PGY4 Program Educational Objectives
& Curriculum Outline

Curriculum Goals | Curriculum & Description of Rotations

Curriculum Goals for the PGY 4 Resident

By the end of the final year of residency, residents are expected to develop and cultivate the skills learned in the first three years as well as:

General:

  1. Supervise junior residents in the care of patients with complex problems and surgical conditions.
  2. Demonstrate a high level of scientific, clinical and technical knowledge about all aspects of general obstetrics and gynecology.
  3. Assume independent responsibility for patient care in general obstetrics and gynecology.
  4. Operate independently with a high level of technical skill and clear decision-making.
  5. Demonstrate effective management of time in care of outpatients.
  6. Be able to lead discussions with junior residents and students regarding ethical, psychosocial and professional issues related to the practice of Ob/Gyn.
  7. Demonstrate an ability to obtain appropriate consultations and collaborations with specialists from other fields.
  8. Evaluate the skills and knowledge of junior residents and students and provide appropriate guidance for improving these skills.
  9. Take responsibility for administrative issues in the practice of medicine.
  10. Demonstrate appropriate follow up of patients.

Obstetrics:

  1. Identify all normal and abnormal variations in physiology due to pregnancy and provide appropriate counseling and management for patients.
  2. Recognize the effects of pregnancy on diagnostic studies and interpret these studies appropriately.
  3. Manage pregnancies with abnormalities of fetal development and physiology
  4. Provide comprehensive preconception care and counseling
  5. Provide basic genetic counseling and evaluation
  6. Provide prenatal care to complicated obstetric patients
  7. Determine the need for and demonstrate the ability to interpret and act on antepartum fetal evaluation studies
  8. Identify and manage medical complications of pregnancy such as diabetes, diseases of the urinary system, infections, hematologic problems, cardiac diseases, pulmonary diseases, GU disorders, nervous system problems, endocrinopathies, collagen vascular disorders, psychiatric problems, substance abuse and HIV.
  9. Identify and manage second trimester loss including induction of labor and D&E
  10. Identify and manage complications of pregnancy including preterm labor, bleeding in the 2nd and 3rd trimesters, hypertension, multiple gestation, growth restriction, isoimmunization, dystocia, post-term pregnancy PROM, IUFD etc.
  11. Provide intrapartum care to complicated patients including fetal assessment, induction and augmentation of labor, operative deliveries and cesarean section.  The resident should also be familiar with the principles of midforceps, rotational forceps and breech extraction.
  12. Identify and manage with minimal guidance, intrapartum emergencies such as eclampsia, hemorrhage, uterine inversion and uterine rupture.
  13. Demonstrate a detailed understanding of obstetric anesthesia/analgesia and associated complications
  14. Provide care to all postpartum patients, including those requiring intensive care. 
  15. Demonstrate a thorough understanding of lactation and be able to counsel patients appropriately
  16. Manage postpartum hemorrhage and shock, including identification of the problem, administration of appropriate resuscitation, post-partum hysterectomy
  17. Manage postpartum complications including infections, thrombophlebitis, PE, mastitis and anemia.

Gynecology:

  1. Evaluate abnormal uterine bleeding, including performing appropriate history/physical and diagnostic tests, and interpretation of data as well as management including hormonal, antimicrobial, and surgical therapies. The resident should also demonstrate the ability to develop follow up plans.
  2. Diagnose and treat vaginal and vulvar infections, including medical therapy, cryotherapy and laser treatment of condyloma, extraction of foreign bodies, assessment of the presence of systemic disease and other concurrent infections.
  3. Recognize, diagnose and treat vulvar dystrophies and dermatoses
  4. Manage dyspareunia, vulvodynia, vaginismus
  5. Be able to perform and interpret a sexual history
  6. Understand normal female sexual function
  7. Diagnose and manage male/female sexual disorders
  8. Identify, treat and counsel patients with all types of STD's including HIV.
  9. Demonstrate a sensitivity to issues related to informing patients of the presence of STD's, be available to assist with notification of sex partners and STD registries.
  10. Identify, evaluate and manage pelvic masses, and demonstrate appropriate consultation of an oncologist if necessary.
  11. Perform appropriate laparoscopic and open management for disorders of the adnexa including TOA and PID.
  12. Diagnose and manage chronic pelvic pain, including identification and management of etiologies other than gynecologic, including GI, neurological, psychological, and physical/sexual abuse.
  13. Identify and manage endometriosis, including medical and surgical interventions appropriate for patients interested or not interested in future childbearing
  14. Diagnose and manage benign conditions of the breast including ordering appropriate diagnostic studies, performing needle aspiration of cystic masses, and management of breast pain, galactorrhea and infection
  15. Screen appropriately for malignancies and other diseases of the breast and counsel patients on the proper techniques for performing BSE.
  16. Diagnose and treat Toxic Shock Syndrome, septic shock, ARDS.
  17. Understand and perform hemodynamic monitoring, CPR, and evaluation of allergic reactions.
  18. Identify and manage ectopic pregnancy including medical treatment, laparoscopic and open treatment, and appropriate follow up.
  19. Identify, manage and counsel patients with early pregnancy loss and recurrent pregnancy loss
  20. Understand the different options available to patients interested in pregnancy termination, and be able to discuss the risks and benefits associated with each option
  21. Perform all the procedures and manage the complications listed in section V of the CREOG Educational Objectives ( pp184-188, 5th ed.)

