RESIDENT ORIENTATION HANDBOOK 2017-18 - PBworks

RESIDENT ORIENTATION HANDBOOK

Division of Plastic Surgery

2017-2018

FACULTY

Christopher P. Demas, MD, Professor of Surgery – Division Chief and Program Director

Anil K. Shetty, MD, Assistant Professor of Surgery Director of Pediatric Plastic Surgery

Eugene C. Wu, MD, Assistant Professor of Surgery

Director of Burn Surgery

Jeffrey Wu, MD, Assistant Professor of Surgery

Mid-Levels Providers Maria Abeyta, PA-C

Leigh Higgins, PA-C Alyssa Anastasi, NP

PLASTICS SURGERY RESIDENT Orientation Booklet 2017-2018

Welcome to the integrated Plastic Surgery Residency Program at the University of New Mexico Health Sciences Center. Our residency is a 6 year integrated program. We are accredited by the ACGME. Attached are a series of documents covering the current policies of the program as well as the goals and objectives of your training. These will be reviewed with you bi-annually. You should make yourself familiar with these documents so that you are clear about your responsibilities and our expectations of your performance. Catherine Castillo is the residency program coordinator. She can be reached at 2-4264. Attachments: v Goals

¨ General Plastic Surgery ¨ Level Specific ¨ Burn Rotation ¨ Community Aesthetic Rotation ¨ Dermatology Rotation ¨ ENT Rotation ¨ Oral Rotation ¨ Research Rotation ¨ Hand Rotation ¨ Urology Rotation ¨ General Surgery Related Rotations ¨ Oculoplastic Rotation ¨ Orthopedic Rotation ¨ Thoracic Rotation ¨ Anesthesia Rotation ¨ Pediatric Surgery

v Policies and Schedules v Call Schedule / Duty Hours v Supervision v Clinical Responsibilities v Operative / Clinical logs v Advancement in training v Conferences v Evaluations v Documentation v Vacation Policy v Travel Policy and Away Rotations

PGY1

EGS EGS TRAUMA

ORTHO VASCULAR

SURG. ONC.

SURG. ONC

ER PEDS PLASTIC

PLASTIC

PLASTIC

PGY2

ANES. THORACIC BURN UROLOGY

HAND SURG. ONC.

PLASTIC PLASTIC PLASTIC

ENT ENT SICU

PGY3

EGS EGS HAND PLASTIC PLASTIC PLASTIC

OCULOPLA S/OMFS

OCULOPLA S/OMFS

DERM MOHS

DERM MOHS

SICU RESEARCH

PGY4

RECON BREAST HAND RECON

PGY5

ANESTHETIC COMMUNITY

RESEARCH BURN HAND

PGY6

RECON RECON RECON

GOALS AND OBJECTIVES

Overall Goals Competency

1. Graduate residents who are well versed in all general aspects of our specialty such that they are competent to either enter practice or to proceed to fellowship training if they desire subspecialty experience in plastic surgery.

PC, K

2. Graduate residents who can fully function in a changing health care environment. S, PBL/I, K, PC 3. Graduate residents who are able to cope with complications of surgery and to be well versed in risk management.

P, PBL/I, PC, C

4. Familiarize residents with ethical and appropriate coding and billing practices. P, S 5. Prepare residents to contribute nationally to our specialty, for example by educating them in the importance of collaborative clinical research and modeling participation in organized plastic surgery

PC, PBL/I, A

6. Graduate residents who will serve as educators of patients, students and colleagues. P, C, K, PC, S 7. Graduate residents who can critically review the literature and use this information to practice evidence based medicine.

PBL/I, K

8. Graduate residents who will be ambassadors for plastic surgery by exemplifying the highest standards of ethical, compassionate, and appropriate patient care.

P, PC, C, S

Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement S = system based practice

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GOALS AND OBJECTIVES PGY 4+

PGY-4+ (Plastic Surgery Y1)

1. The resident will demonstrate progressive understanding and independence in the evaluation and management of plastic surgery patients.

PC, K

2. The resident will understand, integrate and accurately communicate the key anatomical features of at least 6 major flap donor sites.

K, C

3. The resident will apply their knowledge of internal and surface anatomy to examine all parts of the body relevant to plastic surgery.

PC, K

4. The resident will successfully complete 10 microsurgical anastomoses in a laboratory setting. PC

5. The resident will complete consultations for complex wound problem’s from other specialties and make appropriate recommendations for wound care

PC, K, C

6. The resident will demonstrate appropriate decision making for work-up and management of trauma cases (extremity and facial) seen in the Emergency room

PC, K, C

7. For common plastic surgical problems, the resident will develop operative and non-operative management plans and be able to execute these.

PC, K, C

8. At the weekly Core Curriculum sessions, the resident will respond to feedback and demonstrate a trend to improving performance throughout the year. Sessions will be graded on a fail, pass, and high pass scale.

K, C, PBL/I

9. At the weekly Indications conference, the resident will respond to feedback and demonstrate a trend to improving case presentations throughout the year. Presentations will be evaluated and immediate feedback provided until performance has reached an acceptable level.

10. The resident will demonstrate respect, understand the concept of “culture of safety” and will collaborate with paramedical personnel (hand therapist, operating room nurses, clinic nurses, and secretarial and administrative staff).

P, C, S

11. The resident will demonstrate familiarity with digital cameras, image acquisition, use of stand digital imaging databases and power point presentation preparation.

PC

12. The resident will demonstrate a trend to improved completion of charting by using feedback from faculty. The resident will demonstrate increasing ability to seek resources to help with CPT coding.

P, S, PC, S

13. The resident will achieve a score at the 25%ile or higher in the Plastics Surgery In-Service exam, relative to his/her peers.

K, S


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PC, K

2. The resident will attend a week long biostatistics course provided by UNM K, PBL/I P 3. The resident will attend an educational session on system redesign and improvement and will initiate and lead a quality improvement project including appropriate measures of success.

PC, K, PBL/I C, S

4. At the weekly Core Curriculum sessions, the resident will respond to feedback and demonstrate a trend to improving performance throughout the year. Sessions will be graded on a fail, pass and high pass scale.

K, C, PBL/I

5. The resident will demonstrate skills in dealing with complications including an awareness of risk management.

PC, C, Pl, K

6. The resident will accurately plan and execute major procedures in plastic surgery, including microsurgery.

PC, K

7. The resident will a) accurately apply CPT coding to 80% of surgical cases in which he/she participates and b) complete charting consistent with the level of E&M coding applied, 80% of the time

S, P

8. The resident will prepare and present a formal presentation to Plastic Surgery Rounds, using computer-generated slides.

C, K

9. The resident will meet all EMR Meaningful use criteria for ambulatory care consistent with UNM standards for all providers.

PC, P, S

10. The resident will demonstrate knowledge of pros and cons of private practice versus academic practice.

11. The resident will prepare and submit an abstract to at least one regional or national plastic surgery form based on research initiated in the PGY3 year.

12. The resident will achieve a score at the 25%ile or higher in the Plastic Surgery In-Service exam, relative to his/her peers.

K, S


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PC, K

2. The resident will discuss alternative surgical solutions for complex reconstructive cases and state a clear preferred solution with the ability to defend the solution.

PC, K, C

3. The resident will complete preoperative evaluations of patients in all major areas of plastic surgery, including a thorough discussion of the risks and benefits of surgical procedures and through process of shared decision making elicit patients informed choices.

PC, K, C, P

4. At the weekly Core Curriculum sessions, the resident will respond to feedback and demonstrate a trend to improving performance throughout the year. Sessions will be graded on a fail, pass and high pass scale.

K, C, PBL/I

5. The resident will demonstrate skills in dealing with complications including an awareness of risk management.

PC, C, P, K

6. The resident will accurately plan and execute major procedures in plastic surgery, including microsurgery.

PC, K

7. The resident will a) accurately apply CPT coding to 90% of surgical cases in which he/she participates and b) complete charting consistent with the level of E&M coding applied, 90% of the time

S, PC

8. The resident will demonstrate knowledge of and utilization of resources of ASPS and other plastic surgery organizations.

P, K, PBL/I

9. The chief resident will perform administrative duties: organize Indications conference as well as other conferences where applicable, the OR case assignments and the call schedule.

P

10. The resident will demonstrate a) familiarity with standard photographic patient posing b) ability to acquire quality clinical images using digital cameras and incorporating principles of patient framing, lighting and background c) facility in the use of standard digital imaging databases. The resident will be versed in issues (medico-legal and ethical) relating to a) the provision of informed consent as it pertains to medical photography and b) to the clinical use and misuse of digital image manipulation

PC, P

11. The resident will achieve a score at the 25%ile or higher in the Plastic Surgery In-Service exam, relative to his/her peers.

K, S


Objectives – Burn Rotation

Assumptions: 1. The resident has previously acquired a fundamental knowledge base of cutaneous/subcutaneous

anatomy and burn-response pathophysiology. 2. In accordance with current Residency Review Committee requirements and previous national data

information, the resident will be intimately involved in the clinical care of at least the following number cases during his/her rotation:

5 burn reconstruction cases 3. The following objectives have been developed utilizing a “performance-condition-criteria” model. The

condition for all objectives is consistent with a typical spectrum of clinical scenarios. The criteria for all objectives conform with published clinical standards in current plastic surgery reference sources including Selected Readings in Plastic Surgery (Baylor University Medical Center) Plastic Surgery (Achaeur et. Al., Mosby 2000) Clinics in Plastic Surgery (Vol. 27:1, Jan., 2000) etc. The objective resident performance level is listed below.

Objectives:

1. The resident will be able to accurately assess burn injury depth and surface area. PC, K 2. The resident will be familiar with standard recommendations for burn center referral. PC, K, S 3. The resident will be well-versed in the protocols of immediate and early fluid resuscitation for burn patients.

PC, K,

4. The resident will be able to readily assess a patient for inhalational injury: • Will be familiar with assessment and management of carbon monoxide toxicity. • Wil be familiar with techniques for assessment and treatment of inhalational airway

edema

PC, K

5. The resident will be able to readily assess a patient following electrical injury: • Will be able to differentiate between low voltage vs high voltage injury • Will be familiar with the techniques for assessment and treatment of myoglobinurea • Will be familiar with the unique pattern of tissue destruction and debridement

requirements often associated with electrical injuries

PC, K

6. The resident will be well-versed in the indications and techniques of escharotomy. PC, K Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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7. The resident will be familiar with the wide spectrum of non-surgical interventions used in burn patients both in the acute and chronic settings:

• Wound cleansing and topical care • Calculation of nutritional requirements • Methods of nutritional support • Methods of nutritional support • Splinting, physical therapy, occupational therapy, pressure garments • Scar management, including available modalities for the treatment of hypertrophic scars

(silicone sheeting, pressure garments, massage, steroid injection, etc.)

