Neuro Surgery Goals and Objectives

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Neuro Surgery Goals and Objectives

  1. 1. EDUCATIONAL EXPERIENCE BY TRAINING LEVEL POST-GRADUATE YEAR 1 Overview. The PGY 1 year is designed to provide an educational and clinical environment such that first year residents become competent in the pre- and post-operative management of surgical diseases, develop aptitude for assessing and treating critically ill patients, and begin to develop technical skills in operative surgery. PGY 1 residents are expected to be able to perform a history and physical exam, order medication and diagnostic tests, collect and analyze test results and communicate these results to the members of the team and faculty. The PGY 1 resident is also expected to learn to obtain informed consent, assist in the operating room and perform invasive under the supervision of the faculty or senior residents at the discretion of the responsible faculty member. PGY 1 expected to begin their didactic studies in neurosurgery emphasizing patient care, but also beginning to read from the textbooks provided by the department as well as critical articles and references recommended by senior residents and staff. At the completion of the PGY 1 year the resident should understand enough of the basics of neurosurgery to be able to begin seeing consults and managing patients as a junior resident at the beginning of the PGY 2 residency year. Rotations during the PGY 1 year include 12 weeks of neurosurgery, 12 weeks of neurology in Neurology/Neurosurgery Intensive Care Unit, 4 weeks of ophthalmology, 4 weeks of orthopaedic surgery and 4 weeks of emergency medicine; the remainder of the 1st post- graduate year consists of general surgery rotations. Note: Neurosurgery PGY 1 residents are currently employed as general surgery interns. The general surgery residency program oversees the non-neurosurgery rotations for the PGY 1 residents. Beginning with the 2009-2010 academic year, neurosurgery PGY 1 residents will be employed as neurosurgery interns. At which time, the neurosurgery program will take responsibility for the non-neurosurgery rotations for PGY 1 neurosurgery resident. Complete PGY 1 rotation descriptions, including goals and objectives, will be added to the neurosurgery residency policies & procedures for the 2009-2010 academic year. Adult Neurosurgery Introduction. The broad goal of this rotation is to introduce and familiarize the first year resident with the clinical presentation, diagnostic work-up and treatment of cervical, thoracic, lumbar spine disease, hemorrhagic and ischemic stroke, brain tumors, hydrocephalus, cranial and spinal trauma. The essentials of pre-, intra-, and post-operative care are emphasized. The rotation also provides a substantial exposure to a broad spectrum of adult neurosurgical procedures. Responsibilities. The responsibilities of the PGY 1 include patient work-up, pre, intra- and postoperative care, diagnostic procedures, daily rounds, weekly grand rounds and case conferences, and neurosurgery clinic. As a member of the neurosurgery team, the PGY 1 works closely with the neurosurgery residents, becoming competent in managing critically ill patients and
  2. 2. developing technical skills in the operating room. The PGY 1 is actively involved with the daily management of patients on the neurosurgery floor and ICU. Daily rounds are conducted in the morning with the rest of the team, led by the neurosurgery chief resident. Evening rounds are often conducted with the various attending physicians on the service. The PGY 1 will care for ICU patients and scrub in the Operating Room on various neurosurgical cases. PGY 1s will also observe functional neurosurgery and aneurysm clipping. The PGY 1 is placed on night call one night per week. At this time, the PGY 1 is involved in the initial evaluation of patients on the neurosurgery service. These patients may then be admitted to the neurosurgery service where the PGY 1 continues to be involved in the patient’s care and operative management. PGY 1s are expected to gain knowledge in the diagnosis of lesions, interpretation of appropriate imaging studies, decision-making regarding multi-modality treatment options including surgery. The PGY 1 resident also attends two weekly neurosurgery conferences that deal with case management, morbidity and mortality, as well as neurosurgery topics from visiting professors and other faculty. Supervisory Lines of