The Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency Program in Obstetrics and Gynecology is designed to provide outstanding clinical and academic training in Obstetrics and Gynecology. The four-year training period is organized into eleven rotations at our parent institutions, Brigham and Women's Hospital and Massachusetts General Hospital, and affiliated institutions including Newton Wellesley Hospital, Children's Hospital Boston and South Shore Hospital. Approximately 90% of the educational experiences in the program are spent at the two parent institutions, MGH and BWH. Residents rotating at the affiliate institutions return to BWH for participation in Wednesday didactic learning time. To conform to the ACGME duty hours guidelines, the residency rotations and duty shifts were restructured July 2003, such that strict compliance with the 80-hour workweek guidelines did not adversely affect resident education. The entire program is scrutinized annually to ensure that all rotation and experiences are clearly educational and are in support of our overall educational mission. The PGY 1 rotations include obstetrics, gynecology, primary care and inpatient general medicine, gynecologic oncology and surgical intensive care. The PGY 2, PGY 3 and PGY 4 rotations provide a broad experience with a progressive increase in the level of responsibility in obstetrics, gynecology, maternal-fetal medicine, gynecologic oncology, pediatric gynecology, reproductive medicine and infertility, family planning, urogynecology and minimally invasive surgery. Clinical learning takes place primarily through the responsibility for supervised patient care in the inpatient and ambulatory setting and operating room. Current block resident rotations are shown below.
Residents have experience in inpatient obstetrical management during all four years of their training. At BWH, there are approximately 8000 deliveries performed per year, of which approximately 1700 are from the resident service. The dedicated labor floor resident team assumes primary responsibility for all resident clinic and Maternal Fetal Medicine patients under the supervision of the in-house covering OB/GYN generalist or Maternal Fetal Medicine attending. This responsibility includes assessing patients in OB triage and identifying patients that need admission to L&D or the antenatal high-risk obstetrical service; performing and interpreting electronic fetal monitoring (internal and external), fetal scalp stimulation, vibroacoustic stimulation, fetal scalp blood sampling for pH; performing cervical exams, assessment of fetal presentation, status of membranes; evaluating progress of labor and identifying abnormalities of labor including managing abnormal fetal heart rate patterns or presentation; and implementing appropriate interventions including spontaneous and operative vaginal delivery, cesarean delivery or vaginal birth after cesarean delivery. They also routinely perform ultrasounds on all admitted patients to assess fetal position, amniotic fluid volume and, if appropriate, biometry and biophysical profile. The Labor and Delivery unit also functions as an ICU, and residents care for critical care obstetric patients under the supervision of the MFM attending and Obstetric anesthesia attending. The chief resident serves as the primary consultant to the midwifery service and performs all assisted vaginal or cesarean midwife deliveries under the direct supervision of the on-call OB/GYN generalist or Maternal Fetal medicine attending.
Residents are generally not involved in the care of private obstetrical patients who have uncomplicated vaginal deliveries, however, they do regularly participate in the care of private patients who undergo cesarean section, operative vaginal delivery (forceps/vacuum extraction and multi-fetal deliveries) or intrapartum/postpartum complications. Physician extenders (OR assistants) were hired in 2004 to assist in uncomplicated cesarean deliveries, helping to assure a proper balance of education over service.
The PGY 4 OB Clinic Chief at BWH is responsible for providing supervision of junior residents in the management of the postpartum patients, as well as directly managing the sick post-partum patients under the supervision of the Maternal Fetal Medicine attending. This includes any patients with operative complications, medical complications of pregnancies, complicated deliveries or patients in the intensive care unit.
At MGH, there are approximately 3500 deliveries performed per year. Residents participate in all faculty deliveries and are available to assist with any complicated midwife deliveries under the direct supervision of the on-call OB/GYN generalist or MFM attending.
During the intern year, residents learn the basics of routine labor and delivery management, spontaneous vaginal and cesarean deliveries, episiotomy repair, and are exposed to operative vaginal deliveries. PGY 2 residents spend 2 rotations on L&D, assuming more responsibility in managing laboring and complicated postpartum patients and participating in complex vaginal and operative deliveries. PGY 3 residents assume the role of chief resident (including antepartum management) while taking weekend call on L&D, as well as during their night float rotation. In addition to their clinical responsibilities on the floor, residents assume greater teaching and supervisory roles for more junior residents and medical students and function as consultants on complex midwifery cases. PGY 4 residents function as the "junior attending" while on L&D, managing the labor floor with assistance from the in-house supervising faculty member. They take a prominent role in the supervision and teaching of junior residents and medical students in uncomplicated vaginal deliveries and participate in complicated vaginal, instrumental and cesarean deliveries. They function as first assistant to the junior residents on cesarean deliveries under the supervision of the on-call attending, who is present during the critical portions of all cases and is immediately available.
