Genesys FP Residents - Resident Site

Introduction

Family Practice residents require training that will enable them to provide comprehensive care for their patients, and many family physicians choose to practice obstetrics because it is rewarding and because it keeps their practice young. Family Practice is the only specialty in which the physician cares for both the pregnant woman and the newborn, thus the issues of good nutrition during pregnancy, breast feeding, and preparation for parenting have added investment for the family physician. Since obstetrical skills are an integral part of many family physician's practices, and since being able to provide obstetrical care will enable the family physician to maintain a growing practice and serve the community over one generation. The obstetrical training at GRMC - Health Park - Family Practice Residency Program is intensive with opportunity to be involved in many deliveries over all three years.

Training in the first year focuses on the ability to do normal vaginal deliveries and assist at Cesarean Sections. For those residents that wish more advanced obstetrical training (OB Track) the second and third years provide additional emphasis to complicated deliveries, as well as, the opportunity to learn to perform C-Sections, if the resident so desires. Appropriate prenatal management is learned in the clinic where residents see a large volume of their OB patients from initial presentation through postpartum care throughout the three years of residency.

The curriculum and training is intended to provide the resident with exposure to many normal as well as abnormal pregnancies. The resident will learn to differentiate between those pregnancies within the scope of this or her training that need to be handled in conjunction with an obstetrician as well as those that need to be referred on completely for care for a specialist. The level of responsibility increases throughout the three years. The responsibility in the third year includes teaching junior residents, as well as for management for more complicated patients.

While on the obstetrical rotation, the first year residents are a part of a four or five resident team. The PGY1 residents are supervised by the second and third year OB residents on the team as well as by the individual attendings. The PGY1 residents are responsible for covering the labor and delivery floor for two weeks of nights and two weeks of days. While covering the labor and delivery floor the PGY1 resident is responsible for all initial histories and physicals and the management of labor of all patients on the floor. The PGY1 resident is also responsible for performing all normal vaginal deliveries that occur while he/she is covering the labor floor with supervision by the patient's private physician or the senior resident. The PGY1 resident is also required to be the first assistant for all scheduled and emergent C-Sections for the private physicians while on the labor and delivery floor. The PGY1 resident follows all the patients that he or she delivers vaginally or by assisting at cesarean sections on the postpartum floors until the time of discharge.

The patient population for the labor and delivery floor at GRMC - Health Park is private OB/GYN and family physicians, all of who encourage resident involvement with their patients. In addition, the PGY1 resident facilitates the care of the Family Health Center patients who present to the labor and delivery floor while working closely with the Family Health Center patient's primary resident. At that time the PGY1 is supervised by the senior resident, the OB attending staff and the Family Health Center faculty.

Rotation Goals

1.       Help the resident develop the appropriate skills to manage the laboring patient.

2.       Help the resident recognize and manage obstetrical and medical problems in the pregnant patient.

3.       Through required readings and didactics, the resident will understand the pathophysiology and treatment of obstetrical and medical problems in the pregnant female population.

4.       Help the resident recognize and manage routine gynecological problems requiring hospitalization or surgery.

PGY1 Goals

1.       To manage with appropriate supervision routine triage and labor and delivery patients.

2.       To manage with appropriate supervision routine gynecologic patients.

Rotation Learning Objectives

Core Competency: Patient Care

 

Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

 

PGY-1 Residents are expected to:

·         Demonstrate the ability to fully assess any patient presenting on the labor and delivery floor, including appropriate history taking and thorough review of dates as well as physical exam with assessment of whether or not rupture of membranes has occurred.

·         Diagnose prodromal versus active labor as well as common complications presenting on the labor and delivery floor including pyelonephritis, abruptio placenta, pre-eclampsia, and placenta previa.

·         Decide when augmentation is necessary for a laboring patient as well as when consideration must be given to surgical intervention for the laboring patient.

·         Demonstrate the following procedure skills:

1.       Accurately interpret fetal monitor strips

2.       Insertion of uterine pressure catheters and fetal scalp monitors

3.       Accurate assessment of cervical dilatation

4.       Performance of normal vaginal deliveries

5.       Episiotomy and repairs

6.       Assistance at C-Sections

·         Demonstrate respect, compassion and empathy for patients and their families, This includes the necessary communication skills and sensitivity required when dealing with difficult issues such as miscarriage, still birth or fetal demise.

·         Correctly delineate normal from abnormal physical exam findings, and understand the diagnostic relevance of abnormal findings.

