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Resident Education Program in Thoracic Surgery

General Surgery Curriculum (PGY4)

EDUCATIONAL CURRICULUM

Surgery Curriculum (PGY4)

PGY4 Thoracic Surgery:  Approximately a 6 week rotation

Description:  During this rotation, the resident will better understand the pathophysiology of thoracic diseases including lung, esophagus, and chest wall diseases.  The resident will identify the general risks and complications of thoracic surgery operations, and learn the preoperative and postoperative care of patients undergoing thoracic surgery operations

Evaluation of the resident's understanding of the patient and disease process will be reviewed (in part) at the time of operation and through resident-faculty interaction. Feedback will be verbal and timely; residents are encouraged to establish a dialogue with the faculty to facilitate feedback.

Faculty will evaluate residents based upon the ACGME core competencies. Faculty will evaluate residents at the end of the rotation in writing. Residents will evaluate faculty teaching and education efforts as well as each rotation at its conclusion.

A final "end of rotation" review will be conducted with Dr. Putnam.   Questions or comments can be directed to Dr. Putnam, Program Director, or any of the thoracic surgery faculty.

Other Comments and Responsibilities

Daily rounds will include the General Care Wards and the Intensive Care Unit at the VA and the Vanderbilt University Hospital.

Surgery residents are expected to achieve at least 1 full clinic day each week

Surgery residents are invited to participate in the

  • Resident Teaching conference on either Friday or Tuesday mornings (7 am Oxford House 6th floor  Thoracic Surgery Conference Room) ,
  • Esophageal Conference on the 1st and 3rd Thursday mornings (7 am PRB 8th floor), and
  • Thoracic Surgery QI Conference on Wednesday morning (7 am Oxford House 6th floor  Thoracic Surgery Conference Room) and
  • Surgery Grand Rounds on Friday mornings.
  • An invitation to attend Journal Club is extended while on the Thoracic Surgery rotation.

EVALUATION INSTRUMENTS

The evaluation instruments for the rotation include:

  • Faculty Evaluation of Resident, Resident Evaluation of Faculty, Resident Evaluation of Rotation
  • Daily verbal feedback from faculty to resident
  • Didactic lectures
  • Faculty assessment of the resident from interactions in various patient care settings (e.g. Operating room, Intensive care unit, General care wards, Outpatient clinics, Other)

 

GENERAL SURGERY ROTATION IN THORACIC SURGERY

ACGME Core Competencies to be developed during this rotation include:

Medical Knowledge and Patient Care:

I. CHEST WALL

A. Anatomy, Physiology and Embryology

Learner Objectives:

  • Understands the anatomy and physiology of the cutaneous, muscular, and bony components of the chest wall and their anatomic and physiologic relationships to adjacent structures;
  • Knows various operative approaches to the chest wall.

Clinical Skills:

  • Recognizes the normal and abnormal anatomy of the chest wall.

B. Acquired Abnormalities and Neoplasms

Learner Objectives:

  • Evaluates and diagnoses primary and metastatic chest wall tumors, knows their histologic appearance, and understands the indications for incisional versus excisional biopsy;
  • Knows the radiologic characteristics of tumors.

Clinical Skills:

  • Performs a variety of surgical incisions to expose components of the chest wall and interior thoracic organs.

C. Congenital Abnormalities

Learner Objectives:

  • Recognizes pectus excavatum and pectus carinatum, understands possible physiologic disturbances, and interprets diagnostic tests to identify such physiologic disturbances;
  • Understands the indications for the operative treatment of congenital chest wall abnormalities;
  • Knows the complications of reconstruction of congenital chest wall abnormalities and their management.

Clinical Skills:

  • Reads and interprets diagnostic x-ray and performs physiologic examinations for congenital chest wall defects and thoracic outlet syndromes.

