune aberrations that result from malnutrition and cachexia. 4. List the principal consequences of immunosuppression (e.g., increased susceptibility to infection and poor wound healing) Pathology and neoplasia 1. Describe the histology of malignancies of the pelvic organs and breast. 2. Describe the pathogenesis of malignancies of the pelvic organs and breast. 3.Describe the prognosis for the major malignancies of the breast and reproductive organs Physiology 1. Describe the ability of vital organ systems to tolerate cancer therapy and define the concept of the therapeutic index. 2. Describe the changes in cellular physiology that result from injury due to radiation and chemotherapy. 3. Describe the metabolic changes that occur in patients with a malignancy of the pelvic organs or breast Malignant gestational trophoblastic disease 1. Describe the conditions that may precede malignant GTD. 2. Describe the histologic appearance of invasive mole versus choriocarcinoma versus placental site trophoblastic tumor. 3. Diagnose malignant GTD using a combination of physical examination, ?-hCG, chest X-ray, CT scan, and ultrasonography. 4. Classify GTD into good prognosis (low risk) versus poor prognosis (high risk). 5. Describe the medical and surgical management of malignant GTD. 6. Provide, in consultation with a subspecialist, medical and su rgical treatment for a patient with malignant GTD. 7. Provide appropriate follow -up at the completion of treatment. 8. Counsel patients regarding risk of recurrence and prognosis for future pregnancies. a. Squamous cell cancer b. Basal cell carcinoma c. Pagets disease d. Sarcoma e Verrucous carcinoma f. Bartholins gland carcinoma Page 171 of 185

Radiation therapy 1. Describe the general principles of radiation therapy. 2. Describe the indications for radiation therapy in the treatment of gynecologic neoplasms. 3. Describe the mechanism of action of: a. Intracavitary irradiation b. External-beam irradiation c. Interstitial irradiation d. Radioisotopes e. Palliative radiation therapy 4. Describe the factors that influence decisions regarding intervention, such as: a. Classification and FIGO staging of disease and histology b. Age of patient c. Underlying medical conditions d. Implications for future fertility e. Concomitant therapy with radiosensitizers or chemotherapy f. Previous abdominal procedures g. Maximal dose tolerance of selected organ systems 5. Describe the potential complications of radiation therapy. 6. In consultation with a subspecialist, manage the complications of radiation therapy Terminal care 1. Describe the basic principles of palliative care. 2. Describe medical, radiation, and operative modalities for palliation of symptoms in terminally ill patients. 3. Describe the appropriate indications for a do-not-resuscitate (DNR) order. 4. Describe the medical, ethical, and legal implications of such an order. 5. Describe the concept of therapeutic index when considering medical or operative intervention to improve patients quality of life. 6. Describe the basic principles of pain management.

PGY 3 Pharmacology 1. List the major chemotherapeutic agents used for treatment of malignancies of the reproductive organs and breast. 2. Describe the principal adverse effects of the major chemotherapeutic agents. 3. Describe the medications of most value in treatment of complications resulting from chemotherapy and irradiation, such as: a. Marrow suppression b. Nausea and vomiting c. Hemorrhagic cystitis d. Peripheral neuropathy e. Renal toxicity f. Cardiac toxicity Carcinoma of the endometrium 1. Describe the epidemiology and pathogenesis of invasive endometrial cancer. 2. Describe the typical clinical manifestations of invasive endometrial cancer. 3. Describe the FIGO staging of invasive endometrial cancer. 4. Describe the differential diagnosis of invasive endometrial cancer. 5. Describe the treatment of invasive endometrial cancer. 6. Describe the prognosis for invasive endometrial cancer. 7. With the assistance of a subspecialist, provide definitive treatment for a patient with endometrial carcinoma. Page 172 of 185

