OBGU-4031 - A/I in Urogynecology and Robotic Surgery

OBGU-4031 - A/I in Urogynecology and Robotic Surgery

Elective Title: A/I in Urogynecology and Robotic Surgery
Course Number: OBGU-4031
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 2
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful Completion of an OB Gyn Clerkship. Visiting students must seek prior approval. All students being enrolled within 3 weeks of the start date must seek prior approval.
Responsible Faculty Director: Elisha Jackson, MD Periods Offered: 1-7, 9-13 excluding holiday period 8 
Coordinator: Other Faculty: Gokhan Kilic, MD; Gabriela Halder, MD
Location to Report on First Day:
CSB 335, Galveston

Enhance student competencies in the newest technology in gynecology to medical students. Develop a basic understanding of evaluation and management of female pelvic floor disorders including but not limited to urinary incontinence, pelvic organ pro-lapse, overactive bladder and painful bladder syndrome. Introduce students to surgical management of pelvic floor disorders and other gynecology disorders using the newest technology. Recognize the importance of the interdisciplinary approach to patient care. Prepare to function as an intern in gynecological surgery.

Combining research and hands on clinical experience to facilitate futures surgeons career development. Evaluate and propose management plans for problems of Female Health in both inpatient and outpatient settings. Provide daily comprehensive hospital management of patients after surgeries. Participate in the positive impact of adapting new technology in fast recovery.

Description of course activities
Students will participate in the Urogynecology clinics where they will interview and present patients and perform exams under faculty supervision. Students will have opportunities to observe clinic procedures that are used to evaluate or treat patients with pelvic floor disorders. Students will have at least 2 days in the operating room to have hands on experience with surgical cases. For students interested in clinical research, there are opportunities to join existing projects and/or develop and complete new quality improvement projects. There will be about 32 hours a week of faculty time and about 8 hours a week for data collection/analysis which will be held on Wednesday and Thursday's from 1:00pm - 5:00pm.

Type of students who would benefit from the course
Any 3rd and 4th year students interested in seeing how to implement the new technology in medicine, academic career, seeking for Obstetrics and Gynecology residency. Consent only required for visiting students.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday 7:00 5:00
Tuesday 7:00 5:00
Wednesday 7:00 5:00
Thursday 7:00 5:00
Friday 7:00 5:00
Saturday Off Off
Sunday Off Off

 Average number of patients seen per week: 30
 Call Schedule: N/A

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
    3 days a week
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    Pre-operative Gynecology conference: Gynecology residents and faculty. Local gynecology meetings based on the availability: Gynecologists, Obstetricians, fellows and residents
  B. Frequency / Duration of Presentation(s)?
    At the end of the rotation.
  C. Format - What guidelines are set for the student's presentation?
    Academic abstract presentation
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Abstract at the end of the rotation
  B. Format - What guidelines are set for the student's written work?
    Academic abstract formation for peer review journals
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
    PubMed online
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    I will select the research project
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Resident lecture attendance.

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    Simulation: Detailed feedback from computer recorded performance scores
Surgery: Ability to perform in an actual case certain basic skills
Academic: Being able to finish an abstract in a given project

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    On robotic simulation lab, our technology allow us to measure each surgical skill sets numerically using multiple parameters such as visibility, power accuracy, movement feasibility, time frame, successfully achieving the goal, number of attempt. Each exercise consists of 12 parameters for each drill. Students are expected to finish at least 20 exercises with over 80% success rate for each surgical skill set.
Hands on active surgical participation as a first year resident in an actual cases belongs to MIS faculty. This includes suturing, uterine manipulation, trocar placement, Camera control, robotic counsel active participation. Console time will be granted after completing the simulation lab completed. After each surgical case, verbal feedback is provided to improve. If needed, more specific simulation exercises are provided.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    In an actual surgical case, students learn H&P preparation, positioning in the operating room, bladder emptying, uterine manipulator placement, Trocar placement, Laparoscopic camera maneuver, robotic counsel participation, laparoscopic trocar side closing, cystoscopy active participation, post operative rounding, reporting directly to me until discharging patient to home. Follow up the patients pathology reports. Post operative clinic visit. Acting interns actively participate in pre-, intra, and post-operative care.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    When Dr. Lee and Dr. Kilic called for in house or ER consultation for any Gynecology reason AI students join us actively evaluating and managing the patient. Most of the time faculty waits until AI finishes his/her evaluation as our junior residents would do. Same process applies when these two faculty members called in for intra operative consultation as well. Dr. Kilic is also a board certified Urogynecologist. In his vaginal urogynecology surgical cases AI students actively participate as well. In addition, open surgical cases are not an exception to the rule. AI students scrub in as well. In my private patients, whenever I have a delivery, I take my AI student to actively participate.
In addition, Dr. Kilic gets Pelvic pain referrals from UTMB faculties. I invite AI students to complete initial evaluations of these patients. Later on I set up a management plan with AI students. Dealing with this complex issue might be the only opportunity to get exposed during medical training provided to our AI students.

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    Our set up for MIS cases consists of faculty as a main surgeon, one senior resident as a first assist, one junior resident as a second assist. Our AI has been implanted to this team as a junior resident level. Depending on the surgical complexity and senior residents surgical skill level we regroup to accommodate the AIs. Such as in low complexity surgical cases with a sufficient senior resident level, I supervise without scrubbing to the case: Senior resident will be the main surgeon, junior resident will be first assist, AI will be second assist. In a high complex case, I will be the main surgeon, senior resident will be the first assist, AI will be the second assist. We will not utilize a junior resident on this case. Reminding that regular students role are always a third assist in those cases.
Pre and post op care, clinical patients care, consultations, surgical assistance role AIs resume are exactly the same way as junior residents.
The only thing they are not allowed to put an EPIC note as resident would do.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    First of all I am proud to say this is a premium rotation to develop a strong CV for their residency applications. So far our average per AI 3 abstract submission, at least 1 of them as a first author. Initial meeting with AI we define whether the student finalized his/her decision in regard to specialty they want to go. If student has not made his/her decision to Gynecology we pick the research projects which will be compatible to apply other specialties. The most important thing we provide facts to reveal what a Gynecology residency requires and what kind of life style is ahead of them if they choose this. The simulation lab, and research study office is cross my office, and I have an open office policy. Our communication is based on open communication and honesty under low pressure relationship. We facilitate inside information for them to finalize their decision. Then we develop a CV to shine.
A the end of the rotation research participation, number of surgical cases as a second assist, achievements in simulation lab automatically puts them ahead of the game in compare to their competitors in residency application process.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    Midpoint feedback is verbal based on objective and subjective parameters. Simulation lab scores, number of exercised completed to the day, number of surgical cases scrubbed in, and update on the research projects.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    There are 2 faculty members actively involved with student: Dr Kilic and Dr. Lee. On Thursdays, AIs work with Dr Kilic, and whenever Dr Kilic has surgical case. Remaining days they work closely with Dr. Lee. Faculty interaction for AIs is much superior to residents because AIs situated in very close proximity to faculty offices. In any time of the day they get the exposure to the faculty to get one on one dialog including: didactic learning, reviewing previous surgery video footages, observing surgical atlas to prepare for the next day surgery, scientific writing, statistical analysis, update in technology.
AIs vs residents interactions includes during rounding on our patients, intra operative collaborations. Pre operative meetings actively participate with residents.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    The student will work directly with multiple faculty members in the operating room and during inpatient rounds/consults. She/He will have ample opportunities to earn a quality letter of recommendation from departmental faculty. OB/Gyn residents will work closely with the student and be asked to give a detailed explanation of how they experienced the student as an acting intern.