PC, K, C, S

8. The resident will be familiar with the unique needs of the pediatric burn patient including differences in fluid resuscitation, nutritional support, burn scar, disturbance of growth, etc.

PC, K,

9. The resident will be able to assess a patient’s need for surgery. This includes an awareness of surgical timing depending on the patient’s overall medical status, need for escharotomy, inhalational injury, depth of burn, intensive care support etc.

PC, K,

10. The resident will be well-versed in: • Burn wound debridement, including tangential excision techniques • Techniques of split-thickness skin graft harvest, meshing and insetting • Skin graft donor site care • Appropriate techniques of splitting for extremities and digits • Alternatives to autografting • Routine post-operative care, including regular burn wound and skin graft assessment • Pain control, including the use of opioids and patient-controlled analgesia (PCA)

11. The resident will be familiar and sensitive to the profound psychosocial issues associated with burn injuries.

PC, K, S, C, P

12. The resident will be well-versed in the principles and techniques of secondary burn reconstruction:

• The importance of aesthetic units in the face • The use of split-thickness and full-thickness skin grafting in burn scar

contracture release and burn scar resurfacing • The use of z-plasty in burn scar contracture release • The use of transposition flaps in burn scar contracture release • The use of tissue expansion in burn scar contracture release and

burn scar resurfacing

13. The resident will develop an appreciation for the “team approach” to burn including pharmacists, nutritionists, nurses, social workers, PT/OT etc.

PC, K, C, P, S

14. The resident will become proficient in the knowledge of temporary skin coverage, including allograft and integra

PC, K

Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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Objectives – Dermatology Rotation

Assumptions: PRIOR to the start of the Dermatology rotation 1. The resident will have reviewed the pertinent literature on basal cell cancer, squamous cell cancer and

melanoma. Rotation Description

• The resident will attend the Dermatology clinics with their attending for 8 weeks • During the rotation, the resident will be off site and not responsible for day time consultations when they

are on call • The resident will observe at least 25 Moh’s procedures • The resident will participate in at least 16 Dermatology clinics

Learning Objectives: 1. The resident will gain familiarity with the most common lesions in the pediatric and adult age groups 2. The resident will demonstrate the ability to distinguish a basal cell cancer from squamous cell cancer

and melanoma on both clinical basis and histologic basis. 3. The resident will be able to distinguish appropriate ways to establish the diagnosis of skin lesions in

order to develop a treatment plan 4. The resident will demonstrate the ability to organize a workshop of a patient with skin cancers 5. The resident will be able to describe the TNM classification systems for these skin cancers 6. The resident will be able to describe standard surgical and medical treatments for each stage of skin

cancer 7. The resident will be able to describe the recommended follow up regimens for patients with skin cancer 8. The resident will demonstrate knowledge of risk factors and preventive measures for skin cancer 9. The resident will summarize their understanding of the Moh’s technique in a 15 minute presentation to

the plastic surgery faculty Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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Objectives – ENT Rotation

Assumptions: PRIOR to the start of the ENT rotation 1. The resident will have reviewed the pertinent literature on head and neck cancers and salivary gland

diseases. Rotation Description

• The resident will attend the ENT clinic for 8 weeks (preferably observing Head and Neck cancers as well as the typical types of problems faced in an ENT clinic)

• During that time, the resident will not be responsible for day time plastic surgery consultations when they are on call

• The resident will observe at least 8 neck dissections and 4 parotid gland operations and 8 thyroid operations

• The resident will participate in at least 16 ENT clinics (half day sessions) Learning Objectives: 1. The resident will communicate the indications for the operations they observe to our group in a 15

minute presentation. 2. The resident will be able to distinguish appropriate ways to establish the diagnosis of the diseases that

present to the ENT surgeon. 3. The resident will be able to describe the workup and develop a treatment plan for common head and

neck masses. 4. The resident will be able to describe the TNM classification systems for the common head and neck

cancers. 5. The resident will be able to describe standard surgical and medical treatments for each stage of head and

neck cancer. 6. The resident will be able to describe the recommended follow-up regimens for patients with head and

neck cancer 7. The resident will be able to describe the different levels of neck dissections and the indications for their

use. 8. The resident develop an understanding of common ENT surgical approaches to the neck. 9. The resident will successfully describe facial nerve anatomy as it relates to the skull base and parotid

gland. Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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Objectives – Oral Maxillofacial Surgery Rotation

Assumptions: PRIOR to the start of the OMFS rotation The resident will have reviewed the pertinent literature on (i) dental occlusion and squamous cell carcinoma of the head and neck and salivary gland diseases. Rotation Description

• The resident will attend the OMFS clinics/surgeries of Dr. Candelaria and Associates • During the rotation, the resident will be considered “off site” and not responsible for day time

consultations when they are on call • The resident will observe at least 4 orthognathic or alveolar cleft repair procedure; at least 5 dental

extraction; and at least 1 malignant or benign head and neck pathology case. • The resident will participate in at least 15 half-day OMFS clinics.

Learning Objectives: 1. The resident will be able to describe the TNM classification systems for head & neck squamous cell

cancer. 2. The resident will be able to perform a good oral examination including hard and soft-tissues of the oral

cavity; resident will be familiar with the formal dental nomenclature 3. The resident will be able to competently evaluate a head and neck CT exam and identify relevant

pathology. 4. The resident will demonstrate competence in evaluating an orthognathic surgical candidate. 5. The resident will become familiar/gain exposure to the Oral Surgery laboratory facility and understand

its potential. 6. The resident will give a presentation on a topic of his/her choice to the Plastics Surgery faculty. Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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Objectives – Plastic Surgery Research Rotation

PGY 3, 5

Assumptions: PRIOR to the start of the research rotation 1. The resident will clearly identify an area of interest, or research question, upon which to focus his/her inquiry. 2. The resident will identify a willing research supervisor/mentor with whom a project will be conceived

implemented, and developed. 3. The resident and supervisor will determine availability of necessary funding (and other resources) to

carry out study. 4. The resident will possess a fundamental expertise in performing an efficient and effective literature

review (or will arrange for a session with a Medical Librarian to acquire this skill). 5. The resident will have read, and be familiar with the principles described in, the article “Preparing

Manuscripts for Submission to Medical Journals: The Paper Trail“ by H.G. Welch Effective Clinical Practice. 1999; 2:131-137.

Objectives: 1. During the first week of the research rotation, the resident will present for review in conference to the

Section of Plastic Surgery an outline of the proposed project (question, hypothesis, study model, draft of protocol, study parameters).

2. The resident will communicate early with the Committee for the Protection of Human Subjects and prepare and complete a CPHS application during the rotation.

3. The resident will schedule weekly research meetings with his/her supervisor 4. The resident will demonstrate the ability to use a reference management database program such as

EndNote or RefWorks. 5. With assistance, the resident will write up a full study design including proposed statistical

methodology. 6. The resident will present an interim report to the Section of Plastic Surgery Rounds in the last quarter of their third year.

7. The resident will successfully complete patient enrollment and data collection by the 4th month of their 4th year.

8. The resident will submit at least one abstract to a regional society meeting and to a national society meeting.

9. The resident will prepare and submit at least one full manuscript prior to completion of residency 10. The resident will protect his/her own research time from outside influence. Days when the resident is

absolutely needed for clinical responsibilities will be “give back” to the resident during a clinical rotation.


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Objectives – Community Aesthetic Rotation

Assumptions: 1. The resident has previously acquired a fundamental knowledge base of plastic surgery in an academic

setting. 2. The private practice experience will assist the resident in acquiring uniquely different aspects of several

of the core competencies such as team work, system-based practice, interpersonal and communications skills, practice based learning and professionalism.

3. In addition to the specific objectives listed below, the resident will have exposure to a broad spectrum of plastic surgical patients.

4. The following learner objectives have been adapted from the Association of Academic Chairmen of Plastic Surgery (AACPS) Requisite Core Curriculum.

THE PRACTIC OF PLASTIC SURGERY – Patient Management/Office Management UNIT OBJECTIVE: At the end of the unit, the resident is familiar with patient evaluation CPT terminology and office operating room management. LEARNER OBJECTIVES: Upon completion of the unit, the resident: 1. Understands how to interview and evaluate the patient, especially the aesthetic surgery candidate. 2. Knows the principles of how to equip and organize an office operating suite to comply with AAAAPSF

standards. CLINICAL PRACTIVE ACTIVITIES: During the course of the training program, the resident: 1. Participates in outpatient management including observation of faculty managing private patients

including initial consultation and management of complications. 2. Discusses risk management principles with faculty; applies these principles in daily practice of plastic

surgery. 3. Participates in the post-operative management of patients in non-hospital based “surgicenters” (true cosmetic surgery recovery center vs hotel-based with nurse supervision). 4. Experiences working in a non-academic environment; i.e., the dynamic (the necessity) of greater MD-

MD, MD-nurse, MD administration cooperation and communication (due to lack of resident intermediaries). Different profile of time commitments (greater patient care-business management vs teaching-research)

5. Experiences the business of running a practice, i.e, MD-office staff dynamics, hiring-firing, budgeting, risk management, professional liability, advertising (personal websites, etc.)

6. Demands on private practice surgeons to independently maintain CME credits, stay current “maintenance of certification”, etc.


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CORE OF KNOWLEDGE/GENERAL PLASTIC SURGICAL PRINCIPLES AND TECHNIQUES UNIT OBJECTIVE: At the end of the unit, the resident understands the principles of a variety of special techniques in plastic surgery including: liposuction, tissue expansion botox and filler injections and utilizes the techniques effectively in appropriate clinic settings. LEARNER OBJECTIVES: Upon completion of the unit, the resident: 1. Understands the basic principles, the common techniques and the instrumentation of suction lipectomy

including tumescence, standard and ultrasonic liposuction. 2. Is able to perform preoperative, intraoperative and postoperative management of the patient undergoing suction lipectomy; is familiar with the complications of liposuction and their management. 3. Knows difference injection techniques, fluid and suction limits and safety precautions. 4. Understands the pharmacology, risk profiles, indications, and injection techniques for Botox and at least one type of dermal filler. 5. Understands the physiologic and pathologic principles of dermabrasion, chemical peel and laser

resurfacing; recognizes the differences between the techniques and the indications for choice between the techniques. Understands the physiologic and pathologic principles of laser intervention for the treatment of vascular and pigmented lesions, traumatic and professional tattoos and hair removal; recognizes the differences between the techniques and the indications of choice between the techniques.

