Resource Network: Curriculum Model

University of Virginia School of Medicine
Acting Internship in Ambulatory Gynecology

Description

This is a one-month elective rotation for fourth-year medical students, and Pediatrics and Ob-Gyn residents. It is also a required rotation for first-year Primary Care track Internal Medicine residents and first year Family Medicine residents, and can be chosen as an elective by residents in other Departments. 

All clinical care takes place in the University of Virginia Student Health Gynecology Clinic on Brandon Avenue at Jefferson Park Avenue. The rotation offers an opportunity to participate in the ambulatory gynecologic care of University students: this includes well-woman care, the normal and problematic aspects of contraception, the diagnosis and management of menstrual disorders and of vaginal and pelvic infections (including sexually-transmittable diseases), and the evaluation of breast concerns and vulvar lesions. 

The majority of the patients are between the ages of 18 and 30, but older students (including peri- and post-menopausal women) also present for care.

Rotation Goals

Medical students and residents are expected to achieve (or refine) the following competencies:

• Elicit a complete gynecologic history (including menstrual, sexual and contraceptive, obstetric, medical, surgical, abuse, eating disorder, substance use, exercise, nutrition, sleep, safety, and social aspects)
• Perform a comprehensive female genitourinary examination (see current HCFA guidelines)
• Elicit a directed gynecologic history
• Perform a directed female genitourinary examination
• Demonstrate sensitivity and non-judgmental attitude in interpersonal interactions
• Obtain vaginal and cervical specimens for diagnostic and screening tests
• Order and interpret other standard gynecologic screening and diagnostic tests
• Evaluate vaginal wet mounts (microscopy)
• Evaluate contraceptive needs and provide appropriate recommendations (and prescriptions, when needed)
• Develop a differential diagnosis for gynecologic complaints/findings
• Utilize clinical protocols for evaluation and management
• Determine indications for consultation or referral to a gynecologic specialist
• Evaluate risk factors and demographics in relation to disease and to the interpretation of gynecologic screening tests
• Prepare and deliver three or more "short talks" on gynecologic topics.

Teaching Methods

There are two major teaching arenas: consultation in the course of patient care, and scheduled didactic sessions. Trainees are expected to follow existing Student Health Gynecology clinical protocols whenever applicable in providing care for patients, and to request consultation liberally. Direct consultation is required for all medical students’ patients and for all residents’ non-protocol patients.

An attending faculty Gynecologist and four Nurse Practitioners are present in the clinic for supervision and consultation. All trainees’ charts are reviewed and co-signed by the attending physician.

Didactic sessions are held for 4 hours each week. These are informal but structured small group sessions with the attending physician, 1-3 residents and 2 medical students. The attending physician provides interactive presentations on amenorrhea, oral contraceptives, Bayesian analysis of gynecologic screening tests, pelvic inflammatory disease, pregnancy tests, fertility, HPV and Pap smears, and other topics as requested. Each resident and student is expected to present a 10-15 minute "short talk" each week on a topic of his/her choosing in the area of women’s health.

A nurse practitioner provides a session on contraceptive diaphragm fitting, and a pregnancy counselor provides a session on pregnancy counseling. Medical students and residents are not expected or permitted to provide pregnancy counseling for unplanned pregnancies. However, if they feel prepared, they can provide pre-conception counseling for patients who are planning a pregnancy.

Prior to the start of each rotation, the trainee can borrow or purchase (~$25) a binder containing 150 pages of articles and three AMA monographs which he/she is expected to read during the rotation. The list of material included in the binder is attached. The trainee can keep that material, and is welcome to photocopy any other educational material available in the attending’ physician’s extensive files in the clinic.

Standard gynecologic texts are available in the clinic, as are the major gynecologic journals. CD-ROMs on contraception, colposcopy and vulvar diseases are also available for resident use. Computer access to on-line databases and websites is available.

Trainees are expected to attend Student Health departmental continuing education meetings once a month, and Ob-Gyn Grand Rounds twice per month. They are also scheduled to attend any Departmental conferences expected of them.

Medical Student and Resident Responsibilities

Ambulatory patient care is the trainee’s main responsibility. Trainees are expected to spend a full work week (M-F, 8-5) in the Student Health Gynecology Clinic, except for one half-day for residents’ own continuity clinic, and any "post-call" days that may occur following night coverage for the "home" Department.

For residents, one week of vacation time as assigned by the Chief Resident is allowed, as is potential absence during "contingency coverage" (for other residents’ medical or family emergencies) by advance arrangement.  Medical students are allowed time off as needed for residency interviews. Trainees are assigned a full schedule of patients on their own appointment schedules. 

They are also assigned to the "work-in" patients for one or two half-days per week. No night call or weekend call for Student Health is required. The weekly "short talk" mentioned above is the only required teaching responsibility, but informal opportunities for interacting with other trainees are continually present.

Evaluation and Performance

In the binder provided for each trainee at the start of the rotation, an introductory letter spells out the objectives of the rotation. During an orientation session with clinic staff and the attending Gynecologist, trainees are given an opportunity to express any particular areas of interest and establish additional individual objectives.

Trainees are observed daily by the clinic staff both during patient visits and at the time of consultation. If problems are observed, the trainee is given immediate feedback. Staff review trainees’ overall performance at weekly staff meetings and provide any additional feedback as soon as possible.

A formal evaluation is written up and sent to the Student Affairs Office or Chief Resident at the end of the rotation. For satisfactory or outstanding performance, an exit interview provides an opportunity for feedback. Trainees are also asked for both oral and written feedback on their experience on the rotation.

Strengths and Limitations

Trainees frequently comment that the strengths of this rotation are their autonomy within a highly supportive environment, the patient population (generally healthy young women who are interested in learning about health-related matters), the informal scheduled didactic sessions, and the wellness/prevention orientation of the clinic.

Also cited are the expertise, enthusiasm, and pleasant demeanor of the professional and support staff. The capitation model of Student Health allows patients to have return visits for follow up without financial burden, which encourages trainees to observe the natural history of self-limited conditions and the results of their recommendations for other illnesses.

The clinic operates as a collaborative practice between the faculty Gynecologist and the Nurse Practitioners. This provides an opportunity for trainees to observe and participate in a long-standing and highly successful primary health care delivery system that differs from the hospital environment. In addition, utilization of the clinical and educational expertise of the Nurse Practitioners serves to foster mutual respect and to encourage the future provision of service in a collaborative system.

Limitations mentioned by trainees include the limited exposure to the gynecologic issues of older women, and the paperwork burden. The student population at the University determines the age range of patients.  Required reading materials cover medical issues for peri- and post-menopausal women. The paperwork (filling out lab forms and labels) is lessening as a newly computerized appointment and registration system makes possible the pre-printing of patient labels.

Residents’ vacation and contingency assignments can potentially shorten the rotation by as much as two weeks, which substantially decreases both clinical experience and exposure to didactic sessions.

For more information regarding this curriculum, please contact:

Christine M. Peterson, M.D.
Assistant Professor of Clinical Obstetrics and Gynecology
Department of Student Health
University of Virginia
400 Brandon Ave.
PO Box 800760
Charlottesville, VA  22908
Phone: (804) 924-2773
Fax: (804) 243-6689
E-mail: cmp8x@virginia.edu