OTOLARYNGOLOGY SUBSPECIALTY ROTATION SPECIFIC GOALS AND
OBJECTIVES
EDUCATIONAL GOALS & OBJECTIVES: HEAD AND NECK
PGY 1 residents spend a portion of their first year Otolaryngology rotation
(approximately 2 weeks) on the Head and Neck service. During the PGY 2 year
residents complete a 2 month rotation on the head and neck service as the
designated "head and neck junior” resident. An additional 2 month rotation is
completed during the first 6 months of the PGY 2 year as a split rotation where
weekly duties are divided between the head and neck service and the pediatrics
service. On designated pediatric clinic and OR days this resident’s responsibilities
will be to the pediatric service, while on other days he or she will participate in head
and neck operative cases or head and neck attendings’ private clinics. This “pediHN” resident will not participate in the Thursday head and neck staff clinic at
Jackson Memorial Hospital (JMH). This conflicts with pediatric service
responsibilities, but he or she will round on the head and neck inpatient service on a
daily basis during the week. PGY 2 residents will participate in the Thursday JMH
head and neck clinic on a weekly basis when they rotate on the service as the head
and neck junior. PGY 3 residents will complete a 2 month rotation as the designated
head and neck junior on months when this slot is not filled by a PGY 2 resident.
PGY 4 and 5 residents will complete a total of 3 months on the head and neck
service during each year. Two of these months will be spent as the Chief of the
service, while one will be spent as the senior resident who is not the overall service
chief but who has primary responsibility for the inpatient head and neck service at
the University of Miami Hospital (UMH). This is primarily an organizational point, as
the head and neck senior resident may participate in operative cases or clinics at
JMH and the University of Miami Hospital and Clinics / Sylvester Comprehensive
Cancer Center (UMHC/Sylvester), just as the head and neck Chief resident will
participate in operative cases at UMH.
The Head and Neck service has responsibility for all head and neck patients
at Jackson Memorial Hospital (JMH), the University of Miami
Hospital/Sylvester Comprehensive Cancer Center (UMHC/Sylvester), and the
University of Miami Hospital (UMH), providing opportunities for
comprehensive inpatient and outpatient management of indigent and private
patients with head and neck neoplasms. All private patients with head and
neck tumors are evaluated in the outpatient clinics of the Sylvester
Comprehensive Cancer Center. Their long term follow-up continues in the
private attending clinics at the Cancer Center. Indigent patients with head
and neck tumors are evaluated in the Head and Neck Clinic at Jackson
Memorial Hospital. Resident participation in the attending private clinics at
the Sylvester Comprehensive Cancer Center is strongly encouraged. The
indigent head and neck clinic at Jackson Memorial Hospital operates under
the direct on-site supervision of Elizabeth Franzmann, MD, one of the head
and neck attendings. All patients seen in the indigent clinic are evaluated by
residents, with medical decision-making and administrative management of
these patients directed by the chief resident of the head and neck service in
consultation with the head and neck attending. Indigent patients requiring
surgery are all operated upon at Jackson Memorial Hospital. Private patients
evaluated in the Sylvester Cancer Center clinics may be operated upon at
any of the three institutions (Jackson Memorial, University of Miami Hospital
and Clinics/Sylvester, University of Miami Hospital) depending upon operating
room availability and medical comorbidities. Continuity of care is insured by
resident participation in both indigent and private clinic settings in new patient
evaluation and work-up, in the multidisciplinary head and neck tumor
conference where patients from both the indigent and private clinics are
discussed, participation in the surgical and inpatient care of these patients
regardless of the institution where their surgery is performed, and finally in
their long-term follow-up of these patients in the outpatient clinics. The
inpatient care of all head and neck patients at Jackson Memorial Hospital,
and the University of Miami Hospital, and the University of Miami Hospital and
Clinics/Sylvester Comprehensive Cancer Center is managed by residents on
the head and neck service with input from the head and neck fellows and
under the supervision of the head and neck attending responsible for that
patient’s care. The residents have equal opportunities and responsibilities for
the operative care of both indigent and private patients at each hospital.
Similarly, all inpatients are managed by the resident members of the head
and neck team irrespective of their funding status. Other head and neck
experience is gained during two month rotations at the VA hospital during the
PGY 2 year of training.
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate,
and effective for the treatment of health problems and the promotion of health. The
goals and objectives of the head and neck rotation is described in terms of
diagnostic and procedure-oriented learning by PGY year. Mastery of these
principles and techniques forms the foundation of competency in patient care in
Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and
work-up, while procedure-oriented learning goals focus on the development of
proficiency with both diagnostic and therapeutic procedures in a graduated PGYlevel specific fashion. Follow-up and post-operative patient care is strongly
emphasized starting with the first PGY year, and an expected mastery of this area
by senior resident years is expected. Mastery should be demonstrated by effective
patient care and accurate teaching of peri-operative care principles to the junior
residents.
Procedural Oriented Learning
Residents begin their head and neck experience mastering the fundamentals of the
head and neck examination and outpatient procedures such as fiberoptic
laryngoscopy and fine needle biopsy. These concepts and techniques are
introduced in the PGY 1 year and mastered in the PGY 2 year. Surgical skills initially
are gained as first and second assistant on major head and neck surgical
procedures. This provides opportunities to learn proper tissue handling skills,
fundamentals of skin flap elevation, principles of hemostasis and surgical knot tying.
Importance of exposure is learned through proper retraction. The role of surgeon is
first taught with direct faculty and senior resident supervision on basic surgical
procedures including tracheotomy, endoscopy, and submandibular gland excision.
More advanced surgical procedures are introduced after competencies are
demonstrated on basic procedures as surgeon, and after adequate experience have
been gained as assistant on these procedures. Faculty review resident case logs to
assess areas of weakness and constantly assess individual surgical skills on a very
busy operative rotation. Senior residents gain valuable perspective as teaching
assistant on straightforward procedures while mastering more advanced techniques
as surgeon. While all residents participate in the care of head and neck patients
regardless of residency level, the following clinical and procedural competencies are
expected to be mastered by each PGY level.
PGY1: Head and neck examination, fiberoptic laryngoscopy, feeding tube
placement, surgical drain management, identification of causes of wound
infection or breakdown, orotracheal intubation, familiarity with surgical
instrumentation and nomenclature, fine needle biopsy, tracheotomy, upper
rigid endoscopy.
PGY2: Head and neck examination, fiberoptic laryngoscopy, feeding tube
placement, surgical drain management, management of wound complications
(including fistula, flap necrosis, and major vessel bleeding), open and needle
biopsy, upper rigid surgical endoscopy, submandibular gland excision,
tracheotomy, cervical node biopsy, neck dissection, split skin graft.
PGY3: Neck dissection, parotidectomy, thyroidectomy, laryngectomy,
composite resections, pectoralis flap harvest.
PGY4: Conservation laryngectomy, endoscopic laser resection, greater
emphasis on primary tumor resection, craniofacial resection, maxillectomy,
pedicled flap inset and pharyngeal reconstruction.
PGY5: Role as teaching assistant on above procedures, lateral skull base
procedures, microvascular flap inset.
Diagnostic Oriented Learning
Outpatient skills are honed and perfected primarily in the outpatient staff head and
neck clinic at Jackson Memorial Hospital, with additional exposure in attending
clinics at the Sylvester Comprehensive Cancer Center. Greater sophistication of
knowledge and understanding of the head and neck core curriculum is developed as
clinical experience increases. Clinical decision making is taught and critiqued in the
weekly multidisciplinary head and neck tumor conference. Operative experience
gains a greater breadth and depth progressively through the residency training,
while medical management of head and neck problems in the inpatient and
outpatient setting is handled with increasing independence and responsibility as
PGY level increases. Research opportunities are provided throughout the remaining
years and are encouraged based upon interest level. Level specific learning is
outlined as follows:
PGY-1: The first year otolaryngology resident gains a brief but in-depth exposure to
the outpatient evaluation and management of head and neck patients in the indigent
head and neck clinic. There the techniques of a proper head and neck examination,
fiberoptic examination, fine needle biopsy, and head and neck imaging interpretation
are emphasized. The goal of the PGY 1 resident is to gain an early familiarity with
diagnostic techniques, and to gain competency in formulating an initial diagnosis.
PGY-2: The second year otolaryngology resident is expected to master the
fundamentals of medical management of head and neck oncologic patients and
those patients undergoing surgery for benign tumors of the head and neck. This
includes the mastery of the head and neck physical examination with the appropriate
use of laryngeal mirror for indirect laryngoscopy as well as the fiberoptic
laryngoscope. Familiarity with basic CT scan and MRI scan findings for benign and
malignant tumors of the head and neck is expected. The first year resident will
develop a systematic approach to the head and neck patient as an outpatient to
include appropriate history taking, accurate physical examination, familiarity with
appropriate diagnostic testing and the interpretation thereof, whereby he or she may
formulate a reasonable list of differential diagnoses and may distinguish among
these to arrive at the proper diagnosis for each patient. These skills will be
developed in the Jackson Memorial Hospital Head and Neck Clinic which meets
weekly and which is staffed by a faculty member with fellowship training in head and
neck oncology, as well as a chief resident and physician assistant. This approach
provides a balance between hands-on teaching and considerable autonomy in the
work-up and disposition of these patients as experience is gained. These skills will
be further perfected as the junior resident is given the opportunity to rotate among a
number of faculty members’ private clinics on the Head and Neck Service such that
differences in management styles may be appreciated. Practical techniques for
interacting appropriately with cancer patients in the outpatient setting are introduced.
While the focus in the first year with regard to outpatient management of head and
neck cancer patients will be on the appropriate development of differential diagnoses
such that the proper diagnosis may be accurately identified, the medical decision
making involved in the clinical management of these patients is introduced and
explored at a very practical level with each patient evaluated. This comes in the
form of direct supervision in the outpatient clinical setting, as well as the academic
conferences such as Head and Neck Tumor Board. The second year resident is
expected to have a fundamental understanding of the principals of radiation
oncology and medical oncology, and the important applications of these fields in the
multidisciplinary management of the head and neck cancer patients. Mastery of the
TNM staging system of head and neck cancers is mandatory, and working
knowledge of treatment options and outcomes is expected for squamous cell
carcinoma of the head and neck at all subsites. Emphasis for the second year
resident in the Core Curriculum during this year is on mastery of the anatomy of the
head and neck pertinent both to the office examination as well as surgical anatomy
of the head and neck, combined with a thorough understanding of the neoplasms
that affect each sub-site of the head and neck. Principals of tumor cell biology and
the genetics of head and neck cancer are introduced.
As the second year resident masters the outpatient work-up and evaluation of head
and neck tumor patients, the inpatient medical management of pre and
postoperative head and neck surgical patients is introduced. The second year
resident quickly learns the fundamentals of tracheotomy tube management,
parenteral feeding tube management, as well as surgical drain management.
Appropriate preoperative testing is emphasized, and a fundamental understanding of
surgical procedures is mandatory as preoperative teaching and surgical consents
are obtained. Postoperative wound care management is emphasized, with specific
attention to assessment for postoperative fistula, postoperative bleeding
complications, and the complex airway issues common to many head and neck
surgical patients. Head and neck surgical emergencies are emphasized from a
didactic standpoint to prepare the second year resident for clinical situations where
he or she may be the first responder and primary caregiver in emergency situations.
Critical care techniques are mastered in conjunction with the appropriate intensive
care unit multidisciplinary teams. Throughout the head and neck rotation as second
year otolaryngology resident an emphasis on appropriate patient and staff
interaction is maintained. The head and neck rotation provides perhaps the a
multitude of examples of effective systems based practice with regard to the
coordination of the complex multidisciplinary care of head and neck cancer patients,
the proper support of these patients by social services and home health agencies,
and the appropriate scheduling of surgical procedures in the context of significant
medical comorbidities. The complex psychosocial aspects of the care of head and
neck cancer patients and their families demand a high degree of professionalism
and interpersonal communication skills. These competencies are fostered,
improved, and evaluated throughout the second year of otolaryngology training but
with particular emphasis on the head and neck service.
Surgical expectations during the second year of otolaryngology training on the head
and neck service begin with an emphasis on mastery of appropriate basic surgical
skills including efficient and reliable suture tying, appropriate use of both blunt and
sharp dissection techniques, and a thorough understanding of surgical anatomy. A
priority is placed on mastery of the often-unheralded techniques of surgical assistant
on complex head and neck procedures such as neck dissections, primary tumor
resections, and a variety of reconstructive techniques. The first year resident is
expected to master basic techniques of rigid upper endoscopy, straightforward head
and neck procedures such as tracheotomy, submandibular gland excision, and
cervical lymph node biopsy, and is expected to participate as surgeon in more
complex head and neck procedures such as neck dissection or pectoralis flap
reconstruction as experience is gained. A working familiarity with the common
surgical instruments and the endoscopic instrumentation in the head and neck
armamentarium is expected.
