A MANUAL FOR PLASTIC SURGERY RESIDENTS 2013 - 2014
WHAT THE SURGEON OUGHT TO BE "The conditions necessary for the surgeon are four: First, he should be learned; second, he should be an expert; third, he must be ingenious; and fourth, he should be able to adapt himself. It is required for the First that the Surgeon should not know only the principles of Surgery, but also those of medicine in theory and practice; for the Second, that he should have seen others operate; for the Third, that he should be ingenious, of good judgment and memory to recognize conditions; and for the Fourth, that he be adaptable and able to accommodate himself to circumstances. Let the surgeon be bold in all sure things, and fearful in dangerous things; let him avoid all faulty treatments and practices. He ought to be gracious to the sick, considerate to his associates, cautious in his prognostications. Let him be modest, dignified, gentle, pitiful, and merciful; not covetous nor an extortionist of money; but rather let his award be according to his work, to the means of the patient, to the quality of the issue, and to his own dignity." Guy de Chauliat, 1300-1370 Ars Chirugica THE PHYSICIAN "No greater opportunity, responsibility or obligation can fall the lot of a human being than to become a physician. In the care of suffering he needs technical skill, scientific knowledge and human understanding. He who uses these with courage, with humility and with wisdom will provide a unique service for his fellowman and will build an enduring edifice of character within himself. The physician could ask of his destiny no more than this; he should be content with no less." Tinsley R. Harrison, M.D. Principles of Internal Medicine 1950
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CONTENTS FACULTY ............................................................................ 6 2013-2014 Tulane/LSU Plastic Surgery Residency Contact Information ...................................................................... 12 THE RESIDENCY IN PLASTIC SURGERY ........................... 17 COGNITIVE SKILLS .......................................................... 21 GOALS AND OBJECTIVES ................................................. 23 Residency Goals and Objectives: First Year .................... 54 Goals and Objectives: Second & Third Year .................... 55 TULANE ROTATION OBJECTIVES ..................................... 57 OCHSNER ROTATION OBJECTIVES .................................. 58 CHILDRENS ROTATION OBJECTIVES .............................. 59 EAST JEFFERSON: HAND ROTATION OBJECTIVES .......... 60 OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER ROATION OBJECTIVES .................................................... 67 TOURO: PRIVATE PRACTICE ROTATION OBJECTIVES .... 68 THE EMERGENCY DEPARTMENT ...................................... 69 CONSULTATIONS ............................................................. 70 OPERATING ROOM .......................................................... 71 OPERATIVE CONSENT ...................................................... 66 Resident Expectations………………………………………...….69
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Evaluation………………………………………………………….77 Plastic & Reconstructive Surgery Procedural Eval .......... 78 DIDACTIC COMPONENT .................................................. 78 CONFERENCES ................................................................. 80 PLASTIC SURGERY OPERATIVE LOG (PSOL) ................... 87 RESEARCH PROJECTS ...................................................... 88 ACGME: Definition of surgeon ......................................... 89 SCHEDULING REQUIREMENTS ........................................ 94 DISASTER PLAN ............................................................... 95 DAYS OFF ......................................................................... 95 VACATION TIME .............................................................. 95 Meetings .......................................................................... 96 Sick Leave ........................................................................ 96 Benefits ........................................................................... 97 Institutional Policies: please review the following website ......................................................................................... 99 ABPS REQUIREMENTS ................................................... 100
FOREWARD 4
Welcome! The Faculty is pleased that you have chosen to continue your education in Plastic Surgery with us. Few departments offer the educational and clinical opportunities that are available here. The overall clinical and academic strength of the University is the foundation of our program. This manual has been written for your benefit and it will give you an insight into the philosophy of our plastic surgical training program. It outlines certain suggestions to help you in your educational process and it also lists certain requirements that we ask of our residents. The faculty joins me in emphasizing to you the necessity to assume, as early in your training as possible, certain critical behavior patterns which are typical of successful surgeons. These are embodied, in brief form in the passage from Guy de Chauliac, which is reproduced on the front inside cover of this manual. Inherent in the professional behavior of the surgeon is the commitment to provide first-class, continuous care for his/her patient. This means that whenever you are not available to care for your patient you will be certain that the level of care provided by your substitute is identical in intensity to the care that you would provide personally. The patient and his family should be aware of any change in the personnel responsible for their care, even for a brief interval. The conceptual foundation is the belief of the faculty that the program should be flexible enough to meet the needs of the trainees in the program. You are allowed to review your evaluations and hopefully give feed back to us so that we may continually improve the residency. You are required to meet with the Program Director at least once each quarter. You should be aware that the ultimate responsibility for your education rests with you. This faculty places a great deal of emphasis on academic and research activities. Any of the faculty will be happy to assist you in meeting these requirements.
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Once again, the Faculty welcomes you to the Tulane Plastic Surgery Residency and we look forward to fostering your growth during your surgical training. David Jansen, M.D. Program Director and Chief
FACULTY David Jansen, MD Program Director and Chief Tulane Division of Plastic Surgery Plastics: Baylor College of Medicine American Board of Plastic Surgery, 1995
Rick I. Ahmad, MD Private Practice Fellowship: The Indiana Hand Center, Indianapolis, IN Hand Surgery Fellowship American Board of Orthopaedic Surgery Certificate of Added Qualification in Hand Surgery
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Christopher R. Babycos, MD Department of Surgery, Ochsner Clinic Plastics: Tulane University Fellow in Craniofacial Surgery: Australian Craniofacial Unit, Adelaide, Australia American Board of Plastic Surgery, 1998
Benjamin J. Boudreaux, MD Private Practice Division of Plastic Surgery
Plastics: Cleveland Clinic Foundation Residency: University of Tennessee Hlth. Sciences Ctr. – Memphis, TN
Abigail E. Chaffin, MD Assistant Clinical Professor of Surgery Assistant Program Director – Tulane University Plastic Surgery Residency Tulane Division of Plastic Surgery Plastics: Tulane University Residency: Wayne State University – Detroit, MI American Board of Plastic Surgery, 2009
John Church, MD Director of Aesthetic Surgery Plastic Fellowship: Tulane University American Board of Plastic and Reconstructive Surgeons, 1977 Louisiana Society of Plastic and Reconstructive Surgeons
Calvin Johnson, Jr., MD Faculty – Aesthetic: Touro American Board of Plastic Surgery American Academy of Facial Plastic and Reconstructive Surgery, 1989 American Board of Otolaryngology-Head and Neck Surgery, 1974
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William P. Coleman, III, MD Private Practice Dermatology Residency: Tulane American Board of Dermatology, 1978 American Board of Cosmetic Surgery, 1985
Alireza Sadeghi, MD Training Director: Touro Infirmary Clinical Assistant Professor of Plastic Surgery LSU Division of Plastic Surgery Plastics: LSU Health Sciences Center-New Orleans American Board of Plastic Surgery, 2007
Charles L. Dupin, MD Clinical Professor of Plastic Surgery Program Director and Chief LSU Division of Plastic Surgery Plastics: Lenox Hill Hospital, NY American Board of Plastic Surgery, 1979
Frank J. Dellacroce, MD Private Practice Otolaryngology/Head and Neck Surgery Residency, University of Texas Health Sciences Center at Houston Plastics: LSU Health Science Center at New Orleans American Board of Otolaryngology/Head and Neck Surgery American Board of Plastic Surgeons
Lucius Doucet, MD Chief Plastic: Our Lady of the Lake Regional Medical Center Plastics: UC-Davis American Board of Plastic Surgery
Taylor Theunissen, M.D. Training Director: Our Lady of the Lake Regional Medical Center Plastics: University of Nebraska Medical Center in Omaha American Board of Plastic Surgery, 2012 8
Juan R. Escobar, MD Private Practice Plastics: Maricopa Medical Center, Mayo Clinic Scottsdale and Tulane University
Eric George, MD Private Practice Plastics: Grand Rapids, Michigan Hand Fellowship: Phoenix Integrated Mayo Clinic American Board of Plastic Surgery, 1997 Certification of added qualifications in Surgery of the Hand
Kamran Khoobehi, MD Assistant Clinical Professor of Surgery Division of Plastic Surgery Plastics: LSU School of Medicine-New Orleans American Board of Plastic Surgery, 2000 John Lindsey, MD Private Practice Plastics: UT Southwestern Medical Center, Dallas, TX Fellowship, Hand and Microsurgery: UT Southwestern Medical Center, Dallas, TX American Board of Plastic Surgery, 1996 Added qualifications Surgery of the Hand, ABS 1996
Cynthia Mizgala, MD Private Practice Plastics: Plastic Surgery Associates, PA Woodbridge Cosmetic Surgery Hospital Scarborough General Hospital Plastic Surgery: Fellow of the Royal College of Surgeons (Canada), 1991
Michael Moses, MD Private Practice Chief, Division of Plastic Surgery Touro Infirmary 9
Director, Craniofacial Clinic Children’s Hospital Plastics: Massachusetts General Hospital, Boston, MA Fellow in Craniofacial Surgery: Children’s Hospital and Brigham and Women’s Hospital, Boston, MA American Board of Plastic Surgery, 1985
Michael R. Robichaux, Jr., MD Private Practice Residency: Alton Ochsner Medical Foundation, New Orleans, LA Orthopaedic Surgery American Board of Orthopaedic Surgery: Hand
Stephen E. Metzinger, MD Private Practice Plastics: American Academy of Facial Plastic and Reconstructive Surgery, Preceptor: G. McCollough, Birmingham, AL Fellowship: Craniomaxillofacial Surgery/Microvascular Surgery, University of Maryland Medical Center, Baltimore, Maryland American Board of Otolaryngology American Board of Facial Plastic and Reconstructive Surgery American Board of Plastic Surgery
Hugo St. Hilaire MD, DDS Assistant Professor of Clinical Surgery LSU Division of Plastic Surgery Plastics: LSU Health Sciences Center at New Orleans Fellowship: Johns Hopkins OMF, 2008 American Board of Plastic Surgery, 2009
Anthony Stephens, MD Clinical Assistant Professor – Plastic Surgery Plastics: LSU Health Sciences Center at New Orleans American Board of Plastic Surgery, 2001 Harold Stokes, MD Clinical Professor of Plastic Surgery and Orthopaedic Surgery LSU Department of Orthopaedic Surgery 10
Orthopaedic Surgery: Henry Ford Hospital, Detroit, MI Hand Fellowship: R. Guy Pulvertaft, Derby, England American Board of Orthopaedic Surgery, 1974 Added Qualifications in Surgery of the Hand, 1989, 1996
Scott K. Sullivan, MD Private Practice Plastics: LSU Health Sciences Center at New Orleans American Board of Plastic Surgeons
John Williams, MD Private Practice Plastics: The New York Hospital-Cornell Medical Center American Board of Plastic Surgeons, 1984
M. Whit Wise, MD Assistant Professor of Plastic Surgery LSU Division of Plastic Surgery Plastics: Cleveland Clinic Foundation American Board of Plastic Surgery, 2004
Tulane Plastic 11
Surgery Residency 2013-2014
Contact Information Name
Contact Number
Pager Number
Email Address
RESIDENTS Craig Blum (3rd Yr.) Joseph P. Lupo (3rd Yr.) Steven Clark (2nd Yr.)
843-818-8747 603-359-7262 214-850-5624
504-538-5174 504-538-5332 504-268-3141
[email protected];
[email protected]
Orlando Canizares (2nd Yr.)
787-949-5027
504-268-3144
[email protected];
[email protected]
Tim Matatov (1st Yr.) Rahul Vemula (1st Yr.)
718-685-6285 201-454-2196
504-538-1596 504-538-2345
[email protected];
[email protected]
[email protected];
[email protected] [email protected];
[email protected]
[email protected];
[email protected]
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M’liss Hogan (LSU - 3rd Yr.) Sybile Val (LSU-3rd Yr. ) James Mayo (LSU-2nd Yr.) Christopher Sanders (LSU-2nd Yr.)
504-669-5945 917-647-2473 843-813-6089 570-449-9919
504-423-3402 504-423-3556 504-538-2524 504-423-3446
[email protected] [email protected] [email protected] [email protected]
Daniel Womac (LSU- 1st Yr.) Mark Stalder (LSU – 1st yr.)
504-812-3090 225-802-6020
504-268-3606 504-538-2556
[email protected] [email protected]
504-988-5500 (o) 504-231-6353 (c) 504-988-3740 (f) 504-231-6353 (c) 504-455-1000 (o) 504-455-1555 (f)
Thibodeaux 985-448-0448
[email protected] [email protected] [email protected]
FACULTY David Jansen @ Tulane (Debra) David Jansen (Debbie) Charlie Dupin (Connie) Brittany Copeland LSU Coordinator Abby Chaffin (Debra) Hugo St. Hilaire
504-258-1119 (c) 504-349-6460 (o) 504-568-4748 (o) 504-568-4633 (f)
[email protected] [email protected] [email protected]
504-988-5500 (o) 313-492-0098 (c) 504-988-3740 (f)
[email protected]
504-287-7704 (c) 504-412-1310 (o) 504-835-4568 (h) 504-779-5538 (o) 504-779-5399 (f) 504-722-3188 (c) 504-568-2721 (o) 504-210-3831 (o) 504-273-9800 (c) 504-234-9326 (c) 504-842-0594 (o) 504-842-5003 (f) 985-237-6050
Kamran Khoobehi Whit Wise Alireza Sadeghi Chris Babycos (Lauren Haws) Benjamin Boudreaux
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[email protected]
504-423-7160
[email protected] [email protected]
888-307-1003
[email protected]
504-423-3471
[email protected]
504-538-8821
[email protected] [email protected] [email protected] [email protected]
Michael R. Robichaux, Jr.