II. LUNGS AND PLEURA

A. Anatomy, Physiology, Embryology and Testing

Learner Objectives:

  • Understands the arterial, venous and bronchial anatomy of the lungs and their inter-relationships;
  • Understands the lymphatic anatomy of the lungs, the major lymphatic nodal stations, and lymphatic drainage routes of the lung segments;
  • Knows the indications for different thoracic incisions, the surgical anatomy encountered, and the physiological impact;
  • Knows the indications for plain radiography, CT scan, magnetic resonance imaging, and PET scanning for staging of lung cancer;
  • Knows the indications, interpretation, and use of nuclear medicine ventilation /perfusion scanning (V/Q scan) to determine the operability of candidates for pulmonary resection;
  • Understands the methods of invasive staging (e.g., endobronchial ultrasound (EBUS) mediastinoscopy, Chamberlain procedure, scalene node biopsy, thoracoscopy);
  • Knows how to interpret pulmonary function tests.

Clinical Skills:

  • Reads and interprets pulmonary function studies, ventilation/perfusion scans, pulmonary arteriograms and arterial blood gases, and correlates the results with operability;
  • Applies knowledge of thoracic anatomy to the physical examination of the chest, heart, and vascular tree;
  • Uses knowledge of chest, pulmonary, and cardiac physiology to interpret tests involving the thoracic cavity and to understand and treat diseases of the chest and its contents;
  • Reads and interprets plain radiography, CT scans, magnetic resonance imaging, and PET scanning of the chest.

B. Non-Neoplastic Lung Disease

Learner Objectives:

  • Understands diagnostic procedures used to evaluate non-neoplastic lung disease;
  • Knows the common pathogens that produce lung infections, including their presentation and pathologic processes, and knows the treatment and indications for operative intervention;
  • Understands the natural history, presentation and treatment of chronic obstructive lung disease;
  • Understands the pathologic results and alterations of pulmonary function due to bronchospasm;
  • Understands the mechanisms by which foreign bodies reach the airways, how they cause pulmonary pathology, and the management of patients with airway foreign bodies.

Clinical Skills:

  • Diagnoses and treats patients with bacterial, fungal, tuberculous, and viral lung infections;
  • Manages patients with chronic obstructive lung disease, bronchospastic airway disease, foreign bodies of the airways, and hemoptysis;
  • Performs thoracentesis, mediastinoscopy, mediastinotomy, flexible and rigid bronchoscopy, thoracoscopy, and open lung biopsy.

C. Neoplastic Lung Disease

Learner Objectives:

  • Understands TNM staging of lung carcinoma and its application to the diagnosis, therapeutic planning, and management of patients with lung carcinoma;
  • Evaluates and diagnoses neoplasia of the lung, using a knowledge of the histologic appearance of the major types;
  • Knows the signs of inoperability;
  • Understands the complications of pulmonary resection and their management;
  • Understands the indications for resection of benign lung neoplasms;
  • Understands the indications for resection of pulmonary metastases.

Clinical Skills:

  • Evaluates patients with lung neoplasia and recommends therapy based on their functional status, pulmonary function and tumor type;
  • Performs staging procedures (e.g., EBUS, bronchoscopy, mediastinoscopy, mediastinotomy, and thoracoscopy);
  • Performs operations to extirpate neoplasms of the lung (e.g., local excision, wedge resection, lobectomy);
  • Performs bedside bronchoscopies and placement of tracheostomies and/or mini-tracheostomies;
  • Recognizes and treats the early signs of non-cardiac pulmonary edema.

D. Diseases of the Pleura

Learner Objectives:

  • Is familiar with the clinical presentation of benign and malignant diseases of the pleura;
  • Understands the types of pleural effusions, their evaluation and treatment;
  • Understands the indications, contraindications, and complications of video assisted thoracic surgery and has a working knowledge of the equipment.

Clinical Skills:

  • Evaluates pleural effusions and recommends appropriate therapy;
  • Performs invasive diagnostic studies (e.g., incisional and excisional biopsy, needle biopsy, fluid analysis);
  • Places tube thoracostomy and performs chemical or mechanical pleurodesis;
  • Performs video assisted thoracoscopic surgery as necessary for the diagnosis and treatment of pleural disease;
  • Places pleuroperitoneal shunts.

III. TRACHEA AND BRONCHI

A. Anatomy, Physiology and Embryology

Learner Objectives:

  • Understands the anatomy and blood supply of the trachea and bronchi;
  • Understands the endoscopic anatomy of the nasopharynx, hypopharynx, larynx, trachea, and major bronchi;
  • Understands and interprets pulmonary function studies of the trachea and bronchi;
  • Understands the radiologic assessment of the trachea and bronchi.