Academically the second year resident on the head and neck service is expected to
focus his or her reading in the general otolaryngology texts, and expand this didactic
knowledge by pursuing problem focused reading in head and neck oncology texts.
Landmark reference articles are highlighted for particular clinical problems as a
means by which the resident may begin to build his or her personal reference library.
This is facilitated by a weekly Head and Neck Journal Club held in conjunction with
Head and Neck Tumor Conference where both current clinical articles as well as
classic articles are discussed. Depending upon the second year resident’s interest;
clinical projects such as case reports, case reviews, as well as basic science
projects are encouraged as faculty-resident collaborations.
Faculty assessment of the second year resident’s clinical competencies on the head
and neck services is performed at a variety of levels. Direct contact in the outpatient
setting is focused in the staff head and neck clinic at Jackson Memorial Hospital, but
broadly encouraged among other faculty clinics. The Head and Neck Tumor
Conference provides a forum for lively discussion, questioning, and debate on a
weekly basis. Assessment of clinical competency at the first year level is focused on
the appropriateness of differential diagnoses and the accuracy of the final diagnosis.
Fundamental understanding of radiographic findings is similarly explored both in the
outpatient clinical setting as well as in the Head and Neck Tumor Conference.
Medical management skills of pre and postoperative inpatients are evaluated both
with the assistance of the senior resident as well as by direct attending rounds with
the house-staff on an individual basis. Surgical competencies are assessed by
direct faculty interaction with the junior resident as primary surgeon and first
assistant, or as assistant to the junior resident as primary surgeon were appropriate.
By the end of the second year resident’s experience on the head and neck service,
he or she will be prepared to provide a thorough and appropriate evaluation of the
head and neck patient in order to arrive at an accurate diagnosis, to understand the
treatment options that the patient will have and begin to formulate treatment plans
among those options, to develop the fundamental surgical skills of open head and
neck surgical procedures, of diagnostic endoscopic techniques, both as assistant, as
well as surgeon for a common head and neck surgical cases, and finally to master
the techniques of postoperative care as outlined above.
PGY-3: The third year otolaryngology resident continues to function as the junior
resident on the head and neck service. The daily responsibilities of this resident are
as during the first year, with clinic time spent primarily in the staff clinic at Jackson
Memorial Hospital with ample opportunity for supervision and guidance from both a
senior resident and faculty member. Understanding of complex head and neck
treatment paradigms is expected to be mastered, and greater sophistication in
physician-patient interaction, particularly with regard to communication of treatment
options with patients, is expected. Weekly participation in Head and Neck Tumor
Conference provides opportunities for resident teaching as well as faculty
evaluation of each resident’s progress in these areas. Operative experience during
the third year emphasizes greater participation as surgeon in more complex surgical
procedures to include neck dissection, parotidectomy, thyroidectomy, and primary
tumor resections including total laryngectomy and composite resections. Broad
experience in the full range of head and neck surgical procedures is continued as
first assistant where appropriate. Encouragement of head and neck related
research interests are actively encouraged among a broad range of research
projects in the head and neck division.
PGY-4: The fourth year otolaryngology resident transitions to the senior resident
role on the Head and Neck Service, and his or her responsibilities increase
accordingly. Outpatient management and medical decision making in the staff clinic
becomes the primary responsibility of the senior resident. Readily available
attending input provides for a smooth transition between the junior and senior
resident roles in this context. A more global responsibility is assumed for the care of
the head and neck patients in the staff clinic. The senior resident is integral in the
decision making process, the communication of information to patients such that
truly informed decisions are made, and finally the shepherding of patients through
their treatment. Staff patients are generally presented by the senior resident at the
Head and Neck Tumor Conference, providing additional opportunities for comments
and critiques of management plans based upon resident evaluation of all available
data including imaging studies. Surgical work-ups of the staff patients are the
primary responsibility of the senior resident in consultation with the covering
attending.
Surgical experience changes significantly during this year as the third year resident
will have the autonomy to assign cases between him or herself and the junior
resident on the service. The senior resident is expected to review the running totals
of all their head and neck cases as surgeon and assistant with the attending on the
service responsible for resident evaluations. This interaction will assist the resident
in their selection of cases to assure an adequate numbers of cases are performed in
the proper distribution. Much greater emphasis is placed in this year on primary
tumor resection to include more advanced techniques such as conservation
laryngectomy, endoscopic laser resections of primary tumors, and more
sophisticated reconstructions. Participation in both anterior and lateral skull base
procedures as surgeon is expected. Pedicled flap harvest and inset is emphasized,
and familiarity with various microvascular options for reconstruction with appropriate
indications is stressed. Finally the senior resident assumes a teaching role as
teaching assistant for his or her junior resident for cases such as tracheotomy,
submandibular gland excision, etc. Both primary surgeon and teaching assistant
experience is broadly gained with the patient populations of both Jackson Memorial
Hospital and the University of Miami Hospital and Clinics/Sylvester Comprehensive
Cancer Center.
The senior resident on the Head and Neck service assumes an administrative role
beyond that required for individual patient care issues and questions. Resident and
fellow case assignment and attending resident-coverage are determined by the
senior resident. These assignments require organization and planning, and become
a useful measure of each senior resident’s ability to manage the service efficiently
and effectively.
For those residents considering head and neck subspecialty fellowship training
additional time is spent in faculty counseling. Research opportunities are
encouraged and fellowship application strategies are reviewed.
PGY-5: The chief resident year provides the opportunity to bring together all that
has been learned in the management of head and neck patients in the preceding
years. The chief resident is experienced in the medical and surgical management of
these patients, has developed proper methods of physician-patient and physicianstaff interaction, and is familiar with the administrative responsibilities of the service.
A critical assessment of case numbers as well as perceived areas of weakness is
made in conjunction with the attending responsible for resident evaluation on the
service. Care is taken to be sure that these areas are addressed in terms of surgical
case assignments. The entire range of head and neck surgical procedures are
included. Opportunities for traditionally “fellow-level” cases are crafted depending
upon individual chief resident interests, including advanced skull base procedures
as all as microvascular reconstruction. Resident teaching is also emphasized, both
in the operating room as well is in didactic and conference settings. Research
projects are concluded. Perhaps most importantly the opportunity for individual
faculty interaction is strongly encouraged as management styles and operative
techniques are fine-tuned and career plans are finalized.
Continuity of Care: A resident continuity clinic with emphasis on head and
neck patients has been developed. As the residents rotate through the head and
neck service, all new patients seen and evaluated by them during their time on
the head and neck service will become enrolled in their individual continuity
clinic. This patient cohort has been identified as most likely to remain in our
clinics over a period of 4 years. Most others are treated and returned to their
primary providers.
Residents see their continuity patients once every six weeks, seeing these
patients concurrent with the weekly head and neck clinic as run by the head and
neck service. This provides for attending coverage of both the weekly head and
neck resident clinics as well as the resident continuity clinic, as two residents are
scheduled each week for their continuity clinic in the morning or afternoon of the
head and neck clinic days. The resident head and neck continuity clinic will be
staffed by the attending head and neck surgeon available in the resident head
and neck clinic. Any clinical issues identified in continuity clinic follow-up that
mandate intervention or evaluation earlier than a six week evaluation schedule
will be transferred to the supervision of the residents on the head and neck
service at that time. Otherwise, all other regular head and neck related follow-up
for these patients will be maintained within each individual resident’s continuity
clinic. The continuity clinics were initiated in December of 2003, although
implementation of the clinics has been a logistical challenge with progress still to
be made.
MEDICAL KNOWLEDGE
Residents on the head and neck rotation must demonstrate medical knowledge
about established and evolving biomedical, clinical, and cognate sciences and the
application of this knowledge to patient care. Otolaryngology residents are expected
to become familiar with all of the pertinent medical literature relevant to each clinical
situation and disease process, and to apply an analytical approach to evaluating
each clinical situation. A thorough knowledge of basic science is required as it
applies to the normal physiological function of systems related to Otolaryngology (ie,
auditory, olfactory, salivation, airway physiology), but also as it applies to pertinent
disease processes, including benign and malignant neoplastic processes, that are
encountered on the head and neck rotation. Educational opportunities begin during
the first year of residency, with PGY1 residents attending weekly lectures in basic
otolaryngology topics prepared and given by senior otolaryngology residents. In
addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces
these basic principles with 2 weeks spent on the head and neck service. During the
core clinical years of Otolaryngology (PGY 2-5) medical knowledge is disseminated
through core curriculum and basic science lectures given throughout the year, while
rotation specific conferences including the weekly multidisciplinary tumor conference
and the monthly thyroid conference and head and neck journal club provide
opportunities for didactic and interactive teaching while on the rotation. The head
and neck core curriculum lecture topics for the 2008-2009 academic year are
summarized below. Residents rotating on the head and neck service are expected
to develop an increasingly sophisticated understanding of these topics in their
application to real clinical scenarios and patient problems. This occurs in a
graduated fashion by post-graduate year, such that the PGY2 and 3 residents have
an understanding of the fundamental concepts of tumor biology, clinical cancer
staging, and options for therapy. The senior residents are expected to develop a
greater depth of understanding of these topics while demonstrating the ability to
correctly apply these topics to specific and challenging clinical scenarios. Residents
at all levels of training are expected to demonstrate the appropriate application of
medical knowledge and relevant medical literature to each particular clinical
problem.
Didactic Curriculum: The head and neck didactic curriculum is based on the
head and neck core curriculum lecture series. Lecture topics for the 2008-2009
academic year include thyroid/parathyroid disorders, sinonasal malignancies,
oral cavity/oropharynx malignancies, larynx/hypopharynx malignancies, neck
dissection/N0 neck management, head and neck reconstruction, salivary gland
neoplasms, and tumor biology with applied basic science principles of
chemotherapy and radiation oncology. These lectures are given by faculty from
the Departments of Otolaryngology, Pathology, Radiation Oncology, and Medical
Oncology. One grand rounds lecture per month is dedicated to a head and neck
topic. The weekly head and neck multidisciplinary head and neck tumor board is
a treatment planning conference but also functions as a resident and fellow
teaching conference, with participation of faculty, residents and fellows from
otolaryngology, radiation oncology, medical oncology, pathology, and radiology.
A monthly thyroid conference functions in a similar manner as the head and neck
tumor board, with participation from representatives from otolaryngology, general
surgery, endocrinology, radiation oncology, nuclear medicine, radiology, and
pathology. The head and neck journal club occurs at least once monthly
following the Thursday afternoon head and neck tumor conference.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents on the head and neck service must demonstrate practice-based learning
and improvement that involves investigation and evaluation of their own patient care,
appraisal and assimilation of scientific evidence, and improvements in patient care.
An electronic portfolio is required of all residents to contain records of, among other
areas of competency, clinical scenarios of both favorable and unfavorable patient
outcomes from which self directed learning may be demonstrated and utilized well
beyond the residency training years. A critical review of current medical literature as
it relates to clinical management and ongoing modification of techniques and
methods is emphasized on the head and neck rotation in the context of the
multidisciplinary tumor conference and head and neck journal clubs. Residents’
present head and neck patients cared for during their head and neck rotation at the
quarterly morbidity and mortality conference where frank and open discussion
among residents and faculty serves to assess specific patient treatments and
outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct
faculty supervision of clinical and operative performance provides the foundation for
practice based learning and improvement in a progressive fashion through each
post-graduate level. Each resident on the head and neck rotation is expected to
demonstrate the ability to recognize their own strengths and weaknesses in clinical
and surgical skills and decision making with appropriate input from the supervising
faculty. Similarly, each resident is expected to show initiative in their efforts to
improve weaknesses as measured by demonstrable improvements in clinical
decision making and surgical skills.
INTERPERSONAL AND COMMUNICATION SKILLS
The head and neck resident is expected to demonstrate interpersonal and
communication skills that result in effective information exchange and learning with
patients, their families, and other health professionals. The importance of
interpersonal and communication skills is stressed at every level of training
throughout the head and neck rotation. Demonstration of these skills is monitored in
clinical case presentations, observation of the resident’s participation in the informed
consent from pre-operative patients, direct observation of resident-patient
interactions in the inpatient and outpatient settings where difficult and challenging
topics such as end of life decisions are encountered, formal conference
presentations, as well as in clear and precise medical writing techniques. The head
and neck resident is expected to communicate effectively with staff and ancillary
personnel as one who is part of a complex multidisciplinary treatment team caring
for the cancer patient. Evaluation of these skills comes from all levels, including
feedback from clinic nursing and operating room personnel in the form of 360 degree
evaluations.
