Department of Surgery

Cardiothoracic Surgery Residency Program

Cardiothoracic Surgery Residency

Educational Goals and Strategies

Resident Assignments (Rotations)

Educational Goals and Strategies

A. General Goals and Objectives
The educational goal of the Division is to prepare surgeons-in-training for the independent practice of thoracic surgery. Independent practice implies the capability to take responsibility for all aspects of the care of the patient before and after operation, in the hospital and in ambulatory care settings. Thoracic surgeons tend to focus their practices on one or more of the subdivisions of the specialty. A corollary goal, therefore, is to prepare our residents broadly in all areas of the specialty, so that by the end of their training they will be prepared to practice in any of those areas; that is, they will be totipotential in cardiothoracic surgery. The specific educational goals encompass all areas of care of the cardiothoracic patient. They are to impart to the surgeon in training:

1. knowledge of the relevant anatomy and physiology of cardiac, pulmonary, and digestive systems, including interpretation of current literature;

2. facility in assessment of thoracic diseases through clinical examination and laboratory testing to include imaging techniques;

3. judgment regarding the relative roles of all available treatments, both medical and surgical;

4. skill in carrying out indicated surgical procedures for specific thoracic diseases;

5. understanding of normative issues relating to ethics and law in the practice of cardiothoracic surgery;

6. dedication to independent life-long learning as an essential tool to maintain and improve the excellence attained during training.

B. Strategies
Several strategies are used to achieve those goals.

1. Didactic Teaching and Conferences

a. The Comprehensive Thoracic Curriculum published by the Thoracic Surgery Directors Association has been fully implemented in the Division. The curriculum is covered in one-hour sessions scheduled weekly over a three-year period.

b. Several sessions of General Surgical Grand Rounds are attended by cardiothoracic residents, particularly those that discuss cardiothoracic ethical, legal, social, and economic issues in medicine.

c. A recent innovation has been the introduction of a series of lectures for all residents in training at MUSC. These cover areas of common or mutual interest among all physicians and include: Risk Management, End of Life Care, Sexual Harassment, Professionalism, Medicare Compliance, Medical Legal Issues, Evidence Based Medicine, and Hospital Protocols.

d. A journal club is held in the evening once a month, consisting of two hours of discussion of pertinent articles from recent issues of cardiothoracic journals. Both residents and faculty present for discussion the most important articles in that issue. Attendance includes thoracic surgery residents, general surgery residents, attendings, physician assistants, nurse practitioners, perfusionists, and medical students.

e. Several routine weekly one-hour conferences include an adult medical-surgical cardiac catheterization conference, two pediatric medical-surgical cardiac catheterization conferences, thoracic tumor board, a Divisional conference at which all deaths, complications, and unusually interesting cases of the preceding week are discussed.
f. In addition, each resident attends at least one cardiothoracic national meeting each year, at Divisional expense. They attend any other meetings at which they have had an abstract accepted for presentation.

2. Clinical Education

a. Progressively increasing (graded) responsibility for patient care is assigned throughout the three years of residency. In the operating room, each resident starts as an assistant and over time, takes on increasing responsibility for the technical aspects of operating, depending upon previous experience, current operative skill, and the particular demands of a specific operation. On the wards, units, and clinics, the level of supervision of the residents activities is very close at first, and as experience and clinical judgment mature, the resident is given progressively more responsibility for decision making.

b. Daily and frequent contact with attendings in all areas of clinical practice (operating room, wards, intensive care units, thoracic surgical clinics, and conferences), allows not only for transmission of factual information regarding the care of patients, but also absorbing the normative aspects of clinical practice through role modeling by attendings.

3. Published information

a. Independent life-long learning requires the capability to interpret information in journals and books. To this end, each resident is expected to give two hour-long seminars each year on a topic within the general field of cardiothoracic surgery. The presentations are expected to be detailed analyses of a specific area, including slides and other audiovisual materials. They are carried out under the direction of a division faculty member.

b. Toward the same end, residents are encouraged to write one or more scientific papers for publication in the cardiothoracic literature each year. This not only teaches analytic and interpretive skills in reading the surgical literature, but it also provides insight into the process of producing scientific literature, from beginning to end.

