UCSF Residency Program in Obstetrics, Gynecology and Reproductive Sciences Educational Objectives

R1 Primary & Preventive Ambulatory Health Care

Training in primary and preventive ambulatory health care comprises several rotations and continuity clinic experiences across the 4-year residency, including 3 months during the PGY-1 year. Residents spend one month studying inpatient medicine, as well as 120 half-day sessions of continuity clinic. The UC Ambulatory Care rotation comprises 5-6 weeks of outpatient clinical experiences and spans across a wide area of primary care and preventative medicine as well as speciality clinics. The DPH Ambulatory Rotation consists of 5-6 weeks focusing on marginalized women in low resource settings. Ambulatory care is also a principal focus during the PGY-1 SFGH OB-Clinic rotation, SFGH Gynecology-Clinic rotation, as well. Working through these rotations will help you become comfortable interviewing patients, providing patient-centered care and understanding basic ambulatory medicine and gynecology. In addition, understanding the nuances of the care of women in an underserved setting is a primary goal.

During the UC Ambulatory Care rotation, you will rotate through the UC high risk Ob resident clinic and prenatal diabetes clinic (DAPP) and endocrine clinic. Rotating through the High Risk Ob clinic at UCSF provides exposure to pregnant women with complex medical problems. You will participate in a ½ day of breast clinic with Dr. Goldman, which is a component of your R1 longitudinal experience in breast care and health (in combination with benign breast clinic at SFGH during the DPH ambulatory rotation.) Finally, you will spend time participating in our new genetics curriculum which will be a combination of prenatal genetics with Dr. Mary Norton.

In the DPH ambulatory rotation, you will spend ½ day in the city jail focusing on issues particular to incarcerated women and also work in the City Clinic, a public health clinic that focuses primarily on STIs in both men and women. New Generations is a city teen clinic established by our department.

Residency training reflects a progression of knowledge and skill acquisition through clinical work. The OB/GYN ACGME Milestones map this process across 28 milestone competencies divided into subcompetencies that should be achieved over the 4 years of residency. The UCSF OB/GYN residency program has assigned benchmarks of where residents are expected to be in each milestone at 6 months intervals. Thus, understanding the progression of skill across a milestone gives a resident an awareness of where his or her performance should be at different time intervals in residency.

Below are the milestones that pertain to the R1 Ambulatory care rotations. Milestones on communication, systems-based practice, professionalism and problem based learning and improvement are included in each rotation to emphasize their importance in the development of a competent physician. The residency program recognizes that a resident’s particular schedule will influence when subcompetencies are achieved, and the benchmarks reflect the expected level of skill at 6 months and the end of the year.

In addition to the milestones, the CREOG GYN Objectives are listed below for your reference of what CREOG identifies as key learning topics. Educational objectives are organized according to ACGME/RRC competencies.

Additionally, you have two required modules to complete during your DPH Ambulatory Rotation one during your UC Ambulatory Rotation. We have identified several key ACOG practice bulletins that pertain to intern level objectives for ambulatory care. Try to complete these readings at least once over your first year.

Required Online Modules

DPH Ambulatory Rotation Caring for women in low resource settings, empowering women and fostering leaders. This curriculum includes a set of modules designed specifically to highlight disparities and health inequities encountered by marginalized women. Clinical Care in Low Resource Settings ARHP module on Adolescent Health (link to this module will be sent to you)

UC Ambulatory Rotation ARHP module on 1st trimester bleeding (link to this module will be sent to you)

Recommended Introductory Reading ACOG Practice Bulletins 148 Thyroid Disease in Pregnancy (April 2015) 141 Management of Menopausal Symptoms (January 2014) 140 Management of Abnormal Cervical Cancer Screening Test Results and Cervical Cancer Precursors (December 2013) 137 Gestational Diabetes Mellitus (August 2013) 131 Screening for Cervical Cancer (November 2012) 129 Osteoporosis (September 2012) (Replaces Practice Bulletin Number 50, January 2004, Reaffirmed 2014) 122 Breast Cancer Screening (August 2011, Reaffirmed 2014) 121 Long-Acting Reversible Contraception: Implants and Intrauterine Devices (July 2011, Reaffirmed 2013) 119 Female Sexual Dysfunction (April 2011, Reaffirmed 2015) 117 Gynecologic Care for Women With Human Immunodeficiency Virus (December 2010, Reaffirmed 2015) 112 Emergency Contraception (May 2010, Reaffirmed 2014) 126 Management of Gynecologic Issues in Women With Breast Cancer (March 2012, Reaffirmed 2014) 57 Gynecologic Herpes Simplex Virus Infections (November 2004, Reaffirmed 2014) 72 Vaginitis (May 2006, Reaffirmed 2015) 90 Asthma in Pregnancy (February 2008, Reaffirmed 2014) 95 Anemia in Pregnancy (July 2008, Reaffirmed 2013)

ACGME Milestones (on Google drive and flash drive) There are no specific milestones assigned to ambulatory rotations.

CREOG Educational Objectives, A Core Curriculum in Obstetrics and Gynecology, Tenth Edition Unit 4 (on your flash drive)

Patient Care  Demonstrate caring and respectful behaviors when interacting with patients and their families.  Gather essential information about patients by performing a complete and accurate medical history and physical examination.  Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.  Develop, negotiate, and implement effective patient management plans.  Counsel and educate patients and their families.  Use information technology to support patient care decisions and patient education.  Perform competently all medical and invasive procedures considered essential for generalist practice in the discipline of obstetrics and gynecology.  Understand the differences between screening and diagnostic tests essential for generalist practice in obstetrics and gynecology.  Provide health care services aimed at preventing health problems or maintaining health.  Work with health care professionals, including those from other disciplines, to provide patient-focused care.  Perform competently a medical history including a history of genetic diseases and physical examination and provide appropriate periodic screening, evaluation and preventive services at an ambulatory or inpatient visit.  Demonstrate a positive attitude toward the provision of services to women of all ages and an understanding of the impact of socioeconomic status, lifestyle, and social support on patient well-being.

Counsel patients regarding: (CPSP, DAPP, breast clinic)  General health risk behavior  Healthy diet and exercise  Substance abuse  Weight management  Contraception  Prevention of sexually transmitted infections  Prevention of accidents in home and workplace  Maintenance of dental health  Psychosocial issues  Cancer screening, specifically breast, cervical, and colon

Understand and perform the following procedures (SACC clinic/Medicine rotation)  Arterial blood gas measurement  Complete physical examination  Electrocardiogram  External auditory canal and tympanic membrane examination  Fecal occult blood testing  Basic fundoscopy of the eye  Insertion/removal of intrauterine device  Insertion and removal of implantable steroid contraception  FEV-1 determination  Fitting of diaphragm and cervical cap  Pulse oximetry  Skin biopsy  Visual field testing using standard eye chart

PRECONCEPTIONAL CARE (CPSP)  Perform a thorough history assessing historical and ongoing risks that may affect a future pregnancy.  Counsel a patient regarding appropriate lifestyle modifications conducive to favorable pregnancy outcome.  Counsel a patient regarding appropriate preconception evaluation.

