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Lloyd Holm, DO Clerkship Director Generalist Faculty Sonja Kinney, MD Assistant Clerkship Director Generalist Faculty Jill Ramsdell Student Education Coordinator M3’s, M4’s Welcome to OB/GYN Orientation Agenda Morning: Clerkship Overview and Expectations

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Welcome to ob gyn l.jpg

Lloyd Holm, DO

Clerkship Director

Generalist Faculty

Sonja Kinney, MD

Assistant Clerkship Director

Generalist Faculty

Jill Ramsdell

Student Education Coordinator

M3’s, M4’s

Welcome to OB/GYN


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Orientation Agenda

Morning:

  • Clerkship Overview and Expectations

  • Tour of Conference Rooms and Clinics

  • Pictures

  • Pelvic Model

  • UNMC OB students – L&D system orientation

    Afternoon:

  • UNMC OB students-Page residents

  • Methodist OB students– site orientation


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Methodist Site Orientation

  • Please go to the Medical Staff Office on the first floor of MH and ask for Kristi. Orientation at MH will begin promptly at 2:00PM, therefore, please try to be at the staff office by 1:55PM.


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Overview: Clerkship “Blocks”

  • Obstetrics Block (2 weeks)

  • Gynecology Block (2 weeks)

    • Gynecologic Oncology- 1 week

    • Benign Gynecology – 1 week

  • Outpatient Clinics Block (2 weeks)


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University Assigned Students:

  • Obstetrics- 2 weeks University

  • Gynecology block- 2 weeks University

  • Outpatient Clinics block- University


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OB Methodist Students

  • Obstetrics block done at Methodist

    • on team with residents and MFM’s

  • Gynecology block and Outpatient Clinics blocks done at University Hospital


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Sample Schedule

  • Student A:

  • Weeks 1-2 Weeks 3-4 Weeks 5-6

    Obstetrics Gynecology Clinics

    (Kinney & Amoura)

    * Call expected approx 3 weeknights and one weekend night during Weeks 1-2 (OB)

    * Weeks 5-6 schedule found on Kinney & Amoura clinic advisor handout


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*Sample Advisor Schedule:

*Sample only, please see actual advisor schedule in your packet


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Who will teach, supervise, and evaluate you?

  • Obstetrics 2 weeks

    *UNMC- 1 faculty/week and service team

    *Methodist- MFM faculty, one resident

  • Gynecology 2 weeks

    * Benign- resident team and faculty in cases

    * Oncology- Dr. Remmenga and team

  • Outpatient Clinics 2 weeks

    * One faculty per week


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Who are the Chief Residents?

Joshua Sampson, DO Allison Sampson, DO Maria Gondra, MD OB ONC GYN


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Who are the Methodist Residents?

Matthew Bruner, MD Sara Gross, MD

Gynecology Obstetrics


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Wednesday Teaching Mornings

  • No matter which clinical block or hospital currently assigned to, every student should attend

    0800AM Grand Rounds –University

    0900-1200noon Lectures

    √ schedule in notebook


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Other scheduled teaching conferences:

Students on OB rotation at Methodist

Tuesday 0700AM meet with Dr. Bassett

Students on Outpatient Clinics and Benign Gyn

Teaching rounds:

Monday 0700AM GYN - Chapter

Tuesday 0700 AM GYN – Preop Conf DOC 4608

Wednesday 0700AM – Questions

Thursday 0700AM GYN – Student presentations

Thursday (once/month) 12-1 Dysplasia conf.

Friday 0700AM Diagnostics Obstetrics and Gynecology (DOG) in DOC 4608 (OB classroom).


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Other scheduled conferences:

  • UNMC Obstetrics-

    - Friday 12 noon FHT Tracing Rounds


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Chairman’s Luncheon

  • Dr. Carl Smith will host a luncheon towards the end of the 6-week clerkship.

  • Lunch will be provided (Mexican, Chinese, Greek, Italian, etc)

  • All students on this rotation are expected to attend.


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Communication

  • You will be responsible for reading your email.

  • Jill and Dr. Holm will communicate all information by email or at the Wednesday morning student lectures.


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Text Books

  • Required textbook:

    Beckman, Obstetrics and Gynecology

    5th Edition

    Reading assignments listed for each lecture.