6. Understands the principles of pre-and postoperative management of patients undergoing facial resurfacing; recognizes the complications of the technique and its management.

7. Is familiar with the pharmacologic aspects and the techniques of chemical peel. CLINICAL PRACTICE ACTIVITIES: During the course of the training program, the resident: 1. Evaluates and treats patients using dermabrasion and/or chemical peel. 2. Evaluates and treats patients with problems amenable to laser therapy Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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PLASTIC SURGICAL ASPECTS OF SPECIFIC RELATED DISCIPLINES –

Mediocolegal and Psychiatric Aspects of Plastic Surgery

UNIT OBJECTIVE: At the end of the unit, the resident has a clear understanding of medicolegal and carries out an effective basic psychological evaluation upon them when appropriate. LEARNER OBJECTIVES: Upon completion of the unit, the resident: 1. Understands the medical and legal perspectives of the contractual agreement between a physician and

his/her patient. 2. Understands the concepts of informed consent and implied guarantee. 3. Understands the role of the medical record as a legal document. 4. Understands the impact physical deformity can have on patients and their families. 5. Knows techniques to explore the motivations of patients seeking cosmetic surgery, and how to

distinguish acceptable, unacceptable, and pathological motivations. 6. Knows legal and ethical ways to sever the physician/patient relationship. 7. Understands the various types of malpractice insurance. 8. Recognizes the basic principles of risk management. CLINICAL PRACTICE ACTIVITIES: During the course of the training program, the resident: 1. Evaluates patients for aesthetic surgery from a physical and psychological perspective. 2. Contributes effectively and accurately to the medical record of both inpatients and outpatient. 3. Participates in the management of problem patients, including angry patients, dissatisfied patients

“doctor shoppers,” “drug seekers,” etc. Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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PLASTICS SURGICAL ASPECTS OF SPECIFIC RELATED DISCIPLINES – Anesthesia and Critical Care UNIT OBJECTIVE: At the end of this unit, the resident understands the indications, principles, techniques and complications of local, regional and general anesthesia in a wide variety of clinic settings. LERNER OBJECTIVES: Upon completion of the Unit, the resident: 1. Demonstrates knowledge of common agents for local anesthesia regional anesthesia and general

anesthesia (intravenous agents, inhalation agents, muscle relaxants, antiemetics, etc). 2. Knows the principles and the techniques for administration of local anesthesia including appropriate use

of local and regional blocks. 3. Has basic knowledge of the principles and techniques for general anesthesia using different anesthetic

techniques. 4. Is generally familiar with the type and the incidence of complications from various kinds of anesthesia,

and the causes of morbidity and mortality and its occurrence in local anesthesia regional anesthesia, general anesthesia and hypotensive anesthesia.

CLINICAL PRACTICE ACTIVITIES: During the course of the training program, the resident: 1. Participates in the decision as to which technique of anesthesia should be used on his/her patients. 2. Utilizes the techniques of local anesthesia. 3. Becomes familiar with all monitoring equipment in facilities used for general anesthesia, regional

anesthesia and local anesthesia. Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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PLASTIC SURGERY OF THE INTEGUMENT – Benign and Malignant Skin Lesions: UNIT OBJECTIVE: At the end of the unit, the resident has a thorough understanding of benign and malignant skin lesions, recognizes the morphologic and histologic features of the more common lesions, and effectively manages small and large skin tumors using a variety of treatment modalities. LEARNER OBJECTIVES: Upon completion of the unit, the resident: 1. Is familiar with the clinical presentation of benign and malignant cutaneous lesions and generalized skin

disorders. 2. Is able to provisionally evaluate both simple and complex cutaneous lesions and proceed with diagnostic

steps necessary to secure a definitive diagnosis. 3. Formulated 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. Is able to explain in a comprehensible but simplified manner to the patient the nature of the lesions, its

extent, treatment options and long per results. CLINICAL PRACTICE ACTIVITIES: During the course of the training program, the resident: 1. Evaluates a variety of cutaneous lesions, recommends an approach to therapy based on the lesion’s size,

clinical characteristic, location and condition of the patient 2. Executes 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.

3. Executes 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.


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PLASTIC SURGERY OF THE INTEGUMENT-Congenital, Aesthetic and Functional Problems UNIT OBJECTIVE: At the end of the unit, the resident is familiar with common congenital disorders and generalized disease processes of the skin and with the physiology of aging and successfully undertakes plastic surgical treatments of these processes and disorders. LERNER OBJECTIVES: Upon completion of the unit, the resident: 1. Knows the basic physiology of the aging process of the skin. 2. Understands the basic physiologic processes of sun exposure on the skin. 3. Understands the role of lasers in the management of various skin lesions and conditions. 4. Is familiar with common nonsurgical methods and agents for treatment of the aging process of skin. 5. Knows the principles of prevention of sun exposure effects and familiar with pharmacologic agents for

prevention of sun exposure and the details of their prescription and use. CLINICAL PROACTICE ACTIVITIES: During the course of the training program the resident: 1. Utilizes pharmacologic agents for treatment of aging skin. 2. Recommends pharmacologic agents for prevention of sun exposure; instructs patients in use of the

agents in general principles of skin protection from the sun. Competency abbreviations: PC = patient care including clinical judgment and surgical skills K = medical knowledge C = interpersonal and communication skills P = professionalism PBL/I = practice-based learning and improvement / S = system based practice

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HAND & UPPER LIMB

Description:

The goal of the hand and upper limb rotation is to provide a breadth of experience and exposure to: a) disorders affecting the hand and upper limb, and b) clinical and surgical management of these disorders

Resident role and expectations:

Residents on the hand and upper limb service (PGY2,3,4 and 5) will be a primary member of the care team under the supervision of attending staff. The resident will work closely with the attendings and fellows. The resident will gain proficiency in soft-tissue handling and microsurgery as well as the treatment of a broad variety of hand and upper limb disorders.

Readings:

A core curriculum is used, from the UT Southwestern selected readings. This is augmented by selected readings and conference topics as chosen by the faculty and fellow.

Goals and objectives:

By the end of the last rotation, the resident will:

1) Medical Knowledge: Obtain knowledge and comprehension of the basic disorders that afflict the upper limb, and gain insight into the methodology and procedures incorporating its treatment. Particular emphasis is placed on the importance of interdisciplinary approach. Interpreting information obtained from a history and physical examination, incorporating data from radiology and laboratory studies, understanding anatomy, and incorporating this knowledge into surgical skills for hand and microsurgery is fundamental to the required knowledge. Soft tissue handling, microvascular environment of the limb, and pathology of systemic disease processes are as essential as learning the indications for surgery and the type of fixation chosen.

2) Patient Care: Obtain acumen in diagnosing and proposing treatment in the clinical setting, and analyze available information to make diagnostic and therapeutic decisions based upon sound clinical judgment, best available evidence, and patient preferences. Perform at an upper resident level in surgical techniques pertaining to soft tissue, nerve, skeletal structures, and microsurgical procedures. The resident will participate in self-evaluation and improvement in the microsurgery lab for surgical skills.

3) Interpersonal and Communication Skills: Demonstrate the interpersonal skills and professionalism necessary to adequately diagnose and treat a variety of traumatic and elective hand injuries and disorders. This reflects the behavior of a role model to peers, junior residents, and medical students. Demonstrate courtesy and timeliness with patient, family, and professional interactions.

4) Professionalism: Demonstrates respect, compassion, integrity, and honesty as it relates to patient interaction. Takes initiative in addressing the needs of patients and peers; acknowledges and addresses errors, and pursues self-improvement.

5) System-Based Practice: Demonstrate competence and ability to interact with outside institutions in the timely transfer and decision making process for traumatic hand injuries, and utilizes institutional resources in the emergent care of amputated digits at outside hospitals. Interpret and apply techniques and protocols in conjunction with hand, physical, and occupational therapy as it relates to patient care and management. Utilize and synthesize outside resources and professional online resources (American Academy of Orthopaedic Surgeons, American Society of Surgery of the Hand, American Association of Hand Surgeons), pubmed, and other educational opportunities which enrich the clinical and academic education of the resident.

PGY 2 UROLOGY ROTATION GOALS AND OBJECTIVES

sionate, appropriate, and effective. OBJECTIVES: 1. Obtain a complete and accurate history and physical examination from patients

with genitourinary/renal failure complaints. 2. Be able to provide initial care to patients in the outpatient and inpatient setting. 3. Appropriately counsel and educate patients and their families about common

outpatient problems such as hematuria, and recurrent urinary tract infections. 4. Demonstrate knowledge of the appropriate laboratory and imaging tests to evaluate patients

presenting with hematuria, calculous disease, ESRD and urinary retention. 5. Demonstrate basic surgical skills of knot tying, circumcision and prostate biopsy. 6. Demonstrate safe and effective transfer of patient care (handoffs). 7. Discuss the diagnostic /management algorithm in postoperative kidney transplant patients for: a)

evaluating oliguria, b) fever, and c) elevated creatinine. 8. Discuss the essential parameters required to rule out bleeding in a post-transplant patient.

1. MEDICAL KNOWLEDGE GOAL: Acquire clinical and basic science knowledge of urologic disease and renal transplantation, and be able to apply this knowledge to the care of patients. OBJECTIVES: 1. Demonstrate knowledge of the pathophysiology of prostate hyperplasia and male voiding

dysfunction. 2. Understand indications for and methods of treatment for prostate hyperplasia. 3. Appreciate abnormalities of video-dynamic studies in patients with neurologic voiding

dysfunction. 4. Understand evidence-based approaches for surveillance in patients who have been surgically

treated for cancer. 5. Discuss the potential infectious complications associated with immunosuppression. 6. List and describe the basic mechanisms of action and potential adverse effects of commonly used

immunosuppressive agents. 7. Discuss the basic cellular immune interactions that lead to a rejection response and the clinical

manifestations of allograft transplantation. 8. Describe the role of HLA antigens in human transplantation.

2. PRACTICE BASED LEARNING AND IMPROVEMENT GOAL: Improve urologic patient care practices by the critical evaluation of current practice patterns and by the appraisal and assimilation of scientific evidence.