PRENATAL CARE (CPSP/DAPP)  Perform a comprehensive history and physical examination.  Order and interpret routine laboratory tests and those based on risk factors during pregnancy.  Counsel patients regarding lifestyle modifications that improve pregnancy outcome, including activity, employment, nutrition, travel, and substance use.  Counsel patients regarding warning signs of adverse pregnancy events.  Schedule and perform appropriate antepartum follow-up visits for routine and high-risk obstetric care.  Counsel patients about appropriate immunizations during pregnancy  Counsel patients about the benefits of breastfeeding.

DIABETES MELLITUS (CPSP/DAPP)  Interpret screening tests for gestational diabetes.  Manage gestational and pregestational diabetes in the antepartum, intrapartum and postpartum period.

DISEASES OF THE URINARY SYSTEM (CPSP/DAPP)  Evaluate signs and symptoms of urinary tract pathology in pregnant patients.  Interpret the results of common diagnostic tests for renal disease in pregnancy.

INFECTIOUS DISEASES (CPSP/DAPP)  Perform a focused history and physical examination in pregnant patients who have a known or suspected infectious disease.  Choose and perform laboratory tests to confirm the diagnosis of infection.

PSYCHIATRIC DISORDERS (CPSP/DAPP)  Perform a mental status examination.  Perform screening for antepartum and postpartum depression.

SUBSTANCE USE IN PREGNANCY (CPSP/DAPP)  Perform a thorough history and physical examination in patients suspected of substance use in pregnancy.

HYPERTENSION IN PREGNANCY (CPSP/DAPP)  Perform a physical examination pertinent to patients with hypertension.  Manage hypertension in the antepartum, intrapartum and postpartum period.

INTRAUTERINE GROWTH RESTRICTION (CPSP/DAPP)  Assess uterine size by physical examination and identify size/date discrepancies.

VAGINAL BIRTH AFTER CESAREAN DELIVERY (CPSP/DAPP)  Document an accurate history of a patient’s previous operative delivery  Counsel patients on risk and benefits of trial of labor after cesarean delivery.

THE PUERPERIUM (CPSP/DAPP)  Perform a focused physical examination in postpartum patients.  Describe methods of reversible contraception.  Counsel patients about permanent sterilization.  Counsel patients regarding future pregnancies.  Counsel patients about the advantages of and answer questions related to breastfeeding.

GENOMICS (GENETIC COUNSELING)  Elicit a history for inherited disorders, ethnic-- or race-specific risks, and teratogen exposure.  Counsel patients about the manifestations of common genetic disorders.  Counsel patients about the risks and benefits of various methods of invasive fetal testing, such as: o Chorionic villus sampling o Amniocentesis o Cordocentesis  Counsel a patient about the genetic implications of advancing maternal and paternal age.  Counsel patients on the advantages and disadvantages of umbilical cord blood banking.  Counsel patients on the advantages and disadvantages of all non-invasive genetic fetal testing.

BREAST CARE: (Breast clinic)  Practice breast exams and perfect technique for doing breast exam  How to work-up and follow-up breast mass (role of FNA, of ultrasound, of mammo, how often to follow-up etc)  How to treat breast pain  Non-peripartum etiologies of breast infections

Medical Knowledge  Demonstrate an investigatory and analytic thinking approach to clinical situations.  Demonstrate sound understanding of the basic science background of women’s health and apply this knowledge to clinical problem solving, clinical decision making, and critical thinking  Demonstrate a sound understanding of the basic science background of reproductive medicine and apply this knowledge to the ambulatory problems in women’s health.  Demonstrate the ability to use the scientific method and the deductive reasoning process.  Describe the elements of periodic health assessments according to patients’ age and risk factor status.  Describe the appropriate indications for selective immunizations such as rubella, measles, varicella, hepatitis A and B, influenza, pneumococcal infection, tetanus, and diphtheria.  Understand the indications, contraindications and principles of the following procedures: (SACC) o Auditory acuity testing o Bone densitometry studies o Gastrointestinal endoscopy o Visual field deficit testing o Scraping of skin lesions for microscopy o Pedigree analysis o Gene testing

GENERAL MEDICINE GENETICS (SACC/Med rotation) Describe the opportunities to apply genomics or genetically based technology to primary and preventive ambulatory heath care  Describe the general indications for genetically based diagnostics.  Describe the sensitivity and specificity of various genetic tests and the implication of these parameters in clinical practice.  Describe the role of genetics in drug metabolism and individual variation in drug efficacy.  Discuss the factors involved in the development of and recommendations for genetic testing.  List the types of genetic abnormalities that may result in clinically significant abnormalities.  Describe stem cells and potential uses of stem cell technology.

GERIATRIC GYNECOLOGIC CARE (Laguna Honda)  Familiarity with common gynecological problems in nursing home residents, including pelvic organ prolapse, post- menopausal vaginal bleeding, vulvar lesions, and other disorders.  Appreciation for the importance of quality of life in diagnostic and therapeutic decision-making for elderly nursing home residents.

BREAST CANCER GENETICS COUNSELING: (Genetics/Breast clinic)  Recognize women who are at high risk for breast cancer and recommend appropriate surveillance  Understand BRC1 & 2  Recognize and care for the particular gynecologic issues specific to breast cancer patient survivors including chemotherapy induced menopause, contraception, fertility and pregnancy after breast cancer, sexual functioning and the gynecologic side effects of Tamoxifen and Aromatase Inhibitors.