8. Manage, in combination with a subspecialist, the common complications of surgical and radiation treatment for endometrial cancer. Invasive cervical cancer 1. Describe the epidemiology and pathogenesis of invasive cervical cancer. 2. Describe the typical clinical manifestations of invasive cervical cancer. 3. Describe the FIGO staging of invasive cervical cancer. 4. Describe the differential diagnosis of invasive cervical cancer. 5. Describe the treatments for invasive cervical cancer. 6. Describe the prognosis for invasive cervical cancer. 7. With the assistance of a subspecialist, provide definitive treatment for a patient with invasive cervical cancer. 8. Manage, in combination with a subspecialist, the common complications of surgical and radiation treatment for cervical cancer. 9. Describe the psychosocial concerns of patients who have invasive cervical cancer. 10. Describe the indications for referral to a specialist for treatment of psychosocial dysfunction Carcinoma of the fallopian tube 1. Describe the epidemiology and pathogenesis of fallopian tube cancer. 2. Describe the typical clinical manifestations of fallopian tube cancer. 3. Describe the histology, FIGO staging, and prognosis of fallopian tube tumors. 4. Perform appropriate tests to diagnose cancer of the fallopian tube. 5. Describe the treatment for fallopian tube cancer based on: a. Type b. Grade c. Stage d. Patient characteristics 6. Perform procedures to treat women with fallopian tube cancer, in consultation with subspecialists when indicated. 7. Manage, in consultation with a subspecialist, the common complications resulting from treatment of fallopian tube cancer. 8. Provide psychosocial support and appropriately palliate women dying of fallopian tube cancer Carcinoma of the ovary 1. Describe the epidemiology and pathogenesis of ovarian cancer. 2. Describe the inherited syndromes that increase a womans likelihood of developing ovarian cancer. 3. Describe the screening protocols that may identify patients who have an inherited form of ovarian cancer. 4. Describe the typical clinical manifestations of ovarian cancer. 5. Describe the histology, staging, and prognosis for: a. Epithelial tumors b. Germ cell tumors c. Stromal tumors d. Sarcomas e. Metastatic tumors f. Tumors of low malignant potential 6. Interpret the following tests to diagnose ovarian cancer: a. Ultrasonography b. Serum tumor markers c. Cytology from paracentesis d. CT scan 7. Describe the treatment of ovarian cancer based on: a. Type b. Grade c. Stage Page 173 of 185

d. Patient characteristics 8. With the assistance of a subspecialist, provide definitive treatment for a patient with ovarian cancer. 9. Describe the indications for secondary cytoreductive surgery. 10. Manage, in consultation with a subspecialist, the common complications resulting from treatment of ovarian cancer. 11. Provide psychosocial s upport and appropriate palliative therapy for w women dying of ovarian cancer Invasive carcinoma of the vagina 1. Describe the epidemiology and pathogenesis of invasive vaginal cancer. 2. Describe the typical clinical manifestations of invasive vaginal cancer. 3. Describe the FIGO staging of invasive vaginal cancer. 4. Describe the differential diagnosis of invasive vaginal cancer. 5. Describe the treatments for invasive vaginal cancer. 6. Describe the prognosis for invasive vaginal cancer. 7. With the assistance of a subspecialist, provide treatment for a patient with invasive cancer of the vagina. 8. Manage, in combination with a subspecialist, the common complications of surgical and radiation treatment for vaginal cancer Invasive vulvar carcinoma 1. Describe the epidemiology and pathogenesis of invasive vulvar lesions: a. Melanoma b. Squamous cell cancer c. Basal cell carcinoma d. Pagets disease e. Sarcoma f. Verrucous carcinoma 2. Describe the clinical manifestations of invasive vulvar malignancies. 3. Describe the staging of invasive vulvar cancers using the system adopted by the International Federation of Gynecology and Obstetrics (FIGO). 4. Describe the differential diagnosis of vulvar cancer. 5. Describe the treatments for invasive vulvar malignan cies. 6. Describe the prognosis for invasive vulvar malignancies. 7. With the assistance of a subspecialist, provide definitive treatment for a patient with an invasive vulvar malignancy. 8. Manage, in consultation with a subspecialist, the common complications of surgical and radiation treatment for invasive vulvar cancer. 9. Describe the impact of treatment of vulvar cancer on sexual function and appropriately refer the patient for specialized treatment if sexual dysfunction develops. Chemotherapy 1. Describe the general mechanism of action of chemotherapy. 2. Describe the indications for chemotherapy in the treatment of gynecologic neoplasms. 3. Describe the likelihood of response of each common gynecologic malignancy to chemotherapeutic agents. 4. Describe the mechanisms of action and most appropriate indication for chemotherapeutic agents, such as: a. Alkylating agents b. Antimetabolites c. Vinca alkaloids d. Antibiotics e. Hormones f. Heavy metals g. Immunotherapy 5. Describe and manage the potential complications of chemotherapy. 6. Describe the long-term effects of chemotherapy on fertility. Page 174 of 185