Clinical Skills:

  • Interprets plain radiographic analyses, CT scan, MRI, and pulmonary function studies involving the trachea and bronchi;
  • Performs endoscopy of the upper airway, trachea and major bronchi.

B. Congenital and Acquired Abnormalities

Learner Objectives:

  • Understands congenital abnormalities and idiopathic diseases of the trachea;
  • Understands the etiology, presentation and management of acquired tracheal strictures and their prevention;
  • Understands the radiologic evaluation of tracheal abnormalities.

Clinical Skills:

  • Evaluates diagnostic tests of the trachea and bronchi;
  • Performs laryngoscopy and bronchoscopy of the trachea and bronchi, including dilation of stenosis;
  • Performs tracheostomy.

IV. MEDIASTINUM AND PERICARDIUM

A. Anatomy, Physiology and Embryology

Learner Objectives:

  • Understands the anatomic boundaries of the mediastinum and the structures found within each region;
  • Understands the embryologic development of structures within the mediastinum and the variations and pathologic consequences of abnormally located structures;
  • Understands the radiologic assessment of the mediastinum including CT scan, MRI, contrast studies, and angiography;
  • Understands the aberrations caused by pericardial abnormalities and their effects on the heart and circulation.

Clinical Skills:

  • Reads and interprets mediastinal plain radiographs, CT scans, MRI, and contrast studies.

B. Congenital Abnormalities of the Mediastinum

Learner Objectives: Upon successful completion of the residency program:

  • Is able to diagnose mediastinal cysts.

Clinical Skills: During the training program, the resident:

  • Reads and interprets plain radiographs, CT scans, and MRI’s and contrast studies of congenital abnormalities of the mediastinum.

C. Acquired Abnormalities of the Mediastinum

Clinical Skills: During the training program the resident:

  • Performs diagnostic tests and operations on the mediastinum;

D. Congenital and Acquired Abnormalities of the Pericardium

Learner Objectives:

  • Understands the physiologic consequences of increased pericardial fluid and the techniques for diagnosis and management.

Clinical Skills:

  • Uses an understanding of abnormal physiologic findings to diagnose pericardial pathology;
  • Performs diagnostic tests and therapeutic interventions for the treatment of pericardial tamponade, pericardial effusions, and constrictive pericardial disease.

V. DIAPHRAGM

A. Anatomy, Physiology and Embryology

Learner Objectives:

  • Knows the embryologic origin of the diaphragm;
  • Understands the anatomy of the diaphragm and adjacent structures;
  • Understands the neural and vascular supply of the diaphragm and the pathologic consequences of injury;
  • Understands imaging studies for assessing the diaphragm.

Clinical Skills:

  • Uses knowledge of the normal anatomy and physiology of the diaphragm to treat primary or contiguous abnormalities;
  • Evaluates and interprets radiographic studies of the diaphragm, including fluoroscopy, CT scan, and MRI.

B. Acquired Abnormalities, Neoplasms

Learner Objectives:

  • Knows evaluation methods for penetrating injuries of the diaphragm;
  • Understands the etiology, diagnosis, and treatment of diaphragmatic paralysis.

Clinical Skills:

  • Interprets plain and contrast x-rays, fluoroscopy, CT scans, and MRI of the diaphragm;

C. Congenital Abnormalities

Learner Objectives:

  • Understands the anatomy of congenital diaphragmatic hernias;
  • Understands the physiologic consequences of diaphragmatic hernias;
  • Knows the indications for operative repair of diaphragmatic hernias.

Clinical Skills:

  • Performs operative treatment of adults with delayed presentation of diaphragmatic hernias;
  • Manages eventration of the diaphragm in children and adults.

VI. ESOPHAGUS

A. Anatomy, Physiology and Embryology

Learner Objectives:

  • Understands the anatomy, embryology, innervation, and vascular supply of the esophagus and adjacent structures;
  • Understands the physiologic function of the esophagus and pharynx;
  • Understands the radiographic evaluation of the esophagus.