225-924-2424 (o)
[email protected]
John Church
504-891-0726 (h) 504-453-1310 (c) 504-349-6330 (o) 504-477-4596 (p) 504-458-8399 (c) 504-669-8558 (c) 504-895-7200 (o) 504-894-8707 (h) 504-895-9710 (f) 225-281-2816 225-766-1899 (o) 225-766-1995 (f) 504-885-4508 (0) 504-885-4715 (f) 504-459-3517 (o) 504-495-2381 (c) 504-522-7819 (h) 832-260-6673 (c) 504-454-2191 504-914-9820 (c) 504-454-2191(o) 504-378-1837 (f)
[email protected]
Juan Escobar (Debbie)
Michael Moses
John Williams (Jeanette Kimble) John Lindsey (Theresa) Stephen Metzinger (Tiffany)
Hal Stokes Eric George (Pattie)
Charlie Clasen
[email protected]
[email protected] [email protected]
[email protected] [email protected] [email protected] [email protected]
[email protected] [email protected]
[email protected]
Taylor Theunissen Donald Faust
504-319-5122 (c) 504-899-1000 (o)
[email protected] [email protected]
Scott Sullivan
504-352-0341 (c)
[email protected]
Frank DellaCroce
504-220-5942 (c)
[email protected]
Michelle Cooper
985-646-2227 (p)
[email protected]
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Hamid Massiha Thomas Guillot
504-455-9441 (o) 504-885-5063 (f) 225-769-2955 (o)
Lucius Doucet
225-769-2955 (o)
[email protected]
Cynthia Mizgala
504-885-4515 (o) 504-554-2881 (c) 504-865-0859 (h) 504-349-6460 (o)
[email protected]
(+57) 315-559-3990 (c) 504-988-3040 (o) 985-705-0938 (c) 504-883-8900 (o)
[email protected]
504-883-8900 (o) 504-274-8545 (c) 225-767-7575 (o)
[email protected] [email protected] [email protected] [email protected]
Jon Boraski William Murillo Reza Izadpanah Elliott Black Summer Black (Anna) Anthony Stephens (Kelly) Bob Allen
504-258-9450 504-282-4949 (h)
[email protected] [email protected]
[email protected]
[email protected] [email protected]
[email protected]
John Andy Dean (Cristy Richards)
Bill Coleman
Alan Lewis Calvin Johnson Thomas Moulthrop
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225-924-7514 (o) 225-975-2118 (c) 504-251-6189 (c) 504-455-2572 (h) 504-455-3180 (o) 504-988-6332 (o) 504-220-7011 504-895-7642 (o)
[email protected]
504-895-7642 (o) 504-975-6991 (c)
[email protected]
[email protected]
[email protected] [email protected]
Rick Ahmad (Kathy) Elizabeth Kinsley Michael S. Hanemann, Jr.
Likith V. Reddy Constance M. Chen ADMINISTRATION Romney T. McLellan Staff Coordinator Vista Surgical Hospital Dr. John Clifford Medical Director GME, OLOLRMC Dr. Howard Kisner Associate Medical Director OLOLRMC Deanna Whittle Landon Tucker - Administrator Houma Outpatient Surgery Ctr.
225-921-5379 (c) 225-408-7937 (o) 985-893-3737 (o)
[email protected] [email protected] [email protected]
225-333-2552 (c) 225-766-2166 (o) 225-766-2164 (f) 504-430-3487 (c) 504-941-8216 (o) 917-697-2429 (c) 504-897-9111 (h)
[email protected]
225-819-4101
[email protected]
225-202-2225 225-765-1955
[email protected]
225-765-8871 225-765-8546
[email protected]
[email protected] [email protected]
504-456-1515 (o)
[email protected] [email protected] m
988-8060 – Main line 988-8061 – Fax line 988-8100(o), 9888102 988-8101 (f) 988-8168 988-5800
Burn Nurse: Bette Kussmann 259-5729
HOSPITALS: Tulane/Lakeside Surgery Clinic:
Tulane/Lakeside Breast Health: Tulane/Lakeside Burn Clinic: Tulane/Lakeside Aesthetic Clinic
Tulane/Downtown Clinic 16
Melanie Jeansonne: 988-8168 Plastics Appts: 988-4167
Appointments Tulane /Downtown OR Tulane/Downtown Operator
Nurse: Bette Kussmann 988-5906 988-5236
Touro Operator Touro-OR (Prytania) Touro Wound Care Center Ochsner Operator Ochsner OR Children’s Hospital -Operator Children’s Hospital –OR Children’s Hospital – ER East Jefferson Operator East Jefferson ASC
897-7011 897-8880 897-7732 842-3011 842-3540 899-9511 896-9478 896-9474 454-4000 274-2208 or 2204/2200 895-8610
Hedgewood OR OR Managers: Kathy Pratt (Ochsner)
842-3540
Mary Jo D’Amico (Touro)
897-8300
Judy Montecello (Children’s) Baton Rouge General
896-9478 225-387-7000 225-387-7767 504-454-2017 x101 504-456-1515 504-454-3810 (f)
GNO (Penny Nichols) Surgeryplex (Donna Schindler, RN)
UPDATED: 08/7/2013
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[email protected] [email protected]
CLINICAL EXPERIENCE The clinical experience available during your training will be designed to give you an in-depth education in the care of patients that fall under the broad definition of plastic surgery. The resident will rotate through eight institutions with the main core component being Tulane and Ochsner. 1. Tulane University Hospitals and Clinic In 1834, seven physicians banded together to form the Medical College of Louisiana, which today is Tulane University Health Sciences Center. At that time there were only fourteen medical schools in the United States and none west of the Allegheny Mountains. It closed during the Civil War, but during the last 100 years, has come to be known as one of the leading medical schools in the nation. Prior to Hurricane Katrina the Hospital included a 300bed tertiary care facility staffed by the faculty of the medical school. Tulane University Hospital and Clinic and the Tulane University School of Medicine are components of the Tulane University Health Sciences Center. The facility is rapidly rebuilding and has resumed operations. Seventy-two medical specialties are recognized in the Medical Center. At Tulane, the plastic surgery resident will be offered the entire breadth of our specialty and be given graded responsibility under direct faculty supervision. 2. Ochsner Foundation Hospital Includes a 442-bed tertiary care hospital dedicated to patient care, education and research. Ochsner Foundation Hospital and Clinic was founded under the leadership of Dr. Alton Ochsner, Sr., former Professor and Chairman of the Department of Surgery, Tulane University School of Medicine and several Tulane Faculty. Since its origin the Ochsner Hospital and Clinic has had congruent interests 18
and cooperative programs with Tulane. Ochsner Foundation Hospital and Clinic has a distinguished history of excellence and teaching and provides highly tertiary services as well as primary surgical care. A close relationship exists between the Department of Surgery at Ochsner and the Department of Surgery at Tulane. For nearly 60 years Ochsner has cared for residents in the greater New Orleans communities. The Ochsner main campus, which includes the hospital and clinic, are located in Jefferson Parish, but Ochsner Clinic Foundation (OCF) has 27 clinics throughout the region. 3. Touro Infirm ary Founded in 1852, Touro Infirmary is New Orleans' only community based, not-for-profit faith-based hospital. For more than 150 years, Touro has been in the vanguard of medical excellence. As one of New Orleans' most enduring monuments, Touro Infirmary stands for stability with modern facilities utilizing the latest technology. Touro is known for its quality and excellence. In 1923, Touro was one of only fifteen hospitals in the country approved to use insulin to treat diabetes. Today, thousands of people from our community take advantage of our free diabetes screenings and education seminars. 4. East Jefferson Hospital On February 14, 1971, the hospital opened its doors with 250 beds and 250 physicians. Today, East Jefferson General Hospital has 450 beds and a medical staff of nearly 900. With over 3,000 team members, the hospital is one of the largest employers in the parish. East Jefferson General has grown over the past three decades to become a medical landmark with the addition of medical office buildings, the Yenni Pavilion for outpatient cancer treatment, and the Domino Pavilion, which houses Same Day Surgery, outpatient 19
laboratory and outpatient radiology services. Most recently, the Wellness Center, a 38,000 square foot, state-of-the-art fitness facility, was added to the hospital's main campus.
5. Our Lady of the Lake Regional M edical Center Our Lady of the Lake Regional Medical Center is the dominant institution in healthcare in the Greater Baton Rouge area. It is also the largest private medical center in Louisiana, with 763 licensed beds. Opened in 1923, the Lake has grown from its modest beginning to a major player in healthcare, with an outreach spanning geographical and political boundaries. In a given year, Our Lady of the Lake treats approximately 25,000 patients in the hospital, and serves about 350,000 persons through outpatient locations with the assistance of almost 900 physicians and 3,000 staff members. Established in 1923 by the Franciscan Missionaries of Our Lady, the Lake continues to set the standard for quality patient care.
COGNITIVE SKILLS Education in surgery is designed to simultaneously develop cognitive knowledge, judgment, technical ability and teaching skills. The practice of surgery requires the application of clinical data and technical skills to cure disease. Surgical judgment is that combination of knowledge, confidence, ability, and compassion that leads to the successful practice of our specialty.
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The cognitive basis of plastic surgery is summarized and developed in a body of literature pertinent to the specialty. Mastery of this resource is a necessary task. The resident will be expected to study the literature of our specialty diligently and apply the information therein to the problems of his patients. As the resident moves toward senior responsibility a greater breadth and depth of knowledge is required, such they will be required to know how to perform operations that they have never seen and will be required to teach students and junior residents the discipline necessary to search the literature. Evaluating the literature is a difficult skill acquired only through practice. This skill will be taught by example of the Faculty. Dr. John Gibbon, inventor of the extracorporeal pump-oxygenator, accurately made the following observation: "Unless he has a real understanding of what constitutes a valid measurement, he will be buffeted on the seas of surgical opinion. He will either change his ideas with every new article he reads, a slave to the authority of the printed word, or he will cling to the opinions of those surgeons with the greatest reputations in their field. How pathetic it is to hear a young surgeon parroting some authority without bothering to examine the evidence on which such an opinion is based! The pleasures and rewards of exercising critical judgment contribute to the self assurance and self reliance which assuredly are valuable attributes of a surgeon." John Gibbon, M.D. Annals of Surgery 142:321, 1955 21
The following suggestions are offered: 1) During the first year use a standard textbook and periodical. Read the textbook from cover to cover over a 12-month period. A second standard text should be read during your second year. Suggested Textbooks: a. Grabb and Smith’s: Plastic Surgery b. Achauer: Plastic Surgery Indications, Operations and Outcomes c. Mathes: Plastic Surgery d. Grabbs: Encyclopedia of Flaps Suggested Periodicals: e. Lippincott: Plastic and Reconstructive Surgery and Annals of Plastic Surgery f. Selected Readings in Plastic Surgery g. Clinics in Plastic Surgery
2) Selected Readings in Plastic Surgery is required reading and will be studied in the core curriculum conference. 3) The residents should subscribe to the following journal: Plastic and Reconstructive Surgery (PRS). The Annals of Plastic Surgery along with PRS will be reviewed as the content for Journal Club. 4) Atlases are not a substitute for availing yourself of the opportunity to see every operation possible. The alert resident should be able to learn from every operation whether he/she functions as the surgeon, first assistant, second assistant or observer. Take advantage of participating in all available cases.
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5) The library in the Plastic Surgery Division is for your use; however please do not remove any material from the office. The development of judgment requires an inquiring mind. Your most frequent question to yourself, the faculty and colleagues should be "Why”.
GOALS AND OBJECTIVES The basic science and clinical skills objectives are listed individually below. The objectives will be emphasized on certain rotations; however it will be important for the resident to be able to integrate these broad topics into an effective comprehensive patient treatment and care. Regarding technical skills, the resident is expected to master the less complex procedures before proceeding to the more complex. Furthermore, he/she is expected to first assist until he/she understands the principles and methods, at which time the resident becomes the operating surgeon with faculty supervision, and eventually moves to teaching others. Tulane Plastic Surgery Residency
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Training Objectives- Core Competencies
GOALS AND TRAINING OBJECTIVES The Tulane Plastic Surgery Residency will stress: 1)
Ethical, appropriate, specific and effective treatment, independent thinking, life-long learning and improvement. 2) After completion of training the resident will have broad training in plastic surgery giving him a solid foundation on which to provide competent patient care. Education in surgery is designed to simultaneously develop cognitive knowledge, judgment, technical ability and teaching skills. The practice of surgery requires the application of clinical data and technical skills to cure disease. Surgical judgment is that combination of knowledge, confidence, ability, and compassion that leads to the successful practice of our specialty. The basic science and clinical skills objectives are listed individually below. The objectives will be emphasized on certain rotations; however it will be important for the resident to be able to integrate these broad topics into an effective comprehensive patient treatment and care. Regarding technical skills, the resident is expected to master the less complex procedures before proceeding to the more complex. Furthermore, he/she is expected to first assist until he/she understands the principles and methods, at which time the resident becomes the operating surgeon with faculty supervision, and eventually moves to teaching others. The following resident has demonstrated cognitive knowledge, technical ability and sound surgical judgment in meeting the goals and training objectives in the required plastic surgical residency rotations. He/she has acted in a professional manner and can now be considered to have completed the Tulane University Plastic Surgery Residency.
Resident
Program Director’s Signature
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PROFESSIONALISM
Required Professionalism of Patient Care during each Plastic Surgery Rotation. Goal: Upon completion of this rotation the Plastic Surgical Resident will understand commitment to professional responsibilities, adherence to ethical practices and sensitivity to diverse patient populations. He/she will present himself in a respectful, professional, honest and congenial manner in all interaction with patients, colleagues, other health care professionals and ancillary staff. Terminal Performance Objective: The Surgical Resident will be able to demonstrate a commitment to their professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations as judged against applicable standards of patient care. Enabling Objectives: Condition: Upon completion of this rotation the Surgical Resident will: 1) 2) 3) 4) 5) 6)
Demonstrate a commitment to professional responsibilities Perform patient care in an ethical manner Display sensitivity to the needs of a diverse patient population Demonstrate the principles of the highest standard of patient care Demonstrate commitment to continuity of patient care Demonstrate sensitivity to patient age, gender and culture
Standard: As judged against applicable standards for the Medical Professional.
Resident
Program Director’s Signature
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INTERPERSONAL AND COMMUNICATION SKILLS Required Interpersonal and Communication Skills of Patient Care during each Plastic Surgery Rotation Goal: Upon completion of this rotation the Surgical Resident will be able to communicate in a collaborative model with patients, patient’s families and members of the health care team relevant and important information. Terminal Performance Objective: The Plastic Surgical Resident will be able to demonstrate effective communication with members of the health care team, counsel and educate the patient, patient’s family and health care team and accurately document all patient care information as judged against applicable standards of patient care. Enabling Objectives: Condition: Upon completion of this rotation the Surgical Resident will: 1) Discuss the patient’s medical condition, progress and outcome with the patient and patient’s family (if requested) to assure complete understanding 2) Team with the patient, their family and other health care providers to optimize the patient’s recovery 3) Demonstrate effective communication with other health care professionals 4) Demonstrate education of the patient’s family 5) Demonstrate counsel of the patient’s family 6) Document all steps in patient care 7) Document patient education and counseling 8) Document development of patient care plan 9) Demonstrate ability to obtain informed consent, including the components of condition, proposed treatment, alternative treatment, complications, risk, benefits, outcomes of treatment and alternatives 10) Demonstrate maintenance of patient confidentiality in communication with family, friends and other health care workers 11) Demonstrate integration and understanding in how Professionalism and Communication are critical and essential in overall optimal patient care and equally crucial in risk management and therefore effective Systems Based Practice. Standard: As judged against applicable standards of Physician-Patient interaction.