Reproductive Endocrinology:

  1. Recognize and treat developmental anomalies of the female urogenital tract, with referral to and collaboration with appropriate pediatric specialists. This includes diagnostic studies such as appropriate physical exam, endocrine and electrolyte evaluation, hormonal treatment, operative therapy such as vaginal dilation and excision of septa, and recognition of psychosocial implications for the patient and family.
  2. Appropriately evaluate pediatric and adolescent patients with gynecologic problems such as pain, discharge, mass, foreign body. Perform hymenotomy.
  3. Identify and manage disorders of puberty, intersex disorders and ambiguous genitalia
  4. Evaluate and treat dysmenorrhea and PMS
  5. Evaluate and treat dysfunctional uterine bleeding, endometriosis and habitual abortion
  6. Evaluate and treat amenorrhea, hirsuitism and polycystic ovarian syndrome
  7. Perform a basic infertility evaluation and counsel patients/partners appropriately
  8. Demonstrate a detailed understanding of assisted reproductive technologies currently available
  9. Manage the symptoms of menopause and the climacteric period
  10. Counsel patients regarding hormone replacement therapy, options and alternatives, and manage the side effects of HRT
  11. Counsel patients regarding alternatives and side effects and options for fertility care
  12. Perform operative Laparoscopy (pelviscopy). and operative hysteroscopy
  13. Perform sonohysterogram and interpret results
  14. Be able to discuss indications and perform intrauterine insemination
  15. Understand role of pre-implantation genetic screening and diagnosis, implications, alternatives
  16. Perform preconceptual screening and counseling
  17. Understand the role of fertility drugs:  management, risks and benefits, alternatives
  18. Understand the psychosocial implications of reproductive diseases and counseling, therapeutic alternatives, including medications
  19. Be able to review journal articles and perform appropriate evaluation
  20. Be able to set up a model research protocol

Oncology:

  1. Be familiar with and be able to perform radical hysterectomy
  2. Demonstrate a basic mastery of radical vulvar surgery
  3. Understand the principles of surgical treatment of all stages of ovarian cancer
  4. Understand the issues involved in terminal care and provision of palliative care to dying patients and families.
  5. Be familiar with the techniques necessary to perform intestinal surgery such as colostomy and bowel resection

Urogynecology:

  1. Understand etiologies and clinical presentation of different types of urinary incontinence, including stress, urge, neurogenic incontinence and intrinsic sphincter deficiency
  2. Understand etiologies and clinical presentation of different types of anal incontinence
  3. Understand etiologies and clinical presentation of different types of pelvic organ prolapse
  4. Understand pelvic floor anatomy and the relations of anatomy to incontinence and prolapse
  5. Perform physical examinations employing simple office cystometrics and the POPQ prolapse grading scale in the evaluation of incontinence and pelvic floor disorders
  6. Understand the basic principles and uses of multi-channel urodynamics
  7. Understand medical management techniques of incontinence including available medications, mechanisms of action, side effects and contraindications of pharmaceuticals
  8. Understand the use of pessaries and other techniques (biofeedback, etc.) in the treatment of urinary incontinence
  9. Understand clinical uses of pessaries used in the treatment of pelvic floor prolapse
  10. Understand surgical options available for the treatment of genuine stress incontinence
  11. Understand surgical options available for the treatment of intrinsic sphincter deficiency
  12. Understand surgical options available for the treatment of anal incontinence
  13. Understand surgical options available for the treatment of pelvic organ prolapse, including pelvic floor reconstruction as well as obliterative techniques
  14. Learn the common complications of pelvic reconstructive surgery including procedure failure, post-operative urinary retention, graft rejection, cystotomy, hemorrhage, etc.

