I. GOALS AND OBJECTIVE:
The Women’s Health elective is designed to equip the house officer with the knowledge and skills needed:
a) to diagnose and treat women with medical conditions complicating pregnancy,
b) to provide care prior to conception to women with medical disease pregnancy in a manner that maximizes maternal health and future pregnancy outcome, and
c) to manage common out patient gynecologic complaints and conditions.
It is a third year rotation that builds upon the earlier teaching and is aimed at refining knowledge and skills in these areas.
The Women’s Health rotation exists in two forms. For the resident in the Primary Care and Social Medicine program it is a requirement and it is assigned in combination with an ambulatory care block. These residents spend approximately six half-days per week in the Women’s Health activities and 4 half-days per week in continuity clinic. Categorical resident choose this rotation as an elective and have additional day per week available to participate in these activities. The didactic teaching and clinic experience is largely identical for the two groups although elective residents have additional exposure to inpatient consultation in Obstetrical Medicine and opportunities to add urogynecology and additional obstetrical medicine outpatient experiences.
The elective is of 1 block duration (approximately 4 weeks).
In addition to the didactic sessions outlined below, the basic outpatient clinical exposure is as follows: High Risk Obstetrical Clinic where patients with medical complaints of pregnancy and to a lesser extent women with medical problems referred for evaluation prior to conception are seen (0-2 sessions per weeks); HIV in pregnancy (0-1 session per week); Gyn endocrinology (0-1 session per week); gynecology clinic (0-2 session per week). Opportunities to add increase High Risk Ob sessions, urogynecology, and colposcopy clinics are available, primarily but no exclusively to those on elective rotation.
The elective is run in conjunction with the Ob-Gyn faculty. The Department of Obstetrics & Gynecology and Women’s Health at Montifiore has over 5000 deliveries per year and is Regional Prenatal Center which receives referrals of complaints obstetric patients from the region. The MFM division is large and varied with faculty with special expertise in HIV and AIDS, obesity and nutrition, substance abuse, smoking, public health, and global health among other areas. Dr. Harrison who is jointly appointed in the Department of Medicine and Obstetrics and Woman’s Health in the Maternal Fetal Medicine division directs the rotation. She directs the Obstetrical Medicine in the Montefiore Medical Center, delivers the didactic potion of the curriculum, and, in conjunction with the MFM faculty, precepts the residents in the High Risk Obstetrics clinic. MFM and pharmacology faculty supervises the HIV in pregnancy clinic. The Gyn clinic is precepted by two generalist ob-gyns selected for they’re clinical and teaching acumen. A medical endocrinologist and two gynecologic endocrinologists run the Gyn Endocrine Clinic jointly.
B. Competency Based Objectives:
1. Patient Care:
a. Recognize the way the Physiologic changes of pregnancy alter the history, physical exam, laboratory, findings and imaging and be able to use this knowledge in assessment of pregnant women with medical disease.
b. Recognize the altered differential diagnoses possibilities in pregnancy, which contains unique conditions and conditions with altered prevalence.
c. Recognize the altered appearance of disease in this population of largely young otherwise well women in whom significant hemodynamic stressors can be under-appreciated.
d. Recognize unique issues pertaining to fetal protection involving medication, radiation exposure, fetal effects of maternal disease states and need for heightened awareness of work with all providers to provide.
2. Medical Knowledge:
Use the literature to increase knowledge and awareness of the common gynecologic problems and diagnostic strategies, of common gyn endocrine conditions, of physiology of pregnancy, of major disease processes seen in young women in pregnancy and principles of care (see list of topics).
Special issues in practice of ob gyn include confidentiality issues, respect for patients autonomy and decision making in areas fraught with controversy, altered role of family member in care of obstetric patient, sensitivity to ethical concerns involved with prenatal diagnosis; work with the multidisciplinary team; understand limitations and ask supervisors for help when indicated
4. Interpersonal and Communication Skills:
Write clear consult notes that anticipate the different expertise of the physician to whom the consultations are addressed; deal with colleagues from related disciplines with respect; be aware of special anxieties and sensitivities attendant to pregnancy and to sexual activities and allow patient to communicate their concerns or report their relevant behavior without judgmental reaction
5. Practice Based Learning and Improvement:
Recognizelimitations of knowledge and use reference and literature to improve your practice
patterns; appreciate contributions of colleagues from related specialties in caring for this group of patients; learn to avoid pitfalls in care through one’s own cases and those of others discussed in clinic and conferences; ask for help when needed;
6. Systems Based Practice:
Become aware of the interdisciplinary cooperation necessary in planning the care of patients shared with colleagues from radiology, anesthesiology and Ob gyn as well as medical sub specialists
II. AREAS COVERED DURING ROTATION:
1. Approaches to Clinical Care of the Pregnant Women
a. Physiologic Changes of pregnancy and to lesser extent L&D
b. Changes in history PE, Labs, Imaging
c. Unique diagnostic considerations
d. Medication use in pregnancy: agent, dose, pharmacokinetics
e. Diagnostic Imaging
a. Chronic hypertension
b. Preeclampsia/ eclampsia
a. Preconception care
a. Principles of Rx in pregnancy
ii. Altered obstetric management preventive transmission
b. Safe Conception
c. Vertical transmission
5. Thyroid disease
c. Special issues with Graves disease
d. Postpartum thyroiditis
6. Pituitary disease
c. Lymphocytic hypophysits
8. Cardiac Disease
a. Course of disease in selected cardiac condition
b. Aortic disease
c. Planning Labor and Delivery
10. Lupus and Antiphopholipid Ab syndrome
B. Gynecology And Women’s Health
a) Family planning and contraception
d) Abnormal menses
e) Routine gynecologic care including prevention, STDs
f) Examination techniques
III. METHODS OF TEACHING COMPETENCE AND COMPETENCY ASSESSMENT
1. Patient care Consults, clinics, case conferences, didactic teaching
2. Med knowledge Curriculum in Obstetric Medicine
Didactic session in contraception
Didactic session in bone densitometry
3. Professional Clinic, consults, case conferences
4. Interpersonal skills Clinics, consults
5. PBL+ I Clinics, consults, conferences
6. Systems based practice Clinics, consults, and conferences
Assessment is done through ongoing feedback, mid-month feedback, and end-of-month evaluation.