Resident
Program Director’s Signature
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PRACTICED BASED LEARNING AND IMPROVEMENT
Required Practice Based Learning and Improvement of Patient Care during each Plastic Surgery rotation. Goal: Upon completion of this rotation the Surgical Resident will understand the role of Practice-Based Learning and Improvement in the management of their patients and as a life-long process for optimal health care. Terminal Performance Objective: The Plastic Surgical Resident using an individual critique of their patient care practice outcomes will be able to demonstrate methods of improvement in patient care through the recognition and practice of lifelong learning skills in the surgical field as judged against applicable standards of patient care. Enabling Objectives: Condition: Upon completion of this rotation the Surgical Resident will: 1) 2) 3) 4)
Evaluate patient care through a personal QA program Appraise scientific evidence as to correctness of data Appraise scientific evidence as to applicability in patient care Assimilate new scientific knowledge to improve the care of one’s own patient 5) Evaluate methods of acquiring scientific knowledge to improve the care of one’s own patient based on changing standards Standard: As judged against applicable standards of physician knowledge, skill improvement and quality improvement.
Resident
Program Director’s Signature
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SYSTEMS BASED PRACTICE
Required Systems Based Practice of Patient Care during each Plastic Surgery Rotation. Upon completion of the each rotation the Plastic Surgical Resident will meet the following GOALS: 1) Understand and discuss how the Plastic Surgeon is a vital component to support ALL specialties 2) Understand how the Plastic Surgeon is BEST utilized in the context of maximizing results and minimizing expenditures 3) Understand specific examples of efficient and inefficient resource allocation and how this impacts the total health care system Terminal Performance Objective: The Surgical Resident will be able to demonstrate an awareness of the health care system, respond to the larger context of the health care system and manage health care system resources to provide optimal care as judged against applicable standards of patient care. Enabling Objectives: Condition: Upon completion of this rotation the Surgical Resident will: 1) Define cost-effective patient care 2) Describe how to meld together both high-quality and cost-effective care methods in providing health care 3) Demonstrate risk benefit analysis in day-to-day patient care 4) Describe the appropriate use of specialists in health care 5) Describe the use of non-physician health care team members in daily care of the patient 6) Demonstrate the role of the individual physician in the development of the overall health care system at the local, state, national and international level 7) Describe the importance of using the political process to enhance the medical health care system Standard: As judged against applicable standards of medical practice.
Resident
Program Director’s Signature
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ROTATIONAL COMPETENCIES Resident Name: Aesthetics Basic Sciences / Medical Knowledge Objectives 1) The resident will be familiar with concepts of beauty and aesthetic principles of the facial structures. 2) He/she can recognize the varying effects of aging and sun exposure on the facial skin and structures. 3) He/she can recognize the various aesthetic deformities of the ear and appreciates the principles and techniques of surgical correction. 4) He/she will be familiar with aesthetic and functional problems of the eyelid including blepharochalasis and ptosis and knows the treatment techniques for these problems, complications and their prevention. 5) He/she will understand the principles and techniques of aesthetic rhinoplasty 6) He/she will recognize the differences in approach between primary and secondary rhinoplasty. 7) He/she will be familiar with diagnostic and therapeutic techniques in the management of nasal airway obstruction. 8) He/she will understand the implication of Bariatric Surgery Clinical / Surgical Skills Objectives 1) The resident will be familiar with techniques of rhytidectomy, suction lipectomy, brow lift, blepharoplasty and other methods for treatment of the aging face and body. 2) He/she will understand the complications of facial aesthetic surgery, their prevention and treatment. 3) He/she will perform surgical therapy for patients with aging face including rhytidectomy, brow lift, blepharoplasty and understand open and endoscopic techniques. 4) He/she will treat patients with mammary hypoplasia including both acute management and the care of patients with late problems (such as 29
capsular contracture). 5) He/she will evaluate and treat patients with mammary ptosis. 6) The resident will also treat patients with aesthetic deformity of the abdomen, trunk and lower extremity and performs abdominoplasty, panniculectomy, and abdominal suction lipectomy. 7) He/she will evaluate patients with nasal deformities and perform rhinoplasty and septal surgery. 8) He/she understands the evaluation of patients with aesthetic problems of the ear and performs otoplasty. 9) He/she will perform aesthetic procedures on patients with massive weight loss.
ROTATIONAL COMPETENCIES Resident Name: Anesthesia and Critical Care Basic Sciences / Medical Knowledge Objectives 1) The resident will demonstrate knowledge of common agents for local anesthesia (esters and amides), regional anesthesia and general anesthesia (intravenous agents, inhalation agents, muscle relaxants, antiemetics, etc). 2) He/she will know the principles and the techniques for administration of local anesthesia and understand the pharmacology and safe utilization of agents in "conscious sedation."
Clinical / Surgical Skills Objectives 1) The resident will participate in the decision as to which technique of anesthesia should be used on his patients. 2) He/she will utilize the techniques of local anesthesia and carry out emergency management of burn and trauma patients. 3) He/she will manage all plastic surgical patients postoperatively. 30
ANESTHESIA ROTATIONAL COMPETENCIES Basic Sciences: Medical Knowledge Objectives a.
The resident will demonstrate knowledge of common agents for local anesthesia (esters and amides), regional anesthesia and general anesthesia (intravenous agents, inhalation agents, muscle relaxants, antiemetics, etc). b. He/she will know the principles and the techniques for administration of local anesthesia and understand the pharmacology and safe utilization of agents in "conscious sedation." Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives a. The resident will demonstrate knowledge of common agents for local anesthesia (esters and amides), regional anesthesia and general anesthesia (intravenous agents, inhalation agents, muscle relaxants, antiemetics, etc) (MK). b. The resident will participate in the decision as to which technique of anesthesia should be used on his patients (PC, PBLI). c. He/she will utilize the techniques of local anesthesia and carry out emergency management of burn and trauma patients (PC, PBLI).
d. He/she will manage all plastic surgical patients postoperatively (PC, PBLI). 31
ROTATIONAL COMPETENCIES Resident Name: A). Benign and Malignant Skin Lesions Basic Sciences / Medical Knowledge Objectives 1) The resident will understand the natural history of benign lesions and the pathophysiology of malignant lesions. 2) He/she will comprehend histologic grading and clinical staging systems currently in use for the malignant and premalignant skin tumors. 3) He/she will understand the lymphatic drainage pattern of the head and neck structures and its relationship to the management of malignant tumors. 4) He/she will know the methods for diagnosis and the options for treatment of squamous cell carcinoma of the head and neck, basal cell carcinoma and malignant melanoma. Clinical / Surgical Skills Objectives 1) The resident will be familiar with the clinical presentation of benign and malignant cutaneous lesions and generalized skin disorders. 2) He/she will be able to provisionally evaluate both simple and complex cutaneous lesions and proceed with diagnostic steps necessary to secure a definitive diagnosis. 3) The resident will formulate a definitive treatment plan for the particular lesion in question choosing a surgical or nonsurgical treatment modality, which best suits the lesion (based on size, anatomical location and physical condition of the patient). 4) He/she will be familiar with other treatment modalities including (but not limited to) x-ray therapy, Mohs micrographic surgery, cryotherapy, laser therapy and topical chemotherapy. 5) The resident will be able to explain in a comprehensible but simplified manner, to the patient, the nature of the lesion, its extent, treatment options and long-term results. 6) He/she will formulate a definitive treatment plan for regional or distant spread of malignant cutaneous tumors. 7) The resident will performs all invasive diagnostic studies including (but not limited to): direct incisional and excisional biopsy, needle biopsy, punch biopsy; recognizes under which circumstances each should be used. 32
8) He/she can execute extirpative surgery of a variety of benign and malignant cutaneous lesions and associated locoregional disease, choosing the optimal surgical incision or excision for the particular region to be treated. 9) He/she also will be able to execute complex procedures for the reconstruction of surgically created wounds (including skin grafts, local or distant flaps, or free tissue transfer) resulting from skin tumor extirpation.
B). Skin Basic Sciences: Medical Knowledge Objectives a. The resident will appreciate the basic physiology of the aging process of the skin and will discuss the basic physiologic processes of sun exposure on the skin. b. He/She will discuss the role of lasers in the management of various skin lesions and conditions. c. He/She will discuss the natural growth history of skin cancers and the value of Mohs Chemosurgery. Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives a. He/She will recognize common inflammatory disorders of the skin such as impetigo, cellulitis, lymphangitis, hidradenitis suppurativa, and will be familiar with medical management and surgical treatment of inflammatory disorders of the skin (PC, PBLI). b. The resident will demonstrate knowledge of common generalized dermatologic disorders such as: psoriasis, seborrheic dermatitis, acne, and 33
benign skin lesions such as nevi and seborrheic keratoses (PC, PBLI). c. He/She will recognize common skin malignancies and formulate plan to include staging, extirpation and reconstruction (PC, PBLI). d. He/She will become familiar with the pathologic interpretation of common skin malignancies. He/She will discuss the process of Mohs surgery (PC, SBP, PBLI)
C). Functional Problems Basic Sciences: Medical Knowledge Objectives a. The resident will knows the basic physiology of the aging process of the skin and will discuss the basic physiologic processes of sun exposure on the skin. b. He/She demonstrates knowledge of common generalized dermatologic disorders such as: scleroderma, dermatomyositis, and lupus erythematosus. Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives a. He/She is familiar with basic principles of medical treatment of generalized skin disorders and can recognizes common inflammatory disorders of the skin such as impetigo, cellulitis, lymphangitis, hidradenitis suppurativa, necrotizing fasciitis
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b. Familiar with medical management and surgical treatment of inflammatory disorders of the skin.
D). Mohs Chemosurgery Basic Sciences: Medical Knowledge Objectives 1) The resident will appreciate the basic physiology of the aging process of the skin and will understand the basic physiologic processes of sun exposure on the skin. 2) He/she will understand the role of lasers in the management of various skin lesions and conditions. 3) The resident will understand the natural growth history of skin cancers and the value of Mohs Chemosurgery (MK, SBP). Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives 1) The resident will recognize common inflammatory disorders of the skin such as impetigo, cellulitis, lymphangitis, hidradenitis suppurativa, and will be familiar with medical management and surgical treatment of inflammatory disorders of the skin (PC). 2) The resident will demonstrate knowledge of common generalized dermatologic disorders such as: psoriasis, seborrheic dermatitis, 35
acne, and benign skin lesions such as nevi and seborrheic keratoses (PC, PBLI). 3) He/she will recognize common skin malignancies and formulate plan to include staging, extirpation and reconstruction (PC, PBLI). 4) He/she will become familiar with the pathologic interpretation of common skin malignancies. He will understand the process of Mohs surgery (PC, SBP). In addition to an overview of dermatologic disease the educational experience will also emphasize the importance of cutaneous signs as an indicator of internal disease. The dermatology experience will be of value because of the large number of lesions which are initially seen and evaluated by plastic surgeons. ROTATIONAL COMPETENCIES Resident Name: Hand Objectives Basic Sciences / Medical Knowledge Objectives 1) The resident will know, in detail, the anatomy of the muscles, tendons, and ligaments of the hand and upper extremity. 2) He/she will understand the anatomy of the vascular tree and major nerves of the upper extremity including relationships to the surrounding structures. 3) He/she also will understand the functional anatomy of the upper extremity including the cutaneous cover. 4) The resident will be familiar with the spectrum of congenital abnormalities of the upper extremity. 5) He/she will understand the principles of diagnosis and treatment of upper extremity tumors. 6) He/she will know the clinical techniques for physical examination of the hand. 7) He/she will know the techniques for operative and nonoperative 36
management of traumatic injuries of the upper extremity, their indications and contraindications, and their potential complications and treatment thereof. 8) He/she will demonstrate knowledge of the nerve compression and entrapment syndromes of the upper extremity and understand the basic principles of their treatment. 9) He/she will be familiar with the pathologic anatomy and physiology of upper extremity joint contractures and Dupuytren’s disease. Clinical / Surgical Skills Objectives 1) The resident will perform physical examination of the hand and upper extremity in both normal and pathologic states (PC). 2) He/She will obtain and interpret radiographs and other diagnostic images for evaluation of traumatic, congenital and degenerative problems of the hand and upper extremity and develop treatment plans (PC, MK). 3) The resident will débride, repair and close acute and chronic wounds involving both bony and soft tissue injuries of the upper extremity. (PC). 4) He/She will operate on patients with fractures of the extremity and performs closed reductions, open reductions, internal fixations, and bone grafting (PC). 5) The resident will perform rigid bony fixation and be able to access and manage the complication thereof (PC). 6) The resident will understand timing for surgical procedures both of congenital and traumatic nature (PC, PBLI). 7) He/She will evaluate and manage nerve, tendon, fingertip and bony injuries (PC). 8) He/She will diagnose, evaluate and treats upper extremity infections (PC). 9) He/She will perform skin grafting and flap closure of soft tissue defects of the upper extremity (PC). 10) The resident will direct rehabilitation of upper extremity trauma following surgical treatment (SBP). 11) He/She will know and practice the principles of immobilization and splinting (PC, PBLI, SBP). ROTATIONAL COMPETENCIES Resident Name:
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Burns and Trauma Basic Sciences / Medical Knowledge Objectives 1) The resident will understand normal skin anatomy, circulation and how it is impacted by injury. 2) He/she will also understand the physiologic changes, which occur with thermal or traumatic injury. 3) He/she understands the relationship between duration of exposure and temperature and the specific changes which occur in the zone of coagulation, stasis, and hyperemia. 4) He/she understands the pathophysiology and treatment of inhalation injuries and carbon monoxide poisoning. 5) He/she also understands the pathophysiologic changes unique to chemical burns. 6) The resident will understand the pharmacology and utilization of topical antibacterial agents, analgesics and antibiotics in the treatment of burns. Clinical / Surgical Skills Objectives 1) He/she will recognizes the Rule of Nines, the use of more detailed body surface charts, and the difference in relative body surface area comparing children to adults. 2) He/she knows the parameters, which define major, moderate and minor burns. 3) He/she understands the various factors, in addition to body surface area, which affect prognosis of a patient with a thermal injury. 4) He/she understands the principles and techniques of fluid resuscitation. 5) He/she will recognize injuries and sequelae associated with electrical injuries. 6) He/she will understand principles pertinent to burn rehabilitation and reconstruction including aesthetic units of the face, tissue expansion, hair transplantation and hand splinting.
ROTATIONAL COMPETENCIES Resident Name:
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Mohs Chemosurgery Basic Sciences / Medical Knowledge Objectives 1) The resident will appreciate the basic physiology of the aging process of the skin and will understand the basic physiologic processes of sun exposure on the skin. 2) He/she will understand the role of lasers in the management of various skin lesions and conditions. 3) He/she will understand the natural growth history of skin cancers and the value of Mohs Chemosurgery. Clinical / Surgical Skills Objectives 5) He/she will recognize common inflammatory disorders of the skin such as impetigo, cellulitis, lymphangitis, hidradenitis suppurativa, and will be familiar with medical management and surgical treatment of inflammatory disorders of the skin. 6) The resident will demonstrate knowledge of common generalized dermatologic disorders such as: psoriasis, seborrheic dermatitis, acne, and benign skin lesions such as nevi and seborrheic keratoses. 7) He/she will recognize common skin malignancies and formulate plan to include staging, extirpation and reconstruction. 8) He/she will become familiar with the pathologic interpretation of common skin malignancies. He/she will understand the process of Mohs surgery.