    Other suggested text:

    Hacker, Essentials of Obstetrics and Gynecology

    5th Edition


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Web Site

  • The department’s education website is found under Ob/Gyn department: www.unmc.edu/obgyn

  • Lecture materials located here:

    - Student Education

    - Lecture schedule

    - Click for Power Point presentations

  • You may access resident education information from this address as well.


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What do I do with “down-time”?

* Read, read, read – try to focus on mechanisms of disease

  • Review practice questions from books Jill has in her office

    • (Appleton & Lang Review, Wylen Pretest, On-Call)

  • Preview lectures for week

    • (Print out web site Power Point lecture, review recommended reading)

  • Directed studying web-site links

  • Blackboard practice questions


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Policies: Attendance

  • Excused ABSENCES:

  • If you are ill, you must contact:

    • Jill Ramsdell @ 9-8133 (no emails)

    • Your current assigned service faculty or chief resident.

    • If you miss more than 1 day in the 6-week clerkship, you must make up this time. All make up time should be arranged with Jill Ramsdell.


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Clerkship Grading Structure

  • 50 % Evaluations – based on faculty and resident evaluations (department grading meeting)

    - Clinic advisors, Gyn chief, OB chief and faculty

  • 50% Testing -Shelf Exam: NBME 2 hour and 10 min exam, last Friday of the clerkship @ 9 AM

    (nursing staff comments do not count towards final grade points)


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PASS, HIGH PASS, HONORS

  • Our department complies with the College of Medicine’s recommended grade distribution of

    • 20% = Honors

    • 20% = High Pass

    • 60% = Pass


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Criteria for Passing Rotation:

  • Minimum requirements for passing this clerkship include:

    • Receiving ≥ 10th% scaled score on the NBME shelf exam

      AND

    • Receiving satisfactory resident & faculty evaluations


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Policies: Marginal or Fail Grades

  • MARGINAL Grade:

    • < 10th% scaled score on the NBME shelf exam

    • Student may opt to re-take the shelf exam:

      - if they pass second exam then his/her grade sheet will have an addendum noting the improved exam performance, but the grade remains MARGINAL

      - if they fail the second exam then his/her grade will be changed to a FAIL and the entire rotation must be repeated.

  • FAIL Grade:

    A student may also receive a FAIL grade if significant professionalism issues have occurred on the rotation.


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Grade Appeals

  • All students have the right to appeal a clerkship grade and/or comments for the Dean’s letter.

  • Initial requests must be made by email to Jill @ [email protected]

  • Requests must be made within 30 days of grades being emailed to students

  • OB/Gyn department has committee to evaluate these requests


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OB/Gyn Clerkship Expectations

  • Expectations for each Block

    -Website listing of areas to focus on for each Clinical Block


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Obstetrics: Knowledge and Skills Expectations

By the end of the Obstetrics block students will be expected to competently:1)  Obtain, present, and document a relevant history on patients being evaluated or admitted; examinations will be done with supervising resident/ faculty2)  Interpret and document fetal heart rate monitoring strips3)  Assess and document labor course in patients, postpartum assessments4)  Write appropriate post-delivery orders (vaginal and C/S)5)  Understand the normal hospital course for the patient after a normal vaginal delivery or operative C/S delivery



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Professionalism Expectations:

  • Attendance, on-time to activities

  • Take your professional role seriously

  • Demonstrating respect for patients, staff, and supervising residents and faculty


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Professionalism Problems: Examples

  • Being late/not writing notes on assigned patients

  • Talking to patient about experimental therapies

  • Talking about patient information on elevator

  • Laughing and talking during lectures

  • Inappropriate discussions in front of patients during pelvic exams, labor and delivery, etc.


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Professionalism Problems: Other examples

  • Not following patients after surgery

  • Informal conduct: calling attending faculty or resident physicians by first names

  • Residents and/or faculty will give appropriate feedback and notify Clerkship director of this interaction if problems arise


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Feedback

  • Mid Clerkship meeting:

    • Dr. Holm will meet with each student.

    • Mandatory.

    • Informal 10 min. meeting to give you feedback and receive feedback from you regarding the first half of the clerkship.

    • See schedule in your binder.

    • Please let Jill know right away if you have any conflicts during your scheduled time.

  • End of rotation comments:

    • You will receive written comments in your Wittson Hall mailbox.


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COM Professionalism Forms:

  • Will be filled out on each student and sent to Sue Pope along with your grade at the end of the clerkship.

  • NOTE: This is separate from your actual “letter” grade received at the end of the clerkship.


