Goals and Objectives for McMaster
Neurosurgery Residents
PREAMBLE
The goals and objectives described herein
are intended to guide the training of each
resident enrolled in the McMaster
Neurosurgery Program.
The first section describes the general goals
and objectives of this 6 year residency
program. The second section describes
rotation specific objectives.
These objectives have been formulated
To conform to CanMEDS 2000
principles and to the objectives of training
in Neurosurgery stipulated by the
Royal College of Physicians and
Surgeons of Canada.
It is anticipated that training in this program
will lead to the production of fully trained
neurosurgeons with the potential for
successful careers in academic or
community-based neurosurgery.
Part A: Overall Program Goals and
Objectives
Part B: Rotation Specific Goals and
Objectives for:
1. Junior adult neurosurgery
2. Senior adult neurosurgery
3. Chief resident adult neurosurgery
4. Junior pediatric neurosurgery
5. Senior pediatric neurosurgery
6. Neurology
7. Critical Care
8. Orthopedics
9. Plastic surgery
10. Trauma
11. Anesthesia
12. Emergency medicine
13. General Surgery
14. Internal Medicine
1
Part A: Overall Program Goals and Objectives for Each Resident
1. To obtain a fundamental knowledge of basic neuroscience including neuroanatomy,
neurophysiology, neurochemistry and neuropharmacology.
2. To obtain a practical working knowledge of neurology, neuropathology and neuroradiology.
3. To develop a thorough and in-depth knowledge of clinical neurosurgery.
4. To interact with patients and all others in a caring, competent, reliable, honest, and fully
professional manner at all times.
5. To develop excellence in clinical judgment.
6. To develop excellence in the techniques of neurosurgery.
7. To develop interest and understanding of the techniques of clinical and basic science research as
they relate to the clinical neurosciences.
8. To develop an ability and interest in teaching.
9. To develop sufficient clinical expertise to transition into independent neurosurgical practice.
10. To develop sufficient clinical expertise, research and teaching ability to join the consultant staff of
an academic medical centre and to be eligible for a university academic position.
11. To be adequately prepared to pass the Principles of Surgery examination and the Specialty
Examination in Neurosurgery of the Royal College of Physicians and Surgeons of Canada
12. To be prepared to make valuable contributions to the community and to the development of
academic neurosurgery.
2
Part B: Rotation Specific Goals and Objectives
B1. Junior adult neurosurgery
Medical Expert/Clinical Decision Maker
relevant to seizures, pain, trauma, coagulopathic states, familial or genetic syndromes, sexual
function, endocrine function, cardiorespiratory function, mood, disability, grief, diet, nutrition,
drug/medication use, infection, neoplasia, sleep, occupation, social factors, coping capacity,
competence, fitness, etc.
examination of the spine, cardiovascular system, respiratory system, musculoskeletal system, and
abdomen.
attention, awareness, cognition, communications, behaviour, mood, memory, speech, cranial
nerves, and motor and sensory function.
neurological disorders based on clinical findings and investigations.
le to formulate a differential diagnosis based on a critical evaluation of the symptoms and
signs.
cardiopulmonary support, fluid management, the appropriate use of pharmacology, and functional
rehabilitation.
peri-operative problems including infection, seizure, hemorrhage, respiratory distress, cardiac
dysfunction, hypertension, endocrine dysfunction, intracranial hypertension, herniation syndromes,
spinal instability, progressive neurologic deficit, hydrocephalus, vasospasm, mood disorder, family
distress, risks for aspiration or falls, drug related problems, etc.
course of their training so much so that they can function independently by the time they are in the
senior year.
To become familiar with the basic science of the nervous system and the diseases of the nervous
system to include the anatomy of the brain, spinal cord, peripheral nerve and muscles;
neurophysiology; the pathology and pathophysiological mechanisms of neurological disease; neuroendocrinology; metabolism and pharmacology of brain, spinal cord, peripheral nerve and muscle;
neuropsychology.
ding of the techniques and interpretation of the ancillary aids to the
3
diagnosis of neurological disease to include:
Neuroradiology: plain radiography, computed tomography, magnetic resonance imaging,
arteriography and radioactive nucleotide imaging.
Neurovestibular testing, cerebral blood flow testing, electroencephalography,
electromyography and nerve conduction studies, evoked potentials and
neuropsychological testing.
chnical skills to perform neurosurgical procedures as delineated
below. It is recognized that there will be some variability in terms of learning technical skills.
However, those listed below are to be used as goals that will be best achieved by a gradual increase
in responsibilities.
Communicator
The resident is expected to demonstrate proficiency in communication skills in both verbal and
written modalities with:
1. Patients, their relatives, and other entitled parties:
disability, practical consequences and adaptation strategies
experiences
neurosurgical disorders
neurosurgical conditions
understand feedback from patients and families and other concerned parties
regarding care given by oneself and one’s team during a neurosurgical illness
2. Other health care professionals, as listed below, in order to maintain best care and practice while
maintaining confidentiality according to legal and professional codes
her specialties
4
lied staff such as speech pathologists
3. Junior residents are expected to develop proficiency in dictating and charting including history and
physical examination, consultation, progress notes, discharge summaries, pre-op notes, and
operation notes.
4. The junior resident is expected to show sophisticated ability to evaluate self and other members of
the health care team, maintaining the values of professionalism while working to bring continuous
improvement in skills and knowledge to self and all members of the team.
5. The resident is expected to become very comfortable with presentation of clinical and
investigative information at teaching rounds and scientific conferences using computerized teaching
aids.
Collaborator
efficiently and with effective professional behaviours.
other members of the
health care team.
to decision making as a Neurosurgeon.
those of other health care
team members.
d to collaborate with other non-medical health care personnel to achieve
the best possible outcome for patients.
5
and surgeons from other
specialities. For combined cases, the collective and individual responsibilities to the patients need to
be clearly understood. The boundaries between specialties have to be recognized and respected.
Most importantly, the residents need to make sure that in a collaborative surgical effort, important
health and social issues are not missed.
Manager
the clinical diagnosis.
junior resident needs to understand how to function within the confines of the structure,
finances and the general operation of the Canadian health care system.
the
wider health care community, such as:
o
o
o
o
committees at various levels,
community organizations which support particular groups of neuro patients
national and international organizations pertinent to the speciality of neurosurgery
research accounts
staff functions-specifically appropriate delegation of activities, call schedules and other issue with
equanimity and a sense of fairness.
ed on best available
evidence.
delegating tasks, and running meetings smoothly.
Health Advocate
consequences of systematic problems such as access to health care resources for diagnosis and
treatment. In the appropriate situations they are expected to learn how to be a health advocate for
the individual patient to facilitate the best possible outcome for that patient.
that have been shown to be efficacious. For example, better education to vulnerable groups such
spinal injury patients.
is active in prevention of neurotrauma and CHAT, which is a community and hospital combined
initiative against trauma.
6
Scholar
Clinical issues: The resident is expected to identify clinical issues that he/she does not fully
understand, and perform the following:
er own knowledge and its limitations
Research issues: The resident is expected to:
enerate a research question
relevant literature
Presenting at conferences
Writing a paper for publication
It is understood that there may be a considerable overlap between the clinical cases and research
questions, depending on the area of interest.
Educational issues:
derstand the principles of self-directed learning
and surgical aspects of Neurosurgery.
personnel.
7
be comfortable with the surgical approach prior to coming to the operating room.
seminars at relatively short notice.
study and use all sources (electronic and written) to gather
information relating to management of consultations seen in the emergency room, clinics, and the
Neurosurgical wards.
Professional
The Neurosurgical resident is expected to be able to behave as a professional in every aspect of
Neurosurgical practice. He/She is expected to:
manner
he/she expects to be treated
rsonal life that is fulfilling professionally
ations.
-specifically ask for help from colleagues when he/she is not
comfortable with a clinical situation.
responsibility and compassion toward their
patients and their families
8
B2. Senior Adult Neurosurgery
The senior neurosurgery resident is expected to demonstrate knowledge and
skills as documented for junior neurosurgery residents with the following
additions and modifications:
Medical Expert/Clinical Decision Maker
to age, ethnicity, family dynamics, economics, geographic factors, etc.
behavioural features.
literature and including classification, etiology, pathologic anatomy, pathophysiology, and temporal
components for each diagnostic label applied.
am with inclusion of practical measures of
status and outcome.
nd variants from expected outcomes and to relate these to appropriate medical
and surgical literature sufficiently to present cases at interdisciplinary mortality and morbidity rounds.
The residents are expected to gradually improve their clinical decision making skills over the
course of their training so much so that they can function independently by the time they are in the
senior year.
pertinent to particular neurosurgical cases and to suggest references and learning resources useful
9
Training Level
Independently
Under Supervision
PGY4
- intra/extra-axial spinal tumor
removal
syringosubarachnoid/peritoneal/pleu
ral shunting
- Chiari malformation
decompression
- extra-axial intracranial tumor
dissection
- frontal lobectomy
- transphenoidal nasal/intrasellar
dissection
- craniectomy for posterior fossa
tumors or microvascular d
decompression
- aneurysm surgery dissection of
basal cisterns
- stereotactic calculation of target
coordinates/biopsy/cyst drainage
- carpal tunnel, ulnar nerve
procedures
- primary nerve anastomosis
- aneurysm dissection and clipping
anterior/posterior circulation
- AVM dissection/removal
- supra/infratentorial craniotomy for
complex tumors
craniopharyngioma
colloid cyst
hypothalamic tumors
acoustic neuroma
brainstem lesions
- thermal/glycerol rhizolysis
- carotid arteriotomy, plaque
removal,
arterial closure,
insertion of shunt
- complex craniofacial repair
PGY5/6
- all procedures previously
supervised at end of PGY4
- carpal tunnel, unar nerve
procedures
- pediatric
repair of myelomeningocele
other spinal dysraphic states
cranial dysraphic states
craniosynostosis repair
-Complex craniofacial procedures
-Neuro-endoscopy in the cranial
cavity as well as thoracic spine
for efficient learning of that material.
disease with health professionals specialized in their performance and reporting.
below. It is recognized that there will be some variability in terms of learning technical skills.
However, those listed below are expected to be used as goals. It is expected that these goals will be
best achieved by gradual increase in delegated activities.
10
Communicator
The senior resident is expected:
1. To be able to overcome potential limiters of patient autonomy, confidence, and comfort such as
perceptual disability, cognitive impairment, aphasia, language or cultural potential barriers with
competence and precision, the potential anatomical sites of neurological disorders based on clinical
findings and investigations.
2. The resident is expected to demonstrate proficiency not only in the presentation of clinical and
investigative information at teaching rounds and scientific conferences but also to engage the
audience in an interactive manner and to accurately evaluate the learning results of each session.
3. Senior residents are expected to demonstrate proficiency in dictating and charting including
history and physical examination, consultation, progress notes, discharge summaries, pre-op notes,
and operation notes.
Collaborator
rgical resident is expected to be able to help others to participate in
interdisciplinary team meetings efficiently and with effective professional behaviours.
ay as
to optimize patient care while maximizing knowledge sharing.
aware of each other’s strengths and weaknesses in a timely and fully professional manner.
The resident is expected to maintain efficient and collegial concurrent and collaborative planning
and care for patients who can benefit from such an arrangement.
Manager
11
s to know the economics and
potential errors involved
patient care indicates a need for such changes
tients and their significant others to
organizations and information sources that might provide valuable knowledge or service
junior residents and clerks
and guidelines, indicating those sources in written and verbal communications with other members
of the health care team.
Health Advocate
senior resident is expected to assume an activist role when needed to overcome systematic
problems such as access to health care resources for diagnosis and treatment.
opriate and
effective means for helping patients to use measures of health maintenance effectively for
themselves and their families.
.
Scholar
Clinical issues: The resident is expected to identify clinical issues that he/she does not fully
understand, and perform the following:
ed health care personnel as needed
Research issues: The resident is expected to:
erate a research question
12
Presenting at conferences
Writing a paper for publication
It is understood that there may be a considerable overlap between the clinical cases and research
questions, depending on the area of interest.
Educational issues:
xemplify the principles of self-directed learning.
residents, peer residents, and other health professionals with particular emphasis on the basic and
clinical sciences that relate directly to neurosurgery.
personnel.
Professional
The senior neurosurgical resident is expected to consistently demonstrate professional behaviours
which tend to bring best care for patients and families, best health outcomes, and optimal functioning
of involved health care teams
When problems occur in team activity or relationships, the senior neurosurgical resident is
expected to demonstrate knowledge and skill in the perception and analysis such situations and to
address them effectively.
B.3 Chief Neurosurgery Resident
The chief neurosurgery resident is expected to demonstrate knowledge and
skills as documented for junior and senior neurosurgery residents brought to a
level meeting the requirements of the Royal College of Physicians and
Surgeons of Canada.
Given a patient with a health concern that might be treated by neurosurgical intervention, the chief
13
resident will consistently demonstrate ability to:
Medical Expert/Clinical Decision Maker
Assess a patient’s capacity to make autonomous medical decisions
Assess accurately his/her own knowledge and skills as they pertain to the potential surgical
procedure
Write a concise but accurate and comprehensive pre-op note which includes the following
features: primary diagnosis, concurrent diagnoses, goals for the procedure, expected course, risks,
peri-operative monitoring and management plans, special operative equipment and techniques
needed
Establish the human and other resources needed for optimal accomplishment of neurosurgical
procedures
Correctly choose and use surgical instruments
Properly position the patient for surgery
Provide optimal surgical exposure with minimal disruption of healthy tissues, minimal loss of
blood, minimal cosmetic change, minimal risk of bacterial contamination
Efficiently complete an intended surgical intervention, e.g., removal of lesion, clipping of
aneurysm, insertion of shunt, etc.
