Resident Education Program in Thoracic Surgery

EDUCATIONAL CURRICULUM

ROTATION: Thoracic Surgery

LOCATION: VUMC and VA Nashville (integrated service)

Provided below are the specific educational objectives and clinical skill acquisition goals for the 4th year General Surgery Residents as it pertains to their acquisition of knowledge in Thoracic Surgery.

Medical Knowledge (Learner Objectives) and Clinical Skills (Patient Care) follow. This list is meant to be a starting point for the General Surgery Resident and is not meant to preclude additional reading or independent study nor limit time within the operating room, general care wards, or the outpatient clinic.

Learner Objectives will be taught / learned through the following:

Specific lectures pertaining to topics listed in the TSDA (Thoracic Surgery Directors Association) Comprehensive Requisite Thoracic Surgery Curriculum.

• Didactic and other conferences
• Perioperative and operative management
• Self-education and reading
• Faculty demonstration of ACGME core competencies coupled with resident counseling on a daily, or as needed, basis.

Evaluation of the resident's understanding of the topic will be reviewed (in part) at the time of operation and through resident-faculty interaction. Feedback will be verbal and immediate.

Faculty will evaluate residents based upon these objectives as part of the ACGME core competencies. Faculty will evaluate residents at the end of the rotation, in writing, based upon these objectives and the ACGME core competencies. Additional evaluations will be conducted for operative skill performance (faculty evaluating residents), and operative skill education (residents evaluating faculty).

The remaining core competencies will be taught and evaluated as per the Goals and Objectives for Thoracic Surgery Residents.

Residents will evaluate faculty"s 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 Karen Kennedy, Program Coordinator (615-343-2951) or Dr. Putnam, Program Director.

Other Comments and Responsibilities

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

General Surgery residents are expected to participate in the Resident Teaching conference on Tuesday mornings, Esophageal Conference on Thursday mornings, and Surgery Grand Rounds on Friday mornings. An invitation to attend Journal Club is extended while on the Thoracic Surgery rotation.

Residents will attend the Outpatient Clinic for Thoracic Surgery at the VA and also at Vanderbilt University Hospital This opportunity for one full day per week in the outpatient clinic may be assigned.

EVALUATION INSTRUMENTS

The evaluation instruments for the rotation include:

• Faculty Evaluation of Resident
• Resident Evaluation of Faculty
• Resident Evaluation of Rotation
• Daily feedback from faculty to resident
  • Didactic lectures
  • Non-patient care settings
  • Other
• Patient care settings
  • Operating room
  • Intensive care unit
  • General care wards
  • Outpatient clinics
  • Other
• Other

GENERAL SURGERY ROTATION IN THORACIC SURGERY

I. CHEST WALL

A. Anatomy, Physiology and Embryology

Learner Objectives: Upon completion of this unit the resident:

· 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 all operative approaches to the chest wall;

Clinical Skills: During the training program the resident:

· Recognizes the normal and abnormal anatomy of the chest wall;

B. Acquired Abnormalities and Neoplasms

Learner Objectives: Upon completion of this unit the resident:

· Evaluates and diagnoses primary and metastatic chest wall tumors, knows their histologic appearance, and understands the indications for incisional versus excisional biopsy;

Clinical Skills: During the training program the resident:

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

C. Congenital Abnormalities and Thoracic Outlet Syndrome

Learner Objectives: Upon completion of this unit the resident:

· Recognizes pectus excavatum and pectus carinatum, understands possible physiologic disturbances, and interprets diagnostic tests to identify such physiologic disturbances;

· 4. Understands the etiology, evaluation, differential diagnosis, and diagnostic criteria for thoracic outlet syndrome;

Clinical Skills: During the training program the resident:

· Recognizes the varied presentations of thoracic outlet syndrome and interprets diagnostic tests;

II. LUNGS AND PLEURA

A. Anatomy, Physiology, Embryology and Testing

Learner Objectives: Upon completion of this unit the resident:

· 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., mediastinoscopy, Chamberlain procedure, scalene node biopsy, thoracoscopy);

Clinical Skills: During the training program the resident:

· 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;

B. Non-Neoplastic Lung Disease

Learner Objectives: Upon completion of this unit, the resident:

· 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: During the training program the resident:

· Diagnoses and treats patients with bacterial, fungal, tuberculous, and viral lung infections; or demonstrates proficiency in this skill set by other means.

