New Application: Female Pelvic Medicine and Reconstructive Surgery
Review Committee for Obstetrics and Gynecology or Urology
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
SPONSORING INSTITUTION
1. Does the sponsoring institution also sponsor ACGME-accredited residency programs in the
following: [PR I.A.1.]
a) Obstetrics and Gynecology ..................................................................................... ☐ YES ☐ NO
b) Urology.................................................................................................................... ☐ YES ☐ NO
2. Describe how the program functions as an integral part of an ACGME-accredited residency in either
obstetrics and gynecology or urology. [PR I.A.1.a)] (Limit response to 100 words)
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3. Is the fellowship program affiliated with an LCME-accredited medical school? [PR I.A.1.b)]
..................................................................................................................................... ☐ YES ☐ NO
PROGRAM PERSONNEL AND RESOURCES
Faculty
1. Does the faculty include: [PR II.B.9.]
a) Colorectal surgeons ................................................................................................ ☐ YES ☐ NO
b) Gastroenterologists ................................................................................................. ☐ YES ☐ NO
2. Briefly explain the role of the colorectal surgeon and gastroenterologist faculty member(s) in the
education of fellows. [PR II.B.9.] (Limit response to 200 words)
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Resources
1. Indicate whether the following resources are available at the primary clinical site and whether
access to these resources is available at all times. [PR II.D.1.]
Available at Primary Clinical
Site
☐ YES ☐ NO
Accessible at All Times
☐ YES ☐ NO
Ambulatory clinic facilities
☐ YES ☐ NO
☐ YES ☐ NO
Recovery rooms
☐ YES ☐ NO
☐ YES ☐ NO
Intensive care units
☐ YES ☐ NO
☐ YES ☐ NO
Blood banks
☐ YES ☐ NO
☐ YES ☐ NO
Diagnostic laboratories
☐ YES ☐ NO
☐ YES ☐ NO
Imaging services
☐ YES ☐ NO
☐ YES ☐ NO
Operating rooms
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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2. Does the program have clinical and laboratory infrastructure for research facilities equipped to
enable fellows to engage in scholarly activities? [PR II.D.2.] ......................................... ☐ YES ☐ NO
3. Briefly explain the facilities and infrastructure for clinical and laboratory research available to the
fellowship. Include type of laboratory space, equipment, database access, faculty resources,
including statistical support available, and other pertinent resources. [PR II.D.2.] (Limit response to
200 words)
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FELLOW APPOINTMENTS
Are fellows informed, prior to entering the program, of the requirements for completing the program,
including the criteria to qualify for the subspecialty board examination? [PR III.A.3] ........... ☐ YES ☐ NO
EDUCATIONAL PROGRAM
At the beginning of the program, does each fellow receive an individual educational plan that includes a
monthly block rotation diagram displaying the clinical, didactic, and research activities by rotation?
[PR IV.A.2.a)] ...................................................................................................................... ☐ YES ☐ NO
The Review Committee recommends the use of either Option 1 or Option 2 of the sample block
diagram.
Regularly Scheduled Didactic Sessions
1. Indicate whether fellows participate in the following activities: [PR IV.A.3.a)]
a) Didactics ................................................................................................................. ☐ YES ☐ NO
Indicate frequency ...................................................... [ Frequency ]
b) Journal clubs ........................................................................................................... ☐ YES ☐ NO
Indicate frequency ...................................................... [ Frequency ]
c) Morbidity and mortality conferences ........................................................................ ☐ YES ☐ NO
Indicate frequency ...................................................... [ Frequency ]
d) Seminars ................................................................................................................. ☐ YES ☐ NO
Indicate frequency ...................................................... [ Frequency ]
2. Indicate whether the didactic topics include the following:
Have the conference schedule available for the site visitor.