ROTATIONAL COMPETENCIES Resident Name: Congenital/Embryology Basic Sciences / Medical Knowledge Objectives
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1) He/she will know the anatomy of the facial bones, their ostia and bony relationships, and embryology. 2) He/she will be familiar with the general principles of embryology of the head and neck, with special reference to the development of the facial structures including lip, palate and ear. 3) He/she will demonstrates intimate knowledge of the common congenital disorders of the head and neck including cleft lip and palate, craniofacial syndromes, vascular malformations, auricular abnormalities. Clinical / Surgical Skills Objectives 1) He/she will understand the basic principles of the surgical and nonsurgical management of common congenital disorders of the head and neck. 2) The resident will participate in the surgical planning for patients with common congenital disorders of the head and neck including cleft lip and palate and craniosynostosis. 3) He/she will perform primary and secondary surgery on patients with common congenital disorders of the head and neck, chest, trunk and extremities.
ROTATIONAL COMPETENCIES Resident Name: Facial Trauma 1) The resident will knows the anatomy of the skull including suture lines, foramina, and structures exiting foramina; is familiar with the anatomy and functions of the cranial nerves. 2) He/She will know the anatomy of the facial bones, their ostia and bony relationships, and embryology. 3) He/She has special knowledge of the vascular structures of the skull, head and neck. 4) The resident will know the priorities involved in treating patients with multiple trauma, the timing of treatment of head and neck injuries, and 40
5) 6)
7) 8)
9) 10) 11)
the indications for endotracheal intubation and tracheostomy in such patients. He/She knows an orderly, systematic approach to the physical examination of patients with facial trauma. He/She will discuss the indications for specific diagnostic studies including conventional radiography, Panorex films, computer-assisted tomography, three-dimensional CT scan imaging, and magnetic resonance imaging. He/She appreciates the mechanical properties of the facial skeleton and patterns of injury associated with facial trauma including associated cervical and cranial trauma. The resident will demonstrate management of open facial injuries including: anesthesia, local wound care, principles of debridement, and biologic features, which distinguish facial injuries from those in other locations. He/She will discuss the concepts of primary bone healing, malunion, nonunion and osteomyelitis. He/She will recognize the indications for operative treatment of facial fractures. He/She will know the advantages and disadvantages of various techniques for treatment of facial fractures including nonoperative treatment, closed reduction, mandibulomaxillary fixation, open reduction with and without fixation, wire fixation, compressive and non-compressive fixation, intraoral splints, external fixation (including halo and biphasic techniques) and bone grafting.
Clinical / Surgical Skills Objectives 1) The resident will treat patients with minor and major soft tissue injuries of the face including injuries to the facial nerve, lacrimal apparatus and parotid gland. 2) He/she will diagnose and treats patients with closed and open fractures of the facial skeleton. 3) He/she will operate on patients with fractures of the facial skeleton and performs closed reductions, open reductions, internal fixations, and bone grafting. 4) The resident will manage patients postoperatively after surgical treatment of facial fractures. 5) Specifically the resident will understand treatment of maxillary, mandibular, orbital, nasoethmoidal, frontal, zygoma and zygomatic arch fractures; the potential complications of such treatment (including 41
malposition, deformity, malocclusion, etc); the management of these complications. ROTATIONAL COMPETENCIES Resident Name: Flaps and Grafts Basic Sciences / Medical Knowledge Objectives 1) The resident understands the physiology of flaps and grafts, is thoroughly familiar with surgery in all types of flaps and grafts, and can design and utilizes flaps effectively for reconstruction in the full spectrum of plastic surgical practice. 2) He/she will understand the terminology of flap movement, composition and vascular supply. 3) The resident will recognize the physiology of normal flaps, ischemic flaps, and the "delay" phenomenon. 4) He/she will understand the specific physiology of split and full thickness skin grafts, dermal grafts, cartilage grafts, bone grafts, tendon grafts, nerve grafts, fascial grafts, and composite grafts. Clinical / Surgical Skills Objectives 1) The resident will knows specific grafting techniques including the operation of various types of dermatomes, management of graft donor sites, and care of graft recipient sites. 2) He/she will understand the principles and applications of special grafting techniques including dermabrasion, xenografts, cadaver grafts, skin matrix and synthetic or chemically manipulated materials. 3) He/she shall perform operations incorporating the full spectrum of flaps and grafts including skin grafts, local flaps, fascial and musculocutaneous flaps, free tissue transfers, bone grafts, composite grafts. The resident will treat patients who have
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complications of flaps and grafts including skin graft loss, flap necrosis, wound dehiscence and wound infection.
ROTATIONAL COMPETENCIES Resident Name: Functional Problems Basic Sciences / Medical Knowledge Objectives 1) The resident will knows the basic physiology of the aging process of the skin and will understands the basic physiologic processes of sun exposure on the skin. 2) He/she demonstrates knowledge of common generalized dermatologic disorders such as: scleroderma, dermatomyositis, and lupus erythematosus. Clinical / Surgical Skills Objectives 1) He/she is familiar with basic principles of medical treatment of generalized skin disorders and can recognizes common inflammatory disorders of the skin such as impetigo, cellulitis, lymphangitis, hidradenitis suppurativa, necrotizing fasciitis and is familiar with medical management and surgical treatment of inflammatory disorders of the skin.
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ROTATIONAL COMPETENCIES Resident Name: Head and Neck Reconstruction Basic Sciences / Medical Knowledge Objectives 1) The resident will knows the anatomy of the skull including suture lines, foramina, and structures exiting foramina; is familiar with the anatomy and functions of the cranial nerves. 2) He/she will know the anatomy of the facial bones, their ostia and bony relationships, and embryology. 3) He/she has special knowledge of the vascular structures of the skull, head and neck. 4) He/she understands the anatomy of the eye including normal dimensions, bony structures, the eyelids, the extraocular muscles, the innervation of the eye and adnexal structures, the vascular supply, and the lacrimal apparatus. 5) He/she understands the anatomy of the ear including common measurements of the ear, relationships of the ear to other structures, and the vascular and sensory supply. 6) The resident will know the anatomy of the nose and septum including bones and cartilages, nerve and vascular supply and he will be familiar with the physiology of the nose with particular reference to air flow and airway obstruction. 7) He/she will know the anatomy of the oropharynx including muscular structures, lymphatic drainage, and contiguous neurovascular structures and he will be familiar with the physiology of the oropharynx including 44
palatal function, speech, and swallowing. 8) He/she knows the anatomy and function of facial structures including facial muscles, facial layers and salivary glands. 9) He/she will know the lymphatic drainage pattern of the head and neck structures and its relationship to the management of malignant tumors. 10) He/she understands the methods for diagnosis and the options for treatment of squamous cell carcinoma of the head and neck (particularly the oropharynx), basal cell carcinoma and malignant melanoma. 11) He/she will understand the methods for diagnosis and the options for treatment of benign and malignant processes of the salivary glands. Clinical / Surgical Skills Objectives 1) The resident will be able to evaluate and treat patients with benign and malignant conditions of the head and neck. 2) He/she will appreciate a non-operative and operative plan depending on the patient’s diagnosis, age and condition. 3) He/she will understand the reconstructive ladder and can make an applicable operative plan. 4) He/she will understand the principles and techniques available for appearance restoration and understand the specific reconstructive needs of special tissues such as oral mucosa, nasal lining, etc. 5) He/she will utilize flaps, grafts, tissue expansion, free flaps and/or alloplastic insertions for head and neck reconstruction. 6) He/she will perform reconstruction of specific head and neck structures such as eyelid, lips, nose, oropharynx, ear, mandible, scalp and skull. ROTATIONAL COMPETENCIES Resident Name: Implants and Biomaterials Basic Sciences / Medical Knowledge Objectives 1) At the end of the unit, the resident is familiar with the biology of the various implant materials including bone, cartilage, and alloplasts.
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2) He will know the local wound factors which influence bone graft survival and recognizes the biologic differences between vascularized and non-vascularized bone grafts. 3) The resident will understand the influence of perichondrium and on the warping of cartilage grafts. 4) He/she will recognize the various types of breast implants and the factors involved in implant choice including surfaced content characteristics and is aware of the issues regarding silicone and is able to discuss these with a patient. 5) He/she understands the effects of breast implant surface characteristics on formation of capsular contracture and recognizes the various injectable materials for subcutaneous filling and the principles of their use.
Clinical / Surgical Skills Objectives 1) The resident will performs surgical procedures using solid and injectable implant materials. 2) He/she will understand the procedures for carving autografts and alloplastic implants. ROTATIONAL COMPETENCIES Resident Name: Lower Extremity Reconstruction Basic Sciences / Medical Knowledge Objectives
1) The resident will know the vascular, muscular, neural, and osseous anatomy of the lower extremity. 2) He/she will understand the various muscular and vascular anatomies of specific flaps including tensor fascia lata, vastus lateralis, rectus femoris, sartorius, gastrocnemius, gracilis, and biceps femoris flaps. 3) The resident will understand the concept of fasciocutaneous flaps and can design them on the distal lower extremity. 4) He/she will know the cutaneous margins and vascular anatomy of foot 46
5) 6) 7) 8) 9)
flaps including medical plantar, lateral plantar, V-Y plantar, and dorsalis pedis-based flaps. He/she will understand the physiology of arterial insufficiency, venous hypertension, and diabetes as they pertain to the lower extremity. He/she will understand the indications for and timing of closure of soft tissue traumatic defects of the lower extremity. He will have a thorough knowledge of coverage techniques (including skin grafts, local skin flaps, distant flaps, musculocutaneous flaps, and free flaps) for soft tissue and bony closure of the lower extremity. He/she will understand the management of infectious processes (including osteomyelitis) related to traumatic injuries of the lower extremity. He/she will know the etiology and treatment of lymphedema (including nonoperative and operative measures).
Clinical / Surgical Skills Objectives 1) The resident will undertake perioperative management and surgical treatment of patients with major acute and chronic injuries of the lower extremities requiring reconstruction and resurfacing. 2) He/she will evaluate and treats patients with lower extremity trauma and ulceration of a variety of etiologic origins.
ROTATIONAL COMPETENCIES Resident Name: Medicolegal and Psychiatric Aspects of Plastic Surgery Basic Sciences / Medical Knowledge Objectives 1) The Resident will understand the medical and legal perspectives of the contractural agreement between a physician and his/her patient. 2) He/she understands the concepts of informed consent and implied guarantee and understands the role of the medical record as a legal document. 3) He/she knows the impact a physical deformity can have on patients and their families.
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4) The resident utilizes various techniques to explore the motivations of patients seeking cosmetic surgery, and how to distinguish acceptable, unacceptable, and pathological motivations. 5) The resident will obtain informed consent from all patients and effectively documents the consent agreement. 6) He/she will evaluate patients for aesthetic surgery from a physical and psychological perspective. 7) He/she contributes effectively and accurately to the medical record of both inpatients and outpatients. 8) He/she will treat patients with physical deformity and explores the psychological aspects of their care.
ROTATIONAL COMPETENCIES Resident Name: Microsurgery Basic Sciences / Medical Knowledge Objectives 1) The resident is familiar with the principles of microsurgery and recognizes the mechanisms and consequences of the no-reflow phenomenon; knows how to treat a failing flap. 2) He/she will understand the technologic, pharmacologic and physiologic principles of postoperative monitoring of free flaps. 3) He/she will know the basic physiology of nerve injury (axonotmesis, neurotmesis, neuropraxia, Wallerian degeneration) and of nerve healing. Clinical / Surgical Skills Objectives 1) The resident will have mastered the basic microsurgery techniques including micro-neural repair and microsurgical anastomosis. 2) He/she will become familiar with the use of the operating microscope and understand the indications for, the contraindication 48
to, and the techniques for accomplishing replantation of amputated parts. 3) He/she shall be familiar with the tissue composition of free flaps and know the anatomy for harvesting the most common free flaps. 4) He/she also will be able to recognize the indications for harvesting various flaps and matching specific donor sites to specific recipient site needs and manage the long-term aspects, including donor site problems, of patients who have undergone free tissue transfers. ROTATIONAL COMPETENCIES Ophthalmology Basic Sciences / Medical Knowledge Objectives 1) The resident will demonstrate knowledge of the anatomical features of the bony orbit and surrounding soft tissue structures. 2) The resident will understand the different evaluation tools available for assessment of orbit and surrounding structures. 3) The resident will demonstrate knowledge of the pathological conditions which are a result of abnormal anatomy, pathology and or disease.
Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives
1) The resident will demonstrate knowledge of common orbit and periorbital problems and develop individual treatment plans (PC, MK). 2) Evaluate patients in clinic, perform complete ophthalmic plastic examinations and formulate assessments and plans, both medical and surgical (PC).
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3) The resident will be able to assess eyebrow position for brow ptosis and paralysis and determine its relation to upper lid dermatochalasis (PC). 4) The resident will be able to assess facial paralysis. Evaluate the effect of midface cicatricial, paralytic, and involutional changes on lower eyelid position. 5) The resident will know treatment plans for common orbital disorders including the following (PC, PBLI): a.
Inflammatory disorders i. Orbital cellulitis - know how etiology, organisms, and treatments ii. Thyroid orbitopathy - etiology, diagnosis, physical signs, management, surgical rehabilitation. iii. Orbital pseudotumor iv. Vasculitis - Wegener's, PAN, sarcoidosis, lethal midline granuloma
b.
Neoplasm i. Vascular tumors - cavernous hemangioma, hemangiopericytoma, AV malformations ii. Lacrimal gland tumors - benign and malignant mixed tumors, adenoid cystic carcinoma, and other inflammatory and lymphoid causes of lacrimal gland enlargement. iii. Fibro-osseous tumors - fibrous dysplasia, osteoma iv. Neural tumors - meningioma, schwannoma, optic nerve glioma
c.
Trauma - blow out fractures, le forte fractures, optic canal and other orbital fractures - diagnosis and management, traumatic optic neuropathy, orbital hemorrhage, penetrating orbital injury. 50
ORTHOPAEDIC ROTATIONAL COMPETENCIES Basic Sciences: Medical Knowledge Objectives a. The resident will know, in detail, the anatomy of the muscles, tendons, and ligaments of the hand and upper extremity. b. The resident will discuss the anatomy of the vascular tree and major nerves of the upper extremity including relationships to the surrounding structures. c. The resident also will discuss the functional anatomy of the upper extremity including the cutaneous cover. d. The resident will be familiar with the spectrum of congenital abnormalities of the upper extremity. e. The resident will discuss the principles of diagnosis and treatment of upper extremity tumors. f. The resident will know the clinical techniques for physical examination of the hand. g. The resident will know the techniques for operative and nonoperative management of traumatic injuries of the upper extremity, their indications and contraindications, and their potential complications and treatment thereof. h. The resident will demonstrates knowledge of the nerve compression and entrapment syndromes of the upper extremity and discuss the basic principles of their treatment. i. The resident will be familiar with the pathologic anatomy and physiology of upper extremity joint contractures and Dupuytren’s disease.