OBJECTIVES:

1. Locate , appraise and assimilate scientific studies from the urologic and transplant literature applicable to patient management.

2. Facilitate the education of nursing staff and medical students. 3. Incorporate performance feedback from faculty to improve practice. 4. Become facile at using PUBMED to query the medical literature. 5. Describe the basic criteria used to determine a patient’s candidacy for transplant. 6. Describe the basic steps required to select and prepare a patient for living donation.

3. INTERPERSONAL AND COMMUNICATION SKILLS GOAL: Develop interpersonal and communication (verbal and writing) skills that will allow effective exchange of information with urologic/transplant patients, their families and other health care professionals.

OBJECTIVES:

1. Develop rapport with your patients and their families. 2. Develop effective listening skills and be able to elicit information from patients. 3. Enter coherent, concise and informative notes in the EMR. 4. Work effectively with others as a member of the Urology health care team. 5. Interact and communicate effectively with nurses and other health professionals and allied staff. 6. Be courteous to patients and staff.

4. PROFESSIONALISM GOAL: Be professional by adherence to high ethical standards, accountability and sensitivity to the diverse urologic and transplant patient population. OBJECTIVES: 1. Have respect, compassion and integrity in your interactions with patients, their families and

other healthcare professionals. 2. Outline important considerations in discussing DNR status with a patient’s family. 3. Outline the important steps in explaining a surgical complication to a patient. 4. Be punctual to conference and see patients as asked by the senior residents and attendings. 5. Understand and commit to the ethical principles pertaining to patient confidentiality. 6. Ask for assistance from senior residents or attendings when you have reached the limit of your

abilities. 7. Comply with federal and state laws, and ACGME/institutional/program requirements.

5. SYSTEMS BASED PRACTICE GOAL: Be aware of and responsive to the health care system in which you practice, and use available resources to optimize care of the urologic/transplant patient. OBJECTIVES: 1. Continually advocate for quality patient care and patient safety. 2. Practice cost –conscious health care without compromising quality of care. 3. Coordinate patient care by partnering with case managers, social workers, other physicians, and

support staff. 4. Participate in identifying system errors and implementing potential solutions. 5. Assist urology/transplant patients in dealing with health care system complexities.

6. PATIENT CARE GOAL: To provide care to patients with urologic disease and renal failure that is compas

GASTROINTESTINAL SURGICAL ONCOLOGY

EDUCATIONAL GOALS

At the time of completion of this rotation, the resident will be able to:

1. Exhibit a broad knowledge base, good judgement, and appropriate technical skills for the surgical treatment of cancer.

2. Appreciate the complex co-morbidities often associated with the patient with cancer. 3. Be aware of the limitations of surgery and the areas wherein the very best combination of surgery and other

modalities has not been reached.

EDUCATIONAL OBJECTIVES

Patient Care Skills

PGY 1 and PGY2

1. Perform an appropriate and adequate history and physical examination of the patient with cancer. 2. Participate in surgical procedures and develop the skills to be a superior first assistant with respect to the

following: a. Counter-traction b. Suction c. Knot-tying d. Hemostasis

3. Become skillful with the following interventions: a. Nasogastric tubes b. Peripheral IV lines c. Central venous line d. Urinary bladder catheter

Medical Knowledge

PGY 1 and PGY2

4. Familiarization with how cancer is diagnosed and the information that is clinically applicable from the definite histologic diagnosis of any given cancer.

5. Recognition of co-morbid diseases, as cancer so often strikes the elderly 6. Understand the work-up of co-morbidities, including the utilization of colleagues in Anesthesiology, Cardiology,

and Radiology to minimize and better quantitate these co-morbid factors. 7. Appreciate the frailty of the population upon who we are treating. 8. In close rapport with the pathologists, appreciate the carious strategies necessary to obtain tissue for diagnosis:

a. Needle biopsy b. True-cut biopsy c. Stereotactic biopsy d. Incisional biopsy e. Excisional biopsy

Interpersonal Communication Skills

In patients undergoing surgery for cancer:

1. Be able to create and sustain a therapeutic and ethically sound relationship with patients and their families 2. Use effective listening skills 3. Provide information to patients using effective nonverbal, explanatory, questioning and writing techniques. 4. Work effectively with other members of the health care team 5. Be prepared to describe an acceptable method to handle the following example interactions.

a. Preoperative counseling of an extremely anxious patient with pancreatic mass of undetermined nature despite maximal preoperative work-up

b. Patient referred for management of soft tissue sarcoma of the extremity that had an attempted excisional biopsy done is such a manner that severely compromised the respectability of the tumor and functionality of the limb and resection.

Professionalism

While caring for the patients undergoing surgery for cancer:

1. Demonstrate respect, compassion, and integrity. 2. Demonstrate responsiveness to the needs of patients and society and supercedes self-interest 3. Demonstrate accountability to patient, society, and the profession of surgery 4. Demonstrate a commitment to excellence and on-going professional development. 5. Demonstrate a commitment to ethical principles pertaining to provision of or withholding of clinical care 6. Maintain confidentiality of patient information 7. Be able to obtain informed consent for planned interventions 8. Demonstrate sensitivity and responsiveness to patient’s culture, age, gender, and disabilities

Practice-Based Learning:

For patients undergoing surgery for cancer

1. Develop a method to record and track over time the results of intervention performed by the resident 2. Be involved in the teaching of students and more junior residents and colleagues 3. Present patients for discussion during rounds and seminars, with appropriate literature references to support

planned intervention. 4. Understand the role of study design and the use/misuse of statistical analysis in review the results of published

research in this surgical field. 5. Demonstrate the ability to use information systems to obtain-related information. 6. Use information technology to manage and provide patient-related information. 7. Be prepared to describe how to obtain relevant information to support patient management in the following

example situations: a. Type preoperative diagnostic testing necessary for treatment of a suspected pancreatic cancer being

considered for Whipple pancreaticoduodenectomy.

Systems-based Practice

For patients undergoing surgery for cancer:

1. Understand the role of a tertiary referral center in the surgical management of simple and complex problems. 2. Practice cost-effect health care and resource allocation, specially reducing the use of unnecessary preoperative

and postoperative screening and/or testing. 3. Practice cost-effect health care that does not compromise patient care. 4. Understand the responsibility of the surgeon in managing indigent patients.

5. Direct patients and their families towards individuals within the Institution that can help them with understanding complex issues of societal support and resources.

6. Understand an awareness of the role of health care managers and surgeon-extenders in the surgical management of patients.

7. Advocate for quality patient surgical care. 8. Demonstrate awareness of the costs associated with providing care to patients. 9. Be prepared to discuss the interplay of the competing societal and patient needs in the following example

situations: b. Cost-benefit of routine hemoccult testing for all patients during annual physical examination to detect

colon cancer.

Cardiothoracic Rotation PGY2: The Cardiothoracic Service is responsible for the care of patients at UNM with a wide range of disease of the heart and thorax. Cardiothoracic surgery represents one of the additional components of surgery that must be encompassed by the training program including clinical experience in the preoperative, operative, and postoperative care of such patients. Exposure to the unique perspective provided by this rotation strengthens the resident’s knowledge, experience, and overall competence in this arena.

Goals: To become more competent in the preoperative, operative, and postoperative management of patients undergoing cardiothoracic surgery. The PGY2 will participate meaningfully in a wide variety of operations and procedures on the service. However, the major focus of this rotation remains to further the resident’s competency in the perioperative care of patients undergoing cardiothoracic surgery. In addition to caring for patients on the cardiothoracic surgery floor, the PGY 2 may sometimes see new consults to the service.

Specific objectives: . Although the resident will be exposed to and have the opportunity to learn about a variety of conditions on this rotation, the major focus for the PGY2’s medical knowledge and patient care objectives on this service should be to develop a more advanced level of competency in perioperative care of patients undergoing cardiothoracic surgery. To accomplish these competency-based objectives, the PGY2 should:

• Perform history and physical examination and share information with the senior resident, fellow, and/or attending. • Use available information, in combination with the interpretation of basic laboratory and radiographic data, to

develop a plan for the preoperative preparation of the patient and discuss this with the senior resident/attending. • Understand the basic pathophysiologic disease process and its surgical implications. • Understand the basics of the surgical procedure performed. • Develop a plan for the postoperative care of the patient with the senior resident/attending. • Provide the day to day care of patients on the service. • Teach and help to supervise medical students on the service. • Develop interpersonal skills for dealing with patients and other members of the health care team. • Master the basic science principles impacting the care of patients on the service. • Further their knowledge of basic surgical skills. • Develop skills in practice-based learning and systems based practice. • Become proficient with invasive monitoring techniques and minor invasive procedures (central line placement,

thoracostomy tube placement, arterial line placement, occasionally even balloon pump placement).

In addition to the above focus, the PGY2 on the cardiothoracic service will have expectations regarding the following four competencies:

. Practice-Based Learning and Improvement Requirements: Residents must be competent in the investigation and evaluation of their own patient care, in the appraisal and assimilation of scientific evidence, and in improvements of patient care. Specifically, surgeons are expected to critique personal practice outcomes and demonstrate recognition of the importance of lifelong learning in surgical practice. They should facilitate the learning of students and other health professionals.

Approach: A variety of approaches throughout the residency promote such competence. In particular, the residents are exposed to many different surgeons and each takes a unique approach to the same problems,

giving the resident the opportunity to learn from a variety of practice patterns. The Service Conference and Morbidity and Mortality Conference, gives residents the opportunity to review their own care and that of others, developing concrete plans to prevent adverse outcomes in the future. The resident’s ability to learn from previous experience and mistakes is continuously evaluated and the teaching staff clearly has the opportunity to observe the resident’s maturation as he/she passes through the service. Residents are generally made to feel that teaching their more junior colleagues and medical students is an important part of their duties.

4. Interpersonal and Communication Skills

Requirements: Residents are expected to develop skills that result in effective information exchange and teaming with patients, their families, and other health professionals. Specifically residents are expected to learn to communicate effectively with other health care professionals, counsel and educate patients and families, and effectively document practice activities.

Approach: Clearly these are skills that are in fact are a part of our resident selection process, although informally. However, they are refined as the residents progresses through his/her training. Some of this is accomplished through observation of teaching faculty and more senior residents and some through the experience of interacting with patients, families, and other health professionals. Such skills are evaluated by the faculty, by other members of the team, and by patients and the feedback from such evaluation is used to help in the further development of such skills.

