GOALS AND OBJECTIVES OB/GYN RESIDENCY PROGRAM THOMAS JEFFERSON UNIVERSITY HOSPITAL OVERALL EDUCATIONAL GOALS PGY 3 Medical Knowledge All residents must demonstrate evidence of preparation and retention of information, regular attendance and participation in scheduled educational conferences, and acceptable CREOG examination performance. A resident scoring 2 standard deviations below the mean on the exam must undergo remediation and directed reading. The resident must be familiar with basic textbook level knowledge and begin to use journal articles The resident must demonstrate an advanced understanding of basic science principles and of routine clinical management issues. The resident must also demonstrate a thorough knowledge of surgical anatomy, and details of basic to moderately complex operative techniques and procedures. The resident must demonstrate a progressive familiarity with the literature for each area in which they rotate and begin to function as a consultant. The resident must demonstrate progress through continuity clinic and independent office practice management. Patient Care In addition to mastery of those skills learned as a junior resident, the resident must demonstrate the ability to independently evaluate patients in acute and emergency situations and to develop an appropriate care plan for patients with complex ob/gyn problems or multiple co-morbid conditions. The resident must be able to care for patients in the post-operative setting, and to appropriately manage critically ill patients. The resident must be able to communicate a management plan and justify management decisions with appropriate reference to the accepted standard of care and citations from the literature. Surgical Skills In addition to mastery of those skills learned as a junior resident, the resident must demonstrate the development of surgical judgment as well as advanced surgical skills and techniques including advanced suturing skills, proficiency with endoscopic and laparoscopic techniques, knowledge and demonstration of appropriate surgical exposure for various procedures. Although residents are not expected to be fully independent in the operating room at this stage, they should be developing and exhibiting increasing skill and confidence. They should complete the PGY 3 level log book. Professionalism The resident must continuously demonstrate the attributes of reliability, integrity, honesty, altruism, respect, and compassion. The resident must demonstrate an appropriate attitude regarding commitment to excellence and learning, and to patient care. The resident must be open to constructive criticism and improvement. The resident must complete statistics, duty hours logging and medical records on time. Communication The resident must demonstrate appropriate interpersonal relations with patients and their families, peers and attendings, and nurses and ancillary staff. The resident must be able to work as an effective part of the healthcare team in order to achieve desired patient care and educational outcomes. In addition to teaching medical students, the resident must demonstrate the interest and ability to oversee and teach the junior residents serving under them. Systems Based Practice The resident must demonstrate awareness of costs of medical intervention and tests. The residents should be familiar with the role of case managers and other non-medical members of the team and the effects of insurance status. The resident must complete their medical record responsibilities and statistics in an accurate and timely fashion. Any medical record fines accrued during the year must be paid off in full or an acceptable payment plan must be arranged with the administrator of the Department of Ob/Gyn. In addition, the resident should be able to coordinate the care of complex patients and be familiar with coding of visits and surgery. Practice-Based Learning The resident must present and participate in M&M as required by case assignments. They must develop ability to coordinate patients through clinic, hospital and discharge. In addition, the residents research project must be well under way. Goals and Objectives for PGY-3 1. Family Planning /Ambulatory Care Continuity Clinics The Family Planning and Ambulatory Clinics take place in the Jefferson Obstetrics and Gynecology Associates clinic. All residents will see patients with contraceptive needs, routine annual evaluations, uncomplicated obstetric and postpartum patients and patients with gynecologic complaints, appropriate to their level of training. PGY-1 residents have clinic with an emphasis on Family Planning during the ICN, Anesthesia, Emergency Medicine, Ultrasound, Family Medicine West Jersey OB and Gyn rotations as well as during a dedicated 2 week block. All others will have one half day per week during specified rotations for a total of 30 months of continuity clinic. The aims of the rotation are to prepare residents to provide outpatient patient care and counseling that is compassionate, appropriate and effective for the treatment of outpatient reproductive and basic primary care problems. The rotation will provide opportunities for residents to master clinical skills including antepartum care, contraceptive counseling, pregnancy options counseling, manual vacuum aspiration, transvaginal ultrasound, and permanent and long-acting reversible contraceptive methods (LARC). In addition, residents will learn the scope of outpatient gynecologic care in a graduated fashion. Lastly, they will provide primary and preventive care screening for their patients of all ages, including those related to general health maintenance. Goals: 1. Residents will develop the knowledge, skills and attitudes to manage common ambulatory problems related to the female reproductive system including abnormal bleeding, pelvic floor disorders, and pelvic pain.