The Division of Gynecologic Oncology

GYNECOLOGIC ONCOLOGY ROTATION

RESIDENT GUIDELINE (Revised 9-1-2008)

1. Introduction
Welcome! Drs. Santoso, Tillmanns, Smiley, Reed, and staff look forward to working with all of you. This Gynecologic Oncology rotation is demanding in terms of hours, energy, and emotion. We are asking for your full commitment to this rotation. In return, we promise you that we will always be there with you to guide you in providing care to these brave women.  We believe your training in this rotation will make you a better surgeon academically and a better physician clinically. Finally, we hope to share with you the excitement of learning and operating!

2. Mission statement
Provide the highest quality, most compassionate, and cost-effective care to women with gynecologic cancers. Dedicate ourselves to teach residents, students, and other professionals to provide care as above, and to continue life-long self-improvement through teaching and research. In short: “providing care that exceeds expectation.”

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3. Work flow in clinic
New patient: Residents see, complete the H&P and initial exam by herself/himself. Please call the Attending to return for the pelvic exam. Established patients: Resident may see the patient directly and then report to the Attending. Pelvic exams are to be done with the Attending. Please be courteous with clinic staff, they are not used to having many residents in this private practice. Things are very different than the usual academic practice (i.e., insurances are more complicated). Once you are ready to send the patient home, please ask the nurse to help you get the patient a follow up appointment, labs, x-rays, etc. If the patient needs to be scheduled to begin chemotherapy, please ask the nurse for assistance.

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4. Weekly schedule
Residents cover all gyn-oncology patients admitted to Baptist Women’s, Baptist East and Methodist University. We want to be very physician and patient-friendly. This kind of service will encourage other physicians to refer patients to us. As a result, residents should benefit with more learning experience. We cover consults anywhere and anytime. However, we will pull back quickly to our core hospitals (Meth University, Baptist East and Women).
We split the residents into 3 different hospitals during the day to reduce travel time for the residents. The attending will still travel thus allowing residents to get exposure to various faculties. If there is any doubt as to what time to round with the attending, the chief resident should contact the rounding faculty the night before to make a plan.

• Abbreviation: MU (Meth. University), GT (Meth. Germantown), BE (Baptist East), BW (Baptist Women), SF (St Francis Parkway), DS (Desoto Clinic)
• Santoso’s clinic on Thursday PM does not need resident coverage
• Round with Santoso: he commonly rounds with residents in between OR cases on Monday, Wednesday and Thursday.   On Tuesday and Friday, he usually rounds before clinic.  

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5. Rounding
Please present using SOAP note presentations with clearly stated assessment and plan.  During postoperative period, do not use Demerol since its metabolites may cause more confusion.  For PCA order, Tillmanns dislikes using maintenance dose.  Santoso approves maintenance dose unless the patient is easily drowsy or older than 60 years old.
Have all films that were done overnight with you on rounds for the attending to view. It is best to review any ordered studies (CT, x-ray studies) with the radiologist. This will rapidly improve your skills at reading films and as well provide the radiologist with valuable information.
When you get a consult at Methodist University and you need to do gyn exam (i.e., biopsy), please order the “Gyn Cart” on the patient chart (order this from the Central Supply). The cart has speculums, light, pap smear, endometrial biopsy, etc and stored at the central supply.  Please order the cart every time you get consult. If we don’t use it, we will lose it.
Residents will round in the morning and afternoon every day. This will ensure that patients receive the best care. This will also ensure good check out at night as well as allow the resident on call a buffer for nightly calls from the hospitalized patients’ nurses. Do your best to avoid unnecessary calls from the floor to the resident on call by acts of omission or commission on evening rounds. A list of hospitalized patients with essentials to assist in managing them at night will be checked out nightly by a web-based approach. For the e-mail site and password, please contact the chief resident.

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6. Surgery
Surgery scheduling is done through Rachel Song (East Clinic, phone: 683-0055 ext - 1229). When you add surgery cases for patients already in the hospital, please let Rachel Song at the West Clinic, Operating Room and Anesthesia (MAG group at Meth University) know. For each surgery, the Attending will dictate the OP note and the resident will write the OR note and orders.
Tandem and ovoid placement: at Methodist hospital will require admission to the hospital for 2-3 days after the surgery in collaboration with radiation oncology (low dose radiation). At Baptist Hospital, it is done as same day surgery (high dose radiation).  See the post op radiation order in the appendix A
There is a surgery folder kept by the residents that should be updated with all information on the patients for surgery. Have H&P, consents, labs, path, tumor markers, radiology results, and films. Patients will usually have films with them. If you are missing anything from the packet call the MA or nurse of the doctor that is operating. Packets should be obtained and reviewed by the residents for any potential problems 3 days prior to surgery. Residents need to be prepared for the surgery that they will perform with the attending. Residents that are not prepared for the surgery or do not have a good working knowledge of the patient's history should not be involved in the patient's surgery. There will be times when this is not possible, but should be avoided in almost every circumstance. The goal is for the resident to maximally benefit from every surgery that they are involved with. The only way to ensure this is proper preparation before the surgery.