PROFESSIONALISM
The head and neck service residents are expected to demonstrate professionalism
at all times, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population. Otolaryngology residents are carefully monitored throughout their
training to ensure that they demonstrate respect, compassion, and perform with
integrity at all levels. Residents at the University of Miami are actively involved with
patients and staff from many diverse economic, cultural, religious, and social
backgrounds. Faculty provide direct feedback regarding resident interactions with
patients, hospital staff, departmental staff, and physicians. Unprofessional behavior,
and in particular patterns of behavior, are monitored by both the program leadership
and the senior resident leadership such that appropriate interventions may be
undertaken. The faculty are responsible for demonstrating ethical and professional
behavior at all levels of interpersonal interactions, serving as role models for the
housestaff.
SYSTEMS-BASED PRACTICE
The head and neck residents are expected to demonstrate an understanding of the
principles of systems-based practice, as manifested by actions that demonstrate and
awareness of and responsiveness to the larger context and system of health care
and the ability to effectively call on system resources to provide care that is of
optimal value. In addition to didactic lectures on this topic, examples of systemsbased practice are highlighted on the head and neck rotation during interactions
between residents and ancillary services or hospital staff to illustrate the concept of
the medical care team and the physician’s part in that team. Important billing and
coding issues are introduced during the first years of training since all operative
cases are coded with appropriate diagnosis codes through computers in the
operating room at the conclusion of each procedure. These processes are
particularly important on the head and neck service where complex patient needs
often collide with the reality of limited patient resources. While preparing patients
for discharge from the hospital, residents serve as the primary organizers of the
complex network of support services needed for postoperative care. Residents
facilitate home health needs, inpatient rehabilitation, coordination of follow-up care,
and negotiate these services in the context of the family social issues, insurance
limitations, and the service availability. The resident works closely with patient
families and other related professionals, including social workers and
representatives of home health agencies, to accomplish these complex tasks.
Mastery of this practical understanding of systems based practice principles as they
apply to the individual patient begins in the first clinical years on the head and neck
service, and progresses to a greater sophistication in the senior years of training.
Useful Treatment Protocols:
DVT Prophylaxis: Start on POD1 in all patients unless contraindicated.
Jackson/SCC/BPEI/VA
Fragmin 5000 units SQ daily
Or
Heparin 5000 units SQ Q 8 Hours
UMH:
Lovenox 40 mg SQ BID
Or
Heparin 5000 units SQ Q 8 Hours
Serial compression devices on at all times when patients are non-ambulatory;
OOB/ambulate early, PT/OT as needed
Post-operative prevention of hypocalcemia in patients undergoing total
thyroidectomy:
Decision to initiate prophylactic calcium supplementation based on attending preferance
and intra-operative details.
1.) Prophylactic calcium supplementation: 2 gram cal citrate tid, 0.25 microgram
calcitriol qd. Ionized calcium q6-8hrs x 3. If values are stable and last iCa++ is greater
than 1.05, then home on same regimen. Otherwise, titrate PO calcium supplementation
accordingly. Endocrinology consultation in cases of refractory hypocalcemia/cases
where patients require titration of IV Ca++ drip.
2.) Post-operative monitoring for hypocalcemia in post-thyroidectomy patients who do
not receive prophylactic supplementation: iCa++ q6hrs in first 24hr period, q6-8hrs
subsequently
* if iCa++ is < 0.90 or patient has signs of symptoms of hypocalcemia with an iCa++ <
1.0: replace Ca++ with 2gm IV Calcium gluconate, slow IVPB and inititiate calcium
supplementation as above.
* if iCa++ values are stable and last iCa++ is above 1.05, then patient can be
discharged home without Ca++
EDUCATIONAL GOALS & OBJECTIVES: OTOLOGY
Residents each year will complete a two month rotation in otology and neurotology
in each of the PGY 2-5 years. Although all the Residents will be exposed to and are
expected to participate in all aspects of otology & neurotology, certain milestones
should be adequately achieved at the end of each year of residency training. The
level specific clinical and surgical procedures to be learned are listed below:
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate,
and effective for the treatment of health problems and the promotion of health. The
goals and objectives of the otology rotation is described in terms of diagnostic and
procedure-oriented learning by PGY year. Mastery of these principles and
techniques forms the foundation of competency in patient care in Otolaryngology.
Diagnostic oriented learning goals focus on clinical evaluation and work-up, while
procedure-oriented learning goals focus on the development of proficiency with both
diagnostic and therapeutic procedures in a graduated PGY-level specific fashion.
Follow-up and post-operative patient care is strongly emphasized starting with the
first PGY year, and an expected mastery of this area by senior resident years is
expected. Mastery should be demonstrated by effective patient care and accurate
teaching of peri-operative care principles to the junior residents.
Procedural Oriented Learning
Competency in these areas will be taught at a level specific manner at the beginning
of each rotation. Residents will observe faculty performing these procedures.
Residents will then perform weekly dissections in the temporal bone microsurgerytraining center using cadaver specimens and the faculty will review these. During the
second month of the otology rotation, the residents will perform the level specific
clinical and surgical procedures on live patients under direct supervision of faculty
members. It is expected at the conclusion of their otology rotation the residents will
be able to provide a step by step description of specific procedures for which they
are responsible. At the end of the rotation the otology faculty will review the
residents’ competence in performing level-specific procedures and note any
deficiencies. Areas of weakness will be remediated through individual counseling,
additional resident observation of faculty, and further supervised dissection of
cadavers specimens in the temporal bone microsurgery training center as needed.
The number of level specific procedures performed by each resident will be counted
at the end of their rotation and compared to the total number of that procedure which
is expected to be performed for adequate competency based on national averages
from otolaryngology training programs.
PGY-1: Otologic binolcular examination, cerumen removal
PGY-2: Foreign body, cerumen removal, myringotomy and tubes, auricular incisions,
harvesting temporalis fascia graft.
PGY-3: Tympanomeatal flap, middle ear exploration, complete mastoidectomy,
tympanoplasty type I.
PGY-4: Fistula repair, complete mastoidectomy, radical mastoidectomy, and
excision mastoid cholesteatoma.
PGY-5: Facial recess approach mastoidectomy, ossicular reconstruction,
stapedectomy, removal of middle ear cholesteatoma, labyrinthectomy, temporal
bone resection, facial nerve decompression, skull base approaches.
Diagnostic Oriented Learning
Residents will be expected to acquire level specific competency in diagnosis of
otologic and temporal bone disorders. The level specific diagnostic categories are
listed below:
PGY-1: The resident will be expected to become proficient at performing an otologic
history and otoscopic examination with the hand-held otoscope and microscope.
The important aspects of common otologic symptoms will be taught at this stage of
resident training. Ability to identify normal structures on the auricle, external ear
canal and tympanic membrane will be expected. Differentiation between the normal
and pathologic states of the ear will be emphasized during patient office
examinations. The resident should be able to perform a simple cleaning of and
cerumen removal from the external ear canal by the completion of this year’s
rotation. Understanding of the normal function of the peripheral auditory structures
and hearing will be expected. The resident will learn the interpretation of the basic
audiogram (e.g., pure-tone thresholds, speech discrimination, tympanogram,
acoustic reflexes).
PGY-2: Identification of the normal landmarks of the auricle, ear canal and tympanic
membrane; tuning fork examination (Weber, Rinne, Schwabach); proper use of the
handheld otoscope and otologic microscope; basics of the otologic history;
recognition and initial evaluation of otologic emergencies (sudden sensory hearing
loss, coalescent mastoiditis, central nervous system complications of otomastoiditis,
acute facial paralysis, temporal bone trauma); interpretation of basic behavioral
audiogram, tympanogram and acoustic reflex; identification of a core group of basic
and common otologic disorders (acute otitis media, chronic otitis media with
perforation, middle ear vascular masses, cholesteatoma, otosclerosis, Meniere’s
Disease, benign paroxysmal positional vertigo, acoustic neuroma, auricular
perichondritis, otitis externa, Bell’s Palsy); anesthetic blocks of the ear and ear
canal.
PGY-3: Differential diagnosis of progressive or fluctuating sensorineural hearing
loss, indication for cochlear implantation, interpretation of auditory brainstem
response and electrocochleography, anatomy of the temporal bone by CT scanning,
management of acute and chronic facial nerve paralysis, management of acute
peripheral vestibular dysfunction, management of necrotizing otitis externa.
PGY-4: Interpretation of vestibular testing (electronystagmography, rotary chair,
posturography); positional nystagmus tests ( Dix-Hallpike) and particle repositioning maneuvers (EPLEY); temporal bone and posterior cranial
fossa anatomy by magnetic resonance imaging; evaluation and management of
autoimmune inner ear disease; interpretation of otoacoustic emissions testing;
evaluation and management of inner ear ototoxicity; management of complications
(cerebral spinal fluid, intracranial hemorrhage, acute vestibular loss, cranial nerve
paralysis, meningitis); cochlear implant candidacy.
PGY-5: At this level the resident should be competent enough in the initial
evaluation of patients using history and physical examination along with additional
diagnostic test results to obtain a diagnosis that correlates to that of the faculty for all
but the most complicated patients; residents at this level should be able to interpret
all of the audiological and vestibular tests and their indications; the appropriate use
of imaging studies (including CT scans, MRI scans, angiography, nuclear medicine
tests); pre and post-operative care; multidisciplinary planning; patient family
counseling; congenital and genetic disorders of the ear and hearing and temporal
bone.
Residents will be evaluated on their competency of clinical diagnosis and
management. Supervising faculty will review all initial intakes of new and established
patients in the otology clinic. In addition Faculty will directly observe and evaluate
selected resident/patient interactions in the clinic.
MEDICAL KNOWLEDGE
Residents on the otology rotation must demonstrate medical knowledge about
established and evolving biomedical, clinical, and cognate sciences and the
application of this knowledge to patient care. Otolaryngology residents are expected
to become familiar with all of the pertinent medical literature relevant to each clinical
situation and disease process, and to apply an analytical approach to evaluating
each clinical situation. A thorough knowledge of basic science is required as it
applies to the normal physiological function of systems related to otology (ie, normal
auditory and vestibular function), but also as it applies to pertinent disease
processes affecting these systems. Educational opportunities begin during the first
year of residency, with PGY1 residents attending weekly lectures in basic
otolaryngology topics prepared and given by senior otolaryngology residents. In
addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces
these basic principles with time spent on the otology service and with audiology.
During the core clinical years of Otolaryngology (PGY 2-5) medical knowledge is
disseminated through core curriculum and basic science lectures given throughout
the year, while rotation specific conferences including the weekly otology journal
club provide opportunities for didactic and interactive teaching while on the rotation.
The otology core curriculum lecture topics for the 2008-2009 academic year are
summarized below. Residents rotating on otology service are expected to develop
an increasingly sophisticated understanding of these topics in their application to
real clinical scenarios and patient problems. This occurs in a graduated fashion by
post-graduate year, such that the PGY2 and 3 residents have an understanding of
the fundamental concepts of acute and chronic ear disease, disorders of vestibular
function, otologic neoplasms, and options for therapy. The senior residents are
expected to develop a greater depth of understanding of these topics while
demonstrating the ability to correctly apply these topics to specific and challenging
clinical scenarios. Residents at all levels of training are expected to demonstrate the
appropriate application of medical knowledge and relevant medical literature to each
particular clinical problem.
The didactic educational program for otology will include the following: ten core
curriculum lectures, JMH otology clinical quality assurance, temporal bone
laboratory dissection, formal and informal review of the literature, Grand Rounds
presentation (monthly otology topic), annual Resident temporal bone course, and
weekly otology journal club. Informal daily oral quizzing will take place to ensure that
Residents are properly prepared for the patients that they will see, assist on and
operate as primary surgeon. The sequential progress and improvement in their
scores on the inservice examination otology section will serve as a guide to the
progress of the residents’ fund of knowledge. It should be noted that the didactic
teaching in otology, including the ten week core curriculum lecture series, is
designed to incorporate all of the critical areas encompassed in the scope of
knowledge report by the American Board of Otolaryngology specific to the
knowledge areas in otology and neurotology.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents on the otology service must demonstrate practice-based learning and
improvement that involves investigation and evaluation of their own patient care,
appraisal and assimilation of scientific evidence, and improvements in patient care.
