In clinic, residents are encouraged to review the medical chart of the upcoming patient and any pertinent imaging. Discuss with your attendings how he/she prefers to organize the day. Some will encourage you to go in and see the patient before them and gather the medical history and formulate an idea of what you think is going on; others may prefer that you see the patient simultaneously with them, as they often have long-term relationships with these patients and know them very well. One of your primary goals should be to learn about the evaluation and management of abnormal uterine bleeding and benign pelvic masses (i.e. symptomatic uterine fibroids).
The gynecology service is typically composed of interns, junior/senior residents, fellows, and attendings. Try to be an integral part of the team. Select a couple new patients or continue to follow the patients that you have observed in the clinic or operating room. You can certainly ask the upper level resident or fellow for guidance on this. Learn to manage their primary and secondary conditions while they are in the hospital, with an emphasis on peri-procedural management. Many patients have post-operative complications or are admitted for diagnoses that require the services of interventional radiology (see below).
The resident’s core diagnostic radiology skills will be very useful and frequently called upon throughout this rotation. The attendings typically review the imaging and report. However, they may turn to you as an experienced radiologist. In the clinic setting, new patients frequently present to the clinic with only outside imaging available; this is an excellent opportunity for you to showcase your expertise and help the clinician understand the findings on the pelvic ultrasound or abdominal/pelvic CT or MRI. This is a great time to learn and build upon your ultrasonographic, CT, and MRI imaging knowledge. Furthermore, this experience will improve your clinical judgment as you observe how clinicians decide when an imaging study is indicated or needed, how they respond to radiologists interpretations, and how our reports affect patient management and their course in the hospital.
This rotation will allow the resident to further develop their clinical knowledge and judgment to progress towards becoming a practicing clinical interventionist. Obstetric/gynecologic patients often require the services of interventional radiology. As a member of the referring team, the IR resident will have an opportunity to learn how our colleagues care for our patients before, during and after IR procedures, which will enhance the resident’s ability to care for these patients themselves in the future. This is also a chance to enhance your knowledge of the indications and limitations of the common interventional radiology procedures this patient population typically requires (see below). Furthermore, you will observe how obstetricians/gynecologists interact with other clinicians, radiologists, and surgeons.
Frequently requested interventional radiology procedures:
- Uterine fibroid embolization
- Percutaneous pelvic vein embolization for pelvic congestion syndrome
- Pelvic abscess drain
- IVC filter placement and retrieval
- Percutaneous nephrostomy tube placement
- Visceral angiography and embolization for post-op hemorrhage
Specific Rotation Goals and Objectives
- History Taking and Physical Examination
- Practice and refine the physical exam and medical history skills learned during internship year (PGY-1)
- Knowledge and Clinical Decision Making
- Describe the muscular and vascular anatomy of the pelvis.
- Evaluate possible causes of anemia, thrombocytopenia, deep vein thrombosis, and coagulopathy in pregnancy.
- Describe the etiology of bleeding in late pregnancy.
- Interpret diagnostic tests, such as:
- Platelet count
- Coagulation profile
- Manage serious complications of abruptio placentae and placenta previa, such as hypovolemic shock and coagulopathy.
- Be able to identify and manage the most common maternal complications that occur in the puerperium:
- Uterine hemorrhage
- Injury to the urinary tract
- Pulmonary embolism (including amnionic fluid)
- Deep vein thrombosis
- Describe the principal causes of abnormal uterine bleeding and distinguish abnormal uterine bleeding from dysfunctional uterine bleeding.
- Perform a focused physical examination to investigate the etiology of abnormal uterine bleeding.
- Perform and interpret the results of selected diagnostic tests to determine the cause of abnormal uterine bleeding, particularly pelvic ultrasonography.
- Be able to diagnose and work-up major causes of pelvic masses, including non-gynecologic sources and those arising from the female genital tract, such as:
- Uterine fibroids
- Adnexal cystic and solid masses
- Tubo-ovarian abscess
- Adnexal torsion
- Ovarian cysts/benign neoplasms
- Know when and how to treat benign pelvic masses (i.e. uterine fibroids), using nonsurgical, surgical, or endovascular methods, considering such factors as the patient’s:
- General health
- Treatment preference
- Desire for future childbearing
- Severity of symptoms
- Choose appropriate pain control based on the surgical procedure, degree of patient discomfort, and patient characteristics, including age and presence of coexisting morbidities.
- Describe the pathophysiology of acute blood loss.
- Describe the laboratory evaluation of acute blood loss, including:
- Complete blood count
- Evaluation of coagulopathy
- Electrolyte evaluation
- Evaluation of acute renal failure
- Describe the treatment of acute blood loss, including:
- Fluid and electrolyte replacement
- Blood transfusion
- Correction of coagulopathies
- Develop an appreciation for the clinical presentation of commonly encountered pelvic malignancies and imaging findings.
Systems Based Practice
- Take on new patients and consultations with the goal of assigning team resources to address them in an appropriate and timely manner
- Be able to coordinate care within the team over multiple patients and multiple problems of varying urgency (i.e. be able to triage effectively)
- Coordinate hospital and physician resources in regards to transferring patients who are critically ill from other institutions
- Complete full consult notes and progress notes every day on the patients that you are covering in a detailed and accurate format that is easily translatable to other services
- Be an active, effective and efficient team member by effectively transferring care between duty hours completely and responsibly
Practice-Based Learning and Improvement
- Shows appropriate use of consultation with medical and non-medical services, including special diagnostic studies
- Uses evidence from the medical literature to answer clinical questions
- Identifies areas for potential improvement in personal delivery of care
- Maintains a positive attitude towards learning, including attendance and participation on patient rounds and conferences, and evidence of reading or other methods of gaining knowledge
- Participates actively in teaching others, including students, residents, and faculty
- Serve as a radiology advisor/liaison to the team when called upon
- Educate the team regarding imaging utilization, radiation concerns and
- Develop the clinical skills necessary to successfully manage a patient throughout the peri-procedural course, to help facilitate improved non-procedural interventional radiology patient care during your career.
- Review past and current imaging on all patients you are involved with.
- Perform procedures within the level of your knowledge under supervision.
- Assist in the admission and discharge of patients when appropriate.
- Assist in consults when appropriate.
Interpersonal and Communications Skills
- Presents a patient effectively and efficiently
- Communicates with patients and concerned others effectively
- Writes accurate and complete entries in the medical record
- Works constructively as part of a team
- Exchanges information effectively and efficiently during rounds that reflects pertinent issues and problems, current therapeutic plans, and expected complications and issues
- Establish therapeutic and empathetic relationships with patients and their families
- Remember you are a guest in another specialties’ practice. Be prompt, present
- Take on progressive amounts of responsibilities during your rotation and live up
- Dress code: White coat and business casual attire is expected in the outpatient clinic. Scrubs under white coat may be acceptable on the floor depending on your attending. Scrubs alone are acceptable during procedures.