5. Professionalism

Requirements: Residents should develop a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations. They are expected to maintain high standards of ethical behavior and demonstrate a commitment to continuity of patient care and sensitivity to age, gender, and culture of patients and other health professionals. They should demonstrate a commitment to ethical principles pertaining to provision or withholding of care, confidentiality, informed consent, and business practices.

Approach: Some of this is accomplished through observation of teaching faculty and more senior residents and some through the experience of interacting with patients, families, and other health professionals. Such skills are evaluated by the faculty, by other members of the team, and by patients and the feedback from such evaluation is used to help in the further development of such skills.

6. Systems-Based Practice

Requirements: Residents will demonstrate an awareness of and response to the larger system of healthcare and effectively call on system resources to provide optimal care. They are expected to practice high quality, cost-effective patient care, demonstrate a knowledge of risk-benefit analysis, and demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.

Approach: Systems-based practice is learned throughout the residency through a variety of venues. They receive a range of didactic instruction on these subjects, including, for example, a yearly Grand Rounds on coding, elective classes offered by health care sciences library on the medical information system and the division endeavors in quality improvement. On this and all rotations, such skills are evaluated by the faculty, by other members of the team, and by patients and the feedback from such evaluation is used to help in the further development of such skills

Breast Rotation PGY 4

GOAL:

This is a 3 month rotation with dedicated breast surgeon and interdisciplinary breast program, occurring during the PGY-4 year. It is focused on development of medical knowledge and patient care of the breast and breast diseases, particularly breast cancer, and knowledge and practice of treatment alternatives, including surgical treatment and its technical aspects.

The resident will also acquire system-based experience in working with a multi-disciplinary team of surgeons, medical oncologists, radiologists, pathologists and allied health professionals, in evaluating patients with breast cancer and planning diagnosis and treatment. Finally, the resident will practice and enhance their interpersonal and communication skills and professionalism in dealing with patients with breast cancer and other breast diseases and their supports, dealing with challenging issues for patients and their families. OBJECTIVES:

a. Medical Knowledge Objectives

i. Describe the anatomy of the breast ii. Explain the hormonal regulation of the breast iii. Summarize the incidences, epidemiology, and risk factors associated with breast cancer iv. Be familiar with the ANDI classification of benign breast disorders v. Be familiar with cancer risk associated with benign breast disorders and in situ carcinoma of the breast vi. Familiar with classification of benign breast disorder:

1. Nonproliferative disorders of the breast 2. Proliferative breast disorders without atypia 3. Atypical proliferative lesions

vii. Distinguish between these common entities in the differential diagnosis of breast masses 1. Fibroadenomas 2. Cysts-gross and fibrocystic disease and risk factors 3. Abscesses 4. Fat necrosis 5. Cancer 6. Sclerosing adenosis 7. Recurrent subareolar sepsis

viii. Be familiar with the relative risk estimates for the “Gail Model” xi. Explain the general indications, uses, and limitations of mammography. Be familiar with current recommendations for screening mammography

1. Be familiar with indications and limitations of the diagnostic modalities including ultrasound, MRI

x. Discuss the principles and historic context of the basic options available for the treatment of breast cancer such as:

1. radical mastectomy 2. modified mastectomy 3. Patey mastectomy 4. lumpectomy and axillary dissection xi. Outline the genetic and environmental factors associated with carcinoma of the breast xii. Describe the following pathological types of breast cancer, including the biology, natural history, and prognosis of each:

1. Infiltrating ductal carcinoma 2. Ductal carcinoma in situ (DCIS) 3. Infiltrating lobular carcinoma 4. Lobular carcinoma in situ (LSIS) 5. Other

xiii. Be able to differentiate the salient characteristics of in situ (DCIS) lobular (LCIS) carcinoma of the breast xiv. Define the TNM staging system for breast cancer, and other classifications for breast cancer xv. Define the staging of breast cancer and prognosis, survival results and treatment options

including hormone manipulation and chemotherapeutic options and bone marrow transplantation xvi. Describe the presentation, natural history, pathology, and treatment of the following benign

breast diseases: 1. Lactational Breast Abscess 2. Chronic Recurring Subareolar Abscess 3. Intraductal Papilloma 4. Atypical Epithelial Hyperplasia 5. Fibroadenoma 6. Sclerosing Adenosis

xvii. Explain the steps in the clinical decision tree that are involved in the work-up of a breast mass xviii. Discuss the role of mammography, needle aspiration, fine needle biopsy, open biopsy and mammographic needle localization and biopsy (Stereotaxic) xix. Explain the mechanics and potential values of the stereotactic needle biopsy xx. Outline the diagnostic work-up in the differential diagnoses of various forms of nipple discharge. xxi. Explain use of tumor size, nodes and metastases (TNM) staging and treatment of breast cancer with the additional sentinel lymph node staging system. xxii. Summarize a rationale for using a team approach to facilitate the complex discussions and

explanation of options for the newly diagnosed breast cancer patient prior to definitive treatment (e.g., oncologists, surgeon, plastic surgeon and radiation therapist).

xxiii. Explain the role of reduction and augmentation mammoplasty xxiv. Discuss several causes of gynecomastia and outline an appropriate workup xxv. Discuss indications for Mammo site insertion, technical aspects, and complications xxvi. Describe the technique of Sentinel Lymph Node Biopsy (SLNB) complications and indications

xxvii. Be familiar with percent incidence of sporadic, familial, and hereditary breast cancer

1. Sporadic breast cancer 2. Familial breast cancer 3. Hereditary breast cancer

a. BRCA-1 b. BRCA-2 c. Other less common hereditary breast cancer (p53-Li- Fraumeni, Cowden’s

disease, Peutz-Jehger, Muir-Torre) xxviii. Describe the characteristics diagnoses and therapy of less common lesions of the breast

such as: 1. Inflammatory carcinoma 2. Paget’s disease 3. Lactiferous duct fistula 4. Mondor’s disease 5. Cystosarcoma Phylloides 6. Bilateral breast carcinoma 7. Male Breast carcinoma

xxix. Understand the methodologies and results of landmark breast cancer trials: B-04, B-06, B-17, B-24 (NSABP)

xxx. Be able to discuss the natural history of treated and untreated breast cancer and survival patterns both historically and modern day.

xxxi. Summarize the role of adjuvant chemotherapy and radiation therapy in the treatment of primary breast cancer.

xxxii. Outline the importance of estrogen and progesterone receptors in the prognosis and treatment of breast cancer.

xxxiii. Describe the basic issues in the staging and treatment of metastatic breast cancer including the role of:

1. Chemotherapy 2. Radiation therapy 3. Hormonal therapy

xxxiv. Know treatment options of chemotherapeutic regimens for breast cancer in patients with: 1. Node-negative patient 2. Node positive patient

xxxv. Summarize the physiologic changes associated with pregnancy, including breast problems peculiar to pregnancy. Theorize appropriate management of breast cancer diagnosed during pregnancy

xxvi. Summarize the major considerations for post-mastectomy breast reconstruction xxxvii. Formulate plans for basic patient care, including pre-intra and post-operative care xxxviii. Identify and analyze data addressing controversial areas of breast disease

such as:

1. Current concepts in the management of cancer 2. Cancer prevention techniques, such as tamoxifen and raloxifene 3. Role of various adjuvant therapy programs 4. Biological behavior of lesions such as lobular carcinoma in situ (LCIS) 5. Benefits and frequency of screening mammograms 6. Relationship of mammographic parenchymal pattern to the risk of

Subsequent malignancy xxxix. Review and evaluate the following areas of research in breast disease:

1. Role of breast cancer susceptibility genes 2. Monoclonal antibodies 3. Other breast markers including Her-2/neu, Cathepsin D and flow

Cytometry with chromosomal analysis. xl. The role of sentinel lymph node biopsy for breast cancer:

1. Sensitivity and specificity 2. Indication and contraindications 3. Technique 4. Treatment plan based on findings

BREAST DISEASE IN THE ELDERLY

Medical Knowledge Objectives: As this rotation provides exposure to breast disease in all age groups, the resident experience in this rotation will include exposure to elderly patients with breast disease, including carcinoma. From a medical knowledge competency perspective, the resident will be able to:

• Articulate currently accepted guidelines for breast cancer screening in the elderly patient

• Describe the demographics of breast cancer in the elderly • Describe currently accepted surgical treatment • Discuss the use of adjuvant chemotherapy • Describe the barriers that prevent adequate treatment in some elderly women • Discuss appropriate modification of cancer therapy in the frail

Elderly women • Discuss a diagnostic evaluation of the elderly male with breast lump • Discuss the treatment of male breast cancer • Discuss the role of hormonal therapy in older patients

b. PATIENT CARE OBJECTIVES:

Building on skills already acquired at the PGY-1 and 2 level, the resident in the rotation shall be able to (upon completion): i. Take an appropriate history to evaluate breast patients to include:

1. Pertinent risk factors 2. Previous history of breast problems 3. Current breast symptoms

ii. Demonstrate an increasing level of skill in the physical examination of the breast, including recognition of the range of variation in the normal breast

iii. Perform simple procedure such as: 1. Diagnostic fine-needle aspiration of cysts 2. Drainage of simple breast abscesses 3. Core biopsy of breast masses 4. Open biopsy of superficial masses

iv. Identify common lesions such as fibroadenomas, cysts mastitis and cancer v. Interpret signs of suspicious for malignancy on mammogram such as stellate

masses or suspicious micro calcifications vi. Perform open breast biopsies and other operative procedures such as simple

mastectomy and excision of intraductal papillomas under direct supervision vii. Demonstrate the ability to satisfactorily orient the surgical specimen for pathologic

examination viii. Determine the indications and special requirements for tissue processing for

estrogen and progesterone receptors ix. Educate patients to perform breast self-examination x. Demonstrate familiarity with male breast problems, including gynecomastia

and male breast cancer: 1. Discuss risk factors 2. Outline appropriate work-up and management

xi. Independently evaluate a new breast patient by a thorough history and physical examination, ordering appropriate and cost-effective tests such as mammogram, ultrasound or fine needle aspiration (FNA) or stereotactic breast biopsy (SBB)