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Resident Assignments (Rotations)

The Cardiothoracic Surgical Residency Program is one in which there is a progressive chain of graded responsibility beginning with the first year CT resident and progressing up through the Chief Resident to the Attending Surgeon and ultimately to the Chairman of the Department.

Residents at each level are expected to participate in the teaching of junior residents, students, nurses and ancillary personnel at a level that is appropriate to their own knowledge and abilities. Interaction with peers and ancillary personnel will be maintained at a professional level. Appearance, attire, and behavior with patients, peers, and other personnel must be of the highest professional standards. Communication among members of the cardiothoracic surgical team is critical at all levels. The clinical status of each patient needs to be accurately communicated to superiors at an appropriate level of decision-making, especially when significant changes occur. The cardiothoracic surgical resident at all levels has a major role and responsibility in the education of the junior members of the team including other residents, medical students, and ancillary personnel.

A. Assignment to Clinical Services

Residents are assigned specific rotations throughout their residency. Each rotation focuses on education in specific areas, listed in the accompanying table.

Resident
July-September
October-December
January-March
April-June
Year 1
Pediatric CT
General Thoracic
Adult CT
Adult CT
Year 2
VAMC
Adult CT
Adult CT / 1 month elective
Adult CT
Year 2
Adult CT
Adult CT
VAMC
Adult CT / 1month elective
Year 3
Adult CT
VAMC
Adult CT
VAMC
Pediatric Fellow
Pediatric CT
Pediatric CT
Pediatric CT
Pediatric CT
Visiting Resident
-
-
Pediatric CT
-

B. Goals and Objectives of Specific Rotations

The goals described below are adjusted for individual residents according to their specific talents and skills; the goals should be regarded, therefore, as only approximations of the progression of training for a particular resident. These goals, listed below, are structured to conform with the 6 general competency requirements set forth by the ACGME and TSDA. At all levels of training, residents are expected to participate in teaching younger house officers and medical students, consistent with their own knowledge and experience. Throughout the training of all cardiothoracic residents, an attending surgeon is scrubbed or immediately available for all operations.

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Resident Assignments (Rotations) Year 1

MUH - Pediatric CT Surgery (3 months)

Preoperative and Postoperative Assessment

Preoperative and postoperative assessment and management are carried out by the resident with increasing responsibility, under close supervision by the attending surgeons.

Operative experience

The resident initially assists with the performance of all congenital heart operations, ranging from straight- forward, to more complex operations. The resident is expected to quickly grasp the principles and techniques of arterial and venous cannulation in preparation for cardiopulmonary bypass, as well as how to place patients on bypass and remove them at the end of the procedure. By the end of the rotation he will be expected to be competent in performing bronchoscopy in infants and children, closed procedures (such as pacemaker implantation, division of patent ductus arteriosus and repair of aortic coarctation), and straightforward open procedures (such as repair of secundum, primum and sinus venosus atrial septal defects). He will also be expected to assist in all congenital heart operations including complex open procedures in neonates. During this rotation, the resident will rotate through the regular MUH CT Surgery call schedule and will be expected to become involved with adult CT surgical cases when logistically necessary.

At the completion of this rotation the resident will be able t
Articulate an understanding of the history of congenital heart surgery and describe guidelines for evaluating patients with congenital heart defects.
Describe the fundamental physiologic principles involved in univentricular and biventricular circulations.
Describe the potential anatomic and physiologic implications of congenital heart surgery in infants.

Goals and Objectives

1. Patient Care
Develop and execute appropriate postoperative management in patients who have undergone congenital cardiac surgery, including appropriate ventilator management. Demonstrate technical ability in closed operations including patent ductus ligation, and vascular rings, as well as open operations including secundum, primum and sinus venosus ASD’s. Demonstrate competent assistance for complex neonatal repairs. Appropriately evaluate preoperative echocardiograms and cardiac catheterizations.