GENETICS: (Genetics)  Demonstrate caring and respectful behaviors when dealing with the genetic information of patients and their families.  Residents should identify areas in clinical genetics where there is significant potential for paternalism, discrimination, or injustice.  Discuss the role other (specialized) health care professionals play in the development of genetic information and testing that is used in the clinical setting.  Describe the general indications for genetically based diagnostics.  Perform or interpret genetic risk assessment through: o Pedigree analysis o Gene testing . Antenatal, Adult  Discuss the factors involved in the development of and recommendations for genetic testing. o Frequency of the condition in the population. o Nature and range of severity of the condition. o Treatment, intervention, and/or prevention. o Reproductive options to avoid or reduce risk. o Test availability including prenatal screening and/or diagnostic testing. o Sensitivity, specificity, and positive predictive value of the test. o Genotype-phenotype correlation. o Frequency of gene mutation in general population or selective sub-groups based on ethnicity/race. o Cost and cost-effectiveness of screening. o Usefulness of test information to individual, to family and to society. o Availability of public and professional educational material/programs. o Availability of adequate genetic counseling services for follow-up. o Potential for uncertainty of tests results o Potential for misuse of information and genetic discrimination.  List the types of genetic abnormalities that may result in clinically significant abnormalities. o Deletions o Additions o Trinucleotide repeats o Microsatellite instability o Mitochondrial DNA abnormalities  Describe stem cells and potential uses of stem cell technology.  Basic mechanism of genetic inheritance: o Describe the basic structure and replication of DNA. o Describe the processes of mitosis and meiosis. o Describe common terms associated with genetic expression. . Exon . Intron . Codon . Transcription . Translation  Describe the clinical significance of karyotype abnormalities, such as: o Trisomy (13, 18 and 21) o Polyploidy o Monosomy o Sex chromosome abnormalities o Deletions o Inversions o Translocations o Mosaicism o Chimeras  Describe the normal process of gametogenesis.  Describe the normal process of fertilization and the combination of genetic information.  Clinical implications of heritable disease: o Describe the clinical significance of heritable diseases, such as cystic fibrosis, Tay-Sachs disease, and hemophilia. o Counsel patients about the techniques for and implications of testing for heritable diseases. o Discuss treatment and surveillance options for patients or newborns with genetically derived disease.  Describe the concepts of penetrance and variable expression and their impact on prognosis for a given genetic disorder.  Distinguish between various forms of genetic inheritance: o Autosomal dominant o Autosomal recessive o X-linked o Mitochondrial o Genomic imprinting  Describe the indications for, and limitations of, noninvasive diagnostic tests for fetal aneuploidy and structural malformations (e.g., ultrasonography, serum analytes).  List ultrasonography findings that are often associated with genetic disorders for: o Duodenal atresia o Omphalocele o Nuchal translucency/nuchal skin folds o Echogenic bowel o Heart defects o Diaphragmatic hernia o Ventriculomegaly  Describe the indications and uses for umbilical cord stem cells.  Describe the inheritance of hemoglobinopathies.

PHARMACOLOGY (CPSP/DAPP)  Describe the role of nutritional supplementation in pregnancy (e.g., iron, folic acid).

PHYSIOLOGY IN PREGNANCY (CPSP/DAPP)  Describe the major physiologic changes in each organ system during pregnancy.

MICROBIOLOGY AND IMMUNOLOGY (CPSP/DAPP)  Describe the principal features of the host immunologic response.  Describe how the maternal immune response is altered by pregnancy.  Describe the basic features and timing of development of the fetal immunologic response.  Describe the association between genital tract infection and adverse perinatal outcomes, such as: o Preterm labor o Preterm premature rupture of membranes o Neonatal infection o Maternal infection

DIABETES MELLITUS (DAPP) –  Discuss rationale for diabetes screening during pregnancyClassify diabetes mellitus in pregnancy.  Discuss the screening methods for diagnosis of gestational diabetes  Describe monitoring of blood sugars while pregnant including target goals  List treatment options and goals for glucose management with GDM  Discuss antepartum, intrapartum, and postpartum management of women with GDM

DISEASES OF THE URINARY SYSTEM (CPSP/DAPP)  Describe the indications for the common diagnostic tests used to evaluate renal disease in pregnancy.

SUBSTANCE ABUSE IN PREGNANCY (CPSP/DAPP)  Describe behavior patterns suggestive of substance abuse.

PRETERM LABOR (CPSP/DAPP)  Describe the multifactorial etiology of preterm labor.

BLEEDING IN LATE PREGNANCY (CPSP/DAPP)  Describe the etiology of bleeding in late pregnancy.  Describe the factors that predispose to placenta previa and abruptio placentae.

HYPERTENSION IN PREGNANCY (CPSP/DAPP)  Describe the possible causes of hypertension in pregnancy

MULTIPLE GESTATION (CPSP/DAPP)  Describe the physical findings suggestive of multiple gestation.  Describe the factors that predispose to multiple gestation.

Interpersonal and Communication Skills  Sustain therapeutic and ethically sound relationships with patients, patients’ families, and colleagues.  Provide effective and professional consultation to other physicians and health care professionals.  Elicit and provide information using effective listening, non-verbal, explanatory, questioning, and writing skills.  Communicate effectively with patients in language that is appropriate to their age and educational, cultural, and socioeconomic background.  Maintain comprehensive, timely, and legible medical records.  Communicate effectively with others as a member or leader of a health care team or other professional group.  Use effective verbal and nonverbal communication skills to achieve the 3 functions of the patient interview: elicit information, establish rapport, and educate the patient.  Communicate effectively with other healthcare professionals.  Work effectively as a member of a patient care team.  Improve communication skills with patients who are in very different and challenging life circumstances

Professionalism  Demonstrate respect, compassion, integrity, and responsiveness to the needs of patients and society that supersedes self-interest.  Demonstrate accountability to patients, society, and the profession.  Demonstrate uncompromised honesty.  Develop and maintain habits of punctuality and effi ciency.  Maintain a good work ethic (i.e., positive attitude, high level of initiative).  Demonstrate a commitment to excellence and ongoing professional development.  Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care.  Describe basic ethical concepts such as: autonomy, benefi cence, justice, and nonmalfeasance.  Describe the process of informed healthcare decision making, including the elements that must exist and the specifi c components of an informed-consent discussion.  The resident must demonstrate an understanding of the use of advanced directives, living wills, and durable power of attorney for health care and strategies for the resolution of ethical conflicts.  Discuss surrogate decision making for incapacitated patients, including who can and should act as a proxy decision maker and what standards they should use to make healthcare choices for another.  The resident should be able to examine their personal values and preferences for end-of-life treatment and the values of diverse patients.  Differentiate between institution-based DNR orders, community-based DNR orders (also called out-of-hospital or portable DNR orders), and advance directives. Describe the legal, ethical, and emotional issues surrounding withholding and withdrawing medical  therapies.  Discuss when it is appropriate to use all available technology to sustain a life and when it is appropriate to limit treatment.  Discuss the principle of justice and the use of limited medical resources.  Discuss the differences in ethical decision making if the patient is an adult or a child.  Discuss ethical implications of commonly used ob/gyn technologies.  Analyze an ethical conflict and develop a course of action that is ethically defensible and medically reasonable.  Maintain confidentiality of patient information.  Describe current standards for the protection of health-related patient information.  List potential sources of loss of privacy in the health care system.  Demonstrate sensitivity and responsiveness to the culture, age, sexual preferences, behaviors, socioeconomic status, beliefs, and disabilities of patients and professional colleagues.  Describe the procedure for, and the significance of, maintaining medical licensure, board certification, credentialing, hospital staff privileges, and liability insurance.

SLEEP/STRESS MANAGEMENT  Discuss important issues regarding stress management, substance abuse, and sleep deprivation.  List preventive stress-reduction activities and describe their value.  Identify the warning signs of excessive stress or substance abuse within one’s self and in others.  Intervene promptly when evidence of excessive stress or substance abuse is exhibited by oneself, family members, or professional colleagues.  Understand the signs of sleep deprivation and intervene promptly when they are exhibited by oneself or professional colleagues.