1. Be familiar with role and indications of MRI in breast disease. xii. Formulate a diagnostic work-up and treatment plan for most common breast

problems, including the common types of breast carcinomas. xii. Consult and interact with members of the professional cancer team in explaining options to

the newly diagnosed breast cancer patient. xiii. Describe and/or perform, under direct supervision, advanced procedures on the breast

such as: 1. Radical mastectomy 2. Modified mastectomy

3. Lumpectomy and axillary dissection 4. Sentinel lymph node biopsy 5. Excision of lactiferous duct fistula 6. Needle-localized breast biopsy 7. Simple mastectomy for gynecomastia 8. Mammo site insertion

xiv. Acquire basic experience with breast reconstruction and cosmetic surgical techniques, including implants, transrectus abdominal mastoplasty (TRAM) flaps, observing or assisting a plastic surgeon when possible.

xvi. Evaluate the physical status of patients who report for evaluation of augmentation and reduction mammoplasty.

xvii. Prescribe various types of adjuvant therapy such as: 1. Chemotherapy 2. Hormonal therapy 3. Radiation therapy 4. Mammo site xviii. Manage unusual breast diseases such as: 1. Inflammatory carcinoma 2. Paget’s disease 3. Lactiferous duct fistula 4. Mondor’s disease 5. Bilateral breast cancer 6. Male breast cancer 7. Cystosarcoma Phylloides xix. Describe the evolving role of bone marrow transplantation in the management of selected

breast cancer patients. xx. Outline an appropriate follow-up schedule for patients who have undergone: 1. Treatment of breast cancer with curative intent 2. Treatment of DCIS 3. Biopsy which revealed fibroadenomas, benign epithelial hyperplasia or fibrocystic disease with atypia

c. SYSTEM-BASED AND PRACTICE-BASED LEARNING AND IMPROVEMENT OBJECTIVES Improvement Objectives

Building on any experience gained during a PGY-1 and PGY-3 surgery rotations, the resident will participate in a multi-disciplinary environment, including weekly breast conference, and achieve the following objectives: a) Acquire knowledge and experience in diagnostic and therapeutic resources in the management of breast disease, especially breast cancer b) Review of therapeutic alternatives, and selection of most clinically and cost-effective

treatment plan for patients c) Use of ancillary resources in managing the physical and emotional issues faced by patients with breast cancer d) Gain a greater understanding of the effectiveness of various treatments and follow patient outcomes e) Further develop continuity of care skills in management of breast disease d. COMMUNICATION AND INTERPERSONAL SKILLS OBJECTIVES The resident will further develop communication and interpersonal skills acquired at PGY-1 – PGY 3 levels and apply them specifically to the patient and their families dealing with breast disease especially cancer, achieving the following objectives:

a) Engage the patient as a vital part of treatment decisions at all steps b) Communicate a diagnostic plan to a new patient presenting with a breast lesion in a clear

manner, answering all questions, and allaying patient fear and anxiety c) Communicate a diagnosis of breast cancer to the patient and their family or support in a clear,

forthright manner, acknowledging and helping the patient cope with fear and anxiety associated with the diagnosis

d) Communicate a treatment plan and treatment alternatives to a patient with breast cancer using clear, non-technical language, and evaluating patient comprehension of the information

e) Communicate with colleagues and members of the interdisciplinary team to effectively and safely coordinate the care of the patient f) Communicate with patient’s family members, especially counseling family members regarding

treatment/diagnosis in cases of suspected hereditary or genetic-based carcinoma and its implications for screening/management

e. PROFESSIONAL OBJECTIVES: The resident will further develop professional skills acquired at the PZGY -1- PGY-3 level in interactions

with patients and their families dealing with the physical and emotional challenges of breast disease, achieving the following objectives: a) Demonstrate conduct, demeanor and appearance that presents a confident, reassuring

professional image to the patient and their family b) Confer with colleagues and other team members to identify the most appropriate therapeutic

alternatives c) Present viable treatment alternatives guided by the patient’s needs and in their best interest and if exceeds their own knowledge or skill, direct the patient to appropriate personnel or

facilities d) Identify areas for improvement in knowledge or skill in managing breast disease, and effect a

self-improvement plan to address these

VASCULAR SURGERY

EDUCATIONAL GOALS

At the time of completion of this rotation, the resident will be able to:

4. Evaluate patients for vascular disease. 5. Perform the preoperative assessment and postoperative care of patients undergoing major vascular procedures. 6. Understand the fundamental principles of the management of chronic and acute arterial and venous disease.

EDUCATIONAL OBJECTIVES

Patient Care Skills

PGY 1

9. Evaluate patients for vascular disease. 10. Demonstrate competence in basic surgical techniques, including:

a. Knot-tying b. Exposure and Reaction

11. Participate in amputations with specific attention to demarcation levels. 12. Demonstrate proficiency in venous access procedures. 13. Perform Preoperative assessment and postoperative care of patients undergoing major undergoing major

vascular procedures.

Medical Knowledge

PGY 1

1. Describe human arterial and venous and related regional anatomy. 2. Describe basic arterial and venous hemodynamics. 3. Discuss the anatomy, pathology, and pathophysiology of the arterial wall. 4. Assess patients’ vascular systems using appropriate skills in history-taking and clinical exam. 5. Describe life-threatening signs of vascular disease and indicate when immediate intervention is required. 6. Differentiate between the following diagnostic tools available for assessing vascular disease and explain the

relative contribution of each a. Angiography b. Computed axial tomographic scanning c. Ultrasound d. Magnetic resonance imaging

7. Summarize the pathophysiology, clinical manifestations, and therapeutic option of specific categories. a. Venous disease

i. Thromboembolic disease ii. Pulmonary embolism

b. Arterial disease i. Atherosclerosis and its related disorders

ii. Occlusive disease iii. Aneurysmal disease

8. Discuss basic principles of Doppler ultrasound for performing bedside arterial and venous Doppler testing.

9. Outline the principles of noninvasive laboratory diagnosis, including a description of the role and limitations of the vascular laboratory.

a. ABI/ waveforms b. Carotid duplex c. Venous duplex d. PPG/LRR venous e. Graft flow studies

10. Outline the principles of care for ischemic limbs 11. Summarize principles for the preoperative assessment and post-operative care of patients undergoing major

vascular surgical procedures. 12. Outline the fundamental elements of non-operative care of the vascular patient, including the role of risk

assessment and preventative measures. 13. Describe the hemodynamics and pathophysiology of specific clinical symptoms:

a. Claudication b. Transient ischemic attack TIA c. Stroke d. Mesenteric angina e. Angina pectoris f. Renovascular hyperextension g. Arteriovenous fistula

14. Explain the concept of critical arterial stenosis 15. Differentiate between acute arterial and acute deep venous occlusion 16. Determine a plan for assessment of operative risk in these categories

a. Cardiac b. Pulmonary c. Renal d. Metabolic e. Levels of anesthetic risk

Interpersonal Communication Skill

In patients with vascular disease:

1. Be able to create and sustain a therapeutic and ethically sound relationship with patients and their families 2. Use effective listening skills 3. Provide information to patients using effective nonverbal, explanatory, questioning, and writing techniques. 4. Work effectively with other members of the health care team 5. Be prepared to describe an acceptable method to handle the following example interactions.

a. patient’s referring doctor has told patient that his aortic aneurysm is a “time bomb” but in fact it is too small to offer repair. b. patient’s family refuses to assume at home care after operation, but refuses to allow patient to be transferred to a long term care facility.

Professionalism While caring for patients with vascular disease:

1. Demonstrate respect, compassion, and integrity.

2. Demonstrate responsiveness to the needs of patients and society and supersedes self-interest. 3. Demonstrate accountability to patients, society, and profession in surgery. 4. Demonstrate a commitment to excellence and on-going professional development 5. Demonstrate a commitment to ethical principles pertaining to provision of or withholding of clinical care. 6. Maintain confidentiality of patient information. 7. Be able to obtain informed consent for planned interventions 8. Demonstrate sensitivity and responsiveness to patient’s culture, age, gender, and disabilities. 9. Be prepared to discuss the professional and ethical principles with respect to the following example situations.

a. patient with lower extremity claudication who refuses to stop smoking, but demands intervention. b. role of carotid angioplasty in the management of carotid artery disease.

Practice-based Learning For patients with vascular disease 1. Develop a method to record and track over time the results of intervention performed by the resident 2. Be involved in the teaching of students and more junior residents and colleagues 3. Present patients for discussion during rounds and seminars, with appropriate literature references to

support planned intervention 4. Understand the role of study design and the use/misuse of statistical analysis in review the results of

published research in the surgical field. 5. Demonstrate the ability to use information systems to obtain pertinent information regarding surgical issues

and problems. 6. Use information technology to manage and provide patient related information. 7. Be prepared to describe how to obtain relevant information to support System-based Practice For patients with vascular disease: 1. Review critical factors for decision making in vascular surgery

a. Risk: Reward Ratio b. Morbidity and mortality probability c. Preoperative and postoperative assessment d. Noninvasive laboratories, duplex scanning e. Role of advanced radiologic techniques: angioplasty, CT scanning, MRI/MRA

2. Apply the decision making process in analyzing complex vascular diseases including the following: a. Cerebrovascular problems b. Mesenteric vascular disease c. Renovascular disease d. Aneurysmal disease e. Venous disease

3. Understand the role of a tertiary referral center in the surgical management of simple and complex problems.

4. Practice cost-effect health care and resource allocation, specifically reducing the use of unnecessary preoperative and postoperative screening and/ or testing.

5. Practice cost-effect health care that does not compromise patient care. 6. Understand the responsibility of the surgeon in managing indigent patients. 7. Direct patients and their families towards individuals within the institution that can help them with

understanding complex issues of societal support and resources. 8. Understand an awareness of the role of health care managers and surgeon extenders in the surgical

management of patients. 9. Advocate for quality patient surgical care 10. Explain the risk reward ratios of surgical care for patients with vascular disease 11. Be prepared to discuss the interplay of the competing societal and patient needs in the following example

situations: a. Routine renal artery arteriography in patients undergoing cardiac catheterization

b. Serial screening carotid duplex ultrasound for all patients at risk of having systematic atherosclerosis.

OCULOPLASTIC ROTATION

Oculoplastic Learning Objectives:

1. The resident will communicate the indications for operations they observe to our group in a 15 minute presentation. PC, K, C

2. The resident will be able to distinguish appropriate ways to establish the diagnosis of diseases that present to the oculoplastic surgeon. PC, K

3. The resident will be able to describe the workup and develop a treatment plan for common periorbital soft tissue problems. PC, K

4. The resident will be able to describe the TNM classification systems for periorbital cancers. K 5. The resident will develop an understanding of common surgical approaches to the periorbital problems.