An electronic portfolio is required of all residents to contain records of, among other
areas of competency, clinical scenarios of both favorable and unfavorable patient
outcomes from which self directed learning may be demonstrated and utilized well
beyond the residency training years. A critical review of current medical literature as
it relates to clinical management and ongoing modification of techniques and
methods is emphasized on the otology rotation in the context of the weekly otology
journal club. Residents present otology patients cared for during their otology
rotation at the quarterly morbidity and mortality conference where frank and open
discussion among residents and faculty serves to assess specific patient treatments
and outcomes, with a goal to improve patient care, patient safety, and outcomes.
Direct faculty supervision of clinical and operative performance provides the
foundation for practice based learning and improvement in a progressive fashion
through each post-graduate level. Each resident on the otology rotation is expected
to demonstrate the ability to recognize their own strengths and weaknesses in
clinical and surgical skills and decision making with appropriate input from the
supervising faculty. Similarly, each resident is expected to show initiative in their
efforts to improve weaknesses as measured by demonstrable improvements in
clinical decision making and surgical skills.
INTERPERSONAL AND COMMUNICATION SKILLS
The otology resident is expected to demonstrate interpersonal and communication
skills that result in effective information exchange and learning with patients, their
families, and other health professionals. The importance of interpersonal and
communication skills is stressed at every level of training throughout the rotation.
Demonstration of these skills is monitored in clinical case presentations, observation
of the resident’s participation in the informed consent from pre-operative patients,
direct observation of resident-patient interactions in the inpatient and outpatient
settings, formal conference presentations, as well as in clear and precise medical
writing techniques. Residents will be encouraged to engage in presentations at local
and national meetings as well as manuscripts preparation of case reports, clinical
and basic research studies. This type of academic activity is invaluable for resident
education, and faculty of the otology section make every effort to ensure that during
each residents training at least one manuscript involving otology related research is
submitted to a peer reviewed journal. The otology resident is expected to
communicate effectively with staff and ancillary personnel as one who is part of a
complex multidisciplinary treatment team caring for the cancer patient. Evaluation of
these skills comes from all levels, including feedback from clinic nursing and
operating room personnel in the form of 360 degree evaluations.
PROFESSIONALISM
The otology service residents are expected to demonstrate professionalism at all
times, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population. Otolaryngology residents are carefully monitored throughout their
training to ensure that they demonstrate respect, compassion, and perform with
integrity at all levels. Residents at the University of Miami are actively involved with
patients and staff from many diverse economic, cultural, religious, and social
backgrounds. Faculty provide direct feedback regarding resident interactions with
patients, hospital staff, departmental staff, and physicians. Unprofessional behavior,
and in particular patterns of behavior, are monitored by both the program leadership
and the senior resident leadership such that appropriate interventions may be
undertaken. The faculty are responsible for demonstrating ethical and professional
behavior at all levels of interpersonal interactions, serving as role models for the
housestaff.
SYSTEMS-BASED PRACTICE
The otology residents are expected to demonstrate an understanding of the
principles of systems-based practice, as manifested by actions that demonstrate and
awareness of and responsiveness to the larger context and system of health care
and the ability to effectively call on system resources to provide care that is of
optimal value. In addition to didactic lectures on this topic, examples of systemsbased practice are highlighted on the otology rotation during interactions between
residents and ancillary services or hospital staff to illustrate the concept of the
medical care team and the physician’s part in that team. Important billing and coding
issues are introduced during the first years of training since all operative cases are
coded with appropriate diagnosis codes through computers in the operating room at
the conclusion of each procedure. While preparing patients for discharge from the
hospital, residents serve as the primary organizers of the complex network of
support services needed for postoperative care. Residents facilitate home health
needs, outpatient rehabilitation services, and coordination of follow-up care, and
negotiate these services in the context of the family social issues, insurance
limitations, and the service availability. The resident works closely with patient
families and other related professionals, including social workers and
representatives of home health agencies, to accomplish these complex tasks.
Mastery of this practical understanding of systems based practice principles as they
apply to the individual patient begins in the first clinical years on each clinical
rotation, and progresses to a greater sophistication in the senior years of training.
EDUCATIONAL GOALS & OBJECTIVES: FACIAL PLASTIC SURGERY
Residents spend two months each year on the facial plastic and reconstructive
surgery service during PGY-4 and PGY-5. Residents are also exposed to this
subspecialty during all years of residency, while rotating at the Veteran’s
Administration Hospital, taking trauma call, and during combined procedures that
involve other subspecialties and facial plastic faculty.
The Facial Plastic service has responsibility for facial plastic patients at Jackson
Memorial Hospital (JMH), the University of Miami Hospital/Sylvester Comprehensive
Cancer Center (UMHC/Sylvester), the University of Miami Hospital (UMH), the
Miami Veteran’s Administration Hospital, and Anne Bates Leach Eye Hospital
(ABLEH), providing opportunities for comprehensive inpatient and outpatient
management of patients with facial plastic and reconstructive needs. Continuity of
care is insured by resident participation in both clinical and surgical management of
patients in each of these practice locations while on service. While all residents
participate in the care of facial plastic patients during each year of residency, the
following clinical and procedural competencies are expected to be achieved as
indicated below.
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate,
and effective for the treatment of health problems and the promotion of health. The
goals and objectives of the facial plastics rotation is described in terms of diagnostic
and procedure-oriented learning by PGY year. Mastery of these principles and
techniques forms the foundation of competency in patient care in Otolaryngology.
Diagnostic oriented learning goals focus on clinical evaluation and work-up, while
procedure-oriented learning goals focus on the development of proficiency with both
diagnostic and therapeutic procedures in a graduated PGY-level specific fashion.
Follow-up and post-operative patient care is strongly emphasized starting with the
first PGY year, and an expected mastery of this area by senior resident years is
expected. Mastery should be demonstrated by effective patient care and accurate
teaching of peri-operative care principles to the junior residents.
Procedural Oriented Learning
PGY-1: soft tissue closure, tissue handling and dissection, suture selection.
PGY-2: simple cyst excision, skin grafting, open wound management after MOHS
surgery or trauma, Mohs reconstruction (mainly skin grafts and local flaps), trauma
airway management.
PGY-3: facial plating techniques, nasal airway surgery (mainly septoplasty, turbinate
reduction), refinement of above.
PGY-4: rhinoplasty (incision, approaches, exposure, external septoplasty, closure),
advanced nasal airway surgery (nasal valve reconstruction, including placement of
spreader, alar batten, columelar strut, butterfly grafts); exposure and repair of facial
fractures (mandibular, orbital, maxillary, frontal, nasal); advanced Mohs
reconstruction (regional flap design and transfer, repair of defects involving multiple
facial subunits( ie, lip and periocular reconstruction); scar revision and keloid
management; facial reanimation (static sling, ectropion repair, browplasty);
management of pediatric facial lesions and deformities.
PGY-5: advanced rhinoplasty (osteotomies, refinement of nasal tip, reduction and
augmentation techniques); advanced repair of facial fractures (minimally invasive
techniques); complex Mohs reconstruction (repair of full thickness nasal and
auricular defects, calvarial bone and rib grafting, mucosal flaps); facial reanimation
(dynamic slings); aging face management, including minimally invasive techniques
(fillers, chemodenervation, resurfacing) and blepharoplasty; understanding of
rhytidectomy, browlift, neck lift (mostly observational); microtia repair.
Competency in these areas will be taught in a level specific manner during
each rotation. Residents will be exposed to many facets of reconstructive and
cosmetic facial plastic surgery via participation in peri-operative patient care.
Residents will learn both by assisting faculty during facial plastic procedures
and by performing many of these same procedures (with faculty supervision)
in a level appropriate manner. At the conclusion of the rotation, residents
should be able to provide a step-by-step description of each procedure for
which they are responsible. Facial plastics faculty review with residents their
level of competence and note any deficiencies. Areas of weakness will be
remediated through individual counseling, additional operative experience,
and/or supervised dissection of cadaver specimens. At end of the rotation, the
number of level specific procedures performed by each resident will be
evaluated and compared to the corresponding national average for
otolaryngology training programs.
Diagnostic Oriented Learning
Residents will be expected to acquire competency in the evaluation of facial plastic
and reconstructive surgery patients. The level-specific diagnostic competencies are
listed below:
PGY-1: evaluation and clinical management of facial trauma, including facial
fractures and open wounds.
PGY-2: advanced evaluation and clinical management of facial fractures and open
wounds, basic aesthetic analysis of the nose and face.
PGY-3: comprehensive aesthetic analysis of the face and nose, nasal airway
evaluation (including assessment of the nasal valve and complicated septal
deformities).
PGY-4: interpretation of trauma imaging studies (including CT scans, MRI scans,
angiography); peri-operative management of the trauma patient, including facilitation
of multidisciplinary planning and patient family counseling; evaluation and clinical
management of facial scarring and keloids; assessment of patients with facial
paralysis, including medical management related symptoms (especially periocular
complaints).
PGY-5: advanced trauma assessment and clinical management; evaluation of
complicated Mohs defects, advanced evaluation and counseling of patients seeking
rhinoplasty or facial rejuvenation procedures; evaluation and clinical management of
pediatric patients, including microtia.
Competency in these areas will be taught at a level specific manner during each
rotation. Residents will be exposed to exposed to the evaluation of facial plastic
patients by faculty, and actively participate in the assessment of patients with faculty
supervision. Supervising faculty will review initial intakes of new and established
patients in the facial plastic clinic and/or emergency room. In addition, faculty will
directly observe and evaluate selected resident/patient interactions in the clinic.
Facial plastics faculty review with residents their level of competence and note any
deficiencies. Areas of weakness will be remediated through individual counseling,
and/or additional clinic experience.
Residents also spend one month each year on the oral and maxillofacial surgery
service during PGY4 and PGY5. During this rotation, residents are exposed to the
evaluation and management of patients with facial trauma. Residents participate in
clinical assessment and procedural care in the emergency room and clinic. In
addition, residents serve as primary surgeon during facial plating procedures for a
variety of facial fractures. Specific objectives are listed below:
1. Proficiency in performing an appropriate oral and maxillofacial examination,
including definitive understanding of occlusal relationships and other cephalometric
relationships.
2. Competence in the evaluation of facial trauma patients with primary and advanced,
complicated and/or multiple injuries to the facial skeleton (in the clinical and
emergency care settings).
3. Competence in the discussion of treatment alternatives and formulation of a
management plan for the facial trauma patient.
4. Competence in the pre-operative preparation of the patient for facial trauma
procedures (i.e., placement of maxillomandibular fixation wires prior to surgical
procedures).
5. Gain experience with various plating systems and the principles of immediate
reconstruction of the facial trauma.
6. Gain experience as resident surgeon in the care of patients with mandibular,
zygomaticomaxillary complex, orbital floor, LeFort, and other facial fractures.
7. Competence in recognition of surgical complications related to facial trauma
procedures, and an understanding of their treatments.
MEDICAL KNOWLEDGE
Residents on the facial plastics rotation must demonstrate medical knowledge about
established and evolving biomedical, clinical, and cognate sciences and the
application of this knowledge to patient care. Otolaryngology residents are expected
to become familiar with all of the pertinent medical literature relevant to each clinical
situation and disease process, and to apply an analytical approach to evaluating
each clinical situation. A thorough knowledge of basic science is required as it
applies to the normal physiological function of systems related to facial plastic
surgery, but also as it applies to pertinent disease processes affecting these
systems. Educational opportunities begin during the first year of residency, with
PGY1 residents attending weekly lectures in basic otolaryngology topics prepared
and given by senior otolaryngology residents. In addition, the Otolaryngology 2
month rotation during the PGY 1 year reinforces these basic principles with time
spent on the facial plastics rotation, as well as time spent on the general plastics and
burn rotations. During the core clinical years of Otolaryngology (PGY 2-5) medical
knowledge is disseminated through core curriculum and basic science lectures given
throughout the year. Didactic sessions in facial plastic surgery include core
curriculum lectures (eight to ten per year), grand rounds presentations (monthly
topic), facial plastic conferences (quarterly), formal and informal literature review,
and departmental sponsored CME courses. In addition, separate annual hands-on
cadaveric dissection courses are provided in the following areas: (1) rhinopplasty
and (2) facial rejuvenation and soft tissue surgery. Simulation laboratory training in
facial trauma management, including technical skills related to plating of mandibular,
maxillary, orbital, frontal fractures, is provided annually. It should be noted that the
didactic teaching in facial plastics is designed to incorporate all of the critical areas
encompassed in the Scope of Knowledge report by the American Board of
Otolaryngology, and to the meet educational goals established by the AAO HNS
Resident Online Study Guide Curriculum.