Ambulatory experience in normal obstetrics is acquired through management of routine prenatal care by PGY 1 and 2 residents assigned to the BWH labor floor rotations, and PGY 1 residents in their yearlong OB continuity clinics. The PGY 4 OB Clinic Chief provides consultation for patients undergoing cesarean delivery, high-risk consultation for the CNM practice, as well as formal teaching to the PGY1 and 2 residents and medical students during morning rounds three times per week. Resident responsibilities in clinic include taking a comprehensive history; performing a physical exam; ordering/interpreting prenatal labs; counseling patients about nutrition, exercise, breast feeding, tobacco/alcohol/drug use; fetal movements/kick counts and appropriate weight gain; interpreting NST and biophysical profiles; and identifying patients for referral to the high-risk OB resident practice or triage unit/L&D floor. This occurs under the supervision of on-site OBGYN Generalist and Maternal Fetal Medicine faculty specifically assigned to the ambulatory sessions.
Formal teaching "Board rounds" on labor and delivery occur at both institutions twice daily. These are attended by OBGYN generalist faculty, perinatologists, midwives, residents and medical students. In addition to formal board rounds, interdisciplinary rounds occur twice daily on the L&D units at both BWH and MGH, which include nurses, anesthesiologists and pediatricians. During interdisciplinary rounds, every patient on labor and delivery is discussed among all teams to provide consensus about patient care. Didactic instruction is provided in these rounds as well as in weekly resident lectures, Chief's Rounds (Wednesdays at noon) and Grand Rounds. The PGY 4 is responsible for the weekly Chief's Rounds, which are a presentation to the Department of OB-Gyn of the weekly statistics from the labor floor, with an evidence-based review of management of complicated and interesting cases. Workshops during didactic time include repair of 3 rd and 4 th degree lacerations, knot tying and suturing, forceps deliveries, pudendal blocks, and postpartum hemorrhage workshops. Residents participate in shoulder dystocia skills workshops occurring during didactics and on labor and delivery utilizing a mannequin, and receive immediate feedback on performance.
Both faculty and nursing staff at BWH and MGH are committed to the promotion of breastfeeding. Certified lactation consultants and staff nurses on the Labor and Delivery units and postpartum floors assist in lactation support, with education for patients and residents, and breastfeeding immediately after delivery is strongly encouraged. In addition, a certified lactation consultant/RN is on site in the antenatal Obstetrics clinic to assist in the identification of any potential patient challenges with breastfeeding that may be addressed by the resident proactively. Lectures during protected didactic time on breastfeeding occur once yearly by the lactation consultant staff, covering the physiology of lactation and practical aspects such as positioning strategies and other frequently asked questions. The CDC Guide to Breastfeeding Interventions is provided to each resident for quick practical reference in the clinical setting. In spring 2006, our residents were funded to attend the local symposium on breastfeeding at Harvard Medical School entitled Breastfeeding: What Every Doctor Needs to Know. There is informal instruction during the antenatal clinics and at board rounds regarding the implications of medication on breastfeeding, given the significant proportion of medically complicated patients seen at both institutions.
High Risk Obstetrics
Residents participate in the care of women experiencing complications of pregnancy during all four years of their training. All PGY 3 residents spend 6 weeks on the High Risk Antepartum (Fuller) Service at BWH, where they work closely under the supervision of Maternal Fetal Medicine faculty and fellows. On this service the resident is involved in the care of all hospitalized antepartum patients and in labor and delivery management decisions. At MGH, residents are involved in the care of antepartum patients presenting to OB triage and Labor & Delivery. Residents participate in the placement of cervical cerclages and any gynecologic surgery on pregnant patients. Amniocenteses and biophysical profiles are performed on the labor floor and in the Antenatal Diagnostic Center where residents are invited to participate. The BWH labor floor has a large volume of high-risk transfer patients. These patients are primarily managed by the PGY 1 and PGY 2 residents on the labor floor under the supervision of the PGY 4 OB chief and the Maternal Fetal Medicine attending. The responsibilities are to assess and manage the patients, often coordinating consultations from other services, as well as neonatology and anesthesiology. Residents may be responsible for managing medication infusions, admitting critically ill women to the antepartum service and performing ultrasound on patients too unstable to leave the labor floor.
There are three weekly ambulatory clinics primarily managed by the PGY 4 OB Clinic Chief at BWH. The multidisciplinary Diabetes clinic is staffed by Endocrine and MFM faculty who provide direct supervision. Residents counsel patients, perform physical exams, arrange and interpret fetal testing. They also review weekly glucose levels on the patients, initiate and adjust insulin regimens with guidance from the MFM and Endocrine attendings. The resident high-risk clinic ("Special OB") at BWH is staffed by an MFM attending and contains patients with complex comorbidities including chronic hypertension, maternal cardiac defects, severe asthma, lupus, sickle cell disease, HIV, isoimmunization and pregnancy-related issues including multiple gestations and cervical incompetence. For this clinic, the Chief resident is required to present the patients at a noontime conference and a management plan is developed with the assistance of the MFM staff. Residents are responsible for all aspects of patient care and management including planning inductions, performing cesarean deliveries and seeing the patients postpartum. The third clinic is dedicated to midwifery consults, reviewing cesarean consents with patients from the low-risk clinic and following up patients from the high risk clinic that need to be seen twice-weekly. This ensures continuity of care and maximizes learning for the resident who is responsible for interpreting and managing patients who need more intensive surveillance.