PC, K 6. The resident will successfully describe all aspects of periorbital anatomy. K

UNIVERSITY OF NEW MEXICO

DEPARTMENT OF ANESTHESIOLOGY

AND CRITICAL CARE MEDICINE

Overall Goals and Objectives

Educational Goals:

The UNM Department of Anesthesiology maintains the highest standards for the practice of anesthesiology. Residents who complete training within our department will be able to manage life-threatening situations in an independent and timely fashion with empathy for their patients. Residents in the UNM Department of Anesthesiology will be exposed to all facets of the modern practice of anesthesiology. This practice will be taught to residents and they will be evaluated within the context of the six core competencies in anesthesiology including:

Patient Care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health.

Medical Knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. 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. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, and the ability to effectively call on system resources to provide care that is of optimal value.

Educational Objectives: 1. Acquire the ability to assess, consult, and prepare patients for anesthesia. 2. Learn expertise in the relief and prevention of pain during and following surgical, obstetric, therapeutic and diagnostic

procedures. 3. Ensure adequate and appropriate monitoring and maintenance of normal physiology during the perioperative period. 4. Learn how to assess and treat critically ill patients. 5. Learn the diagnosis and treatment of acute, chronic and cancer related pain. 6. Acquire certification in Advanced Cardiac Life Support and learn the ability to manage cardiac and pulmonary resuscitation. 7. Learn how to use accessory anesthetic devices and interpretation of anesthetic monitors 8. Learn the evaluation of respiratory function and the application of respiratory therapy. 9. Participate in the teaching of both medical and paramedical personnel involved in perioperative care. 10. Participate in health care administration and medical education.

PGY 2

Knowledge:

• Understand many of the aspects involved in neuroanesthesia, vascular anesthesia, orthopedic anesthesia, obstetrical anesthesia and ambulatory anesthesia.

• Accurately interpret and utilize information from arterial and central venous catheters. • Understand the design and functioning of anesthesia equipment and machines.

Skills:

• Maintain an airway during general anesthesia by face mask. • Perform laryngoscopy and oral and nasal intubation in patients with uncomplicated airways independently with oversight. • Perform airway management of patients with complicated airways with assistance and oversight. • Perform fiberoptic intubations with assistance and oversight. • Perform arterial cannulation, including setting up of transducers and lines and calibration of monitors. • Perform central venous cannulation (brachial, external jugular, internal jugular or subclavian) with assistance. • Perform technical aspects of spinal anesthesia in uncomplicated patients independently with oversight. • Perform technical aspects of lumbar epidural anesthesia in uncomplicated patients independently with oversight. • Learn the basic usage of the ultrasound machine as an effective adjunct in line placements and regional blocks • Perform or participate in at least three different types of regional anesthesia blocks (other than spinal and lumbar epidural

blocks) with assistance and oversight. • Placement of intravenous catheters with aid of ultrasound guidance.

Performance:

• Evaluate and present to an attending anesthesiologist, in a concise manner including all important pre-anesthetic factors and problems, all cases involving adult patients, with the exception of neurosurgical and cardiothoracic cases.

• Formulate and describe in detail a plan including a list of likely problems and possible solutions for the anesthetic management of all adult patients, with the exception of cardiothoracic and neurosurgical cases.

• Provide general, regional, spinal, or epidural anesthesia with minimal assistance for PS I to III patients. • Formulate an airway management plan for patients with difficult airways. • Evaluate patients in the post anesthesia care unit and manage respiratory, hemodynamic, fluid and pain issues with

assistance. • Evaluate patients with uncomplicated acute pain symptoms and provide a basic treatment plan. • Explain the rationale for all drugs and procedures used.

SECTION OF PLASTIC SURGERY RESIDENT TRAVEL POLICY for CME Prior Authorization Prior to incurring any professional development travel expenses for courses or conferences, a resident must receive approval from the Residency Program Director. Purpose and Scope The purpose of the policy is to: v Set policy and provide guidelines of the requirements for requesting time away

for conferences and courses, and obtaining reimbursement to Plastic Surgery Residents for professional development related travel expenses.

v Provide a mechanism for residents to submit for reimbursement approved Travel expenses that meets IRS requirements.

It is the intent that this policy comply with all relevant regulatory requirement. POLICY OVERVIEW Residents traveling on CME/Business for the Section of Plastic Surgery will Be reimbursed by the Section as indicated in this protocol. If you have been accepted for a podium presentation, there is the potential for additional funding for meeting attendance from Divisional or Departmental funds. It is the expectation of the Division that you will be economical when deciding upon Accommodations for travel and lodging. As such, reimbursement will be made for coach airfares only. You are encouraged to use any and all discount fares whenever possible. In addition, once your travel has been arranged, expenses incurred to make changes to your itinerary will be at our expense as these can be costly. Of course if there is an emergency which requires the change, the appropriation may be approved. To be sure such costs are covered, you need approval from the Division Chief in advance. When incurring a reimbursable expense on behalf of the Division of Plastic Surgery, the resident is responsible for requesting the reimbursement, which is properly documented Authorized by the residency program director, including original receipts, and submitted timely. This policy ex plains what type of expense is reimbursable and the reimbursement process.

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REIMBURSABLE EXPENSES Professional development related travel and meals will be reimbursed if they are Reasonable, appropriately documented, submit original itemized receipts and are Properly authorized, and may include: v Mileage for private auto and parking fees. v Airfare v Ground Transportation (taxi, train, bus, etc.) v Lodging v Any incidental charges or meals will be reimbursed at a maximum per diem v

allowance rate of $50.00 per day (itemized receipts required). v Registration fees for event/conference NON-REIMBURSABLE EXPENSES: UNM and Department of Surgery Policy specifies that the following items are considered non-reimbursable travel related expenses (additional restrictions may apply depending on funding sources): v Airline seating upgrades to first class v Air phone calls v Airline WiFi v Air phone calls v Charter airfare, limousines and rental cars (unless determined in advance to be

Essential for the accomplishment of the mission for which traveling.

v Hotel recreational activities (e.g. spas, athletic facilities) v Hotel room movies and/or videos v Expenses related to vacation or personal days taken before, during or after a trip. v Expenditures of a personal nature v Expenditures for family members v Any expense that has been or will be reimbursed from any outside sources

The resident will be responsible for all non-reimbursable expenses incurred while traveling

PROCEDURES Mileage Rate Reimbursement When the use of a personal automobile is necessary, reimbursement for its use will be made using the Federal government mileage rate per mile and within IRS guidelines. The reimbursement rate is announced annually (generally in January) and covers the resident’s use of their vehicle and gasoline. The most current rate can be found on the IRS Website or within the eTravel program at www.concursolutions.com Only actual miles in excess of the resident’s normal commute are eligible for reimbursement. Mileage from the resident’s home to normal office site is commuting cost, and not reimbursable.

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In addition to the mileage rate reimbursement, a resident may be reimbursed for tolls and parking. A resident will not be reimbursed for the following, even if these costs are incurred during business travel:

v Car repair v Rental car costs during repair of personal car v Towing charges v Tickets, fines, or traffic violations v Gasoline or vehicle maintenance

RECEIPTS AND DOCUMENTATION Receipts, must be original and include the vendor name, location, date and expense detail. Any foreign currency expense amounts should ve converted to US Dollars. It is The resident’s responsibility to retain and submit original receipts for all expenditures Regardless of amount and under no circumstances should the resident be reimbursed more than once for the same expense. ACCEPTABLE DOCUMENTATION INCLUDES: **Original Itemized Receipt** Photocopies of credit card charge slips or billing statements are not sufficient

documentation, nor tear-off stubs for meals. In the case of airfare, resident’s must submit their boarding pass(es). Travel itineraries do not constitute receipts for reimbursement purposes.

HOW TO BE REIMBURSED Once the expense has been incurred, it is the resident’s responsibility to retain and submit original receipts (faxes are not accepted). Submit all original receipts to Catherine Castillo. Receipts must be itemized and show payment in full to be eligible for reimbursement. It is the resident’s responsibility to turn in all expense reimbursements within 30-days in order to receive reimbursement for business related expenses. Rental cars are considered special accommodations and will not be a reimbursable expense unless determined to be essential for the accomplishment of the mission for which traveling. A special request must be submitted to Catherine Castillo to submit to the Chief to make a determination. **Please note that if you elect to make side trips to other cities on your way to or from a business travel location you will have to pay the difference in airfare and lodging costs. Lastly, and of particular IF you submit your registration to a conference late, the Division will Not cover the cost of the late registration fee – this will be up to you to pay.

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Department of Surgery Resident Business Travel, Meals, and Entertainment Policy

**This policy relates to Department of Surgery funding for poster or oral presentations

I. PURPOSE and SCOPE

The purpose of the policy is to:

• Set policy and provide guidelines of the requirements for reimbursement to Department of Surgery Residents for professional development related travel expenses to present a poster or an oral presentation at regional or national scientific meetings.

• Provide Travel Expense forms which residents will use in order to receive reimbursement for approved travel expenses that meet IRS requirements.

The primary responsibly for compliance with these policies rests with the departments and divisional residency program directions who are authorizing travel and approving expense reimbursements. Residents requesting reimbursement should also keep in mind that government agencies and other observers may perceive certain expenditures as being either excessive or inappropriate.

It is the intent that this policy comply with all relevant regulatory requirements.

II. POLICY OVERVIEW

For and academic year, the Department of Surgery will Contribute $30,000 total to reimburse reasonable travel expenses for residents presenting a poster or an oral presentation. To be sure that a reasonable number of residents have an opportunity to do this, the total per resident per year amount will be limited to $1,200 and once the $30,000 overall total is reached, any additional requests for reimbursement will have to be covered by individual program/section academic enhancement funds.

NOTE: We will be sure to let all of you know when this total has been accumulated.

During the normal course of business activity, a resident may attend regional or national meetings with the intention of presenting a poster or an oral presentation (only one person can be reimbursed per poster/ oral presentation, usually the presenter or first author) and may incur expenses of a maximum of $1,200 per resident per academic year that can be reimbursed from the department of Surgery when all other external funding sources have been exhausted. The resident should pay for these expenses with personal funds and request a reimbursement at a maximum of $1,200. When incurring a reimbursable expense on behalf of the department of surgery, the resident is responsible for requesting the reimbursement, which is properly documented, authorized by the sectional residency program director, including original receipts, and submitted timely. This policy explains what type of expense is reimbursable and the reimbursement process.