Practice-Based Learning and Improvement  Identify areas for personal and practice improvement and implement strategies to enhance knowledge, skills, attitudes, and processes of care, as well as making a commitment to life-long learning.  Analyze and evaluate personal practice experience and implement strategies to continually improve the quality of patient care provided using a systematic methodology.  Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.  Obtain and use information about their population of patients and the larger population from which their patients are drawn.  Demonstrate receptiveness to instruction and feedback.  Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.  Use information technology to manage information, access online medical information, and support their education.  Facilitate the learning of students and other health care professionals  Identify areas for personal and practice improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care.  Obtain and use information about own population of patients and larger population from which own patients are drawn.  Demonstrate receptiveness to instruction and feedback.  Use information technology to manage information, access online medical information, and support self- education.  Facilitate the learning of students and other health care professionals.

Systems-Based Practice  Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society, and how these elements of the system affect their practices. Understand the processes for obtaining licensure, receiving hospital privileges and credentialing.  Describe how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources. o List common systems of health care delivery, including various practice models. o Describe common methods of health care financing. o Discuss common business issues essential to running a medical practice. o Apply current procedural and diagnostic codes to reimbursement requests.  Practice cost-effective health care and resource allocation that does not compromise quality of care.  Advocate for quality patient care and assist patients in dealing with system complexities. o Recognize that social, economic and political factors are powerful determinants of health and incorporate these factors into how they approach patient care. o Demonstrate knowledge of disparities in health and health care in a variety of populations. o Recognize the role of the women’s health provider to advocate for patients, particularly poor and vulnerable women, and to help develop methods of care that are effective, efficient, and accessible to all women. o Be aware of ACOG and community resources and advocacy on behalf of underserved and vulnerable populations such as poor women and teenagers. o Learn to communicate effectively about women’s health concerns to family and community groups. o Recognize the role of the physician in legislation as it relates to women’s health policy.  Acknowledge that patient safety is always the first concern of the physician. o Demonstrate the ability to discuss errors in management with peers and patients to improve patient safety. o Develop and maintain a willingness to learn from errors and use errors to improve the system or process of care. o Participate in hospital/departmental QI activities and Patient Safety initiatives o Demonstrate understanding of institutional disclosure processes and participate in disclosure and discussions of adverse events with patients.

QUALITY IMPROVEMENT  Partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance. Describe the process of quality assessment and improvement including the role of clinical indicators, criteria sets, and utilization review.  Participate in organized peer review activities and use outcomes of such reviews to improve personal and system-wide practice patterns.  Demonstrate an ability to cooperate with other medical personnel to correct system problems and improve patient care.

RISK MANAGEMENT AND PROFESSIONAL LIABILITY  List the major types and providers of insurance.  Describe the most common reasons for professional liability claims.  Describe a systematic plan for minimizing the risk of professional liability claims in clinical practice.  Describe basic medical-legal concepts regarding a professional liability claim and list the steps in processing a claim.  Demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide care of optimal value.  Describe how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.  Practice cost-effective healthcare and resource allocation that does not compromise quality of care.  Advocate for quality of patient care and assist patients in dealing with system complexities.  Acknowledge that patient safety is always the first concern of the physician  Know how to partner with healthcare managers and providers to assess, coordinate, and improve healthcare and know how these activities can affect system performance.

UCSF Residency Program in Obstetrics, Gynecology and Reproductive Sciences Educational Objectives

R1 Gynecology

R1s have a 5-6 week outpatient and inpatient gynecology rotation at SFGH. In this rotation, the experiences include ER consultations, inpatient care of postsurgical patients, problem-oriented ambulatory care visits, and maintenance gynecologic care. It is also prudent to review the gynecologic oncology goals and objectives for your year as many are applicable to the gynecology rotation. Educational objectives are organized according to ACGME/RRC competencies.

Below are the milestones that pertain to the R1 SFGH Gynecology rotation. Milestones on communication, systems-based practice, professionalism and problem based learning and improvement are included in each rotation to emphasize their importance in the development of a competent physician. The residency program recognizes that a resident’s particular schedule will influence when subcompetencies are achieved, and the benchmarks reflect the expected level of skill at 6 months and the end of the year.

In addition to the milestones, the CREOG GYN Objectives are listed below for your reference of what CREOG identifies as key learning topics.

Additionally, we have identified several key ACOG practice bulletins that pertain to intern level objectives for gynecology. Try to complete these readings at least once over your first year. You can let your chief or attending know what you are reading and suggest folding the readings into team learning goals or you can lead a team learning session based on what you read.

Recommended Reading

ACOG Practice Bulletins (on ACOG website) 136 Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction 128 Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women 121 Long-Acting Reversible Contraception: Implants and Intrauterine Devices 114 Management of Endometriosis 117 Gynecologic Care for Women with Human Immunodeficiency Virus 112 Emergency Contraception 94 Medical Management of Ectopic Pregnancy 83 Management of Adnexal Masses 72 Vaginitis 73 Use of Hormonal Contraception in Women with Coexisting Medical Conditions

Textbooks References Droegemueller: Comprehensive Gynecology TeLinde: Operative Gynecology Speroff and Darney: Clinical Guide for Contraception Glass: Office Gynecology

ACGME Milestones (on Google drive and flash drive) SFGH Clinic-Gynecology Rotation Milestones Evaluated

CREOG Educational Objectives, A Core Curriculum in Obstetrics and Gynecology, Tenth Edition Unit 4 (on your flash drive)

Patient Care

 Demonstrate caring and respectful behaviors when interacting with patients and their families.  Gather essential information about patients by performing a complete and accurate medical history and physical examination.  Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.  Develop, negotiate, and implement effective patient management plans.  Counsel and educate patients and their families.  Use information technology to support patient care decisions and patient education.  Perform competently all medical and invasive procedures considered essential for generalist practice in the discipline of obstetrics and gynecology.  Understand the differences between screening and diagnostic tests essential for generalist practice in obstetrics and gynecology.  Provide health care services aimed at preventing health problems or maintaining health.  Work with health care professionals, including those from other disciplines, to provide patient-focused care. *******************  Perform a complete and accurate medical history and physical examination of:  a patient with abnormal uterine bleeding.  a patient with a possible infection of the vulva and vagina  a patient with a possible sexually transmitted infection  a patient suspected to have PID  a patient with a possible urinary tract infection or nephrolithiasis  a patient with a possible diagnosis of early spontaneous abortion  a patient with a possible diagnosis of ectopic pregnancy

 Evaluate other epidemiologic factors to assess a woman’s risk for developing breast cancer, such as:  Patient age  Parity  Ethnicity  Lactation  Hormone replacement  Alcohol consumption

 Interpret the results of diagnostic tests, for example:  microbiologic cultures of the genital tract  complete blood count and coagulation profile  electrolytes, BUN, Cr, and liver function tests  urinalysis, urine culture  serum hCG values and patterns  chest xrays  arterial blood gases  pulse oximetry  pulmonary function tests  serologic tests for STIs

 Safely and correctly perform and interpret the results of the following diagnostic and surgical procedures:  basic cardiac life support (E2)  determination of vaginal pH  saline and potassium hydroxide microscopy  bacterial, fungal, and viral culture or ANA probe  pap smear  biopsy of ectocervix, endocervix, endometrium  cervical polypectomy  vulvar skin biopsy  dilation and curettage, including manual vacuum aspiration  abscess incision and drainage  IUD placement  Diagnostic hysteroscopy

Medical Knowledge

EMBRYOLOGY  Describe the embryology of normal mullerian tract and ovarian development

ANATOMY  Describe the anatomy of the anterior and posterior abdominal wall.  Describe the anatomy of the fallopian tube and most common location of ectopic gestation.