Properly close the surgical wound with minimal blood loss, minimal infection risk, optimal
circumstances for best wound healing and functional recovery
Communicator
Communicate with patients and their associates as well as with other members of the in-patient
and out-patient health care teams to maximize patient comfort, safety, information, and recovery
Reasonably overcome potential barriers to communication with a patient in order to maximize the
patient’s autonomy for medical decision making
List management options and present information needed for informed consent for surgery with
verification that the patient or substitute decision maker has adequate recall and understanding of
that information
Accurately inform and advise family or other significant associates of the completion of a
procedure, its expected outcomes and consequences, and plans for the early post-operative phase
Present best available evidence to support the information and advice he/she has given to the
14
patient
Inform other significant stakeholders such as patient partners, families, and referring physicians of
the information and advice he/she has given to the patient
Document accurately and concisely the information relevant to decisions made
Collaborator
Completion of tasks need for the efficient and safe transfer of the patient from the OR to the
recovery room including communications with the recovery room staff
Carry out the surgical procedure accurately and efficiently, demonstrating the following:
a. Organization of tasks so that the surgical team carries them out efficiently and safely
b. Anticipation of next steps and communication with other members of the team in order to
avoid unnecessary confusion, stress, and delay
c. Proper technique and lexicon in relating to the surgical nurses
Manager
Organize and manage substitute decision maker involvement in medical decisions
Having obtained informed consent and discussed appropriately the planned surgical intervention
with a patient’s relevant associates, the chief resident will demonstrate ability to organize and
prepare for the surgical procedure by:
a. Proper scheduling including urgency and duration of the procedure
b. Organization of the appropriate equipment for the procedure
c. Assembling a sufficient and appropriate team for completion of the procedure
d. Accurately noting potential teaching and learning opportunities associated with the
procedure and planning for their implementation
Terminate a planned contact with the patient in a manner that allows patients and their significant
associates to understand accurately any operation done, its medical outcome, its significance, and
the prognosis for the condition treated
Health advocate
The chief resident will understand determinants of health as they apply to neurosurgical patients and
seek to bring appropriate resources and opportunities for best health and autonomy to their cases.
15
Scholar
The chief resident will incorporate evidence based research and guidelines into treatment
decisions and discussions accurately, consistently, and conspicuously, noting especially points of
controversy and new progress.
The chief resident will support, frequently attend, and often organize educational sessions for the
neurosurgical team.
The chief resident will support research activity by members of the teams and institutions with
which he/she is affiliated.
The chief resident will attend professional courses and conferences sufficiently to acquire
knowledge and skills to meet Royal College standards while continuing to meet clinical and
administrative responsibilities by using effective planning, communication, and delegation.
Professional
Having completed and reported a neurosurgical intervention, the chief resident will demonstrate
appropriate continuing care for the patient by completing and documenting post-operative visits with
frequency and content appropriate to the patients needs for comfort, safety, information, and best
potential health.
The chief resident will help guide senior and junior residents in all aspects of their learning and
training.
Evaluation of self and fellow health professionals will be shown to be accurate, effective, and
professional and carried out in a timely manner
The rules for neurosurgical practice established by the Royal College will be followed rigorously by
the chief resident.
Participate fully in the combined efforts of the Royal College, McMaster University, PAIRO, and
our neurosurgical training program to provide high quality training and professionally and personally
rewarding experiences for all members of our residency program.
B4. Junior Pediatric Neurosurgery Resident
Preamble.
The Pediatric Neurosurgery rotation is expected to provide the junior neurosurgical residents the
opportunity to become familiar with the common neurosurgically addressed pathologies and the
particular needs of infants, children, and their families. Many of the neurological conditions of
16
children amenable to surgical intervention present differently from their adult counterparts, and have
different nuances of management and outcome, although the fundamental principles of care are the
same as those that govern practice in older individuals. The emotional backdrop of an illness in a
child provides a setting that allows the new physician to hone and refine his/her communications
skills.
The pediatric neurosurgical service at McMaster Children’s Hospital provides a full range of
neurosurgical care to infants and children, as well as prenatal consultation to families expecting
delivery of infants with identified in-utero neuropathological conditions. “Elective” cases are generally
seen in consultation in the pediatric neurosurgical outpatient clinics, and admitted to neurosurgery
only following appropriate outpatient evaluation and preparation. Children who are in distress and
potentially unstable are generally admitted to the care of the appropriate pediatric critical care
specialist. Children in whom the diagnosis is unclear requiring in-patient evaluation or observation
for conditions which may or may not require neurosurgical intervention are commonly admitted
under the general pediatric service. In these situations, the neurosurgical service remains closely
involved with their management in a consultative basis, maintaining frequent communication with the
caregiving team on the ward, as well as with the patient and family. Thus the resident will have the
opportunity to act in either a primary or in a consultative role. In either role, in order to maximize the
educational opportunities, the resident is expected to maintain close observation of all patients, even
when not responsible for hands on care.
Evaluation
It is an expectation of the program that formal evaluations take place at the halfway point of the
rotation and during the final week of the rotation. The mid-rotation evaluation is expected to identify
and document any concerns of both resident and staff, and provide an opportunity to initiate any
required remediation strategies. The final evaluation will document any ongoing concerns. We
expect the residents to make full use of the T-Res program to provide documentation of her/his
attendance at all rounds, clinics, and surgical procedures and to identify the CanMeds roles
exemplified in each situation.
The resident should understand that at the time of evaluation, the neurosurgical staff may and
should request input from any health professionals who have interacted with the residents, as well
as considering their own observations.
Medical Expert/Clinical Decision Maker
The evaluation of the many components of this role will occur on a day-to-day and case-by-case
basis through direct observation and questioning by the neurosurgical staff.
Knowledge: Basic Science and Anatomy.
The resident should have an awareness of human embryology as it relates to the nervous system
to allow an understanding of the different congenital abnormalities that can arise resulting from
insults at different stages of gestation.
The resident should know the developmental milestones of childhood and be able to assess these
accurately.
17
The resident should understand the anatomy of the cranial vault and spinal column and have an
understanding of the pathological processes that can affect their morphological development.
The resident should have a basic knowledge of cerebrospinal fluid physiology and an
understanding of how various congenital, infectious, traumatic, and neoplastic processes can affect
its circulation.
The resident should understand the concepts of spinal stability and the variations in anatomy and
development that make spinal injury assessment different in children than in adults.
The resident should understand the pathophysiological concepts of spinal cord tethering, and
recognize the congenital abnormalities that can lead to this condition in children.
Knowledge: General Clinical Skills
The resident should be able to demonstrate a facility in the communication skills necessary to
obtain focused, appropriate histories from parents/guardians who may be emotionally distraught.
The resident should be able to perform an appropriate physical/neurological assessment in
children despite potentially poor compliance and differing developmental stages.
Knowledge: Specific Clinical Issues
By the completion of the rotation, the neurosurgical resident should be able to:
obtain a relevant history and use the information in reaching a differential diagnosis
perform an appropriate physical examination
order appropriate laboratory, imaging, and other diagnostic tests as guided by the history
and physical findings, demonstrating knowledge in the indications for and interpretation of
these investigations
formulate an appropriate plan for both outpatient and inpatient management, including
follow-up
recognize the various clinical presentations of increased intracranial pressure in different
age groups and different clinical scenarios.
recognize heat regulation problems in infants and the need for careful environmental
control in their management.
recognize the limited host resistance and the high risk of nosocomial infections in
18
newborns, and the need for aseptic protocols to minimize bacteriologic hazards.
be able to individualize fluid administration and drug dosage on the basis of weight, and be
able to quickly calculate fluid and electrolyte requirements using standard formulae.
recognize and allow for altered physiological states that affect drug administration (e.g.
immature hepatic and renal function).
predict the risk of apnoea post anaesthesia and post narcotic administration in small
infants.
apply pediatric trauma principles in the initial resuscitation and management of traumatized
children.
appraise the indications for operative and non-operative management of the head/spine
injured child.
understand the indications for, and demonstrate facility in various techniques of monitoring
intracranial pressure.
understand the rationale and use of preventative measures with respect to dysraphism.
understand the concepts related to genetic counseling, and be able to initiate discussions
and counseling with prospective parents of children with prenatally diagnosed congenital
malformations.
Knowledge: Technical Skills.
By completion of the training period, the resident should:
be able to perform infant subdural taps via the anterior fontanelle appropriately.
be familiar with techniques of CSF diversion in infants and children, as well as being cognizant of
approaches to diagnosing shunt malfunction.
become skilled at planning operative approaches for varying pediatric neurological conditions, and
using the equipment needed for positioning and draping children appropriately in the O.R.
become familiar with the procedures for managing craniosynostosis, craniocervical issues
(including procedures for Chiari decompressions), brain tumour biopsies and resections, and
neurotrauma including hematoma evacuation, and repair of depressed skull fractures.
become skilled at setting up the operative microscope correctly for various approaches.
become comfortable in setting up and using the frameless stereotactic system, and knowing its
limitations in small children.
become adept at techniques of opening and closing in order to minimize blood loss in infants and
19
children, and in order to maximize complication-free wound healing.
Communication
The evaluation of this role will be through direct observation by the neurosurgical
staff, by the staffs’ solicitation of the observations of other health professionals, and by
from observations of the patients and their families.
During his/her rotation, the resident will be part of the care of children in multidisciplinary clinics
(neuro-oncology, head injury, spina bifida) and must demonstrate an ability to interact appropriately
with other health professionals and physicians. He/she should be able to communicate at an
appropriate level with both the patient and the caregivers to promote the necessary understanding
and comfort with the clinical process. He/she should demonstrate the ability to produce appropriate,
concise written consultations, progress notes, and discharge summaries to document the
interactions and outline the proposed management and its rationale.
Collaborator
Evaluation of the collaborative role will occur both through the observation of
satisfactory and appropriate planning and management having occurred and through the
observations of other health care professionals.
Using his/her communication skills, the resident should demonstrate an ability to co-ordinate care
involving various providers, including anaesthesia, diagnostic imaging, intensive care,
physiotherapy, occupational therapy, nutritional therapy, and nursing care.
Manager
Direct observation and questioning by the staff on a case-by-case basis will inform the
evaluation of the resident in the performance of this role.
The resident should demonstrate an ability to plan and initiate a course of therapy from initial
consultation through diagnostic evaluations, surgical treatment, and follow-up care.
Scholar
Evaluation of the resident’s achievements in this role may be informed by questioning, observation
of formal presentations, and/or through the preparation of an academic paper, as well as soliciting
the input of other learners on the service with respect to how well the resident functions in facilitating
their learning (educator role).
It is expected that the resident will use the clinical material to initiate appropriate literature reviews,
which will highlight the knowledge available about a given problems, demonstrate the quality of the
evidence supporting any proposed therapeutic intervention, and apply that new information to the
child’s problem. Hopefully, this process will allow him/her to perceive the gaps in the body of
knowledge available, and possibly to propose a study or research plan which would answer or fill in
those gaps.
20
Health Advocate
This role will be evaluated primarily by direct observation during clinical and ward encounters with
children and their guardians.
The rotation gives ample opportunity for the resident to demonstrate appropriate counseling with
respect to disease prevention, particularly with respect to trauma and disease prevention, but also in
such areas as preparation for parenting and prevention of dysraphic states.
Professional
Again, this role will be evaluated by the neurosurgical staff on the basis of direct observation during
clinical encounters, but also importantly through guided questioning and discussions afterwards.
There are a number of very significant ethical issues which often present in a pediatric neurosurgical
practice. The resident will be expected to gain an understanding of the ethical basis underlying
physician/parent communications with respect to problems, varying from the possibility of
termination of pregnancy through the decisions with respect to the degree(s) of appropriate
interventions for children with neoplasia or chronic severe disability.
B5. Senior Pediatric Neurosurgery
Preamble.
The Pediatric Neurosurgery rotation will provide the senior neurosurgical residents the opportunity to
further their knowledge and skills with respect to the management of common neurosurgically
addressed pathologies and the particular needs of infants, children, and their families. Many of the
neurological conditions of children amenable to surgical intervention present differently from their
adult counterparts, and have different nuances of management and outcome, although the
fundamental principles of care are the same as those that govern practice in older individuals. The
emotional backdrop of an illness in a child provides a setting that allows the new physician to hone
and refine his/her communications skills.
The pediatric neurosurgical service at McMaster Children’s Hospital provides a full range of
neurosurgical care to infants and children, as well as prenatal consultation to families expecting
delivery of infants with identified in-utero neuropathological conditions. “Elective” cases are generally
seen in consultation in the pediatric neurosurgical outpatient clinics, and admitted to neurosurgery
only following appropriate outpatient evaluation and preparation. Children who are in distress or
potentially unstable are generally admitted to the care of the appropriate pediatric critical care
specialist. Children in whom the diagnosis is unclear requiring in-patient evaluation or observation
for conditions which may or may not require neurosurgical intervention are commonly admitted
under the general pediatric service. In these situations, the neurosurgical service remains closely
involved with their management in a consultative basis, maintaining frequent communication with the
caregiving team on the ward, as well as with the patient and family. Thus the resident will have the
opportunity to act in either a primary or in a consultative role. In either role, in order to maximize the
educational opportunities, the resident is expected to maintain close observation of all patients, even
when not responsible for hands on care.
Evaluation
21
It is an expectation of the program that formal evaluations take place at the halfway point of the
rotation and during the final week of the rotation. The mid-rotation evaluation is expected to identify
and document any concerns of both resident and staff, and provide an opportunity to initiate any
required remediation strategies. The final evaluation will document any ongoing concerns. We
expect the residents to make full use of the T-Res program to provide documentation of her/his
attendance at all rounds, clinics, and surgical procedures and to identify the CanMeds roles
exemplified in each situation.
The resident should understand that at the time of evaluation, the neurosurgical staff may and
should request input from any health professionals who have interacted with the residents, as well
as considering their own observations.
Medical Expert/Clinical Decision Maker
The evaluation of this role will occur on a day-to-day and case-by-case basis through direct
observation and questioning by the neurosurgical staff.
22
Knowledge: Basic Science and Anatomy.
The resident should have knowledge of human embryology as it relates to the nervous system to
allow an understanding of the different congenital abnormalities that can arise resulting from insults
at different stages of gestation.