·         Integrate information obtained from the history and physical exam to develop a pertinent and prioritized problem list and an initial differential diagnosis.

·         Based on the initial differential diagnosis, select initial diagnostic (laboratory, imaging, etc.) studies and therapeutic interventions, with some supervision.

·         Integrate the results of diagnostic studies to refine the differential diagnosis.

·         Select additional diagnostic studies and therapeutic interventions based on the refined differential diagnosis, with some supervision.

·         Counsel patients/families about their medical conditions and educate them and reassure patients who come in with prodromal labor and routine post-partum patients.

·         Work toward completing the requirements for technical and cognitive proficiency for invasive procedures, especially those required by the ABFM and ACOFP.  Perform invasive procedures under supervision until those requirements are met.

·         Recognize the role of healthcare providers from other disciplines and services, and work in cooperation with those providers to provide comprehensive, patient-centered care.

 

Core Competency: Medical Knowledge

 

Goal: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

 

Progressive Learning Objectives:

 

PGY-1 Residents are expected to:

 

·         Have a basic understanding of the mechanism of diseases commonly encountered in a hospital labor and delivery floor.

·         Display an attitude of inquisitiveness and a desire to continuously expand their knowledge base.

·         Utilize reference materials (e.g. textbooks, Up-To-Date®, pocket references) to correct deficits in knowledge related to the diagnosis and treatment of the patients for which they providing care.  

·         Achieve a 90% correct score on the quarterly exam or rotation quiz for any rotation they perform which has such a quiz.

·         Attend Journal Club, lectures, Condon and SCS sessions as required.

 

Core Competency: Practice-Based Learning and Improvement

 

Goals: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

 

Progressive Learning Objectives:

 

PGY-1 Residents are expected to:

 

·         Be able to teach medical students.  Seek and accept feedback from students and use that feedback to improve their teaching and supervisory skills.

·         Seek and accept feedback from attendings and supervising residents, and utilize that feedback to improve their clinical performance.

·         Set short-term learning goals for each rotation they perform.  Self-evaluate their own performance relative to those goals at the beginning and end of each rotation.

·         Set long-term learning goals (learning plan) for the academic year and residency with their advisor.

·         Perform competency-based, semi-annual self-assessments.

·         Be able to formulate clinically relevant questions related to the diagnosis and treatment of their patients’ medical conditions.

·         Be familiar with common databases of medical literature (e.g. Medline) and common search engines (e.g. OVID, PubMed, etc.).

 

Core Competency: Interpersonal and Communication Skills

 

Goals: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates.

 

Progressive Learning Objectives:

 

PGY-1 Residents are expected to:

 

·         Provide verbal presentations that are thorough, yet succinct and pertinent, and that reflect understanding of the patients’ condition and/or support a differential diagnosis.

·         Provide dictated and written notes that meet the same criteria.  In addition, written notes should be legible.

·         Provide written/electronic and verbal sign-out of patients that is efficient, pertinent, and explicit.

·         Be open and receptive to questions and recommendations from members of the nursing staff and ancillary healthcare services.

·         Develop a therapeutic relationship with patients and their families, regardless of their background.

·         Be able to explain a patient’s condition and plan of care to the patient and family in terms that are understandable and appropriate.

·         Be able to discuss the risks and benefits of procedures or interventions with patients and families, and obtain informed consent.

·         Be able to discuss resuscitation status with patients and families, answer their questions regarding this issue, and elicit the patient’s wishes in regard to cardiopulmonary resuscitation.

·         Communicate expectations to students and provide them with feedback.

·         Dictate discharge summaries that succinctly summarize and convey the pertinent details of the patient’s hospitalization and post-hospitalization follow-up needs.

 

Core Competency: Systems Based Practice

 

Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

 

Progressive Learning Objectives:

 

PGY-1 Residents are expected to:

 

·         Complete all charting/documentation/dictations in a timely manner.

·         Learn the role of other members of the healthcare team, including case managers, social workers, physical/occupational/speech/respiratory therapists, dieticians, clinical pharmacists, and others.

·         Recognize when their patients may benefit from the involvement of other healthcare providers, and invoke their assistance when appropriate.

·         Learn what evidence-based guidelines and standardized order sets are available in our institution.  Know how to find these resources, and utilize them when appropriate for patient care.

·         Prescribe medications and diagnostics in accordance with the patient's health plan or obtain prior authorization/patient assistance when necessary.