PGY 4 Procedures The following table lists additional procedures that are specific to gynecologic oncology 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. PROCEDURE Colectomy (partial or total) Colostomy Fistula Repair Enterocutaneous Ureterovaginal Hysterectomy Extrafascial Radical Lymph Node Biopsy/Dissection Axillary Inguinal Paraaortic Pelvic Sentinel Paracentesis Pelvic Exenteration Port Placement Radiation Therapy Brachytherapy External Beam Interstitial Resection of Large and Small Bowel Staging Laparotomy Biopsy of Pelvic Lymph Nodes Biopsy of Peritoneal Implants Cytologic Smear of the Diaphragm Exploration of the Abdomen Infracolic Omentectomy Suction Evacuation of Molar Pregnancy Vaginal Reconstruction Gracilis flap Martius flap Skin graft Transverse rectus flap Venous Access Device Placement Vulvectomy, Radical Wide Local Excision of Breast Mass UNDERSTAND X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X PERFORM

Reproductive Endocrinology and Infertility

PGY 1 Page 175 of 185

Anatomy 1. Describe and interpret normal and abnormal reproductive tract anatomy visualized by imaging procedures, such as: a. Hysterosalpingography b. Pelvic ultrasonography and saline infusion ultrasonography (sonohysteroscopy or hydrosonographic) c. CT d. MRI 2. Describe normal and abnormal reproductive tract anatomy visualized by hysteroscopy and laparoscopy. 3. Describe the gross anatomic appearance of mllerian abnormalities. 4. Describe the gross anatomic abnormalities that occur in patients with disorders of sexual differentiation. Amenorrhea 1. Describe the classification of amenorrhea (i.e., primary versus secondary). 2. List the major causes of primary and secondary amenorrhea. 3. Elicit a pertinent history to determine the most likely cause of amenorrhea. 4. Perform a focused physical examination to determine the cause of amenorrhea. 5. Perform selected diagnostic tests to determine the cause of amenorrhea, such as: a. Progestin challenge test b. Hysteroscopy c. Hysterosalpingogram d. Endovaginal ultrasonography 6. Interpret other diagnostic tests, such as: a. Qualitative and quantitative serum hCG b. Serum gonadotropin assays c. Thyroid-stimulating hormone assay d. Prolactin assay e. Dexamethasone suppression test f. Corticotropin stimulation test g. Peripheral blood karyotype h. CT or MRI 7. Describe the long-term follow -up for a patient with amenorrhea, focusing particularly on the risks for endometrial hyperplasia and hypoestrogenism. Delayed puberty 1. Describe the principal causes of delayed puberty. 2. Describe the typical history of a patient with delayed puberty. 3. Perform a focused physical examination to confirm the diagnosis of delayed puberty and determine its etiology. 4. Interpret tests to determine the etiology of delayed puberty, such as: a. Vaginal cytology b. X-rays for bone age c. Endocrinologic assays d. Peripheral blood karyotype e. CT scan or MRI of the head 5. Describe the treatment of a patient with delayed puberty. Consult with a subspecialist as needed. 6. Describe the indications for referral to a subspecialist. 7. Counsel a patient and her family about her long-term follow -up and prognosis and the effect of her condition on reproduction. Dysfunctional uterine bleeding 1. Describe the principal causes of dysfunctional uterine bleeding (DUB). 2. Elicit a pertinent history to determine the etiology of DUB. 3. Perform a focused physical examination to determine the etiology of DUB. Page 176 of 185