Rounds occur twice daily on the antenatal service where patients are reviewed with the attending perinatologists and formal care plans are made. Residents attend a weekly Maternal Fetal Medicine teaching conference (BWH Thursday Noon) and Special OB Rounds of all charts and lab results of "active" patients occurs weekly (BWH Tuesday Noon). The PGY 3 resident on the high-risk (Fuller) service is responsible for presenting a case with literature review at the MFM teaching conference once during their rotation. A series of weekly didactic lectures provided by Maternal Fetal Medicine attendings follow the CREOG Objectives for Obstetrics. Each month at MGH, there is an Obstetrics Case Conference presented by the PGY 1 on OB , which highlights the management of medically complicated patients with critical literature review and discussion.
Immediate Care of the Newborn, Including Resuscitation
Residents receive an instructional lecture in neonatal resuscitation during protected didactic time at the start of each academic year by a faculty neonatologist. PGY 1 residents attend an NRP certification session with a neonatologist during intern orientation in which they learn immediate evaluation of the newborn, including neonatal resuscitation and learn the skills needed for proper suctioning and airway management. In addition, teaching is provided to instruct residents on the use of the laryngoscope and insertion of oral/tracheal tubes. Residents are involved in the consultation of the pediatric team and in the initial resuscitation of depressed neonates. Residents perform all of the circumcisions requested on the resident service patients at BWH, under the direct supervision of the assigned covering faculty.
Residents participate in the perioperative and surgical management of both private and clinic patients. At both MGH and BWH, faculty from the OBGYN Generalist, GYN Oncology, Urogynecology, Minimally Invasive Surgery and Reproductive Endocrinology departments are assigned to supervise residents in the management of clinic patients for a week's duration. This faculty member attends daily morning rounds to review the GYN service, discuss management and teach. For private patients, residents are under the supervision of the individual patient's private attending physician. The amount of surgical responsibility given to individual residents varies based on complexity of the case and is graduated to the level of resident training. The program has recently established a list of gynecologic surgical skills (operating room and lab trainer) that residents should be able to accomplish at the completion of residency training, and residents obtain directed feedback on their skills through a surgical evaluation form, completed at the end of selected cases. This evaluation form provides for immediate feedback on operative performance and forms the basis of this checklist. The residents have unrestricted access to laparoscopy and hysteroscopy lab trainers between both MGH and BWH and work with OB/GYN generalists, minimally invasive surgeons and reproductive endocrinologists to improve their skills and satisfy requirements on the trainers during their surgical rotations.
PGY 1 residents are involved in the pre-operative evaluations and postoperative management of patients on the inpatient gynecology service. They participate in surgical cases geared toward developing skills in basic laparoscopy, hysteroscopy, and open abdominal cases. They provide consultation to the emergency department and inpatient units, as well as manage the Ectopic list, learning about early pregnancy loss and ectopic pregnancy management. They are also intimately involved in the decisions re: medical and surgical management of ectopic pregnancies and are included in these surgeries as appropriate. All of these activities are performed under the supervision of the senior residents and attending faculty.
PGY 2 residents are involved in more advanced surgeries, including abdominal hysterectomy, more advanced laparoscopy, and hysteroscopy. They assume increasing responsibility for the management of inpatients, including night-float rotations with ED consultations, and participation in emergent GYN surgeries. PGY 2 residents also rotate to Children's Hospital Boston, which affords one-on-one inpatient, outpatient and operative supervision with a pediatric and adolescent gynecology specialist in a high-volume surgical practice, as well as North Shore Medical Center ( Salem Hospital ) and South Shore Hospital (starting July 2009), which allows them to learn about operative gynecology in a community hospital setting.
PGY 3 residents have an increased level of responsibility and involvement in major gynecologic vaginal and abdominal surgeries, advanced laparoscopic surgeries, urogynecologic and GYN oncology cases as well as an increased supervisory role over the junior residents and medical students on the service. There is a 6-week rotation with concentration in Minimally Invasive Surgery at Newton-Wellesley Hospital . While at Newton-Wellesley hospital, residents have the opportunity to take part in lab simulator exercises to hone laparoscopic techniques. Residents take a pre-test on a laparoscopic trainer and at the end of the rotation are required to take a post-test on the same trainer. There are two different types of laparoscopic training activities-- a computer-based simulator ("Lap-Sim") and a "box trainer" equipped with a real laparoscope and camera tower. The Lap-Sim program includes mock-laparoscopic tools and a computer-generated model of laparoscopic suturing, and residents are able to work their way through all levels of hand-eye coordination drills. The minimally invasive surgery fellow reviews the results of the posttest with the PGY 3 resident at the end of the rotation and gives directed feedback in this regard. The box trainer includes multiple different hand-eye drills, as well as models for laparoscopic suturing and intra- and extra-corporeal knot tying. One of the minimally invasive fellows helps orient residents to the training modules as well as to provide additional teaching. A hysteroscopic simulation is also available using hysteroscopes and a pig-bladder set-up to simulate the uterine environment. All residents participate in a pig lab one day during the PGY 3 NWH operative rotation to provide residents with the opportunity to practice laparoscopic skills.