(MK, PC, P, C) 2. Residents will develop the ability to provide comprehensive, non-directive contraceptive counseling and provision to women at all stages of their reproductive careers, including the knowledge of contraceptive devices and the ability to serve as a consultant for management of complex cases. This includes knowledge of method effectiveness and user effectiveness, national and local policies that affect control of reproduction, how religious, ethical and cultural differences affect providers and users of contraception, the impact of contraception on population growth in the United States and other nations, factors that influence the individual patients choice of contraception, and the advantages, disadvantages, failure rates and complications associated with all methods of contraception, including post-coital methods.(MK,PC,P,C,SBP) 3. Residents will recognize and manage the symptoms of menopause, understand the health implications of menopause and its treatment, and counsel patients effectively on these issues.(MK, PC, C) 4. Residents will be familiar with evidence based screening recommendations for female patients at all stages of the life cycle. They will be familiar with techniques to effectively counsel on and encourage healthy lifestyles in their patients.(MK,PC, C, SBP) 5. Residents will develop the ability to manage the outpatient aspects of uncomplicated pregnancies and the post- partum state. They will understand the ambulatory management of pregnancy-related issues, including standard diagnostic tests, common complaints and complications. (MK,PC) 6. Residents will understand the impact of patients’ insurance status and the local health care system on the care of their patients, and will develop the knowledge to adequately code and bill visits, obtain consultant services for their patients, prescribe medications and contraceptives, and arrange diagnostic testing for their outpatients in the clinic. They will learn about community-based resources which may be available to augment various aspects of patient care, and how to help patients access such facilities (PC, SBK) Objectives: Upon completion of these rotations, the resident will be able to: 1. Perform a complete and comfortable breast and pelvic examination (PC,C) 2. Demonstrate the ability to communicate successfully with the patient so as to obtain both a problem-specific and annual history (C, PC) 3. Perform routine ambulatory procedures, including Pap smears, wet preps, manual vacuum aspiration, endometrial and vulvar biopsy and insertion of intrauterine devices and implantable contraceptives (PC) 4. Counsel a patient on medical and surgical options for elective termination of pregnancy, describe the state-specific regulations concerning abortion, the risks benefits and alternatives of the procedure and arrange for performance of the procedure at our institution or with local providers, regardless of personal beliefs. (MK, PC,P,C, SBP) 5. Describe the available forms of hormonal and non-hormonal contraception, including long-acting reversible contraception, male and female sterilization, and barrier methods; counsel a patient on the advantages, disadvantages and contraindications of each method; and perform insertion of IUD, implantable rods, and diaphragm fitting in the office. (MK, PC, C) 6. Prescribe medical and behavioral therapies for the management of menopausal symptoms, including the advantages and contraindications of each. (MK, PC) 7. Perform an evaluation of a patient with urinary incontinence and prolapse, including a history of related symptoms, a cough stress test, and a POP-Q examination (MK) 8. Complete five annual examinations every 6 months that pass the criteria for age – specific annual examination, as documented by checklist. (MK,SBP) 9. Perform an initial obstetrical visit, with complete documentation as reviewed by staffing attending physician, including a comprehensive history and physical examination, ordering routine laboratory tests and those required because of risk factors during pregnancy, counseling patients about lifestyle modifications that improve pregnancy outcome, counseling patients about warning signs of adverse pregnancy events, appropriate immunizations, and the benefits of breast feeding. (PC) 10. Generate a complete and accurate medical record, electronic or paper, that can be accurately interpreted by others (SBK,C). Demonstrate the ability to use the electronic medical record for the retrieval of patient information, adding diagnostic and therapeutic data, and prescribing, with reference to insurance status. (SBP, PBL). 