MICROBIOLOGY AND IMMUNOLOGY  Describe the normal bacteriologic fl ora of the lower genital tract.  Describe the microbiologic principles germane to the diagnosis and treatment of gynecologic infectious diseases.  Describe the epidemiologic principles involved in the spread of infectious diseases, including transmission and prevention of HIV (human immunodeficiency virus), in both patients and health care workers.  Describe the epidemiologic principles involved in the spread of infectious diseases in both patients and health care workers, including transmission and prevention of human immunodeficiency virus (HIV) and hepatitis.  Discuss the immunologic response to infection.

ABNORMAL/DYSFUNCTIONAL UTERINE BLEEDING  Describe the principal causes of abnormal uterine bleeding and distinguish abnormal uterine bleeding from dysfunctional uterine bleeding.

VAGINAL AND VULVAR INFECTIONS  Describe the principal infections that affect the vulva and vagina

SEXUALLY TRANSMITTED INFECTIONS  Describe the most common causes of STIs, such as gonorrhea and chlamydia; syphilis; hepatitis B, C and HIV; herpes simplex virus, human papilloma virus, chancroid

PELVIC MASSES  Describe the major causes of pelvic masses including:  Uterine fi broids  Adnexal cystic and solid masses  Tuboovarian abscess  Adnexal torsion  Ovarian cysts/benign neoplasms  Diverticulitis  Appendicitis

PELVIC INFLAMMATORY DISEASE (PID)  Describe the diagnostic criteria for PID.  List the common infections agents implicated in PID.  Summarize the potential long-term effects and counsel patients regarding risks of further complications, including:  Chronic pelvic pain  Infertility  Ectopic pregnancy

URINARY TRACT DISORDERS  Distinguish the types of urinary tract infection, including bacteruria, urethritis, cystitis, and pyelonephritis.  Describe the pathophysiology related to urinary tract infection, including the organisms commonly implicated in lower and upper urinary tract disorders, and host factors, such as urinary retention, age, and pregnancy.  Describe the pathophysiology of the common forms of nephrolithiasis, including patient risk factors for the development of nephrolithiasis.  Describe typical clinical presentations in a patient with a possible urinary tract infection or nephrolithiasis.  Describe the diagnostic methods and diagnostic criteria for the various types of urinary tract infections.  Summarize the methods used for the diagnosis of nephrolithiasis.  Describe modes of therapy for acute, chronic, and complicated urinary tract infections, including prophylaxis for recurrent infection.  Summarize therapeutic options for nephrolithiasis, and strategies to prevent recurrence.

CHRONIC PELVIC PAIN  Define chronic pelvic pain.

SPONTANEOUS ABORTION  Describe the principal causes of, or predisposing factors for, spontaneous first-trimester abortion.  Describe the usual symptoms and findings experienced by a patient with an early pregnancy loss.  Describe the differential diagnosis of early spontaneous abortion.  Describe the indications of anti-D immune globulin in patients experiencing an early spontaneous abortion

ECTOPIC PREGNANCY  Describe the major factors that predispose to ectopic pregnancy  Describe the differential diagnosis of ectopic pregnancy  Describe the indications for anti-D immune globulin in patients experiencing an ectopic pregnancy  Describe the role of vaginal ultrasound and serum Beta-HCG in the diagnosis of ectopic pregnancy

Interpersonal and Communication Skills

 Sustain therapeutic and ethically sound relationships with patients, patients’ families, and colleagues.  Provide effective and professional consultation to other physicians and health care professionals.  Elicit and provide information using effective listening, non-verbal, explanatory, questioning, and writing skills.  Communicate effectively with patients in language that is appropriate to their age and educational, cultural, and socioeconomic background.  Maintain comprehensive, timely, and legible medical records.  Communicate effectively with others as a member or leader of a health care team or other professional group.

Professionalism

 Demonstrate respect, compassion, integrity, and responsiveness to the needs of patients and society that supersedes self-interest.  Demonstrate accountability to patients, society, and the profession.  Demonstrate uncompromised honesty.  Develop and maintain habits of punctuality and effi ciency.  Maintain a good work ethic (i.e., positive attitude, high level of initiative).  Demonstrate a commitment to excellence and ongoing professional development.  Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care.  Describe basic ethical concepts such as: autonomy, benefi cence, justice, and nonmalfeasance.  Describe the process of informed healthcare decision making, including the elements that must exist and the specifi c components of an informed-consent discussion.  The resident must demonstrate an understanding of the use of advanced directives, living wills, and durable power of attorney for health care and strategies for the resolution of ethical conflicts.  Discuss surrogate decision making for incapacitated patients, including who can and should act as a proxy decision maker and what standards they should use to make healthcare choices for another.  The resident should be able to examine their personal values and preferences for end-of-life treatment and the values of diverse patients.  Differentiate between institution-based DNR orders, community-based DNR orders (also called out-of-hospital or portable DNR orders), and advance directives. Describe the legal, ethical, and emotional issues surrounding withholding and withdrawing medical  therapies.  Discuss when it is appropriate to use all available technology to sustain a life and when it is appropriate to limit treatment.  Discuss the principle of justice and the use of limited medical resources.  Discuss the differences in ethical decision making if the patient is an adult or a child.  Discuss ethical implications of commonly used ob/gyn technologies.  Analyze an ethical confl ict and develop a course of action that is ethically defensible and medically reasonable.  Discuss important issues regarding stress management, substance abuse, and sleep deprivation.  List preventive stress-reduction activities and describe their value.  Identify the warning signs of excessive stress or substance abuse within one’s self and in others.  Intervene promptly when evidence of excessive stress or substance abuse is exhibited by oneself, family members, or professional colleagues.  Understand the signs of sleep deprivation and intervene promptly when they are exhibited by oneself or professional colleagues.  Maintain confidentiality of patient information.  Describe current standards for the protection of health-related patient information.  List potential sources of loss of privacy in the health care system.  Demonstrate sensitivity and responsiveness to the culture, age, sexual preferences, behaviors, socioeconomic status, beliefs, and disabilities of patients and professional colleagues.  Describe the procedure for, and the significance of, maintaining medical licensure, board certifi cation, credentialing, hospital staff privileges, and liability insurance.

