Division of Reproductive Endocrinology, Infertility, and Genetics

DIVISION OF REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY

RESIDENTS RESPONSIBILITIES

Download Resident Responsibilities PDF

Welcome to the Division of Reproductive Endocrinology and Infertility.  Dr. William Kutteh is director of the division; Dr. Raymond Ke directs clinical services, and Dr. Rink Murray, Jr. is participating in resident education. Residents are welcome to all clinical activities in the division, but remember, this is also a private practice. Therefore, all clinical activities and decision-making will be under the direct supervision of Drs. Kutteh, Ke, and Murray. If patients request not to see residents, then these wishes have to be honored.  Similarly, while all residents wish to gain more experience with procedures, in some cases, observation and assisting will have to suffice.  If you have any concerns, then please discuss this with Drs. Ke or Kutteh.

The purpose of this document is to orient the resident to the curriculum, routine, responsibilities and expectations of the Reproductive Endocrinology service at the University of Tennessee Department of Obstetrics and Gynecology. It is our goal that the individuals rotating on our service will become familiar with the physiology, diagnosis, and treatment of reproductive and hormonal problems as described by the CREOG Educational Objectives. The series of clinical interactions, lectures, and readings that are outlined are not optional, and the evaluation of the resident will directly reflect his/her level of knowledge and preparedness.  It is expected that each resident will own and completely read the latest edition of Clinical Gynecologic Endocrinology and Infertility by Speroff during this rotation.

GENERAL ADMINISTRATIVE ISSUES

1. Dr. Kutteh or Ke must approve all personal leave that occurs during the Reproductive Endocrinology Rotation prior to the rotation.  Medical leave and emergencies should be discussed as they arise.
2. Residents are expected to dress professionally and have clean white coats. Men are expected to have shirt and tie and women will follow our dress code policy. Clean scrubs are acceptable only if the resident had surgery with one of our staff and reported immediately to the clinic.
3. A resident should be available by beeper every weekend.  During this time, residents cannot have other call responsibilities as they may be needed to see patients at any hospital or assist in emergency surgery.  Notify the faculty and nurses on call for the weekend on Friday.
4. Generally more than two activities will be occurring at the same time.  Please refer to the Resident Assignment instructions to determine resident responsibilities.
5. If emergencies arise on another service, a resident on RE can only be pulled from this rotation with prior approval of Dr. Ke or Dr. Kutteh.
6. Use of Internet in the office is restricted. A resident desk is provided and the library has textbooks and journals in all areas of Ob/Gyn to review when time allows.
   

back to top

OUTPATIENT CLINICS

New Patients
New patients expect to be seen by the physician they were referred to on their initial visit. In most cases the resident will observe and learn interview techniques from the attending physician (Look, listen, learn teaching method). A copy of our patient history form is enclosed.  The patients fill out the left hand side of the form themselves and the right side is for notes.  Any positive findings on history are fully explored by asking the patient or reviewing the old records.  The date of tests and the results available are recorded on the right hand side of the page.   Ensure that all diagnoses are noted along with their appropriate CPT codes. 

Specific Objectives

1. The resident will observe and learn interview techniques with specific reference to potential contributors to infertility or reproductive problems.
   
   
2. The resident will develop the ability to present patient problems and plans in an organized and comprehensive manner, learn the subtleties of the basic infertility evaluation, and the indications for each of the diagnostic techniques.
   
   
3. The resident will understand and be able to outline steroid biosynthesis and abnormalities as they may relate to various reproductive problems.
   
   
4. The resident will understand the principles and practice of ovulation monitoring and ovulation induction.
   
   
5. The resident will learn the technique of vaginal sonography to specifically include appreciation of normal anatomy, identification of ovaries, identification of early intrauterine pregnancy and pregnancy abnormalities, and identification and diagnosis of follicular development.
   
   
6. The resident will be expected to understand current coding techniques using CPT (Current Procedural Terminology) and ICD-9-CM (International Classification of Diseases) used for outpatient clinics used in Reproductive Endocrinology.

Return Patients

For return patients, first ask your attending physician if it is appropriate for you to see that particular patient.  For infertility patients, please document a progress note as noted by the example attached.  This is an easy and organized way of ensuring that no facts are missed.  Check on lab and pathology results, operative reports and old records.  Include date of tests, lab values and units.  Quickly review these with the patient and see if there are any other pertinent findings in the history since the last visit.  Try not to get into a discussion with the patient on treatment plans, as this will be reviewed with the staff physician.  After updating the history, review with Drs. Kutteh, Ke, or Murray and they will see the patient with you. 

back to top

EXAMPLES OF PROGRESS NOTES

Notes should be legible, organized as listed below, dates of tests listed, and units of labs listed.