The PGY 4 residents spend 4 rotations on the gynecology services. Ward service responsibilities include surgical and medical management and oversight of the inpatient and outpatient services. The PGY 4 residents function as "junior attendings", providing operative instruction to more junior residents and performing the more complicated surgeries. These residents are also involved in facilitating the operative planning for surgical patients presenting from the resident continuity clinics.
Residents participate in a weekly GYN continuity clinic in the PGY 2-4 years at either BWH or MGH under the direct supervision of GYN faculty assigned to the clinic. They are involved in the decision-making process for surgery, preoperative workup and postoperative care of all patients requiring and undergoing surgery. These cases are brought to the ward chief for evaluation and review at OR Committee at both BWH and MGH, a weekly meeting to discuss the evidence-based approach to operative planning supervised by generalist, REI and oncology faculty.
In addition to OR Committee, didactic experiences for gynecology include CREOG based lectures during protected didactic time, teaching rounds every morning, GYN case conference teaching rounds ("11500 conference") and resident GYN case presentations (MGH - Thursdays). These case-based conferences involve an evidence-based discussion of management of gynecologic issues that have arisen during the team's rotation. Grand rounds are presented in the PGY 2, 3 and 4 years. Annually during didactic time, residents participate in an anatomy workshop concentrating on the intricacies of perineal and pelvic floor anatomy with prosections from the Harvard Medical School . To enhance surgical training in endoscopy, the Reproductive Endocrinology division developed basic hysteroscopy and laparoscopy workshops, which were implemented in 2006 at both institutions and will occur each summer. Residents are expected to participate in these courses at least once during their training.
North Shore Medical Center (Salem Hospital) and South Shore Hospital: Salem and South Shore Hospitals offer a community hospital setting for training in gynecologic surgery during the PGY 2 year. The overall goal is for the residents to develop a greater appreciation of the similarities and differences between the practice of Obstetrics and Gynecology in the community as compared with an academic setting. Residents rotate at either Salem or South Shore Hospital which allows for increased exposure to the faculty and maximizes operative gynecologic experience. This is primarily an operative block for the residents, with time spent learning to recognize and understand the different surgical approaches for hysterectomy, myomectomy, and female incontinence. Three goals for this rotation are: 1) to develop their skills in operative laparoscopy and hysteroscopy, vaginal surgery and various urethropexy procedures, 2) to feel comfortable in the diagnosis and management of intraoperative and postoperative complications, such as incidental cystotomy and enterotomy, postoperative infection, postoperative bleeding, ureteral injury, small bowel obstruction, vascular trocar injuries, delayed bowel injuries, fluid overload, and uterine perforation, and 3) to learn basic obstetric and gynecology pathology, with each resident having a weekly didactic with a staff pathologist.
Children's Hospital Boston : In the PGY 2 year, there is one rotation at the Children's Hospital Boston in Adolescent and Pediatric Gynecology. Children's Hospital is an outstanding educational resource with a strong base of referrals of complex cases involving congenital anomalies and high acuity pediatric and adolescent gynecology. During the rotation, the resident participates in advanced laparoscopic surgery and complicated surgery for Mullerian anomalies with a pediatric and adolescent gynecology specialist in a high-volume surgical practice. Typical problems include labial adhesions, lichen sclerosis, pre-pubertal vaginal bleeding, sarcoma botryoides, ovarian cysts and tumors, pelvic pain and adolescent endometriosis, Mullerian anomalies, breast masses and tumors, gynecologic and reproductive issues for cancer patients/survivors. In addition, there are strong educational opportunities in ambulatory adolescent community gynecology; including issues of family planning and contraception, sexually transmitted infections, pelvic pain, nutrition and exercise, substance abuse, immunizations and various interventions to prevent accidents at home and at school. The residents also learn counseling skills in complex psychosocial issues that affect the patients and the families of the patients that come to Children's Hospital. It is a unique opportunity to participate in and observe expert physicians counseling adolescents on a variety of problems including depressive disorders and suicidal impulses, anxiety disorders, physical and sexual abuse, family interactions and relationships, and psychological and sexual identity.
Newton - Wellesley Hospital (NWH) : This is a community teaching hospital in a suburb of Boston with 35 OBGYN physicians on staff. There are approximately 2700 gynecologic surgeries performed annually at NWH. Residents focus most of their time in the preoperative, operative, and postoperative care of patients that receive care at the Minimally Invasive Gynecology Surgery (MIGS) Center which performs over 500 advanced hysteroscopic and laparoscopic surgeries per year. Some of the more commonly performed procedures include total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, laparoscopic myomectomy, and laparoscopic surgical treatment of advanced endometriosis which makes the MIGS Center an ideal site for advanced training in laparoscopic surgery for the PGY 3 resident. In addition, a significant number of vaginal hysterectomies and urogynecological procedures are performed annually at NWH, further enhancing the surgical experience of the senior residents. Residents also participate in twice monthly journal clubs staffed by the MIGS division faculty.