Practice-Based Learning and Improvement

 Identify areas for personal and practice improvement and implement strategies to enhance knowledge, skills, attitudes, and processes of care, as well as making a commitment to life-long learning.  Analyze and evaluate personal practice experience and implement strategies to continually improve the quality of patient care provided using a systematic methodology.  Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.  Obtain and use information about their population of patients and the larger population from which their patients are drawn.  Demonstrate receptiveness to instruction and feedback.  Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.  Use information technology to manage information, access online medical information, and support their education.  Facilitate the learning of students and other health care professionals.

Systems-Based Practice

 Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society, and how these elements of the system affect their practices. Understand the processes for obtaining licensure, receiving hospital privileges and credentialing.  Describe how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.  List common systems of health care delivery, including various practice models.  Describe common methods of health care financing.  Discuss common business issues essential to running a medical practice.  Apply current procedural and diagnostic codes to reimbursement requests.  Practice cost-effective health care and resource allocation that does not compromise quality of care.  Advocate for quality patient care and assist patients in dealing with system complexities.  Recognize that social, economic and political factors are powerful determinants of health and incorporate these factors into how they approach patient care.  Demonstrate knowledge of disparities in health and health care in a variety of populations.  Recognize the role of the women’s health provider to advocate for patients, particularly poor and vulnerable women, and to help develop methods of care that are effective, efficient, and accessible to all women.  Be aware of ACOG and community resources and advocacy on behalf of underserved and vulnerable populations such as poor women and teenagers.  Learn to communicate effectively about women’s health concerns to family and community groups.  Recognize the role of the physician in legislation as it relates to women’s health policy.  Acknowledge that patient safety is always the first concern of the physician.  Demonstrate the ability to discuss errors in management with peers and patients to improve patient safety.  Develop and maintain a willingness to learn from errors and use errors to improve the system or process of care.  Participate in hospital/departmental QI activities and Patient Safety initiatives  Recognize the value of input from all members of the health care team and methods by which to facilitate communication among team members.  Demonstrate understanding of institutional disclosure processes and participate in disclosure and discussions of adverse events with patients.  Partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.  Describe the process of quality assessment and improvement including the role of clinical indicators, criteria sets, and utilization review.  Participate in organized peer review activities and use outcomes of such reviews to improve personal and system-wide practice patterns.  Demonstrate an ability to cooperate with other medical personnel to correct system problems and improve patient care.  Risk management and professional liability  List the major types and providers of insurance.  Describe the most common reasons for professional liability claims.  Describe a systematic plan for minimizing the risk of professional liability claims in clinical practice.  Describe basic medical-legal concepts regarding a professional liability claim and list the steps in processing a claim.

LAL June 2005, May 2006, AMA 2007, TR October 2007, AMA June 2009, LCP June 2014, SW/LCP June 2015

Educational Objectives UCSF Residency Program in Obstetrics, Gynecology and Reproductive Sciences

R1 Obstetrics

R1s learn obstetrics in labor and delivery rotations, outpatient clinic experience and overnight call. R1s have 3 months of inpatient Obstetrics at UCSF Mission Bay, 1½ months of night float at UCSF Mission Bay and 1½ months of Clinics / Ob at SFGH. They have 3 additional rotations where they take obstetric call.

Below are the milestones that pertain to R1 obstetrics rotations. Milestones on communication, systems-based practice, professionalism and problem based learning and improvement are included in each rotation to emphasize their importance in the development of a competent physician. The residency program recognizes that a resident’s particular schedule will influence when subcompetencies are achieved, and the benchmarks reflect the expected level of skill at 6 months and the end of the year.

In addition to the milestones, the CREOG Obstetric Objectives and the Obstetrics genomics objectives are listed below. Of note, the genetics objectives are repeated throughout the obstetrics rotations as the information is complicated, vast and rapidly changing.

Additionally, we have identified several key ACOG practice bulletins that pertain to intern level objectives for obstetrics. Try to complete these readings at least once over your first year. We recommend giving yourself a goal of finishing a few of the readings per rotation. We have also supplied some key articles that pertain to the work you will be doing as an intern. We do not think it is essential that you read these over your intern year, but have provided them as references. You can let your chief or attending know what you are reading and suggest folding the readings into team learning goals or lead a team learning session based on what you read.

Recommended Reading

ACOG Practice Bulletins Recommended for R1 Obstetrics 146 Management of Late-Term And Postterm Pregnancies 116 Management of Intrapartum Fetal Heart Rate Tracings 115 Vaginal Birth After Previous Cesarean Delivery 107 Induction of Labor 106 Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles 80 Premature Rupture of Membranes 76 Postpartum Hemorrhage 71 Episiotomy 52 Nausea and Vomiting of Pregnancy 49 Dystocia and Augmentation of Labor 36 Obstetric Analgesia and Anesthesia 13 External Cephalic Version

Additional Reading: Key Articles for Obstetrics, Labor and Delivery

ACOG: Safe Prevention of the Primary Cesarean Delivery

Preventing the first cesarean delivery Spong et al, Obstet Gynecol. 2013 Mar;121(3):687

Evidence-based surgery for cesarean delivery: an updated systematic review Dahlke et al October 2013Volume 209, Issue 4, Pages 294–306 Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? Altman et al Lancet. 2002 Jun 1;359(9321):1877-90.

Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. Hannah et al N Engl J Med. 1996 Apr 18;334(16):1005-10.

Hypertension in Pregnancy: Executive Summary Obstetrics & Gynecology: November 2013 - Volume 122 - Issue 5 - p 1122–1131

Additional Reading: ACOG Committee Opinions recommended for R1 Obstetrics

561 Nonmedically Indicated Early-Term Deliveries 560 Medically Indicated Late-Preterm and Early-Term Deliveries 559 Cesarean Delivery on Maternal Request 545 Noninvasive Prenatal Testing for Fetal Aneuploidy 543 Timing of Umbilical Cord Clamping After Birth 530 Access to Postpartum Sterilization 524 Opioid Abuse, Dependence, and Addiction in Pregnancy 517 Communication Strategies for Patient Handoffs 514 Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia 487 Preparing for Clinical Emergencies in Obstetrics and Gynecology 485 Prevention of Early-Onset Group B Streptococcal Disease in Newborns 476 Planned Home Birth 473 Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician-Gynecologist 464 Patient Safety in the Surgical Environment 453 Screening for Depression During and After Pregnancy 441 Oral Intake During Labor 439 Informed Consent 435 Postpartum Screening for Abnormal Glucose Tolerance in Women Who Had Gestational Diabetes 433 Optimal Goals for Anesthesia Care in Obstetrics 382 Fetal Monitoring Prior to Scheduled Cesarean Delivery 379 Management of Delivery of a Newborn With Meconium-Stained Amniotic Fluid 348 Umbilical Cord Blood Gas and Acid-Base Analysis 333 The Apgar Score 260 Circumcision

Book Chapters:

Gabbe’s Normal and Problem Obstetrics and/or Williams Obstetrics, including chapters on cesarean delivery and laceration repair.

