DEPARTMENT OF SURGERY SECTION OF THORACIC SURGERY GENERAL THORACIC SURGERY ROTATION (STG)

Cardiovascular Center University Hospital

House Officer III House Officer IV

Curriculum/Rotation Goals and Objectives for Surgery Residents

1

General Thoracic Surgery Service (STG) House Officer III Goal: The goal of the HO III General Thoracic Surgery rotation is to continue to expand and reinforce overall thoracic surgical knowledge and operative experience, as well as to provide more concentrated exposure in those clinical conditions treated with advanced minimal access techniques, including achalasia, hiatal hernia repair, esophageal and pulmonary resection and gastroesophageal reflux, among others, and to develop skills in advanced thoracic surgery techniques (e.g., pulmonary vascular and airway anastomoses).

Learning Objectives: Patient Care: By the end of the General Thoracic Surgery rotation, the HO III resident will be able to: 1. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families 2. Gather essential and accurate information about their patients, especially regarding hiatal hernias, gastro-esophageal reflux, esophageal and lung cancer, airway or other mediastinal lesions 3. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment 4. Counsel and educate patients and their families, under the guidance and direction of senior residents and faculty 5. Use information technology effectively to support patient care decisions and patient education 6. Demonstrate safe and effective management of the critically-ill thoracic surgery post-operative patient, including interpretation of data obtained from non-invasive and invasive monitoring 7. Demonstrate placement of basic invasive monitoring devices such as central lines and arterial monitoring lines 8. Perform airway assessment and management 9. With appropriate supervision and intraoperative assistance, perform surgical procedures considered essential for the area of practice, with the ability to: a. Describe the intraoperative risks for mediastinoscopy in the staging of lung cancer b. Execute diagnostic staging procedures such as mediastinoscopy, mediastinotomy and thoracoscopy c. Perform safe and effective port placement for all minimal-access basic (e.g., thoracoscopic lung biopsy) and some advanced procedures (e.g., esophagectomy, esophagomyotomy, antireflux operations, lobectomy or DaVinci robot assisted operations) d. Perform intra-peritoneal access for laparoscopic surgery (both Veress needle and open Hassan trocar approaches) e. Perform majority of the dissection in a straightforward laparoscopic esophagomyotomy or VATS lung biopsy f. Demonstrate the early steps of dissection for VATS g. Discuss surgical anatomy relevant to thoracic transplant organ procurement 10. Collaborate with health care professionals, including those from other disciplines, to provide patientfocused care, with a particular attention to the multidisciplinary care of the oncology patient which includes interactions with pulmonology, gastroenterology, medical and radiation oncology, dietitians, and advanced practice providers from the clinic and inpatient service

3

Medical Knowledge: By the end of the General Thoracic Surgery rotation, the HO III resident will be able to: 1. Hiatus Hernia and Gastro-esophageal Reflux a. Describe the anatomy and physiology of primary and recurrent hiatus hernias b. Discuss the pathophysiology and clinical presentation of gastro-esophageal reflux disease (GERD), and to list both classic and atypical symptoms of GERD c. Explain the pathophysiology and clinical presentation of para-esophageal hernia (including Types I-IV), and recite both the most common urgent and chronic symptoms d. Describe the management of acute gastric volvulus in the context of a paraesophageal hernia e. Discuss the common treatment options for hiatus hernia and antireflux operations, including both thoracic and trans-abdominal approaches f. Discuss the difference in technique and explain the rationale for complete and partial fundoplication g. Describe in detail the anatomy for minimal access and transthoracic approaches to esophageal hiatus surgery h. Discuss the common treatment options for para-esophageal hernia, i. Recite the intra-operative risks of both open and laparoscopic hiatal hernia repair and/or fundoplication j. Demonstrate safe and effective post-operative management of hiatal hernia repairs, including provision of dietary counseling k. List the common post-operative complications and sequelae, both short and long term for hiatal hernia repair and fundoplication l. Demonstrate safe and effective management of esophageal hiatus operations, including provision of adequate pain control, wound and dietary management m. Demonstrate safe and effective management of post-operative complications, including dysphagia, esophageal injury, recurrent hernia, hemodynamic instability, including “red flags” for notifying senior residents or faculty regarding potential need for reoperation 2. Esophageal Cancer a. Describe and discuss the anatomy of the cervical, intrathoracic and abdominal esophagus and normal esophageal physiology b. Review the algorithm for diagnosis and staging of esophageal cancer c. Identify the absolute contraindications to esophagectomy for cancer d. Describe and discuss the roles of the relevant clinical specialties involved in the who have input in the multidisciplinary management of esophageal cancer patients e. Explain and contrast the common treatment options for resectable esophageal cancer f. Describe and discuss the risks and benefits of the techniques of esophageal reconstruction g. Recite and discuss the intra-operative risks of both open and minimal access esophagectomy h. Describe the role of endoscopy in the preoperative assessment and postoperative management of patients undergoing esophagectomy i. Demonstrate safe and effective management of patients undergoing esophagectomy, including provision of adequate pain control, wound and dietary management j. Recall post-operative complications, both short and long term for patients undergoing esophagectomy k. Demonstrate safe and effective management of post-operative complications, including anastomotic leak, chylothorax, recurrent laryngeal nerve injury, dumping syndrome, including “red flags” for notifying senior residents or faculty regarding potential need for reoperation 3. Lung Cancer a. Recite and discuss the preoperative assessment for patients being considered for pulmonary resection b. Explain the different treatment options for patients with early stage (AJCC 7 th ed Stage I or II) lung cancer c. Describe the key steps in pulmonary resection including wedge excision, lobectomy, pneumonectomy and parenchymal-sparing options