RECURRENT PREGNANCY LOSS PROGRESS NOTE

 To be completed after discussion with Drs. Ke/Kutteh/Murray:
 
Assessment:

1. Primary RPL (CPT 629.81)
2. Asherman’s Syndrome (CPT 621.5)

Plan:

1. Discussed intrauterine adhesions and increased risk of pregnancy loss.  Counseled on need for Op HS w/LOA.  Discussed risks of bleeding, infection, possible injury to bowel, bladder, uterus, blood vessels and chance of open laparotomy.  Questions answered.  An information booklet was given to patient to reinforce the above. Patient to call if she desires surgery desired or further questions.

INFERTILITY PATIENT PROGRESS NOTE

To be completed after the discussion with Drs. Ke/Kutteh:

back to top

EARLY IUP ULTRASOUND PROGRESS NOTE

7/20/07 33 yo female G1 PO pregnant at 7 weeks after first cycle of IVF.

Patient denies N/V, F/C, C/D, bleeding/spotting

IVF: Embryo transfer of one blastocyst on day 5 grade AAB on 6/15/07

MEDS: Prog in oil 50 mg/q hs, Prog vag supp 100 mg/bid, PNV, aspirin 81mg/d,

LABS: 6/30/07 QhCG 234 miu/ml Repeat 7/2/07 504 miu/ml

SONAR: viable pregnancy CRL 9.3 mm = 7 weeks 1 day, FHM = 132 bpm , gest sac 25 mm

ASSESSMENT: Twins, viable at 7 weeks ( 640.03)

PLAN:

1. Scan for growth next week
2. Schedule OB initial visit
3. Wean progesterone per protocol
4. Call if any bleeding, cramps, or problems.

back to top

SURGERY

Surgical schedules vary.  Although each staff physician will have designated days to perform most of their surgery, check the weekly schedule for cases and check with OR Schedule log on the computer at the nurse’s station to look for last minute changes in surgical scheduling.   A resident is expected to attend all surgical procedures. For patients who are admitted, the resident who assisted with the case is expected to round on the patient twice a day and report to the staff. Appropriate discharge summaries should be dictated with a copy sent to our office, prescriptions completed, and discharge orders completed. 

Specific Objectives

1. The resident will be expected to fully understand the diagnosis, indications for surgery, and potential management alternatives of every patient going to the operating room. The resident should read about the case prior to surgery. Any resident may be dismissed from the OR if the attending staff realizes that the resident is not prepared to participate in the case.
   
   
2. The resident will learn the principles of diagnostic laparoscopy for infertility as well as the techniques of performing laparoscopy with one or more accessory punctures.
   
   
3. The resident will become familiar with instrumentation for advanced laparoscopy including safe use and appropriate maintenance of the equipment.
   
   
4. The resident will learn the common complications of laparoscopy, the best techniques to avoid these complications, and techniques and management of all major complications of laparoscopy.
   
   
5. The resident will increase his/her technical skills in operative laparoscopy to include lysis of adhesions, treatment of endometriosis, tuboplasty, and tubal anastomosis procedures under direct and ongoing supervision by the attending.
   
   
6. The resident will learn indications and techniques of both diagnostic hysteroscopy and      operative hysteroscopy in a manner analogous to objectives of laparoscopy.
   
   
7. The resident will be expected to maintain surgical care experience logs and document all surgical cases attended will on the service.

PRE-OP ORDERS

POST-OP ORDERS

back to top

POST-OP PATIENTS IN CLINIC

The resident will staff the post-op clinic.  During this clinic, all patients who were operated on last week are seen and patients needing preoperative evaluation being operated on next week are seen.  The purpose of this clinic is to make sure post-op patients are having a normal recovery, that the dictated op note is on the chart, and that the pathology report is reviewed and on the chart.

POST-OP NOTE
33yo female with RPL here for post-op.

S/P Op H/S with resection of myoma and Dx L/S on 2/4/07.