Freeman & Garite’s book on Fetal Heart Rate Monitoring

Chapters on tubal sterilization in the Atlas of Pelvic Surgery (Wheeless), TeLinde’s Operative Gynecology, and/or A Clinical Guide for Contraception (Speroff & Darney)

ACGME Milestones (on Google drive and flash drive) MB OB Days Rotation Milestones Evaluated MB OB Nights Rotation Milestones Evaluated SFGH Clinics-OB Rotation Milestones Evaluated

CREOG Educational Objectives, A Core Curriculum in Obstetrics and Gynecology, Tenth Edition Unit 4 (on your flash drive)

Patient Care

 Demonstrate caring and respectful behaviors when interacting with patients and their families.  Gather essential information about patients by performing a complete and accurate medical history and physical examination.  Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.  Develop, negotiate, and implement effective patient management plans.  Counsel and educate patients and their families.  Use information technology to support patient care decisions and patient education.  Perform competently all medical and invasive procedures considered essential for generalist practice in the discipline of obstetrics and gynecology.  Understand the differences between screening and diagnostic tests essential for generalist practice in obstetrics and gynecology.  Provide health care services aimed at preventing health problems or maintaining health.  Work with health care professionals, including those from other disciplines, to provide patient-focused care. ******************* PRECONCEPTIONAL CARE  Perform a thorough history assessing historical and ongoing risks that may affect a future pregnancy.  Counsel a patient regarding appropriate lifestyle modifications conducive to favorable pregnancy outcome.  Counsel a patient regarding appropriate preconception evaluation.

PRENATAL CARE  Perform a comprehensive history and physical examination.  Order and interpret routine laboratory tests and those based on risk factors during pregnancy.  Counsel patients regarding lifestyle modifications that improve pregnancy outcome, including activity, employment, nutrition, travel, and substance use.  Counsel patients regarding warning signs of adverse pregnancy events.  Schedule and perform appropriate antepartum follow-up visits for routine and high-risk obstetric care.  Counsel patients about appropriate immunizations during pregnancy.  Counsel patients about the benefits of breastfeeding.

GENOMICS (GENETIC COUNSELING)  Elicit a history for inherited disorders, ethnic-- or race-specific risks, and teratogen exposure.  Counsel patients about the manifestations of common genetic disorders.  Counsel patients about the risks and benefits of various methods of invasive fetal testing, such as:  Chorionic villus sampling  Amniocentesis  Cordocentesis  Pre-implantation genetic testing  Counsel a patient about the genetic implications of advancing maternal and paternal age.  Counsel patients on the advantages and disadvantages of umbilical cord blood banking.  Counsel patients on the advantages and disadvantages of all non-invasive genetic fetal testing.

DIABETES MELLITUS  Interpret screening tests for gestational diabetes.  Manage gestational and pregestational diabetes in the antepartum, intrapartum and postpartum period.

DISEASES OF THE URINARY SYSTEM  Evaluate signs and symptoms of urinary tract pathology in pregnant patients.  Interpret the results of common diagnostic tests for renal disease in pregnancy.

INFECTIOUS DISEASES  Perform a focused history and physical examination in pregnant patients who have a known or suspected infectious disease.  Choose and perform laboratory tests to confirm the diagnosis of infection.

PSYCHIATRIC DISORDERS  Perform a mental status examination.  Perform screening for antepartum and postpartum depression.

SUBSTANCE USE IN PREGNANCY  Perform a thorough history and physical examination in patients suspected of substance use in pregnancy.

HYPERTENSION IN PREGNANCY  Perform a physical examination pertinent to patients with hypertension.  Manage hypertension in the antepartum, intrapartum and postpartum period.

INTRAUTERINE GROWTH RESTRICTION  Assess uterine size by physical examination and identify size/date discrepancies.

PREMATURE RUPTURE OF MEMBRANES  Perform diagnostic tests to confirm rupture of membranes.  Assess patients with PROM for lower and upper genital tract infection.  Counsel patients on risks and benefits of labor augmentation in setting of PROM.

INTRAPARTUM FETAL ASSESSMENT  Perform and interpret the following methods of fetal monitoring:  Intermittent auscultation  Electronic monitoring (external and internal)  Fetal scalp stimulation  Vibroacoustic stimulation

LABOR AND DELIVERY  Obtain an accurate history describing onset of uterine contractions and ruptured membranes  Perform a pertinent physical examination to assess:  Status of membranes (as above)  Presence of vaginal bleeding  Fetal presentation  Fetal position  Fetal weight  Cervical effacement  Cervical dilatation  Station of the presenting part  Clinical pelvimetry  Uterine contractility  Assess the progress of labor  Identify abnormalities of labor:  Failed induction  Prolonged latent phase  Protracted active phase  Arrest of dilatation  Protracted descent  Arrest of descent  Recognize the appropriate role and complications of the following interventions for abnormal labor:  Analgesia/anesthesia  Amniotomy  Augmentation of Labor  Uterine contraction monitoring  Episiotomy: Midline, Mediolateral

VAGINAL BIRTH AFTER CESAREAN DELIVERY  Document an accurate history of a patient’s previous operative delivery  Counsel patients on risk and benefits of trial of labor after cesarean delivery.

EVALUATION OF THE NEWBORN  Perform an immediate assessment of the newborn infant and determine if resuscitative measures are indicated.  Obtain cord blood for the following purposes:  Blood gas analysis  Determination of fetal blood type  Cord blood storage  Interpret cord blood gas results.  Counsel parents on the advantages and disadvantages of circumcision.

THE PUERPERIUM  Perform a focused physical examination in postpartum patients.  Identify and treat the most common maternal complications that occur in the puerperium: -Infection: Endometritis, urinary tract infection, wound infection, mastitis.  Describe methods of reversible contraception.  Counsel patients about permanent sterilization.  Counsel patients regarding future pregnancies.  Counsel patients about the advantages of and answer questions related to breastfeeding.