2. Medical Knowledge
Be familiar with the history of cardiopulmonary bypass and early operations for congenital heart disease.
Be knowledgeable in the physiology, presentation and evaluation of common congenital heart defects.
Be able to describe the current surgical management of 1 and 2 ventricle congenital heart repairs.

3. Practice Based Learning
Demonstrate ability to practice lifelong learning as manifested by reading the current issues of Annals of Thoracic Surgery and Journal of Thoracic and Cardiovascular Surgery focusing on congenital heart disease.
Use information technology to perform appropriate clinical research.

4. Interpersonal and Communication Skills
Develop skill in the communication of patient care issues with the congenital heart team and use of sensitivity and tact during discussions with patients’ families.

5. Professionalism
Maintain high standards of ethical behavior. Demonstrate sensitivity to the particular issues involved in taking care of pediatric patients

6. Systems-Based Practice
Discuss prenatal diagnosis in the care of patients with congenital heart defects.
Discuss risk-benefit analysis involved in:
a. ligation of a patent ductus arteriosus in an 800gm premature baby in the NICU
b. revision of an atriopulmonary Fontan connection in a 25-year old.
Develop an understanding of the South Carolina Congenital Heart Network.

MUH - General Thoracic Surgery (3 months)

Preoperative and Postoperative Assessment

Preoperative and postoperative assessment and management is carried out by the resident with increasing responsibility, under close supervision by the attending surgeon. The resident is expected to attend the weekly Thoracic Tumor Board in order to develop skills in assessment and management of thoracic malignancies. In addition, the resident is able to participate in preoperative evaluation and postoperative follow-up in the outpatient clinic under direct attending supervision. The resident is expected to develop proficiency with the diagnosis and staging of malignant disease, the interpretation of preoperative studies such as pulmonary function tests and imaging (e.g. computed tomography, positron emission tomography, and endoscopic ultrasound) and the evaluation of benign disorders of the esophagus. The resident supervises the activities of lower level general surgery residents in caring for patients after surgery, and is primarily responsible for managing the inpatient consultation service, with increasing independence as skill development permits.

Operative Experience

The degree of operative responsibility is graded to the resident’s skills. Initially, the resident acts as assistant on all general thoracic procedures but is expected to quickly become proficient with flexible bronchoscopy and esophagoscopy, thoracoscopy, and the various techniques of thoracotomy. As surgical expertise is demonstrated, the resident is rapidly provided the opportunity to supervise lower level general surgery residents with the conduct of procedures that are appropriate for surgeons who have completed general surgery training (e.g., chest tube insertion and jejunostomy tube placement). By the end of the rotation the resident is expected to be facile with the conduct of major pulmonary and esophageal procedures under the direct supervision of the attending surgeon, and to be able to conduct minor thoracic procedures, such as thoracoscopic lung biopsy, with minimal attending supervision. Experience with rigid endoscopy is provided as the resident’s skills progress.
During this rotation, the resident will rotate through the regular MUH CT Surgery call schedule and will be expected to become involved with adult CT surgical cases when logistically necessary.

Goals & Objectives

1. Patient Care
Develop skills in effective and compassionate communication with patients and their families regarding the diagnoses of lung and esophageal cancer.
Become adept at designing and interpreting studies for the diagnosis and staging of lung and esophageal cancer.
Develop and carry out plans for management of patients with lung and esophageal cancer through interactions with attendings and through participation in Thoracic Tumor Board Rounds.
Become facile with operative skills such as endoscopy, mediastinoscopy, VATS, pulmonary and esophageal resections.
Understand the importance of smoking cessation, and learn how to counsel patients about its importance.

2. Medical Knowledge
Become facile with interpretation of chest x-rays and CT scans, pulmonary function studies, endoscopic ultrasound results, and PET scans.
Understand the staging of lung and esophageal cancer, and stage appropriate therapy.
Become familiar with recent trends in multi-modality therapy for lung and esophageal cancer.
Understand test results for evaluation of benign esophageal disease (manometry, pH probe).
Understand pulmonary physiology and ventilatory support.