Responsibility. Dr. Ralph G. Dacey, Jr. is the residency Program Director and is responsible for overseeing the training of the PGY 1s as well as all neurosurgery residents. The PGY 1 is directly supervised by the neurosurgery residents and is further directed by the chief resident and the attending physicians. The neurosurgery residents and the chief resident provide supervision of the PGY 1 at rounds and with patient care. Two full-time Nurse Practitioners on the service provides assistance with orders, H&Ps, dictations, and other aspects of patient management. The neurosurgery residents, as well as the attending neurosurgeons, provide surgical instruction in the operating room. Patient Care Goals & Objectives 1. Be able to describe the relevant findings, symptoms, family and social histories for patients with neurosurgical disease. 2. Be able to describe and document the elements of a complete neurosurgical history and review of systems, including a. Chief Complaint b. Current illness history c. Allergies d. Current medications e. Previous operations and associated medical problems f. Social history g. Family history 3. Be able to review systems and document the findings, emphasizing systemic conditions that may affect the brain and spinal cord 4. Be able to perform and evaluate a neurologic examination on head-injured and spine-injured patients 5. Be able to recognize the motor and sensory deficits of various incomplete spine injuries 6. Be able to perform the following procedures: a. Ventriculostomy b. Insertion of intracranial pressure monitoring device 7. Be able to assist with the following procedures: a. Craniotomy b. Laminectomy 8. Be able to clinically evaluate cervical and lumbar radiculopathy, spinal stenosis, spinal tumors, subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and
  3. 3. brain tumor. 9. Be able to interpret findings on various neuroimaging studies, including: a. Plain x-rays b. CT c. MR d. MRA 10. Be able to preoperatively manage patients undergoing neurosurgery. Medical Knowledge Goals & Objectives 1. Learn the acute management of neurosurgical trauma and the management of critically ill patients. 2. Learn the pathophysiology, natural history, spectrum of treatment and diagnosis of common neurosurgical disease processes, including cervical and lumbar disc disease, spinal tumors, malignant & benign brain tumors, subarachnoid hemorrhage, and stroke. 3. Learn the indications, contraindications and risks of diagnostic and neurosurgical procedures for patients undergoing cranial and spinal neurosurgery. 4. Be able to discuss the overall method, expected abnormal findings and risks of common neurosurgical diagnostic tests and procedures 5. Be able to discuss the indications for CT, MR, and MRA as they apply to the diagnosis and management of neurosurgical diseases 6. Be able to discuss and explain the indications, contraindications and risks of diagnostic and neurosurgical procedures for patients undergoing cranial or spinal neurosurgery. 7. Learn the anatomy of the brain and spine. 8. Be able to discuss the blood supply, spatial relationships and landmarks for specific regions of the brain and spine. 9. Be able to discuss the anatomy of specific disease processes relevant to the brain and spine. Practice-based Learning and Improvement Goals & Objectives 1. Use hand-held computers, desktop PC’s and Internet electronic references to support patient care and self-education. 2. Assist medical students in their own acquisition of knowledge through technology. 3. Demonstrate improvement in clinical management of patients by continually improving knowledge and skills during the rotation. 4. Learn how to effectively utilize hospital and University educational resources and begin to apply literature based and evidence based concepts as well as experimental evidence to the daily practice of surgery. 5. Develop and maintain a willingness to learn from failures and use failures to improve both personal performance and the overall process of patient care. Interpersonal and Communication Skills Goals & Objectives 1. Perform legible and accurate hospital admission notes which will be reviewed by supervising residents and faculty. 2. Write appropriate preoperative orders for patients undergoing neurosurgical procedures. 3. Write legible, relevant and accurate postoperative and daily notes for neurosurgery patients. 4. Establish rapport with patients and their families. 5. Perform a patient-centered medical interview.