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Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives a. The resident will perform physical examination of the hand and upper extremity in both normal and pathologic states (PC). b. The resident will obtain and interpret radiographs and other diagnostic images for evaluation of traumatic, congenital and degenerative problems of the hand and upper extremity and develop treatment plans (PC, MK). c. The resident will débride, repair and close acute and chronic wounds involving both bony and soft tissue injuries of the upper extremity. (PC). d. The resident will operate on patients with fractures of the extremity and performs closed reductions, open reductions, internal fixations, and bone grafting (PC). e. The resident will perform rigid bony fixation and be able to access and manage the complication thereof (PC). f. The resident will understand timing for surgical procedures both of congenital and traumatic nature (PC, PBLI). g. The resident will evaluate and manage nerve, tendon, fingertip and bony injuries (PC). h. The resident will diagnose, evaluate and treats upper extremity infections (PC). i. The resident will perform skin grafting and flap closure of soft tissue defects of the upper extremity (PC). j. The resident will direct rehabilitation of upper extremity trauma following surgical treatment (SBP). 52
The resident will know and practice the principles of immobilization and splinting (PC, PBLI, SBP).
OMFS ROTATIONAL COMPETENCIES Basic Sciences: Medical Knowledge Objectives a) The resident will know the anatomy of the skull including suture lines, foramina, and structures exiting foramina; is familiar with the anatomy and functions of the cranial nerves. b) The resident will know the anatomy of the facial bones, their ostia and bony relationships, and embryology. c) The resident has special knowledge of the vascular structures of the skull, head and neck. d) The resident will know the priorities involved in treating patients with multiple trauma, the timing of treatment of head and neck injuries, and the indications for endotracheal intubation and tracheostomy in such patients. e) The resident knows an orderly, systematic approach to the physical examination of patients with facial trauma. f) The resident will discuss the indications for specific diagnostic studies including conventional radiography, Panorex films, computer-assisted tomography, threedimensional CT scan imaging, and magnetic resonance imaging. g) The resident appreciates the mechanical properties of the facial skeleton and patterns of injury associated with facial trauma including associated cervical and cranial trauma.
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h) The resident will demonstrate management of open facial injuries including: anesthesia, local wound care, principles of debridement, and biologic features, which distinguish facial injuries from those in other locations. i) The resident will discuss the concepts of primary bone healing, malunion, nonunion and osteomyelitis. j) The resident will recognize the indications for operative treatment of facial fractures. k) The resident will know the advantages and disadvantages of various techniques for treatment of facial fractures including nonoperative treatment, closed reduction, mandibulomaxillary fixation, open reduction with and without fixation, wire fixation, compressive and noncompressive fixation, intraoral splints, external fixation (including halo and biphasic techniques) and bone grafting. Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives a) The resident will treat patients with minor and major soft tissue injuries of the face including injuries to the facial nerve, lacrimal apparatus and parotid gland (PC). b) The resident will diagnose and treats patients with closed and open fractures of the facial skeleton (PC). c) The resident will operate on patients with fractures of the facial skeleton and performs closed reductions, open reductions, internal fixations, and bone grafting (PC).
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d) The resident will manage patients postoperatively after surgical treatment of facial fractures (PC). e) Specifically the resident will discuss treatment of maxillary, mandibular, orbital, nasoethmoidal, frontal, zygoma and zygomatic arch fractures; the potential complications of such treatment (including malposition, deformity, malocclusion, etc); the management of these complications (PC, SBP, PBLI).
ROTATIONAL COMPETENCIES Resident Name: Practice Management Basic Sciences / Medical Knowledge Objectives
1) The resident will understand how to interview and evaluate the patient, especially the aesthetic surgery candidate. 2) He/she will know the coding of diagnoses by the ICD-9 system and the coding of procedures by the CPT system. 3) He/she will understand ethical principles as they relate to billing and coding. 55
4) He/she understands how to take and catalogue standardized medical photographs. 5) He/she will be thoroughly familiar with the principles of risk management. 6) The resident will participate in outpatient management including both a clinic experience in which the resident has independent responsibility and observation of faculty managing private patients including the initial consultation and management of complications.
ROTATIONAL COMPETENCIES Resident Name: Research Basic Sciences: Medical Knowledge Objectives
1) Use the medical literature to obtain information necessary to make evidence-based decisions in the management of patients 2) Understand the features of clinical trials 3) Critically appraise the medical literature to make evidence-based clinical decisions 4) Apply the principles of preventive medicine in managing patients 5) Develop a question of interest 6) Search and evaluate the medical related literature 7) Identify appropriate research collaborators 8) Constructively critique and synthesize the literature 9) Develop specific, feasible problem statements 10) Design a study 11) Generate the research methods 12) Develop an area of expertise by mastering the literature and research methods appropriate to that area of interest 13) Conduct a research study 14) Write a manuscript 15) Seek and obtain critique of manuscript 16) Present findings from the literature and individual research at local and national meetings
56
ROTATIONAL COMPETENCIES Skin Basic Sciences: Medical Knowledge Objectives 1) The resident will appreciate the basic physiology of the aging process of the skin and will discuss the basic physiologic processes of sun exposure on the skin. 2) He/She will discuss the role of lasers in the management of various skin lesions and conditions. 3) He/She will discuss the natural growth history of skin cancers and the value of Mohs Chemosurgery. Clinical: Patient Care (Surgical Skills), IPCS, Professionalism, Systems Based Practice and PBLI Objectives 1) He/She will recognize common inflammatory disorders of the skin such as impetigo, cellulitis, lymphangitis, hidradenitis suppurativa, and will be familiar with medical management and surgical treatment of inflammatory disorders of the skin (PC, PBLI). 2) The resident will demonstrate knowledge of common generalized dermatologic disorders such as: psoriasis, seborrheic dermatitis, acne, and benign skin lesions such as nevi and seborrheic keratoses (PC, PBLI). 3) He/She will recognize common skin malignancies and formulate plan to include staging, extirpation and reconstruction (PC, PBLI). 4) He/She will become familiar with the pathologic interpretation of common skin malignancies. He/She will discuss the process of Mohs surgery (PC, SBP, PBLI) ROTATIONAL COMPETENCIES Resident Name: Special Techniques
57
Basic Sciences / Medical Knowledge Objectives 4) The resident will understand the principles of a variety of special techniques in plastic surgery including: liposuction, tissue expansion, laser treatments, chemical peel and dermabrasion. 5) He/she will know the different injection techniques, fluid and suction limits and safety precautions for liposuction. 6) He/she will understand the physiology of cavitation. 7) The student will know the physiologic principles of tissue expansion and understand the various techniques for expansion. 8) The resident will comprehend the physiologic principles of dermabrasion, chemical peel and laser resurfacing and recognize the differences between these techniques and the indications for one method over another. Clinical / Surgical Skills Objectives 1) He/she will understand the common techniques and the instrumentation of suction lipectomy. He will know the indications for and contraindications to suction lipectomy. 2) He/she will be familiar with the principles of preoperative assessment and recognize the limitations of liposuction. 3) He/she can perform preoperative, intraoperative and postoperative management of the patient undergoing suction lipectomy and will be familiar with the complications of liposuction and their management. 4) He/she will know the principles of management of patients undergoing tissue expansion; recognizes the complications of tissue expansion and is competent in their treatment. 5) He/she is familiar with the instrumentation and techniques for dermabrasion and laser resurfacing. 6) He/she will be competent in the principles of pre and postoperative management of patients undergoing facial resurfacing and can recognize the complications of the technique and their management.
ROTATIONAL COMPETENCIES Resident Name: Trunk and Breast Reconstruction Basic Sciences / Medical Knowledge Objectives
58
1) The resident will demonstrate knowledge of the musculature; blood supply, lymphatic drainage and innervation of the trunk, abdominal wall and breast. 2) He/she will understand the glandular structure and function of the breasts and appreciate the hormonal influence on breast development and function. 3) He/she will recognize differences in breast structure and function in adolescence, the reproductive years, pregnancy, lactation and menopause. 4) He/she will understand the basic principles and techniques of the surgical treatment of common developmental breast anomalies including amastia, Poland’s syndrome, asymmetry, ectopic mammary tissue, virginal hypertrophy, gynecomastia, etc. 5) He/she will be familiar with chest wall embryology and anatomy as applied to developmental chest wall deformities. 6) He/she will recognize the physiologic consequences of developmental chest wall defects and understand the biologic behavior, histologic characteristics and clinical manifestations of malignancies of the breast. 7) He/she will be familiar with plastic surgical options for management of the opposite breast after mastectomy for carcinoma and the principles of long-term management of patients with breast carcinoma. 8) He/she will have a thorough knowledge of breast reconstruction including autologous tissue and the use of prosthetic devices. 9) He/she will understand the etiology of gynecomastia and is familiar with the various surgical options for treatment. 10) He/she will understand the basic principles of medical and surgical management of common acute traumatic trunk and breast injuries including sternal wounds. 11) He/she will understand the etiology and nonsurgical management of pressure sores (including preventive measures). 12) He/she will have a detailed knowledge of surgical aspects of pressure sore reconstruction. Clinical / Surgical Skills Objectives 1) The resident will evaluate and treats patients with congenital and postsurgical breast deformities. 2) He/she will perform breast reconstruction with various techniques, such as implants, tissue expanders and flaps. 3) He/she will perform nipple and areolar reconstruction. 59
4) The resident will evaluate and treats patients with pressure sores and formulate a reconstructive plan for patients with pressure sores. 5) He/she will evaluate patients with mammary hypertrophy, marks and operates upon them, and performs postoperative care. T 6) He/she resident will formulate a care plan for patients with both malignant and infectious chest wall pathology.
ROTATIONAL COMPETENCIES Resident Name: Wound Care Basic Sciences / Medical Knowledge Objectives 1) The resident will understand the physiology and biochemistry of normal and abnormal wound healing. 2) He/she will also become familiar with the pharmacologic agents and other non-surgical methods for treatment of abnormal healing of skin and subcutaneous tissue. 3) He/she shall become familiar with the role of nutrition has in the wound healing process and understands the pathologic processes involved in keloid formation and the methods available to treat keloids. Clinical / Surgical Skills Objectives 1) The resident will be able to assess any wound and be able to formulate an optimal treatment plan. 60
2) He/she will become competent in the management of dressings, splints and other devices and techniques utilized in wound management. 3) He/she will understand when surgical debridement is necessary and the correct use of pharmacologic wound manipulating agents. 4) He/she will treat complex wound problems such as dehiscence, delayed healing, multiple traumatic wounds and evaluate patients with scar problems and revise scars to achieve maximum functional and aesthetic benefit. 5) He/she shall become skilled in the application, planning and surgical performance of techniques to alter scar (such as Z-plasty, W-plasty) and recognize the various lines of the skin (such as Relaxed Skin Tension Lines) and their importance in placement of incisions for maximum aesthetic benefit.
Residency Goals and Objectives: First Year By the end of the first year the resident will be com petent in:
1) Communicating effectively with resident staff, faculty, nursing and others such that patients with emergent needs may be safely transferred from off campus or on campus to the environment appropriate to their specific need within the Tulane and Other Rotation Institutional Systems. (IPC, P and SBP*) 2) Obtaining consultation from appropriate services for elective cases of patients on campus. (SBP) 3) Utilizing the appropriate information systems on and off campus to provide excellent patient care and to facilitate his/her further education. (IPC and P)
61
4) Delivering a comprehensive one hour didactic conference on a selected topic. (M, IPC) 5) Evaluating his own educational progress through regular recording and review of cases performed and by meeting with faculty and the Program Director and communicating those needs to the faculty and the Program Director. (PC and PBLI) 6) Communicating with patients and families a treatment plan including appropriate informed consent for operation. Describing that treatment plan clearly to other physicians and recording it in textural and other forms. (IPC, P and M) 7) Leading a team consisting of plastic surgeons, general surgeons, nurses, PA’s, medical students and others to perform excellent patient care. (PC, SBP, M, IPC and P) 8) Obtaining the knowledge and technical skills to perform procedures and solve patient care problems and perform operative procedures encountered in specific rotations. (PC, PBLI and M) 9) Performing microsurgical vascular anastomosis and neural repair on a laboratory animal. (PBLI and M) * Competencies: PC = Patient Care, M = Medical Knowledge, SBP = Systems Based Practice, PBLI = Practice Based Learning and Improvement, IPC = Interpersonal and Communication Skills
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Goals and Objectives: Second and Third Year By the end of training the resident will be com petent in:
1) Communicating effectively with resident staff, faculty, nursing and others such that patients with emergent needs may be safely transferred from off campus or on campus to the environment appropriate to their specific need within the Tulane and Other Rotation Institutional Systems. (IPC, P and SBP*) 2) Obtaining consultation from appropriate services for elective cases of patients on campus. (SBP) 3) Utilizing the appropriate information systems on and off campus to provide excellent patient care and to facilitate his/her further education. (IPC and P) 4) Delivering a comprehensive one hour didactic conference on a selected topic. (M, IPC) 5) Evaluating his own educational progress through regular recording and review of cases performed and by meeting with faculty and the Program Director and communicating those needs to the faculty and the Program Director. (PC and PBLI) 6) Communicating with patients and families a treatment plan including appropriate informed consent for operation. Describing that treatment plan clearly to other physicians and recording it in textural and other forms. (IPC, P and M) 7) Leading a team consisting of plastic surgeons, general surgeons, nurses, PA’s, medical students and others to perform excellent patient care in an 63
independent and comprehensive manner. (PC, SBP, M, IPC and P) 8) Obtaining the knowledge and technical skills to independently perform procedures and solve patient care problems and perform operative procedures encountered in all the specific rotations. (PC, PBLI and M) 9) Performing microsurgical vascular anastomosis and neural repair on a laboratory animal. (PBLI and M) 10) Assessing aesthetic patients for their suitability for operation and choosing an appropriate operative or non-operative approach. (PC, M, P and IPC) 11) Describing patient care actions in CPT language in an accurate and ethical fashion. (IPC and SBP) 12) Writing a medical paper (case report, chapter, etc) for possible publication. (M and IPC) 13) Accurately assessing the performance of first year residents, rotating residents from other services and medical students. (IPC, P) 14) Evaluating the accuracy, validity and usefulness of a publication or presentation on plastic surgery. (M and PBLI) * Competencies: PC = Patient Care, M = Medical Knowledge, SBP = Systems Based Practice, PBLI = Practice Based Learning and Improvement, IPC = Interpersonal and Communication Skills
TULANE ROTATION OBJECTIVES Dr. Chaffin will oversee this rotation. The following categories will 64
be emphasized: • Wound Care/Burn Care • Flaps and Grafts • Microsurgery • Implants and Biomaterials • Functional Problems • Reconstruction of Head and Neck • Reconstruction of Trunk and Breast • Reconstruction of Lower Extremity • Aesthetics • Ophthalmology The resident (starting with the first three-year residency class) will rotate at Tulane University for three months the first year and three months the second year with graduate responsibility.