3. Practice-Based Learning and Improvement
Become familiar with recent literature on developments in lung and esophageal cancer care.
Participate in multi-disciplinary conference and clinic.
Assume graded responsibility for post-operative care.
Develop an understanding of clinical trials design and conduct with respect to the existing lung and esophageal cancer trials.
Educate junior residents and medical students in the operating room and on the wards about basic thoracic surgery problems.

4. Interpersonal and Communication Skills
Create and sustain sound relationships with patients based on effective communication and empathy.
Learn to use constructive criticism for improvement.
Work well with the operating room team.
Interact with physicians from other disciplines (Pulmonary, Oncology, GI, Radiation therapy) in multidisciplinary clinic and conference.
Manage the surgical team effectively, insuring that cases are covered, pre-operative studies are known by the member assigned to the case, and that post-operative care is efficient.

5. Professionalism
Dress appropriately at all times, and attend conferences and the operating room on time. Demonstrate respect and integrity. Develop skills in ethical behavior, with a particular emphasis on the conduct of clinical trials and patient confidentiality.

6. Systems-Based Practice
Understand the impact of lung and esophageal cancer on society, and in particular South Carolina.
Develop an appreciation for the cost-benefit analysis of studies such as screening chest CT, PET scan and endoscopic ultrasound.
Learn appropriate use of routine post-operative tests.

MUH - Adult CT Surgery (6 months)

Preoperative and Postoperative Assessment

Preoperative and postoperative assessment and management will be carried out by the first-year thoracic resident under immediate supervision by more senior resident and attending surgeons.

Operative Experience

1. Adult Cardiac Surgery
The resident will initially assist with the performance of adult cardiac procedures. He will be expected to quickly grasp the principles and techniques of preparation of the saphenous vein for bypass grafting, removal of the radial artery for bypass grafting, and takedown and preparation of the internal mammary arteries for bypass grafting. He will be expected to learn techniques for arterial and venous cannulation in preparation for cardiopulmonary bypass as well as how to place patients on bypass and remove them at the end of the procedure. By the end of the rotation he will be expected to be competent in performing parts of individual adult cardiac procedure such as proximal and/or distal anastomoses (CABG), very straight- forward valve procedures and management of cardiothoracic trauma.

2. Pacemakers and Implantable Electronic Devices
The resident will be taught the principles and characteristics of implantable electronic devices including pacemakers and cardioverters. He will participate in the Pacemaker Journal Club along with the cardiology fellows. By the completion of the rotation he will be capable of doing straightforward pacemaker implantations and will be increasingly comfortable with implantations of cardiac defibrillators.

3. Perfusion
The resident will learn the principles and practice of cardiopulmonary bypass through exposure to these topics in didactic lectures, journal clubs, service conference, and observation and discussions with the perfusionist. He will be comfortable with cannulation techniques of all types and with placing patients on cardiopulmonary bypass as well as removing them from cardiopulmonary bypass. He will become familiar with cardiac assist devices such as the intra-aortic balloon pump, the ABIOMED BVS 5000, and the HeartMate left ventricular assist device.

Goals and Objectives

1. Patient Care
Understand the standard preoperative work-up and evaluation prior to surgery.
Understand those preoperative conditions which might adversely impact on the successful performance of surgery or recovery.
Understand any preoperative techniques for lessening the impact of such co-morbidities.
Understand the causes of perioperative infections and available techniques for prevention of perioperative infections.
Be able to read and understand data presented in a cardiac catheterization report.
Be able to read and describe the images obtained at a cardiac catheterization.
Be able to read an electrocardiogram.
Understand the methodology, reports and perioperative significance of pulmonary function testing.
Understand the methodology, reports, and preoperative significance of noninvasive vascular testing.
Know the expected clinical pathways for recovery from each of the usual surgical procedures.
Know the common complications and their diagnosis and treatment that may occur after cardiac surgery.
Know the available treatments for congestive heart failure and their rationale.
Know the available incisions, indications, and complications for the exposure of thoracic organs.
Perform a median sternotomy and appropriate closure.
Demonstrate the ability to dissect and prepare an internal mammary artery bypass conduit.
Demonstrate the ability to harvest a saphenous vein conduit. Understand anticoagulation of cardiac valve patients and the use of Coumadin.
Understand pre-transplant work-ups.
First assist and then perform straightforward, cardiac transplants in patients who had not previously undergone cardiac surgery.
Become familiar with the post-transplant surgical care of the transplant recipient, including the principles and pharmacologic dosing of maintenance immunosuppression and post-transplant monitoring.
The fellow will be introduced to mechanical assist devices.