The resident should know the developmental milestones of childhood and be able to assess these
accurately.
The resident should understand the anatomy of the cranial vault and spinal column and have an
understanding of the pathological processes that can affect their morphological development.
The resident should have an advanced knowledge of cerebrospinal fluid physiology and an
understanding of how various congenital, infectious, traumatic, and neoplastic processes can affect
its circulation.
The resident should understand the concepts of spinal stability and the variations in anatomy and
development that make spinal injury assessment different in children than in adults.
The resident should understand the pathophysiological concepts of spinal cord tethering, and
recognize the congenital abnormalities that can lead to this condition in children.
Knowledge: General Clinical Skills
The resident should be able to demonstrate a facility in the communication skills necessary to
obtain timely, focused, appropriate histories from parents/guardians who may be emotionally
distraught.
The resident should be able to perform an appropriate physical/neurological assessment in
children despite potentially poor compliance and differing developmental stages.
Knowledge: Specific Clinical Issues
By the completion of the rotation, the neurosurgical resident should be able to:
recognize the unique natural history of neurological diseases in children and use the information in
reaching a differential diagnosis.
recognize the various clinical presentations of increased intracranial pressure in different age
groups and different clinical scenarios.
recognize heat regulation problems in infants and the need for careful environmental control in
their management.
recognize the limited host resistance and the high risk of nosocomial infections in newborns, and
the need for aseptic protocols to minimize bacteriologic hazards.
23
be able to individualize fluid administration and drug dosage on the basis of weight, and be able to
quickly calculate fluid and electrolyte requirements using standard formulae.
recognize and allow for altered physiological states that affect drug administration (e.g. immature
hepatic and renal function).
predict the risk of apnoea post anaesthesia and post narcotic administration in small infants.
apply pediatric trauma principles in the initial resuscitation and management of traumatized
children.
appraise the indications for operative and non-operative management of the head/spine injured
child.
understand the indications for, and demonstrate facility in various techniques of monitoring
intracranial pressure.
understand the rationale and use of preventative measures with respect to dysraphism.
understand the concepts related to genetic counseling, and be able to initiate discussions and
counseling with prospective parents of children with prenatally diagnosed congenital malformations
Knowledge: Technical Skills
By completion of the training period, the resident should:
be able to perform infant subdural taps via the anterior fontanelle appropriately.
be able to perform techniques of CSF diversion in infants and children, as well as being cognizant
of approaches to diagnosing shunt malfunction.
become skilled at planning operative approaches for varying pediatric neurological conditions, and
using the equipment needed for positioning and draping children appropriately in the O.R.
become skilled at setting up the operative microscope correctly for various approaches.
become comfortable in setting up and using the frameless stereotactic system, and knowing its
limitations in small children.
become adept at techniques of opening and closing in order to minimize blood loss in infants and
children, and in order to maximize complication-free wound healing.
with appropriate guidance and supervision be able to perform common pediatric neurosurgical
procedures such as sagittal craniosynostosis repair, operative management of trauma,
ventriculoperitoneal shunting and revision procedures, Chiari decompressions, and posterior fossa
approaches for tumour resection.
24
Communication
The evaluation of this role will be through direct observation by the neurosurgical
staff, by the staffs’ solicitation of the observations of other health professionals, as well
as from observations of the patients and their families.
During his/her rotation, the resident will be part of the care of children in multidisciplinary clinics
(neuroncology, head injury, spina bifida) and must demonstrate an ability to interact appropriately
with other health professionals and physicians. He/she should be able to communicate at an
appropriate level with both the patient and the caregivers to promote the necessary understanding
and comfort with the clinical process. He/she should demonstrate the ability to produce appropriate,
concise written consultations, progress notes, and discharge summaries to document the
interactions and outline the proposed management and its rationale.
Collaborator
Evaluation of the collaborative role will occur both through the observation of
satisfactory and appropriate planning and management having occurred and through the
observations of other health care professionals.
Using his/her communication skills, the resident should demonstrate an ability to co-ordinate care
involving various providers, including anaesthesia, diagnostic imaging, intensive care,
physiotherapy, occupational therapy, nutritional therapy, and nursing care.
Manager
Direct observation and questioning by the staff on a case-by-case basis will inform the
evaluation of the resident in the performance of this role.
The resident should demonstrate an ability to plan and initiate a course of therapy from initial
consultation through diagnostic evaluations, surgical treatment, and follow-up care.
Scholar
Evaluation of the resident’s achievements in this role may be informed by questioning, observation
of formal presentations, and/or through the preparation of an academic paper, as well as soliciting
the input of other learners on the service with respect to how well the resident functions in facilitating
their learning (educator role).
It is expected that the resident will use the clinical material to initiate appropriate literature reviews,
which will highlight the knowledge available about a given problems, demonstrate the quality of the
evidence supporting any proposed therapeutic intervention, and apply that new information to the
child’s problem. Hopefully, this process will allow him/her to perceive the gaps in the body of
knowledge available, and possibly to propose a study or research plan which would answer or fill in
those gaps.
Health Advocate
25
This role will be evaluated primarily by direct observation during clinical and ward encounters with
children and their guardians.
The rotation gives ample opportunity for the resident to demonstrate appropriate counseling with
respect to disease prevention, particularly with respect to trauma and disease prevention, but also in
such areas as preparation for parenting and prevention of dysraphic states.
Professional
Again, this role will be evaluated by the neurosurgical staff on the basis of direct observation during
clinical encounters, but also importantly through guided questioning and discussions afterwards.
There are a number of very significant ethical issues which often present in a pediatric neurosurgical
practice. The resident will be expected to gain an understanding of the ethical basis underlying
physician/parent communications with respect to problems, varying from the possibility of
termination of pregnancy through the decisions with respect to the degree(s) of appropriate
interventions for children with neoplasia or chronic severe disability.
B6. Neurology
PREAMBLE
These objectives are expected to serve as a guideline for the training of a Neurosurgical resident
rotating through the Neurology service. It is anticipated that the training will lead to the production of
fully trained neurosurgeons, gaining an understanding neurological disorders with the potential for
careers in academic or community based Neurosurgery. These objectives have been formulated to
conform to the CanMEDS 2000 principles and the objectives of training in Neurosurgery as
recommended by the Royal College of Physicians and Surgeons of Canada. The objectives will be
described under the headings of the various CanMEDS 2000 roles-those of Medical Expert/Clinical
decision maker, Communicator, Collaborator, Manager, Health Advocate, Scholar and the
professional.
Medical Expert/Clinical Decision Maker:
General Objectives:
1. To obtain a fundamental knowledge of basic neurological disorders.
2. To obtain a practical working knowledge of neurological disorders.
3. To develop a thorough and in-depth knowledge of clinical neurology.
4. To develop excellence in clinical judgement.
5. To develop excellence in the techniques of neurology.
6. To develop an interest and understanding of the techniques of clinical and basic science research
as they relate to the clinical neurology.
7. To develop an ability and interest in teaching.
26
8. To be adequately prepared to pass the Principles of Surgery examination and specialty
examination in neurosurgery of the royal College of Physicians and Surgeons of Canada.
9. To master the principles of surgery.
10. To be an expert in obtaining a detailed and accurate relevant history.
11. To be able to formulate a differential diagnosis based on a critical evaluation of the symptoms
and signs.
12. To be able to order appropriate and properly utilized laboratory aids to document and
substantiate the clinical diagnosis.
13. The residents are expected to gradually improve their clinical decision making skills over the
course of their training so much so that they can function independently by the time they are in the
senior year.
Specific Objectives:
The development of competence in clinical neurology requires the trainee:
1. To have an understanding of the fundamental of neurological conditions which are treated without
surgery but may present to a neurosurgeon, e.g., motor neuron disease and multiple sclerosis.
2. To become familiar with the basic science of neurology and to outline the etiology,
pathophysiology, clinical presentations, natural history, prognosis, appropriate investigations, and
treatment of disease present with the following symptoms complexes.
3. Bilateral weakness including:
a. spinal cord disorders e.g. motor neuron disease
b. peripheral neuropathies, e.g. Guillain-Barre syndrome
c. neuromuscular disorders, e.g. myasthenia gravis
d. muscle disorders, e.g. inflammatory, endocrine, dystrophic
4. Unilateral or focal weakness including:
a. focal cerebral lesion, e.g. primary and secondary brain tumors, infections, hematoma,
infarcts
b. unilateral spinal cord lesions, e.g. Brown-Sequard syndrome
c. mononeuropathies
5. Bilateral numbness including:
a. brainstem lesions, e.g. central medullary syndrome
b. spinal cord lesions, e.g. syringomyelia, ependymoma
c. peripheral neuropathies, e.g. alcoholic neuropathy
6. Focal or unilateral numbness including:
a. transient ischemic attacks
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b. partial seizures
c. migraine aura
d. mononeuropathy
7. Anosmia including
a. vitamin deficiency
b. endocrine deficiency
c. drug side effects
8. Visual loss including:
a. transient ischemic attacks
b. cortical blindness
c. optic neuritis
d. optic nerve compression
9. Diplopia including:
a. central lesions
b. peripheral lesions
10. Altered hearing, dizziness and vertigo including:
a. meniere’s disease
b. benign positional vertigo
c. brainstem lesions
11. Cardiac arrhymias, postural hypotension
12. Ataxia and gait disturbance including:
a. differentiating cerebellar disease, posterior column disease, and large fibre sensory
neuropathies
b. recognizing classical gait patterns such as those in Parkinson’s disease, hemiparesis, limb
girdle weakness and normal aging
13. Speech disturbances including differentiating between major aphasic syndromes
14. Dementia and delirium including:
a. reversible causes of dementia, e.g. hypothyroidism, B12 deficiency
b. common causes of dementia, e.g. Alzheimer’s, multi-infarct dementia
c. acute confusional states, e.g. Wernicke’s encephalopathy
15. Coma including:
a. mass lesions, e.g. tumor, infarct, abscess
b. metabolic causes, e.g. hypercalcemia, ketoacidosis
16. Infections, e.g. meningitis
17. Subarachnoid hemorrhage
18. Involuntary movements including:
a. Parkinson’s syndrome and disease
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b. benign essential tremor
c. dystonias
d. drug-induced movement disorders
19. Syncope including:
a. cardiac causes, e.g. Strokes-Adams attacks
b. seizure disorders
c. vertebro-basilar insufficiency
d. autonomic failure
20. Seizure including medical management of status epilepticus
21. Headache including:
a. tension
b. analgesic rebound
c. migraine
d. medical management of trigeminal neuralgia
22. Regional pain including:
a. myofascial pain syndromes
b. neuropathic pain
c. postherpetic neuralgia
d. reflex sympathetic dystrophy
23. Urinary incontinence and impotence including:
a. cerebral causes
b. spinal cord lesions, e.g. multiple sclerosis
c. cauda equina lesions and peripheral neuropathies
d. drug-related, e.g. anticholinergics
24. To obtain a thorough understanding of the techniques and interpretation of the ancillary aids to
the diagnosis of neurology disorders including: Neurovestibular testing, Cerebral blood flow testing,
Electroencephalography, Electromyography and nerve conduction studies, Evoked potentials and
Neuropsychological testing.
25. Neuroradiology: Plain Radiography, Computed Tomography, Magnetic Resonance Imaging,
Arteriography and Radioactive nucleotide imaging.
26. To develop the necessary technical skills to perform neurology procedures:
a. Lumbar puncture
b. Cisternal puncture
c. Instruction of exercises for BPV
d. Hallpike-Dix maneuver
27. Interpretation of EEG
28. Interpretation of EMG and nerve conduction studies
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Communicator:
1. Learn how to give an accurate, concise verbal report of the history and physical examination
to staff and to resident colleagues.
2. Communicate effectively with health care professionals and other members of the team.
3. Gain experience in requesting, and responding to requests for consultations from colleagues.
4. Maintain complete, accurate and up to date medical records, clearly written or dictated.
5. Recognize the need for, and practice clear communication
6. Listen effectively.
7. The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
The resident is expected to demonstrate acceptable proficiency in communication skills in both
verbal and written modalities with:
1. Patients and their relatives
a. To be able to explain the neurological disease process
b. To be able to obtain an INFORMED consent related to Neurology procedures
2. Other physicians
a. Family Physicians
b. Other resident staff
c. Neurology staff
d. Consultants in Internal Medicine, Respirology, Endocrinology, and others
e. Radiologists
f. Medical students and clinical clerks
g. Surgical specialties
3. Health care professional other than physicians
a. Nursing staff
b. Physiotherapists
c. Occupational therapists
d. Social workers
e. Pharmacists
f. Clerical and other allied staff such as speech pathologists, nutritionists, psychologists, and
others
4. The resident is also expected to become very comfortable with presentation of clinical
30
investigative information at teaching rounds and scientific conferences using computerized teaching
aids.
Collaborator:
1. The resident is expected to be able to participate in interdisciplinary team meetings.
2. The resident is expected to be able to consider and respect the opinions of other members of the
health care team.
3. The resident is expected to be able to comprehend the depth of expertise of others and contribute
to decision making as expected of a Neurosurgery resident.
4. The resident is also expected to be aware of his/her limitations and those of other health care
team members.
5. The resident is, in essence expected to be able to collaborate with other non-medical health care
personnel to achieve the very best possible outcome for the patients.
Manager:
a. The resident needs to understand how to function within the confines of the structure, finances
and the general operation of the Canadian health care system.
b. The resident needs to be cognizant of the functioning of the organizations within the hospital such
as
a. committees at various levels
b. local organizations
c. national and international organizations pertinent to the specialty of Neurology
d. research accounts
c. The resident is expected to comprehend principles of care and decisions based on best available
evidence.
d. Manage effectively the different tasks involved in the diagnosis and treatment of patients.
e. Prioritize responsibilities.
f. Utilize health care resources safely and effectively.
g. Utilize information technology effectively.
