New Application: Female Pelvic Medicine and Reconstructive Surgery

Review Committee for Obstetrics and Gynecology or Urology

ACGME

Sponsoring Institution

  1. Does the sponsoring institution also sponsor ACGME-accredited residency programs in the following: [PR I.A.1.]

a)Obstetrics and Gynecology...... ☐ YES ☐ NO

b)Urology...... ☐ YES ☐ NO

  1. Describe how the program functions as an integral part of an ACGME-accredited residency in either obstetrics and gynecology or urology. [PR I.A.1.a)](Limit response to 100 words)

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  1. Is the fellowship program affiliated with an LCME-accredited medical school? [PR I.A.1.b)]
    ☐ YES ☐ NO

Program Personnel and Resources

Faculty

  1. Does the faculty include: [PR II.B.9.]

a)Colorectal surgeons...... ☐ YES ☐ NO

b)Gastroenterologists...... ☐ YES ☐ NO

  1. Briefly explain the role of the colorectal surgeon and gastroenterologist faculty member(s) in the education of fellows. [PR II.B.9.](Limit response to 200 words)

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Resources

  1. Indicate whether the following resources are available at the primary clinical site and whether access to these resources is available at all times.[PR II.D.1.]

Available at Primary Clinical Site / Accessible at All Times
Operating rooms / ☐ YES ☐ NO / ☐ YES ☐ NO
Ambulatory clinic facilities / ☐ YES ☐ NO / ☐ YES ☐ NO
Recovery rooms / ☐ YES ☐ NO / ☐ YES ☐ NO
Intensive care units / ☐ YES ☐ NO / ☐ YES ☐ NO
Blood banks / ☐ YES ☐ NO / ☐ YES ☐ NO
Diagnostic laboratories / ☐ YES ☐ NO / ☐ YES ☐ NO
Imaging services / ☐ YES ☐ NO / ☐ YES ☐ NO
  1. Does the program have clinical and laboratory infrastructure for research facilities equipped to enablefellows to engage in scholarly activities? [PR II.D.2.] ☐ YES ☐ NO
  1. Briefly explain the facilities and infrastructure for clinical and laboratory research available to the fellowship. Include type of laboratory space, equipment, database access, faculty resources, including statistical support available, and other pertinent resources. [PR II.D.2.](Limit response to 200 words)

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Fellow Appointments

Are fellows informed, prior to entering the program, of the requirements for completing the program, including the criteria to qualify for the subspecialty board examination?[PR III.A.3] ☐ YES ☐ NO

Educational Program

At the beginning of the program, does each fellow receive an individual educational plan that includes a monthly block rotation diagram displaying the clinical, didactic, and research activities by rotation?
[PR IV.A.2.a)]...... ☐ YES ☐ NO

The Review Committee recommends the use of either Option 1 or Option 2 of the sample block diagram.

Regularly Scheduled Didactic Sessions

  1. Indicate whether fellows participate in the following activities: [PR IV.A.3.a)]

a)Didactics...... ☐ YES ☐ NO

Indicate frequency...... [ Frequency]

b)Journal clubs...... ☐ YES ☐ NO

Indicate frequency...... [ Frequency]

c)Morbidity and mortality conferences...... ☐ YES ☐ NO

Indicate frequency...... [ Frequency]

d)Seminars...... ☐ YES ☐ NO

Indicate frequency...... [ Frequency]

  1. Indicate whether the didactic topics include the following:
    Have the conference schedule available for the site visitor.

a)Anatomy and physiology of the pelvic floor, including the lower urinary tract, and colorectal-anal and vaginal function [PR IV.A.3.a).(1)] ☐ YES ☐ NO

b)Behavioral, pharmacological, functional, and surgical treatment of urinary incontinence, anal incontinence, and pelvic floor dysfunction, including micturition and defecation disorders, and pelvic organ prolapse [PR IV.A.3.a).(2)] ☐ YES ☐ NO

c)Diagnosis and evaluation of pelvic floor dysfunction, including urinary incontinence, voiding dysfunction, pelvic organ prolapse, defecation disorders, and sexual dysfunction
[PR IV.A.3.a).(3)] ...... ☐ YES ☐ NO

d)Diagnosis and management of genitourinary and rectovaginal fistulae, urethral diverticula, injuries to the genitourinary tract, congenital anomalies, and infectious and non-infectious irritative conditions of the lower urinary tract and pelvic floor [PR IV.A.3.a).(4)] ☐ YES ☐ NO

e)Management of genitourinary complications of vaginal delivery, spinal cord injuries, and medical, psychiatric, and geriatric conditions related to pelvic floor disorders [PR IV.A.3.a).(5)]
☐ YES ☐ NO

f)Pathophysiology of pelvic floor dysfunction, including urinary incontinence, voiding dysfunction, pelvic organ prolapse, anal incontinence,defecation disorders and sexual dysfunction
[PR IV.A.3.a).(6)]...... ☐ YES ☐ NO

g)Research design, grant writing, research methodology, and scientific writing and presentation skills [PR IV.A.3.a).(7)] ☐ YES ☐ NO

Patient Care

Indicate the settings and activities in which fellows demonstratecompetence in each of the following areas of patient care. Also indicate the method(s) used to assesscompetence.

