Vascular Thoracic PGY 5

Length of Goals: 3 Months
Supervisor: Afshin M Molkara, MD
Contact Information: (951) 486-4175, amolkara@co.riverside.ca.us

Goals

Riverside County Regional Medical Center will provide a learning environment for the PGY-5 resident to develop cognitive and technical skills in management of complex surgical diseases of vascular and thoracic systems.   Clinically, residents will assess surgical pathology pre-operatively, develop clinical judgment on managing these issues, and learn operative skills to address the problem.  Careful postoperative care and follow up will be emphasized.  Residents will develop cognitive and technical skills in dealing with complex gastrointestinal pathology.

Objectives

Medical Knowledge

• Describe human arterial and venous anatomy.
• Describe basic arterial and venous hemodynamics.
• Discuss the anatomy, pathology, and pathophysiology of the arterial wall.
• Review and describe the basic clinical manifestations of the following vascular disorders:
  • Obstructive arterial disease
  • Aneurysmal arterial disease
  • Thromboembolic disease--arterial and venous
  • Chronic venous insufficiency and lymphatic obstruction
  • Portal hypertension
  • Congenital vascular disease
• Assess patients' vascular systems using appropriate skills in history-taking and clinical
• Discuss basic principles of Doppler ultrasound in preparation for performing bedside arterial and venous Doppler testing.
• Outline the principles of care for ischemic limbs.
• Describe the natural history of medically treated vascular disease in the following categories:
  • Carotid arterial stenosis
  • Abdominal aortic aneurysm
  • Chronic femoral artery occlusion
• Summarize principles for the preoperative assessment and postoperative care of patients
• undergoing major vascular surgical procedures.
• Outline the fundamental elements of non-operative care of the vascular patient,
• including the role of risk assessment and preventive measures.
• Indicate the role of anticoagulant agents, including anti-platelet agents, in the management of patients with vascular disease.
• Analyze the role of the endothelium in atherosclerosis, thrombosis, and thrombolysis.
• Describe the hemodynamics and pathophysiology of:
  • Claudication
  • Transient ischemic attack (TIA)
  • Stroke
  • Mesenteric angina
  • Angina pectoris
  • Renovascular hypertension
  • Arteriovenous (AV) fistula
• Explain the concept of critical arterial stenosis.
• Differentiate between acute arterial and acute deep venous occlusion.
• Discuss the principles of angiography to include the following considerations:
  • Indications and complications (including contrast-induced renal failure)
  • Principles and techniques of intra-operative angiography
  • Principles and techniques of emergency room angiography
• Discuss the principles of and contraindications for anticoagulation and thrombolytic therapy.
• Describe the surgically correctable causes of hypertension and their diagnostic modalities.
• Explain the risk: reward ratios of surgical care for patients with vascular disease.
• Discuss the mechanics of action and the therapeutic role of the following pharmacologic types of agents:
  • Vasopressors
  • Vasodilators
  • Adrenergic blocking agents
  • Anticoagulants
  • Antiplatelet agents
  • Thrombolytics
• Illustrate the general principles of vascular surgical technique including:
  • Vascular control and suturing
  • Endarterectomy
  • Angioplasty
  • Bypass grafting
• Determine a plan for assessment of operative risk in these categories:
  • Cardiac
  • Metabolic
  • Pulmonary
  • Levels of anesthetic risk
  • Renal
• Discuss clotting factors and how they interact (coagulation cascade).
• Discuss the role of the following factors in maintaining homeostasis in the coagulation
• pathways:
  • Protein S
  • Platelet granules
  • Protein C
  • Endothelial cell
  • Platelets
  • Antithrombin III
• Describe the use of adjunctive measures in the management of patients with vascular disease such as:
  • Antibiotics
  • Thrombolytic agents
  • Anticoagulants
  • Antiplatelet agents
• Name segments of right and left lung.
• Describe the location of mediastinal lymph nodes.
• Describe perfusion and ventilation mechanics of the lung.
• Describe pathophysiology of empyema formation.
• Explain different types of lung interstitial diseases.
• Explain staging system for lung cancer.