A resident MUST submit all requests in advance through their Program Director to the Department of Surgery for their approval. See below for process under procedures.

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III. DEFINITIONS

Reimbursable Expenses: professional development related travel and meals will be paid by the Department of Surgery at a Maximum of $1,200 if they are reasonable, appropriately documented, submits original receipts, and properly authorized and may include:

• Airfare coach class • Ground transportation (taxis only, no limos) • Lodging • Meals – as part of travel • Personal mileage • Parking/tolls • Registration fees for event/conference

See “Non-reimbursable Expenses” below for those travel expenses that are specifically identified by the Depart of Surgery policy as ineligible for reimbursement. Expenses for alcohol are not reimbursed.

Non-Reimbursable expenses: UNM and the department of surgery policy specify that the following items are considered non-reimbursable travel related expenses (additional restrictions may apply depending on funding source):

• Airline seating upgrades to first or business class • Air phone calls

• Alcohol • Hotel Recreational Activities (e.g. spas, athletic facilities, etc.) • Hotel room video rentals • Expenses related to vacation or personal days taken before, during, or after trip • Expenditures of personal nature • Expenditures for family members • Any expenses that has been or will be reimbursed from any outside sources

A resident will be responsible for all non-reimbursable expenses incurred while travelling.

IV. PROCUDURES

Before incurring any Business Expense

Prior to incurring any professional development travel expenses, a resident must receive approval from the sectional Residency Program Director. The Travel Authorization Request Form should be completed for this purpose.

To Reserve Funds

A resident MUST submit a request in advance through their Program Director to the Department of Surgery for approval. (Please work with Catherine to work p a proposal and a budget). Once the approval is received from the Program Director, resident will submit a detailed budget and copy of letter of invitation/confirmation of presentation to the Department of Surgery for their approval. Once the submission has been approved, the Department of Surgery will notify the resident, Program Director, and Program Coordinator of approval.

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Mileage Rate reimbursement

When the use of a personal automobile is necessary, reimbursement for its use will be made using the Federal government mile rate per mile and within IRS guidelines. The reimbursement rate is announced annually (generally in January) and covers the residents use of their vehicle and gasoline. The most current rate is indicated on the current Reimbursement Request Form. It is the responsibility of the resident to carry adequate insurance.

Only actual miles in excess of the resident’s normal commute are eligible for reimbursement. Mileage from the resident’s home to normal office site is commuting cost, and not reimbursable.

In addition to the mileage rate reimbursement, a resident may be reimbursed for tolls and parking.

A resident will NOT be reimbursed for the following, even if these costs are incurred during business travel:

• Car repair • Rental car costs during repair of personal car • Towing charges • Tickets, fines, or traffic violations • Gasoline or vehicle maintenance

Receipts and Documentation

Receipts must be original and include the vendor name, location, date, and expense detail. Any foreign currency expense amounts should be converted to US Dollars.

It is the resident’s responsibility to retain and submit original receipts for all expenditures regardless of amount, and under no circumstances should the resident be reimbursed more than once for the same expense.

Acceptable Documentation Includes:

**Original Receipt

Photocopies of credit card charge slips or billing statement are not sufficient documentation, nor are tear-off stubs for meals. In the case of airfare, resident’s must submit their boarding pass(es). Travel itineraries do not constitute receipts for reimbursement purposes.

How to be reimbursed Gather Documentation Once the expense has been incurred, it is the resident’s responsibility to retain and submit original receipts (faxes are not accepted) at the completion of their trip. (Reimbursement will not be processed prior to the completion of the trip)

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Obtain the Reimbursement Request Form To fill out the form accurately the following must be completed:

• Resident/Vendor • Complete Mailing Address • Purpose/Description

o Who incurred the expense o What the expense entailed o When and where this occurred

• Dollar Amounts/Original Receipts • All Appropriate Expenditure Codes (Account, Site, Department etc., ) • Amount due Resident • Resident (Reimbursee) Signature/Date • Residency Program Director’s Approval Signature/Date

It is the resident’s responsibility to process all expense reimbursements within 30-days in order to receive reimbursement for business related expenses. Expenses should be entered on the applicable lines of the form which best describe the type of expenses incurred.

Submit Forms/Documentation

Submit completed and approved forms along with supporting documentation to Financial Manager in the Department of Surgery.

Inaccurate or incomplete forms will be returned to the resident

DIDACTIC FRIDAY

Indications Conference (weekly, mandatory)

Each Friday will be our dedicated educational morning. Indications conference that covers interesting cases for the upcoming week will be conducted. A list of the scheduled cases is circulated the Monday prior. This conference will be chaired by the Chief or Senior resident who organizes assignments and prepares cases for discussion. This conference focuses on developing competencies in 1) patient care, 2) medical knowledge and 3) practice-based learning and improvement.

Core Curriculum (weekly, mandatory)

Interactive didactic sessions (corequest) are held each Friday. During the course of the academic year, the entire curriculum of Plastic Surgery is covered. An attending or invited faculty from outside of the section is assigned a topic. S/he prepares a series of questions and relevant cases which are provided for the residents at least one week in advance of the conference. The residents are expected to come to the conference prepared to discuss the topic. Each resident is assigned a grade based on the thoroughness of their preparation and their responses. This conference focuses on developing the Medical Knowledge competency Life-Long Learning Laboratory (monthly, mandatory)

The 1st Friday of each month is Life Long Learning Lab. Each session is led by an assigned faculty or resident who selects an area to discuss in some detail. This provides an opportunity for each participant to showcase a recent or ongoing true life example of their own personal life long learning. This conference focuses on developing the Medical Knowledge, Professionalism and Practice-based Learning and Improvement competencies. Practice Based Learning & Improvement Conference (monthly, mandatory) The 3rd Friday of each month is Practice Based Learning & Improvement. The topics are variable and include topics such as morbidity rounds, sentinel events, clinical research and long term follow-up of the year’s cases. For example, reviewing our implant based breast reconstruction cases utilizing before and after photographs and operative details to brainstorm “best practices” for our department. We will also utilize this conference to

brainstorm “system” improvement opportunities for achieving a high compliance rate with recommended perioperative antibiotic use, correct site surgery and appropriate DVT prophylaxis. This conference presents an opportunity to reflect on actual clinical practice through single case reports or systematic review of a case series . This conference focuses on developing the Practice-based Learning and Improvement, Systems Based Practice and Professionalism competencies. Quality Improvement Projects (monthly, optional)

Quality improvement projects will be initiated throughout the year. This provides a learning opportunity for the resident to bring together an interdisciplinary team of individuals from within the division and from outside the division. The resident’s role may be as a team participant or as a team leader. The team is held accountable and reports during monthly Section Meeting on their progress and recommendations. In this way, there is department-wide “buy-in” to the recommendations made by the improvement project team. This exercise focuses on the competencies of 1) interpersonal and communication skills, 2) practice based learning and improvement and 3) systems based practice. Journal Club (monthly, mandatory)

Each resident selects 1 article to discuss in detail. The selected articles are circulated electronically, in advance of the conference, to all attending physicians and residents. Journal articles are critiqued using a “quality of evidence” and “usefulness in practice” rating scale. As time permits, questions from previous In-service exams, relevant to the journal articles, are reviewed or difficult cases presented using power point. This conference focuses on developing the Medical Knowledge and Practice-based Learning and Improvement competencies.

Section Meeting Conference (monthly, mandatory)

The fourth Friday of each month is Section Meeting. This is a team meeting with all medical and support staff from within the section attending. This meeting is chaired by the division chief. Improvement projects and team building are the focus of this monthly conference, giving the residents learning opportunities for the competencies of 1) interpersonal and communication skills, 2) practice based learning and improvement and 3) systems based practice.

CLINICAL RESPONSIBILITY POLICY

Inpatient Rounds and Consults The resident team is responsible for twice daily rounds on inpatients with accurate and timely documentation in the EMR. The team is also responsible for timely completion of discharge summaries. The resident on-call is responsible for responding to inpatient consults that are requested during the period when they are on-call. Typically, consults are called via the pager. If a nurse, midlevel provider or secretary receives the request for consultation, they will notify the on-call resident. If it is an outpatient request they will triage it to an available clinic appointment the same day, or discuss it with the on-call attending to determine the best disposition. Residents will review all consults with the attending on-call, document the evaluation and recommendations and communicate these to the requesting service either verbally or electronically.

Clinic Schedules Residents will be exposed to diverse outpatient clinic experience with graded responsibilities. Residents will begin by observing attendings during patient sessions, and as they gain skills they will be responsible for conducting independent sessions with oversight. During the PGY 4 year residents will be assigned a weekly shadow clinic by the program director or chief resident. Each resident must choose and keep track of 4 patients seen in pre-op consultation until post-operative care is finalized. You will need to devise a system to keep track of these patients. It will be the resident’s responsibility for presenting your experie4nce with long term patient encounters in a presentation at the end of the year. The independent resident clinics will include a variety of new patients as well as follow-up patients. If for any reason a senior resident is not able to be in a scheduled clinic, they must notify the residency coordinator immediately so that patients can be rescheduled. Emergency Department Coverage It is also very important that all ED patient interactions be documented into the EMR since no patient records are sent to the division. Having Ed notes in the EMR will greatly benefit other providers and improve continuity of care for patients. The on-call resident is responsible for responding to to ED call and questions. It is expected that the on-call resident will provide prompt and thorough care to patients in the ED under the supervision of the on-call attending (indirect supervision directly available with escalation to direct supervision as indicated by the case and resident level of training). The resident on-call is responsible for completion of all necessary documentation efficiently and appropriately. When arranging for clinic follow-up of patients seen or discussed by phone with the ED staff, the division office staff must be notified by email of patient’s name, MR# (or DOB), contact phone number, diagnosis, attending responsible, appropriate date range and length for the appointment.

SERVICE EXPECTATIONS

- Rounds completed on time to be available for preoperative assessment and markings - Communication with attendings (either resident or midlevel provider), starting at 7am, on all of their patients,

either by text, phone call, or direct contact - All consultations should be staffed by a plastic surgery resident, unless he or she is involved in an index case

or on night or weekends when not on call - All primary patients and free flaps should be seen at least twice daily - Plastic surgery residents are expected to cover primary patients and consultations until 6 pm Mon-Fri and

weekends on call - If workday finishes early and plastic surgery resident is going home, he or she must touch-base with midlevel

providers (if they are still present)

Documents

RESIDENT ORIENTATION HANDBOOK 2017-18 - PBworks