Health Advocate:
1. For the individual patient, the resident is expected to be familiar with the potential deleterious
31
consequences of systematic problems such as access to health care resources for diagnosis and
treatment. In the appropriate situations they are expected to learn how to be a health advocate for
the individual patient to facilitate the best possible outcome for the patient.
2. For various patient groups at risk, the resident is expected to be aware of preventative measures
that have been shown to be efficacious.
3. Advocate on behalf of patients, families and communities regarding good health practices.
Scholar:
1. Demonstrate a commitment to, and success with, a personal continuing education strategy.
2. Read about clinical cases and participate appropriately by asking questions.
3. Understand the basics of critical appraisal as they pertain to neurology practice.
4. Teach medical students and other health care professionals.
5. Participate in academic rounds, teachings sessions and other educational outlets.
6. Evaluate proposed diagnosis and treatment with current literature when appropriate.
Clinical issues: The resident is expected to identify clinical issues that he/she does not fully
understand, and perform the following:
1. Generate a clinical question
2. Identify his/her own knowledge and its limitations
3. Develop a plan for doing the appropriate research
4. Assimilate and analyze the material available
5. Consult other physicians and allied health care personnel as needed
6. Propose a solution to the clinical question posed
7. Implement the solution
8. Evaluate the efficacy of the solution
9. Generate new clinical question as relevant
Professional:
The resident is expected to be able to behave as a professional in every aspect of their Neurology
32
rotation. He/She is expected to:
1. Interact with patients, relatives, his/her peers and other health care personnel in a very
professional manner
2. Respect the opinions of others
3. Treat all others as he/she expects to be treated
4. Provide medical care in an honorable and ethical fashion
5. Find a balance between professional and personal life that is fulfilling professionally
6. Be able to evaluate his/her knowledge and abilities along with the limitations
7. Act according to his/her limitations-specifically ask for help from colleagues when he/she is not
comfortable with a clinical situation
8. To ensure the development of a keen sense of responsibility and compassion toward their
patients and their families
9. Accept constructive feedback and act appropriately.
B7. Critical Care
Medical Expert/Clinical Decision Maker
Preamble
These objectives are expected to serve as a guideline for the training of a Neurosurgical Resident
rotating through the Critical Care Department. It is expected that this training will provide the resident
with the capability to respond appropriately to the spectrum of urgent and emergent medical and
surgical issues, which patients and their families bring to critical care setting. Further, this rotation
should provide the resident with an understanding of both the capabilities and limitations of critical
care departments within a modern hospital in the Canadian Health Care System.
The resident’s function in the ICU will require that she/he gain a working knowledge of both normal
physiology and pathophysiology to enable the expeditious identification and management of the
patient who is unstable and at risk from the full range of disease processes. Under supervision, the
resident shall initiate appropriate investigations and avoid inappropriate interventions, as well as
facilitate ongoing care.
Medical Expert/Clinical Decision Maker:
General Objectives
1. Take a pertinent complete history.
33
2. Perform a satisfactory physical examination.
3. Order appropriate laboratory and imaging tests.
4. Formulate a prioritized problem/differential diagnoses list.
5. Formulate a management plan, including medical and surgical interventions and monitoring
requirements.
6. Establish a good therapeutic relationship with the patients and their families.
7. Discuss the effects, risks, and benefits of treatment recommendations.
8. Discuss the issues of treatment withdrawal and resuscitation limits.
9. Learn how to deal with sub-optimal outcomes and complications.
Knowledge: Basic Science and Anatomy.
The resident is expected to have a good comprehension of basic anatomy, physiology, and
metabolism to be able to understand the deviations there from with which patients in the ICU may
present.
Knowledge: General Clinical:
The resident will be expected to learn the algorhythmic expeditious assessment of an ICU, as well
as the rapid formulation and institution of a management plan. She/he will be expected to
demonstrate an understanding of the pathophysiology of common medical and surgical diseases
presenting to the Emergency Department.
Knowledge: Specific Clinic Problems.
1. These include myocardial ischaemia and infarction, pulmonary oedema, respiratory failure, the
acute abdomen, musculoskeletal emergencies, infectious processes including septicaemia,
urosepsis, meningoencephalitis, wound infections, bronchitis, conjunctivitis, pharyngitis, pneumonia,
and cellulitis.
2. The resident should demonstrate an ability to manage both minor and major soft tissue injuries.
3. The resident will demonstrate a working understanding of ischaemia as it applies to all organs,
including the brain, the heart, the kidneys, the intestinal tract, and the extremities. This knowledge
shall include an understanding of strategies to limit the effect of ischaemia.
Knowledge: Technical.
1. The resident is expected to be able to establish, use, and maintain the following lines and tubes:
a. Endotracheal and tracheostomy tubes
b. Intravenous lines including central lines via jugular or subclavian punctures
34
c. Arterial lines
d. Feeding tubes
e. Chest tubes
2. The resident will learn to interpret information from bedside monitors and from laboratory and
imaging results in order to help provide best management of critical illnesses
Knowledge Clinical:
The resident will demonstrate adequate knowledge of:
a. Airway assessment and management.
b. Respiratory failure of various causes.
c. Cardiac disorders, including acute MI, cardiac arrest, arrhythmias, pulmonary edema,
pulmonary hypertension, electro-mechanical dissociation, etc.
d. Circulatory failure/shock.
e. Renal failure, including dialysis.
f. Fluid, electrolyte and acid/base balance.
g. Nutritional assessment and management (including enteral and parenteral nutrition).
h. Coagulation disorders.
i. Endocrine disorders.
j. Neurological disorders (including coma, seizures, brain death).
k. Pharmacology of critically-ill patients, including antibiotics, inotropes, cardiac medications,
anesthetic agents.
l. Toxicology-related disorders, including overdoses, intoxications and poisonings.
m. Perioperative management of critically ill patients.
Technical/Procedural Skills:
The resident will learn to:
a.
b.
c.
d.
e.
f.
g.
h.
Obtain and maintain an airway by appropriate means.
Intubate.
Carry out Advanced Cardiac Life Support.
Obtain venous and arterial access, including central lines.
Perform flexible fibreoptic bronchoscopy.
Insert chest tubes.
Thoracentesis, paracentesis, lumbar puncture.
Tube insertions, including nasogastric, Foley catheters.
Communicator:
The resident shall demonstrate an ability to communicate with patients and with their families, and to
amplify and verify histories in charts of admitted patients.
Communicate effectively with health care professionals and other members of the team.
He/she will establish communications with the referring physicians and associated residents, family
physicians, and other involved health professionals in both a written and oral manner to enable the
35
facilitation of care.
Maintain complete, accurate and up to date medical records, clearly written or dictated.
Listen effectively.
The ability to communicate with patients and their families explaining to them their disease process
and the benefits, risks, and complications, and alternatives of management recommendations in
terms each individual can comprehend.
Collaborator:
The resident is expected to be able to participate in interdisciplinary team meetings.
Consult and interact with respect to other health care professionals, in particular with the
anesthesiologists, the surgeons and their team, nurses in the operating room and on the ward.
Consult and work effectively with the attending staff.
Consults and works effectively with other medical specialists.
Consults and works effectively with colleagues, medical clerks and students.
Effectively work with other health care professionals to prevent, negotiate, and resolve interpersonal
conflict.
The resident is expected to be able to consider and respect the opinions of other members of the
health care team.
The resident is also expected to be aware of his/her limitations and those of other health care team
members.
The resident is, in essence expected to be able to collaborate with other non-medical health care
personnel to achieve the very best possible outcome for the patients.
The resident will recognize the competencies and respect the professionalism of other health
professionals, utilizing their expertise in an appropriate manner to facilitate the patient’s care.
Manager:
Manage effectively the different tasks involved in the diagnosis and treatment of patients.
Prioritize responsibilities.
Utilize health care resources safely and effectively.
Utilize information technology effectively.
36
The resident is expected to comprehend principles of care and decisions based on best available
evidence.
The resident needs to understand how to function within the confines of the structure, finances and
the general operation of the Canadian health care system.
Work well in the health care organization (clinic, ward, ICU, ER and operating room).
Learn to use their time efficiently.
The resident shall demonstrate an ability to manage medical, surgical, and psychiatric problems in
the ICU in an algorhythmic fashion, providing timely management decisions with an eye to the
efficient and expeditious care of the patient.
Health Advocate:
For the individual patient, the resident is expected to be familiar with the potential deleterious
consequences of systematic problems such as access to health care resources for diagnosis and
treatment. In the appropriate situations they are expected to learn how to be a health advocate for
the individual patient to facilitate the best possible outcome for the patient.
For various patient groups at risk, the resident is expected to be aware of preventative measures
that have been shown to be efficacious.
Advocate on behalf of patients, families and communities regarding good health practices.
Become aware of health advocacy issues related to the ICU patient population.
Scholar:
1.
2.
3.
4.
5.
6.
7.
Demonstrate a commitment to, and success with, a personal continuing education strategy.
Read about clinical cases and participate appropriately by asking questions.
Understand the basics of critical appraisal as they pertain to ICU practice.
Teach medical students and other health care professionals.
Participate in academic rounds, teachings sessions and other educational outlets.
Evaluate proposed diagnosis and treatment with current literature when appropriate.
The clinical material seen in the ICU shall be used by the resident as an opportunity to
stimulate reading and literature reviews around specific surgical and medical issues.
Particular attention shall be paid to ICU disease presentations, with a view to the
consideration of evidence-based management and care.
Professional:
The resident is expected to be able to behave as a professional in every aspect of their ICU rotation.
She/he is expected to:
The resident must behave in a manner demonstrating his/her reliability, integrity, honesty, and ethical
approach to the care of his/her patients, respecting the cultural and ethnic issues appropriate to them.
37
Interact with patients, relatives, his/her peers and other health care personnel in a very professional
manner
Respect the opinions of others
Treat all others as he/she expects to be treated
Provide medical care in an honorable and ethical fashion
Find a balance between professional and personal life that is fulfilling professionally
Be able to evaluate his/her knowledge and abilities along with the limitations
Act according to his/her limitations-specifically ask for help from colleagues when he/she is not
comfortable with a clinical situation
To ensure the development of a keen sense of responsibility and compassion toward their patients
and their families
The ability and willingness to work in a cooperative manner with other health care personnel, being
sensitive to their roles and abilities, and to be able to give and receive advice in a manner that is
consistent with the harmonious operation of a health care team. The resident is expected to exhibit
appropriate personal and interpersonal professional behaviours, to show integrity, honesty, and
compassion, and to practice in an ethical manner.
Recognize own limitations and seek advice and help when needed.
Accept constructive feedback and act appropriately.
B8. Orthopedics
Medical Expert/Clinical Decision Maker
GENERAL OBJECTIVES
1. To gain a knowledge of musculoskeletal physiology and pathophysiology pertinent to the practice
of orthopedic surgery, especially spine surgery.
2. To gain a working knowledge of current orthopedic practice.
Specific Objectives:
38
Medical Expert
The resident is expected to learn how to:
To obtain a fundamental knowledge of basic orthopedic surgery.
To obtain a practical working knowledge of orthopedic surgery.
To develop a thorough and in-depth knowledge of clinical orthopedic surgery.
To develop excellence in clinical judgment.
To develop an interest and understanding of the techniques of clinical and basic science research as
they relate to the clinical orthopedic surgery.
To be adequately prepared to pass the Principles of Surgery examination and specialty examination
in neurosurgery of the royal College of Physicians and Surgeons of Canada
To obtain a detailed and accurate relevant history.
To carry out a thorough and accurate relevant examination.
To formulate a medical and surgical management program to include the appropriate use of
pharmacology and functional rehabilitation.
EDUCATIONAL OBJECTIVES
1. CLINICAL SKILLS
Given a patient with a musculoskeletal problem, the neurosurgery resident is expected to be able to
do the following to the satisfaction of his/her supervisor(s):
1. Take a relevant history.
2. Perform an acceptable physical exam concentrating on the relevant areas.
3. Arrive at an appropriate differential diagnosis.
4. Order appropriate laboratory, radiologic and other diagnostic procedures demonstrating
knowledge in the interpretation of these investigations, especially radiographs of long bones.
5. Arrive at an acceptable plan of management, demonstrating knowledge in operative and nonoperative management of the disease process.
6. Formulate an initial hypothesis in light of conflicting data or events.
7. Manage patients in the ambulatory setting, demonstrating knowledge of common office
techniques and procedures.
39
8. Manage the patient throughout the entire in-hospital course, demonstrating knowledge of and
being able to treat potential complications of the disease processes and operative procedures.
9. Provide a plan for patient follow-up.
10. Identify conditions that require urgent treatment.
11. Interpretation of radiographic spine images: MRI, CT, skeletal x-rays
12. Work-up for metastatic disease
2. KNOWLEDGE BASE
Given a patient with a musculoskeletal problem, the neurosurgical resident rotating through
orthopedics must be able to perform the clinical skills listed in section 1, and be able to demonstrate
to the satisfaction of his/her supervisors(s) a fundamental knowledge and understanding of the
general areas in 2a and a practical working knowledge of the specific disease processed listed in 2b.
These lists are not intended to be exhaustive or exclusive.
a. General Areas
1. Anatomy and physiology of the musculoskeletal/locomotor system
a. muscles, tendons, ligaments, long bones, spine, pelvic
b. spinal & peripheral nerves
c. arterial & venous systems in extremities
2. Pharmacology as related to diseases of the bone and joints
a. osteoporosis drugs
b. Calcium
3. Resuscitation and care of the multiple injured patient in the trauma setting.
4. Principles of treatment of fractures, including open fractures.
5. Principles of treatment of soft tissue injuries.
6. Principles of treatment of spinal fractures.
7. Principles of treatment of spinal cord injuries.
b. Specific Disease Entities/Clinical Syndromes
1. Upper and lower extremity fractures (classification, treatment, complications & results)
2. Spinal fractures (diagnosis, treatment, complications and prognosis)
40
3. Ligamentous and tendinous injuries, especially pertaining to the spine
4. Vascular and neurologic complications of limb injuries eg: Compartment syndrome
5. Principles of reconstruction of arthritic joints
6. Principles of treatment of degenerative spinal disease
a. spondylosis, spondylolisthesis
b. degenerative disc disease
7. Principles of spinal cord decompression & fusion (cervical, thoracic, lumbar, sacral)
8. Osteoporosis & Osteoarthritis
9. Bone Cancers
a. Primary Tumors (osteosarcoma, multiple myeloma, etc.)
b. Secondary Tumors (mets)
3. TECHNICAL SKILLS
At the end of a rotation on an orthopedic service, the neurosurgical resident must be able to show
technical competence in the following procedures to the satisfaction of his/her supervisor(s).