2. Medical Knowledge
Know the causes of coronary artery disease and possible medical treatment plans for prevention or stabilization.
Know the indications for surgery for coronary artery disease. Understand normal clotting function.
Know the genetic abnormalities of clotting function and their appropriate treatment.
Know the possible acquired abnormalities of clotting function. Know their causes and appropriate treatment.
Know the pathophysiology, possible impact on clinical result, and treatment of heparin induced thromobocytopenia and thrombosis.
Understand the function, construction, and operation of the cardiopulmonary bypass machine.
Understand the choices, advantages, potential complications of harvest, and durability of coronary artery bypass graft conduits.
Understand the pathologic conditions requiring cardiac pacing.
Understand the various pacing modes and their indications.
Understand the measurement of electrical parameters and programmable options of cardiac pacing.
Develop a textbook level understanding of transplant immunology, immunosuppression, indications for cardiac transplantation, donor and recipient selection, and post-transplant complications.
Learn effective strategies preventing deal with opportunistic infections and medication related complications in immunosuppressed patients.
Expand knowledge base of current therapeutic issues and develop peer relationships through attendance at a national CT surgery conference and an industry-sponsored course.

3. Practice-Based Learning and Improvement
Read and understand and be prepared to discuss articles published in the standard cardiothoracic surgical journals.
Read appropriate articles in various medical journals.
Appropriate study preparation and performance on in-training written and oral examinations.
Research of problems not fully covered at the textbook level encountered during the course of transplant patient care through the surgical transplant literature.
Critically evaluate the advantages and disadvantages of preferred surgical techniques of different attending surgeons.

4. Interpersonal and Communication Skills
Demonstrate the consistent and timely ability to dictate a clear and concise CT surgery operative report.
Demonstrate the ability to hand off and receive patients for coverage while ensuring complete and knowledgeable care during cross coverage.
Become competent and effective in dealing with referring cardiologists, and other members of the patient care team.
Effectively deal with the special emotional needs of heart transplant patients and their families.

5. Professionalism
Respond to pages and requests for assistance in a timely fashion. Report for activities in a timely fashion, including punctuality for conferences and patient care responsibilities.
Demonstrate patient, sensitive, and tactful manner in dealing with the moral, legal, and ethical issues associated with cardiac transplantation.
Demonstrate a working knowledge of the Health Information Portability Accountability Act (HIPAA).

6. Systems-Based Practice
Develop efficient, timely, and cost effective practice patterns.
Develop and use good judgment in making cost-effective decisions within the framework of transplant care protocols.
Through required attendance at CT Faculty Division meetings, understand management of clinical practice and human resource issues, and participate in the evaluation of CT team members.

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Resident Assignments (Rotations) Year 2

MUH Adult CT Surgery (8 months)

Preoperative and Postoperative Assessment

Preoperative and postoperative assessment and management responsibilities during this rotation will be similar to those of the rotation from July through September at MUH. However, residents will be given increasing levels of responsibility and independence in all areas. The resident will be responsible for not only pre and postoperative care, but for operating room assignments for all residents as well as other ward responsibilities. The resident will assume an increasing role in the education of other members assigned to the service such as physician assistants, nurse clinicians, and medical students. By the completion of this rotation, the resident is expected to be ready to enter his third year of cardiothoracic surgery residency with sufficient technical skills and fund of knowledge to allow him/her to independently perform most operative procedures as well as to provide overall care for the most complex patients in the postoperative period.

During this time, the resident will spend increased time and effort consolidating his or her knowledge of imaging and other diagnostic modalities such as echocardiography, MRI, CT scanning, nuclear medicine, pulmonary function testing, esophageal diagnostic studies and EKG interpretation. To this end, the second year resident will spend one month in an “elective” rotation during which time will be spent observing and interpreting the aforementioned diagnostic study techniques and results. The resident will be relieved of clinical responsibility at this time with the exception of call requirements.