Examples of assessment methods:

Direct observation, videotaped/recorded assessment, global assessment, simulations/models, record/chart review, multisource assessment, patient survey, structured case discussions, anatomic or animal models, formal oral or written exam, practice/billing audit, review of case or procedure log, review of patient outcomes, review of drug prescribing.

Competency Area / Settings/Activities / Assessment Method(s)
Assessing the effects of treatment, and recognizing and managing the complications of therapy
[PR IV.A.5.a).(2).(a).(i)] / Click here to enter text. / Click here to enter text. /
Diagnosing and managing patients with urinary incontinence, pelvic organ prolapse, genitourinary and rectovaginal fistulae, anal incontinence, urethral diverticula, injuries to the genitourinary tract, congenital anomalies, and infectious and non-infectious irritative conditions of the lower urinary tract and pelvic floor
[PR IV.A.5.a).(2).(a).(ii)] / Click here to enter text. / Click here to enter text. /
Evaluating the lower urinary and genital tracts for abnormalities, including neoplasms, and interpreting cytology and biopsy results
[PR IV.A.5.a).(2).(a).(iii)] / Click here to enter text. / Click here to enter text. /
Performing advanced laparoscopic, abdominal, and vaginal surgery for uterovaginal and post-hysterectomy vaginal vault prolapse, including reconstructive and obliterative procedures
[PR IV.A.5.a).(2).(a).(iv)] / Click here to enter text. / Click here to enter text. /
Performing cystoscopy and cystoscopic manipulations, including stent placement retrograde pyelograms, and ureteral stent placement
[PR IV.A.5.a).(2).(a).(v)] / Click here to enter text. / Click here to enter text. /
Performing urodynamic testing
[PR IV.A.5.a).(2).(a).(vi)] / Click here to enter text. / Click here to enter text. /
Performing surgery for urinary incontinence, including native and synthetic slings and periurethral bulking agents
[PR IV.A.5.a).(2).(a).(vii)] / Click here to enter text. / Click here to enter text. /
Performing surgery for complicated obstetric lacerations, and treatment of related benign conditions occurring in the female pelvis
[PR IV.A.5.a).(2).(a).(viii) / Click here to enter text. / Click here to enter text. /
Fellows Completing the F1 Year:
Evaluating and managing hematuria
[PR IV.A.5.a).(2).(b).(i)] / Click here to enter text. / Click here to enter text. /
Evaluating and managing painful bladder, including interstitial cystitis
[PR IV.A.5.a).(2).(b).(ii)] / Click here to enter text. / Click here to enter text. /
Evaluating and managing neurogenic voiding dysfunction
[PR IV.A.5.a).(2).(b).(iii)] / Click here to enter text. / Click here to enter text. /
Evaluating and treating urinary tract infections
[PR IV.A.5.a).(2).(b).(iv)] / Click here to enter text. / Click here to enter text. /
Performing a female pelvic exam, including quantification of pelvic organ prolapse
[PR IV.A.5.a).(2).(b).(v)] / Click here to enter text. / Click here to enter text. /
Fellows Completing the F2 Year:
The behavioral, pharmacological, functional, non-surgical, and surgical treatment of:
Micturition and defecation disorders
[PR IV.A.5.a).(2).(c).(i)] / Click here to enter text. / Click here to enter text. /
Pelvic organ prolapse
[PR IV.A.5.a).(2).(c).(ii)] / Click here to enter text. / Click here to enter text. /
Urinary incontinence
[PR IV.A.5.a).(2).(c).(iii)] / Click here to enter text. / Click here to enter text. /
Fellows Completing the F3 Year:
Diagnosing and managing genitourinary and rectovaginal fistulae, urethral diverticula, injuries to the genitourinary tract, and congenital anomalies
[PR IV.A.5.a).(2).(d).(i)] / Click here to enter text. / Click here to enter text. /
Managing genitourinary complications of vaginal delivery spinal cord injuries and similar health events
[PR IV.A.5.a).(2).(d).(ii)] / Click here to enter text. / Click here to enter text. /

Medical Knowledge

Indicate the activities (lectures, conferences, journal clubs, clinical teaching rounds, etc.) in which fellows demonstratecompetence in their knowledge of each of the following areas. Also indicate the method(s) used to assessfellow competence.