4. Perform selected tests to determine the etiology of DUB, such as: a. Microbiologic cultures of the lower and upper genital tract b. Endometrial biopsy c. Endovaginal ultrasonography d. Hysteroscopy e. Laparoscopy 5. Interpret other diagnostic tests to determine the etiology of DUB: a. Qualitative and quantitative serum hCG b. Complete blood count and coagulation studies c. Endocrinologic assays d. CT or MRI 6. Treat DUB medically and surgically. 7. Describe the long-term follow -up for a patie nt who has been treated for DUB. Dysmenorrhea 1. Describe the classification of dysmenorrhea (i.e., primary versus secondary). 2. List the principal causes of primary and secondary dysmenorrhea. 3. Elicit a pertinent history to determine the most likely cause of dysmenorrhea. 4. Perform a focused physical examination to determine the cause of dysmenorrhea. 5. Perform selected tests to determine the cause of dysmenorrhea, such as: a. Microbiologic cultures of the lower genital tract b. Endometrial biopsy c. Endovaginal ultrasonography/hydrosonography d. Hysteroscopy e. Laparoscopy 6. Interpret the results of other tests to determine the cause of dysmenorrhea, such as: a. Histology of the endometrium b. CT or MRI 7. Treat dysmenorrhea medically and surgically. 8. Describe the long-term follow -up and prognosis for a patient with dysmenorrhea. Embryology and developmental biology 1. Describe the embryology of normal mllerian tract development. 2. Describe the pathophysiology of mllerian agenesis and dysgenesis. 3. Describe the pathophysiology of disorders of sexual differentiation. Evaluation - Climacteric 1. Describe the normal physiologic changes that occur at the time of menopause. 2. Describe the typical symptoms experienced by a woman at the time of menopause. 3. Perform a focused physical examination in a perimenopausal or menopausal patient. 4. Interpret selected laboratory tests to confirm the diagnosis of menopause, such as serum folliclestimulating hormone concentration. 5. Assess the risk of osteoporosis by history, examination, and testing. 6. Interpret the results of other screening tests that should be performed in menopausal patients (outlined in Periodic health assessments, Unit 2, Primary and Preventive Ambulatory Health Care). Galactorrhea 1. Describe the cause of galactorrhea. 2. Elicit a pertinent history in a patient with galactorrhea, including assessment of the following areas: a. Nipple discharge b. Menstrual abnormalities c. Headaches d. Visual disturbances e. Drug use (e.g., phenothiazines) Page 177 of 185

f. Current or past chest wall lesions or trauma g. Repetitive breast stimulation 3. Perform a targeted physical examination, noting: a. Distribution of sexual hair b. Character of nipple discharge c. Development of secondary sexual characteristics d. Size of thyroid e. Presence of visual field defects 4. Order and interpret selected diagnostic studies, including: a. Serum prolactin b. Serum thyroid-stimulating hormone c. MRI of sella turcica 5. Treat galactorrhea medically with dopamine agonists. 6. Describe the indications for referral to a neurosurgeon for surgical treatment. 7. Describe long-term follow-up for the patient with galactorrhea, focusing particularly on the risk of complications, such as: a. Headaches b. Visual field defects c. Infertility d. Hypoestrogenism Hirsutism 1. Describe the principal causes of hirsutism. 2. Elicit a pertinent history to determine the most likely etiology of hirsutism. 3. Perform a focused physical examination to determine the most likely etiology of hirsutism. 4. Perform selected tests to determine the etiology of hirsutism, such as: a. Adrenal suppression and stimulation testing b. Imaging studies such as ultrasonography and MRI 5. Interpret the results of other tests to determine the etiology of hirsutism, such as: a. Serum androgen and 17-OH progesterone assays b. Serum gonadotropin assays c. CT or MRI 6. Treat hirsutism with medical and surgical interventions. 7. Describe the indications for referral to a subspecialist. 8. Describe the long-term follow -up for an affected patient and counsel her about possible effects on reproduction. Microbiology and immunology 1. Describe the normal bacteriologic flora of the lower genital tract. 2. Describe the possible effect of pathogenic vaginal organisms on the composition of cervical mucus. 3. Describe the histologic alterations in the endometrium and fallopian tubes associated with bacterial infection. 4. Describe the possible immunologic causes of infertilit y. 5. Describe the immunologic alterations associated with aging Pathology and neoplasia 1. Describe the histologic appearance of endometriosis. 2. Describe the histologic changes of the endometrium associated with: a. The normal menstrual cycle b. Patients who receive ovulation-inducing or _-inhibiting agents c. Chronic anovulation 3. Describe the histologic appearance of the ovary: a. In its normal state b. In androgen-excess disorders, such as polycystic ovarian syndrome and hyperthecosis Page 178 of 185