a) Anatomy and physiology of the pelvic floor, including the lower urinary tract, and colorectal-anal
and vaginal function [PR IV.A.3.a).(1)] .................................................................... ☐ YES ☐ NO
b) Behavioral, pharmacological, functional, and surgical treatment of urinary incontinence, anal
incontinence, and pelvic floor dysfunction, including micturition and defecation disorders, and
pelvic organ prolapse [PR IV.A.3.a).(2)] ................................................................. ☐ YES ☐ NO
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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c) Diagnosis and evaluation of pelvic floor dysfunction, including urinary incontinence, voiding
dysfunction, pelvic organ prolapse, defecation disorders, and sexual dysfunction
[PR IV.A.3.a).(3)] .................................................................................................... ☐ YES ☐ NO
d) Diagnosis and management of genitourinary and rectovaginal fistulae, urethral diverticula,
injuries to the genitourinary tract, congenital anomalies, and infectious and non-infectious
irritative conditions of the lower urinary tract and pelvic floor [PR IV.A.3.a).(4)] ....... ☐ YES ☐ NO
e) Management of genitourinary complications of vaginal delivery, spinal cord injuries, and
medical, psychiatric, and geriatric conditions related to pelvic floor disorders [PR IV.A.3.a).(5)]
................................................................................................................................ ☐ YES ☐ NO
f)
Pathophysiology of pelvic floor dysfunction, including urinary incontinence, voiding dysfunction,
pelvic organ prolapse, anal incontinence, defecation disorders and sexual dysfunction
[PR IV.A.3.a).(6)] ..................................................................................................... ☐ YES ☐ NO
g) Research design, grant writing, research methodology, and scientific writing and presentation
skills [PR IV.A.3.a).(7)] ........................................................................................... ☐ YES ☐ NO
Patient Care
Indicate the settings and activities in which fellows demonstrate competence in each of the following
areas of patient care. Also indicate the method(s) used to assess competence.
Examples of assessment methods:
Direct observation, videotaped/recorded assessment, global assessment, simulations/models,
record/chart review, multisource assessment, patient survey, structured case discussions, anatomic or
animal models, formal oral or written exam, practice/billing audit, review of case or procedure log,
review of patient outcomes, review of drug prescribing.
Competency Area
Assessing the effects of
treatment, and recognizing and
managing the complications of
therapy
[PR IV.A.5.a).(2).(a).(i)]
Diagnosing and managing
patients with urinary incontinence,
pelvic organ prolapse,
genitourinary and rectovaginal
fistulae, anal incontinence,
urethral diverticula, injuries to the
genitourinary tract, congenital
anomalies, and infectious and
non-infectious irritative conditions
of the lower urinary tract and
pelvic floor
[PR IV.A.5.a).(2).(a).(ii)]
Evaluating the lower urinary and
genital tracts for abnormalities,
including neoplasms, and
Settings/Activities
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Assessment Method(s)
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Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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Competency Area
Settings/Activities
Assessment Method(s)
interpreting cytology and biopsy
results
[PR IV.A.5.a).(2).(a).(iii)]
Performing advanced
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laparoscopic, abdominal, and
vaginal surgery for uterovaginal
and post-hysterectomy vaginal
vault prolapse, including
reconstructive and obliterative
procedures
[PR IV.A.5.a).(2).(a).(iv)]
Performing cystoscopy and
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cystoscopic manipulations,
including stent placement
retrograde pyelograms, and
ureteral stent placement
[PR IV.A.5.a).(2).(a).(v)]
Performing urodynamic testing
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[PR IV.A.5.a).(2).(a).(vi)]
Performing surgery for urinary
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incontinence, including native and
synthetic slings and periurethral
bulking agents
[PR IV.A.5.a).(2).(a).(vii)]
Performing surgery for
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complicated obstetric lacerations,
and treatment of related benign
conditions occurring in the female
pelvis
[PR IV.A.5.a).(2).(a).(viii)
Fellows Completing the F1 Year:
Evaluating and managing
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hematuria
[PR IV.A.5.a).(2).(b).(i)]
Evaluating and managing painful Click here to enter text.
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bladder, including interstitial
cystitis
[PR IV.A.5.a).(2).(b).(ii)]
Evaluating and managing
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neurogenic voiding dysfunction
[PR IV.A.5.a).(2).(b).(iii)]
Evaluating and treating urinary
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tract infections
[PR IV.A.5.a).(2).(b).(iv)]
Performing a female pelvic exam, Click here to enter text.