Surgical:

  1. Learn techniques of basic cystoscopy.
  2. Learn techniques of suprapubic catheterization and trouble-shooting common problems.
  3. Learn instruments and techniques involved in procedures such as Burch and Marshall-Marchetti-Krantz retropubic urethropexy, fasica lata pubovaginal slings, and tension free vaginal taping in the treatment of urinary incontinence.
  4. Learn specific techniques employed in the surgical treatment of ISD such as suburethral sling procedures and periurethral bulking agents.
  5. Learn instruments and techniques involved in procedures such as sacrocolpopexy, sacrocolpoperineopexy, paravaginal repair, enterocele repair, anterior and posterior colporrhaphy, colpectomy, LeForte, and perineorrhaphy procedures in the treatment of pelvic floor prolapse.
  6. Reinforce understanding of detailed pelvic anatomy intra-operatively as it relates to specific defects and/or is used for reconstruction.
  7. Evaluate and manage different types of incontinence including pathophysiology, history/physical exam, diagnostic tests, surgical and medical therapy. Perform the q-tip test, evaluate PVR, test perineal muscle strength, perform and interpret cystometric studies, perform basic cystoscopy.

Minimally Invasive Surgery:

Skills:

1.      Perform, with minimal assistance, retroperitoneal dissection with identification of key anatomic structures.

2.      Perform, with minimal assistance, ureterolysis and enterolysis.

3.      Demonstrate the ability to identify and release the bladder edge (flap).

4.      Understand and perform mass extraction (morcellating, morcellating through a mini-lap, and vaginal morcellation).

5.      Continue to develop skill with laparoscopic stapling, suturing and intra and extra-corporeal knot tying.

6.      Perform, with minimal assitance, specific procedures such as: LAVH, LSH, TLH, ovarian cystectomy, laparoscopic myomectomy, laparoscopic uterosacral ligament fixation, and uterine artery ligation.

7.      Perform global endometrial ablation with minimal assistance

8.      Perform operative hysteroscopy with minimal assistance, including resection of submucous myomas, endometrial polyps and intrauterine synechiae.

Knowledge:

1.      Continue to develop knowledge of the topics introduced as a PGY1, PGY 2 and PGY 3.

Research:

  1. Demonstrate an ability to perform a literature search on a difficult clinical question and to utilize this information to improve patient care and to evaluate ones own practices.

  2. Research and present lectures on advanced topics in obstetrics and gynecology.

  3. Continue to work with a faculty mentor to finish a research project, if desired, and prepare this research for publication.

  4. Demonstrate an ability to utilize principles of evidence based medicine, including epidemiology, statistics and critical analysis of the literature and assist junior residents in understanding these topics.

< top >

Curriculum & Description of Rotations:

Reproductive Endocrinology:
This rotation is completed at the George Washington University. The resident is integrated into all REI division activities during this rotation. Didactic teaching occurs during the weekly REI journal club, medical student presentations, faculty presentations and case discussions. Residents are provided a schedule of regular weekly sessions (journal clubs, case reviews, research meetings) and are expected to attend. This resident is assigned to all REI surgeries: laparotomies, hysteroscopies, pelviscopies, IVF and emergency surgery. Fundamentals of advanced infertility management, which include OHSS, Asherman's Syndrome, Ovulation Induction, and application of ART will be reviewed during the rotation. A comprehensive review of REI and medical endocrinology, as outlined in the CREOG handbook, (appendix C, p 277-287) will be followed. The chief resident on call answers all phone calls from patients after hours, and may contact the REI faculty member on call with any problems. Surgical proficiency is determined and feedback is given in verbal and written form after the rotation by REI faculty.
Faculty Contact: Dr. Paul R. Gindoff

Gynecologic Oncology:
There are two separate experiences in gynecologic oncology in the senior year. Each resident spends a month on the oncology services at GW and the service at Fairfax hospitals. There is also a less structured gynecologic oncology experience for the administrative chief residents at Holy Cross Hospital.

At George Washington University the chief resident is responsible for running the GYN oncology service, participates in all outpatient sessions with Dr. MacKoul, assists in pre-operative evaluations, assists in all surgical cases, and performs all consultations. This rotation provides an opportunity for the resident to learn and perform radical pelvic surgery. Colposcopic skills and proficiency at office procedures such as LEEP are highly emphasized. There is exposure to chemotherapeutic principles and management, as the service also includes inpatients receiving chemotherapy for gynecologic malignancies. Experience in radiation oncology is achieved through direct management of patients (both inpatients and outpatients) requiring it for gynecologic cancer. Residents are often required to independently research specific topics in gynecologic oncology. The chief resident develops his/her leadership and teaching skills by organizing daily inpatient rounds and educational meetings with the medical students and junior resident on the service.  Evaluation is performed by Dr. MacKoul at the end of the rotation.

Faculty Contact: Dr. Paul MacKoul

 At Fairfax Hospital the chief resident on the oncology service oversees a busy service with four private gynecologic oncologists. The surgical experiences are numerous and provide ample exposure to the surgical management of all varieties of gynecologic malignancies. The chief resident's role as a teacher is developed by coordinating a tumor board, held jointly with pathology and medical oncology. For this conference the chief resident selects cases to be presented, coordinates with the department of pathology to facilitate presentation of histologic slides, helps prepare the cases for oral presentation, and provides supplemental readings or information for all the resident participants. Evaluation is performed by one of the oncology attendings at the end of the rotation.