Clinical Skills:

  • Interprets esophageal plain radiographs, contrast studies, CT scans, MRI, intraluminal echo;
  • Orders and interprets manometric and pH studies of the esophagus;
  • Performs rigid and flexible endoscopy of the pharynx and esophagus.

B.  Acquired Abnormalities

Learner Objectives:

  • Understands the pathophysiology, histology, complications, and dx of esophageal reflux;
  • Understands the indications for and principles of anti-reflux operations;
  • Understands the clinical presentation, diagnosis, and management of paraesophageal hernias;
  • Knows the clinical presentation, causes, diagnosis, and treatment of motility disorders of the esophagus;
  • Understands the clinical presentation, diagnosis, and management of esophageal perforation;
  • Understands the clinical presentation, diagnosis, and management of chemical injuries and trauma of the esophagus.

Clinical Skills:

  • Interprets esophageal plain radiographs, contrast studies, CT scans, MRI, manometry, pH studies, and intraluminal echo;
  • Performs esophagoscopy, foreign body removal and biopsy;
  • Uses various operative approaches to different parts of the esophagus;
  • Performs anti-reflux operations including management of strictures;
  • Performs resection and reconstruction using various esophageal substitutes;
  • Evaluates and manages patients with esophageal motility disorders, performs myotomy and resection of diverticula;
  • Manages the complications of esophageal operations;
  • Uses video assisted thoracic surgery for esophageal diseases where appropriate.

C.  Neoplasms

Learner Objectives:

  • Understands the types of benign esophageal neoplasms, their clinical presentation, diagnosis, and treatment;
  • Understands the types of malignant esophageal neoplasms, their clinical presentation, diagnosis, histologic appearance, and treatment;
  • Understands the TNM staging of esophageal cancer;
  • Understands the principles of patient management after esophageal resection;
  • Understands the nutritional management of patients with esophageal neoplasms.

Clinical Skills:

  • Evaluates malignant and benign esophageal tumors and recommends overall management, including neoadjuvant therapy;
  • Performs diagnostic tests for esophageal neoplasms and correlates the results with clinical staging;
  • Performs esophagectomy through various approaches;
  • Performs reconstruction with various esophageal substitutes;
  • Diagnoses and manages complications of esophageal surgery;
  • Manages nutritional needs after esophageal surgery;
  • Performs palliative operations for obstructing esophageal lesions.

Professionalism:

  • Communicate effectively with patients, families, and other members of the health care team.
  • Be honest, reliable, and respectful of the religious, racial, and gender characteristics of patients, their families, and other members of the health care team.
  • Understand the psychological needs of the patient facing potentially life threatening disease and interventional cardiology.
  • Give and receive advice in a manner that is consistent with the harmonious operation of a health care team.
  • An understanding of the obligation of continuing self-education and teaching others.
  • Keep succinct, pertinent, and current medical records.
  • Recognize when to seek assistance from more experienced colleagues.
  • Appreciate the importance of acquiring and maintaining an appropriate professional attitude in order to practice in any specialty.

Interpersonal and Communication Skills:

  • Establish therapeutic relationships with patients and families.
  • Obtain and synthesize relevant history from patients and families.
  • Listen effectively.
  • Discuss appropriate information with patients and families, and the health care team.
  • Write clear consultation note/discharge summary/clinic note.

Practice-Based Learning and Improvement:

  • Develop, implement, and monitor a personal continuing education strategy.
  • Critically appraise sources of medical information.
  • Facilitate learning of patients, housestaff/students, and other health professionals.
  • Contribute to development of new knowledge.
  • Read around clinical cases.
  • Participate actively in scheduled morbidity and mortality conferences.
  • Actively participate in journal club.
  • Participate effectively in teaching fellow professionals including junior housestaff.

Systems-based Practice:

  • Utilize resources effectively to balance patient care, learning needs and outside activities.
  • Allocate finite health care resources wisely.
  • Work effectively and efficiently in a health care organization.
  • Understand the importance of and mechanisms to safely utilize resources in a cost-effective manner to benefit all patients.
  • Recommend practices to effectively utilize resources including undertaking studies to assess effectiveness of standard care procedures.

 

Copyright © 2014, Vanderbilt University Medical Center, Department of Thoracic Surgery

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