Residents spend four rotations on the Gyn Oncology services at BWH and MGH in the PGY 1 and PGY 3 years. They are involved in all aspects of the care of gyn oncology patients, from diagnosis to management. Learning objectives for the PGY 1 resident focus on the management of pre and post-operative care of the oncology patients, including evaluation of ileus, fever, chest pain, and issues of fluid and wound management in the critically ill patient. PGY 3 resident objectives focus on preoperative evaluation, cancer staging, surgical care, and medical management of the oncology patient. They also responsible for direct supervision of the PGY 1 floor management of the service. The surgical and inpatient management of patients is supervised directly by fellows and faculty. Residents participate in the surgical management of gyn oncology patients, which includes open staging procedures, radical hysterectomy, bowel surgery and advanced laparoscopic surgery for gyn cancers, node dissection and treatment of complicated benign conditions including advanced endometriosis. Residents receive ambulatory exposure to Gyn Oncology patients when they evaluate patients in the outpatient clinic under the supervision of the Gyn Oncology faculty during their office hours, as well as in colposcopy clinics at both institutions. There is colposcopy clinic exposure in each year of training. Additionally, residents manage consultations from the Emergency Department and inpatient services under the supervision of Gyn Oncology fellows and staff. This solidifies a broad based education in the diagnosis and management of gynecologic cancers in the clinical arena.
Rounds occur twice daily with fellows and/or faculty, and residents attend all educational conferences throughout the oncology rotation including weekly Tumor Board at MGH and Multidisciplinary Cancer Conference and Pathology Conference at BWH. Additional gyn oncology lectures occur during protected Wednesday didactic time at BWH that follow oncology topics based on the Educational Objectives outlined by CREOG. These occur approximately every 6 weeks.
Reproductive Endocrinology and Infertility
Although residents have both a dedicated REI and Children's Hospital rotation in the second year, experiences in all four years of residency complement these rotations to provide a broad educational experience. The PGY 1 resident conducts the hysterosalpingograms and office hysteroscopies for patients undergoing infertility evaluation from the BWH GYN clinic. Residents also gain additional exposure to advanced laparoscopy and the infertility workup including office hysteroscopy during their third year rotations at Newton-Wellesley Hospital and as the MGH clinic senior.
During the dedicated PGY 2 REI rotation, residents are closely involved with the surgical and medical management of all of the inpatients on the service, as well as having exposure to the large number of outpatients during various office sessions. Direct supervision by REI faculty and fellows provides significant opportunity for the residents to learn basics of infertility diagnosis and treatment options, endocrinopathies commonly encountered in general gynecologic practice, and diagnosis and management of major congenital anomalies and their sequelae.
Surgical cases include diagnostic laparoscopy for infertility treatment, diagnostic hysteroscopies, as well as hysteroscopic resections of myomas, intrauterine septae, or adhesions from Asherman's syndrome. In addition, several attendings perform advanced laparoscopic surgery for anomalies (laparoscopic hemi-hysterectomy), endometriosis, oopheropexies and ovarian cystectomies. Abdominal surgeries, including myomectomies and hysterectomies for stage IV endometriosis, also occur as part of this rotation.
Residents have ample opportunity in the outpatient setting, working directly with attendings in the basic evaluation of endocrine disorders, as well as the basic infertility evaluation. Patients with PCOS, hypothalamic amenorrhea, premature ovarian failure, galactorrhea and hirsutism are all seen in the Reproductive Endocrinology offices. Residents gain exposure to endocrinopathies in the pediatric population by working with the attending staff during their Children's Hospital of Boston rotation. Finally, the third year resident rotating through the MGH clinic spends one half-day per week working with an REI attending in a menopause specialty practice.
The PGY 2 resident on the REI rotation is encouraged to spend up to 1 day per week with the IVF or embryology staff. Residents are encouraged to observe egg retrievals and transfers, as well as spend time in the embryology lab learning the specifics of IVF, ICSI, assisted hatching, and blastomere biopsy for Preimplantation Genetic Diagnosis and morphologic features guiding embryo transfer.