Faculty Contact: Dr. Annette Bicher

 Urogynecology:
The formal experience in surgery for female incontinence and pelvic floor defects is obtained in a rotation at Fairfax Hospital. The resident learns and practices the surgical principles and post-operative management of these patients with the three private urogynecologists and the uro-gynecology fellow.  One day per week is spent in the private office of this practice and consists of evaluation of patients, observation of counseling sessions and interpretation of urodynamic studies.  Exposure to pelvic floor physical therapy is also available during this rotation.  Once a month the resident evaluates and creates a management plan for the clinic urogynecology patients under the supervision of the faculty.  Evaluation and feedback is an ongoing process during the rotation. In addition, at the end of each rotation the attending of the resident's choice is asked to evaluate the resident in a face to face manner using an approved evaluation form provided by the residency program office.

Faculty Contact: Dr. Nicolette Horbach

Recommended Reading:

  1. Retzky, Sandra S. and Rogers, Robert M. Clinical Symposia: Urinary Incontinence in Women. Ciba-Geigy Corporation. 1995; 47(3)
  2. Ostergard, Donald R. and Bent, Alfred E., eds. Urogynecology and Urodynamics, Theory and Practice, 3rd ed. William & Wilkins, 1991.Hurt, W. Glenn, ed.
  3. Urogynecologic Surgery, Second Edition. Lippincott Williams & Wilkins, 2000.
  4. Additional required readings are available in the chief call room at Fairfax hospital

 Minimally Invasive Surgery:

This 4 week rotation at The George Washington University is spent working closely with the gynecologic surgeons at GW to advance laparoscopic and hysteroscopy skills in the operating room.  In addition this resident will be expected to attend office sessions in the MFA to gain experience in office procedures such as SIS, hysteroscopy, HSG and urodynamics.  There is additional exposure to gynecologic ultrasound during this rotation.  Finally, this resident will also gain some additional exposure to urogynecologic procedures and management of pelvic floor disorders and incontinence. This resident will be evaluated at the end of the rotation by Dr Robinson and/or Dr Chahine.
Faculty Contact: Dr Jim Robinson

Obstetrics and High Risk Obstetrics: 

At Fairfax Hospital the fourth year resident spends one month on the High Risk service. There is intensive involvement in the care of clinic hospitalized antepartum patients on a busy High Risk Perinatal unit, with daily rounds led by perinatologists The chief resident on the service is responsible for overseeing the care provided by all the junior residents on the service, and reviews all cases and sees all clinic/service patients prior to daily rounds with the perinatologists. The chief oversees the resident on day-call with increasing responsibility for interpretation of antenatal testing of hospitalized and outpatients. There is a weekly high risk clinic, supervised by chief residents and perinatologists, where the resident primarily evaluates and increasingly takes more responsibility in the development of management plans for and care of high risk obstetric patients. The chief resident reviews all charts, ultrasounds and labs done on patients seen the obstetrics clinic, and discusses problem or difficult patients with the perinatologists. There is increasing responsibility for management of more complicated patients, abnormal labors, multifetal pregnancies, and operative vaginal deliveries. A premium is placed on development of teaching skills during this rotation. Residents are also expected to learn about systems-based practice during this rotation, as they become facilitators of care for patients with limited resources. They also become directly involved in coordinating care of complicated high-risk patients with other specialist consultants. Residents are encouraged to take primary responsibility for clinic patients during this rotation and to this end are frequently coordinating delivery of bad news and management plans for complicated patients.  The MFM faculty at the end of the rotation performs evaluation of this resident.
Faculty Contact: Dr. Alfred N. Khoury  

The fourth year resident spends approximately 3 months of the year supervising junior residents on Labor and Delivery during the daytime and nighttime hours at both Fairfax Hospital and GW.  These residents are responsible for overseeing the care of all laboring patients, ER consults, emergency gyn cases, oncology patients and antepartum patients.  During these months there is ample opportunity for operative vaginal delivery, to solidify the resident’s capability to manage obstetric and gynecologic emergencies, and to teach junior residents and medical students a variety of techniques.  There is a night float system in place, and residents working the night float shift work from 7pm until 7 am.  Evaluation is done by the 24 hour attending faculty at Fairfax hospital and by the full time faculty at GW at the end of the rotation.   

Teaching:
Residents are always expected to provide informal teaching to medical students and junior residents, in the clinics, ORs and on labor and delivery.   Senior residents are expected to provide feedback to each junior resident after call periods and OR cases. More sophisticated teaching and evaluation is expected from residents at this level of training. There is special emphasis on teaching of junior residents, and chief residents are given increasing responsibility for teaching procedures and surgical techniques. Feedback is given to each junior resident and to the Program Director regarding progress or areas of concern.

< top >