Residents at all levels of training are expected to demonstrate the appropriate
application of medical knowledge and relevant medical literature to each particular
clinical problem. Residents will be orally quizzed during clinic and surgical
procedures to assess knowledge and ensure clinical competency. The sequential
progress and improvement in their scores on the inservice examination will serve as
a guide to the progress of the residents’ fund of knowledge in facial plastic and
reconstructive surgery.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents on the facial plastics service must demonstrate practice-based learning
and improvement that involves investigation and evaluation of their own patient care,
appraisal and assimilation of scientific evidence, and improvements in patient care.
An electronic portfolio is required of all residents to contain records of, among other
areas of competency, clinical scenarios of both favorable and unfavorable patient
outcomes from which self directed learning may be demonstrated and utilized well
beyond the residency training years. A critical review of current medical literature as
it relates to clinical management and ongoing modification of techniques and
methods is emphasized on the facial plastics in the context of journal clubs and
patient-specific didactic teaching and dialogue with the facial plastics faculty.
Residents present facial plastic surgery or trauma patients cared for during their
rotation at the quarterly morbidity and mortality conference where frank and open
discussion among residents and faculty serves to assess specific patient treatments
and outcomes, with a goal to improve patient care, patient safety, and outcomes.
Direct faculty supervision of clinical and operative performance provides the
foundation for practice based learning and improvement in a progressive fashion
through each post-graduate level. Each resident on the rotation is expected to
demonstrate the ability to recognize their own strengths and weaknesses in clinical
and surgical skills and decision making with appropriate input from the supervising
faculty. Similarly, each resident is expected to show initiative in their efforts to
improve weaknesses as measured by demonstrable improvements in clinical
decision making and surgical skills.
INTERPERSONAL AND COMMUNICATION SKILLS
The facial plastics resident is expected to demonstrate interpersonal and
communication skills that result in effective information exchange and learning with
patients, their families, and other health professionals. The importance of
interpersonal and communication skills is stressed at every level of training
throughout the rotation. Demonstration of these skills is monitored in clinical case
presentations, observation of the resident’s participation in the informed consent
from pre-operative patients, direct observation of resident-patient interactions in the
inpatient and outpatient settings, formal conference presentations, as well as in clear
and precise medical writing techniques. Evaluation of these skills comes from all
levels, including feedback from clinic nursing and operating room personnel in the
form of 360 degree evaluations. Residents will be encouraged to engage in
presentations at local and national meetings as well as manuscript preparation of
case reports, clinical and basic research studies. Furthermore, active participation
in academic facial plastic and reconstructive surgery is encouraged as a step
towards fellowship training in this subspecialty, if further training is desired.
PROFESSIONALISM
The facial plastics service resident is expected to demonstrate professionalism at all
times, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population. Otolaryngology residents are carefully monitored throughout their
training to ensure that they demonstrate respect, compassion, and perform with
integrity at all levels. Residents at the University of Miami are actively involved with
patients and staff from many diverse economic, cultural, religious, and social
backgrounds. Faculty provide direct feedback regarding resident interactions with
patients, hospital staff, departmental staff, and physicians. Unprofessional behavior,
and in particular patterns of behavior, are monitored by both the program leadership
and the senior resident leadership such that appropriate interventions may be
undertaken. The faculty are responsible for demonstrating ethical and professional
behavior at all levels of interpersonal interactions, serving as role models for the
housestaff.
SYSTEMS-BASED PRACTICE
The facial plastics resident is expected to demonstrate an understanding of the
principles of systems-based practice, as manifested by actions that demonstrate and
awareness of and responsiveness to the larger context and system of health care
and the ability to effectively call on system resources to provide care that is of
optimal value. In addition to didactic lectures on this topic, examples of systemsbased practice are highlighted on the facial plastics rotation during interactions
between residents and ancillary services or hospital staff to illustrate the concept of
the medical care team and the physician’s part in that team. Important billing and
coding issues are introduced during the first years of training since all operative
cases are coded with appropriate diagnosis codes through computers in the
operating room at the conclusion of each procedure. Education into the distinction
between cosmetic (self-pay) procedures vs. functional procedures that will be
covered by insurance occurs with direct input from the faculty and their management
of private cases. While preparing patients for discharge from the hospital, residents
serve as the primary organizers of the complex network of support services needed
for postoperative care. Residents facilitate home health needs, outpatient
rehabilitation services, and coordination of follow-up care, and negotiate these
services in the context of the family social issues, insurance limitations, and the
service availability. The resident works closely with patient families and other related
professionals, including social workers and representatives of home health
agencies, to accomplish these complex tasks. These issues are commonplace for
the trauma patients cared for by the service. Mastery of this practical understanding
of systems based practice principles as they apply to the individual patient begins in
the first clinical years on each clinical rotation, and progresses to a greater
sophistication in the senior years of training.
EDUCATIONAL GOALS & OBJECTIVES: PEDIATRIC OTOLARYNGOLOGY
Residents will have varying levels of formalized pediatric training throughout the fiveyear training process. During the PGY-1 year, interns spend one to two weeks rotating
through pediatric otolaryngology, participating in the attending physician clinics, JMH
clinic, and in the operating room observing procedures with the pediatric otolaryngology
team. In the PGY-2 year, residents will spend 2 days of the week during each their twomonth rotations participating in pediatric otolaryngology care. One day each week is
spent in the JMH pediatric otolaryngology clinic under the direct supervision of a faculty
member, and one day is spent in the operating room performing basic pediatric
otolaryngology procedures. During the PGY-4 and PGY-5 years, each resident will
complete a two-month rotation dedicated to only pediatric otolaryngology. This includes
direct participation in the private clinics of each faculty member, active participation in
the operating room at least two days a week as primary resident surgeon, and one day
a week directing the JMH pediatric otolaryngology clinic. During the JMH clinic, the
Peds Service Chief is responsible for teaching PGY-1 and 2 residents and medical
students about the care of these patients, under the supervision of the attending
physician. One day a week is spent as both primary surgeon and teaching surgeon in
the operating room.
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health. The goals
and objectives of the pediatric otolaryngology rotation is described in terms of diagnostic
and procedure-oriented learning by PGY year. Mastery of these principles and
techniques forms the foundation of competency in patient care in Otolaryngology.
Diagnostic oriented learning goals focus on clinical evaluation and work-up, while
procedure-oriented learning goals focus on the development of proficiency with both
diagnostic and therapeutic procedures in a graduated PGY-level specific fashion.
Follow-up and post-operative patient care is strongly emphasized starting with the first
PGY year, and an expected mastery of this area by senior resident years is expected.
Mastery should be demonstrated by effective patient care and accurate teaching of perioperative care principles to the junior residents.
Procedural Oriented Learning
Residents begin their pediatric experience in both the clinic and the operating room,
mastering the head and neck examination in children and simple procedures such as
fiberoptic laryngoscopy and ear examination in the uncooperative child. Surgical skills
are acquired as the primary surgeon under the direct supervision of the teaching faculty
member and the senior resident surgeon as teaching assistant. These initial cases,
including tonsillectomy and myringotomy and tube placement, are used to teach
principles of tissue dissection and microscopic ear surgery. Head and neck cases such
as node, gland or mass excision are valuable teaching cases for the junior resident to
learn principles of retraction, exposure and hemostasis.
After basic competency is demonstrated in these initial phases as primary surgeon and
as assistant surgeon for more complicated cases, the transition is made to assume
more responsibility as the primary surgeon for complex cases under direct guidance of
the faculty member. At the completion of each rotation, it is expected that the resident
will be able to describe the indications, potential risks, benefits, complications and
alternatives to each surgery in addition to describing in step-wise fashion each
procedure. At the end of each rotation, faculty reviews the resident competence in each
level-specific procedure and any areas of weakness are identified. Also, an index
clinical and surgical patient are presented and assessed by the faculty at the resident’s
appropriate level of training. Any specific deficiencies are addressed through individual
counseling and education, additional training time observing and under the observation
of each faculty member, and further clinical experience. Faculty review resident case
logs to assess any deficient areas. As senior residents, in addition to acting as primary
surgeon for complex cases, valuable experience is gained as a teaching assistant
supervising the junior resident procedures. Certain milestones are expected to be
reached at the completion of each year of pediatric otolaryngology. Specific procedures
that should be mastered by the end of each year of training are as follows:
PGY-1: Initial pediatric otolaryngology history and physical exam, clinic-based
procedures such as the microscopic ear exam, flexible nasopharyngoscopy in selected
children, suture removal and dressing changes.
PGY-2: Complete pediatric history and physical exam, microscopic ear examination,
foreign body and cerumen removal, myringotomy and tube placement, tonsillectomy
and adenoidectomy.
PGY-3: Tympanoplasty, cortical mastoidectomy, basic endoscopy including flexible and
direct laryngoscopy, bronchoscopy and esophagoscopy, esophageal foreign body
removal, sinonasal endoscopy
PGY-4: Excision of neck masses, branchial cleft cysts and arch anomalies, basic
endoscopic sinus surgery (including maxillary sinus antrostomy and anterior
ethmoidectomy), endoscopic laryngeal and bronchoscopic procedures including
papilloma removal and excision of tracheal lesions
PGY-5: Laryngotracheal reconstruction, excision of larger neck masses, cholesteatoma
removal and middle ear reconstruction, extensive endoscopic sinus surgery including
drainage of orbital and frontal sinus abscesses, complicated endoscopy and airway
evaluation
Diagnostic Oriented Learning
Residents are expected to acquire level-specific competency in the diagnosis and
treatment of specific disorders within pediatric otolaryngology. Level-specific diagnostics
are listed as follows:
PGY-1/PGY-2: Primary objective in the first year of pediatric otolaryngology is to learn
the examination of the normal child and identification of normal findings on physical
exam, radiographic and audiologic studies in children. Identification of primary
pathology, including complications, includes a basic understanding of the pathology,
pathophysiology, and initial treatment of otitis media, tonsillitis, obstructive sleep apnea
and airway obstruction. In addition, on-call responsibilities include primary management
of emergent situations including assessment of airway obstruction, complications of
otitis media and sinusitis, and control of hemorrhage and epistaxis.
PGY-3: In conjunction with the learning process in other subspecialties in
otolaryngology, residents at this level are expected to learn the diagnosis, evaluation
and treatment of common otologic conditions in children including chronic suppurative
otitis media, cholesteatoma and sensorineural hearing loss; they are also expected to
have a basic interpretation of normal and abnormal audiograms and auditory brainstem
response testing. General otolaryngology skills include interpretation of allergy testing
and allergy management in children and a preliminary understanding of voice disorders
and sinusitis at age-specific levels. Residents are expected to have read and be able to
identify basic airway pathology in children including flexible laryngoscopy and
identification of supraglottic and glottic laryngeal pathology and endoscopic evaluation
of subglottic and tracheal pathology. Head and neck skills include the diagnosis and
workup of neck masses and the differentiation of neoplastic, inflammatory and
congenital lesions. Encouragement of pediatric otolaryngology-related research projects
in conjunction with faculty research interests are developed in this year.
PGY-4: At this level residents are expected to act as senior patient managers in the
comprehensive care of the pediatric patient in conjunction with appropriate pediatric
specialty services. This includes a comprehensive management of otolaryngology
problems in the child with multiple medical problems. Specifically, management of
tracheotomy-dependent children includes an understanding of underlying pulmonary
and gastrointestinal disorders and the senior resident will coordinate care and
management in conjunction with these services. The senior resident will be responsible
for endoscopic examination and surgical treatment planning for complex airway
disorders under the faculty supervision. In addition, senior residents are expected to
study imaging and interpret sinonasal pathology on endoscopic examination and CT
and MRI scanning and plan medical and surgical treatments appropriately based on the
scientific literature. Senior residents should also be able to plan surgical management of
head and neck masses in children based on physical exam and appropriate imaging.
PGY-5: As a chief resident in pediatric otolaryngology residents are expected to fully
integrate patient management and evaluation skills to arrive at a diagnosis and
treatment plan that is commensurate with faculty evaluation and based on pertinent
scientific literature. At this level residents should be able to complete and entire physical
exam, review appropriate audiologic and radiographic studies and formulate a
management plan based on the above. This also includes comprehensive preoperative
counseling, postoperative management, multidisciplinary care planning, and most
importantly family and patient counseling.