1. Assisting (both first and second) in the operating room, developing a facility for anticipation of
surgical maneuvers, gentle retraction on tissues, an ability to take direction well, to make reasonable
suggestions and enquiry, and to contribute to a positive operating room atmosphere.
2. Surgical approaches to upper and lower extremities, and spine (decompression, fusion).
3. Closed reduction of fractures and cast application techniques in the ER setting.
4. Open reduction of fractures and application of internal fixation devices including plate and IM
nails.
5. Surgical repair of tendon injuries.
6. Measurement of compartment pressures.
7. Traction of long bones for temporary reduction of fractures.
8. Cervical spine reduction with traction.
9. Use of halo vests and rigid C-spine collars.
Communicator
1. Learn how to give an accurate, concise verbal report of the history and physical examination
to staff and to resident colleagues.
41
2. Communicate effectively with health care professionals and other members of the team.
3. Gain experience in requesting, and responding to requests for consultations from colleagues.
4. Maintain complete, accurate and up to date medical records, clearly written or dictated.
5. Recognize the need for, and practice clear communication in the operating room.
6. Listen effectively.
7. The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
The resident is expected to demonstrate acceptable proficiency in communication skills in both
verbal and written modalities with:
1. Patients and their relatives
a. To be able to explain the Orthopedic disease process
b. To be able to obtain an informed consent related to surgical procedures
2. Other physicians
a. Family Physicians
b. Other resident staff
c. Neurosurgical staff
d. Consultants in Internal Medicine, Respirology, Endocrinology and others
e. Radiologists
f. Medical students and clinical clerks
g. Other surgical specialities
3. Health care professionals other than physicians
a. Nursing staff
b. Physiotherapists
c. Occupational therapists
d. Social workers
e. Pharmacists
f. Clerical and other allied staff such as speech pathologists, Nutritionists, Psychologists, and
others.
The resident is also expected to become very comfortable with presentation of clinical and
investigative information at teaching rounds and scientific conferences using computerized teaching
aids.
Collaborator
1. The resident is expected to be able to participate in interdisciplinary team meetings.
2. The resident is expected to be able to consider and respect the opinions of other members of the
health care team.
42
3. The resident is expected to be able to comprehend the depth of expertise of others, and
contribute to decision making as an Orthopedic resident.
4. The resident is also expected to be aware of his/her limitations and those of other health care
team members.
5. The resident is, in essence expected to be able to collaborate with other non-medical health care
personnel to achieve the very best possible outcome for the patients.
6. The resident is expected to learn how to interact with specialists from other specialities. For
combined cases, the collective and individual responsibilities to the patients need to be clearly
understood. The boundaries between specialities have to be recognized and respected. Most
importantly, the residents need to make sure that in a collaborative surgical effort, issues do not get
missed.
Manager
1. The resident needs to understand how to function within the confines of the structure, finances,
and the general operation of the Canadian health care system.
2. The resident needs to be cognizant of the functioning of the organizations within the hospital such
as:
a. committees at various levels,
b. Local organizations
c. national and international organizations pertinent to the speciality of orthopedics
d. research accounts
3. The resident is expected to, as he/she progresses in the training program manage his/her junior
staff functions-specifically appropriate delegation of activities, call schedules and other issue with
equanimity and a sense of fairness.
4. The resident is expected to comprehend principles of care and decisions based on best available
evidence.
5. The resident is expected to learn some practical matters such as arranging meetings and running
meetings smoothly.
Health Advocate
1. For the individual patient, the resident is expected to be familiar with the potential deleterious
consequences of systematic problems such as access to health care resources for diagnosis and
treatment. In the appropriate situations they are expected to learn how to be a health advocate for
the individual patient to facilitate the best possible outcome for that patient.
2. For various patient groups at risk, the resident as expected to be aware of preventative measures
that have been shown to be efficacious. For example, better education to vulnerable groups such as
spinal injury patients.
43
3. The resident is expected to actively get involved with such organizations such as “Thinkfirst” that
is active in prevention of neurotrauma and CHAT, which is a community and hospital combined
initiative against trauma.
Scholar
Clinical issues: The resident is expected to identify clinical issues that he/she does not fully
understand, and perform the following:
1. Generate a clinical question
2. Identify his/her own knowledge and its limitations
3. Develop a plan for doing the appropriate research
4. Assimilate and analyze the material available
5. Consult other physicians and allied health care personnel as needed
6. Propose a solution to the clinical question posed
7. Implement the solution
8. Evaluate the efficacy of the solution
9. Generate new clinical question as relevant
Research issues: The resident is expected to (if time permits):
1. Generate a research question
2. Review relevant literature
3. Assimilate the literature
4. Identify and collaborate with appropriate personnel
5. Write a research proposal
6. Conduct the research
7. Disseminate the results of the results by:
a. Presenting at conferences
b. Writing a paper for publication
8. Identify future research possibilities
44
Educational issues:
1. The resident is expected to understand the principles of self-directed learning.
2. The resident is expected to teach the junior residents, clinical clerks, undergraduate students the
various clinical and surgical aspects of Orthopedics.
3. The resident is expected to over the course of the program learn to impart appropriate clinical
information to the allied health care personnel.
4. The resident is expected to review text-books, papers and other publications prior to surgery and
be comfortable with the surgical approach prior to coming to the operating room.
6. The resident is expected to be able to prepare for Orthopedics rounds and seminars at relatively
short notice.
7. The resident is expected to be able to study and use all sources (electronic and written) to gather
information relating to management of consultations seen in the emergency room and the
Orthopedic wards.
Professional
At the end of the rotation, the resident must have demonstrated to the satisfaction of his/her
supervisor(s):
1. The ability and willingness to work in a cooperative manner with other health care personnel,
being sensitive to their roles and abilities, and to be able to give and receive advice in a manner that
is consistent with the harmonious operation of a health care team.
2. The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
3. Respect for patients’ rights to privacy.
4. Sensitivity to the sexual, moral, ethical, religious and ethnic characteristics of the patient and
family, understanding of the special psychological needs of the patient with musculoskeletal
problems, and the capacity for supportive and compassionate care in the course of terminal disease
5. A knowledge of the ethical and legal aspects of orthopedic surgery.
6. Honesty, reliability, and respectfulness in working with patients and colleagues alike.
7. The discipline of continued self-education and the appropriate application of this current
knowledge to the clinical setting; the ability to supervise and educate undergraduate and
postgraduate students; the skills to educate colleagues, patients, families, and other health care
45
professionals; the capacity to undertake research, and be aware of the importance of peer review
protocols, ethical considerations, and the limitations of such endeavors.
8. The ability to keep succinct pertinent, and up-to-date medical records.
B9. Plastic
surgery
PREAMBLE
These objectives are expected to serve as a guideline for the training of a Neurosurgical resident
rotating through the Plastic Surgery service. It is anticipated that the training will lead to the
production of fully trained neurosurgeons, gaining an understanding of benign and malignant lesions
of the skin, wound creation and closure as well as the technical experience in optimal incision
planning, suturing techniques and handling of wounds, with the potential for careers in academic or
community based Neurosurgery. These objectives have been formulated to conform to the
CanMEDS 2000 principles and the objectives of training in Neurosurgery as recommended by the
Royal College of Physicians and Surgeons of Canada. The objectives will be described under the
headings of the various CanMEDS 2000 roles-those of Medical Expert/Clinical decision maker,
Communicator, Collaborator, Manager, Health Advocate, Scholar and the professional.
Medical Expert/Clinical Decision Maker:
General Objectives:
1. To obtain a fundamental knowledge of basic plastic surgery.
2. To obtain a practical working knowledge of plastic surgery.
3. To develop a thorough and in-depth knowledge of clinical plastic surgery.
4. To develop excellence in clinical judgement.
5. To develop excellence in the techniques of plastic surgery.
6. To develop an interest and understanding of the techniques of clinical and basic science research
as they relate to the clinical plastic surgery.
7. To develop an ability and interest in teaching.
8. To be adequately prepared to pass the Principles of Surgery examination and specialty
examination in neurosurgery of the royal College of Physicians and Surgeons of Canada.
9. To master the principles of surgery.
10. To obtain a detailed and accurate relevant history.
11. To carry out a thorough and accurate relevant examination.
46
12. To be able to formulate a differential diagnosis based on a critical evaluation of the symptoms
and signs.
13. To be able to order appropriate and properly utilized laboratory aids to document and
substantiate the clinical diagnosis.
14. To formulate a medical and surgical management program to include the appropriate use of
pharmacology and functional rehabilitation.
15. The residents are expected to gradually improve their clinical decision making skills over the
course of their training so much so that they can function independently by the time they are in the
senior year.
Specific Objectives:
The development of competence in clinical plastic surgery requires the trainee:
1. To have an understanding of the fundamental of anesthetic options.
2. To become familiar with the basic science of plastics including the pathophysiology of trauma,
both general and specific to the plastic surgery service; pathophysiology of burns; wound healing in
aseptic and septic conditions; options for wound closure; reconstructive surgery options for head,
neck, hand, and trunk.
3. Trauma
a. Polytraumatized patient
b. Head and neck trauma
c. Facial fractures
d. Facial soft tissue injury
e. Hand trauma including: Skin loss
i. Tendon injury
ii. Open and closed hand fractures
f. Burn patient
g. Frostbite
h. Hypothermia
4. Wound healing problems:
a. Diabetes
b. Immunosuppressed patients
c. Paraplegic patients
5. Hand lesions
a. Malformations
b. Deficiencies
6. Neoplastic skin lesions
a. Benign tumors
b. Malignant tumors
47
7. Soft tissue infections
a. Spontaneous
b. Post-traumatic
c. Post operative
8. Techniques of skin surgery
a. Skin grafting
b. Z-plasty
c. Rotation flaps
d. Myocutaneous flaps
9. Skin ulcers
a. Vascular
b. Diabetic
c. Decubitus ulcers
10. Microvascular techniques
11. To obtain a thorough understanding of the techniques and interpretation of the ancillary aids to
the diagnosis of plastic surgery disease using appropriate radiological investigations.
12. To develop the necessary technical skills to perform plastic surgery procedures. It is recognized
that there will be some variability in terms of learning technical skills. However, those listed below
are expected to be used as goals. It is expected that these goals will be best achieved by gradual
increase in delegated activities.
Communicator
1. Learn how to give an accurate, concise verbal report of the history and physical examination
to staff and to resident colleagues.
2. Communicate effectively with health care professionals and other members of the team.
3. Gain experience in requesting, and responding to requests for consultations from colleagues.
4. Maintain complete, accurate and up to date medical records, clearly written or dictated.
5. Recognize the need for, and practice clear communication in the operating room.
6. Listen effectively.
7. The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
The resident is expected to demonstrate acceptable proficiency in communication skills in both
verbal and written modalities with:
48
1. Patients and their relatives
a. To be able to explain the disease process
b. To be able to obtain an informed consent related to surgical procedures
2. Other physicians
a. Family Physicians
b. Other resident staff
c. Neurosurgical staff
d. Consultants in Internal Medicine, Respirology, Endocrinology and others
e. Radiologists
f. Medical students and clinical clerks
g. Other surgical specialities
3. Health care professionals other than physicians
a. Nursing staff
b. Physiotherapists
c. Occupational therapists
d. Social workers
e. Pharmacists
f. Clerical and other allied staff such as speech pathologists, Nutritionists, Psychologists, and
others.
4. The resident is also expected to become very comfortable with presentation of clinical and
investigative information at teaching rounds and scientific conferences using computerized teaching
aids.
Collaborator:
1. The resident is expected to be able to participate in interdisciplinary team meetings.
2. The resident is expected to be able to consider and respect the opinions of other members of the
health care team.
3. The resident is expected to be able to comprehend the depth of expertise of others and contribute
to decision making as expected of a Neurosurgery resident.
4. The resident is also expected to be aware of his/her limitations and those of other health care
team members.
5. The resident is, in essence expected to be able to collaborate with other non-medical health care
personnel to achieve the very best possible outcome for the patients.
Manager:
1. The resident needs to understand how to function within the confines of the structure, finances
and the general operation of the Canadian health care system.
2. Manage effectively the different tasks involved in the diagnosis and treatment of patients.
49
3. Prioritize responsibilities.
4. Utilize health care resources safely and effectively.
5. Utilize information technology effectively.
6. The resident needs to be cognizant of the functioning of the organizations within the hospital such
as:
a. committees at various levels
b. local organizations
c. national and international organizations pertinent to the specialty of Plastic surgery
d. research account
7. The resident is expected to comprehend principles of care and decisions based on best available
evidence.
Health Advocate:
1. For the individual patient, the resident is expected to be familiar with the potential deleterious
consequences of systematic problems such as access to health care resources for diagnosis and
treatment. In the appropriate situations they are expected to learn how to be a health advocate for
the individual patient to facilitate the best possible outcome for the patient.
2. For various patient groups at risk, the resident is expected to be aware of preventative measures
that have been shown to be efficacious.
3. Advocate on behalf of patients, families and communities regarding good health practices.
4. The resident is expected to actively get involved with such organizations such as “Thinkfirst” that
is active in prevention of neurotrauma and CHAT, which is a community and hospital combined
initiative against trauma.