Operative Experience

1. Adult Cardiac Surgery
The resident will perform nearly all procedures on which he/she scrubs except for the most complex and challenging. On some general thoracic procedures the resident will serve as the teaching assistant to junior residents but with in-room supervision by the attending surgeon. At the end of this rotation the resident should be capable of performing most valve replacements, all coronary artery bypass procedures including off pump coronary artery bypass, and all general thoracic procedures.

2. Congenital Heart Surgery
The resident will have the option of participating in any congenital heart procedure of his choice as either the operating surgeon or first assistant and should be capable on completion of the rotation of performing independently most simple open and closed congenital heart procedures.

3. Transplantation
The resident will procure donor hearts with the assistance of an attending surgeon and will perform portions or in some cases all of the transplant procedure as well.

4. General Thoracic Surgery
The resident will perform more complex procedures, such as VATS lobectomy, major chest wall cases (Pancoast tumor) laparoscopic benign esophageal surgery, and extra-pleural pneumonectomy. He will become facile in all approaches for esophageal resection: Ivor-Lewis, three-field, and transhiatal.

Goals and Objectives

1. Patient Care
Cannulate and place a patient on cardiopulmonary bypass.
Understand and be able to perform the various techniques for implant of an artificial cardiac valve.
Demonstrate fascicle technique for coronary artery anastamosis.
Demonstrate the ability to implant a pacemaker using transvenous or epicardial leads.
Demonstrate increasing sophistication in dealing with more complex problems presented by the post-transplant patient.
Performance of all but the most complex transplant operations.
Development of donor management and procurement skills sufficient to allow independent function at a remote donor site.
Introduction to ventricular assist device (VAD) technology and first assist on VAD implantations.
Participate when possible in donor organ procurement.
Become comfortable in managing immunosuppressive therapy by evaluating clinical and laboratory data including drug levels.
Develop independence in pulmonary, mediastinal, and esophageal case management.

2. Medical Knowledge
Know the causes of valvular heart disease and the indications for valve replacement or repair.
Know the causes and management of cardiomyopathy.
Understand the use of different anticoagulation strategies during cardiopulmonary bypass.
Understand the function, construction, and operation of the cardiopulmonary bypass machine.
Understand the types, construction, complications, long term results, and rationale for the choice of artificial cardiac valves.
Understand the pathologic conditions requiring cardiac pacing. Understand the various pacing modes and their indications.
Understand the measurement of electrical parameters and programmable options of cardiac pacing.
Become familiar with cardiac transplant related issues as presented in the Journal of Thoracic Cardiovascular Surgery, Annals of Thoracic Surgery, and Journal of Heart and Lung Transplantation. Develop a broader understanding of cardiopulmonary bypass technology.
Be familiar with the techniques and interpretation of imaging and diagnostic modalities used in cardiothoracic surgery at a board examination level.
Expand knowledge base of current therapeutic issues and develop peer relationships through attendance at a national CT surgery conference and an industry-sponsored course.
Understand the rationale and options involved in offering patients neoadjuvant or postop adjuvant therapy.
Become acquainted with targeted biologic therapy. Gain knowledge of palliative therapy for obstructing bronchial and esophageal malignancies.

3. Practice-Based Learning and Improvement
Understand and participate in the STS database.
Continue to critically analyze the surgical results in the outcomes of post-transplant medical and surgical interventions.

4. Interpersonal and Communication Skills
Demonstrate the ability to effectively request and utilize consultation from supportive medical services.
Demonstrate the ability to provide complete and adequate information regarding patient status to the patient and family while remaining supportive.
Learn to interact effectively at remote donating hospitals with members of procurement teams from other transplant programs.
Assume a central role in coordinating the care of post-transplant patient among both the patient care providers.