OCHSNER ROTATION OBJECTIVES Dr. Babycos will oversee this rotation. The following categories will be emphasized: • Wound Care • Flaps and Grafts • Reconstruction of Trunk and Breast • Facial Trauma • Microsurgery • Aesthetic • Congenital • Orthopedics The resident (starting with the first three-year residency class) will rotate at Ochsner for three months the first year, three months the second year, and three months the third year with graduate responsibility. 65
CHILDRENS ROTATION OBJECTIVES Dr. Moses will oversee this rotation and the following categories will be emphasized: • Congenital • Embryology • Flaps and Grafts • Facial Trauma • Microsurgery • OMFS Attention will be given to the care of patients at Children s Hospital. This rotation will afford the resident concentrated exposure to the breadth of pediatric plastic surgery. Under Drs. Moses and St. Hilaire s direction, the resident will participate in the preoperative evaluation and planning and post-operative follow-up of these patients. This rotation will be for three months during the second year.
EAST JEFFERSON: HAND ROTATION OBJECTIVES Dr. George will oversee this rotation and the following categories will be emphasized: 66
• • • • • • • • •
Goals of Hand Rotation: Upper Extremity Reconstruction Congenital Hand Tumors of the Hand Upper Extremity Trauma Orthopaedics Goals of Reconstructive Rotation: Flaps and Grafts Microsurgery Implants and Biomaterials Aesthetics
This rotation will afford the resident concentrated exposure to hand surgery. Under Dr. George and Clasen s direction, the resident will participate in the preoperative evaluation and planning and post-operative follow-up of these patients. This rotation will be for three months during the first year. Dr. George will serve as the Local Training Director for this rotation.
OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER ROATION OBJECTIVES Dr. Taylor Theunissen will oversee this rotation and the following categories will be emphasized: • Facial Trauma • Reconstruction of Trunk and Breast • Reconstruction of Lower Extremity • Burns 67
• • • • • •
Wound Care Flaps and Grafts Microsurgery Practice Management Aesthetics Upper Extremity Reconstruction Congenital Hand
• •
Tumors of the Hand Upper Extremity Trauma
Anesthesia Dermatology o Skin o Mohs Benign and Malignant Skin Lesions o Functional Problems • •
•
The resident will rotate at OLOL for three months during the first year and three months during the third year. The resident will interact with and be exposed to a variety of cases. These rotations will be General Plastic Surgery Rotations.
TOURO: PRIVATE PRACTICE ROTATION OBJECTIVES PRIVATE PRACTICE OBJECTIVES
68
Dr. Sadeghi will oversee this rotation and the following Rotation Com petencies will be emphasized: • • • • • • •
Practice Management Aesthetics Functional Problems Medicolegal and Psychiatric Assessment Special Procedures Implants and Biomaterials Benign and Malignant Skin Lesions
This rotation is primarily an operative experience with emphasis placed on aesthetics and practice management but reconstruction will also be covered. The rotation will be for three months during the second year and three months during the third year.
RESEARCH ROTATION: OBJECTIVES 2nd year Tulane Plastic Surgery residents will actively participate in a three month research rotation during their second year Tulane rotation. The objective of this rotation is to provide the resident with the skills required to answer important hypothesis driven questions in the area of plastic surgery. At the completion of the block, the resident will prepare an abstract which will be submitted to a regional, national, or international meeting for presentation. All residents are required to have submitted 1-2 manuscripts to a peer-reviewed journal for publication prior to graduation.
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THE EMERGENCY DEPARTMENT The purpose of the experiences offered in these areas is to acquaint the resident with the characteristics of the critically ill and less severely ill "WALKING WOUNDED." Understand that the patient believes that an emergency exists even though your medical judgment may indicate otherwise. Many problems will be avoided if this fact is kept in mind. Good communication between the physician and the patient assist in continued patient improvement after discharge. If in doubt, admit. Patients who have been discharged from the emergency department, after being deemed to have mild illnesses, but then subsequently return because of persistent or worsening symptoms shall be admitted. All ER patient contacts shall be discussed with appropriate faculty prior to institution of care.
CONSULTATIONS Consultations should be seen promptly. When the consultation is complete, a telephone call to the physician requesting the consultation should be considered as part of your evaluation. If, for reasons of incomplete data a full consult is delayed, a short progress note indicating that the patient has been seen and that a formal consult will be forthcoming. A phone call will serve to keep lines of communication open and will enhance the stream of consultations to the service (System s Bases Practice and Professionalism). Surgeons who answer routine consults immediately and emergency consults even sooner have superior operative case lists in both quantity and quality. Also, consults should be discussed with the 70
attending staff in a timely manner just as any hospital admission would be. When consultations are seen in the Emergency Department, the evaluation should be designed to render an opinion in one hour or less. It is far better to admit a patient and complete the evaluation on the plastic surgical service than to prolong the stay in the emergency department. Bickering over which service will admit the patient will not be tolerated.
OPERATING ROOM Anesthesiologists and operating room nurses are fellow professionals and full participants in the care of the patient (System s Based Practice and Professionalism). They deserve and will receive the consideration and respect offered to any colleague. Remember, it is the patient that takes all of the risks. The full attention of a skilled and collegial operating team should always be available. Attendance in the operating room is required for all patients operated upon. First cases in the m orning are to be ready and outside the operating room 20 m inutes prior to the scheduled tim e to enable the case to start prom ptly. See that perm ission for operation, X-rays, and orders have been properly handled the night before surgery. The resident shall accom pany the patient into the operating room .
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The quality of assistance by a surgeon is directly related to his/her understanding of a given procedure. Prior to the start of any procedure, the resident involved should have read about the technical aspects of the procedure, possible com plications, any m easures that m ay be taken to either avoid or correct these com plications, and discuss the technique with his/her staff. Also, the quality of an assistant indicates his/her readiness to do a procedure. Evaluation of a resident as an assistant is therefore an im portant indicator of progress. At all tim es, the teaching assistant should be prepared to assum e the role of operating surgeon.
OPERATIVE CONSENT For each procedure done on and for the patient, the patient must be fully informed of the risks and benefits of the procedure (Professionalism and Interpersonal and Com m unication Skills). The operating surgeon should discuss with the patient the details of the procedure, the other options for the management of the specific disease process involved, the chances of success and failure of the procedure and the long term expected outcome. Having gotten consent, the surgeon m ust write a preop note, not dealing with labs, but describing the indications, objectives, alternatives, risks and complications of operation. You shall rotate at on the particular service based on the block schedule. Graduated responsibility is offered on all rotations and you will interact with a variety of staff. You will work one-on-one with the faculty (who will provide direct supervision) to understand the importance of patient assessment, formulating and executing 72
a plan and postoperative patient follow up. The emphasis on all rotations will be accomplishing the educational objectives, assisting the resident to develop independent thinking and allow the faculty to directly assess residency competency.
The plastic surgery resident is to assume responsibility for the day-to-day functioning of the plastic surgery clinical service always with direct faculty oversight. In order to obtain the maximal educational benefit, the plastic surgery resident should attempt to function in a manner as if the final responsibility was his. However, ultimate authority and responsibility, for all the patients, rests with the attending. This means that the resident should attempt to assess the problem and formulate a plan of action. The residents plan shall be based on accurately identifying and effectively communicating the problem and based on his medical knowledge the resident shall discuss potential treatment options. Through this maneuver, the resident option for patient care can be evaluated by the faculty and appropriate feedback can be given. In addition the practice-based learning over time can be accessed. It is stressed however; the above concept shall not be confused with a lack of resident supervision. The resident shall not im plem ent any plan of care in an independent fashion. For all patients, on all services, all aspects of patient care require direct approval and oversight from the attending. In addition, the resident shall not delay treatm ent in an em ergency situation. Furtherm ore, the resident shall refrain from discussing any therapeutic plan with the patient or fam ily until confirm ed with the attending. 73
It is our m andatory policy that direct resident oversight, for all aspects of the patients care, on all rotations, without exception is to be ensured. The only resident autonom y we encourage is of thought, not action. Continuity of care is achieved at all of the institutions through resident participation in the various clinics. Faculty and residents will participate in clinics together.
Resident Expectations 1) The plastic's resident is in charge of the plastic surgery clinical service understanding that ALL decisions regarding patient care must be reviewed with the attending staff. The faculty bears sole responsibility for the care of all patients at all times. 2) The plastic surgery resident, along with the faculty, assumes responsibility for the day-to-day management and care of all plastic surgery patients. 3) He should see the patient in the preoperative holding area with staff. Preoperative markings will be performed by the resident and staff prior to the patient proceeding to the operating room. 4) The resident shall accompany the patient into the operating room. 5) Intraoperatively, the plastic surgery resident will perform cases with the discretion of the attending supervision. 6) The resident is expected to have done pre operative 74
reading and planning prior to surgery. 7) The resident will be expected to have formulated a primary operative plan and several back-up operations. 8) Postoperative orders will be reviewed by the plastic surgery resident and staff. 9) The faculty will complete the operative dictation. 10) The plastic surgery resident should examine all the patients on the service every day (written progress note). At the time of attending rounds, the plastic's resident is responsible for updated information from other services involved in the care of the patients, as well as the patient's current status in regards to their plastic surgery problem. 11) Medical Student’s notes are not an acceptable form of documenting patient progress. It is acceptable to have the student follow the patient but there is no need for their chart documentation. 12) The plastic surgery resident is on call during the day for the patients on service. At night, the call will either be covered by the plastic surgery resident on-call or the faculty on call. 13) Weekends: When patients are in hospital on the weekend, they should be seen each morning by the plastic surgery resident or the general surgery resident on service depending on the call schedule. The attending will be available at all times 24 hours a day during the week AND weekend unless out of town at which time a back-up attending will be equally available. 14) The plastic surgery resident should also remain available by beeper while on rotation unless he is scheduled off either for vacation or during his 24hr block off duty. 15) The plastic surgery resident is responsible for reading 75
thoroughly on the problems, which are germane to all inhouse patients as well as those patients encountered in the clinic. 16) The resident is expected to read and concentrate on the goals and objectives for the rotation assigned. Textbooks, journals, and videotapes are available in the Plastic Surgery Library and should be read and viewed on the premises unless special arrangements have been made with the attending. In the clinic, the plastic's resident will evaluate all patients and will formulate a therapeutic plan in conjunction with faculty. The staff will examine, review and discuss all patients. 17) Research: opportunities for clinical research, as well as basic science research, are available at Tulane and Ochsner. Experimental designs for basic science research should be presented to the attending and if meritorious will be presented to the research foundation for possible funding. The attending staff will offer assistance and guidance in the preparation and presentation of a basic research project. 18) The resident is required to be involved in the development of a paper sometime during his two-year residency. Research in which the resident developed a concept, or did the majority of work in regards to data collection, the resident will be listed as first author. 19) Consults: The plastic surgery resident is responsible for daily compilation of consults. Any new consults that appear should be seen in a timely manner then presented to the attending or seen in conjunction with the attending. Emergency room consults should be seen by the resident who will then contact the attending or in an emergency, 76
contact the attending while in route to examine the patient. 20) All medical records must be done in a timely manner. 21) All communications from other services, whether from attendings, residents, interns, or nurses, should be communicated to the attending in an expedient manner. 22) The resident is an ambassador for the staff and the hospital and will be held to the highest standards. He must present himself in a respectful, professional, honest and congenial manner. 23) Sign all verbal orders within 24 hours. 24) Provide feedback for overall residency improvement.
Tulane Plastic Surgery Rotation Schedule 2013-2014 Revised: 6/11/2013
Rotation Schedule: Start of three year transition through full integration Academic Year 2013-2014: Resident's G* and H* are 3rd entering class of 3 year format Resident's E* & F start their 2nd year of their 3 year training Resident's C* and D* start their 3rdyear of their 3 year training (1st grads of 3 yr. program)
July
G Rahul Vemula
H Tim Matatov
E Orlando Canizares
F Steven Clark
C Joseph Lupo
D Craig Blum
1st Year
1st Year
2nd Year
2nd Year
3rd Year
3rd Year
Ochsner
OLOL
Touro
(Anesthesia)
(Research)
August
OLOL
EJ=Hand
September
(Derm)
(Ortho)
October
(Anesthesia) 77
Tulane (Optho)
(Research)
November
EJ=Hand
OLOL
Tulane
December
(Ortho)
(Derm)
(Optho)
Ochsner
Touro
OLOL
Touro
Ochsner
EJ = Recon
Childrens's
EJ = Recon
Ochsner
January February March
Ochsner
Tulane
(Ortho)
Childrens's (OMFS)
April May
Tulane
Ochsner
June
(Ortho)
Touro
(OMFS)
Research will be performed at Tulane during the second year Anesthesia will be covered on the OLOL rotation during the first year Orthopaedics will be covered on the Ochsner and East Jefferson rotations during the first year OMFS will be covered on the Children's rotation during the second year Dermatology will be covered during the first year on the OLOL rotation Ophthalmology and Research will be covered during the second year on the Tulane rotation
ROTATION KEY: Tulane: Chaffin
Rotation Name: Tulane Participating Sites: Tulane University Hospital and Lakeside Hospital Faculty: Jansen, Chaffin, St. Hilaire, Coleman
(General Plastic)
Goals:
78
•
Wound Care/Burn Care
•
Flaps and Grafts
•
Microsurgery
•
Implants and Biomaterials
•
Functional Problems
•
Reconstruction of Head and Neck
•
Reconstruction of Trunk and Breast
•
Reconstruction of Lower Extremity
•
Aesthetics
•
Ophthalmology
Childrens: Moses
Rotation Name: Children's Hospital (Childrens) Participating Sites: Children's Hospital
(Pediatric Rotation)
Faculty: Moses and St. Hilaire Goals: •
Congenital
•
Embryology
•
Flaps and Grafts
•
Facial Trauma
•
Microsurgery
•
OMFS
Ochsner: Babycos
Rotation Name: Ochsner Hospital on Jefferson (Primary) Participating Sites: Ochsner Baptist and Ochsner Kenner Faculty: Babycos, Jansen, St. Hilaire and Wise
(General Plastic)
Goals:
79
•
Wound Care
•
Flaps and Grafts
•
Reconstruction of Trunk and Breast
•
Facial Trauma
•
Microsurgery
•
Aesthetic
•
Congenital
•
Orthopaedics
East Jefferson:
Rotation Name: East Jefferson Hospital (EJ) Participating Sites: East Jefferson Hospital (primary) and East Jefferson Surgery Center Hand Faculty: George and Clasen Reconstructive Faculty: Lindsey, Sands, Escobar, Metzinger Goals of Hand Rotation:
George
•
Upper Extremity Reconstruction
•
Congenital Hand
•
Tumors of the Hand
•
Upper Extremity Trauma
•
Orthopaedics
Goals of Reconstructive Rotation: •
Flaps and Grafts
•
Microsurgery
•
Implants and Biomaterials
•
Aesthetics
Touro: Sadeghi
Rotation Name: Touro Infirmary (Touro) Participating Sites: Touro (primary), SurgeryPlex Hedgewood, Kindred Hospital, GNO, EJ Faculty: Sadeghi, Chaffin, Moses, Church and others: Lindsey, Church, Escobar, Johnson, Mizgala, Black, Jansen, Metzinger and Coleman Goals:
(Cosmetic Rotation)
OLOL: Theunissen
80
•
Practice Management
•
Aesthetics
•
Functional Problems
•
Medicolegal and Psychiatric Assessment
•
Special Procedures
•
Implants and Biomaterials
•
Benign and Malignant Skin Lesions
Rotation Name: Our Lady of The Lake Regional Medical Center (OLOL) Participating Sites: OLOL (primary), BR General, Vista, Aesthetic SC, BRASS, SSCBR Faculty: Theunissen, Boudreaux, Williams, Ahmad, Stephen, Dean and Hanemann Goals:
(General Plastic)
•
Facial Trauma
•
Reconstruction of Trunk and Breast
•
Reconstruction of Lower Extremity
•
Burns
•
Wound Care
•
Flaps and Grafts
•
Microsurgery
•
Practice Management
•
Aesthetics
•
Upper Extremity Reconstruction
•
Congenital Hand
•
Tumors of the Hand
•
Upper Extremity Trauma
•
Anesthesia
•
Dermatology o
Skin
o
Mohs
o
Benign and Malignant Skin Lesions
o
Functional Problems
Tulane: Chaffin
Rotation Name: Tulane Research (Research) Participating Sites: Tulane University Hospital and Lakeside Hospital Faculty: Jansen, Chaffin and Izadpanah Goals:
(Research)
81
•
Literature appraisal
•
Develop question
•
Identify collaborators
updated: 6/11/2013
Evaluation You will be evaluated, throughout your training, on the ACGME core competencies. These should be reviewed and understood: a.