11. Demonstrate the ability to use electronic media at the point of care for consultation of the medical literature. (SBK) 12. Demonstrate the ability to diagnose, treat and counsel patients with a sexually transmitted infection, vaginal or vulvar infection. This includes describing the principal infections that affect the vulva and vagina such as candidiasis, bacterial vaginosis, and trichomoniasis, chlamydia, gonorrhea, syphilis, hepatitis B and hepatitis, human immunodeficiency virus (HIV), herpes simplex and human papillomavirus; performing a focused physical examination; performing and interpreting tests such as vaginal pH,saline microscopy, potassium hydroxide microscopy, bacterial and viral tests; and familiarity with the CDC recommended regimens for treatment of STI. The resident should describe the follow up that is necessary for a patient with a vulvar or vaginal infection, including assessing and treating sexual partner(s), reporting requirements, and counseling the patient about prevention of re-infection. Finally, the resident should describe the long-term concerns for patients with a STI, including infertility, ectopic pregnancy, chronic pelvic pain, and pelvic inflammatory disease (PID). (MK, PC,C) 13. Evaluate and screen post-partum patients for common problems, and obtain consultation and referral services for patients with pelvic floor problems, wound complications, breastfeeding problems, and severe post-partum depression (MK, PC, C, SBE) 14. Demonstrate the ability to work effectively as a member of a team which includes both physicians and other professionals such as social workers, nutritionists and family planning counselors (P,SBK,C) 15. Demonstrate awareness of patients’ cultural, sexual orientation, age-related and gender-based issues, and their impact on providing optimal care (C, PC, P) 16. Demonstrate self-evaluation and improvement of various aspects of their performance in an ambulatory setting (PBL,P) Evaluation Methods Global rotation evaluation after PGY-1 rotation, electronic Evaluation and chart review with immediate feedback after presentation of each patient Elements of Primary Care Checklist, 5 every 6 months Patient evaluations of residents, 1 per week while in clinic CREOG Examination results in primary care sections Completion and logging of IUD and endometrial biopsy procedures for independent performance on electronic system 2. Gynecologic Oncology Virtua West Jersey The rotation shall consist of the bulk of time operating and caring for patients with the gyn oncologists at Virtua Hospital, Dr. Randolph Deger and Dr. Kim. They will perform inpatient and outpatient surgeries and attend office hours. Goals: Build upon the previous Gyn Oncology rotation in the following areas: 1. Learn the basic pathophysiology of gynecologic malignancies. 2. Learn pelvic anatomy as it pertains to surgery for gynecologic malignancy. 3. Provide compassionate and appropriate patient care for patients being treated for gynecologic cancer 4. Learn the appropriate staging and treatment regimens for gynecologic cancer. 5. Competently assist in major gynecologic surgical cases and provide appropriate postoperative care, including in the ICU setting. 6. Residents must develop interpersonal and communication skills appropriate to the community hospital setting. They must deepen a sense of responsibility as the primary resident caretaker for this service. Objectives: Upon completion of this rotation, residents must be able to: 1. Manage and triage vulvar and vaginal malignancies such as Melanoma, Squamous cell carcinoma, Basal cell carcinoma, and Paget’s disease, Bartholin’s gland carcinoma; vulvar intraepithelial neoplasis (VIN) and vaginal intraepithelial (VAIN), including the differential diagnosis of pigmented and non-pigmented vulvar lesions ;perform and interpret the results of diagnostic procedures for VIN and VAIN (MK,PC) 2. Provide psychosocial support and long-term follow up for patients with vulvovaginal cancer. Describe the impact of treatment of vulvovaginal cancer on sexual function and manage/refer patients appropriately (PC,C) 3. Obtain a targeted history in patients who have abnormal uterine bleeding, including assessment of risk factors; describe and perform appropriate imaging such as transvaginal ultrasound and diagnostic tests such as endometrial biopsy and uterine curettage (MK,PC) 4. Describe the epidemiology of ovarian and fallopian tube cancer, including inherited syndromes; clinical manifestations of ovarian cancer; the histology, staging and prognosis for: epithelial, germ cell, stromal, metastatic and low malignant potential tumors. The resident must interpret tests such as ultrasonography and serum tumor markers, and in consultation with a gynecologic oncologist, counsel the patient about the evaluation and treatment (indications, complications) of ovarian cancer (MK,PC,C) 5. Describe the epidemiology and genetics of gestational trophoblastic disease (GTD); diagnose GTD using tests such as ultrasonography, b-hCG titer, chest