REI topics including pediatric and adolescent gynecology as outlined by CREOG are also discussed approximately once/month during protected Wednesday didactic time, with topics covered in a one-year, rotational basis. During the REI rotation, residents attend IVF cycle review conference every week, a multi-disciplinary meeting attended by CRM/REI faculty, embryologists and nurses during which IVF cycles are reviewed and management plans are discussed. Residents also attend the Tuesday afternoon REI conference/journal club. The PGY 2 is responsible for giving one journal club at this conference during the rotation. Once per month, there is a CRM/REI ethics meeting to discuss challenging cases and ethical dilemmas in the treatment of the infertile patient. This conference is attended by CRM/REI faculty, the director of IRB, CRM nurses, embryologist, and social workers. Residents also attend Tuesday lunchtime GYN conference (11500 conference). The REI PGY 2 resident is responsible for giving two evidence-based case presentations during the block
Simulation learning activities
A comprehensive obstetrics and gynecology simulation curriculum was introduced in 2007 that provides simulation based activities for each year of training. Simulation starts during intern orientation with “Intern Boot Camp” in which interns are exposed to simulated vaginal delivery, cesarean section and obtain hand-on experience with abdominal wall closure, knot-tying, suturing and episiotomy repair. Surgical simulation exercises occur monthly during protected didactic time at BWH’s STRATUS Patient Simulation Center and include laparoscopy skills lab, suturing, knot tying, and hysteroscopy skills. The STRATUS Center features two full-scale computer controlled patient simulation systems, a 17-station interactive computer simulation lab, and an advanced skills laboratory. Our laparoscopy surgical simulation curriculum is based on the Fundamentals of Laparoscopic Surgery (FLS) Program and will require the residents to be credentialed in the basic laparoscopic skills prior to graduation. Residents have access to the “Laparoscopy Arcade” 24 hours a day, 7 days per week which has state-of-the-art laparoscopic simulators to practice basic skills, procedures and ob/gyn surgeries. In addition, residents have access to surgical simulation facilities at MGH and during their PGY 3 rotation at NWH that has a laparoscopy and hysteroscopy simulation lab as well as a one-day pig surgical simulation activity.
Obstetric simulation, team training and crisis management was introduced in 2006 and begins in the PGY 2 year with a full day of ob simulation activities and refresher courses in the PGY 3 and 4 year. Other ob/gyn simulation activities include surgical teaching, management of postpartum hemorrhage, operative vaginal deliveries, neonatal resuscitation, circumcision and vaginal breech delivery.
Residents are exposed to both gynecologic and obstetrical pathology during case conferences and grand rounds at both parent institutions occurring during protected didactics time. Additionally, the Multidisciplinary Cancer Conference occurs weekly during Wednesday protected time to provide for interactive, case-based pathology reviews. Residents participate in Tumor Board conferences at each institution during the oncology rotations.
During the PGY 2 rotation at North Shore Medical Center ( Salem Hospital ), residents attend a weekly one-on-one tutorial with an attending pathologist to further understand the embryological, as well as anatomical and histological aspects of the female genital system as a basis for understanding the biology of disease. This course provides a general overview of the developmental, non-neoplastic and neoplastic disease processes involving the female genital system, including disorders involving the vulva, vagina, cervix, uterus, fallopian tubes, ovaries and placenta in six one-hour sessions.
The PGY 4 resident on the Harvard Vanguard Gynecology rotation attends an ambulatory session every other week in the BWH Breast Health Center alongside a nurse practitioner, with learning emphasis on history taking, detailed breast examination, screening recommendations, risk assessment including BRCA testing, evaluation and management of breast masses and common breast abnormalities and complaints. This rotation complements the continued evaluation of breast disease, which occurs during the routine care of patients in the resident continuity practices and supervised by on-site OBGYN faculty. Patients with suspicious lesions or abnormal mammographic findings are followed in conjunction with the general surgeons in the Breast Health Center , who are available for consultation. Patients are seen in follow-up after surgical procedures and treatment. Lectures during protected Wednesday didactics time cover topics related to benign and malignant conditions of the breast.
Urinary incontinence and pelvic floor dysfunction
Exposure to this subspecialty field occurs throughout the four-year training program:
PGY 1&2: Rotations in BWH and MGH Gynecology services provides introduction to procedures performed for urinary incontinence. The PGY 2 North Shore Medical Center ( Salem Hospital ) rotation exposes these residents to vaginal and urogynecologic procedures in a community hospital under the supervision of staff faculty and urologists.
PGY3: The MGH Gyn and NWH rotations provide for dedicated surgical and postoperative management experience in urogynecology under the direct supervision of faculty Urogynecologists, with residents becoming proficient at cystourethroscopy and surgical management of pelvic floor dysfunction and urinary and fecal incontinence.
PGY4: During the BWH Private Gyn, BWH Harvard Vanguard Gyn, and MGH Gyn rotations, residents obtain substantial surgical experience in vaginal and pelvic reconstructive surgeries. Under faculty supervision, these residents assume surgical and postoperative inpatient responsibility for these patients.
Ambulatory exposure to incontinence occurs during the resident continuity clinic practices at both institutions, where residents evaluate patients for incontinence and pelvic floor dysfunction under the supervision of an on-site OBGYN faculty member. A dedicated ambulatory clinic for the evaluation of pelvic floor dysfunction and incontinence occurs at BWH every other week during the PGY 4 Harvard Vanguard rotation with one-on-one supervision with a faculty Urogynecologist. During this time, residents act as consultant for the referring provider from the resident practices, participating in complex multi-channel urodynamic evaluations, and providing recommendation to the referring team.
Lectures in core urogynecology topics occur approximately every six weeks during protected didactic time that emphasize the various diagnostic and therapeutic modalities for patients with urogynecologic disorders. Additionally, a workshop in pelvic floor and perineal anatomy using cadaveric prosections at the Harvard Medical School Anatomy lab was created to enhance learning in this domain. This occurs 1-2 times annually during protected didactic time and is supervised by Urogynecology faculty, HMS anatomy faculty, and an HMS professional educator.