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Evaluations for you to fill out

  • Department Evaluation

  • COM on-line Evaluation


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OB/Gyn Clerkship Helpful Tips

  • How to not only survive. . .

    but enjoy your time with us!


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Obstetrics “Block”

  • 2 weeks on In-patient team service

  • Students follow labor patients and post-partum patients, usually not antepartums

  • Pelvic exams usually limited to labor cervix checks when patients have epidural

  • Be familiar with ACOG antepartum record form used for all patients

  • Outline for note formats included in packet

  • Students usually give one prepared presentation to group on assigned topic


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OB Block Notes

  • Schedule: On-call 3-4 nights (1 weekend night) next day students go home after morning rounds completed

  • Appropriate attire: SCRUBS

  • Introduce yourself to patients, nurses

  • Try to be available for checks, labor assessments, and pushing phase

  • Make sure your gloves and an extra gown are pulled for you

  • Try not to get upset with interns who are learning how to do deliveries


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Obstetrics Block Skills: Determining EGA

Last Menstrual Period

- Sure date, unsure date

Pelvic exam-

- concordant with EGA

Ultrasound-

- best in 1st trimester (good within one week)


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Obstetrics Block Skills:Determining G’s and P’s

  • Gravida __ Para ___ ___ ___ ___

    - Gravity- total number of pregnancies

    - Para-

    * Total term deliveries (>= 37 weeks EGA)

    * Total preterm deliveries (20- 37 weeks EGA)

    * Total deliveries/ abortions under 20 weeks

    * Total living children


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Gravida/ Para Examples:

  • G6 P4024

    • 4 term deliveries, 2 abortions, 4 living

  • G3 P1112

    • 1 term, 1 preterm, 1 abortions, 2 living

  • G4 P0030

    • Currently pregnant, 3 previous abortions

  • G1 P0102

    • 1 preterm delivery of TWINS


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REMEMBER:

  • A woman currently pregnant with her first pregnancy is NOT a Primip!


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Intrapartum Triage

  • Maternal vital signs

  • Auscultate maternal heart and lungs

  • Fetal heart rate

  • Fetal lie and presentation

  • Uterine contractions

  • Cervical exam:

    • dilatation

    • effacement

    • station


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Vaginal ExaminationAlways under supervision, usually limited to patients with epidurals

dilatation & effacement

fetal station


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Normal Presentation: Leopold’s maneuver

  • Longitudinal lie

  • Cephalic presentation “vertex”

  • Fetal head in attitude of flexion


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Intrapartum Triage:PRESENT THE PATIENT

“19-year-old Caucasian Gravida 1 Para 0 at 39 4/7 weeks presents to L&D reporting painful contractions every 5 minutes for the past 3 hours and blood-tinged mucus from the vagina. Her baby is active and she denies any loss of fluid. Her pregnancy has been uncomplicated except she is Group B strep positive. She desires an epidural for labor.”

“Maternal VS are stable,she is afebrile. Fetal heart tones are in the 120s and reactive.


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Intrapartum Triage:PRESENT THE PATIENT

“Contractions are showing on the monitor every 7 minutes . Her cervix is 4-5 centimeters dilated, 100% effaced, with the fetal vertex at -1 station and a bulging bag of water.

“Assessment is 19 yo at term in labor who is GBS + and requests an epid. Fetal and maternal assessment is reassuring.”

“My plan would be to admit her to L&D, continue routine monitoring, get routine labs, start an IV, start penicillin for Group B strep prophylaxis, and notify Anesthesia for placement of an epidural.”



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Subjective:

pain management

Objective:

Maternal vital signs

fetal heart rate

uterine contractions

vaginal examination

medications given

Assessment:

Plan:

medications

procedures

monitoring

“How do I follow a labor patient?”


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Stages of Labor

cervix is not dilated, not effaced = NOT IN LABOR

1st stage of labor- regular contractions, cervix dilates


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Stages of Labor

1st stage continues: cervix is 8 cms dilated, 100% effaced = ACTIVE LABOR

fully dilated, fully effaced, fetus in birth canal = SECOND STAGE LABOR


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Stages of Labor

CROWNING

BIRTH OF THE HEAD



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“How do I make postpartum rounds?

SUBJECTIVE:

breast or bottle feeding?

uterine cramping

perineal pain

bleeding (lochia)

ambulation

urination / defecation

emotions

contraceptive plans


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Postpartum Rounds

OBJECTIVE:

vital signs

heart & lungs

abdomen- incision

uterine fundus

perineum (supervised)

Homan’s sign


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Preparing for Morning Rounds

  • Talk with residents about abnormal assessments before morning report to faculty

    - for example, wound drainage

  • Keep the charts out at nursing station while visiting with patients

  • Try to organize in SOAP format


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SOAP notes

  • Subjective- what patient tells you

  • Objective- vital signs, physical exam,

    laboratory and imaging testing

  • Assessment- Summarize the patient’s current status and problems

  • Plan- what your next steps will be

    (Assessment and Plan should be separate)


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Postpartum Discharge Instructions and Orders

  • Routine analgesics

  • Stool softener

  • FeSO4 PRN

  • Contraception

  • Visiting nurse referral

  • RTC in 6 weeks after C/S or vaginal delivery or as needed


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Gynecology Block: Benign and GYN-Onc

  • 2 weeks of in-patient team services

  • Gynecology notes and post-op course outlined in your orientation packet

  • GYN team covers ER and in-patient consultations as well as OR cases

  • GYN-Onc team does OR cases and also will go to Dr. Remmenga’s clinic


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Gynecology Block:

  • Appropriate attire: wear scrubs when scheduled to be in OR, no scrubs when going to GYN-Onc clinics

  • Students expected to prepare one presentation for both Benign and Onc weeks


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Preparing for an OR case:

- Read background history on that patient, review ultrasounds, pathology, etc.

- Read about that particular surgery

- Introduce yourself in pre-op before surgery

- Assist with moving/positioning of the patient

- Introduce yourself to OR staff, offer to get your own gloves

- Visit the patient after the case, read the op note dictation, and review the pathology findings


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Gynecology: Knowledge and Skills Expectations

By the end of the Gynecology block students will be expected to competently1)  Write a complete operative note and postoperative orders2)  Discuss the normal hospital course after a routine Gyn surgical procedure3)  Discuss the appropriate work-up and differential for postoperative low urine output, fever, and wound problems4)  Discuss the relevant history, examination, and laboratory or radiology work-up involved in ER assessments of 1) pelvic pain and 2) abnormal vaginal bleeding5)  Briefly describe the differences between types of hysterectomies (supracervical, simple, radical, vaginal, laparoscopic)


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Outpatient Clinics “Block”

  • 2 weeks of outpatient clinic exposure: students assigned to 1 faculty/ week

  • Students attend morning Gyn teaching rounds on all mornings except Tuesday

  • Look at faculty schedule the day before to get a sense of topics to prepare, for example- postmenopausal bleeding

  • Variable hands-on opportunities for exams

  • Review Gynecology clinic progress note in orientation packet

  • Scrubs never appropriate


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What if I feel uncomfortable with pelvic exams?

- You are not alone- many physicians do not feel comfortable with pelvic exams

- Today is the practice pelvic exam session

- We expect you to become more familiar with the mechanics of the exam and how to appropriately talk to your patient during the exam- all exams should be supervised

- It takes a lot of practice to do them well.


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Outpatient Clinics:Knowledge and Skills Expectations

  • By the end of this clinical block, students will be expected to competently1)  Conduct a normal annual GYN examination: obtain and present history, under supervision do an appropriate physical exam, and counsel patient appropriately on screening recommended by age group2)  Conduct a new and return obstetric patient clinic visit (exam with supervision of faculty or resident)3)  Discuss appropriate triage of abnormal Pap smears4)  Discuss indications for vulvar biopsy and endometrial biopsy5)  Appropriately counsel patients on choices of contraception/ sterilization6)  Discuss issues related to risks and benefits of hormone replacement therapy


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Student of the Week

  • One student each week will be chosen as Student of the Week

    • Weeks 2-6

    • Announced at Grand Rounds

  • Nominations by house staff and faculty

  • UNMC and Methodist students


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Additional Educational Resources

  • uWISE – APGO educational/testing module. (See info sheet in orientation notebook)

  • The following CD-ROM educational materials are available for check-out:

    - Advanced Colposcopy (abnormal pap smear work-up and management)

    - Blackboard questions

  • Review books (to be checked out from Jill)

    • Appleton & Lange - Review

    • Wylen – Pretest

    • On Call


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How can I make the most of my outpatient experience?

  • Be flexible and keep an open mind. . .

    your schedule is an outline - be available if opportunities to learn come up


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The END

QUESTIONS???


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