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
b.
Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
c.
Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
d.
Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
e.
Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
f.
Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system
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•
Design study
•
Generate research methods
•
Conduct research
•
Write manuscript
•
Present Findings
•
Participate in plastic surgery call schedule
•
Research
of health care and the ability to effectively call on system resources to provide care that is of optimal value
As a prerequisite to successfully completing this fellowship you will be required to successfully demonstrate procedural competence in each of the PSOL defined major categories. During each rotation you are must enter at least two procedural evaluations, utilizing the E*value system, which the faculty will evaluate you on.
DIDACTIC COMPONENT Rotating through a variety of hospitals and clinics, the residency strives to create a balanced and comprehensive plastic surgery training program. We have incorporated the best of both worlds; University based training and Private Practice exposure. The rotations are planned to offer an increase in responsibility during the two years of training. Each of the hospitals has a subspeciality area of interest, which allows the resident to focus their training. During all rotations the educational philosophy is the same. It is that of wide latitude in intellectual inquiry but very close supervision of specific patient care with gradual assumption of clinical decision-making and operative responsibility. Two training methods are fundamental to this philosophy, one for cognitive activities and one for technical matters (M edical Knowledge). The first is that in all cognitive activities the resident is required to "make a plan" prior to discussing the problem with the attending. Basic core knowledge is required for this activity and teaching of this material will be performed on a daily basis utilizing patient 83
examples. Attendings will not dictate diagnostic or therapeutic plans. The resident "makes a plan" which is then discussed with the attending and together a treatment algorithm is created. This method of "making a plan" and then defending it against the critique of the attending physician trains the resident and permits him to assume increasing levels of independence. It is the goal that at the completion of his/her training the resident will have made sufficient independent decisions (under faculty supervision) that he/she can easily assume the position of an independent physician. This philosophy holds for all patients on the wards, in the clinics, pre- and postoperatively, and throughout the program.
CONFERENCES To further develop and promote resident education the Program Directors of both Tulane and LSU have, combined our didactic programs. Faculty from both the schools teach all residents. We share one common goal; optimize resident education by utilizing the best teachers regardless of school affiliation, practice demographics or even specialty: Dermatology, ENT Plastic Surgery all contribute. With participating dedicated and enthusiastic faculty we will always strive towards our primary objective: EDUCATION. The 2013-2014 Conference Schedule has been developed to facilitate Competency Based Learning, examples: i. Basic Medical Knowledge 1. Core Curriculum 2. Grand Rounds Topics 3. Hand Conference 4. Mock Oral Exam ii. Patient Care: 84
iii. iv.
v.
vi. vii.
1. Case Conference 2. Visiting Professorship Practice Based Learning and Improvement: 1. Patient Safety Conference (M&M) 2. Journal Club Systems Based Practice: 1. Resident Research Day 2. Grand Rounds Topics: a. Patient Placement b. Social Services c. Harassment Training d. Compliance Training 3. Sculpture,Drawing&Photography Classes Professionalism 1. Grand Rounds Topics: a. Ethical Coding b. Malpractice Interpersonal and Communication Skills: 1. All conferences Procedural 1. Microsurgery Lab 2. Anatomy Lab 3. Botox/Filler Lab
Curriculum Format and Resident Responsibilities 1) It is the resident’s responsibility to approach your assigned staff for the lecture topic at least 1 month in advance. The entire year’s didactic calendar is distributed in advance so failure to do so is unacceptable. 2) After discussion with your assigned staff for the topic in question, it will be the staff’s decision whether they would like 85
3)
4)
5)
6)
7)
to give the Grand Rounds on Friday morning 7:30-8:30am, at LSU Medical School location or if they would like you, the fellow, to give the assigned Grand Rounds. Thursday evening conference is at Tulane Medical School, Room 6001. Except for the first Thursday of every month (Hand Conference) is held at 5:30, also in Room 6001 at Tulane. The staff will recommend articles for the fellow to collect and then the fellow will distribute those articles electronically to everyone via e-mail at least one week before the topic is discussed in conference. Assigning one article per LSU and Tulane fellow (total of 8 articles) is more than enough. The fellow will glean all of the in-service questions from 1998 through 2008 and place the questions appropriate to that week’s topic in a MS Word document (without the correct answer) but leaving the explanation just beneath each question. These questions and articles will be discussed from 7am to 8am on Friday morning and proctored by either the staff or fellow (staff’s choice). Friday morning conference is held at LSU Medical School, Room 756. From 8am to 9am, pre/postop conference will take place. EVERYONE should always be prepared EVERY WEEK to present a case. While your case may not be presented every week, you should always have one available and will need to sign in with your case topic each week. M&M conference is held monthly from 8am-9am at LSU Medical School, Room 756. Cases should be submitted to the senior residency program coordinator (Debra Felix at
[email protected]) on Wednesday of that week.
Core Curriculum Conference: The Core Curriculum Conference is a joint conference attended and staffed by the residents and faculty of both programs. A yearly schedule is promulgated in July and adhered to as much as possible. 86
The conference is organized by the faculty with direct resident input. Attendance is mandatory for residents. Medical Students and rotating residents on both services also are required to attend. The basic format utilizes Selected Readings in Plastic Surgery. This well recognized publication contains 40 volumes, including reference materials. Each subject is handled once during the year. Residents are required to read both Selected Readings and assigned articles of clinical significance. Each session covers Medical Knowledge, Patient Care, PBLI, Technical aspects of Procedures and often Systems Based Practice. The conference is approximately one hour long.
Preoperative and Postoperative Conference Case Conference This is a weekly conference and resident’s attendance is mandatory. Medical students and rotating residents also attend. Each service presents one or two patients. The presentations are done on “Power Point” which is a good use of information technology in resident education. All patient presentations include history, photo documentation of the pathology and operative plan. The resident is evaluated on the accuracy and completeness of the information gathered about the patient. This session covers PBLI, IPCS, Medical Knowledge, Patient Care, Procedural Based Learning, and Systems Based Practice. 87
Because the other services are not familiar with the patient, the presentations are used as an “unknown “for the audience. The residents are asked to propose a diagnosis and asked to explain the basis for their decision. The presenting resident then must develop a plan of management and defend alternate plans before the faculty: 1) Presenters are expected to provide support based on the literature (text and journals) for the planned management. 2) Presenters are expected to make informed decisions about their treatment plan based on the historical record and the scientific evidence supporting the plan and this must be accurately articulated. 3) This allows all to evaluate the resident’s analytical processes and the ability to propose and defend a reasonable management plan. This exercise, in addition to our Patient Safety Conference, allows evaluation of the resident’s communication skills, Medical Knowledge, PBLI, PC and Procedural Based Learning. We also frequently discuss ethical issues, professionalism and the economic impact of treatment plans.
Anatomy Laboratory In the fall of each year, a joint Anatomy Lab is held. Funding for this session is provided by both schools. A schedule of dissection is published. Each session is 88
approximately 4-5 hours in length and begins with a discussion by an assigned faculty member who then leads the individual breakout resident dissection teams. A dissection manual is supplied to the residents. Flap procedures are demonstrated during dissection as well as surgical techniques relevant to the anatomic area. This helps the resident to develop skills needed to perform surgical procedures competently. This session covers Medical Knowledge, Procedural Based Learning and Patient Care.
Microsurgery Laboratory Tulane University has a microsurgery laboratory with veterinary and animal support. This laboratory is held at the beginning of the academic year and each resident participates as frequently as required to become proficient. Residents learn the basic microsurgical skills under the tutelage of a faculty member. Senior residents participate in teaching of the junior residents. Residents are expected to perform venous and arterial anastomosis which is analyzed by the faculty. This session covers Procedural Based Learning, Patient Care and Medical Knowledge.
Grand Rounds Friday Grand Rounds involve a variety of programs on a regularly scheduled basis. 89
1) Morbidity and Mortality (Patient Safety Conference) is held monthly on the third Friday morning of every month. Two patients are presented by each service. These cases are “Power Point” presentations, presented by the resident involved in the care of the patient. The goal of the conference is the prevention of complications by PBLI and changes in patient care, procedures, effective communication among providers ultimately to reduce complications. Treatment of complications is discussed with the faculty to access their practice experience. This session covers PBLI, IPCS, Medical Knowledge, Procedural Based Learning, Systems Based Practice to improve Patient Care. 2) Grand Rounds is held each Friday morning, except Hand Conference which is held the first Thursday evening of the month, with two onehour topics presented each week. In this conference, residents and faculty present lectures on specified topics. We also have lectures by others in the health care field. Recently we have had sessions on coding, ethics, patient safety and access to varying levels of care. As part of our Grand Round Series we have a Visiting Professorship where a nationally known expert comes and presents several focused lectures on an important key topic. This session covers PBLI, IPCS, Medical Knowledge, Procedural Based Learning, Patient Care and Systems Based Practice. 90
Journal Club Journal Club is held on the last Wednesday evening of every month. Residents are assigned journals articles to read and present. The senior residents rotate assigning the articles. The residents are expected to discuss study designs and statistical methods and to appraise the clinical studies. Residents are required to attend, and normally many of the faculty also are in attendance. This session covers PBLI, IPCS, Medical Knowledge, Procedural Based Learning, Patient Care and Systems Based Practice.
PLASTIC SURGERY OPERATIVE LOG (PSOL) The Plastic Surgery Operative Log (PSOL) is a mandated record of the operative cases done during the residency training. This is required by both the Residency Review Committee (RRC) and the American Board of Plastic Surgery (ABPS) to assess the number of cases done by each individual resident and the surgery resident corps as a whole. The numbers affect both the accreditation program and the application for Board examination of each individual resident. The PSOL is divided into several categories of case types, with assigned minimal numbers for each category, the overall total during residency training and the number of cases done during the chief year. These numbers vary and are changed from year to year and therefore are not included in this manual. It is urged, however, that you get the current minimum number. It is imperative that this data be kept accurate and current on a weekly basis. As a requirement for completing the residency program, every resident 91
must demonstrate competency in each of the defined major PSOL categories along with meeting the minimum requirements and also having completed a minimum of 1000 cases/two years.
RESEARCH PROJECTS For the Tulane Plastic Surgery research program, both basic science and clinical research projects are available. Residents are required to produce one research project during the fellowship period. Twice a year, resident research day is held where the residents present, discuss and defend their research efforts.
Clinical Sciences Research i.
Breast Reconstruction (Techniques & Quality of Life Issues)
ii.
Head & Neck Reconstruction (Anatomical Studies)
iii.
Vascular Malformation
iv.
Diabetic Wound Repair using Human Adult Stem Cells
Drs. Jansen and Chaffin are also collaborating with Dr. Reza Izadpanah the section of cardiology separating and culturing Stem Cells from human adipocyte tissue (ADSC). Ongoing experiments are designed to:
Research Space 92
Currently, surgical research is financially supported by the Department of Surgery. A modern laboratory equipped with modern surgical dissecting microscopes, gel electrophoresis, protein purification, tissue culture hoods, EMG recording, is being constructed. The majority of our collaborators are located in the same building. A certified animal care facility is also in the building. There is a separate cadaver head dissection lab run by Neurosurgery and Plastic Surgery.
ACGME: Definition of surgeon Basic Principle: To be recorded as the surgeon, a resident must be present for all of the critical portions, and must perform the majority of the critical portions of the procedure. Involvement in the preoperative assessment and the postoperative management of that patient is an important element of that participation. Clarifications: 1.
If a plastic surgery resident completes one side of a bilateral procedure, the resident can count that as one case, surgeon. If a plastic surgery resident completes both sides of a bilateral procedure, this still counts as one case, surgeon. If two residents each do one side of a bilateral procedure, each resident can record the procedure as the surgeon, provided that each fulfills the stated criteria for performance as surgeon on one side.
2.
In an operation which involves multiple procedures, more than one plastic surgery resident may be recorded as the surgeon, provided that the resident performs the majority of the critical portions of one or more of the procedures, e.g., tendon repair, vascular repair, nerve repair in a complex hand injury case. If there are multiples of the same procedure in one case,(i.e., tendon or nerve repair), and each resident performs to completion one or more of the repairs, each resident may claim that case as surgeon.
3.
In the circumstances where a fellow, e.g., a hand fellow, oversees a plastic surgery resident in the performance of a procedure, both the 93
fellow, as the teaching assistant, and the plastic surgery resident may be recorded as the surgeon. 4.
If a senior plastic surgery resident oversees a junior plastic surgery resident on a particular case, both may be recorded as the surgeon, providing they meet the stated criteria above.