Scholar:
Clinical issues: The resident is expected to identify clinical issues that he/she does not fully
understand, and perform the following:
1. Generate a clinical question
2. Identify his/her own knowledge and its limitations
3. Develop a plan for doing the appropriate research
4. Assimilate and analyze the material available
5. Consult other physicians and allied health care personnel as needed
50
6. Propose a solution to the clinical question posed
7. Implement the solution
8. Evaluate the efficacy of the solution
9. Generate new clinical question as relevant
Professional:
1. The resident is expected to be able to behave as a professional in every aspect of their Plastic
Surgery rotation. He/She is expected to:
2. Interact with patients, relatives, his/her peers and other health care personnel in a very
professional manner.
3. Respect the opinions of others
4. Treat all others as he/she expects to be treated
5. Provide medical care in an honorable and ethical fashion
6. Find a balance between professional and personal life that is fulfilling professionally
7. Be able to evaluate his/her knowledge and abilities along with the limitations
9. Act according to his/her limitations-specifically ask for help from colleagues when he/she is not
comfortable with a clinical situation
10. To ensure the development of a keen sense of responsibility and compassion toward their
patients and their families
11. Accept constructive feedback and act appropriately.
B10. Trauma
Medical Expert/Clinical Decision Maker
GENERAL OBJECTIVES
1 To gain a knowledge of the physiology of the traumatized patient.
2 To gain a knowledge of the multidisciplinary nature of trauma management and the roles of the
various sub-specialties.
3 To understand the functions of the trauma team, trauma team leader and members within the
team.
51
4 To understand the role of the neurosurgeon in the management of head injuries associated with
multi-system trauma.
5 To gain technical expertise helpful to the developing surgeon
EDUCATIONAL OBJECTIVES
CLINICAL SKILLS
Given a trauma patient, the neurosurgery resident will be able to do the following to the satisfaction
of his/her supervisor(s):
1 Assess the trauma patient rapidly and accurately and demonstrate concepts and principles of
primary and secondary patient assessment.
2 Resuscitate and stabilize the patient on a priority basis and establish management priorities in a
trauma situation.
3 Initiate primary and secondary management necessary within the first hour of emergency care for
acute life threatening emergencies
4 Manage the trauma patient subsequent to the resuscitation in the emergency department.
5 Diagnose and manage commonly encountered orthopedic injuries, abdominal injuries, thoracic
injuries and head injuries.
6 Understand the use of ancillary and consultative services to aid in the comprehensive
management of the trauma patient.
7 Understand the psychosocial aspects of the trauma patient including the dynamics of the trauma
family, the interaction with the medical/legal profession as well as other community agencies such as
Community Care Access Centre and the police department.
8 Understand the importance of trauma prevention.
KNOWLEDGE BASE
Given a trauma patient, the core surgical resident must be able to perform the clinical skills listed in
section 1, and be able to demonstrate to the satisfaction of his/her supervisors(s) a fundamental
knowledge and understanding of the specific areas in 2; This list is intended to be a guide, and is
neither exhaustive nor exclusive.
Specific Areas
1 Initial triage and stabilization of the trauma patient at a peripheral centre.
2 Pre-hospital care to ensure the safe transfer of an acutely injured patient.
3 Establishment of emergency treatment priorities and immediate management of the following life
52
threatening conditions:
a airway obstruction
b shock and overt hemorrhage
c pneumothorax
d hemothorax
e cardiac tamponade
f fractured cervical spine
4 Appropriate diagnostic procedures for conditions identified during a detailed physical examination.
5 Diagnostic procedures and management principles for conscious and unconscious patients with
traumatic head injury.
a assessment - Glasgow Coma Scale
b investigations - skull x-rays, CT scan
c initial management - appropriate use of mannitol
6 Elicit and interpret the clinical features of spinal, paraspinal and cord injuries.
a clinical signs
b categorization
c C-spine protocol and C-spine clearance
d investigations - x-ray, CT scan, MRI
e initial management measures
7. Facial and cervical injuries:
a assessment of extent of injury
b investigation
c initial management
8. Diagnose and perform the initial management of:
a tension pneumothorax
b open sucking chest wound
c massive hemorrhage
d flail chest
e cardiac tamponade
9. Diagnose and understand the initial management of:
a pulmonary contusion
b aortic rupture
c tracheobronchial tree injuries
d diaphragmatic rupture
e esophageal rupture
10. Airway management:
a orotracheal airway insertion
b nasopharyngeal airway intubation
c ventilation without intubation
d adult oral tracheal intubation
e adult nasotracheal intubation
f infant endotracheal intubation
g needle cricothyroidotomy
53
h surgical cricothyroidotomy
i translaryngeal tracheostomy
j open tracheostomy
11 Resuscitation techniques in the hypothermic patient.
12 Shock:
a define and classify
b initial fluid management and evaluation of fluid resuscitation and organ perfusion in the
trauma patient:
i estimate fluid and blood losses
ii fluid replacement with respect to crystalloid, blood products
c use of pneumatic anti-shock garments
13 Nutritional problems in the trauma patient:
a identify trauma patients at risk of nutritional disturbance and describe factors responsible
for the disorder.
b prepare a nutritional plan for the trauma patient
c fluid and electrolyte disorders in the trauma patient
d describe the maintenance requirements of intravenous fluids and electrolytes
e. diagnosis of fluid and electrolyte and acid-base disturbances
f. appropriate clinical or laboratory investigations
g. management of water and electrolyte or acid-base disorders
h enteral and total parenteral nutrition
i percutaneous gastric tube insertion for enteral feeding
j open feeding jejunostomy tube insertion
14 Pharmacological basis of trauma management:
a understand the pharmacological properties of the common medications used in the
management of the trauma patient with respect to medical problems
b understand the pharmacological properties and the common use of the common inotropic
agents in the ICU
15 Rehabilitation medicine:
a outline the basis of spinal cord rehabilitation
b outline the basic rehabilitation plan for closed head injured patients
c outline the basic rehabilitation plan for the multiple injured patient
d be aware of the different ancillary services available to the trauma patient in southwestern
Ontario including rehabilitation medicine, occupational medicine, convalescence
e have knowledge of insurance-related injuries and claims
f have an understanding of Bill 59 and knowledge of what services can be accessed
16 Trauma prevention and injury prevention
a. describe the different programs that are available for trauma prevention including the
IMPACT Program and the Outreach Program
3 TECHNICAL SKILLS
At the end of a trauma rotation, the neurosurgical resident must be able to show technical
competence in the following procedures to the satisfaction of his/her supervisor(s).
54
1 Primary and secondary assessment of the patient with multiple injuries.
2 Establish a patent airway and initiate one and two man ventilation.
3 Orotracheal and nasotracheal intubation.
4 Cricothyroidotomy.
5 Initiation of percutaneous and venous access, central intravenous access with central venous
pressure monitoring, intraosseous infusion, postop symmetry monitoring.
6 Venous cutdown.
7 Pleural decompression by needle thoracentesis and chest tube insertion.
8 Pericardiocentesis.
9 Roentgenographic identification of thoracic injuries.
10 Roentgenographic identification of spine injuries.
11 Immobilization and stabilization of extremity injuries.
12 Immobilization and stabilization of spine injuries.
Communicator
1. Learn how to give an accurate, concise verbal report of the history and physical examination
to staff and to resident colleagues.
2. Communicate effectively with health care professionals and other members of the team.
3. Gain experience in requesting, and responding to requests for consultations from colleagues.
4. Maintain complete, accurate and up to date medical records, clearly written or dictated.
5. Recognize the need for, and practice clear communication
6. Listen effectively.
7. The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
The resident is expected to demonstrate acceptable proficiency in communication skills in both
verbal and written modalities with:
1. Patients and their relatives
a. To be able to explain the disease process
55
b. To be able to obtain an informed consent related to surgical procedures
2. Other physicians
a. Family Physicians
b. Other resident staff
c. Neurosurgical staff
d. Consultants in Internal Medicine, Respirology, Endocrinology and others
e. Radiologists
f. Medical students and clinical clerks
g. Other surgical specialities
3. Health care professionals other than physicians
a. Nursing staff
b. Physiotherapists
c. Occupational therapists
d. Social workers
e. Pharmacists
f. Clerical and other allied staff such as speech pathologists, Nutritionists, Psychologists, and
others.
The resident is also expected to become very comfortable with presentation of clinical and
investigative information at teaching rounds and scientific conferences using computerized teaching
aids.
Collaborator:
The resident is expected to be able to participate in interdisciplinary team meetings.
Consult and interact with respect to other health care professionals, in particular with the
anesthesiologists, the surgeons and their team, nurses in the operating room and on the ward.
Consult and work effectively with the attending staff.
Consults and works effectively with other medical specialists.
Consults and works effectively with colleagues, medical clerks and students.
Effectively work with other health care professionals to prevent, negotiate, and resolve interpersonal
conflict.
The resident is expected to be able to consider and respect the opinions of other members of the
health care team.
The resident is expected to be able to comprehend the depth of expertise of others and contribute to
decision making as expected of a Neurosurgery resident.
The resident is also expected to be aware of his/her limitations and those of other health care team
members.
The resident is, in essence expected to be able to collaborate with other non-medical health care
56
personnel to achieve the very best possible outcome for the patients.
Manager:
1. The resident needs to understand how to function within the confines of the structure, finances
and the general operation of the Canadian health care system.
2. The resident needs to be cognizant of the functioning of the organizations within the hospital such
as:
a. committees at various levels
b. local organizations
c. national and international organizations pertinent to the specialty of Plastic surgery
d. research account
The resident is expected to comprehend principles of care and decisions based on best available
evidence.
Manage effectively the different tasks involved in the diagnosis and treatment of patients.
Prioritize responsibilities.
Utilize health care resources safely and effectively.
Utilize information technology effectively.
Health Advocate:
1. For the individual patient, the resident is expected to be familiar with the potential deleterious
consequences of systematic problems such as access to health care resources for diagnosis and
treatment. In the appropriate situations they are expected to learn how to be a health advocate for
the individual patient to facilitate the best possible outcome for the patient.
2. For various patient groups at risk, the resident is expected to be aware of preventative measures
that have been shown to be efficacious.
3. The resident is expected to actively get involved with such organizations such as “Thinkfirst” that
is active in prevention of neurotrauma and CHAT, which is a community and hospital combined
initiative against trauma.
4. Advocate on behalf of patients, families and communities regarding good health practices.
Scholar:
Demonstrate a commitment to, and success with, a personal continuing education strategy.
57
Read about clinical cases and participate appropriately by asking questions.
Understand the basics of critical appraisal as they pertain to trauma practice.
Teach medical students and other health care professionals.
Participate in academic rounds, teachings sessions and other educational outlets.
Evaluate proposed diagnosis and treatment with current literature when appropriate.
Clinical issues: The resident is expected to identify clinical issues that he/she does not fully
understand, and perform the following:
1. Generate a clinical question
2. Identify his/her own knowledge and its limitations
3. Develop a plan for doing the appropriate research
4. Assimilate and analyze the material available
5. Consult other physicians and allied health care personnel as needed
6. Propose a solution to the clinical question posed
7. Implement the solution
8. Evaluate the efficacy of the solution
9. Generate new clinical question as relevant
Professional
At the end of the rotation, the resident must have demonstrated to the satisfaction of his/her
supervisor(s):
1 The ability and willingness to work in a cooperative manner with other health care personnel, being
sensitive to their roles and abilities, and to be able to give and receive advice in a manner that is
consistent with the harmonious operation of a health care team.
2 The ability to communicate with patients and their families, explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
3 Respect for patients’ rights to privacy.
58
4 Sensitivity to the sexual, moral, ethical, religious and ethnic characteristics of the patient and
family, understanding of the special psychological needs of trauma patients and their families, and
the ability to understand and respond to families of trauma patients as they go through the grieving
process.
5 Knowledge of the ethical and legal aspects of trauma management.
6 Honesty, reliability, and respectfulness in working with patients and colleagues alike.
7 The discipline of continued self-education and the appropriate application of this current
knowledge to the clinical setting; the ability to supervise and educate undergraduate and
postgraduate students; the skills to educate colleagues, patients, families, and other health care
professionals; the capacity to undertake research, and be aware of the importance of peer review
protocols, ethical considerations, and the limitations of such endeavors.
8 The ability to keep succinct, pertinent, and up-to-date medical records.
B11. Anesthesia
PREAMBLE
These objectives are expected to serve as a guideline for the training of a Neurosurgical Resident
rotating through the Anaesthesia Service. Generally, it should be understood that the over-riding
objective for such a rotation is to train the resident in the technical skills required to establish and
maintain an airway, to educate him in the general pathophysiological concerns faced by the
anaesthetist shepherding any patient through a surgical procedure, to educate the resident in the
specific needs of the anaesthetist with respect to knowledge of the surgical issues during a
neurosurgical procedure (so that, as a neurosurgeon, he can communicate these issues in a timely
manner), and to acquaint the resident with the general and specific pharmacological knowledge
relevant to surgical procedures. In this light, the following objectives have been formulated to
conform to the CanMEDS 2000 Principals, and the objectives of training in Neurosurgery as
recommended by the Royal College of Physicians and Surgeons of Canada.
Medical Expert/Clinical Decision Maker:
General Objectives:
Knowledge: Basic Science and Anatomy.
The resident is expected to have a good comprehension of the basic and normal anatomy and
physiology of the respiratory and circulatory systems.
Knowledge: General Clinical.
The resident is expected to learn how to do a preoperative assessment with respect to specific
anaesthetic and surgical risk factors from both a historical and physical viewpoint. He/she should be
able to predict the types of problems specific patients might be likely to encounter with surgical
procedures, and understand the relevant investigations which should be done preoperatively to
assist the anaesthetist in minimizing these risks.
59
Knowledge: Specific Clinical Problems.
These should include an understanding of the Principals of Allergy and Immunology relative to the
surgical process (e.g. allergic reactions, blood transfusions); the resident should understand the
pathophysiology of circulatory diseases relevant to cardiac function in the patient undergoing
anaesthesia; specifically with respect to neurosurgical procedures the resident should have an
understanding of the effect of positioning, pharmacological agents, and ventilatory management on
intracranial pressure andtissue perfusion.