Residents will be evaluated on their competency of clinical diagnosis and management.
The residents will present and review with the faculty all patients necessitating possible
admission or surgery in the pediatric otolaryngology clinic. In addition the faculty will
directly observe and evaluate selected resident/patient interactions in the clinic.
Inpatient hospital consultations will be reviewed and examined with faculty members to
maximize the educational process.
MEDICAL KNOWLEDGE
Residents on the pediatric otolaryngology rotation must demonstrate medical
knowledge about established and evolving biomedical, clinical, and cognate sciences
and the application of this knowledge to patient care. Otolaryngology residents are
expected to become familiar with all of the pertinent medical literature relevant to each
clinical situation and disease process, and to apply an analytical approach to evaluating
each clinical situation. A thorough knowledge of basic science is required as it applies to
the normal physiological function of systems related to pediatric otolaryngology as well
as the pertinent disease processes affecting these systems. Educational opportunities
begin during the first year of residency, with PGY1 residents attending weekly lectures
in basic otolaryngology topics prepared and given by senior otolaryngology residents.
In addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these
basic principles with time spent on the pediatric otolarynoglogy service. The
educational program in pediatric otolaryngology includes the following: 8 core
curriculum lectures in aspects of pediatric otolaryngology, JMH Department of
Otolaryngology Clinical Quality Assurance conference every quarter, endoscopic sinus
anatomy laboratory dissection, formal and informal review of the literature, Grand
Rounds presentations and a monthly Pediatric Otolaryngology Journal Club. Informal
daily oral quizzing and review of surgical cases (prior to surgery) ensures that residents
are properly prepared for the patients that they will see, assist on, and operate as
primary surgeon. The sequential progress and improvement in their scores on the
inservice examination pediatric otolaryngology subspecialty questions will serve as a
guide to the progress of the residents’ fund of knowledge. Teaching in pediatric
otolaryngology, including the core curriculum lecture series, is designed to incorporate
all of the critical areas encompassed in the scope of knowledge report by the American
Board of Otolaryngology specific to the knowledge areas in pediatric otolaryngology.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents on the pediatric otolaryngology service must demonstrate practice-based
learning and improvement that involves investigation and evaluation of their own patient
care, appraisal and assimilation of scientific evidence, and improvements in patient
care. An electronic portfolio is required of all residents to contain records of, among
other areas of competency, clinical scenarios of both favorable and unfavorable patient
outcomes from which self directed learning may be demonstrated and utilized well
beyond the residency training years. A critical review of current medical literature as it
relates to clinical management and ongoing modification of techniques and methods is
emphasized on the pediatric otolaryngology rotation in the context of journal clubs and
patient-specific didactic teaching and dialogue with the pediatric otolaryngology faculty.
Residents present pediatric patients cared for during their rotation at the quarterly
morbidity and mortality conference where frank and open discussion among residents
and faculty serves to assess specific patient treatments and outcomes, with a goal to
improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical
and operative performance provides the foundation for practice based learning and
improvement in a progressive fashion through each post-graduate level. Each resident
on the rotation is expected to demonstrate the ability to recognize their own strengths
and weaknesses in clinical and surgical skills and decision making with appropriate
input from the supervising faculty. Similarly, each resident is expected to show initiative
in their efforts to improve weaknesses as measured by demonstrable improvements in
clinical decision making and surgical skills.
INTERPERSONAL AND COMMUNICATION SKILLS
The pediatric otolaryngology resident is expected to demonstrate interpersonal and
communication skills that result in effective information exchange and learning with
patients, their families, and other health professionals. The importance of interpersonal
and communication skills is stressed at every level of training throughout the rotation.
Demonstration of these skills is monitored in clinical case presentations, observation of
the resident’s participation in the informed consent from pre-operative patients, direct
observation of resident-patient interactions in the inpatient and outpatient settings,
formal conference presentations, as well as in clear and precise medical writing
techniques. These skills are critically important in interactions with children who may be
afraid and may have very limited understanding of their surroundings, as well as their
families. Evaluation of these skills comes from all levels, including feedback from clinic
nursing and operating room personnel in the form of 360 degree evaluations. Finally,
residents will be encouraged to engage in presentations at local and national meetings,
as well as manuscript preparation of case reports, clinical and basic research studies.
This type of academic activity is invaluable for resident education. The faculty of the
pediatric otolaryngology section makes every effort to ensure annual publications by the
residents in a peer-reviewed journal pertaining to a relevant pediatric otolaryngology
topic. Furthermore, active participation in academic pediatric otolaryngology is
encouraged as a step towards fellowship training in pediatric otolaryngology if further
training is desired.
PROFESSIONALISM
The pediatric otolaryngology service resident is expected to demonstrate
professionalism at all times, as manifested through a commitment to carrying out
professional responsibilities, adherence to ethical principles, and sensitivity to a diverse
patient population. Otolaryngology residents are carefully monitored throughout their
training to ensure that they demonstrate respect, compassion, and perform with integrity
at all levels. Residents at the University of Miami are actively involved with patients and
staff from many diverse economic, cultural, religious, and social backgrounds. Faculty
provide direct feedback regarding resident interactions with patients, hospital staff,
departmental staff, and physicians. Unprofessional behavior, and in particular patterns
of behavior, are monitored by both the program leadership and the senior resident
leadership such that appropriate interventions may be undertaken. The faculty are
responsible for demonstrating ethical and professional behavior at all levels of
interpersonal interactions, serving as role models for the housestaff.
SYSTEMS-BASED PRACTICE
The pediatric otolaryngology resident is expected to demonstrate an understanding of
the principles of systems-based practice, as manifested by actions that demonstrate
and awareness of and responsiveness to the larger context and system of health care
and the ability to effectively call on system resources to provide care that is of optimal
value. In addition to didactic lectures on this topic, examples of systems-based practice
are highlighted on the pediatric otolaryngology rotation during interactions between
residents and ancillary services or hospital staff to illustrate the concept of the medical
care team and the physician’s part in that team. Important billing and coding issues are
introduced during the first years of training since all operative cases are coded with
appropriate diagnosis codes through computers in the operating room at the conclusion
of each procedure. While preparing patients for discharge from the hospital, residents
serve as the primary organizers of the complex network of support services needed for
postoperative care. Residents facilitate home health needs, outpatient rehabilitation
services, and coordination of follow-up care, and negotiate these services in the context
of the family social issues, insurance limitations, and the service availability. The
resident works closely with patient families and other related professionals, including
social workers and representatives of home health agencies, to accomplish these
complex tasks. Mastery of this practical understanding of systems based practice
principles as they apply to the individual patient begins in the first clinical years on each
clinical rotation, and progresses to a greater sophistication in the senior years of
training.
EDUCATIONAL GOALS & OBJECTIVES: GENERAL OTOLARYNGOLOGY
The General Service rotation provides exposure to all aspects of inpatient and
outpatient general otolaryngology, with a specific emphasis on rhinology and allergy,
airway disorders and laryngology. A minimum experience in certain surgical techniques
should be adequately achieved at the end of each year of residency training. The levelspecific clinical and surgical procedures to be learned are listed below:
Currently, the Division of General Otolaryngology consists of Dr. Roy Casiano and Dr.
Jose Ruiz as otolaryngology faculty members with a specific interest and expertise in
rhinology and allergy. In addition, Dr Paul Kleidermacher (otolaryngologic allergist))
provides clinical training in the diagnosis and management of otolaryngologic allergy,
with special emphasis on allergy testing and immunotherapy technique. The group sees
patients at UMHC/Sylvester Comprehensive Cancer Center (SCCC) or at the University
of Miami Hospital (UMH), as part of a multidisciplinary team of respiratory specialists
(pulmonologists, otolaryngologists, allergist, speech pathologists, and respiratory
therapists). The center also contains a vocal disorders laboratory and a pulmonary
functions laboratory. This multidisciplinary approach to respiratory disease has
improved the way that we treat patients and has led to numerous collaborative research
efforts. Residents rotate through this Airway Center and adjacent operating rooms, at
SCCC or UMH, during their two month rotation on the service as described below.
Other full time members of the department also help supervise large clinical load of
patients on the JMH general otolaryngology service (Dr Eshraghi, Dr Liu and Dr
Thomas). In addition, residents experience a wide range of experience with common
general otolaryngologic disorders as part of their VAH rotation (summarized elsewhere).
Also, additional allergy experience occurs during their VAH rotation (Dr Nissim).
From the residents’ perspective, the Division of General Otolaryngology consists of a
rhinology fellow, a senior resident (PGY 4 or 5), a otolaryngology consult resident for
the medical center (PGY 3), and a junior resident (PGY 2). There is also a separate
junior resident rotating through the VAH (summarized elsewhere). All of the residents
rotate through the General Otolaryngology Division every two months over the four
years of their residency. Over the course of their training all of the residents spend a
minimum of 8 months on the service. During their rotation, the residents and fellow are
responsible for the Jackson Memorial (JMH) general otolaryngology clinics and OR’s
(see table below). While at JMH, the residents see patients and operate under the
supervision of the general otolaryngology faculty. In order to keep up with the growing
clinical demand and patient load (due to an increase in indigent population needing
medical care in S. Florida) the department has also hired and trained a full time
Otolaryngology ARNP to see patients alongside the residents in their JMH clinic. This
has allowed us to develop additional educational programs for the resident, whereby the
quality of the program has been enhanced. In addition, the rhinology fellow, who
functions as a general otolaryngology attending, adds an additional layer of supervision
in his/her daily interactions alongside the residents in the OR’s and Clinics.
The JMH, SCCC and UMH Clinic and OR supervision currently available for general
otolaryngology/rhinology/allergy patients is summarized as follows:
Dr. Casiano -
Monday OR at UMH or JMH
Wednesday OR @ SCCC
Thursday rhinology clinic @ SCCC
Dr. Ruiz -
Monday OR and clinic @ JMH or VAH
Tuesday clinic and OR @ SCCC
Wednesday OR at UMH
Thursday OR at JMH
Friday clinic @ SCCC
Dr Eshraghi-
Thursday OR at UMH
Dr Liu-
Friday clinic at JMH
Tuesday OR at JMH
While on the service, the residents’ and fellow’s schedule of daily activities goes as
follows:
PGY
4 or 5
3
AM
Monday
JMH OR
Tuesday
JMH OR
Wednesday
SCCC OR
PM
JMH OR
JMH OR
SCCC OR
AM
JMH OR
UMH Allergy
Clinic: Dr.
Kleidermacher
SCCC OR
AM
JMH
General
ENT clinic
JMH
General
ENT clinic
JMH OR
PM
JMH OR
AM
PM
PM
2
Rhinology
Fellow
JMH OR
Thursday
Academics
(7-10 AM)
JMH OR
(>10 AM)
Academics
(7-10 AM)
Friday
JMH General
ENT Clinic
JMH General
ENT Clinic
JMH General
ENT Clinic
JMH OR
(>10 AM)
JMH General
ENT Clinic
JMH
Pediatrics
ENT clinic
JMH
Pediatrics
ENT clinic
SCCC OR
Academics
(7-10 AM)
JMH Pediatrics
Ambulatory OR
SCCC OR
JMH Pediatrics
Ambulatory OR
JMH OR
JMH
OR/Research
SCCC OR
(rhinology)
SCCC Dr
Casiano:
rhinology/allergy
clinic
(>10 AM)
Academics (7-10
AM)
JMH OR
JMH
OR/Research
SCCC OR
SCCC Dr
Casiano:
Rhinology/allergy
Clinic
(> 12:30 PM)
JMH General
ENT Clinic
JMH General
ENT Clinic
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health. The goals
and objectives of the general otolaryngology rotation is described in terms of diagnostic
and procedure-oriented learning by PGY year. Mastery of these principles and
techniques forms the foundation of competency in patient care in Otolaryngology.
Diagnostic oriented learning goals focus on clinical evaluation and work-up, while
procedure-oriented learning goals focus on the development of proficiency with both
diagnostic and therapeutic procedures in a graduated PGY-level specific fashion.
Follow-up and post-operative patient care is strongly emphasized starting with the first
PGY year, and an expected mastery of this area by senior resident years is expected.
Mastery should be demonstrated by effective patient care and accurate teaching of perioperative care principles to the junior residents.
Procedural Oriented Learning
Competency in these areas will be taught in a level-specific manner at the beginning of
each rotation. Initially, residents observe faculty performing these procedures.
Residents then perform pre-assigned dissections in the endoscopic sinus surgery
cadaver lab using fresh cadaver specimens. In addition, the residents participate in an
annual endoscopic sinus anatomy course utilizing fresh-frozen cadaver specimens.