Assessment

• Oral exam at the clinical case conference.
• End of the rotation evaluation.
• Annually at the in-training examination

Patient Care

• Is able to examine, correctly make a diagnosis and provide treatment plan for a patient presenting with chronic limb ischemia.
• Can perform embolectomy in patients with acute limb ischemia.
• Is able to obtain a complete PAD risk factor history and make risk modifications changes.
• Is able to use doppler ultrasound to identify and image arterial and venous images.
• Performs vascular anastomosis well.
• Is able to provide exposure in difficult cases.
• Places and manages chest tubes effectively.
• Performs Video assisted thoracoscopy and is able to identify lung segments and lobes.
• Is able to manage diabetic foot infection.

Assessment

• Patient care and technical skills will be assessed by the attending surgeon on a daily basis.
• Resident performance will be discuss on a mid rotation informal evaluation and during the end of the rotation evaluation.

Professionalism

• Leads all surgical services as the chief resident.
• Assigns cases to the students and residents appropriately.
• Coordinates tumor board and morbidity/mortality conferences.
• Coordinates all surgical clinic assignments of residents and students.
• Is able to complete resident monthly call schedule.
• Complete the Professionalism in Surgery curriculum for the current month.
• Resident must obtain a copy of the ACS DVD “Professionalism in Surgery: Challenges and Choices” and review the curriculum on professionalism established for the months of rotation:

Assessment

• Residents will complete a one page discussion of the vignette including lessons learned. This document will be added to the resident’s portfolio
• Residents will participate in one of two grand rounds on professionalism schedule for the second week of December and June. During these grand rounds residents will make a presentation of a case in which they applied lessons learned on professionalism in surgery.  The presentation and its content will be assessed by the faculty present.

Systems-Based Practice

• Demonstrates firm understanding of wastes and costs involved with certain procedures and tests.
• Is actively involved with the unit managers in facilitating the flow of patients from ED and ICU to Step-Down units and surgical floors.
• Complete the Systems Based Practice curriculum for the current month
• Obtain from the residency office the ACS CD-ROM on “The Practice Management Course for Residents and Young Surgeons”.

• Volume 1 is designed to educate and equip residents with the knowledge to manage their personal surgical future with a focus on issues such as: how to select a career in private practices I and II and Coding for Surgical Residents I and II
• Volume 2 is designed to educate and equip residents with the knowledge to manage their personal surgical future with a focus on issues such as: surgical financial management reports I and II, organizing a surgical practice, and understanding insurance processing
• Volume 3 is designed to educate and equip residents with the knowledge to manage their personal surgical future with a focus on issues such as: accumulation planning, goal planning and risk management, negotiation, and changing the liability equation

Assessment

• Resident will be required to complete the CME credits by the American College of Surgeons.  4.5 credits for Volume 1, 3.5 hours for volume 2 and 3.5 hours for volume 3.
• Residents will be assessed on their leadership skills during the end of the rotation evaluation.

Practice-Based Learning & Improvement

• Is able to learn from his or her mistakes
• Is able to discuss alternative plans to approach same surgical issue
• During this rotation the resident will complete a personal learning project  (PLP)

Assessment

• The completed PLP will be added to the resident’s electronic portfolio and presented at Grand Rounds.  Faculty present will assess the PLP presentation.
• Weekly performance and attendance at conferences
• Weekly performance on Attending rounds
• End of rotation evaluation

Interpersonal & Communication Skills

• Plans future cases effectively with attendings
• Signs out patients to on call attending
• Does effective rounds and communicates patients daily care plan with surgical unit manager
• Communicates in advance with the site coordinator and the residents to maintain compliance with 80 hour work rule
• Complete the Interpersonal and Communications Skills curriculum for the quarter.

Assessment

• Residents are required to write a one page summary describing the cases selected for each topic.
• During May grand round, the resident’s summaries will be distributed among the faculty. Chief residents will present a selected case and will also be prepared to answer questions from faculty about any other example in their summaries.
• Faculty will complete an evaluation of the resident’s presentation.
• 360? evaluation by nurses, residents and students
• End of rotation evaluation.

Conference Attendance: Conference attendance is mandatory at the hospital in which you are rotating. The Clinical Case Conference is required for all PGY 3 - 5 residents and is held at RCRMC, if you are at another hospital, you are released from your duties to attend this lecture series. All residents attend Wednesday Educational Day conferences at RCRMC.