4

d. Describe and discuss the roles of the relevant clinical specialties involved in the multidisciplinary management of lung cancer patients e. Describe and discuss the intra-operative risks of pulmonary resection f. Demonstrate safe and effective post-operative management of the lung resection patient g. List and recite post-operative complications of pulmonary resection, both short and long term h. Demonstrate safe and effective management of post-operative complications, including utilizing APPs, senior residents and faculty i. Recite the “red flags” that may indicate a need for reoperation in lung resection patients 4. Mediastinal Diseases and Benign Esophageal Disorders a. Describe etiologies underlying esophageal dysmotility disorders (e.g. esophageal diverticulum, achalasia) b. Describe the pathophysiology of mediastinitis arising from esophageal injury or perforation c. Recite the differential diagnosis and options for operative management of mediastinal masses d. Explain options for operative and non-operative management of esophageal perforation e. Demonstrate competency in thoracotomy and median sternotomy f. Demonstrate safe and effective post-operative management following operations for esophageal dysmotility disorders g. Demonstrate safe and effective post-operative management following resection of a mediastinal mass 5. Endoscopy a. Demonstrate understanding of the indications for airway and upper GI endoscopy in the perioperative care of patients undergoing thoracic operations b. Explain options for diagnosis and management of anastomotic leak following esophagectomy and esophageal reconstruction c. Explain and demonstrate the basic technique of bronchoscopy and upper GI endoscopy d. Demonstrate safe and effective procedural and post-procedural management following endoscopy

Systems-Based Practice: By the end of the General Thoracic Surgery rotation, the HO III resident will be able to: 1. Recognize how systems in delivering optimal health care, including inferring how “system problems” contribute to quality problems 2. Explain how the house officer’s patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect his/her own practice 3. Describe how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources 4. Define cost-effective health care and discuss how to address issues of resource allocation without compromising quality of care 5. Advocate for quality patient care and assist patients in dealing with system complexities 6. Collaborate with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

Practice-Based Learning and Improvement: By the end of the General Thoracic Surgery rotation, the HO III resident will be able to: 1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology 2. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems 3. When given online resources, conduct an effective literature search about a given general thoracic surgery topic

5

4. Obtain and use information about their own population of patients and the larger population from which their patients are drawn, including knowledge of the Society of Thoracic Surgeons GTS database and reporting platform 5. Describe/design a systematic approach to evaluate the results of one’s own practice 6. Outline the basic tenets of the Scientific Method as applied to clinical research and outline the steps in the generation or statement of a research hypothesis from clinical questions or observations 7. Evaluate experimental design and interpret results in published literature (or planned research), including true randomization, sampling error, blinded studies, prospective versus retrospective evaluations, and the advantages and weaknesses of each; knows the distinction between dependent and independent variables under evaluation and knows the meaning of confidence intervals or “P” value in suggesting statistical significance 8. Explain how information technology is used to manage information, access on-line medical information; and support their own education 9. Participate and present during thoracic surgery journal clubs

Professionalism: By the end of the General Thoracic Surgery rotation, the HO III resident will be able to: 1. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development 2. Demonstrate appropriate sensitivity to the thoracic surgery patient population, and understand how their needs may be different from other patients 3. Recognize the importance of timely record keeping and its impact on the quality of thoracic surgery care 4. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices 5. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Interpersonal and Communication Skills: By the end of the General Thoracic Surgery rotation, the HO III resident will be able to: 1. 2. 3. 4.