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7. Dress Code
Our appearance should project professionalism.  No scrubs (except on OR days), no jeans. Ties for men (except on the weekend/holiday), No athletic shoes or sandals. Socks or hose are required in the clinic, no open toed shoes allowed. On the weekend, dress is less formal but still respectful (no T-shirts or sandals) – scrub is acceptable.  White coat should be white – no blood or dirt please (please launder frequently).

8. On call
Residents will be on call for patients admitted to Baptist East, Baptist Women’s and Methodist University. The answering service will call the on call attending directly if resident does not answer the Blackberry Phone in 10 minutes. The staff doctor on call will take all outpatient calls. Our answering service phone number is our clinic number (683-0055). If you get a consult or admission after hours, this patient can be staffed the next morning with the rounding staff at that hospital in the morning.  Feel free to call the attending on call if you have any question.
Consults: Please call to find out the urgency of a consult. If the consult is emergent (such as severe vaginal bleeding, acute abdominal pain, etc.), please see this patient right away, regardless the time of day or night. If, however, the consult regards something non-emergent (such as vaginal discharge, chronic vaginal spotting, etc.) you may see this consult within 24 hours (the next day).
For Baptist Memphis, there is an exam room on 5 East that has all equipment and supplies needed for gyn exams. All patients will be brought by the resident to this area for exam. Preferably with Dr Reed or Smiley to exam the patient. These consults are generally done early in am, in-between cases  on OR days, and in the afternoon.
For Baptist Women, there is also an exam room on the third floor.   For Methodist University, there is no exam room.  Please order from central supply “ the gyn cart”.  It has speculum, biopsy forcep, etc to be used in the room.

9. Weekend/holiday
The Chief Resident will determine call coverage. There should be two residents on call: one covers the east service (Baptist East and Women) and the other covers west service (Methodist University). If the patient load is light, one resident may round and take call with the other resident works as a backup.  Intern should not take call.

10. Conferences/Academic time
a. M&M downtown Thursday
b. BWH Tumor Board every other Friday

11. Evaluation
Please remind your attendings (especially Santoso, Tillmanns, Reed) to give your evaluation when you are in the mid and end of rotation.  Mid rotation evaluation is important so that any deficiency can be corrected before it is too late. In general, the gynecologic oncology rotation has been one of the rotations that makes or breaks the resident since she/ he will be working very closely with attending all the time.  Our goal is to graduate all of you with skills to help people that we will be proud of. At the same time, we also have responsibility to your future patients that you will be qualified to be an excellent physician.

12. Taking time off during rotation
No vacation is allowed during rotation. Reasonable amount (2-3 days) off for interview may be permitted. Please talk to Dr. Santoso early. There is no vacation during this rotation except for interviews or emergency (death in the family).  We are committed to teach you.  Our rewards come when we see that you are eager to learn.

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13. Gyn Onc Team and offices
Director:
Joseph T. Santoso, MD -- office: (901) 322-0251, cell phone: (901) 726-8676 or SAN-TOSO
Nurse: Mary Crigger --  cell phone: 901-483-4512
Assistant: Londa Schaffer -- office: (901) 322-0251 Ext 2710, pager: 532-0022
Staff Attending:
Dr. Todd Tillmanns --  cell phone: (901) 581-1720
Nurse: Diann Parr --  cell phone: (901) 237-6617
Dr. Linda Smiley --  cell phone: (901) 734-2956
Nurse: Robin Patterson --  cell phone (901) 827-0896             
Dr. Mark Reed -- office:  cell phone: (901) 412-8452
Nurse: Wendy Burrell --  cell phone (901) 268-5298                   
Surgery Scheduling:  Rachel Song 683-0055, extension 1229.  
General office Secretary:  Karen Axley office phone (901) 683-0055  cell phone (901) 734-8141
Clinics:
East Clinic: 100 N. Humphreys Blvd., Memphis, TN 38120
Phone (901) 683-0055, Fax (901) 685-9718
Midtown Clinic: 1588 Union Avenue, Memphis, TN 38104
Phone (901) 322-0251, Fax (901) 322-0262
Desoto Clinic: 7668 Airways Blvd., Southaven, MS 38671
(662) 349-9556, Fax (662) 349-0559

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Students
Students are encouraged to participate actively on rounds, operative procedures, hospital care, and conferences. Students should call the chief resident for questions about rotation and course evaluation. The staff physicians will provide feedback to the students throughout the rotation.