· 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: Upon completion of this unit the resident:

· Understands TNM staging of lung carcinoma and its application to the diagnosis, therapeutic planning, and management of patients with lung carcinoma;

· Knows the signs of inoperability;

· Understands the complications of pulmonary resection and their management;

· Understands the indications for resection of pulmonary metastases.

Clinical Skills: During the training program the resident:

· Evaluates patients with lung neoplasia and recommends therapy based on their functional status, pulmonary function and tumor type;

· Performs staging procedures (e.g., 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 minitracheostomies;

· Recognizes and treats the early signs of non-cardiac pulmonary edema.

E. Diseases of the Pleura

Learner Objectives: Upon completion of this unit the resident:

· Is familiar with the clinical presentation of benign and malignant diseases of the pleura;

· Understands the types of pleural effusions, their evaluation and treatment;

Clinical Skills: During the training program the resident:

· Evaluates pleural effusions and recommends appropriate therapy;

· Performs invasive diagnostic studies (e.g., incisional and excisional biopsy, needle biopsy, fluid analysis);

· Places tube thoracostomies and performs chemical or mechanical pleurodesis;

· Performs video assisted thorascopic surgery as necessary for the diagnosis and treatment of pleural disease.

III. TRACHEA AND BRONCHI

A. Anatomy, Physiology and Embryology

Learner Objectives: Upon completion of this unit the resident:

· Understands the anatomy and blood supply of the trachea and bronchi;

· Understands and interprets pulmonary function studies of the trachea and bronchi;

Clinical Skills: During the training program the resident:

· 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

Clinical Skills: During the training program the resident:

· Performs laryngoscopy and bronchoscopy of the trachea and bronchi

· Performs tracheostomy

IV. MEDIASTINUM AND PERICARDIUM

A. Anatomy, Physiology and Embryology

Learner Objectives: Upon completion of this unit the resident:

· Understands the anatomic boundaries of the mediastinum and the structures found within each region;

· 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: During the training program the resident:

· Reads and interprets mediastinal plain radiographs, CT scans, MRI, and contrast studies;

B. Congenital Abnormalities of the Mediastinum

Learner Objectives: Upon completion of this unit the resident:

· Is able to diagnose mediastinal cysts;

Clinical Skills: During the training program, the resident:

· Reads and interprets plain radiographs, CT scans, MRI's and contrast studies of congenital abnormalities of the mediastinum;

D. Congenital and Acquired Abnormalities of the Pericardium

Learner Objectives: Upon completion of this unit the resident:

· Understands the physiologic consequences of increased pericardial fluid and the techniques for diagnosis and management;

Clinical Skills: During the training program the resident:

· 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: Upon completion of this unit the resident:

· 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;

Clinical Skills: During the training program the resident:

· 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: Upon completion of this unit the resident:

· Knows evaluation methods for penetrating injuries of the diaphragm;

· Understands the etiology, diagnosis, and treatment of diaphragmatic paralysis;

Clinical Skills: During the training program the resident:

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

· Performs diagnostic studies of the diaphragm (e.g., pneumoperitoneum, direct incisional and excisional biopsy, video assisted thoracoscopic surgery); or demonstrates proficiency in this skill set by other means.

C. Congenital Abnormalities

Learner Objectives: Upon completion of this unit the resident:

· 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: During the training program the resident:

· Evaluates neonates with congenital diaphragmatic hernias;

· Performs or participates in the operative treatment of infants with diaphragmatic hernias;

· Participates in the preoperative and postoperative management of multisystem abnormalities of infants with congenital diaphragmatic hernias;

· Performs operative treatment of adults with delayed presentation of diaphragmatic hernias;

· Manages eventration of the diaphragm in children and adults or demonstrates proficiency in this skill set by other means.