Pharmacology 1. Describe the pharmacology of medications used to: a. Induce ovulation b. Inhibit ovulation (e.g., gonadotropin-releasing hormone analogues, steroid contraceptives) c. Inhibit the effects of prostaglandins 2. Describe the pharmacology of hormone replacement therapy and serum estrogen receptor modulators (SERMs). 3. Describe the pharmacology of medications used to inhibit bone resorption (e.g., the bisphosphonates). Physiology 1. Describe the physiology of the following: a. Hypothalamic -pituitar y-ovarian axis b. Adrenal steroid and catecholamine synthesis c. Thyroid gland d. Female and male gametogenesis e. Hormonally regulated tissue receptors 2. Describe the normal process of steroid hormone biosynthesis. 3. Describe the relationship between ovarian and adrenal androgen production and hyperinsulinemia. Premenstrual syndrome 1. Describe the diagnostic criteria for premenstrual syndrome (PMS). 2. List the possible causes of PMS. 3. Elicit a pertinent history to confirm the diagnosis of PMS and determine its most likely etiology. 4. Describe the differential diagnosis of PMS. 5. Treat PMS with interventions, such as: a. Psychosocial support or referral b. Counseling about a healthy lifestyle c. Medication Recurrent pregnancy loss 1. Describe the most common causes of recurrent first -trimester pregnancy loss. 2. Elicit a pertinent history in a patient with recurrent first-trimester pregnancy losses, such as: a. Pedigree analysis b. Detection of underlying medical disorders c. Exposure to toxins 3. Perform a focused physical examination to identify possible causes of recurrent first trimester pregnancy loss, such as: a. Genital tract malformations b. Galactorrhea c. Hypothyroidism d. Autoimmune disease 4. Perform selected diagnostic tests to determine the etiology of recurrent early pregnancy loss, for example: a. Microbiologic cultures of the genital tract b. Hysteroscopy c. Endometrial biopsy 5. Interpret the results of other diagnostic tests, such as: a. Serum prolactin b. Thyroid function tests c. Serum progesterone d. Serologic tests for connective tissue disease e. Peripheral blood karyotype f. Hysterosalpingography 6. Treat medically and surgically patients with a history of recurrent pregnancy loss. Page 179 of 185

7. Counsel patients about the prognosis for successful treatment and the feasibility of alternative approaches, such as assisted reproductive technology and adoption.

PGY 3 Developmental anomalies of the urogenital tract 1. Describe the major developmental anomalies and their implications for sexual functioning, menstrual outflow, fertility and reproductive outcome, including: a. Hymenal abnormalities, such as imperforate hymen b. Vaginal agenesis c. Vaginal septum (1) Obstructive and non obstructive (2) Longitudinal and transverse d. Uterine septum e. Unicornuate or bicornuate uterus f. Uterine didelphys g. Uterine horn 2. Describe the features of a patients history suggestive of a developmental anomaly of the urogenital tract. 3. Perform a focused physical examination to identify a developmental anomaly of the urogenital tract and associated somatic anomalies. 4. Perform procedures (e.g., ultrasound examination, hysterosalpingography, examination under anesthesia, and hysteroscopy and laparoscopy) to confirm the diagnosis of a developmental anomaly of the urogenital tract. 5. Interpret the following tests to help to confirm the diagnosis of a developmental anomaly and determine the etiology and their implications: a. Ultrasonography b. Endocrinologic assays c. Peripheral blood karyotype assessments d. CT/MRI scan 6. Describe appropriate medical and surgical treatments for patients with developmental anomalies. 7. Counsel affected patients and their parents about the impact of genital tract anomalies on reproduction. 8. Describe the indications for referral to a subspecialist. Embryology and developmental biology 1. Describe the normal embryology of mllerian development. 2. Describe the pathogenesis of abnormal mllerian development. 3. Describe the pathogenesis of disorders of sexual differentiation.