5. Professionalism
Continue to demonstrate and project a demeanor suggesting knowledge, competence and compassion.
Recognize and respond to patient needs for unexpected clinical intervention in a timely and appropriate fashion.
Continue to develop and solidify opinions and behaviors suitable for the difficult legal and ethical situations presented that the transplant process.

6. Systems-Based Practice
Demonstrate a regard for cost containment and resource conservation while ensuring appropriate patient care.
Demonstrate the ability to balance the needs of multiple patients in the planning service activities and operating schedules.
The second year fellow will take a leadership role in providing cost-effective, quality, and timely post-transplant care, with working understanding of established post-transplant protocols.
Through required attendance at CT Faculty Division meetings, understand management of clinical practice and human resource issues, and participate in the evaluation of CT team members.

Rotation in CT Imaging and Diagnostic Testing (one month)

During this mandatory rotation, residents will become exposed to various imaging and diagnostic modalities important for CT surgical work-up.

1.1 Patient Care
Understand the indications, pre-test preparation, and performance for CT imaging and diagnostic testing modalities.

1.2 Medical Knowledge
Demonstrate advanced ability to read and interpret the results of CT imaging and diagnostic testing modalities.

1.3 Practice-Based Learning and Improvement
Demonstrate ability to compare and contrast CT imaging and diagnostic testing modalities as they relate to accuracy of test results and the logisitics of obtaining the test

1.4 Professionalism
Demonstrate punctuality to and appropriate personal appearance and behavior for attendance in the testing laboratory and in reading results with attendings.

1.5 Interpersonal and Communication Skills
Demonstrate ability to interact with patients and attendings in a cordial, professional manner.

1.6 Systems-Based Practice
Critically evaluate new diagnostic and imaging systems as they relate to practice economics and logistics.

VA Medical Center Adult CT Surgery (3 months)

Preoperative and Postoperative Management

All preoperative and postoperative assessment and management will be carried out by the PG 2 resident. While attending supervision will always be present and available, additional responsibility will be given to the resident for independent decision making in the management of patients. The resident will supervise the activities of lower level general surgery residents as well as other members of his team including physician assistants, medical students, etc.

Operative Experience

1. Adult Cardiac Surgery
The resident will perform most cardiac surgical procedures.

2. General Thoracic Surgery The resident will perform essentially all parts of all general thoracic procedures except for the most technically demanding.

3. Endoscopy The resident will perform essentially all endoscopies or begin to act as a teaching assistant to general surgery residents.

Residents will be expected to perform clinical, didactic and administrative duties in accordance with the 6 competency requirements outlined for general thoracic surgery and for the second year fellow in adult cardiac surgery (above).

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Resident Assignments (Rotations) Year 3

MUH Adult CT Surgery (6 months)

Preoperative and Postoperative Assessment

Preoperative and postoperative assessment and management of the entire cardiothoracic surgery will be supervised by the Chief Resident. He/she will have major responsibility for overseeing the care of all cardiothoracic surgery patients at MUH and will provide close supervision of both the first year cardiothoracic as well as the general surgery residents on the service. He /she will be given increasing responsibility and while attending supervision will always be immediately available, he will be less closely supervised than in previous years. In addition to responsibility for pre and postoperative care, the resident will have responsibility for operating room assignments and administrative management of the service.

Operative Experience

1. Adult Cardiac Surgery
The resident will now be expected to perform nearly all procedures on which he/she scrubs except for the most complex. This will include valve replacement, straightforward valve repairs and all coronary bypass procedures including off pump bypass. On straightforward general thoracic procedures including some pulmonary resection and endoscopies, he will serve as a teaching assistant to the junior resident, again with direct supervision by the attending surgeon.

2. Congenital Heart Disease
During this rotation the resident will have the opportunity to participate in any congenital heart procedure of his choice and will always serve as either the operating surgeon or the first assistant. Again, he will perform most closed cases as well as increasingly complex open procedures according to his own talents and skills.

3. Transplantation
The resident will procure donor hearts with the assistance of an attending surgeon and will perform most transplants as well.

4. Thoracic Surgery
Senior resident will scrub on cases that are unusual or highly complex, such as tracheal resections, carinal pneumonectomy, colon interposition, extrapleural pneumonectomy for mesothelioma, etc.