VI. ESOPHAGUS

A. Anatomy, Physiology and Embryology

Learner Objectives: Upon completion of this unit the resident:

· 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: During the training program the resident:

· Interprets esophageal plain radiographs, contrast studies, CT scans, MRI, and

· intraluminal echo;

· Orders and interprets manometric and pH studies of the esophagus;

· Performs rigid and flexible endoscopy of the pharynx and esophagus.

C. Acquired Abnormalities

Learner Objectives: Upon completion of this unit the resident:

· Understands the pathophysiology, histology, complications, and diagnosis 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: During the training program the resident:

· Performs esophagoscopy, foreign body removal and biopsy; or demonstrates proficiency by other means.

· Performs resection and reconstruction using various esophageal substitutes; or demonstrates proficiency by other means.

D. Neoplasms

Learner Objectives: Upon completion of this unit the resident:

· 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;

7. Understands the principles of patient management after esophageal resection;

8. Understands the nutritional management of patients with esophageal neoplasms.

Clinical Skills: During the training program the resident:

· 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; or demonstrates proficiency in this skill set by other means.

VIII. ACQUIRED HEART DISEASE

D. Cardiac Arrhythmias

Clinical Skills: During the training program the resident:

· Performs the non-operative management of patients with atrial arrhythmias;

IX. THORACIC TRAUMA

A. Trauma of the Chest Wall

Learner Objectives: Upon completion of this unit the resident:

· Evaluates patients with blunt or penetrating chest wall injury;

· Understands the physiology and mechanics of operative drainage of the thoracic cavity;

· Understands the operative and non-operative management of chest wall injuries;

· Understands the pathophysiology of flail chest.

Clinical Skills: During the training program the resident:

· Evaluates and treats chest wall injuries;

· Performs emergency operations to repair chest wall injuries and provides postoperative management.

B. Tracheobronchial and Pulmonary Trauma

Learner Objectives: Upon completion of this unit the resident:

· Understands clinical presentation and radiologic findings of tracheobronchial injury;

· Understands the principles of airway management;

· Understands the bronchoscopic findings of tracheobronchial and pulmonary injury;

· Understands the injuries associated with tracheobronchial and pulmonary injury.

Clinical Skills: During the training program the resident:

· Evaluates and manages patients with tracheobronchial trauma; or demonstrates proficiency in this skill set by other means.

· Manages the airway of patients with tracheobronchial injuries; or demonstrates proficiency in this skill set by other means.

· Performs non-operative management of pulmonary contusion;

· Performs emergency operations to repair peripheral pulmonary and hilar injuries;

· Uses precautions to avoid air embolism in patients with penetrating and blunt injuries.

C. Esophageal Trauma

Learner Objectives: Upon completion of this unit the resident:

· Understands the etiology and presentation of esophageal trauma;

· Understands the methods of assessment and diagnosis of esophageal trauma;

· Understands the management of injuries that disrupt the esophagus;

Clinical Skills: During the training program the resident:

· Evaluates and interprets diagnostic tests of patients with esophageal trauma;

· Performs the operative treatment of patients with esophageal injuries;

D. Diaphragmatic Trauma

Learner Objectives: Upon completion of this unit the resident:

· Understands the presentation, evaluation, and treatment of blunt and penetrating diaphragmatic injuries;

· Understands the evaluation and management of associated injuries;

Clinical Skills: During the training program the resident:

· Performs emergency evaluation and diagnosis of diaphragmatic and associated injuries;

· Performs operative repair of acute and chronic diaphragmatic and associated injuries;

E. Cardiovascular Trauma

Learner Objectives: Upon completion of the unit the resident:

· Evaluates patients who have sustained cardiovascular trauma;

· Understands the physiology of deceleration injuries to the thoracic aorta;

· Understands both invasive and noninvasive methods for the diagnosis of cardiovascular traumatic injuries.