They also participate in an annual allergy course with special emphasis on basic
immunology and immunotherapy as a treatment option for allergy patients. Cadaver
dissection will be complimented by level-specific clinical and surgical procedures under
direct supervision of faculty members. It is expected that after the conclusion of their
general otolaryngology rotation the residents will be able to explain the indications for
surgery and provide a step by step description of the specific surgical procedures for
which they are responsible. At the end of the rotation the faculty will review the
residents’ competence in the level-specific procedures and note any deficiencies. Areas
of weakness will be remediated through individual counseling, additional resident
observation of faculty, and/or further dissection of cadavers specimens. The number of
level-specific procedures performed by each resident will be counted at the end of their
rotation and compared to the total number of that procedure which is expected to be
performed for adequate competency, based on national averages from otolaryngology
training programs.
PGY-1: Clinical examination of the upper airway and recognizing the diagnosis and
management common voice/airway and sinonasal disorders. Basic OR set-up and
principles behind common surgical procedures for patients suffering from sinonasal and
voice complaints.
PGY-2: Tracheotomy and management of the emergent airway; direct laryngoscopy
with or without simple biopsy; diagnostic bronchoscopy and esophagoscopy,
microlaryngoscopy and excision of simple lesions (polyps and nodules); tonsillectomy
and adenoidectomy; I & D of superficial and deep neck abscesses; excision of
uncomplicated mucosal or skin lesions; septoplasty; endoscopic inferior and middle
turbinoplasty or reduction; endoscopic middle meatal antrostomy in uncomplicated
disease (primary cases with or without nasal polyps); CO2 laser use during
microlaryngoscopy or hand-held applications (ablation or excision of simple mucosal
lesions).
PGY-3: Uvulopalatopharyngoplasty; CO2 laser or radiofrequency ablation of the soft
palate or tongue for the treatment of OSA and for inferior turbinate hypertrophy; partial
endoscopic ethmoidectomy in patients with uncomplicated disease (primary cases with
or without nasal polyps).
PGY-4: Microlaryngoscopy and excision of more complicated mucosal lesions involving
more extensive mucosal or submucosal dissections (papillomas, early glottic carcinoma,
intrachordal cysts, laryngoceles, sacular cysts); total endoscopic ethmoidectomy and
sphenoid sinusotomy in patients with uncomplicated disease (primary cases with or
without nasal polyps); external approaches to the paranasal sinuses (Caldwell-Luc or
sublabial degloving for the maxillary sinus, Lynch incision for the ethmoid sinus,
trephination of the frontal sinus, bicoronal approach for frontal sinus obliteration or
exploration).
PGY-5: Medialization laryngoplasty for unilateral vocal fold paralysis (Thyroplasty type I
or injection techniques ); arytenoidectomy and/or cordotomy for bilateral vocal fold
paralysis; partial or total endoscopic ethmoidectomy and sphenoid sinusotomies in
patients with complicated disease (revision cases, sinus cavities with extensive mucosal
disease, and/or osteoneogenesis); endoscopic frontal sinusotomies; direct
laryngoscopy, bronchoscopy and esophagoscopy for removal of foreign bodies, keel or
stent placement, radial incision and balloon dilation of tracheal stenosis, or
ablation/excision of lesions (stenosis or neoplasms); endoscopic identification and
repair of minor CSF leaks in the nose and paranasal sinuses; minor degrees of
endoscopic skull base surgery; reconstructive procedures of the trachea or larynx after
trauma or stenosis (laryngotracheoplasty or resection and primary anastomosis).
Diagnostic Oriented Learning
Residents will be expected to acquire level-specific competency in the diagnosis and
treatment of common rhinologic, laryngologic, and other upper airway disorders.
Residents will be evaluated on their competency of clinical diagnosis and management.
The residents will present and review with the faculty all patients necessitating possible
admission or surgery, in the general otolaryngology clinic. In addition the faculty will
directly observe and evaluate selected resident/patient interactions in the clinic. The
level specific diagnostic categories are listed below:
PGY-1: Understand the fundamentals of a comprehensive otolaryngologic history and
examination, including fiberoptic nasal endoscopy and laryngoscopy. Develop
familiarity with interpretation of normal and abnormal findings on sinus CT scans. Learn
the basic evaluations steps of common otolaryngologic emergencies including epistaxis,
and complications of head and neck infections.
PGY-2: Develop a systematic approach for the workup, diagnosis, and treatment of
patients with common laryngeal, rhinologic or other upper airway complaints (OSA,
stridor, shortness of breath, wheezing, etc.); Identification of the normal endoscopic and
CT/MRI anatomy of the nose, nasopharynx, oropharynx, oral cavity, hypopharnx, larynx,
and trachea; Identification of the main sinus cavities, (ethmoid, sphenoid, frontal, and
maxillary) during routine postoperative debridement; Identification of abnormal lesions in
the upper airway (neoplasm, polyps, infection); Understand the basic concepts and
indications for objective measurements in the voice laboratory
(videostrobolaryngoscopy, air flow studies, EMG, acoustical analysis). Develop an
understanding for the appropriate use of perceptual measurements in the differential
diagnosis of vocal disorders (voice tremors, spasmodic dysphonia, stroke and other
neurologically impaired patients, vocal fold paralysis, muscular tension dysphonia, and
mass lesions on the vocal folds). Begin to learn the wide variety of growing in-office
procedures and techniques available to otolaryngolists to make a diagnosis and/or for
therapeutic intervention.
PGY-3: Understand the indications and technique for outpatient transnasal or transoral
endoscopic tissue biopsy or culture of suspicious upper airway lesions in the clinic;
Know the appropriate work-up and identification of the site of epistaxis; Know the
indications and techniques to control epistaxis from traditional packing techniques to
endoscopic management in the outpatient clinic; Know the differential diagnosis and
different treatment plans for common laryngeal and sinonasal disorders (neoplastic,
inflammatory, and/or infectious); Know how to perform basic objective and perceptual
measurements and interpret normal versus abnormal findings in patients with common
vocal complaints; Know the basic interpretation of sleep study results in patients with
obstructive sleep apnea or snoring; Know the basic interpretation of pH probe
evaluations, modified and regular swallowing studies, and monametric studies in the
workup of patients suffering from dysphagia, odynophagia, or symptoms of
laryngopharyngeal reflux disease; Know the appropriate work-up and treatment plan for
patients with laryngopharyngeal reflux disease.
PGY-4: Understand the different anatomic variants occurring in the nose and paranasal
sinuses (endoscopic and CT). Know how to interpret CT and MRI scans in the presence
of sinonasal, laryngeal, oral cavity, oropharynx, nasopharynx, or neck pathology
(neoplastic, inflammatory, or infectious).
PGY-5: At this level the resident should be competent enough in the initial evaluation of
patients using history and physical examination along with additional diagnostic test
results to obtain a diagnosis that correlates to that of the faculty members for all but the
most complicated patients; residents at this level should be able to interpret all of the
special objective voice measures in the vocal disorders laboratory and their indications;
the appropriate use of imaging and laboratory studies (including CT scans, MRI scans,
angiography, nuclear medicine tests); pre and post-operative care; multidisciplinary
planning; and patient/family counseling.
Otolaryngologic Allergy:
Allergy Rotation at UMH:
The Department of Otolaryngology recognizes allergy training as part of the residents’
overall core curriculum in Otolaryngology/Head and Neck Surgery. We have two
programs to address this issue: 1) Rotation through an otolaryngologic allergy clinic at
UMH and 2) an annual resident allergy course (both described below). The mission of
allergy training in otolaryngology is to disseminate knowledge and confidence in the
evaluation and treatment of inhalant and food allergies as promoted by the AAOA. The
Division of General Otolaryngology is responsible for the allergy curriculum.
Allergy Rotation Objectives:
The goal of this rotation is to introduce the resident to the clinical practice of allergy
testing and immunotherapy. The resident will work with an experienced allergy nurse
under physician supervision who will discuss and demonstrate the techniques involved
with serial endpoint titration and allergy desensitization. At the conclusion of the
rotation, the resident will understand the following points:













manifestations of allergic disease and indications for allergy testing and
immunotherapy
theory/immunology of allergic response and immunotherapy
the difference between inhalant and food allergies
the difference between seasonal and perennial allergies
the contraindications to immunotherapy/testing
theory behind serial endpoint titration which is the preferred method of testing of the
American
Academy of Otolaryngic Allergy technique of intradermal testing
technique for preparing serial dilutions to be used in immunotherapy
risks/adverse effects of allergy testing and immunotherapy
recognizing the signs and symptoms of anaphylaxis and understanding the
measures to prevent and to treat it.
recognizing common associated respiratory ailments (asthma, bronchitis, laryngitis,
etc.) and learning how to treat these comorbidities, to maximize the patients’ longterm outcomes.
understanding the principles of treatment of inhalant allergy by environmental control
and pharmacotherapy.
knowing the indications, probable mechanisms, and potential side effects of
pharmacotherapy.
Hands-on allergy and rhinology training begins at the PGY 2 level. The resident sees
patients under faculty supervision in the JMH General ENT Clinics, and in the SCCC
Rhinology/Allergy Clinic with Dr Casiano. In this clinic, the resident learns to take an
appropriate rhinologic/allergy history and physical, develop a course of action, and learn
various pharmacotherapeutic measures available to treat chronic inflammatory disease
of the upper airways. At SCCC, the resident gets his/her initial exposure to a
multidisciplinary rhinology/allergy practice. In addition, the resident gets exposure to
other comorbid conditions affecting the respiratory system, ranging from vocal disorders
to immunologic diseases. In addition, the PGY 2 resident receives hands-on training (to
develop hand-eye coordination) with the sinus telescope, by performing postoperative
sinonasal debridements, biopsies, cultures, and other office-based laryngologic and
rhinologic procedures.
At the PGY 3 level, the General Otolaryngology resident spends time in the allergy clinic
on Wednesdays at UMH. Under faculty supervision, this resident is responsible for
obtaining the initial allergy history. He/she then reviews the history and formulates a
treatment plan with the faculty. Many times this may involve pharmacotherapeutic
measures such as the use of various anti-inflammatory agents. In other patients,
immunotherapy would be a reasonable option. During this rotation, the resident obtains
hands-on experience with intradermal testing, interpretation of results, management of
potential complications (i.e., local skin reactions, anaphylaxix, etc.), formulation of a
treatment plan, and administration of desensitization shots.
In the allergy clinic, residents learn confirmatory testing demonstrating the presence of
allergen-specific IgE indirectly through skin testing or directly by in-vitro testing. Skin
testing includes prick and puncture (scratch testing), patch testing, and intradermal
testing. The residents learn to actively evaluate for the pertinent geographical antigens,
read the wheal and allergic parameters from the skin, and understand the mixing of
antigens and the safe practice of immunotherapy. In select patients, in-vitro testing may
be more appropriate. This includes the RAST (radioactive marker) and occasionally the
ELISA (enzymatic marker) test. Allergy treatment also emphasizes environmental
control and pharmacotherapy (including antihistamines, decongestants, mast cell
stabilizers, systemic and topical corticosteroids, and leukotriene inhibitors). New and
innovative pharmacotherapeutic measures (ie, IgE binding IgG or “Xolair”) are
constantly reviewed in conferences and during clinical activities.
MEDICAL KNOWLEDGE
Residents on the general otolaryngology rotation must demonstrate medical knowledge
about established and evolving biomedical, clinical, and cognate sciences and the
application of this knowledge to patient care. Otolaryngology residents are expected to
become familiar with all of the pertinent medical literature relevant to each clinical
situation and disease process, and to apply an analytical approach to evaluating each
clinical situation. A thorough knowledge of basic science is required as it applies to the
normal physiological function of systems related to general otolaryngology (i.e. normal
sinonasal physiology), but also as it applies to pertinent disease processes affecting
these systems (i.e. rhinosinusitis and allergy). Educational opportunities begin during
the first year of residency, with PGY1 residents attending weekly lectures in basic
otolaryngology topics prepared and given by senior otolaryngology residents. In
addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these
basic principles with time spent on the general service rotation. During the core clinical
years of Otolaryngology (PGY 2-5) medical knowledge is disseminated through core
curriculum and basic science lectures given throughout the year.