  4. 4. 6. Engage patients in shared decision-making, and participate in family discussions. 7. Effectively and considerately communicate with team staff in a manner that promotes care coordination. 8. Discuss patient’s fears regarding outcome of surgery. Professionalism Goals & Objectives 1. Respect each patient’s right to privacy. 2. Demonstrate sensitivity to the sexual, moral, ethical or religious characteristics of the patient and family. 3. Provide supportive and compassionate care to patients and their families in the course of terminal disease. 4. Comply with the ethical and legal standards of neurosurgery. 5. Exhibit dependability and reliability in carrying out responsibilities 6. Maintain the highest standards in cleanliness, neatness, personal grooming and dress. 7. Exhibit a courteous, conscientious, and generally businesslike manner in patient areas Systems-based Practice Goals & Objectives 1. Utilize diagnostic tests, studies, procedures and consultations in a cost effective way. 2. Effectively coordinate care with other health care professionals as required for patient needs. 3. Demonstrate understanding of medical delivery systems as they relate to both inpatient and outpatient resources. 4. Effectively access/utilize outside resources 5. Effectively use systematic approaches to reduce errors and improve patient care 6. Enthusiastically assist in developing systems' improvement POST-GRADUATE YEAR 2 Overview. Residents at the PGY 2 level are considered “junior residents” on the neurosurgical service. Over the course of the 2nd post-graduate year, the junior resident develops the ability to assess and participate in the care of neurosurgical patients in the emergency room and on the neurosurgical ward. During the 2nd post-graduate year, the resident should begin examining various research opportunities including basic research, translational research, computerized data management, or outcomes analysis. The PGY 2 schedule includes approximately 12 months of clinical neurosurgery. For three to six months, the PGY 2 is assigned to the Department Chairman and Associate Program Director’s service. He/she will typically spend three to four months on night-float. The balance of the 2nd post-graduate year in training is spent rotating with other adult neurosurgery faculty in the subspecialties of spine, functional, peripheral nerve, cerebrovascular, skull base, and neuro-oncology at Barnes-Jewish Hospital. Adult Neurosurgery Introduction. PGY 2 residents are assigned to the service for Drs. Rich and Brown; Drs. Dowling and
  5. 5. Leuthardt; or Drs. Dacey and Zipfel, in four week blocks for total periods of three to six months and are responsible for the perioperative and intraoperative care of those attendings’ patients. During this year, residents will gain progressive experience with patient positioning, exposure, and closure of routine spinal and cranial procedures. More complex intracranial and spinal procedures are delegated to the resident after that resident has had appropriate experience and attains surgical proficiency. Responsibilities. During this year, residents receive an introduction to inpatient and outpatient clinical neurosurgery. PGY 2 residents are instructed in proper techniques for history-taking, physical examination, and interpretation of radiological studies relevant to neurological surgery in the outpatient department, in the inpatient wards, in the neurosurgical ICU, and in the Emergency Room. Progressive responsibility is delegated to the residents as they become able to perform ventriculostomies, intracranial pressure monitor placement, and burr hole placement for subdural hematoma. The residents work on two services teams at Barnes-Jewish Hospital, which consist of a number of junior and senior assistant residents and a chief resident. The PGY 2 resident typically takes call twice during each block. Supervisory Lines of Responsibility. The PGY 2 resident is directly supervised by the senior neurosurgery residents and is further directed by the chief resident and the attending physicians. The residents work primarily in two teams, each of which is supervised by a chief resident. The senior neurosurgery residents and the chief resident provide supervision of the PGY 2 resident at rounds and with patient care. Senior neurosurgery residents and attendings provide assistance with all aspects of patient management: in the evaluation of patients in the outpatient setting, the emergency room, in the hospital and in the operating room. On the inpatient units, PGY 2 residents report directly to their respective attendings regarding the patient’s clinical findings and course during their hospitalization. All consultations are evaluated with an attending and both the attendings and residents contribute to the documentation of the patients’ clinical course in the hospital chart. The service operates with the expectation that the residents will keep the attendings continuously apprised of the clinical course of their patients and that they will make clinical decisions in conjunction with and under the supervision of the attendings. An extensive system of communication including cell phones and beepers is available to facilitate this communication. As the PGY 2 residents demonstrate competence, progressive responsibility is delegated to them by the chief residents. Typically, residents progress to assist with lumbar and cervical spine procedures and routine cranial procedures during the middle three-to-four months of their first year, and eventually progress to developing more of the primary surgeon role in performing these specific procedures. The neurosurgical clinic is supervised by the chief resident. Attending neurosurgeons are directly available for consultation and patients who are presented at clinic are managed in conjunction with the attendings. The PGY 2 residents also see patients on a selective basis in the faculty offices. During these patient interactions, the residents learn from the faculty using the faculty interactions