Clinical Skills: During the training program the resident:

· Evaluates and treats cardiac contusion

X. TRANSPLANTATION

B. Lung Transplantation

Learner Objectives: Upon completion of the unit the resident:

· Understands the evaluation and management of organ donors;

Clinical Skills: During the training program the resident:

· Performs or participates in donor evaluation and management;

· Performs or participates in donor lung harvest and preservation;

XI. EXTRACORPOREAL BYPASS AND COAGULATION - BLOOD PRODUCTS

A. Physiology of Extracorporeal Bypass

Learner Objectives: Upon completion of the unit the resident:

· Knows the coagulation system and alterations of blood elements;

Clinical Skills: During the training program the resident:

· Understands and treats physiologic derangements caused by blood-artificial surface interaction;

D. Fundamentals of Coagulation Management and Blood Component Therapy

Learner Objectives: At the end of the unit the resident:

· Understands the major blood groups, the clotting cascade, and the pathophysiology of clotting (e.g., abnormal clotting, activation of compliment, Kallikrein, prostanoids);

· Understands the specific hemorrhagic and thrombotic complications of cardiac surgery and their management;

· Understands the methods used in blood component storage and the measures taken to ensure a safe blood supply;

· Understands the use of specific blood components to treat abnormalities of red cell quantity and quality, platelet quantity and quality, and coagulation function;

· Knows the preoperative risk factors for excessive blood loss and blood utilization;

· Understands the operative and postoperative techniques to ensure blood conservation.

Clinical Skills: During the course of the program, the resident:

· Evaluates patients requiring component therapy and develops management strategies to correct abnormalities of the coagulation system;

· Uses appropriate tests to ensure the safety of blood and blood components;

· Uses appropriate blood conservation techniques.

XII. MINOR PROCEDURES

A. Bronchoscopy

· Understands the indications, techniques, and fiberoptic bronchoscopy of the larynx and tracheobronchial tree.

Clinical Skills: During the training program the resident:

· Evaluates and manages patients requiring bronchoscopy;

· Performs fiberoptic bronchoscopy using various anesthetic techniques;

· Obtains diagnostic material using various biopsy techniques;

B. Esophagoscopy

Learner Objectives: Upon completion of this unit the resident:

· Understands the indications, techniques, and fiberoptic esophagoscopy.

Clinical Skills: During the training program the resident:

· Evaluates and manages patients requiring esophagoscopy;

· Performs fiberoptic esophagoscopy using various anesthetic techniques;

D. Tube Thoracostomy

Learner Objectives: Upon completion of this unit the resident:

· Understands the indications and contraindications for tube thoracostomy;

· Knows the techniques and complications of tube thoracostomy and their management.

Clinical Skills: During the training program the resident:

· Evaluates patients for tube thoracostomy;

· Performs tube thoracostomy under local, regional and general anesthesia;

· Treats the complications of tube thoracostomy.

E. Central Venous Lines and Arterial Lines

Learner Objectives: Upon completion of this unit the resident:

· Understands the indications, contraindications, management and complications of central venous lines and arterial lines.

Clinical Skills: During the training program the resident:

· Performs central venous line insertions by appropriate techniques (e.g., internal jugular vein, subclavian vein, femoral vein);

· Performs arterial line insertions by appropriate techniques (e.g., radial, brachial, femoral and pedal arteries);

· Manages complications of central venous and arterial lines.

XIV. NON-CLINICAL ELEMENTS OF THORACIC SURGICAL PRACTICE

Learner Objectives: Upon completion of this unit the resident:

· Understand the ethical components of surgical practice;

· Understands and will be able to use clinical database and outcome analysis in surgical practice;

XV. GERIATRICS AND THE THORACIC SURGERY PATIENT

Learner Objectives: Upon completion of this unit the resident:

· Understands the principles of decubitus ulcer prophylaxis in the postoperative period given the increased predisposition of the elderly to decubiti;

· Understands the principles of end of life decision making (living wills, durable power of attorney).

·

Clinical Skills: During the training program the resident:

· Participates in the preoperative assessment of elderly patients;

· Carries out discussions with the patient and families about the operative risks and postoperative course;

· Prevents and manages common postoperative complications of:

a. Delirium

b. Prolonged intubation

c. Decubitus ulcer

d. Sepsis

e. Low output state

f. Adverse drug effects

g. Depression

h. Immobility, deconditioning, functional decline

i. Falls, fractures

j. Dehydration

k. Incontinence and UTI