Formal obstetrical ultrasound training occurs in the first year, where PGY1 have the opportunity to participate in OB ultrasound at MGH under the supervision of attending OB faculty one full day per week. Residents learn the components of basic structural surveys, fetal biometry, biophysical profiles and placental abnormalities in a one-on-one hands-on setting.
Interactive hands-on obstetrical ultrasound training also occurs weekly during BWH protected didactics time. Under the supervision of a perinatologist who works in the AIUM-certified BWH antepartum facility, 3 residents from the OB and Fuller (MFM) rotations learn biophysical profiles, fetal biometry, placental abnormalities and basic structural surveys, as well as the basic physics of ultrasound equipment including probe choice, depth of presentation, gain, M-mode and resolution. This provides for ongoing, small-group formal instruction in obstetrical ultrasound throughout training; in addition, residents obtain continuing practice during L&D rotations under the supervision of senior residents and attending faculty.
The residents rotating on the Fuller (MFM) service perform appropriate amniocenteses and ultrasounds on the patients on their service. At BWH and MGH, Board certified Maternal-Fetal Medicine specialists perform all obstetrical ultrasounds in an AIUM certified antenatal diagnostic unit. In the PGY 4 year, residents rotate in the MGH unit, fine-tuning their skills and participating in the patient counseling. The PGY 2 resident on the Salem Hospital rotation spends time in MFM office hours, providing further exposure to ultrasound and genetics counseling.
Residents perform vaginal probe ultrasound formally during the MGH (PGY 2), NWH (PGY 3) and MGH Ultrasound (PGY 4) rotations, under the supervision of board certified Reproductive Endocrinologists, as well as during Gyn and OB ambulatory clinics under the supervision of the clinic-assigned faculty.
Ultrasound principles are incorporated in case conferences, as well as during protected didactic time. In 2006, a new "summer ultrasound series" was undertaken during Wednesday didactics, with MFM and radiology faculty. This series is repeated each summer to enhance resident exposure to these topics and training early in the academic year, and to supplement the hands-on training that is ongoing.
Family Planning and Abortion
Residents participate in the full range of family planning services, including induced and surgical abortion, treatment of abnormal pregnancies, pregnancy failure, sterilization and contraception. Residents have significant exposure to FP concerns in their continuity clinics, where they perform diaphragm fittings, intrauterine device placements, and initiation of hormonal methods of contraception and counseling for surgical sterilization. To the extent possible, IUD insertions are performed by the continuity provider of a given patient.
Each summer during protected didactic time, an IUD workshop reviews the principles and mechanism of action of the IUD, followed by insertion and removal workshop on plastic models of both Paragard and Mirena IUD's. Training sessions on Implanon use/insertion have also been arranged during the didactic times at both BWH and MGH. Lectures on abortion techniques and complications, as well as contraception, occur on a rotational basis throughout the Wednesday protected didactics time.
Pregnancy termination services are offered at the BWH Family Planning Center and Women's Health Services for pregnant women in both the first and second trimesters up to 23 6/7 weeks. Residents with moral or ethical reasons may opt out of performing elective abortion, however, must learn the management of complications from abortion, and do so through conferences/didactics, and consultation on patients presenting to the ED or ambulatory clinics. During intern orientation and prior to the FP rotation, an interactive discussion with one of the FP providers allows residents to discuss these issues and encourages residents who may opt out entirely to participate in any number of limited ways, such as observing or providing counseling.
Concentrated exposure to FP and abortion occurs on the PGY 2 BWH Gynecology/Family Planning rotation, as well as on the BWH OB PGY 1 and 2 rotations. Additional exposure occurs on the MGH Gyn and OB daytime rotations. Residents at all levels perform instrumental techniques for first and second trimester pregnancies, as well as medical techniques for early first trimester termination, and intra-amniotic injection and labor induction for second-trimester terminations, and surgical sterilizations. They learn the principles of intravenous conscious sedation, as well as counseling techniques for grief and loss, pregnancy prevention, contraception and prevention of sexually transmitted diseases.
Surgical Intensive Care Unit
The SICU rotation is a 5-6 week block on the Brigham and Women's Hospital Surgical/Burn/Trauma/Thoracic ICU (SBTT ICU). The PGY 1 is part of the critical care team working under direct supervision of the surgical senior residents, anesthesia residents, Surgical Intensive Care Unit fellows and attendings. The SBTT ICU cares for all surgical patients requiring pre- or postoperative critical care as well as for trauma and burn patients. Residents gain knowledge in critical care medicine and management of critically ill patients including management of acute respiratory failure, hemorrhagic/septic/cardiogenic shock, nosocomial infections, and acute renal failure. Residents also gain experience with techniques of invasive monitoring (central line placement, intubation and arterial lines), learn principles of cardiopulmonary pathophysiology, mechanical ventilation and ventilator management, trauma and burn patient management, nutritional supplementation and end-of-life decisions in the critically ill patient.
