Clinical Curriculum

The first-year resident (post-graduate year 1 [PGY-1]) on the eight-week rotation on the obstetric service at UNC Hospitals is expected to achieve competency in performing an initial history and physical on patients who present with suspected labor. The PGY-1 should be able to detect evidence of preeclampsia, abruptio placentae, and malpresentation of the fetus. He/she should be skilled in formulating a plan and writing the usual and customary orders for patients with diabetes, hyperemesis gravidium, and hypertensive disorders of pregnancy. The PGY-1 should become adept in the antepartum and intrapartum management of the normal course of labor and delivery including the interpretation of electronic fetal heart rate monitoring. In regard to operative procedures, the PGY-1 should be able to perform third trimester amniocentesis, repair of episiotomies and perineal lacerations, abdominal tubal ligations, circumcisions, and the performance of primary cesarean sections. During the separated one-month rotation on obstetrical ultrasound, the PGY-1 is expected to be able to obtain the standard obstetric fetal growth parameters. In addition, he/she should be able to determine placental localization, amniotic fluid volume, and fetal lie. Finally, the PGY-1 should become skilled in the basic anatomical survey of the fetus. The third-year resident (PGY-3) should accomplish all objectives expected of the PGY-1 resident in addition to being able to supervise the clinical activities of the first-year resident. The PGY-3 should be accomplished in the diagnosis of complications of pregnancy such as severe preeclampsia, eclampsia, both pregestational and gestational diabetes, and hematologic problems in pregnancy. He/she should be astute in the diagnosis of abruption, amniotic fluid embolism, and fetal distress. In regard to operative procedures, the PGY-3 should be proficient in the performance of repeat cesarean sections, vaginal breech deliveries, and outlet-, low- and mid- forceps deliveries, vaccuum extraction deliveries as well as cervical cerclage. The fourth-year resident (PGY-4) is the leader and the team captain for all activities during the eight-week rotation on obstetrics. This resident is responsible for the supervision of all patients being actively managed in the labor and delivery area as well as all inpatients on both the antepartum and postpartum wards. The PGY-4 makes assignments for teaching rounds, schedules all surgeries, and performs cesarean section deliveries as well as midforceps rotations under the supervision of the attending physician. He/she should be familiar with all complications of pregnancy and be able to formulate a treatment plan. The PGY-4 should then be able to direct the PGY-3 and the PGY-1 in developing a team concept of management for these complications. The PGY-4 should become experienced with the intensive care of the seriously ill obstetric patient secondary to complications of preeclampsia, diabetes and chronic renal failure. He/she should understand and instruct the PGY-1 and PGY-3 residents in standard protocols for the management of such obstetrical emergencies as shoulder dystocia, amniotic fluid embolism and postpartum hemorrhage. The PGY-4 should also become proficient in the ultrasonographic recognition of such fetal anomalies as ventral wall defects and neural tube defects. In addition, the PGY-4 should be conversant in the methods of diagnosis and indications for delivery in cases of fetal distress. .
During the eight-week rotation on the gynecologic oncology service. The resident service includes a PGY-1, PGY-3 and PGY-4. The PGY-1 is expected to accomplish the work-up of a patient with pre-invasive and invasive malignancies of the female reproductive tract. The PGY-1 should be very familiar with the administration of chemotherapy and with toxicities of the standard chemotherapeutic agents. The first-year resident should understand the management of septic events that occur as a result of chemotherapy, and complications associated with the administration of radiation therapy. The PGY-1 should be familiar with standard operative procedures done on the gynecologic oncology service, and should be able to assist minor operative procedures. The PGY-3 resident should accomplish all that is outlined for the PGY-1 resident, and should also be well-versed in the techniques of evaluation of abnormal pap smears to include colopscopy, biopsies, cryosurgery, laser therapy, and LEEP procedures. The third-year resident should be able to do routine hysterectomies both from the abdominal approach and the vaginal approach, and should become familiar with the retroperitoneal space. The PGY-3 should be able to be a first assistant for radical procedures such as radical hysterectomy and groin node dissections. The fourth-year resident should accomplish all that is expected of the PGY-1 and PGY3, and should also be very familiar with pelvic node dissections, able to accomplish selective node biopsies (but not necessarily be proficient in doing complete node dissection), should be familiar with bowel techniques such as resection and bypass, and should be able to accomplish repair of bladder injuries and irotomies and should be able to perform paracentesis and thoracentesis.
The PGY-4 on the urogynecology/reconstructive pelvic surgery service is expected to understand the basic anatomy, physiology, neurology and pharmacology of pelvic floor function. The fourth year resident should understand which diagnostic procedures are appropriate for patients with complaints of pelvic floor dysfunction. He/She should be able to counsel patients on nonsurgical management of urinary incontinence and to perform simple cystometry and cystocopy. He/She should be able to interpret the basic components of multichannel urodynamic studies and participate as first assistant or primary surgeon on pelvic support surgeries.
The PGY-4 is expected to know the indications, contraindications and complications of operative procedures for pelvic relaxation and urinary and defecatory dysfunction. The PGY-4 should be able to perform vaginal hysterectomies with anterior and posterior colporrhaphy, enterocele repairs, vaginal procedures for incontinence and retropubic urethropexy procedures. He/She should be able to assess patients for lower urinary tract injuries.
The PGY-2 on gynecology service should learn to (A) perform clinical evaluation in outpatient management for chronic pelvic pain, abnormal papanicolaou smears, vaginitis, dysfunctional uterine bleeding, ovarian cysts, and straightforward psychosexual problems, (B) perform laparoscopic procedures including tubal cauterization, lysis of simple adhesions, treatment of simple endometriosis, removal of ectopic pregnancies, and salpingo-oophorectomy, (C) assist and partially perform straightforward laparoscopically assisted vaginal hysterectomies, (D) perform simple total abdominal hysterectomies with adnexectomy, (E) perform straightforward vaginal hysterectomies, (F) provide complete care of a therapeutic abortion patient, including post-abortal dilation and cuetage, (G) perform vaginal ultrasound examinations, (H) provide complete postoperative care, including management of common pulmonary, infections, and bleeding complications, (I) and evaluate, provide short-term counseling, and refer for treatment of basic mental and sexual dysfunction problems.

The PGY-3 on the gynecology service should learn to perform total laparoscopic hysterectomies, perform more extensive adhesiolysis by either laparotomy or laparoscopy, perform excision of large adnexal masses by either laparotomy or laparoscopy, perform diagnostic and operative hysteroscopy, and perform cystoscopy and placement of ureteral stents.

The PGY-4, in addition to gaining confidence in all of the above arenas, should learn to perform difficult vaginal hysterectomies, perform difficult myomectomies, perform pelvic support procedures--including sacrocolpopexy, paravaginal repair, sacrospinous ligament suspension and anterior posterior repair, and perform advanced laparoscopic procedures, including lysis of more extensive adhesions, treatment of endometriosis (including endometriomas) and difficult laparoscopic hysterectomies.

The midlevel REI rotation (eight weeks) is split between the second and third years.  Midlevels (PGY-2 and 3’s) are introduced to reproductive endocrinology, infertility evaluation and treatment, and hysteroscopy and laparoscopy.  Midlevel residents learn vaginal ultrasonography (follicular and early pregnancy ultrasounds) and hysterosalpingography by conducting these tests under the guidance of faculty.  Clinical reproductive endocrinology and infertility is learned by shadowing faculty, caring for patients in the resident REI clinic under the guidance of the faculty, reading assignments, and a didactic course (lectures twice weekly).  Midlevel residents cover the outpatient surgical cases including hysteroscopy (diagnostic and operative) and laparoscopy (diagnostic and operative) occurring weekly.  Midlevels also observe assisted reproductive technologies (in vitro fertilization).  Midlevels do a brief presentation on a topic of their choice at the conclusion of their rotation.

Fourth-year residents have an eight-week rotation that allows further exposure to reproductive endocrinology and infertility.  As chief of the service they are responsible for assuring care of the complex REI patients.  The chiefs continue their training by conducting morning follicle scans, shadowing  faculty, participating in the resident REI clinic, and completing assigned readings and the didactic course.  Chief residents cover the inpatient surgical cases (e.g. abdominal myomectomy) and complex laparoscopy and hysteroscopy. PGY-4 residents present an article at the REI journal clubs during their rotation.

Learning objectives for the midlevel and fourth year residents are studied, discussed and completed by the end of each rotation.