Expectations

Above all else, I expect you to be kind and engaged.

The expectations below are divided into three categories: clinical, educational, and professional. It is my job to make sure that the clinical and educational sections overlap as much as possible and I will strive to make the balance of this rotation lean more toward education than to service. If you feel that I am not meeting this goal, please let me know - without worry of judgement or retribution.

If you plan to take vacation while on rotation with us, please let me know ASAP so we can plan accordingly.

Educational

Regular reading, focused on future or recent patients/diagnoses, will serve you very well on the rotation. This type of preparation will show your commitment to learning and your level of engagement which, in turn, will lead to me giving you more responsibility and direct teaching.

Additionally, we expect that you attend didactic sessions and multidisciplinary conferences while on this service. One large benefit of subspecialty rotations is to learn how specialists think. These sessions/conferences will go a long way to meet that objective.

The following urogynecology-relevant items are taken directly from the CREOG Learning Objectives, 12th Edition. I encourage you to read this entire document a couple of times per year to remind yourself of the depth and breadth of information there is to learn across all specialties (and to focus your reading/studying).

• List risk factors of, diagnose, and perform initial management of the following obstetric complications:
  • Obstetric Laceration
  • Perineal hematoma
• Counsel about the normal healing process of obstetric lacerations and episiotomy.
• Screen for urinary and fecal incontinence in the postpartum period. (If you’re looking for a resident research and/or quality project, this is one.)
• Diagnose and perform initial management of postpartum complications, including the following:
  • Infections (UTI)
  • Urinary tract injury
  • Laceration/episiotomy breakdown
• For the following presenting conditions, perform pertinent history and evaluation, including diagnostic procedures, consult subspecialists when appropriate, counsel, and manage medically and surgically:
  • Pelvic pain (acute or chronic) - for urogyn this will focus on musculoskeletal, gastrointestinal, neurologic, and genitourinary
  • Urinary tract infection
  • Pelvic organ prolapse
  • Urinary incontinence
  • Fecal incontinence
• Provide lifestyle and life-phase counseling, such as reproductive health or menopause counseling.
• Perimenopause and Menopause
  • Understand the definition, physiology, and description
  • Counsel and advise patients about perimenopause and natural and induced menopause
  • Manage patients with perimenopause and menopause
    • Counsel and advise patients about nutritional and behavioral interventions
    • Counsel and advise patients about medical and pharmacologic interventions, including hormone therapy.
    • Counsel patients about the benefits and risks of medical interventions.
• Geriatric Care
  • Diagnose and manage pelvic floor support and incontinence disorders.

Core Procedures in Urogynecology

• enterocutaneous, rectovagina, ureterovaginal, urethrovaginal, vesicovaginal

** vaginal, laparoscopic, laparoscopic assisted vaginal

Clinical

In the Office

• Review charts prior to the office day focusing on the new patients.
• Read about the conditions you expect to encounter in these patients.
• Review the new patient paperwork, new data (PVR, uroflow), and take the patient’s history
  • Place orders for uroflow (51741) and bladder scan (51798)
• We’ll do exams together.
• Do your best to develop a plan.

Preoperatively

• Read about the patient and know her history.
  • How did she present? How did we make the diagnosis?
  • What other medical/surgical options did/does she have?
  • Why did we choose this procedure?
  • What postop considerations are unique to this patient?
• Read about the procedure(s) we plan to perform.
  • REVIEW. THE. ANATOMY.
  • Know the basic steps of the operation.
  • Make incision plans.
  • What are the major risks of the procedure?
  • What risks may be elevated in this patient?
  • How would you describe the success rate for this procedure(s)?
  • What can the patient expect postoperatively?
• Complete the Preop H&P when appropriate.
• Review the consent form to be sure it matches the patient, her history, and the office notes.
• Consider preoperative antibiotic and DVT prophylaxis and order accordingly.

Intraoperatively

• Review equipment and instruments that will be used. Ensure that the proper items are available.
• Position lights and screens appropriately for the planned case.
• Position the patient. Know the most common injuries, their presentations, and treatment.
• Teach (and remind me to teach) the medical students the basics of [uro]gyn surgery.
• Ask for guidance if you are uncertain of your role. You will almost always be the first assistant.
• Remember Halstead’s Principles
  • Gentle handling of tissue
  • Meticulous haemostasis
  • Preservation of blood supply
  • Strict aseptic technique
  • Minimum tension on tissues
  • Accurate tissue apposition
  • Obliteration of deadspace

Postoperatively

NOTE: Order sets are NOT a substitute for thinking. If a patient has CKD or is > 65yo, NSAIDS are probably a bad idea. If a patient has liver disease, skip the acetaminophen. You get the picture. Order sets are meant to speed things up and ensure that you haven’t forgotten important things, but they are not to be used without critical thinking. Use your brain.

• Admission and/or discharge orders
  • See the Postoperative Considerations specific to the procedure.
• Discharge medications to pharmacy
• Discharge summaries when appropriate
• Patient education materials for pain control, catheter management, and precautions
• Communicate with nursing to optimize timely delivery of care
• Manage the voiding trial when applicable
• Follow up on ANY pathology for any patient on whom you operated or assisted (this does not mean you have to notify or discuss with the patient)

Professional

Directly from the IU School of Medicine list of core competencies:

Respond to patient needs in a manner that supersedes self-interest, respecting the dignity, privacy and autonomy of the patient, and employing strategies to reduce the effect of one’s own beliefs, values, interests, and biases on patient care.

Demonstrate compassion, honesty, integrity, respect, responsibility, and self-discipline in relationships with all individuals, regardless of gender, age, culture, race, ethnicity, religion, sexual orientation, disability, socioeconomic status, native language, or role.

Apply ethical and legal principles governing medical practice; identify, analyze and address unethical and unprofessional behaviors; maintain appropriate boundaries in relationships with patients and colleagues.