The purpose of this block is to provide dedicated time in the PGY 3 year, where residents are protected from clinical responsibilities in order to facilitate research. Residents are encouraged to utilize this time in whatever manner they choose, with funding available to support study/service rotations for underserved populations in the United States and abroad.
Primary and preventive care
Education in primary and preventive care is accomplished through a combination of clinical rotations, ambulatory clinics and lectures occurring during protected didactic time.
Medicine at BWH - Inpatient rotation : Residents spend 5-6 weeks rotating on the BWH inpatient medicine service. During this rotation, the ObGyn resident functions in the same capacity as a medicine intern, and is supervised by senior residents and faculty from the Department of Medicine. This rotation provides exposure to a broad variety of patients and medical conditions in an acute care hospital setting, as well as an opportunity to better understand the coordination of care between the inpatient and outpatient setting. All primary care providers are contacted while their patients are in the hospital and the intern is responsible for ensuring follow up of care for chronic medical conditions through establishment of visiting nurses, rehabilitation placement and medication management.
MGH Clinic Gynecology rotation : The PGY3 MGH Clinic Gynecology rotation provides residents with exposure to running an ambulatory practice. The resident staffs 10 ambulatory sessions (half-days) at MGH. Six sessions per week are general gynecology, one session/week is their gynecology continuity clinic, two sessions/week are spent in colposcopy clinic, and one session/week in menopause clinic. In addition, two sessions per month are REI clinic. In general gynecology clinic, the PGY 3 sees preoperative patients, emergency department follow-ups, urgent care and problem based visits, as well as routine gynecologic exams, health maintenance, follow-up for abnormal PAP smears, pelvic pain, sexually transmitted diseases, endometriosis, contraceptive counseling, menstrual disorders, sexual dysfunction, early pregnancy loss. The PGY 3 is also responsible for managing the ectopic list in consultation with the gynecology attending. They coordinate the comprehensive care for patients including medical referrals and consultation with community resources including social services, psychiatric and nutritional services. They actively communicate with clinic leadership to facilitate patient care and smooth operation of ambulatory services, as well as triage appropriately from the ambulatory clinic to the emergency department and/or inpatient services.
Continuity Clinics : Maintenance of the weekly ambulatory gynecology continuity practices provides significant exposure to adolescent, adult and geriatric primary care. Each resident maintains a gynecologic continuity practice during the second through fourth years of residency training. Two of the three classes hold their continuity clinic office hours at BWH and one at MGH. Patients are assigned to continuity providers as they enter the practice. They are allowed to request providers based on previous contact, gender, or language preferences. Once assigned to a resident's practice, every effort is made to schedule all subsequent visits with the same provider. Each resident holds a continuity session for one-half day per week. The day and time of the session change as the resident changes rotations.
The resident caseloads range from annual health maintenance examinations for healthy women, contraception or hormone replacement counseling and maintenance, to complicated problem-based visits. In addition, outpatient procedures including vulvar and endometrial biopsies and IUD placements are frequently performed. Over the three years, residents establish long-term management strategies for a variety of issues such as pelvic pain, endocrinopathies, perimenopause and dysfunctional uterine bleeding. By introducing office hysteroscopy, urodynamics, and colposcopy to the practice, the residents have been able to experience the full spectrum of ambulatory Gynecology.
The residents conduct comprehensive health assessments for age-related issues such as safety screening, cancer prevention screening, adult immunizations, and screening for cardiovascular risk factors. The residents are often the only physicians many of their patients see, and as such, they manage a significant number of non-gynecologic issues including nutrition and smoking cessation counseling, exercise, and interpersonal and family relationships. They gain an understanding of, and learn to work within, the healthcare system with attention to the socioeconomic and cultural backgrounds that influence patients, in order to deliver culturally sensitive and effective care. All resident clinic sessions are supervised by on-site OBGYN Generalist faculty well versed in the management of a primary care OBGYN practice.
Menopause Clinic : In addition to patients the residents see in their continuity practices, residents are exposed to patients with particularly complex geriatric and menopausal issues during this weekly clinic during the MGH PGY3 clinic rotation. These patients are seen in conjunction with the menopause specialist at MGH and are offered comprehensive management of osteoporosis, challenges of surgical menopause, and the effects of aging on sexual function.
High-risk Obstetrics (SPOB) Clinic : Residents are primarily involved in the management of complicated medical problems in the pregnant population including diabetes, hypertension, asthma, coagulopathies, and cardiac abnormalities. These ambulatory sessions are supervised by MFM faculty in conjunction with the appropriate medical specialists.
Resident as Teacher Program
Fundamental to being an outstanding resident and clinician is the ability to teach patients, junior residents and students. The Resident as Teacher program is an integral part of learning to be an effective teacher. Our program is an integrated approach led by BWH and MGH student leadership and supported by the residency program leadership. Residents are a critical part of the medical student clerkship. They serve as teachers and role models for all third and fourth year students that rotate through both BWH and MGH. All residents have a clinical appointment through Harvard Medical School and have access to educational resources through the school. The basic curriculum consists of formal lectures on medical education, focused observation of teaching and review of student evaluations and informal teaching and feedback sessions.
Mission of the ObGyn Student Clerkship: