General Obstetrics and Gynecology
At The Mount Sinai Hospital, the inpatient Obstetrics service is responsible for intrapartum and peripartum care of both service and private patients. During the day, first-, second-, and fourth-year residents are responsible for management of the labor and delivery floor. At night, a third-year resident with no daytime responsibilities manages the labor and delivery floor with the assistance of a physician’s assistant or a junior resident. Immediate backup is always available from the in-house chief resident, and 24-hour in-house attending coverage is provided. The postpartum floors are managed by the entire team. Care of service patients is the responsibility of the residents, with supervision and consultation by attending physicians. Over 6,500 deliveries a year take place at Mount Sinai, of which 70 percent are private and 30 percent are service.
The Obstetrics service at Elmhurst Hospital Center (EHC) is managed by a third-year resident working with a first- and second-year resident. Approximately 4,500 patients deliver each year at EHC, all of whom are on the clinic service. The prenatal clinics are staffed by a third-year resident working with nurse-midwives. At night, the labor floor, as well as the emergency room, is managed by either a third- or fourth-year resident, a second-year resident, and an intern. The attending staff provide active supervision of all aspects of the residents’ work. This supervision includes daily rounds and 24-hour in-house coverage for consultation.
Over 3,500 surgical procedures, including major and minor abdominal, vaginal, and endoscopic operations, are performed annually at The Mount Sinai Hospital. Operating rooms are designated for gynecologic cases, five days a week.
The inpatient Gynecology service is supervised by a team of attendings that make daily rounds with the residents. Inpatient and ambulatory gynecologic surgery and patient management are performed by residents under the supervision of attendings and senior residents.
Keeping pace with the rapidly changing world of medicine, the Division of General Gynecology has created several subdivisions and subspecialties. Residents train with faculty whose areas of expertise include urogynecology, infectious disease, breast disease, operative gynecology, operative laparoscopy, adolescent health, colposcopy, family planning, geriatric gynecology, and menopause.
The Division of General Gynecology has designated specialty clinics for urogynecology, reproductive endocrinology, and colposcopy. Residents rotate through these clinics, which are all held at MSMC. The Division of General Gynecology also serves the Department of Emergency Medicine, where many patients with gynecologic problems are seen each year. Nearly 13,000 gynecologic visits per year are managed in the outpatient clinics.
At Elmhurst Hospital Center, the gynecology team staffs an operating room two and a half days per week and runs a busy gynecology clinic three sessions per week. Each year, over 1,300 major and minor gynecologic operative procedures are performed at EHC. As EHC is a major municipal hospital, the rotations there offer the residents valuable exposure to an ethnically diverse patient population with complicated gynecologic problems.
Subspecialties in Obstetrics and Gynecology
The Division of Maternal-Fetal Medicine cares for patients with pregnancies at increased risk of adverse outcome. After being identified as appropriate candidates by their referring physicians, both private and service patients are accepted onto the High-Risk Obstetrics service at any time during their gestation. Each second-year resident spends two months on this service at The Mount Sinai Hospital, and each third-year resident spends two months on this service at Elmhurst Hospital Center.
Weekly high-risk and gestational diabetes clinics are staffed by the residents under the direction of the Maternal-Fetal Medicine fellows and faculty. Other activities performed on the High-Risk Obstetrics service include Level II ultrasound examinations and invasive fetal diagnostic and therapeutic procedures. Depending upon the nature of the procedure, the resident on service performs, observes, or assists in these activities. Postpartum high-risk patients are followed in a special clinic to ensure further continuity of care for those requiring ongoing medical services.
The resident is part of a high-risk team comprising full-time attendings in maternal-fetal medicine, fellows, full-time social workers, and nurse-educators. The entire team makes rounds each morning to discuss all patients on the service and to review the ongoing care of high-risk outpatients. The resident has ample opportunity to discuss cases in depth with the attendings on service.
Several regularly scheduled perinatal teaching conferences enhance resident education. These include monthly maternal-fetal medicine and pediatric pathology conferences, weekly maternal-fetal medicine and neonatology conferences, weekly maternal-fetal medicine and genetics conferences and daily service rounds.
The Division of Reproductive Endocrinology encompasses a wide array of clinical and research activities. Clinical activities include over 600 assisted reproductive technology cycles per year and over 200 surgical procedures for the diagnosis and management of reproductive disorders. An active research program is currently pursuing investigations into oocyte fertilization, implantation, and embryo-endometrial interaction.
During the four-year program, residents attend and assist in the presentation of conferences on selected topics in endocrinology and infertility. They also diagnose, admit, care for, and assist in or perform operative laparoscopy and other surgery. In the general obstetrics and gynecology clinics, residents are able to provide continuing care and follow-up for women with infertility problems or endocrine disease, receiving direct supervision and consultation from attendings in the Division.
A two-month rotation in the Division of Reproductive Endocrinology is provided at the third-year level, when residents attend endocrine and infertility clinics each week. Here residents follow and manage patients under the direction of the division’s attendings. Residents also rotate through Mount Sinai’s in vitro fertilization program in its brand-new state-of-the-art facility.
Opportunities are available during the reproductive endocrinology rotation for residents to attend thyroid and other medical endocrinology clinics and conferences, and to participate in the many research activities of the Division.
Residents gain experience in gynecologic oncology by rotation through the Gynecologic Oncology service during two two-month blocks, once in their first year, and again in their third year. During these times the residents care for patients with gynecologic cancer, under the direct supervision of the gynecologic oncology fellows and attendings. In addition, the residents attend the gynecologic oncology clinic. This allows them experience in the areas of diagnosis and treatment as well as experience in managing pre and post operative patients and the specialized concerns that come with a cancer diagnosis. This is a multidisciplinary experience encompassing palliative care, chemo care, social concerns and med/surg management.
Approximately two dozen inpatients are on the Gynecologic Oncology service at any one time. The third-year residents scrub on all surgical cases with the oncology fellows and attendings. Weekly multidisciplinary conferences are held in which the management of all patients currently under treatment for gynecologic cancer is coordinated with radiation oncologists, pathologists, social workers, nurses, and other specialists.
Fourth-year residents utilize the resources of the Division of Gynecologic Oncology for the management of complex patients on the General Gynecology service. In addition, these residents may perform or assist in surgical procedures too advanced for the first- or third-year residents. During the fourth-year, residents attend the colposcopy and gynecology clinics.
Urogynecology and Pelvic Reconstructive Surgery
The Division of Urogynecology focuses on disorders of the lower urinary tract and pelvic floor. Chief Residents participate directly in the care of private patients and direct the care of a growing population of clinic patients who suffer from problems such as urinary incontinence, lower urinary tract symptoms, and pelvic organ prolapse. Under the supervision of the faculty, residents are taught to diagnose and treat these problems, using a variety of objective and subjective tools, including simple and complex urodynamic testing and a variety of minimally-invasive and transvaginal surgical techniques. Once residents have demonstrated competence and expertise in this area, she or he takes charge of the weekly clinic session and has the primary role in appropriately guiding the therapeutic choices of their patients, in anticipation of their approaching development into Attending Physicians. An interdisciplinary approach incorporating the Departments of Urology and ColoRectal Surgery is currently being implemented. In addition, there are ongoing opportunities for clinical research and training in research study design and implementation.
Other Rotations and Activities
Through a weekly lecture series and departmental Grand Rounds, residents are instructed in a broad curriculum of basic science and clinical medicine, including a full range of topics related to primary health care. Residents are provided with formal courses in Advanced Cardiac Life Support and Neonatal Resuscitation and attend animal and simulator laboratory sessions in endoscopic surgical techniques. In addition, residents actively participate in the education of medical students rotating through the Department.
Residents participate in the various research activities of the Department. There are numerous areas of active research in all divisions, at both the clinical and basic science levels. Each third-year resident presents a research project at the Residents’ Research Day, held each year in the late spring.
Through a unique collaborative effort between Mount Sinai and Planned Parenthood of New York, second year residents receive an in depth education in all aspects of family planning. This includes training in surgical and medical abortion as well as contraception and sterilization. A series of lectures is also provided by attending staff from both institutions.
The Obstetrical Ultrasonography Unit at The Mount Sinai Hospital, staffed entirely by members of the Division of Maternal-Fetal Medicine, performs all obstetrical ultrasound examinations at Mount Sinai and serves as a major referral center for the New York metropolitan area. This seven bed unit, which is outfitted with state-of-the-art ultrasound equipment, operates eight hours a day and is staffed by full-time registered diagnostic sonographers and attending perinatolgists. Various non-invasive and invasive procedures for prenatal diagnosis and therapy, including fetal blood sampling, intrauterine transfusion, fetal skin biopsy, fetal shunt placement, chorionic villus sampling, amniocentesis, and multifetal pregnancy reduction, are performed there.
Throughout the residency program, residents gain extensive experience in sonography. Residents receive formal training in gynecologic and early pregnancy ultrasound at PPNYC. Additional training in endovaginal ultrasonography is given during the Reproductive Endocrinology rotation. Ultrasound machines with endovaginal probes are available in the outpatient clinic, on the Gynecology ward, and in the Emergency Department for use by the residents at any time.
At The Mount Sinai Hospital, there is a weekly pathology conference to discuss all gynecologic oncology cases. Relevant topics are covered with the hospital’s gynecologic pathologist, and surgical cases performed by the Gynecology and Oncology services are reviewed. MSMC’s pathologists contribute a variety of lectures during the Resident Didactic time and are always available for consult.
At Elmhurst Hospital Center, residents meet weekly with a gynecologic pathologist to review the surgical specimens of the previous week. The Department of Pathology conducts a presentation of material from the entire Gynecology service every month.
All first-year residents spend two months assigned exclusively to the Department of Emergency Medicine at The Mount Sinai Hospital. During this rotation, residents take eight- and twelve-hour shifts in the Emergency Department, gaining experience in the management of a broad range of medical and surgical problems.
Ambulatory Obstetrics and Gynecology
The general obstetrics and gynecology clinics at The Mount Sinai Hospital are unified and fully-integrated continuity clinics. Based on a large "group practice" model, the ambulatory clinics take place in a spacious facility within the Hospital. All residents, beginning in their first year, are assigned a weekly panel of patients; assignments are made based on a resident's level of experience. Patients registered in the clinic for gynecologic care continue to see the same resident for prenatal and postpartum care if they become pregnant, and patients registered for obstetrical care continue to see the same resident for postpartum and gynecologic care.
The residents clinics meet weekly throughout the year, including when the resident is on rotation away from The Mount Sinai Hospital. One attending and one or two chief residents are present at each clinic session to teach and supervise all aspects of patient care. Backup coverage for ward duties is provided to ensure that clinic takes precedence over all other assignments. Residents are encouraged to follow their patients when they are admitted to the Hospital and to coordinate their inpatient care.
A number of special and subspecialty clinics are held in addition to the continuity clinics. These include colposcopy, oncology, reproductive endocrinology, high-risk obstetrics, gestational diabetes, family planning and urogynecology clinics.
In addition, separate gynecology, gynecological surgery and high risk obstetrics clinics are held at Elmhurst Hospital Center.
Residency Program Coordinator