Evaluation - Infertility 1. Describe the classification of infertility (i.e., primary versus secondary). 2. List the principal causes of primary and secondary infertility. 3. Elicit a pertinent history to determine the most likely cause of infertility. 4. Perform a focused physical examination to determine the most likely cause of infertility. 5. Perform selected diagnostic tests to determine the most likely cause of infertility, such as: a. Review of basal body temperature chart b. Endometrial biopsy c. Hysterosalpingography d. Laparoscopy e. Microbiologic cultures of the lower and upper genital tract 6. Interpret the results of other diagnostic tests, such as: a. Endometrial histology b. Semen analysis and culture c. Sperm antibody test Page 180 of 185

d. Urine ovulation indicator e. Blood assays 7. Treat infertile patients who have irregular ovulation with nongonadotropin therapy, such as: a. Clomiphene citrate b. Prednisone c. Insulin -sensitivity agents such as metformin 8. Perform selected surgical procedures to correct conditions that cause infertility, such as: a. Lysis of pelvic adhesions b. Excision of endometriomas c. Fulguration of endometriotic implants 9. describe the indications for referral of the patient to a subspecialist for treatment (e.g., gonadotropin therapy, assisted reproductive technologies [ART]). 10. Counsel patients about the long-term prognosis for their condition and alternatives to childbearing, such as adoption. Genetics 1. Describe the genetic basis of the following: a. Normal and abnormal mllerian development b. Disorders of androgen excess c. Repetitive pregnancy loss d. Ambiguous genitalia 2. Describe the principles of preimplantation genetic diagnosis. Management 1. Manage perimenopausal and menopausal conditions, including osteoporosis, using interventions, such as: a. Hormone replacement therapy (estrogen, progestins, SERMs) b. Calcium supplementation c. Behavioral and lifestyle modifications d. Dietary alterations e. Other medications that preserve bone mass such as bisphosphonates 2. Describe the implications of nonhormonal and alternative therapies, such as acupuncture and herbal medications. 3. Describe the long-term follow -up indicated for menopausal patients. 4. Describe the counseling indicated for menopausal patients, including sexual functions. Polycystic ovary syndrome (PCOS) 1. Describe the clinical features of PCOS. 2. Describe the genetic and environmental factors contributing to pathogenesis. 3. Elicit a pertinent history to determine the likelihood of the diagnosis. 4. Perform a focused physical examination to elicit findings to confirm the diagnosis. a. Serum testing, including ovarian, adrenal, pituitary, and pancreatic function 5. Perform selected tests to determine the diagnosis, such as: a. Serum testing, including ovarian, adrenal, pituitary, and pancreatic function b. Endovaginal ultrasonagraphy 6. Describe the medical treatment for PCOS in patients who do not desire pregnancy. 7. Describe the medical and/or surgical treatment for PCOS in patients who desire pregnancy and require ovulation induction. 8. Describe the indications for referral for subspecialty consultation. 9. Describe the long-term follow -up for an affected patient and counsel her about the effects on reproduction and on risk of cancer and cardiovascular disease. Precocious puberty 1. Define precocious puberty and precocious development. 2. Describe the principle cause of precocious puberty. Page 181 of 185

3. Describe the typical history of a patient with precocious puberty. 4. Perform a focused physical examination to confirm the diagnosis of precocious puberty and determine its etiology. 5. Describe the indications for, and interpret the results of, selected tests, such as: a. Ultrasonography b. Gonadotropin assays c. X-ray studies to determine bone age d. CT or MRI scans 6. Describe the treatment and long-term prognosis for patients with precocious puberty. Reproductive health care issues 1. Describe the principal reproductive health care issues of adolescents with developmental delays. 2. Describe the principal reproductive health care issues of physically disabled adolescents. Reproductive technologies 1. Describe the indications for ART procedures, such as: a. In vitro fertilization (IVF) b. Gamete intrafallopian transfer (GIFT) c. Zygote intrafallopian transfer (ZIFT) d. Intracytoplasmic sperm injection (ICSI) e. Gamete donation f. Preimplantation genetic diagnosis 2. Describe the prognosis for, and complications of, ART.