x-ray and thyroid function tests. The resident should be able to perform surgical treatment and provide appropriate follow up for a patient who has had suction evacuation of a molar pregnancy as well as counsel the patient regarding recurrence risk for GTD (MK,PC,C) Evaluation methods: Global rotation evaluation by Dr. Deger Surgical checklist cards Performance on in-service CREOG examination Reading assignments: Clinical Expert Series on Endometrial, Ovarian, Cervical, Vaginal and Vulvar Cancers; Bereck and Hacker’s Gynecologic Oncology 5th Edition Assigned articles 3. Night Float- Virtua Hospital This rotation will consist of night coverage of primarily gynecologic patients with assistance on labor and delivery as needed by the PGY-2 primarily caring for obstetrical patients. Goals: 1. Develop competency in managing and coordinating routine and high risk labor patients including emergencies (PC,SBP, P. C) 2. Develop effective relationships with ancillary staff in the emergency room and operating rooms for effective care of emergency gyn problems and admissions (PC,SBE, P, C) 3. Develop leadership skills in supervising junior residents and medical students (P, C) 4. Develop the ability to triage all types of ob and gyn patients presenting to the emergency department and labor floor (PC, SBE). Objectives: Upon completion of the rotation, the resident must be able to: 1. Effectively manage the triage of emergency room consultations of gynecologic patients (PC, SBP,C) 2. Interact in an effective and professional manner with nursing and anesthesia department colleagues (P, SBP) 3. Coordinate and perform emergent gyn surgery (P, C, PC) 4. Independently assess and triage postoperative problems of gyn patients with supervision by attending staff (PC) Evaluations: Global end of block evaluations 4. OB Night Float TJUH This rotation shall consist of 6 – 7 weeks at night primarily on Labor & Delivery at TJUH. The rotation shall consist of coverage of primarily Ob patients but can include Gyn and emergency room patients as needed at the discretion of the chief resident. Goals: 1. To refine skills in delivering emergency care during pregnancy 2. To increase proficiency in performance of operative deliveries, including forceps and vacuum deliveries 3. To increase competency in managing a busy labor and delivery unit 4. To teach MS-3 students and PGY -1 residents basic obstetrics Objectives: by the end of the rotation, the resident must: 1. Demonstrate diagnostic skill in pregnant patients with a medical or surgical emergency, including the ordering and interpretation of diagnostic tests, such as CT or MRI scan, initiation of therapy, and timing of delivery. (MK,PC) 2. Diagnose patients with threatened or occurrence of second-trimester pregnancy loss, including ultrasonography; implement appropriate medical and surgical management (including cervical cerclage) and manage complications such as chorioamnionitis, retained placenta, uterine hemorrhage; and counsel patients who have experienced second-trimester pregnancy loss about recurrence risk.(MK,PC, C) 3. Understand the causes of preterm labor and manage suspected preterm labor, including history, examination to determine uterine size, fetal presentation and fetal heart rate, cervical effacement and dilation; perform and interpret biophysical, biochemical and microbiologic testes to assess patients with suspected preterm labor, and utilize interventions such as antibiotics, tocolytics, corticosteroids, amniocentesis, cerclage, and bed rest; and appropriately counsel patients about complications, including management options for the extremely premature fetus and available support systems. (MK,PC,C, SBP) 4.Describe the factors that predispose to placenta previa and abruption placentae; perform a focused physical examination in patients with bleeding in late pregnancy; interpret diagnostic tests such as hematocrit, platelet count, coagulation profiles, Kleihauer-Betke test, and perform ultrasonography; determine the appropriate timing and method of delivery; and manage complications such as hypovolemic shock and coagulopathy (MK, PC) 5. Manage hypertension in pregnancy, including differentiating chronic hypertension from preeclampsia and gestational hypertension; assessing fetal well-being ;treatment of hypertensive disorders of pregnancy; and recognition of maternal complications of hypertension in pregnancy such as cerebrovascular accident, seizure, renal failure, pulmonary edema, and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome. (MK,PC) Evaluation methods: Global evaluation Minicex Surgical checklist Professionalism cards Reading: Obgyn textbooks and current literature 5. Gynecology-Virtua Hospital The rotation shall consist of 13 weeks (two blocks) on the General Gynecology service managing pre-operative, intraoperative, and post-operative care as well as seeing consultations and emergency room patients at Virtua Hospital. Residents will see patients in the clinic on a weekly basis under the supervision of the Virtua clinic director as well as return for their continuity clinic at Jefferson. They will teach medical students from JMC. Residents are expected to incorporate the PGY 2 goals and objectives as well as the following: Goals: 1. Refine surgical skills in performance of advanced surgical procedures (PC) 2. Develop strategies for supervising and teaching clinical care and surgical skills to junior residents (C) 3. Develop ability to serve as a consultant to other specialties, including the ability to utilize evidence- based medicine in making recommendations (P,C) 4. Efficient and effective triage of gynecologic problems seen in the emergency room setting (PC) 5. Identifying clinic patients in need of surgery under the supervision of the director. (PC) 6. Develop skills in office procedures such as colposcopy, IUD insertion, and office ablations and sterilizations (PC). 