  6. 6. with their patients as the vehicle. In the Emergency Room, the chief residents and attendings are contacted by the resident regarding the management of emergency room patients prior to their disposition and, depending on the severity of the patient’s condition, the patient is either admitted or the chief residents and the attendings discuss further management. PGY 2 residents are directly supervised in the operating room by senior residents, chief residents, and/or attendings. Neurosurgical attendings are present for the key portions of all neurosurgical cases and are directly available for all operative treatment, Patient Care Goals & Objectives 1. Be able to assist in the OR developing a. an ability to handle tissues appropriately b. an ability to take direction well c. an ability to make reasonable suggestions at appropriate times d. an ability to perform as a team member e. an appreciation of microneurosurgery. 2. Be able to demonstrate a facility for anticipating surgery. 3. Take a thorough history and perform an appropriate examination in order to localize, if possible, a lesion in the nervous system and provide a differential diagnosis. 4. Interpret laboratory and imaging studies appropriately to define the diagnostic hypotheses. 5. Demonstrate thorough understanding of patients and their conditions on daily rounds. 6. Identify potential complications of disease processes and operative therapy and take appropriate steps to prevent or diagnose and treat such complications. 7. Participate in acute resuscitation of a patient with injury to the head, the spine, or the peripheral nervous system in the Emergency Room or critical care setting 8. Become proficient in the following procedures: a. lumbar puncture b. insertion of external ventricular and lumbar drains c. insertion of intracranial pressure monitors d. application of skeletal traction for spinal instability e. positioning of patients for cranial, spinal or peripheral nerve surgery f. use of various head rests for cranial neurosurgery g. burr hole drainage of subdural hematoma 9. Be able to assess and participate in the treatment of patients in the ER or a critical care setting with: a. raised intracranial pressure b. hemorrhagic or ischemic cerebrovascular disease c. spinal cord or cauda equina compression d. acute or chronic seizure disorder Medical Knowledge Goals & Objectives 1. Demonstrate a practical working knowledge of: a. The normal central and peripheral nervous system anatomy and physiology b. The effects of certain pathological processes (e.g. mass lesions, raised ICP, head injury, seizures) c. The pharmacology as related to diseases of the central and peripheral nervous system.
  7. 7. 2. Demonstrate knowledge of nonoperative and operative management of patient problems in an ambulatory setting Practice-based Learning and Improvement Goals & Objectives 1. Recognize capabilities and limitations pertaining to medical knowledge and patient care and take appropriate steps to improve weaknesses. 2. Be able to demonstrate a developing ability to handle tissues appropriately in the operative room. 3. Show a sincere commitment to and performance as an instructor of students and other residents. 4. Use hand-held computers, desktop PC’s and Internet electronic references to support patient care and self-education. 5. Assist medical students and interns in their own acquisition of knowledge through technology. 6. Demonstrate improvement in clinical management of patients by continually improving knowledge and skills during the rotation. 7. Learn how to effectively utilize hospital and University educational resources and begin to apply literature based and evidence based concepts as well as experimental evidence to the daily practice of surgery. 8. Develop and maintain a willingness to learn from failures and use failures to improve both personal performance and the overall process of patient care. Interpersonal and Communication Skills Goals & Objectives 1. Present cases in an organized and articulate manner at appropriate rounds and conferences. 2. Document findings and a plan of management in the medical record 3. Be able to work in a cooperative manner with other health care personnel, recognizing their roles and abilities. 4. Give and receive advice in an objective, constructive manner. 5. Demonstrate the ability to elicit the patient's confidence and cooperation. 6. Recognize and respect the views of others. 7. Communicate with patients and their families, explaining disease processes and treatment options, including benefits, risks, and possible complications in terms each individual can comprehend. Professionalism Goals & Objectives 1. Be honest, reliable and respectful while working with patients and colleagues. 2. Respect each patient’s right to privacy. 3. Demonstrate sensitivity to the sexual, moral, ethical or religious characteristics of the patient and family. 4. Provide supportive and compassionate care to patients and their families in the course of terminal disease. 5. Comply with the ethical and legal standards of neurosurgery. 6. Exhibit dependability and reliability in carrying out responsibilities 7. Maintain the highest standards in cleanliness, neatness, personal grooming and dress. 8. Exhibit a courteous, conscientious, and generally businesslike manner in patient areas Systems-based Practice Goals & Objectives 1. Utilize diagnostic tests, studies, procedures and consultations in a cost effective way.
