Clinical Training

Years two and three of the University Hospitals Gynecologic Oncology Fellowship are devoted to in-depth clinical training. The clinical fellows are involved in all aspects of the care of patients with gynecologic malignancies, including:

• Outpatient evaluation and follow-up
• Surgery
• Chemotherapy and radiation therapy
• Post-operative care
• Intensive care
• Palliative care

Clinical Rotations

Philosophy Graduated responsibility: Our Division embraces the Milestones process as described by ACGME, and progression of clinical responsibility is a central goal for fellowship training programs. These competency-based outcomes serve as a guide to facilitate progressive responsibility of fellows throughout their inpatient and outpatient rotations. Thus, while the physical structure of the rotations for the second and third year fellow are similar, they will differ in very important ways based on a philosophy of progressive responsibility and in a manner outlined by the Gynecologic Oncology Milestones Project. Attending mentors will assess on an ongoing basis each fellow’s progress toward achieving Milestones. When relevant, competency based goals and objectives are distinguished by year of training and align with Milestones metrics. However, the level of responsibility allowed each fellow in each domain and at each stage of training will vary and, by necessity, the process of graduated responsibility needs to be flexible and individualized. Evaluation is competency-based, documented by those having direct observation of the Milestone being assessed, and timely in the event of any observed deficiencies.

Inpatient Gynecologic Oncology Rotation

The Gynecologic Oncology inpatient rotation is centered at University Hospitals Seidman Cancer Center. The rotation provides comprehensive experience on the many aspects of patient care for patients with gynecologic malignancies that require inpatient management. With this experience, the fellow will gain a comprehensive understanding of the oncologic, medical and social issues of patient’s with gynecologic cancers. Fellows participate in relevant surgeries and manage the subsequent postoperative care of the patient. They also participate in the care of all patients admitted to our service for acute problems, for chemotherapy and for palliative care. Fellows also participate in all inpatient consults.

Fellows gain valuable leadership skills on the Gynecologic Oncology inpatient service as they play a pivotal role in directly overseeing the activities of three residents, two nurse practitioners and medical students. They also play a central role in communication with gynecologic oncology faculty, consulting faculty, pharmacy staff, nursing, social work and other ancillary personnel.

Finally, fellows in the outpatient rotation will lead the inpatient and surgery portion of the QA meetings. They will also prepare and participate in discussions at the weekly Tumor Board conferences.

The Inpatient Gynecologic Oncology Team during the week consists of:

• One Gynecologic Oncology attending of the day
• One clinical Gynecologic Oncology fellow
• One Clinical Nurse Practitioner
• Three residents (first, second, and third year resident)
• One Acting Intern (variable)

The Gynecologic Oncology Outpatient Rotation

The Gynecologic Oncology outpatient rotation will serve to provide a focused outpatient experience for fellows-in-training. The rotation provides comprehensive experience on the many aspects of patient care for patients with gynecologic malignancies that require outpatient management. With this experience, the fellow will gain a comprehensive understanding of the oncologic, medical and social issues of patient’s with gynecologic cancers.

Fellows on this rotation will participate in clinics at UH Seidman Cancer Center with the four gynecologic oncology faculty. Fellows will see patients independently, gather relevant background information and present them to the attending, who will examine the patient with the fellow. Following examination, fellows will participate in the review of imaging studies and clinical materials and discuss treatment planning for each individual patient with the attending. Fellow will also perform outpatient procedures as needed. These include, but are not limited to colposcopy, diagnostic biopsy, paracentesis, and ultrasound.

Most chemotherapy is administered in an outpatient setting and, importantly, the outpatient fellow will be immersed in the practical application of chemotherapy by participating in continuity care of our patients on active treatment. Through these interactions the fellows will gain an understanding of chemotherapy indications, dosing, administration and toxicity management. Some patients will be considered for clinical trial participation and fellows will also gain an important understanding of the process of informed consent and clinical trial enrollment in this setting. Moreover, the pharmacists at the satellite cancer centers are physically very closely located in the clinic/infusion centers and time the outpatient fellow will work with the pharmacists to gain their perspectives on chemotherapy administration, preparation and cost.

Key Components

Key components of progression of proficiency and responsibility for both inpatient and outpatient rotations include gaining an understanding of the basic principles of evaluation and management of gynecologic oncology patients as a second year. These include refining an understanding and gaining competency in the mechanisms of carcinogenesis, genetics, disease processes of the gynecologic malignancies, pathophysiology, pharmacology, surgical procedures, chemotherapy management, postoperative care and palliative care. Third year fellows will continue to refine this knowledge base as well as gain further competency in managing unusual presentations and diagnosing and managing complications. They will also be expected to describe the evidence that supports their clinical decision-making and will be afforded a greater degree of latitude for independent decision-making. They will be expected to play a greater role in teaching junior residents, nursing personnel and medical students in varying capacities, formally with didactics and conferences and informally during the course of managing the inpatient service and their outpatient rotation.

The Fellow Service

Third year fellows have an additional clinic of their own. Continuity clinic is structured to prioritize longitudinal relationships for continuous management of all aspects of care for gynecologic cancer patients. It is on Fridays throughout the fellow’s third year and irrespective of which rotation they are on. Comprehensive treatment plans are formulated and executed by the fellow with faculty mentorship using graded autonomy.

Off Service Rotations

In addition to a required rotation with Radiation Oncology in their third year, the fellows have the opportunity to explore other electives. These include Palliative Care, Surgical Oncology, Colorectal Surgery, and Urology.