7. Work effectively in various health care delivery settings and incorporate awareness of cost and insurance issues in different hospital systems (SBP) Objectives: By the end of the rotation, the resident must be able to: 1. Conduct pre-operative assessment for patients in the clinic and navigate the hospital system for scheduling and evaluation, including indications for and perform appropriate preoperative evaluation and referral, including laboratory tests, radiographic imaging and EKG(PC, SBP) 2. Summarize indications and compose appropriate preoperative preparation plans for patients undergoing gynecologic surgery, including antibiotic use and thromboembolism prophylaxis (PC) 3. Choose appropriate pain control bases on the surgical procedure, degree of patient discomfort and patient characteristics, manage and counsel patients about normal postoperative recovery (PC). 4. Elicit appropriate history, perform a physical examination, perform and/or interpret appropriate tests and manage common postoperative complications (PC) 5. Demonstrate the ability to perform minor procedures with minimal guidance, including laparoscopic tubal ligation, d&c and hysteroscopy, and be able to discuss different approaches to hysterectomy and adnexal surgery (PC,PBL). 6. Demonstrate an ability to function independently and seek out supervision as needed in managing common problems and patient evaluations (P, SBP). 7. Work with and communicate effectively with a variety of ancillary staff and attending physicians in a professional manner (P, C). 8. Participate in formal patient presentations at Grand Rounds (PBL, SBP). Evaluation methods: Global evaluations Surgical checklist cards Reading assignments: Gynecology textbooks and journal articles pertaining to patients 6. Elective Rotation This rotation shall consist of 6-7 weeks of outside rotation, to be arranged by the resident and pre-approved by the program director, or else be spent at TJUH working on research project under faculty supervision. There is no call but residents are encouraged to attend didactics if they are on site. 7. Ambulatory Practice The rotation shall consist of 6 -7 weeks at outpatient offices of subspecialists in office practice such as Dr. Sultana, Dr. Lorell, Dr. Kaufman, Dr. Schwartz, Planned Parenthood and the outpatient radiology department, as well as JOGA clinic. Goals: 1. To acquire the knowledge and skills to counsel women in the menopausal period about common symptoms and conditions including effects on sexuality, including breast cancer survivors (MK,PC, C). 2. To gain experience in less common gynecologic complaints seen in the office setting (MK,PC). 3. To competently evaluate and manage patients with breast complaints, and initiate workup of women presenting with breast masses (MK,PC). 4. To be able to screen women for age-specific conditions according to evidence based guidelines (MK,PC). 5. To gain additional experience in transvaginal ultrasound examination. (MK,PC). 6. To gain experience in the management of pediatric gynecologic patients. (MK,PC). 7. To gain additional experience in performing pregnancy termination in the outpatient setting. (MK,PC, SBP). 8. To be able to triage and perform the initial examination in patients complaining of pelvic floor problems such as urinary incontinence and prolapse. (MK,PC). Objectives: By the end of the rotation, the resident shall be able to: 1. Refine the ability to perform initial assessment; gain the patient’s confidence and cooperation in obtaining the history and performing the physical examination, appreciating the effects of age; racial, ethnic and cultural backgrounds; sexual orientation; personality; mental status; and the patient’s level of comfort and modesty (PC). 2. State the recommended ACOG and USPHS guidelines for routine screening tailored to risk factors and the patient’s age, including domestic violence (SBP,PBL, PC). 3. Screen older patients for cognitive problems presenting for routine checkups with a basic assessment of functional status including: activities of daily living, mini-mental status examination, and capacity for independent decision making (MK, PC, C). 4. Counsel patients on a healthy diet and exercise, health problems associated with substance abuse, smoking cessation, weight management, and other psychosocial issues and identify resources to help patients with these issues (MK, PC, C, SBP). 