Knowledge: Technical.
By the end of the rotation the resident is expected to be able to arrive at an acceptable anaesthetic
management plan, and effect that plan through the anaesthetic experience for an individual patient,
with a view to prevention of complications. He should be able to recommend and plan for the safest
anaesthetic route, which should include not only an understanding and knowledge of general
anaesthestic principles, but also knowledge of the appropriate use of spinal, epidural, regional, and
local anaesthetic techniques.
Knowledge: Specific Pathology.
The list of potential anaesthetic concerns covers the gamut of medicine, and will not be covered in
its entirety in this list, but should include cardiac crises, including arrhythmias, arrest, ischaemia,
hypertension, pulmonary oedema; Circulatory Failure, including hypovolaemic shock; Respiratory
Failure; Septicaemia; Metabolic, fluid, electrolyte, and acid base disorders; Endocrine dysfunction,
including diabetes, parathyroid disease, pituitary axis, and the abnormalities of both anterior and
posterior pituitary dysfunction; Coagulopathies and their management; Pharmacology of commonly
used drugs for the critically ill patient; Management of hyperthermia; Use of mechanical ventilators;
Use of anaesthetic agents.
Communicator:
1. The neurosurgical resident rotating in Anaesthesia will need to demonstrate communication
skills in dealing with the patient and the patient’s family, and, just as importantly, with the
entire operating room team, including nurses, technicians, surgeons, and other physicians
involved with the patient’s care.
2. He/she should learn the details of maintaining a complete anaesthetic record.
3. Recognize the need for, and practice clear communication.
4. Listen effectively.
5. The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
Collaborator:
The resident will demonstrate an ability to use his/her communication skills to be able to collaborate
in a professional manner with other health professionals and with the patients and their families.
60
The resident is expected to be able to participate in interdisciplinary team meetings.
Consult and interact with respect to other health care professionals, in particular with the
anesthesiologists, the surgeons and their team, nurses in the operating room and on the ward.
Consult and work effectively with the attending staff.
Consults and works effectively with other medical specialists.
Consults and works effectively with colleagues, medical clerks and students.
Effectively work with other health care professionals to prevent, negotiate, and resolve interpersonal
conflict.
The resident is expected to be able to consider and respect the opinions of other members of the
health care team.
The resident is expected to be able to comprehend the depth of expertise of others and contribute to
decision making as expected of a Neurosurgery resident.
The resident is also expected to be aware of his/her limitations and those of other health care team
members.
The resident is, in essence expected to be able to collaborate with other non-medical health care
personnel to achieve the very best possible outcome for the patients.
Manager:
The managerial role in this rotation is likely to be limited to demonstrating the logistics of cocoordinating the health professional team to achieve an expeditious, gentle and safe induction, an
appropriate “awakening”, and a safe transfer from the operating room to the post-operative care
area. The resident should, in this regard, have a full knowledge and understanding of the appropriate
monitoring equipment to be able to establish effective monitoring throughout and following the
anaesthetic.
Prioritize responsibilities.
Utilize health care resources safely and effectively.
The resident is expected to comprehend principles of care and decisions based on best available
evidence.
Work well in the health care organization
Learn to use their time efficiently.
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Health Advocate:
During the pre-anaesthetic interview, the resident should use the opportunity to inform and educate
the patient in specific preventative strategies that he may wish to undertake in concert with the family
physician, respecting of course the potential stress the patient may be experiencing in relationship to
the impending procedure.
Advocate on behalf of patients, families and communities regarding good health practices.
Scholar:
The anaesthetic rotation affords the resident an opportunity to search the literature and thus educate
himself/herself about many different disease conditions which he may encounter and consider the
opportunities for designing investigations as well as literature searches to answer the many
questions he/she will encounter with respect to management strategies.
Demonstrate a commitment to, and success with, a personal continuing education strategy.
Evaluate proposed diagnosis and treatment with current literature when appropriate.
Ability and willingness to supervise and educate clinical clerks in a manner which promotes a
positive and supportive learning experience
Professional:
The resident shall demonstrate during his rotation the ability to function as an honest, reliable and
respectful individual interacting in a professional manner with patients and colleagues. This will
include an ability to work in a collaborative manner with other health care professionals, and
understanding and respect for the rights of the patients to privacy, a sensitivity and understanding of
the specific psychological demands of a patient undergoing the stress of surgery, which will include
an understanding and allowance for specific ethnic and cultural considerations.
Respect the opinions of others
Treat all others as he/she expects to be treated
Provide medical care in an honorable and ethical fashion
Find a balance between professional and personal life that is fulfilling professionally
Be able to evaluate his/her knowledge and abilities along with the limitations
Act according to his/her limitations-specifically ask for help from colleagues when he/she is not
comfortable with a clinical situation
To ensure the development of a keen sense of responsibility and compassion toward their patients
and their families
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Recognize own limitations and seek advice and help when needed.
Accept constructive feedback and act appropriately.
B12. Emergency Medicine
Preamble
These objectives are expected to serve as a guideline for the training of a Core Neurosurgical
Resident rotating through the Emergency Department. It is expected that this training will provide the
resident with the capability to respond appropriately to the spectrum of urgent and emergent medical
and surgical issues, which patients and their families bring to an Emergency Department. Further,
this rotation should provide the resident with an understanding of both the capabilities and limitations
of Emergency Department care within a modern hospital in the Canadian Health Care System.
The resident’s function in the Emergency Ward will require that she/he gain a working knowledge of
both normal physiology and pathophysiology to enable the expeditious identification, triage, and
management of the patient who is unstable and at risk from the full range of disease processes. The
resident shall initiate appropriate investigations and avoid inappropriate interventions, as well as
facilitate ongoing care.
Medical Expert/Clinical Decision Maker:
Specific Objectives:
The resident is expected to learn how to:
1.
2.
3.
4.
Take a rapid and relevant history.
Conduct an effective physical examination.
Assess, collect, analyze and interpret the medical data in order to reach a diagnosis.
Organize and/or give appropriate treatment to help resolve the patient’s problem.
Knowledge base
During the rotation, the resident will:
1.
2.
3.
4.
5.
Learn to distinguish between a serious and non-serious illness.
Learn the basic skills in resuscitation of critically ill patients.
Learn the basic skills in cardio-respiratory resuscitation.
Gain exposure to various trauma patients.
Gain exposure to acute upper aero digestive tract diseases
Knowledge: Basic Science and Anatomy.
The resident is expected to have a good comprehension of basic anatomy, physiology, and
metabolism to be able to understand the deviations therefrom with which patients in the Emergency
Department may present.
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Knowledge: General Clinical
The resident will be expected to learn the algorhythmic expeditious assessment of an Emergency
Department patient, as well as the rapid formulation and institution of a management plan. She/he
will be expected to demonstrate an understanding of the pathophysiology of common medical and
surgical diseases presenting to the Emergency Department.
Knowledge: Specific Clinical Problems.
These include myocardial ischaemia and infarction, pulmonary oedema, respiratory failure, the acute
abdomen, musculoskeletal emergencies, infectious processes including septicaemia, otitis,
bronchitis, conjunctivitis, pharyngitis, pneumonia, and cellulites. The resident should demonstrate an
ability to manage both minor andamajor soft tissue injuries. The resident will demonstrate a working
understanding of ischaemia as it applies to all organs, including the brain, the heart, the kidneys, the
intestinal tract, and the extremities. This knowledge shall include an understanding of strategies to
limit the effect of ischaemia.
Knowledge: Technical.
The resident is expected to be able to take care of simple lacerations, and to recognize and institute
a management plan for complex soft tissue injuries, including vascular, ligamentous, tendinous, and
neural extremity injuries.
1.
2.
3.
4.
5.
6.
7.
Venipuncture.
Arterial blood gases.
Insertion of nasogastric tubes.
Insertion of Foley catheters.
Performing EKG’s.
Suturing lacerations.
Applying splints and casts.
Communicator:
The resident shall demonstrate an ability to communicate with patients and with their families, and to
recognize when histories need to be corroborated. She/he will establish communications with the
referring physicians, family physicians, and consultants in both a written and oral manner to enable
the facilitation of future care.
Develop interpersonal skills by listening effectively.
Interact with patients and their relatives.
Obtain and synthesize relevant history from patients, families, healthcare colleagues (nurses,
paramedics staff, etc.).
Request consultations from other members of the health care team.
Discuss the diagnosis, investigations and treatment recommendations in an emergency situation.
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Help a frightened child or adult with an acute problem.
Produce clearly written, concise accurate records.
Collaborator:
The resident will recognize the competencies and respect the professionalism of other health
professionals, utilizing their expertise in an appropriate manner to facilitate the patient’s care.
Consult and work effectively with the attending staff.
Consults and works effectively with other medical specialists.
Consults and works effectively with colleagues, medical clerks and students.
Effectively work with other health care professionals to prevent, negotiate, and resolve interpersonal
conflict.
Recognize the strengths and limitations of team members’ expertise.
Manager:
The resident shall demonstrate an ability to manage medical, surgical, and psychiatric problems in
the Emergency Department in an algorhythmic fashion, providing timely management decisions with
an eye to the efficient and expeditious care of the patient.
Learn to use their time efficiently.
Learn to establish priorities in patient diagnosis and treatment.
Utilize resources wisely in determining diagnosis and recommending treatment.
Learn to use his time efficiently.
Work effectively in the emergency department environment.
Health Advocate:
The resident should recognize where patient’s presentations present the opportunity for counseling
with respect to the management of lifestyle issues, to minimize risk and modify disease processes.
Identify risk factors related to urgent illnesses.
Educate patients and their families regarding good health practices.
Scholar:
65
The clinical material seen in the Emergency Department shall be used by the resident as an
opportunity to stimulate reading and literature reviews around specific surgical and medical issues.
Particular attention shall be paid to neurological disease presentations, with a view to the
consideration of evidence-based management and care.
Read around cases seen in the emergency department.
Keep a log of the cases that he/she sees, and to use the cases as a problem-based focus for further
reading, thus instituting a personal education strategy.
Teach medical students and other health care professionals.
Understand the basics of critical appraisal as they pertain to emergency practice.
Professional:
The resident must behave in a manner demonstrating his/her reliability, integrity, honesty, and
ethical approach to the care of his/her patients, respecting the cultural and ethnic issues appropriate
to them.
Continue to pursue a balanced life-style.
The resident is expected to exhibit appropriate personal and interpersonal professional behaviors, to
show integrity, honesty and compassion.
Recognize own limitations and seek advice and help when needed.
Accept constructive feedback and act appropriately.
B13. General Surgery
Overall Objectives:
It is recognized that the resident may not be exposed to all elements of these objectives; however at
the conclusion of the rotation the resident should demonstrate knowledge or competency in the
following:
• The resident is expected to investigate and manage general surgical patients with acute and
chronic illness.
• The resident will improve the depth of knowledge, technical skills and decision- making capacity
with respect to the general surgical patient.
• The resident will gain knowledge and management skills in the principles of surgery.
• The resident is expected to gain understanding and knowledge of the foundational issues in acute
and chronic general surgical problems, including how to assess, and diagnose these conditions
systematically, and how to apply clinical judgment in the prescription of treatment.
66
• The resident will learn how to manage the metabolic, fluid, electrolyte and acid-base needs of
patients.
• The resident will learn the critically important skills of operating room department and surgical
assisting, and as well will function as clinical surgeon at an introductory level in selected procedures.
Specific Objectives:
Medical Expert
The resident is expected to learn how to:
•
Take a relevant, directed and complete history and perform an effective physical exam
concentrating on the appropriate areas.
•
Order appropriate laboratory, radiologic and other diagnostic procedures demonstrating
knowledge in the interpretation of these investigations. Appropriately order and interpret tests
•
Complete data collection using appropriate invasive patient monitoring techniques, biopsy
techniques (FNAB, core biopsy, open biopsy), and endoscopic procedures in particularly
flexible esophagogastroscopy
•
Arrive at an appropriate differential diagnosis.
•
Formulate an initial hypothesis in light of conflicting data or events.
•
Arrive at an acceptable plan of management, demonstrating knowledge in operative and nonoperative management of the disease process.
•
Formulate the treatment plan, considering the effects, risks, and benefits of operative or nonoperative approaches, and the role of co-morbidities
•
Carry out pre-op and post-op care
•
Manage patients in the ambulatory setting, demonstrating a knowledge of common office
techniques and procedures.
•
Manage the patient throughout the entire in-hospital course, demonstrating knowledge of and
being able to treat potential complications of the disease processes and operative
procedures.
•
Provide a plan for patient follow-up.
•
To identify conditions that require urgent treatment.
•
To supervise the management of the critically ill or traumatized patient.
Knowledge Basic sciences and anatomy:
67
The trainee is expected to develop an excellent knowledge base for all of the diseases conditions in
the various anatomic sites relevant to general surgery.
Knowledge clinical:
By the end of the general surgery rotation, the resident will demonstrate adequate knowledge of:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Preoperative assessment and care
Post-operative care
Wound management and healing
Fluid and electrolyte management, acid base disorders
Shock
Hemostasis mechanisms and disorders use of blood products
Metabolic and nutritional care
Sepsis and surgical infections
Acute abdomen
Gastro-intestinal bleeding (upper and lower)
Intestinal obstruction
Oesophageal, gastric and duodenal diseases
Hepatobiliary and pancreatic diseases
Neck masses
Thyroid diseases
Parathyroid diseases
Major salivary gland diseases
Technical skills:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Venous access, including placement and care of central lines
Arterial access (e.g. for ABG’s and placement of arterial lines
Insertion of nasogastric tube
Insertion of Foley catheter
EKG performance and interpretation
Endotracheal intubations
FNAB of masses at various sites
Biopsies of skin, subcutaneous, and mucosal lesions
Incision and drainage of skin and subcutaneous abscesses
Wound suturing, dressing and care
Esophagogastroscopy
Tracheostomy
PEG and opened gastrostomy
Node biopsies (axillary, inguinal, cervical)
Function as first or second assistant for the wide range of general surgical procedures
Function as surgeon, under supervision, for parts of appropriate general surgical procedures
in addition to those detailed above
Communicator
•
Learn how to give an accurate, concise verbal report of the history and physical examination
to staff and to resident colleagues.