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including quantification of pelvic
organ prolapse
[PR IV.A.5.a).(2).(b).(v)]
Fellows Completing the F2 Year:
The behavioral, pharmacological, functional, non-surgical, and surgical treatment of:
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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Competency Area
Settings/Activities
Micturition and defecation
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disorders
[PR IV.A.5.a).(2).(c).(i)]
Pelvic organ prolapse
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[PR IV.A.5.a).(2).(c).(ii)]
Urinary incontinence
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[PR IV.A.5.a).(2).(c).(iii)]
Fellows Completing the F3 Year:
Diagnosing and managing
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genitourinary and rectovaginal
fistulae, urethral diverticula,
injuries to the genitourinary tract,
and congenital anomalies
[PR IV.A.5.a).(2).(d).(i)]
Managing genitourinary
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complications of vaginal delivery
spinal cord injuries and similar
health events
[PR IV.A.5.a).(2).(d).(ii)]
Assessment Method(s)
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Medical Knowledge
Indicate the activities (lectures, conferences, journal clubs, clinical teaching rounds, etc.) in which
fellows demonstrate competence in their knowledge of each of the following areas. Also indicate the
method(s) used to assess fellow competence.
Competency Area
Settings/Activities
Fellows Completing the F1 Year:
The epidemiology of urinary
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incontinence, pelvic organ
prolapse, and defecation
disorders, including birth, aging,
and neurologic disease
[PR IV.A.5.b).(1).(a)]
The impact of urinary
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incontinence, pelvic organ
prolapse, and defecation
disorders on quality of life
[PR IV.A.5.b).(1).(b)]
The use and interpretation of
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disease-specific and global health
questionnaires to evaluate the
impact of pelvic floor disorders on
quality of life
[PR IV.A.5.b).(1).(c)]
The scientific method of problem Click here to enter text.
solving and evidence-based
decision making
[PR IV.A.5.b).(1).(d)]
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Assessment Method(s)
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Competency Area
Settings/Activities
Assessment Method(s)
Indications, contraindications, limitations, complications, techniques, and interpretation of results of
those diagnostic and therapeutic procedures integral to the discipline, to include:[PR IV.A.5.b).(1).(e)]
The indications for and use of Click here to enter text.
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screening tests and
procedures, including
urinalysis, urine cytology, and
pad test
[PR IV.A.5.b).(1).(e).(i)]
Use and interpretation of a
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voiding diary
[PR IV.A.5.b).(1).(e).(ii)]
Fellows Completing the F2 Year:
The anatomy, physiology, and
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pathophysiology of the pelvic
floor, including the lower urinary
tract, and colorectal-anal and
vaginal functioning
[PR IV.A.5.b).(2).(a)]
Clinically pertinent areas of
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pathology, infectious disease,
geriatric medicine, physical
therapy, pain management,
sexual dysfunction, and
psychosocial aspects of pelvic
floor disorders
[PR IV.A.5.b).(2).(b)]
Indications, contraindications, limitations, complications, techniques, and interpretation of results of
screening, diagnostic, and therapeutic procedures for the treatment and evaluation of pelvic floor
disorders, to include: [PR IV.A.5.b).(2).(c)]
Pelvic imaging studies for the Click here to enter text.
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diagnostic evaluation of
urinary and anal incontinence,
pelvic floor dysfunction, and
prolapse
[PR IV.A.5.b).(2).(c).(i)]
Urodynamic assessment
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[PR IV.A.5.b).(2).(c).(ii)]
Fellows Completing the F3 Year:
Assessment and treatment of
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lower urinary tract dysfunction
secondary to neurologic diseases
[PR IV.A.5.b).(3).(a)]
Indications, contraindications, limitations, complications, techniques, and interpretation of results of
screening, diagnostic, and therapeutic procedures for surgery for:
Pelvic organ prolapse
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[PR IV.A.5.b).(3).(b).(i)]
Urinary incontinence
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[PR IV.A.5.b).(3).(b).(ii)]
Rectovaginal fistula related to Click here to enter text.
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obstetric trauma
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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Competency Area
Settings/Activities
[PR IV.A.5.b).(3).(b).(iii)]
Vesicovaginal fistula and
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urethrovaginal fistula
[PR IV.A.5.b).(3).(b).(iv)]
Quantitative techniques, including Click here to enter text.