GENERAL INFORMATION a) Orders i) The nurses, other physicians and the hospital must know which physician writes orders and be able to correctly interpret them. The physician's name, physician number, along with the date and time, should be printed legibly in the left hand margin of the order sheet. This is part of your evaluation as determined by Systems Based Practice and Communication Skills. ii) Orders should be written in such a manner that the nurse can accurately read and understand them. If your script is hard to read PRINT. iii) Flag the orders properly after completion. If they are emergency or stat orders, hand the chart to the nurse and tell her what the order says. Leave nothing to chance. iv) Medications should be written out mg/kg/day followed by mg/dose and the frequency the dose is to be given. v) Fluid orders should be the type of fluid followed by the rate of administration. vi) The use of verbal orders is discouraged. Residents failing to sign verbal orders which were necessary within 24 hours will have verbal order privilege revoked! 94
vii) Please notify charge nurse or ward clerk if you are removing any chart from the station. viii) Admit orders are needed prior to the admission of the patient. ix) Discharge orders are to be completed as early as possible unless prevented by necessary patient care responsibilities. x) Nursing will ask for order clarification (if unclear) for safe delivery of care. This is not an attempt to challenge your knowledge but to assist in patient care. Clarification will be offered using a professional tone and manner in every instance. xi) Verbal orders MUST all be signed the following day. xii) Prescription for medications and supplies need to be written on Friday for week-end discharges. xiii) STATS are expensive - please use discretion when ordering something STAT. xiv) Please return charts to chart rack when completed. xv)Ordering "routine" laboratory studies is not in the best interest of good patient care. Unless you can write down one or more ways in which patient care will be assisted by the study, it is probably unnecessary. Stable values rarely change without a change in clinical condition. Cultures and other laboratory studies are expensive. Do not order unless you have a plan to alter patient care based on the results. Check at least every six months the price of various tests and medication so that you can properly appreciate the rising cost of medical care. b) Progress Notes
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i) Progress notes should be identified with printed name, physician number, and date and time in the left margin. All notes are to be signed when written. ii) M edical Students’notes are not an acceptable form of docum enting patient progress. It is acceptable to have the student follow the patient but there is no need for their chart docum entation. iii) Progress notes should be written when any procedure is performed or there is a change in the condition. iv) There should be at least one note each day as to the patient's general condition and plans for the next 24 hours.
DRESS CODES A well-groomed professional appearance inspires the confidence of patients, their families and visitors. Clothing must be neat, clean and appropriate for the work required and moderate in style. Jeans, cutoffs, shorts, T-shirts, etc., are not acceptable clothing for professionals in the hospital. Patients recognize the white coat as a symbol of a medical professional and should be worn at all times. Operating room attire (scrub suits) must be covered by a white coat if worn outside the O.R. When such clothing is worn it should be clean and not covered by body fluids.
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Shoes should be medium or low heeled, clean and polished. Sandals are not allowed. Stockings/socks/hose should be clean, in good condition and worn at all times where appropriate. Jewelry should be used with moderation. Good personal hygiene is extremely important to patient care as well as the comfort of co-workers and is an integral part of a proper professional attire policy. Professionals should be clean and wellgroomed at all times. Tobacco chewing and gum chewing are not appropriate for physicians on duty.
SCHEDULING REQUIREMENTS All patients scheduled for the OR require: 1) History and physical (ODS patients use the ODS history and physical form 2) Consent for surgery (valid for 30 days) 3) Consent for hospital admission 4) Pre-operative work up orders: a. Type of admit (ODS or SSU) b. patients 40 years or older where anesthesia is planned require: CBC, UA, EKG, Chest X-Ray Call the Anesthesia Department if you have any questions about a specific patient while in clinic. Note: Anesthesia writes preoperative medication orders for all general anesthesia patients. 97
Note: For “in custody" patients do not tell the prisoner or the guard the day of surgery or admission. The Admit Office will contact the facility to inform them of the date.
DISASTER PLAN The physician component was developed by the trauma committee and integrated into the overall hospital plan. A full review of the Disaster Plan is required. Clear lines of communication and responsibility will be distributed as a separate policy: http://emergency.tulane.edu/
DAYS OFF On your days off (including weekends) you are responsible for the care of your patients prior to leaving the hospital. Do not leave work on your ward to be done by the on-call House Officer at your level. If a patient on your ward needs special attention, discuss this with the On-Call House Officer at your level before leaving the hospital.
VACATION TIME Each resident will receive 3 weeks (21 days) of vacation each year. No more than 7 days vacation per rotation. Only one resident may take vacation at any one time with senior residents getting priority. EXCEPT for HOLIDAYS, only 1 resident may be out of town per weekend when a Tulane resident is on the Baton Rouge rotation. When all 6 Tulane fellows are rotating in the New Orleans area, 3 residents may be out of town on the same weekend. 3 residents must be in town each weekend. The 4 Academic holidays, Thanksgiving, Christmas, New Years and Mardi Gras; will be a 4 day call coverage similar to weekend coverage by 98
one primary call person and one back up person. NO vacations allowed in June or July. All vacation time requires formal leave request and preapproval (both Program Director and local training director). Any changes after the schedule is published must be requested in writing to the Program Director.
Meetings One paid meeting per resident/residency. With approval, residents may attend additional meetings at his/her own expense. Meeting attendance (paid or unpaid) does count towards vacation time.
Sick Leave If a resident calls in sick, it is the prerogative of the Program Director to ask for a doctor's excuse from the resident. Each resident must be aware that the RRC for plastic surgery allows only a certain amount of absence from training per year. Absence beyond that designated time--be it for vacation or sick leave--will extend their time in training. As has been pointed out in other sections of this manual, the responsibilities to your patients is paramount both now as a resident and for the rest of your professional life. If you cannot provide that patient care because of illness, death in the family or required absence from the city, you must make sure your patients are adequately covered and that the staff on the service to which you are assigned understands your need to be absent and they have given permission.
Benefits Residents Health Plan: Residents and Fellows are required to enroll in this plan unless they are covered under another health plan. The cost of residents health insurance is a responsibility of the school. 99
Spouses or dependents can be enrolled at registration at resident's expense. Late enrollment is subject to review. Premiums are negotiated yearly and are determined by the previous years' experience and use. Parking ‒ Parking is provided for residents assigned to MCLNO, University Hospital, TUHC, and VAMC NO. Beeper ‒ Beepers are provided for the duration of the residencies.
Health Insurance ‒ United Health Care health insurance is provided to residents at no cost. Family health coverage is available and is paid for by the residents. Dental Insurance ‒ Optional dental insurance is provided through Paid Dental Insurance Company and is available to residents and their families. It is paid for by the residents. Life Insurance ‒ A $25,000 life insurance policy is provided at no cost to residents. Disability Insurance ‒ Disability insurance is provided at not cost to the residents. Malpractice Insurance ‒ Malpractice insurance is provided at not cost to the residents. Educational Leave ‒ With the approval of the program director, educational leave allowed in some programs Vacations ‒ Residents are allowed vacation, the duration is 100
determined by individual programs. Salary ‒ 2013-2014 annual salaries for residents are as follows:
HO-I
$ 44,168
HO-II
45,500
HO-III
47,179
HO-IV
49,029
HO-V
50,720
HO-VI
54,029
HO-VII
54,029
Institutional Policies: please review the following website http://www.som.tulane.edu/departments/gme/resources_residents.htm
Map of the Health Sciences Center Incoming House Officers Resident Handbook Resident Congress Constitution Resident Congress Bylaws Risk Management Medical Malpractice
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Louisiana Malpractice System Benefits and Compensation Louisiana State Board of Medical Examiners Insurance Information Residents Assistance Program Medical Library Reily Center Tulane University Hurricane Emergency Preparedness Office of Environmental Health and Safety HIPPA Sexual Harassment At the above website you will find information regarding the probation, suspension, termination and grievance policy. This is located via the link which says: Resident Handbook.
ABPS REQUIREMENTS See website for updated information: http://www.abplsurg.org/ Program Directors of accredited residency training programs in plastic surgery must require all residents to have an official evaluation and approval of their prerequisite training by the Board before they begin plastic surgery training. TRAINING REQUIREMENTS There are two approved educational (training) models for plastic surgery, 102
the Independent Model and the Integrated Model. A plastic surgery program director may choose to have both training models in a single training program. Several organizations provide governance for these models. These are the Residency Review Committee for Plastic Surgery (RRC-PS) of the Accreditation Council for Graduate Medical Education (ACGME), which sets educational requirements and accredits training programs in plastic surgery; the Association of Academic Chairmen of Plastic Surgery (AACPS), which helps coordinate the training activities of the programs; and The American Board of Plastic Surgery, Inc. (ABPS), which sets educational requirements, examines and certifies the graduates of those programs. In both the integrated and the independent models, plastic surgery training is divided into two parts:
1. The acquisition of a basic surgical science knowledge base and experience with basic principles of surgery (PREREQUISITE TRAINING in the Independent Model). 2. Plastic surgery principles and practice, which includes advanced knowledge in specific plastic surgery techniques (REQUISITE TRAINING). In the independent model, the residents complete the PREREQUISITE TRAINING outside of the plastic surgery residency process, whereas in the integrated model, residents complete all training in the same training program. In a combined or coordinated program, residents complete the prerequisite training for the general surgery training program in the same institution as the plastic surgery program. Residents may transfer, prior to the last two years, from an Independent Program to another Independent Program and from an Integrated Program to another Integrated Program, but they may not exchange accredited years of training between the two different models without prior approval by The American Board of Plastic Surgery, Inc. and the Residency Review Committee for Plastic Surgery. Residents must request any anticipated transfers in writing and obtain prior approval by the Board well in advance of the proposed change in programs.
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The minimum acceptable residency year, for both prerequisite and requisite training, must include at least 48 weeks of full-time clinical training experience per year. A leave of absence during training will not be included toward completion of the minimum 48 weeks requirement. This includes Military Leave and Maternity/Paternity Leave. INDEPENDENT MODEL This model includes programs with two or three years of plastic surgery training. The Independent Model has two options. The first option has two variations. Each of the pathways described satisfy the requirements of the Board for entry into the certification process. 1) Option 1, variation A: requires at least three years of ACGMEapproved clinical general surgery residency training in the same institution with progressive responsibility to complete the PREREQUISITE requirements of the Board. Residents must complete a minimum requirement of 36 months of training including specific rotations, which are noted later in this Booklet of Information. This requirement of the Board stipulates that a minimum of three years of clinical training in general surgery, with progressive responsibility, in the same program must be completed before the resident enters a plastic surgery residency. 2) Option 1, variation B: is the combined or coordinated residency. This option is the same as option #1A, with the exception that medical students are matched into an ACGME-approved general surgery training program with a non-contractual understanding that they will become plastic surgery residents at the same institution after satisfactorily completing the three-year minimum PREREQUISITE requirement in general surgery. During this time they are considered residents in general surgery with an expressed interest in plastic surgery, but are not considered plastic surgery residents by the RRCPS, AACPS, or ABPS until completing the PREREQUISITE training program and entering the requisite training years. These programs are not differentiated in the ACGME s Graduate Medical Education Directory (the Green Book ), but rather are found listed among general surgery and independent plastic surgery programs. PREREQUISITE 104
AND REQUISITE requirements are completed at the same institution in this model. 4)
Option 2: is available for residents who have satisfactorily completed a formal training program (and are board admissible or certified) in general surgery, neurological surgery, orthopedic surgery, otolaryngology, urology, or oral and maxillofacial surgery (the latter requiring two years of clinical general surgery training in addition to an M.D./D.D.S. or D.M.D.). Successful completion of these ACGME or ADA accredited programs fulfills the PREREQUISITE training requirement.
Residents can officially begin a plastic surgery training program (REQUISITE TRAINING) after completion of any of these PREREQUISITE options, which all require confirmation by the Board (Completion of the Request for Evaluation of Training Form with receipt of the Board s Confirmation Letter regarding the acceptability of the prerequisite training for the Board s certification process). In the Independent Model options, only the REQUISITE period of training is under the supervision of the RRC-PS. However in the combined model, the general surgery years are accredited by the RRC for General Surgery and not the RRC-PS. REQUISITE TRAINING Graduate Education in Plastic Surgery Two years of plastic surgery training is required, and the final year must be at the senior level. Residents are required to complete both years of a two-year program in the same institution. Content of Training Residents must hold positions of increasing responsibility for the care of patients during these years of training. For this reason, major operative experience and senior responsibility are essential to surgical education and training. An important factor in the development of a surgeon is an opportunity to grow, under guidance and supervision, by progressive and succeeding stages to eventually assume complete responsibility for the surgical care of the patient. 105
It is imperative that residents hold positions of increasing responsibility when obtaining training in more than one institution, and one full year of experience must be at the senior level. The normal training year for the program must be completed. No credit is granted for a partial year of training. The Board considers a residency in plastic surgery to be a full-time endeavor and looks with disfavor upon any other arrangement. The minimum acceptable training year is 48 weeks. Should absence exceed four weeks per annum for any reason, the circumstances and possible make-up time of this irregular training arrangement must be approved by the program director and the additional months required in the program must be approved by the Residency Review Committee (RRC-PS) for Plastic Surgery and documentation of this approval must be provided to the Board by the program director. No credit but no penalty is given for military, maternity/paternity or other leaves during training. Candidates in the examination process called to active military duty do not need to submit a reapplication if five years expire during the active duty period. Training in plastic surgery must cover the entire spectrum of plastic surgery. It should include experience in both the functional and cosmetic management of congenital and acquired defects of the head and neck, trunk, and extremities. Sufficient material of a diversified nature should be available to prepare the resident to pass the examinations of the Board after the prescribed period of training. This period of specialized training should emphasize the relationship of basic science, anatomy, pathology, physiology, biochemistry, and microbiology, to surgical principles fundamental to all branches of surgery and especially to plastic surgery. In addition, the training program must provide in-depth exposure to the following subjects: the care of emergencies, shock, wound healing, blood replacement, fluid and electrolyte balance, pharmacology, anesthetics, and chemotherapy ACCREDITED RESIDENCY PROGRAMS Information concerning accredited training programs for the Independent Model may be found in the Directory of Graduate Medical Education Programs ("the green book") published by the American Medical Association (AMA) under the aegis of the Accreditation Council for Graduate Medical Education (ACGME). 106
This directory is available at many medical schools and libraries, or may be ordered directly from the AMA by calling toll free 1-800-621-8335, or by writing to: Order Department OP416702, American Medical Association (AMA), P.O. Box 930876, Atlanta, GA 31193-0876, www.ama-assn.org. The Board does not inspect or approve residencies. The Residency Review Committee (RRC-PS) for Plastic Surgery inspects and makes recommendations for or against approval of a residency training program in plastic surgery only after the director of the residency has filed an application for approval by the Residency Review Committee (RRC-PS) for Plastic Surgery. For information contact the office of Doris A. Stoll, Ph.D., 515 North State Street, Suite 2000, Chicago, Illinois 60610; (312) 755-5499; www.acgme.org. The Residency Review Committee (RRC-PS) for Plastic Surgery consists of nine members, three representatives from each of the following: The American Board of Plastic Surgery, Inc., the American College of Surgeons, and the American Medical Association. Updated: 10/08/2013
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