Competency Area / Settings/Activities / Assessment Method(s)
Fellows Completing the F1 Year:
The epidemiology of urinary incontinence, pelvic organ prolapse, and defecation disorders, including birth, aging, and neurologic disease
[PR IV.A.5.b).(1).(a)] / Click here to enter text. / Click here to enter text. /
The impact of urinary incontinence, pelvic organ prolapse, and defecation disorders on quality of life
[PR IV.A.5.b).(1).(b)] / Click here to enter text. / Click here to enter text. /
The use and interpretation of disease-specific and global health questionnaires to evaluate the impact of pelvic floor disorders on quality of life
[PR IV.A.5.b).(1).(c)] / Click here to enter text. / Click here to enter text. /
The scientific method of problem solving and evidence-based decision making
[PR IV.A.5.b).(1).(d)] / Click here to enter text. / Click here to enter text. /
Indications, contraindications, limitations, complications, techniques, and interpretation of results of those diagnostic and therapeutic procedures integral to the discipline, to include:[PR IV.A.5.b).(1).(e)]
The indications for and use of screening tests and procedures, including urinalysis, urine cytology, and pad test
[PR IV.A.5.b).(1).(e).(i)] / Click here to enter text. / Click here to enter text. /
Use and interpretation of a voiding diary
[PR IV.A.5.b).(1).(e).(ii)] / Click here to enter text. / Click here to enter text. /
Fellows Completing the F2 Year:
The anatomy, physiology, and pathophysiology of the pelvic floor, including the lower urinary tract, and colorectal-anal and vaginal functioning
[PR IV.A.5.b).(2).(a)] / Click here to enter text. / Click here to enter text. /
Clinically pertinent areas of pathology, infectious disease, geriatric medicine, physical therapy, pain management, sexual dysfunction, and psychosocial aspects of pelvic floor disorders
[PR IV.A.5.b).(2).(b)] / Click here to enter text. / Click here to enter text. /
Indications, contraindications, limitations, complications, techniques, and interpretation of results of screening, diagnostic, and therapeutic procedures for the treatment and evaluation of pelvic floor disorders, to include: [PR IV.A.5.b).(2).(c)]
Pelvic imaging studies for the diagnostic evaluation of urinary and anal incontinence, pelvic floor dysfunction, and prolapse
[PR IV.A.5.b).(2).(c).(i)] / Click here to enter text. / Click here to enter text. /
Urodynamic assessment
[PR IV.A.5.b).(2).(c).(ii)] / Click here to enter text. / Click here to enter text. /
Fellows Completing the F3 Year:
Assessment and treatment of lower urinary tract dysfunction secondary to neurologic diseases
[PR IV.A.5.b).(3).(a)] / Click here to enter text. / Click here to enter text. /
Indications, contraindications, limitations, complications, techniques, and interpretation of results of screening, diagnostic, and therapeutic procedures for surgery for:
Pelvic organ prolapse
[PR IV.A.5.b).(3).(b).(i)] / Click here to enter text. / Click here to enter text. /
Urinary incontinence
[PR IV.A.5.b).(3).(b).(ii)] / Click here to enter text. / Click here to enter text. /
Rectovaginal fistula related to obstetric trauma
[PR IV.A.5.b).(3).(b).(iii)] / Click here to enter text. / Click here to enter text. /
Vesicovaginal fistula and urethrovaginal fistula
[PR IV.A.5.b).(3).(b).(iv)] / Click here to enter text. / Click here to enter text. /
Quantitative techniques, including biostatistics, epidemiology, research design, and research methods[PR IV.A.5.b).(3).(c)] / Click here to enter text. / Click here to enter text. /

Practice-based Learning and Improvement

  1. Briefly describe one learning activity in which fellows demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on self-evaluation and life-long learning. [PR IV.A.5.c)] (Limit response to 400 words)

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  1. Briefly describe one planned learning activity in which fellows engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; and identify and perform appropriate learning activities to achieve self-identified goals (life-long learning). [PR IV.A.5.c).(1)-(3)] (Limit response to 400 words)

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  1. Briefly describe one planned quality improvement activity or project that will allow the fellow to demonstrate an ability to analyze, improve, and change practice or patient care. Describe planning, implementation, evaluation, and provisions of faculty member support and supervision that will guide this process. [PR IV.A.5.c).(4)] (Limit response to 400 words)

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  1. Briefly describe how fellows will receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is used to evaluate these skills have it available for review by the site visitor.) [PR IV.A.5.c).(5)] (Limit response to 400 words)

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  1. Briefly describe one example of a learning activity in which fellows engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients' health problems. [PR IV.A.5.c).(6)-(7)] (Limit response to 400 words)

The description should include:

  • Locating information
  • Using information technology
  • Appraising information
  • Assimilating evidence information (from scientific studies)
  • Applying information to patient care
  • Conducting a comprehensive literature search

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  1. Briefly describe how fellows will participate in the education of patients, families, students, residents, and other health professionals. [PR IV.A.5.c).(8)] (Limit response to 400 words)

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Interpersonal and Communication Skills

  1. Briefly describe one learning activity in which fellows demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. [PR IV.A.5.d)] (Limit response to 400 words)

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  1. Briefly describe one learning activity in which fellows develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with physicians, other health professionals, and health-related agencies.
    [PR IV.A.5.d).(1)-(2)] (Limit response to 400 words)

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  1. Briefly describe one learning activity in which fellows develop their skills and habits to work effectively as members or leaders of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities. [PR IV.A.5.d).(3)] (Limit response to 400 words)

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  1. Briefly describe how fellows will be provided with opportunities to act in a consultative role to other physicians and health professionals. [PR IV.A.5.d).(4)] (Limit response to 400 words)

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  1. Briefly describe how fellows will be provided with opportunities to maintain comprehensive, timely, and legible medical records, if applicable. [PR IV.A.5.d).(5)] (Limit response to 400 words)

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Professionalism

Briefly describe the learning activity(ies), other than lecture, by which fellows develop a commitment to carrying out professional responsibilities and an adherence to ethical principles, including: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity and responsiveness to a diverse patient population, including diversity in gender, age, culture, race, religion, disabilities, and sexual orientation [PR IV.A.5.e).(1)-(5)] (Limit response to 400 words)

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Systems-based Practice

  1. Briefly describe the learning activity(ies) through which fellows demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. [PR IV.A.5.f)] (Limit response to 400 words)

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  1. Describe the learning activity(ies) through which fellows achieve competence in the elements of systems-based practice: working effectively in various health care delivery settings and systems, coordinating patient care within the health care system; incorporating considerations of cost-containment and risk-benefit analysis in patient care; advocating for quality patient care and optimal patient care systems; and working in interprofessional teams to enhance patient safety and care quality. [PR IV.A.5.f).(1)-(5)] (Limit response to 400 words)

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3.Describe an activity that fulfills the requirement for experiential learning in identifying system errors and implementing potential systems solutions. [PR IV.A.5.f).(6)] (Limit response to 400 words)

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Curriculum Organization and Fellow Experiences

  1. Do fellows have supervised responsibility for the total care of the patient, including initial evaluation, establishment of diagnosis, selection of appropriate therapy, and management of complications? [PR IV.A.6.a).(1)] ☐ YES ☐ NO

If “NO,” explain. Limit response to 100 words.

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  1. Briefly describe how fellows participate in continuity of patient care through pre- and post-operative clinics and inpatient contact. [PR IV.A.6.a).(2)]

Limit response to 100 words.

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  1. Do fellows record all surgical procedures in which they have a significant role in the ACGME Case Log System? [PR IV.A.6.a).(3)] ☐ YES ☐ NO
  1. Do fellows participate in the diagnosis and management of clinically pertinent areas of:
    [PR IV.A.6.d)]

a)pathology...... ☐ YES ☐ NO

b)infectious disease...... ☐ YES ☐ NO

c)geriatric medicine...... ☐ YES ☐ NO

d)physical therapy...... ☐ YES ☐ NO

e)pain management...... ☐ YES ☐ NO

f)pre- and post-operative care...... ☐ YES ☐ NO

g)sexual dysfunction...... ☐ YES ☐ NO

h)psychosocial aspects of pelvic floor disorders...... ☐ YES ☐ NO

Explain any “NO” responses. Limit response to 200 words.

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Fellows’ Scholarly Activities

Describe the curriculum for the fellows’ scholarly activities,to include research design, grant writing, research methodology, scientific writing, and presentation skills.[PR IV.B.2.a)]

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Evaluation

Formative Evaluation

Is each fellow’s scholarly activity monitored by a faculty member and confirmed by a competency assessment committee that includes at least one physician scientist not affiliated with the program?
[PR V.A.2.a).(1)]...... ☐ YES ☐ NO

Summative Evaluation

  1. Does each fellow give an oral presentation of his or her scholarly project (thesis)?
    [PR V.A.3.a).(1)]...... ☐ YES ☐ NO
  1. Do faculty members provide written evaluations of these presentations?[PR V.A.3.a).(1)]
    ☐ YES ☐ NO

Include a copy of the thesis evaluation form with the final (summative) evaluation (Attachment #6).

  1. Provide the name of the Thesis Evaluation Committee faculty mentor and committee members for each fellow in the program.[PR V.A.3.a).(1)]

Fellow / Click here to enter text. /
Faculty mentor / Click here to enter text. /
Committee members / Click here to enter text. /

Institutional Data