Create and sustain a therapeutic and ethically sound relationship with patients Demonstrate and employ effective listening skills Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills Collaborate effectively with others as a member or leader of a health care team or other professional group 5. Interview and evaluate the patient, especially the thoracic surgery candidate

6

General Thoracic Surgery Service (STG) House Officer IV Goal: The goal of the HO IV General Thoracic Surgery rotation is to solidify the resident’s overall general thoracic surgical knowledge and operative experience and provide more concentrated exposure in those clinical conditions treated by the general thoracic surgeon. Residents at the HO IV level should be independent at obtaining peritoneal access and placing ports for thoracoscopy and laparoscopy; they should develop proficiency with basic minimal access surgery techniques (e.g., mobilization of the hiatus, thoracoscopic lung resection and esophageal mobilization). During the HO IV rotation residents will begin to develop proficiency in advanced thoracic operations (including but not limited to minimal access and open anatomic lung resection and esophagectomy; lung transplantation, organ procurement).

Learning Objectives: Patient Care: By the end of the General Thoracic Surgery rotation, the HO IV resident will be able to: 1. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families 2. Gather, summarize, and examine essential and accurate information about their patients, especially regarding lung, mediastinal and esophageal disease 3. Develop treatment plans based on analysis of diagnostic information and integrate patient preferences, up-to-date scientific evidence, and clinical judgment into those treatment plans 4. Demonstrate understanding for management of the critically-ill thoracic surgery post-operative patient 5. Counsel and educate patients and their families, under the guidance and direction of senior residents or fellows and faculty 6. Use information technology to support patient care decisions and patient education 7. With appropriate indirect supervision and intraoperative assistance, perform surgical procedures considered essential for the area of practice, with particular ability to: a. Perform upper GI and airway endoscopy independently b. Obtaining thoracoscopic or laparoscopic access c. Perform the entire dissection in a straightforward pulmonary lobectomy d. Perform the early dissection in open esophagectomy e. Perform the dissection and mobilization of the esophagus and hiatus hernia during transthoracic hiatus hernia repair f. Perform the dissection and mobilization for thoracic organ procurement 8. Collaborate with health care professionals, including those from other disciplines, to provide patientfocused care, with a particular attention to the multidisciplinary care of the thoracic surgery patient which includes interactions with medical specialties, dietitians and advanced practice providers from the clinic and inpatient service

Medical Knowledge: By the end of the General Thoracic Surgery rotation, the HO IV resident will be able to: 1. Hiatus Hernia and Gastro-esophageal Reflux a. Apply knowledge of the anatomy and physiology of primary and recurrent hiatus hernias

7

b. Develop treatment plans taking into account the pathophysiology and clinical presentation of patients with hiatus hernia or gastro-esophageal reflux disease (GERD) c. Compare and contrast the most common urgent and chronic symptoms of paraesophageal hernia d. Develop a treatment plan for management of acute gastric volvulus in the context of a paraesophageal hiatus hernia e. Discuss the common treatment options for hiatus hernia and antireflux operations, including both thoracic and trans-abdominal approaches f. Discuss the difference in technique and explain the rationale for complete and partial fundoplication g. Demonstrate safe and effective post-operative management of hiatal hernia repair, including provision of adequate pain control and wound management h. Analyze patient symptoms and other data to correctly diagnose post-operative complications, both short and long term for hiatal hernia repair i. Demonstrate safe and effective management of post-operative complications, including hematoma, urinary retention, surgical site infection, including “red flags” for notifying senior residents or faculty regarding potential need for reoperation 2. Esophageal Cancer a. Develop appropriate patient treatment plans based on the patient’s cancer stage and fitness for treatment b. Explain and contrast the common treatment options for resectable esophageal cancer including open and minimal access approaches c. Describe and discuss the anatomy and technique relevant to esophageal reconstruction d. Recite and discuss the intra-operative risks of both open and minimal access esophagectomy e. Demonstrate safe and effective post-operative management of esophagectomy patients, including provision of adequate pain control and wound management f. Analyze patient symptoms and other data to correctly diagnose post-operative complications, both short and long term for esophagectomy patients g. Demonstrate safe and effective management of post-operative complications, including anastomotic leak, anastomotic stricture, delayed gastric emptying, hematoma, urinary retention, surgical site infection, including “red flags” for notifying senior residents or faculty regarding potential need for reoperation or intervention 3. Lung Cancer a. Compare and contrast the different surgical approaches currently used for treatment of lung cancer patients, particularly parenchymal-sparing techniques b. Describe indications for combined modality therapy in the treatment of lung cancer c. Evaluate a patient’s history to identify the most common contraindications to lung resection d. Summarize the intra-operative risks of pulmonary resection e. Demonstrate safe and effective post-operative management of lung resection patients, including assessment and treatment of cardiopulmonary complications f. Identify post-operative complications and provide safe and effective management in conjunction with senior residents and faculty, including parenchymal air leaks, bleeding, venous thromboembolism g. Apply their knowledge of the “red flags” that may indicate a need for reoperation in pulmonary surgery patients 4. Mediastinal Diseases and Benign Esophageal Disorders a. Apply knowledge of chest and esophageal pathophysiology to generate appropriate treatment plans b. Integrate knowledge of the pathophysiology with the clinical presentation of esophageal injury, esophageal stricture and mediastinitis c. Compare and contrast the common treatment options for esophageal perforation or rupture d. Compare and contrast operative approaches for esophageal motility diseases, including diverticula and achalasia e. Summarize the options for diagnosis and surgical management of mediastinal masses f. Summarize the intra-operative risks of both open and minimal access approaches for