 

Core Competency: Professionalism

 

Goal: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

 

 Progressive Learning Objectives:

 

PGY-1 residents are expected to:

 

·         Treat all patients, regardless of background, with respect, compassion and empathy.

·         Treat everyone else – nursing staff, ancillary healthcare providers, program personnel, students, residents from our own and other programs, attending physicians in all specialties, others – with respect and courtesy, and in a way that reflects positively on them as individuals and the medical profession as a whole.

·         Respect patients’ autonomy and their right to make informed decisions about their own health care.

·         Commit to advocating for their patients’ needs in the healthcare system, and be willing to place the patients’ needs above their own.

·         Commit to provide the highest quality, most effective and most efficient care that their experience and level of training permit.

·         Understand and safeguard patient confidentiality and protected health information.

·         Be honest in all aspects of their professional life, including documentation of patient information, disclosure of medical errors, and acknowledgement of deficiencies in medical knowledge and clinical skills.

·         Be committed to self-directed learning, self-evaluation, and self-improvement.

·         Comply with the policies and expectations of the residency program, and complete administrative tasks (e.g. evaluation forms, medical records, logs) on time.

·         Be willing to assist their colleagues and the program with patient care and service coverage when needed.

·         Prompt completion of duties such as, but not limited to, timely reporting for clinical duties and educational activities, completion of portfolio requirements, completion of medication and other flow sheets used in the ambulatory setting, timely response to patient messages.

 

Core Competency: Osteopathic Principles and Practice / Osteopathic Manipulative Medicine

 

Goal: Osteopathic resident demonstrates a commitment to osteopathic principles and practice by including and documenting osteopathic diagnosis and treatment in their patient encounters.

 

PGY1 Residents are also expected to:

 

·         Be able to complete and document an osteopathic exam.

·         Perform and review osteopathic examination with osteopathic preceptor for both musculoskeletal and non-musculoskeletal visits.

·         Integrate osteopathic principles and philosophy into patient care in the hospital setting.

·         Include structural and palpatory diagnosis in the management of their continuity patients.

·         Include osteopathic manipulative medicine in the care of their continuity patients.

·         Document osteopathic manipulative diagnosis and treatment in patient’s charts.

·         Understand the indications and contraindications for osteopathic manipulative techniques.

OB/Gyn Learning Areas

1. Normal female growth and development, and variants
2. Appropriate history and physical examination for all age groups
3. Gynecology
   
   1. Disease prevention/health promotion and periodic health evaluation
   2. Physiology of menstruation
   3. Abnormal uterine bleeding
   4. Gynecologic problems of children
   5. Infections and diseases of the female reproductive and urinary systems
   6. Breast health and diseases of the breast
   7. Sexual assault
   8. Domestic violence
   9. Trauma to the reproductive system
   10. Pelvic pain
   11. Benign and malignant neoplasms of the female reproductive system
   12. Menopause and geriatric gynecology
   13. Indications for surgical intervention
   14. Cervical lesions and abnormal cytology
   15. Ectopic pregnancy
4. Obstetrics
   
   1. Pre-pregnancy planning and counseling
   2. Prenatal care, including risk assessment
   3. Labor and delivery
   4. Postpartum care
   5. Care of the normal newborn
   6. Common neonatal problems
   7. Analgesia and anesthesia for labor and delivery
   8. Indications for cesarean delivery
   9. Obstetric complications and emergencies
   10. Lactation
5. Family life education
   
   1. Family planning
   2. Fertility problems
   3. Interconceptional care
   4. Family and sexual counseling
6. Consultation and referral
   
   1. The role of the obstetrician, gynecologist and subspecialist
   2. Women's health care delivery systems
   3. Regionalized perinatal care for high-risk pregnancies
   4. Collaboration with other healthcare providers (i.e., nutritionist, dietitian, childbirth educator, lactation consultant, certified nurse midwife, nurse practitioner, etc.)

Core Procedural Skills:

1.       Emotional preparation of the patient, with a sensitive and thorough performance of the gynecologic examination in patients of all ages.