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PAPER WORK
Resident Work Hour/Load Report
We are monitoring your work load and hours daily.  Please document number of patients and surgery cases on the Report Sheet (see appendix) daily.  Ask your attending for guidance in using CPT codes after surgery thus you receive the appropriate credit for the amount of work you do.   The work report file is stored at computers in various hospitals: At Baptist Women (2nd floor surgical lounge, middle computer next to sleeping room); Baptist East (concourse level, surgery lounge, the most right computer as you enter the room); Meth University (3rd floor surgery lounge, middle computer). 
Dictation number

Post op orders
Please see the example on the Gyn Onc handbook. Always include the onc beeper (201-0042) number on your post-op orders. Please have the nurses call the individual resident’s pager number during the day (e.g. page the 3rd year resident for Baptist East patients) and the onc beeper at night.
Note: West Clinic --Primary Admission Orders, Order and Progress Notes, Post-Operative Orders, and Preoperative Orders can be found in the N drive. Instructions on where they can be found are listed below.

1. Go to My Computer
2. Click on PatientEDU on 'wcnas' (N:)
3. Click on GYN Handouts
4. Click on Primary Admission Orders
5. On the bottom left, you will see tabs that show the named forms. Just click on those tabs to bring up the form

Admission H & P:

Date of Admission, Attending Name, Chief Complaint/Reason for Admission, History of Present Illness, Past Medical History (illness, surgery, ob/gyn, medications, allergy), Past Oncology History, Cancer Diagnosis, Date Type, Stage, and other information: Example: 7-1-2000-Stage IIIC ovarian adenocarcinoma diagnosed by Todd Tillmanns, at the Baptist Women Hospital, Memphis, TN 7-15-03. Recurred and Metastases to lung, Chemotherapy History (i.e., 8-1-2000 to 11-1-2000 Carboplatin and Taxol 6 courses). Radiation History (i.e. 2-3-2001 to 4-1-2001 pelvic radiation, 4500 cGy by Dr. Stephen Lutz, Methodist University Radiation Onc.). Family History (illnesses and cancer history), social history (support, smoking, alcohol, drug), review of systems (all organs) physical exam, labs and x-rays (CXR, CT, etc), assessment and plan.
To get this information check the Methodist or Baptist computer or call the staff physicians nurse or medical assistant during work hours. 

West Clinic EMR:  If it is after hours, you can go directly to the West clinic EMR to get the complete history before you dictate your H&P.  You can log on from home before you go to the hospitals.  Some hospitals East for example will not let you download the program necessary to view some of the documents.  First you go to vpn.westclinic.com.  Next, log in with the user name goresident.  Please get the password from the chief resident.  It must be changed every 6 months; therefore, the 12/07 team will have to contact IT during office hours for an updated password.  The password in case sensitive and in all lower case letters.  Once you get to the interface, TSEMR is the option that will take you to the EMR.  There is a small program to download that will complete your ability to use the EMR. 

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Discharge Summary

Date of admission and discharge, admission diagnosis, discharge diagnosis, brief HPI, past medical history (illness, surgery, ob/gyn, medication, allergy) past oncology history, family and social history, exam on date of discharge, hospital course, procedures done (list all with dates, i.e., 1-2-2000, left subclavian central line), consults (list attending name and service consulted, i.e., David Sloas, GI service), discharge medications, discharge instruction, return precautions, activity, return appointment (i.e., patient is asked to call the office at 683-0055 to make post-op check appointment with Dr. Santoso, Dr. Tillmanns, Dr. Smiley, Dr. Reed (usually 1-2 weeks post-op).
When you send patient home with narcotics, please order antiemetics (i.e., phenergan) and stool softeners.

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Consultants
Here are the names of the usual consultants. Office numbers are included so that they could be reached 24 hours a day and on weekends (through their answering service). If pager numbers are desired, you may call the Methodist operator or the Physician Help Line (a great # to have) 1-800-782-7822 outside Memphis or (726-2100 in the city). This is an MD to MD line and they can connect you with the desired MD at all times. Also be aware that all groups may not accept all insurance plans, especially TennCare.

 ID
    Steven Threkel or associate 685-3496
Nephrology
    Lynn Ebagh  541-5065
Urology
    Yair Walzer    753-9821
    Oncologist Walter Rayford  527-7100
    Oncologist Mark Saslawsky 685-5057

Computer Codes:
Baptist: Call medical records to set up Baptist MD. 227-9175
Methodist: To set up call 516-000. To use, go to www.molli.com then my apps. There is a yellow sticker on the top of all computers at Methodist. Type this code in using all lower case for username and password. On the next screen, you get click the power chart icon and enter the username and password you get when you set up the computer. Everything including vitals is now on the computer so you must get a username and password.