  8. 8. 2. Effectively coordinate care with other health care professionals as required for patient needs. 3. Demonstrate understanding of medical delivery systems as they relate to both inpatient and outpatient resources. 4. Effectively access/utilize outside resources 5. Effectively use systematic approaches to reduce errors and improve patient care 6. Enthusiastically assist in developing systems' improvement POST-GRADUATE YEAR 3 Overview. During the PGY 3 neurosurgical year, residents are considered “intermediate level residents.” It is expected that the intermediate resident be adept in the use of the literature and routinely demonstrate the ability to search selected topics and present these to the surgical team. The intermediate resident should be able to discuss and explain non- operative and operative treatment options for common neurosurgical problems, as well as the expected benefits, risks, and alternatives. This knowledge base is emphasized at departmental conferences where the residents are prepared on a weekly basis for oral discussion of common and more complicated neurosurgical problems Early in the third year, the resident should meet with potential research mentors to identify projects of interest. By the end of the third year, the resident should have identified his/her research mentor, project and what grants will be pursued (e.g. NREF, NIH, Foundation). The third year provides four to six months of advanced experience on the adult neurosurgery services at Barnes-Jewish Hospital. The PGY 3 schedule may include one to two month rotations on neuropathology and/or endovascular/neuroradiology. The remaining months are divided among the night-float rotation at Barnes and pediatric neurosurgery at St. Louis Children’s Hospital. Adult Neurosurgery Introduction. PGY 3 residents assigned to adult neurosurgery rotations with Drs. Rich and Brown, Drs. Dowling and Leuthardt; Drs. Wright and Santiago; Drs. Chicoine and Stewart or Drs. Dacey and Zipfel work individually with the attendings. They are assigned to each of attendings in four week blocks for total periods of three to six months and are responsible for the perioperative and intraoperative care of those attendings’ patients. The residents continue to be instructed by the chief resident and the attendings in the outpatient department, in the inpatient wards, the Emergency Room, the operating room and in the Intensive Care Unit. Responsibilities. On the adult neurosurgery rotations, progressive responsibility is delegated to the PGY 3 residents as they become familiar with the management of more complex spinal reconstructive procedures and cranial procedures for intracranial tumors, aneurysms, and vascular malformations. The resident will continue learning various aspects of cranial and spinal dissection and closure, with increasing responsibility delegated to the resident after he/she attains greater proficiency. The resident continues to participate in the management of trauma and other
  9. 9. intracranial emergencies under the supervision of the chief residents and attendings. Typically, residents progress to developing more of the primary surgeon role in performing these specific procedures. The PGY 3 resident typically takes call two times during each block.