68
•
•
•
•
•
•
Communicate effectively with health care professionals and other members of the team.
Gain experience in requesting, and responding to requests for consultations from colleagues.
Maintain complete, accurate and up to date medical records, clearly written or dictated.
Recognize the need for, and practice clear communication in the operating room.
Listen effectively.
The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
Collaborator
•
•
•
•
•
Consult and interact with respect to other health care professionals, in particular with the
anesthesiologists, the surgeons and their team, nurses in the operating room and on the
ward.
Consult and work effectively with the attending staff.
Consults and works effectively with other medical specialists.
Consults and works effectively with colleagues, medical clerks and students.
Effectively work with other health care professionals to prevent, negotiate, and resolve
interpersonal conflict.
Manager
•
•
•
•
•
•
Manage effectively the different tasks involved in the diagnosis and treatment of patients.
Prioritize responsibilities.
Utilize health care resources safely and effectively.
Utilize information technology effectively.
Work well in the health care organization (clinic, ward, ICU, ER and operating room).
Learn to use their time efficiently.
Health Advocate
•
•
Identify risk factors related to general surgical conditions.
Advocate on behalf of patients, families and communities regarding good health practices.
Scholar
•
•
•
•
•
•
Demonstrate a commitment to, and success with, a personal continuing education strategy.
Read about clinical cases and participate appropriately by asking questions.
Understand the basics of critical appraisal as they pertain to general surgery practice.
Teach medical students and other health care professionals.
Participate in academic rounds, teachings sessions and other educational outlets.
Evaluate proposed diagnosis and treatment with current literature when appropriate.
Professional
69
•
•
•
•
The ability and willingness to work in a cooperative manner with other health care personnel,
being sensitive to their roles and abilities, and to be able to give and receive advice in a
manner that is consistent with the harmonious operation of a health care team. The resident
is expected to exhibit appropriate personal and interpersonal professional behaviours, to
show integrity, honesty, and compassion, and to practice in an ethical manner.
Recognize own limitations and seek advice and help when needed.
Accept constructive feedback and act appropriately.
Continue to pursue a balanced life-style.
Given a patient requiring one of the surgical procedures listed below, the neurosurgical resident will
participate in the patient’s care as a member of the operating team. It is expected that the resident
will initiate the process of technical skill development by assisting in both simple and complex
operations, and by performing, under supervision, simple procedures. It is expected that the resident
will be familiar with surgical instruments and suture materials. It is expected that the resident will be
able to position and drape patients for surgical operations. It is expected that the neurosurgical
resident will be able to open and close surgical wounds, control bleeding, and demonstrate
knowledge of fundamental principles of tissue handling.
At the end of a rotation in general surgery, the neurosurgical resident must be able to show technical
competence in the following procedures to the satisfaction of his/her supervisor(s). Designation is
listed as to expectations of “Surgeon” (S) or “Assistant” (A). The resident may act as surgeon or
assistant in those procedures marked (SA) depending on various factors at the time of surgery.
General diagnostic and therapeutic procedures
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Arterial puncture
S
Venipuncture
S
Naso-gastric intubation
S
Insertion and removal of permanent feeding line
S
Insertion and removal of venous access reservoir S
Proctoscopy & sigmoidoscopy
S
Insertion and removal of peritoneal dialysis catheter S
Skin suturing & stapling, know tying
S
Selection of abdominal incisions
S
Laparotomy & closure of abdominal wall
S
Peritoneal tap
S
electrocardiogram
S
Foley catheter insertion
S
Tracheostomy
S
Specific Procedures
Integumentary System
1
Incision and drainage subcutaneous abscess
2
Foreign body removal
3
Excision skin and subcutaneous lesions
4
Suture of lacerations
S
S
S
S
Breast
1
Aspiration of breast cyst
S
70
2
Excision benign breast tumor
S
Hemic and Lymphatic System
1
Splenectomy
2
Biopsy of enlarged nodes: (cervical, axillary,
A
inguinal, scalene, submandibular)
S
Digestive System
Endoscopy
1
Esophago-gastro-duodenoscopy
S
Gastric
1
Pyloroplasty
2
Gastroenterostomy
3
Closure of perforated ulcer
SA
SA
SA
Intestinal
1
Rigid sigmoidoscopy
2
Flexible sigmoidoscopy
3
Insertion feeding enterostomy
4
Colostomy
5
Entero-enterostomy
6
Resection and anastomosis of small bowel
7
Resection and anastomosis of large bowel
8
Proctectomy (AP resection)
9
Lysis of adhesions
10
Appendectomy
S
S
SA
SA
SA
A
A
A
A
S
Anorectal
1
Anoscopy
2
Excision thrombosed hemorrhoid
S
S
Liver
1
2
S
SA
Incisional liver biopsy
Local excision liver lesion
Biliary Tract
1
Cholecystotomy
2
Cholecystectomy, open
3
Cholecystectomy, laparoscopic
4
Exploration common bile duct
S
S
SA
A
Pancreatic
1
Drainage pancreatic abscess
2
Whipple procedure
3
Distal pancreatic excision
A
A
A
Trauma
1
Laparotomy for acute trauma
A
71
- splenectomy
- repair liver laceration
- repair ruptured diaphragm
- repair ruptured bladder
- nephrectomy
A
A
A
A
A
Abdominal Sepsis
1
Drainage intra-abdominal abscess
- abdominal
- subphrenic
- phrenic
A
A
A
Hernia & Abdominal Wall
1
Insertion peritoneovenous shunt
2
Laparoscopy
3
Repair inguinal hernia
4
Repair femoral hernia
5
Repair ventral hernia
6
Excision hydrocele
7
Closure evisceration
A
S
S
S
SA
S
A
B13. Internal Medicine
Specific Objectives:
Medical Expert
Knowledge:
Given a patient on a medical ward, the core surgical resident must be able to perform the clinical
skills listed in section 1, and be able to demonstrate to the satisfaction of his/her supervisors(s) a
fundamental knowledge and understanding of the specific areas below. This list is meant to be a
guide and is not meant to be all encompassing.
Specific Disease Entities
1
Cardiology: Hypertension, Cardiac arrhythmias, Congestive heart failure, Chest pain of
72
unknown origin and Coronary artery disease.
2
Respirology: Asthma, Chronic obstructive pulmonary disease, pulmonary embolism, the
assessment of hemoptysis and lung infiltrates, and the assessment of masses of unknown
etiology.
3
Gastroenterology: Acute gastrointestinal bleeds, diarrhea, abdominal pain of unknown
etiology, inflammatory bowel disease, malabsorption syndromes, hepatitis, obstructive
jaundice, peptic ulcer disease, alcoholism and alcoholic liver disease, nutritional disorders.
4
Nephrology: Acute and chronic renal failure, Nephritis of unknown etiology and Fluidelectrolyte and acid base imbalance.
5
Hematology/Oncology: Anemia, Thrombocytopenia, Disseminated intravascular coagulation
and other coagulopathies, Leukemia, Lymphoma and the assessment of solid tumors
(carcinoma of the stomach, bowel, pancreas, lung and breast).
6
Endocrinology: Diabetes mellitus, Thyroid disease, Cushing’s syndrome, Nutritional disorders
and Diabetes insipidus.
7
Infectious Diseases: Community and hospital acquired infections, rational use of antibiotics,
Pneumonia, Bronchiectasis, Septic shock, Endocarditis, Urinary tract infections, Meningitis,
Cellulitis, and Pyrexia of unknown origin.
8
Rheumatology: Rheumatoid arthritis, Osteoarthritis, Gout, Collagen vascular diseases and
various vasculitides.
Knowledge: General clinical
•
•
•
•
•
Ability to take a thorough and relevant history efficiently
Demonstration of appropriate physical examination skills
Ability to synthesize information and formulate an adequate problem list
Ability to design, execute and follow-up diagnostic and therapeutic plans with judicious
consideration of costs and benefits
Ability to assess and managing acute emergency presentations of the conditions listed
Knowledge: Specific Clinical Problems
Given a patient on a medical ward, the core surgery resident will be able to do the following to the
satisfaction of his/her supervisor(s):
•
•
•
•
•
•
Take a relevant history.
Perform an acceptable physical exam concentrating on the relevant areas.
Arrive at an appropriate differential diagnosis.
Order appropriate laboratory, radio logic and other diagnostic procedures demonstrating
knowledge in the interpretation of these investigations.
Arrive at an acceptable plan of management.
Manage the patient throughout the hospital stay including potential complications.
73
Knowledge: Technical
At the end of a rotation in internal medicine, the resident must be able to show technical competence
in the following procedures to the satisfaction of his/her supervisor(s).
•
•
•
•
•
•
•
•
Techniques used in advanced cardiac life support, including EKG interpretation.
Techniques of arterial and venous access, including arterial lines, CVP lines and venous cutdowns.
Thoracentesis, Paracentesis.
Lumbar puncture.
Bone marrow aspiration
Physiologic monitoring techniques including O2 saturation and cardiac output measurement.
Interpretation of relevant imaging techniques, including x-rays and nuclear scans.
Other - e.g. insertion of Foley catheters nasogastric tubes and temperature probes.
Communicator
•
•
•
•
•
•
•
Learn how to give an accurate, concise verbal report of the history and physical examination
to staff and to resident colleagues.
Communicate effectively with health care professionals and other members of the team.
Gain experience in requesting, and responding to requests for consultations from colleagues.
Maintain complete, accurate and up to date medical records, clearly written or dictated.
Recognize the need for, and practice clear communication
Listen effectively.
The ability to communicate with patients and their families explaining to them their disease
process and the benefits, risks, and complications, and alternatives of management
recommendations in terms each individual can comprehend.
Collaborator
•
•
•
•
•
•
•
•
•
The resident is expected to be able to participate in interdisciplinary team meetings.
Consult and interact with respect to other health care professionals, in particular with the
anesthesiologists, the surgeons and their team, nurses in the operating room and on the
ward.
Consult and work effectively with the attending staff.
Consults and works effectively with other medical specialists.
Consults and works effectively with colleagues, medical clerks and students.
Effectively work with other health care professionals to prevent, negotiate, and resolve
interpersonal conflict.
The resident is expected to be able to consider and respect the opinions of other members of
the health care team.
The resident is expected to be able to comprehend the depth of expertise of others and
contribute to decision making as expected of a Neurosurgery resident.
The resident is also expected to be aware of his/her limitations and those of other health care
team members.
74
•
The resident is, in essence expected to be able to collaborate with other non-medical health
care personnel to achieve the very best possible outcome for the patients.
Manager
•
•
•
•
•
•
•
•
•
Manage effectively the different tasks involved in the diagnosis and treatment of patients.
Prioritize responsibilities.
Utilize health care resources safely and effectively.
Utilize information technology effectively.
The resident is expected to comprehend principles of care and decisions based on best
available evidence.
The resident needs to understand how to function within the confines of the structure,
finances and the general operation of the Canadian health care system.
Work well in the health care organization (clinic, ward, ICU, ER and operating room).
Learn to use their time efficiently.
Ability to plan efficiently for discharge using adequate communication with primary physicians
and consultants about follow-up
Health Advocate
•
•
•
For the individual patient, the resident is expected to be familiar with the potential deleterious
consequences of systematic problems such as access to health care resources for diagnosis
and treatment. In the appropriate situations they are expected to learn how to be a health
advocate for the individual patient to facilitate the best possible outcome for the patient.
For various patient groups at risk, the resident is expected to be aware of preventative
measures that have been shown to be efficacious.
Advocate on behalf of patients, families and communities regarding good health practices.
Scholar
•
•
•
•
•
•
•
Demonstrate a commitment to, and success with, a personal continuing education strategy.
Read about clinical cases and participate appropriately by asking questions.
Understand the basics of critical appraisal as they pertain to internal medicine practice.
Teach medical students and other health care professionals.
Participate in academic rounds, teachings sessions and other educational outlets.
Evaluate proposed diagnosis and treatment with current literature when appropriate.
Ability and willingness to supervise and educate clinical clerks in a manner which promotes a
positive and supportive learning experience
Professional
The resident is expected to be able to behave as a professional in every aspect of their internal
medicine rotation. She/he is expected to:
•
•
Interact with patients, relatives, his/her peers and other health care personnel in a very
professional manner
Respect the opinions of others
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•
•
•
•
•
•
•
•
•
Treat all others as he/she expects to be treated
Provide medical care in an honorable and ethical fashion
Find a balance between professional and personal life that is fulfilling professionally
Be able to evaluate his/her knowledge and abilities along with the limitations
Act according to his/her limitations-specifically ask for help from colleagues when he/she is
not comfortable with a clinical situation
To ensure the development of a keen sense of responsibility and compassion toward their
patients and their families
The ability and willingness to work in a cooperative manner with other health care personnel,
being sensitive to their roles and abilities, and to be able to give and receive advice in a
manner that is consistent with the harmonious operation of a health care team. The resident
is expected to exhibit appropriate personal and interpersonal professional behaviours, to
show integrity, honesty, and compassion, and to practice in an ethical manner.
Recognize own limitations and seek advice and help when needed.
Accept constructive feedback and act appropriately.
* The neurosurgical residents rotating through internal medicine on a short rotation will likely not be
able to achieve all the goals and objective listed above. However, the residents are expected to
have (to the supervisor’s satisfaction) become familiar with the necessary techniques and achieve a
reasonable knowledge base relevant to internal medicine.
During the clinical teaching unit experience, where possible, one half-day should ideally be identified
for an ambulatory care experience. Where this does not exist for the General Internal Medicine
clinical teaching unit, it should be provided through one of the subspecialties.
76