5. Perform uncomplicated first trimester terminations under local anesthesia, including counseling pregnant patients on all the alternatives available to them. (Residents, who decide not to provide this service because of a moral objection should be able to counsel patients, make appropriate referrals and manage postabortal complications, and will be assigned other duties) (MK, PC, C). 6. Describe the principal disorders of sexual function, including hypoactive desire, difficulty with arousal, anorgasmia, vaginismus, dyspareunia and offer initial therapies and appropriate referrals, including problems of lesbian, bisexual and transgendered patients (MK, PC) 7. Manage perimenopausal and menopausal condition, including osteoporosis, using interventions such as hormone therapy (estrogen, progestins, selective estrogen receptor modulators); calcium and vitamin supplementation; behavioral and lifestyle modifications; dietary alterations; medications that preserve/build bone mass (MK, PC, C) 8. Describe the indications for and be able to perform and/or interpret the results of the following procedures for breast disorder: aspiration of a cyst or abscess, collection of nipple discharge for cytologic examination, fine needle aspiration of a mass, needle localization biopsy, excisional biopsy, mammography, ultrasonography, and manage the adverse effects of antiestrogen medications, such as tamoxifen and aromatase inhibitors (MK, PC) 9. Demonstrate the ability to evaluate pediatric patients for problems such as vulvovaginitis, vaginal bleeding, trauma, foreign body in the vagina including a focused physical examination appropriate for the patient’s age; perform vaginoscopy and vaginal lavage; and counsel the patient and parents. (PC, C) 10. Take a history from a patient with incontinence or prolapse and perform a directed physical examination including POP-Q and neurologic examination, and triage the patient with conservative management or referral to a subspecialist. (PC, SBP) Evaluations: Global rotation evaluations Mini-Cex Assigned readings: Set of articles from Dr. Sultana Office Gynecology textbook Urogynecology textbook 8. Gynecology- TJUH The rotation shall consist of 6-7 on the General Gynecology service managing preoperative, intraoperative, and post-operative care as well as seeing consultations and emergency room patients at TJUH under the supervision of the PGY-4 and attendings. They will participate in Pre-op clinic on Thursday afternoons. They will teach medical students from JMC. Residents are expected to incorporate the PGY 2 goals and objectives as well as the following: Goals: 1. Refine surgical skills in performance of advanced surgical procedures (PC) 2. Develop strategies for supervising and teaching clinical care and surgical skills to junior residents (C) 3. Develop ability to serve as a consultant to other specialties, including the ability to utilize evidence- based medicine in making recommendations (P,C) 4. Efficient and effective triage of gynecologic problems seen in the emergency room setting (PC) 5. Identifying clinic patients in need of surgery under the supervision of the director. (PC) 6. Develop skills in office procedures such as colposcopy, IUD insertion, and office ablations and sterilizations (PC). 7. Work effectively in various health care delivery settings and incorporate awareness of cost and insurance issues in different hospital systems (SBP) Objectives: By the end of the rotation, the resident must be able to: 1. Conduct pre-operative assessment for patients in the clinic and navigate the hospital system for scheduling and evaluation, including indications for and perform appropriate preoperative evaluation and referral, including laboratory tests, radiographic imaging and EKG(PC, SBP) 2. Summarize indications and compose appropriate preoperative preparation plans for patients undergoing gynecologic surgery, including antibiotic use and thromboembolism prophylaxis (PC) 3. Choose appropriate pain control bases on the surgical procedure, degree of patient discomfort and patient characteristics, manage and counsel patients about normal postoperative recovery (PC). 4. Elicit appropriate history, perform a physical examination, perform and/or interpret appropriate tests and manage common postoperative complications (PC) 5. Demonstrate the ability to perform minor procedures with minimal guidance, including laparoscopic tubal ligation, d&c and hysteroscopy, and be able to discuss different approaches to hysterectomy and adnexal surgery (PC,PBL). 6. Demonstrate an ability to function independently and seek out supervision as needed in managing common problems and patient evaluations (P, SBP). 7. Work with and communicate effectively with a variety of ancillary staff and attending physicians in a professional manner (P, C). 8. Participate in formal patient presentations at Grand Rounds (PBL, SBP). 9. Maintain the Beta Book and track patients with abnormal first trimester bleeding as well as be responsible for their follow-up and communication. (SBP,P,C) Evaluation methods: Global evaluations Surgical checklist cards Reading assignments: Gynecology textbooks and journal articles pertaining to patients