Procedures  Fetal assessment, antepartum  Biophysical profile  Nonstress test  Contraction stress test  Vibroacoustic stimulation  Amnioinfusion  Amniotomy  Administration of parenteral analgesics/sedatives  Administration of narcotic antagonists  Basic cardiac life support  Maintenance of airway  Bag-mask ventilation  Chest compressions  Cesarean delivery, low transverse  Episiotomy and repair, mediolateral and midline  Fetal assessment, intrapartum – fetal heart rate monitoring (internal/external), vibroacoustic stimulation test, fetal scalp stimulation test.  Induction of labor with prostaglandins or oxytocin  Suction evacuation for 1st trimester fetal death  Neonatal resuscitation, immediate  Skin incision, vertical and transverse  Vaginal delivery, spontaneous  Sterilization, postpartum  Wound care, debridement

Medical Knowledge

 Demonstrate an investigatory and analytic thinking approach to clinical situations.  Demonstrate a sound understanding of the basic science background of women’s health and apply this knowledge to clinical problem solving, clinical decision making, and critical thinking. *************** GENETICS  Demonstrate caring and respectful behaviors when dealing with the genetic information of patients and their families.  Residents should identify areas in clinical genetics where there is significant potential for paternalism, discrimination, or injustice.  Discuss the role other (specialized) health care professionals play in the development of genetic information and testing that is used in the clinical setting.  Describe the general indications for genetically based diagnostics.  Perform or interpret genetic risk assessment through:  Pedigree analysis  Gene testing  Antenatal  Adult  Describe the sensitivity and specificity of various genetic tests and the implication of these parameters in clinical practice.  Describe the role of genetics in drug metabolism and individual variation in drug efficacy.  Discuss the factors involved in the development of and recommendations for genetic testing.  Frequency of the condition in the population.  Nature and range of severity of the condition.  Treatment, intervention, and/or prevention.  Reproductive options to avoid or reduce risk.  Test availability including prenatal screening and/or diagnostic testing.  Sensitivity, specificity, and positive predictive value of the test.  Genotype-phenotype correlation.  Frequency of gene mutation in general population or selective sub-groups based on ethnicity/race.  Cost and cost-effectiveness of screening.  Usefulness of test information to individual, to family and to society.  Availability of public and professional educational material/programs.  Availability of adequate genetic counseling services for follow-up.  Potential for uncertainty of tests results.  Potential for psychological, emotional, or physical harm to patient.  Potential for misuse of information and genetic discrimination.  List the types of genetic abnormalities that may result in clinically significant abnormalities.  Deletions  Additions  Trinucleotide repeats  Microsatellite instability  Mitochondrial DNA abnormalities  Describe stem cells and potential uses of stem cell technology.  Basic mechanism of genetic inheritance:  Describe the basic structure and replication of DNA.  Describe the processes of mitosis and meiosis.  Describe common terms associated with genetic expression.  Exon  Intron  Codon  Transcription  Translation  Describe the clinical significance of karyotype abnormalities, such as:  Trisomy (13, 18 and 21)  Polyploidy  Monosomy  Sex chromosome abnormalities  Deletions  Inversions  Translocations  Mosaicism  Chimeras  Describe the normal process of gametogenesis.  Describe the normal process of fertilization and the combination of genetic information.  Clinical implications of heritable disease:  Describe the clinical significance of heritable diseases, such as cystic fibrosis, Tay-Sachs disease, and hemophilia.  Counsel patients about the techniques for and implications of testing for heritable diseases.  Discuss treatment and surveillance options for patients or newborns with genetically derived disease.  Describe the concepts of penetrance and variable expression and their impact on prognosis for a given genetic disorder.  Distinguish between various forms of genetic inheritance:  Autosomal dominant  Autosomal recessive  X-linked  Mitochondrial  Genomic imprinting  Describe the indications for, and limitations of, noninvasive diagnostic tests for fetal aneuploidy and structural malformations (e.g., ultrasonography, serum analytes).  List ultrasonography findings that are often associated with genetic disorders for:  Duodenal atresia  Omphalocele  Nuchal translucency/nuchal skin fold  Echogenic bowel  Heart defects  Diaphragmatic hernia  Ventriculomegaly  Describe the indications and uses for umbilical cord stem cells.  Describe the inheritance of hemoglobinopathies.

EMBRYOLOGY AND DEVELOPMENT BIOLOGY  Describe the normal process of gametogenesis.  Describe the normal process of fertilization.  Describe the normal process of embryologic development of the singleton pregnancy.  Describe the embryology of multiple gestations.

ANATOMY  Understand the muscular and vascular anatomy of the pelvis and vulva  Describe the anatomic changes in the mother caused by normal physiologic adaptation to pregnancy.  Describe the anatomic changes that occur during the intrapartum period, such as: cervical effacement and dilatation.  Describe the anatomic changes that occur during the puerperium, such as: alterations in the breast and uterine involution.

PHARMACOLOGY  Describe the role of nutritional supplementation in pregnancy (e.g., iron, folic acid).

PHYSIOLOGY  Describe the major physiologic changes in each organ system during pregnancy. (MK)

MICROBIOLOGY AND IMMUNOLOGY  Describe the principal features of the host immunologic response.  Describe how the maternal immune response is altered by pregnancy.  Describe the basic features and timing of development of the fetal immunologic response.  Describe the association between genital tract infection and adverse perinatal outcomes, such as:  Preterm labor  Preterm premature rupture of membranes  Neonatal infection  Maternal infection

DIABETES MELLITUS  Classify diabetes mellitus in pregnancy.

DISEASES OF THE URINARY SYSTEM  Describe the indications for the common diagnostic tests used to evaluate renal disease in pregnancy.

SUBSTANCE ABUSE IN PREGNANCY  Describe behavior patterns suggestive of substance abuse.

PRETERM LABOR  Describe the multifactorial etiology of preterm labor.

BLEEDING IN LATE PREGNANCY  Describe the etiology of bleeding in late pregnancy.  Describe the factors that predispose to placenta previa and abruptio placentae.

HYPERTENSION IN PREGNANCY  Describe the possible causes of hypertension in pregnancy.

MULTIPLE GESTATION  Describe the physical findings suggestive of multiple gestation.  Describe the factors that predispose to multiple gestation.

PREMATURE RUPTURE OF MEMBRANES  Describe the possible causes of premature rupture of membranes (PROM) in preterm and term patients.

INTRAPARTUM FETAL ASSESSMENT  Describe the possible causes for, and clinical significance of, abnormal fetal heart rate patterns:  Bradycardia  Tachycardia  Variability  Early decelerations  Variable decelerations  Late decelerations  Sinusiodal waveform

LABOR AND DELIVERY  Describe the normal course of labor.  Describe the risk factors for abnormal labor.  Describe appropriate indications for induction of labor  Describe appropriate indications for, and complications of, cervical ripening agents.  Describe appropriate indications for, and complications of, labor-inducing agents.

ANESTHESIA  Describe the types of anesthesia that are appropriate for control of pain during labor and delivery:  Epidural  Spinal  Pudendal  Local infiltration  General  Intravenous analgesia/sedation  Inhalation analgesia

SHOULDER DYSTOCIA  Identify risk factors associated with potential for shoulder dystocia.  Describe the anatomical findings of a shoulder dystocia  Describe signs of shoulder dystocia  Identify possible maternal complications associated with shoulder dystocia  Identify possible fetal complications associated with shoulder dystocia

EVALUATION OF THE NEWBORN  Describe the indications for cord blood gas analysis and interpret the test results.  Describe the rationale for administration of topical antibiotics to prevent neonatal ophthalmic infection.