Goals and Objectives

A. Patient Care
Understand and be able to perform the appropriate cardiac incisions for exposure of cardiac valves.
Understand and perform mitral and tricuspid valve repair.
Understand and demonstrate ability to use stabilization devices in order to perform off pump coronary artery bypass surgery.
Demonstrate proficient strategy and technical performance of complex thoracic aortic surgical procedures.
Demonstrate proficiency in the conduct of complex cardiac surgical procedures such as multiple valve repair/replacement or combined valve/coronary bypass.
The fellow is expected to develop into a mature cardiac surgeon, capable of dealing with all but the most complex intraoperative, and post-operative situations.
Performance of the most complex cardiac transplants under the supervision of attending transplant surgeon.
Participate when possible in donor organ procurement.
Knowledgeable of all aspects of ventricular assist technology, its indications, implantation techniques, and management protocols.

B. Medical Knowledge
Firm understanding of all didactic aspects of the causes and treatment of cardiac diseases.
Understand the types and etiologies of thoracic aortic disease and options for therapy, including use profound hypothermic circulatory arrest.
Understand the medical, interventional, and surgical treatment options for atrial fibrillation.
Well versed in all aspects of candidate selection, pre-transplant management, immunosuppressive protocols, intraoperative management, postoperative management, and the diagnosis and treatment of post-transplant complications.
Expand knowledge base of current therapeutic issues and develop peer relationships through attendance at a national CT surgery conference and an industry-sponsored course.

C. Practice-Based Learning and Improvement
Demonstrate independent, critical evaluation of clinical, interpersonal, and technical performance and demonstrate adaptive ability to correct deficiencies.
Demonstrate independent functioning, incorporating not only current practice but also developing technologies in cardiothoracic surgery, cardiac transplantation and mechanical assistance.

D. Interpersonal and Communication Skills
Demonstrate ability to effectively run a busy CT surgical service, coordinate educational activities, manage operating room and clinic schedules, with a pleasant, motivating attitude and demeanor.
Competency and confidence in dealing with all members of transplant team, members of procurement teams from other institutions, and even the most difficult transplant patient and family members.
Develop and administer monthly resident, physician assistant, and nurse practitioner call schedules in conformity with 80 hour work week requirements.

E. Professionalism
Demonstrate and project a demeanor appropriate for an independently functioning consultant in cardiothoracic surgery.
Develop a comprehensive CT case list and curriculum vitae in preparation for ABTS examinations and for job interviews.

F. Systems-Based Practice
Be able to apply all cardiac and thoracic treatment protocols in the most complex clinical situations taking into account cost-effectiveness, high quality, and adopting a proactive approach in the identification and efficient treatment of complications.
Demonstrate comprehensive ability to enter and review patient data electronically. Critically evaluate the computer based patient management systems currently in use Develop a working knowledge of the databases maintained by the Society for Thoracic Surgeons (STS), International Society for Heart and Lung Transplantation (ISHLT) and the United Network for Organ Sharing (UNOS).

Through required attendance at CT Faculty Division meetings, understand management of clinical practice and human resource issues, and participate in the evaluation of CT team members.

VA Medical Center Adult CT Surgery (6 months)

Preoperative and Postoperative Assessment

Preoperative and postoperative assessment and management will be carried out by the PG 3 resident. While attending supervision will always be present and available, additional responsibility will be given to the resident for independent decision making in the management of patients. The resident will supervise the activities of lower level general surgery residents as well as other members of his team including physician assistants, medical students, etc.

Operative Experience

1. Adult Cardiac Surgery
The resident will perform most cardiac surgical procedures.

2. General Thoracic Surgery
The resident will perform essentially all parts of all general thoracic procedures except for the most technically demanding.

3. Endoscopy
The resident will perform most or all endoscopies or begin to act as a teaching assistant to general surgery residents.

Residents will be expected to perform clinical, didactic and administrative duties in accordance with the 6 competency requirements outlined for general thoracic surgery and for the third year fellow in adult cardiac surgery (above).

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