  10. 10. Supervisory Lines of Responsibility. During PGY 3, the residents at Barnes-Jewish Hospital work under the supervision of the attendings and the chief resident in the evaluation of patients in the outpatient setting, the emergency room, in the hospital and in the operating room. On the inpatient units, residents report directly to their respective chief residents and attendings regarding the patient’s clinical findings and course during their hospitalization. All consultations are evaluated with an attending, and both the attendings and residents contribute to the documentation of the patients’ clinical course in the hospital chart. The service operates with the expectation that the residents will keep the attendings continuously apprised of the clinical course of their patients in that they will make clinical decisions in conjunction with and under the supervision of the attendings. An extensive system of communication including cell phones and beepers are available to facilitate this communication. On the outpatient services, appropriate supervision of residents also occurs in the neurosurgical clinics. The clinics are supervised by the chief resident. Attending neurosurgeons are directly available for consultation and patients who are presented at clinic are managed in conjunction with the attendings In faculty offices, the residents also see patients on a selective basis. During these patient interactions, the residents learn from the faculty using the faculty interactions with their patients as the vehicle. In the Emergency Room, the chief residents and attendings are contacted regarding the management of emergency room patients prior to their disposition and, depending on the severity of the patient’s condition, the patient is either admitted to the hospital or the chief resident and the attendings discuss further management. In the Operating Room, residents are directly supervised by chief residents and attendings. Neurosurgical attendings are present for the key portions of all neurosurgical cases and are directly available for all operative treatments. Patient Care Goals & Objectives 1. Provide a more detailed differential diagnosis for lesions in the nervous system than at junior levels. 2. Be able to construct an algorithm for management of more complex neurosurgical problems (ie CSF fistula, intractable epilepsy, low grade astrocytoma, spinal fracture) 3. Supervise more junior residents and clinical clerks on the wards and in the operating room. 4. Provide inpatient consultations with close supervision of a preceptor. 5. Be able to perform: a. Flap planning for craniotomy b. Incision planning for spinal surgery c. Incision planning for peripheral nerve surgery d. Opening of craniotomies or craniectomies e. Exposure of spinal lamina, dural tube, and nerve root f. Stop simple bleeding g. Spinal and simple nerve surgery h. Carpal tunnel release i. Insertion and revision of ventriculoperitoneal shunt
  11. 11. j. Ulnar nerve decompression or transposition k. Evaluation of depressed skull fracture l. Closure of dura mater in head and spine Medical Knowledge Goals & Objectives 1. Be familiar with the central and peripheral nervous system 2. Learn normal microsurgical anatomy and physiology 3. Be familiar with the disease processes of neurosurgical importance, including: a. incidence b. etiology c. pathophysiology d. natural history e. diagnosis f. investigation g. management h. prognosis i. complications of each disease j. the pharmacology as related to diseases of the central and peripheral nervous system. Practice-based Learning and Improvement Goals & Objectives 1. Recognize capabilities and limitations pertaining to medical knowledge and patient care and take appropriate steps to improve weaknesses. 2. Be able to demonstrate a developing ability to handle tissues appropriately in the operative room. 3. Show a sincere commitment to and performance as an instructor of students and other residents. 4. Use hand-held computers, desktop PC’s and Internet electronic references to support patient care and self-education. 5. Assist medical students and interns in their own acquisition of knowledge through technology. 6. Demonstrate improvement in clinical management of patients by continually improving knowledge and skills during the rotation. 7. Learn how to effectively utilize hospital and University educational resources and begin to apply literature based and evidence based concepts as well as experimental evidence to the daily practice of surgery. 8. Develop and maintain a willingness to learn from failures and use failures to improve both personal performance and the overall process of patient care. Interpersonal and Communication Skills Goals & Objectives 1. Document findings and a plan of management in the medical record 2. Be able to work in a cooperative manner with other health care personnel, recognizing their roles and abilities. 3. Give and receive advice in an objective, constructive manner. 4. Demonstrate the ability to elicit the patient's confidence and cooperation. 5. Recognize and respect the views of others. 6. Communicate with patients and their families, explaining disease processes and treatment options, including benefits, risks, and possible complications in terms each individual can comprehend
  12. 12. Professionalism Goals & Objectives 1. Respect each patient’s right to privacy. 2. Demonstrate sensitivity to the sexual, moral, ethical or religious characteristics of the patient and family. 3. Provide supportive and compassionate care to patients and their families in the course of terminal disease. 4. Comply with the ethical and legal standards of neurosurgery. 5. Exhibit dependability and reliability in carrying out responsibilities 6. Maintain the highest standards in cleanliness, neatness, personal grooming and dress. 7. Exhibit a courteous, conscientious, and generally businesslike manner in patient areas Systems-based Practice Goals & Objectives 1. Utilize diagnostic tests, studies, procedures and consultations in a cost effective way. 2. Effectively coordinate care with other health care professionals as required for patient needs. 3. Demonstrate understanding of medical delivery systems as they relate to both inpatient and outpatient resources. 4. Effectively access/utilize outside resources 5. Effectively use systematic approaches to reduce errors and improve patient care 6. Enthusiastically assist in developing systems' improvement

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