PGY 3 Procedures The following table lists additional procedures that are specific to reproductive endocrinology and summarizes the level of technical proficiency that should be achieved by a PGY 3 resident. The resident should e ither 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. PROCEDURE Assisted Reproductive technologies Gamete Gift ICSI IVF Preimplantation genetic diagnosis ZIFT Creation of neovagina Endometrial biopsy Hysterosalpingography Hysterosonography Incision of vaginal septum Metroplasty Abdominal Hysteroscopic Postcoital test Tubal reanastomosis UNDERSTAND X X X X X X X X X X X X X X PERFORM

Page 182 of 185

Pediatric and Adolescent Gynecology

1. Describe the anatomical changes of the genital tract, including the vulva, uterus and ovaries, related to different ages in the newborn, child, and adolescent, including: a. Tanner Staging b. Hormonal and growth effect 2. Describe the sex hormonal changes that occur anatomically and in the first two years of life and in childhood. 3. Describe the hormonal changes that occur as part of normal puberty. 4. Describe the principal gynecologic disorders or conditions experienced by adolescent patients and the special implications for diagnosis and management of these complex diseases as they pertain to adolescents: a. Normal and abnormal pubertal development b. Normal psychosocial development c. Primary amenorrhea d. Breast mass e. Menstrual irregularities f. Dysmenorrhea g. Vulvovaginitis h. Sexuality i. Contraceptive needs j. Sexually transmitted diseases k. Pregnancy l. Sexual abuse m. Ovarian diseases and masses n. Endometriosis o. Chronic pelvic pain 5. Elicit a pertinent medical and sexual history from an adolescent patient. 6. Perform a focused physical examination with proper technique and instrumentation to identify specific conditions in an adolescent patient with special attention to the appropriateness of sexual development. 7. Provide for the primary care needs of the adolescent, demonstrating knowledge of the following: a. Psychologic health b. Immunizations c. Confidentiality issues d. Facilitation of parent -child communication e. Safety and prevention or morbidity and mortality f. Substance abuse g. Nutrition and dietary management 8. Perform and/or interpret selected tests to confirm the diagnosis of specific gynecologic disorders, such as: a. Microbiologic tests b. Endocrinologic assays c. Ultrasonography and MRI d. Laparoscopy e. Examination under anesthesia 9. Interpret other diagnostic tests, such as: a. Qualitative and quantitative hCG b. MRI c. Serum gonadotropin assays 10. Treat adolescent gynecologic disorders medically and surgically. 11 Describe the indications for referral to a subspecialist. 12. Counsel the patient and her family about the long-term prognosis of her condition and its effect on reproduction and general health. 13. Provide patient and parent education concerning the following: a. Normal anatomic and psychosocia l development b. Personal hygiene Page 183 of 185

c. Menses d. Sexuality e. Prevention of pregnancy and STDs, including emergency contraception f. Psychosocial concerns, e.g., eating disorders, substance use, safety 14. Evaluate and manage Prepubertal children with: a. Vaginal discharge b. Vulvar lesions (labial agglutination, condyloma accuminata, psoriasis, lichen sclerosis, seborrheic dermatitis, hemangioma, molluscum contagiosum) c. Periurethral lesions (urethral prolapse, periurethral cyst, urethral caruncle) d. Sexual assault 15. Evaluate and manage adolescent disorders: a. Developmental Issues b. Body image disturbances, eating disorders c. Substance abuse d. Sexual/Physical violence

Page 184 of 185

STATEMENT OF ACKNOWLEDGEMENTS

I acknow ledge that have access to the Handbook for the Obstetrics and Gynecology Residency
Program at the University of Texas Medical Branch located on our website www.utmb.edu/obgyn/residency. I understand that the handbook covers our duty hours, supervision, the core compentencies, the educational objectives, and policies concerning each rotation, proper leave procedures, and the evaluation process. In addition, this information is being discussed at our Reside ncy Retreat today, May 18, 2007.

I understand if I have more than 10 delinquent charts (aged greater than 30 days), I will
automactically be placed on vacation until the charts are completed. I understand this is a total of both paper and electronic recor ds.

I acknowledge that I understand the call schedule I am given and that I can NOT work more than 80
hours a week averaged over 4 weeks. If I am scheduled to work more than this, I will get in touch with Tony Wen, M.D., Residency Program Director.

NOTE: The vacation days will come out of each residents current vacation balance. If the residents vacation balance is depleted, they will be placed on temporary suspension until the charts or ACGME entries are completed. Any days spent on suspension will be made up at the end of the residency. __________________________ Signature of Resident Printed Name:_________________________

Page 185 of 185