biostatistics, epidemiology,
research design, and research
methods[PR IV.A.5.b).(3).(c)]
Assessment Method(s)
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Practice-based Learning and Improvement
1. Briefly describe one learning activity in which fellows demonstrate the ability to investigate and
evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously
improve patient care based on self-evaluation and life-long learning. [PR IV.A.5.c)] (Limit response
to 400 words)
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2. Briefly describe one planned learning activity in which fellows engage to identify strengths,
deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set
learning and improvement goals; and identify and perform appropriate learning activities to achieve
self-identified goals (life-long learning). [PR IV.A.5.c).(1)-(3)] (Limit response to 400 words)
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3. Briefly describe one planned quality improvement activity or project that will allow the fellow to
demonstrate an ability to analyze, improve, and change practice or patient care. Describe planning,
implementation, evaluation, and provisions of faculty member support and supervision that will
guide this process. [PR IV.A.5.c).(4)] (Limit response to 400 words)
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4. Briefly describe how fellows will receive and incorporate formative evaluation feedback into daily
practice. (If a specific tool is used to evaluate these skills have it available for review by the site
visitor.) [PR IV.A.5.c).(5)] (Limit response to 400 words)
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5. Briefly describe one example of a learning activity in which fellows engage to develop the skills
needed to use information technology to locate, appraise, and assimilate evidence from scientific
studies and apply it to their patients' health problems. [PR IV.A.5.c).(6)-(7)] (Limit response to 400
words)
The description should include:
 Locating information
 Using information technology
 Appraising information
 Assimilating evidence information (from scientific studies)
 Applying information to patient care
 Conducting a comprehensive literature search
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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6. Briefly describe how fellows will participate in the education of patients, families, students,
residents, and other health professionals. [PR IV.A.5.c).(8)] (Limit response to 400 words)
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Interpersonal and Communication Skills
1. Briefly describe one learning activity in which fellows demonstrate interpersonal and communication
skills that result in the effective exchange of information and collaboration with patients, their
families, and health professionals. [PR IV.A.5.d)] (Limit response to 400 words)
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2. Briefly describe one learning activity in which fellows develop competence in communicating
effectively with patients and families across a broad range of socioeconomic and cultural
backgrounds, and with physicians, other health professionals, and health-related agencies.
[PR IV.A.5.d).(1)-(2)] (Limit response to 400 words)
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3. Briefly describe one learning activity in which fellows develop their skills and habits to work
effectively as members or leaders of a health care team or other professional group. In the
example, identify the members of the team, responsibilities of the team members, and how team
members communicate to accomplish responsibilities. [PR IV.A.5.d).(3)] (Limit response to 400
words)
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4. Briefly describe how fellows will be provided with opportunities to act in a consultative role to other
physicians and health professionals. [PR IV.A.5.d).(4)] (Limit response to 400 words)
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5. Briefly describe how fellows will be provided with opportunities to maintain comprehensive, timely,
and legible medical records, if applicable. [PR IV.A.5.d).(5)] (Limit response to 400 words)
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Professionalism
Briefly describe the learning activity(ies), other than lecture, by which fellows develop a commitment to
carrying out professional responsibilities and an adherence to ethical principles, including: compassion,
integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect
for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity
and responsiveness to a diverse patient population, including diversity in gender, age, culture, race,
religion, disabilities, and sexual orientation [PR IV.A.5.e).(1)-(5)] (Limit response to 400 words)
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Systems-based Practice
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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1. Briefly describe the learning activity(ies) through which fellows demonstrate an awareness of and
responsiveness to the larger context and system of health care, as well as the ability to call
effectively on other resources in the system to provide optimal health care. [PR IV.A.5.f)] (Limit
response to 400 words)
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2. Describe the learning activity(ies) through which fellows achieve competence in the elements of
systems-based practice: working effectively in various health care delivery settings and systems,
coordinating patient care within the health care system; incorporating considerations of costcontainment and risk-benefit analysis in patient care; advocating for quality patient care and optimal
patient care systems; and working in interprofessional teams to enhance patient safety and care
quality. [PR IV.A.5.f).(1)-(5)] (Limit response to 400 words)
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3. Describe an activity that fulfills the requirement for experiential learning in identifying system errors
and implementing potential systems solutions. [PR IV.A.5.f).(6)] (Limit response to 400 words)
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Curriculum Organization and Fellow Experiences
1. Do fellows have supervised responsibility for the total care of the patient, including initial evaluation,
establishment of diagnosis, selection of appropriate therapy, and management of complications?
[PR IV.A.6.a).(1)]........................................................................................................... ☐ YES ☐ NO
If “NO,” explain. Limit response to 100 words.