2.       Gynecology

1.       Appropriate screening examination of the female, including breast examination

2.       Obtaining vaginal and cervical cytology

3.       Colposcopy

4.       Cervical biopsy, polypectomy

5.       Endometrial biopsy

6.       Culdocentesis

7.       Cryosurgery/cautery for benign disease

8.       Microscopic diagnosis of urine and vaginal smears

9.       Bartholin duct cyst drainage or marsupialization

10.   Dilation and curettage for incomplete abortion

3.       Family planning and contraception

1.       Oral contraceptive counseling and prescribing

2.       Intrauterine contraceptive device counseling, insertion and removal

3.       Diaphragm fitting and counseling

4.       Insertion and removal of subcutaneous contraceptive implants and counseling

5.       Injectable long-term contraceptives and counseling

4.       Pregnancy

1.       Pre-pregnancy evaluation

2.       Initial pregnancy visit

3.       Risk assessment

4.       History, physical examination, laboratory monitoring, and counseling throughout pregnancy

5.       Noninvasive evaluation of fetal gestational age and fetoplacental adequacy, including limited obstetric ultrasound examination

6.       Management of labor

7.       Pudendal and local block anesthesia

8.       Fetal assessment, antepartum and intrapartum, including limited obstetric ultrasound examination

9.       Induction of labor

10.   Internal fetal monitoring

11.   Normal cephalic delivery including use of vacuum extraction and outlet forceps

12.   Episiotomy and repair, including third-degree lacerations

13.   Management of common intrapartum problems (e.g., hypertension, mild pre-eclampsia, fever, infection, nonreassuring fetal status, unanticipated shoulder dystocia, manual removal of placenta)

14.   Exploration of vagina, cervix, uterus

15.   Emergency breech delivery

16.   Neonatal resuscitation

17.   Management of common postpartum problems (e.g., hemorrhage, endometritis)

18.   First-assist at cesarean delivery

19.   Vaginal delivery after previous cesarean delivery

5.       Surgery

1.       Assist at common major surgical procedures

 

Advanced Procedural Skills (OB Track)

For family practice residents who are planning to practice in communities without readily available obstetric-gynecologic consultation and who need to provide a more complete level of obstetric-gynecologic services for the proper care of patients.

1.       Gynecology

1.       Loop electrosurgical excision procedures

2.       Pregnancy

1.       Ultrasound-guided amniocentesis, mid- and third-trimester

2.       Conduction anesthesia and analgesia (not routinely taught by obstetrician-gynecologists)

3.       Management of preterm labor

4.       Management of multiple gestation

5.       Management of breech delivery

6.       Amnioinfusion

7.       Use of low forceps

8.       Fourth-degree lacerations

9.       Severe pre-eclampsia

10.   Performance of cesarean delivery

11.   Management of complications of vaginal birth after previous cesarean delivery

3.       Surgery

1.       Tubal ligation, postpartum and with cesarean delivery

Monographs: See Monograph Grid.

Additional Reading:

The basic text is William’s Obstetrics and the Family Health Center OB Manual.

Additional selected readings are provided by Dr. Strocel and/or other attendings along with the AAFP Monographs assigned to each rotation.

Resident Responsibilities

1. Round on all your patients prior to attending rounds. Know all relevant labs and tests. If you have questions or concerns check with your senior residents.
2. Daily progress notes.
3. H & P on new admissions.
4. Present your patients during attending rounds.
5. Discharge summaries on all your assigned patients.
6. Read on your assigned patients and present this information when possible (morning report or rounds).
7. Perform procedures with appropriate supervision.
8. Attend OB/Gyn Morning lectures and Wednesday afternoon conferences.
9. Round on weekends per schedule (schedule done by senior residents).
10. Respond to floor calls.

OB/Gyn Faculty

A designated OB/Gyn Faculty will supervise the implementation of the OB Rotation.

1. The faculty member will provide didactic sessions covering selected ob/gyn topics
2. The faculty will monitor and develop a noon conference and morning report schedule to ensure implementation of the curriculum (Learning Areas).
3. The faculty will monitor and take part in the morning OB/Gyn lecture series.
4. The faculty will report back to the Program Director and the CDE committee on issues relating to the OB rotation.

Evaluation

All residents will take the assigned rotation quiz following completion of the rotation.

Residents will be evaluated by the precepting faculty based on defined goals and objectives.

Residents following completion of the rotation will evaluate the rotation and the faculty physicians.

Procedure documentation: All procedures performed while on the obstetrical service are to be documented by the resident and turned in to CDE at the end of the rotation.

Schedule: See OB schedule grid

Vacation: One week of vacation is permitted during these blocks. No two residents may be gone during the same week.

PROCEDURE DOCUMENTATION All procedures performed while on rotation are to be documented by the resident in their logs and turned in to CDE at the end of the rotation.