PATH: leiomyomata, benign

Patient states she is doing well.  Denies F/C, C/D, excessive bleeding from vagina or incisions.  Tolerating po liquids and solids, voiding well and had BM on 12/12/06.  Ambulating well.  Took Percocet x 1 day now only Tylenol.

Abd: Soft, NT, incisions clean and dry. Sutures removed (Ke patients). + BS.

Pelvic: vagina moist, pink. Cx closed and NT. Ut midline NT. Adnexa NT.

LABORATORY PROCEDURES

Residents are expected to observe an oocyte retrieval procedure and to observe a semen analysis in the Andrology laboratory. Please discuss the oocyte retrieval with the attending and schedule the semen analysis observation with our laboratory staff.   You are welcome into the Embryology laboratory to observe laboratory procedures, as long as you change into the appropriate attire and are accompanied.  Please schedule these observation times in advance with our Chief Embryologist.  

TRANSVAGINAL SONOGRAPHY (TVUS)
SONOHYSTEROGRAPHY (SHG)

As a part of the TVUS training program in the Department, residents will become skilled in the performance of early pregnancy scans and sonohysterograms.  TVUS is performed Monday, Wednesday, and Friday from 9 am to 1pm.  Simultaneously, SHG is being performed with our staff. Based on the schedule below you should be at the office by 9 a.m. to assist with TVUS (mainly early IUPs and some gyn scans) and SHG.  This is an excellent opportunity to improve your sonography. PGY-3 residents are expected to learn and perform with sonohysterography procedures performed on Mon and Wed morning and Friday morning if available.  

Specific Objectives

1. The resident should understand the indications for hysterosalpingogram and sonohysterograms, as well as the information obtained by a well-performed study.
   
   
2. The resident should be familiar with the varying techniques of performing
   hysterosalpingograms and sonohysterograms.
   
   
3. The resident will be expected to observe initially and ultimately to perform sonohysterograms.
   
   
4. The resident will be expected to understand TVUS skills and measurements of CRL, gestational sac, yolk sac, and FHM in early pregnancies from 6 to 9 weeks.
   
   
5. TVUS and SHG case experience lists must be maintained by the resident.

back to top

DIDACTIC TEACHING CONFERENCES

All residents rotating on Reproductive Endocrinology will be given a pre-test at the start of their rotation to assess their foundation of knowledge. In addition, during the final week of the rotation, a post-test will be given to evaluate the changes in knowledge based on their experience during the one month rotation. These results will be used to enhance the resident rotation experience, to evaluate the knowledge of our residents at the second and third year level, and to use the results as a component of our evaluation of each resident.

Teaching conferences will be with Drs. Kutteh, Ke, and Murray at a mutually agreeable time. These will generally be unscheduled and spontaneously scheduled when time permits based on the current rotation schedule.  During both the second and third year rotation, he residents should read entire 7th Edition of Speroff and Fritz, Clinical Gynecologic Endocrinology & Infertility, and review the appropriate chapters and be prepared for discussion.   Also, read Chapters from 3rd Edition Comprehensive Gynecology.  Common topics for discussion will be as follows:

back to top

JOURNAL CLUB

We place emphasis on learning the skills necessary to continue your education after formal training is complete. Each month the resident will be expected to present one original article from within the last six months of Fertility and Sterility or Human Reproduction.  Case reports and review articles are not appropriate.  Each resident will review one paper and give a short (10-15 minute) presentation.  He or she will be expected to read methods section and provide some background as to the relevancy of this article.  He or she will also be asked their opinion about the quality of the research.  See attached guidelines for reviewing a medical report.  Faculty will assist in article selection and discussion.

GUIDELINES FOR REVIEWING A MEDICAL REPORT

back to top

Evaluation and Summary

The faculty will assess the performance of each resident by observing his or her ability to evaluate outpatients, preparedness at didactic sessions, self-initiated learning, and technical skills.  The faculty will provide an assessment of the resident to the Chairman's office with individual comments by each faculty member. Time will be scheduled during the last week of the rotation for a conference to discuss resident performance.

The faculty of the Division of Reproductive Endocrinology understands that only a small percentage of residents will choose to pursue careers in this discipline. However, we also recognize that the time spent with our division is likely to be the only formal exposure of a resident to reproductive endocrinology. Therefore, there is significant pressure for both faculty and residents to get the most out of this time. Residents should expect that an enthusiastic commitment to learn would be rewarded with an enthusiastic commitment to teach.

RESIDENT ASSIGNMENTS (2006-2007)

back to top