8

treatment of thymic masses g. Identify post-operative complications and demonstrate safe and effective management (in conjunction with senior residents and faculty) for conditions including esophageal perforation, bleeding, dysphagia, recurrence, and “red flags” that may indicate a need for reoperation 5. Endoscopy a. Perform rigid bronchoscopy and rigid esophagoscopy b. Describe the contraindications for rigid bronchoscopy and rigid esophagoscopy c. Demonstrate use and management of airway and esophageal stents d. Provide safe and effective post-operative management of patients with airway and esophageal stents, especially the recognition of post-operative “red flags” that indicate bleeding or migration and the need for reoperation 6. Respiratory Insufficiency a. Discuss options for the surgical management of patients with emphysema b. Discuss different techniques for providing extracorporeal life support for the patient in acute respiratory failure c. Describe and discuss options for pulmonary transplantation d. Describe the assessment and management of the potential organ donor e. Provide safe and effective post-operative management of patients undergoing operation for respiratory insufficiency (e.g. lung volume reduction, lung transplantation), especially the recognition of post-operative “red flags” that indicate the need for reoperation or urgent intervention

Systems-Based Practice:

By the end of the General Thoracic Surgery rotation, the HO IV resident will be able to: 1. Recognize how systems in delivering optimal health care, including inferring how “system problems” contribute to quality problems 2. Apply systems knowledge to demonstrate how patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect one’s own practice 3. Compare and contrast different medical practice and delivery systems, including differing methods of controlling health care costs and allocating resources 4. Demonstrate responsible, cost-effective health care and discuss how to address issues of resource allocation without compromising quality of care 5. Advocate for quality patient care and assist patients in dealing with system complexities 6. Partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

Practice-Based Learning and Improvement: By the end of the General Thoracic Surgery rotation, the HO IV resident will be able to: 1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology 2. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems 3. When given online resources, conduct an effective literature search about a given general thoracic surgery topic 4. Obtain and use information about their own population of patients and the larger population from which their patients are drawn, including knowledge of the Society of Thoracic Surgeons General Thoracic Surgery database (GTSD) and reporting platform 5. Design a systematic approach to evaluate the results of one’s own practice 6. Summarize the basic tenets of the Scientific Method as applied to clinical research and outline the steps in the generation or statement of a research hypothesis from clinical questions or observations

9

7. Evaluate experimental design and interpret results in published literature (or planned research), including true randomization, sampling error, blinded studies, prospective versus retrospective evaluations, and the advantages and weaknesses of each; knows the distinction between dependent and independent variables under evaluation and knows the meaning of confidence intervals or “P” value in suggesting statistical significance 8. Use information technology to manage information, access on-line medical information; and support self-education

Professionalism:

By the end of the General Thoracic Surgery rotation, the HO IV resident will be able to: 1. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development 2. Demonstrate appropriate sensitivity to the thoracic surgery patient population, and understand how their needs may vary 3. Recognize the importance of timely record keeping and its impact on the quality of general thoracic surgical care 4. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices 5. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Interpersonal and Communication Skills: By the end of the General Thoracic Surgery rotation, the HO IV resident will be able to: 1. 2. 3. 4.

Create and sustain a therapeutic and ethically sound relationship with patients Demonstrate and employ effective listening skills Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills Collaborate effectively with others as a member or leader of a health care team or other professional group 5. Begin to develop skills in the education of medical students, junior residents and advanced practice provider students 6. Interview and evaluate the patient referred for thoracic surgery consultation

10