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2. Briefly describe how fellows participate in continuity of patient care through pre- and post-operative
clinics and inpatient contact. [PR IV.A.6.a).(2)]
Limit response to 100 words.
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3. Do fellows record all surgical procedures in which they have a significant role in the ACGME Case
Log System? [PR IV.A.6.a).(3)] .................................................................................... ☐ YES ☐ NO
4. Do fellows participate in the diagnosis and management of clinically pertinent areas of:
[PR IV.A.6.d)]
a)
b)
c)
d)
e)
f)
g)
h)
pathology ................................................................................................................ ☐ YES ☐ NO
infectious disease.................................................................................................... ☐ YES ☐ NO
geriatric medicine .................................................................................................... ☐ YES ☐ NO
physical therapy ...................................................................................................... ☐ YES ☐ NO
pain management ................................................................................................... ☐ YES ☐ NO
pre- and post-operative care ................................................................................... ☐ YES ☐ NO
sexual dysfunction ................................................................................................... ☐ YES ☐ NO
psychosocial aspects of pelvic floor disorders ......................................................... ☐ YES ☐ NO
Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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Explain any “NO” responses. Limit response to 200 words.
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Fellows’ Scholarly Activities
Describe the curriculum for the fellows’ scholarly activities, to include research design, grant writing,
research methodology, scientific writing, and presentation skills. [PR IV.B.2.a)]
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EVALUATION
Formative Evaluation
Is each fellow’s scholarly activity monitored by a faculty member and confirmed by a competency
assessment committee that includes at least one physician scientist not affiliated with the program?
[PR V.A.2.a).(1)] ................................................................................................................. ☐ YES ☐ NO
Summative Evaluation
1. Does each fellow give an oral presentation of his or her scholarly project (thesis)?
[PR V.A.3.a).(1)]............................................................................................................ ☐ YES ☐ NO
2. Do faculty members provide written evaluations of these presentations? [PR V.A.3.a).(1)]
..................................................................................................................................... ☐ YES ☐ NO
Include a copy of the thesis evaluation form with the final (summative) evaluation (Attachment #6).
3. Provide the name of the Thesis Evaluation Committee faculty mentor and committee members for
each fellow in the program. [PR V.A.3.a).(1)]
Fellow
Faculty mentor
Committee members
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Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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INSTITUTIONAL DATA
Provide the number of procedures performed in each participating site listed in ADS for the most recent
academic year.
Outpatient NEW VISITS with diagnosis of:
Pelvic organ prolapse
Urinary incontinence
Overactive bladder syndrome (nocturia,
urgency, frequency)
Urinary retention
Painful bladder syndrome (interstitial cystitis,
myofascitis, urethral syndrome, dysuria)
Defecation disorders (fecal incontinence and
constipation)
Diagnostic Procedures Performed
Simple urodynamics
Complex urodynamics
Uroflow complex
Cystourethroscopy
Neurodiagnostic studies
Anal ultrasound
Non-Surgical Therapies Performed
Fitting pessary/incontinence ring
Surgical Procedures
Surgical Procedures for Incontinence
TOTAL number of patients operated on for UI
Sling procedures
Periurethral injections
Retropubic procedures
Sacral nerve stimulators
Removal or modification of sling
Surgical Procedures for Prolapse
TOTAL number of patients operated on for
POP
Abdominal procedures
Colpopexy
Uterine suspension
Hysterectomy (total and supracervical)
Laparoscopy with/without robotic assistance
Colpopexy
Uterine suspension
Hysterectomy (total and supracervical)
Vaginal procedures
Hysterectomy
Colpocleisis
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Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 5/2015
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Colpopexy - extraperitoneal approach
Colpopexy - intraperitoneal approach
Insertion of vaginal mesh
Removal of vaginal or abdominal mesh
Surgical Procedures on Urinary System
Vesicovaginal fistula repair
Urethrovaginal fistula repair
Urethral diverticulectomy
Ureteroneocystostomy, ureteroureterostomy
Ureteral stent placement
Retrograde pyelograms
Urethrolysis
Surgical Procedures on Genital System
Construction of neo-vagina
Surgical Procedures on Bowel System
Repair of chronic anal sphincter lacerations
Rectovaginal fistula repair
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Female Pelvic Medicine and Reconstructive Surgery
©2015 Accreditation Council for Graduate Medical Education (ACGME)
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