Didactic Curriculum:
The didactic educational program for general otolaryngology will include the following:
fifteen core curriculum lectures (5 in laryngology and voice, 5 in rhinology, and 5 in
allergy and immunology), JMH Department of Otolaryngology Clinical Quality
Assurance conference every quarter, endoscopic sinus anatomy laboratory dissection,
formal and informal review of the literature, Grand Rounds presentations (monthly
laryngology, allergy, or rhinology topic), and an annual resident endoscopic sinus
anatomy course. Informal daily oral quizzing and review of surgical cases (prior to
surgery) will take place to ensure that residents are properly prepared for the patients
that they will see, assist on, and operate as primary surgeon. The sequential progress
and improvement in their scores on the in-service examination general otolaryngology
sections will serve as a guide to the progress of the residents’ fund of knowledge. It
should be noted that the didactic teaching in general otolaryngology, including the 15
week core curriculum lecture series, is designed to incorporate all of the critical areas
encompassed in the scope of knowledge report by the American Board of
Otolaryngology specific to the knowledge areas in general otolaryngology (with specific
attention to the areas of upper airway disorders, laryngology, voice, rhinology, and
allergy).
Allergy Core Curriculum:
Formal lectures in otolaryngologic allergy are given as part of the annual core
curriculum and as part of the annual resident allergy course. The topics covered in this
course are as follows: Immunology of Allergy, Contemporary Pharmacotherapy for
Otolaryngologic Allergist, Principles and Methods of Skin and In Vitro Testing, Antigen
Selection: Concepts, Seasons and Identification, Allergy Emergencies for the
Otolaryngologist. Yearly visiting professor rounds (local or national) in otolaryngologic
allergy are integrated into the curriculum. Additionally, didactic teaching of
otolaryngologic allergy and immunology occurs periodically during our Grand Rounds
throughout the year.
The core curriculum enables the residents and medical students to understand the
pathogenesis and basic sciences of immunology including the classic Gell and Coombs
reactions, and the involvement of complement, prostaglandins, leukotrienes, and
cytokines (most notably interleukins). During lectures, the residents are familiarized
with the potential complications of allergy treatment such as the causes of anaphylaxis,
the signs and symptoms of anaphylaxis and its management (including use of
tourniquet, epinephrine, airway support, circulatory support, and appropriate
pharmacotherapy). In addition, food allergy is addressed in a manner consistent with
the AAOA standards.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents on the general otolaryngology service must demonstrate practice-based
learning and improvement that involves investigation and evaluation of their own patient
care, appraisal and assimilation of scientific evidence, and improvements in patient
care. An electronic portfolio is required of all residents to contain records of, among
other areas of competency, clinical scenarios of both favorable and unfavorable patient
outcomes from which self directed learning may be demonstrated and utilized well
beyond the residency training years. A critical review of current medical literature as it
relates to clinical management and ongoing modification of techniques and methods is
emphasized on the general otolaryngology rotation in the context of journal clubs and
patient-specific didactic teaching and dialogue with the general otolaryngology faculty.
Residents present patients cared for during their general service rotation at the quarterly
morbidity and mortality conference where frank and open discussion among residents
and faculty serves to assess specific patient treatments and outcomes, with a goal to
improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical
and operative performance provides the foundation for practice based learning and
improvement in a progressive fashion through each post-graduate level. Each resident
on the rotation is expected to demonstrate the ability to recognize their own strengths
and weaknesses in clinical and surgical skills and decision making with appropriate
input from the supervising faculty. Similarly, each resident is expected to show initiative
in their efforts to improve weaknesses as measured by demonstrable improvements in
clinical decision making and surgical skills.
INTERPERSONAL AND COMMUNICATION SKILLS
The general otolaryngology resident is expected to demonstrate interpersonal and
communication skills that result in effective information exchange and learning with
patients, their families, and other health professionals. The importance of
interpersonal and communication skills is stressed at every level of training
throughout the rotation. Demonstration of these skills is monitored in clinical case
presentations, observation of the resident’s participation in the informed consent
from pre-operative patients, direct observation of resident-patient interactions in the
inpatient and outpatient settings, formal conference presentations, as well as in
clear and precise medical writing techniques. Evaluation of these skills comes from
all levels, including feedback from clinic nursing and operating room personnel in
the form of 360 degree evaluations. Finally, residents will be encouraged to engage
in presentations at local and national meetings, as well as manuscript preparation of
clinical and basic research studies. This type of academic activity is invaluable for
resident education. The faculty of the general otolaryngology section makes every
effort to ensure annual publications by the residents in a peer-reviewed journal
pertaining to a relevant general otolaryngology clinical or basic science research
topic.
PROFESSIONALISM
The general otolaryngology service resident is expected to demonstrate professionalism
at all times, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population. Otolaryngology residents are carefully monitored throughout their training to
ensure that they demonstrate respect, compassion, and perform with integrity at all
levels. Residents at the University of Miami are actively involved with patients and staff
from many diverse economic, cultural, religious, and social backgrounds. Faculty
provide direct feedback regarding resident interactions with patients, hospital staff,
departmental staff, and physicians. Unprofessional behavior, and in particular patterns
of behavior, are monitored by both the program leadership and the senior resident
leadership such that appropriate interventions may be undertaken. The faculty are
responsible for demonstrating ethical and professional behavior at all levels of
interpersonal interactions, serving as role models for the housestaff.
SYSTEMS-BASED PRACTICE
The general otolaryngology resident is expected to demonstrate an understanding of
the principles of systems-based practice, as manifested by actions that demonstrate an
awareness of and responsiveness to the larger context and system of health care and
the ability to effectively call on system resources to provide care that is of optimal value.
In addition to didactic lectures on this topic, examples of systems-based practice are
highlighted on the general otolaryngology rotation during interactions between residents
and ancillary services or hospital staff to illustrate the concept of the medical care team
and the physician’s part in that team. Important billing and coding issues are introduced
during the first years of training since all operative cases are coded with appropriate
diagnosis codes through computers in the operating room at the conclusion of each
procedure. While preparing patients for discharge from the hospital, residents serve as
the primary organizers of the complex network of support services needed for
postoperative care. Residents facilitate home health needs, outpatient rehabilitation
services, and coordination of follow-up care, and negotiate these services in the context
of the family social issues, insurance limitations, and the service availability. The
resident works closely with patient families and other related professionals, including
social workers and representatives of home health agencies, to accomplish these
complex tasks. Mastery of this practical understanding of systems based practice
principles as they apply to the individual patient begins in the first clinical years on each
clinical rotation, and progresses to a greater sophistication in the senior years of
training.
EDUCATIONAL GOALS & OBJECTIVES: MIAMI VA ROTATION
Residents rotate through the Miami VA Medical Center twice during the PGY 2 year.
Each rotation is two months in length. The educational director on site for the rotation is
Kenneth Nissim, MD, a member of the faculty of the Department of Otolaryngology at
the University of Miami with interests in general otolaryngology and sleep medicine.
Subspecialty faculty also sees patients and performs surgery in the areas of Head and
Neck Oncology, Otology, and Facial Plastic and Reconstructive Surgery. This rotation
provides a comprehensive, mentored exposure to the care of general, head and neck,
otology, facial plastic and sleep medicine patient. This exposure includes direct
involvement with the initial patient evaluation and diagnostic work-up, medical decision
making, surgical planning, management of medical therapies, surgical procedures, and
facilitation of short term follow-up and post-operative care, all in the first full year of
clinical otolaryngology.
The PGY 2 resident is responsible for the evaluation and work-up of all new patients in
the outpatient clinic and all inpatient consults under the direct supervision of the clinical
faculty. This provides for a focused introduction to the evaluation and management of a
broad spectrum of otolaryngologic problems in a one-on-one faculty/resident mentoring
environment. Decision making regarding surgical planning begins in the clinic, and the
resident is responsible for the preoperative workup and planning. The rotation provides
an early introduction to the intricacies of systems-based practice as the PGY 2 resident
is introduced to the global responsibilities of managing an inpatient and outpatient
service including scheduling, triage of patients, interaction with the anesthesia service,
planning intra-operative airway management, and coordination of appropriate postoperative care. Head and neck cancer patients are evaluated with the head and neck
attending and presented by the resident at the VA’s multidisciplinary tumor board. The
resident participates in the continuity of care of all patients during postoperative clinic
visits.
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health. The goals
and objectives of the general otolaryngology rotation is described in terms of diagnostic
and procedure-oriented learning by PGY year. Mastery of these principles and
techniques forms the foundation of competency in patient care in Otolaryngology.
Diagnostic oriented learning goals focus on clinical evaluation and work-up, while
procedure-oriented learning goals focus on the development of proficiency with both
diagnostic and therapeutic procedures in a graduated PGY-level specific fashion.
Follow-up and post-operative patient care is strongly emphasized starting with the first
PGY year, and an expected mastery of this area by senior resident years is expected.
Mastery should be demonstrated by effective patient care and accurate teaching of perioperative care principles to the junior residents.
Procedural Oriented Learning:
Emphasis is placed on repetition and mastery of the head and neck exam including
micro-otoscopy, anterior nasal endoscopy and indirect laryngoscopy. Clinic procedures
include flexible and rigid endoscopy of the upper aero digestive tract which is digitally
recorded for later review and comparison. Fine needle aspirations, abscess drainage
and incisional biopsies are performed in clinic. The operating microscope is used for
cerumen disimpactions, mastoid debridement and office myringotomy. Nasal
endoscopy is performed for diagnosis, biopsy and postoperative debridement. Fiber
optic laryngoscopy is performed for diagnostic and therapeutic purposes. Trans nasally
assisted laryngeal biopsies and vocal fold injections are performed in conjunction with
attending physicians. The resident is expected to participate in the full range of
otolaryngologic operative procedures as first assistant on more complicated cases, and
primary surgeon when appropriate. He or she acts as primary surgeon, after an
individualized period of mentoring, for operative rigid endoscopy, facial soft tissue defect
repair, tonsillectomy, endoscopic turbinoplasty and myringotomy and tube placement.
These opportunities depend on each resident’s demonstrated level of preparation and
individual experience. When the PGY 2 resident returns to the VA rotation in the
second half of the year, after gaining additional surgical experience, there is the
opportunity to participate as surgeon in more advanced procedures such as neck
dissections, parotidectomy, thryoidectomy, endoscopic sinus procedures,
tympanoplasty, mastoidectomy, laryngoplasty, MOHS defect repairs, septoplasty,
rhinoplasty and surgical treatment of obstructive sleep apnea. Due to the one on one
intraoperative teaching by attending to the resident, the PGY2, who is appropriately
prepared, can perform as surgeon on cases normally reserved for more senior
residents.
Diagnostic Oriented Learning:
The comprehensive history and head and neck examination, including fiber optic and
indirect laryngoscopy, binocular otomicroscopy, and endoscopic nasal examination is
mastered on this rotation as the fundamental starting point for all otolaryngologic
diagnosis. Familiarity with normal and pathologic findings on each of these
examinations is gained with repetition, along with reinforcement by immediate faculty
corroboration of findings. Appropriate radiographic, audiometric, balance, swallowing,
and laboratory testing is discussed and finalized with the attending physician.
Interpretation of imaging studies, audiometric findings, balance testing, swallowing
studies, and laboratory studies is taught with close faculty supervision.
MEDICAL KNOWLEDGE
Residents on the Miami VA otolaryngology rotation must demonstrate medical
knowledge about established and evolving biomedical, clinical, and cognate sciences
and the application of this knowledge to patient care. Otolaryngology residents are
expected to become familiar with all of the pertinent medical literature relevant to each
clinical situation and disease process, and to apply an analytical approach to evaluating
each clinical situation. A thorough knowledge of basic science is required as it applies to
the normal physiological function of systems related to otolaryngology, but also as it
applies to pertinent disease processes affecting these systems. Educational
opportunities begin during the first year of residency, with PGY1 residents attending
weekly lectures in basic otolaryngology topics prepared and given by senior
otolaryngology residents. During the core clinical years of Otolaryngology (PGY 2-5)
medical knowledge is disseminated through core curriculum and basic science lectures
given throughout the year.
Allergy
The resident will spend 6 half days per two month rotation in the VA allergy clinic under
the supervision of an attending medical allergist. They will focus on the evaluation,
diagnostic workup and treatment of allergic patients including history taking, physical
exam, skin testing and pharmacologic and immunotherapeutic management allergic
patients.
Audiology/Speech pathology
Six half days per two month rotation are spent with the audiology staff learning the
theory and practice of audiology and vestibular testing. Residents learn how to interpret
and perform audiograms, impedance testing, ABRs and VNGs. They also participate in
cochlear implant and BAHA evaluations. In addition there is a weekly combined
ENT/Audiology/Speech pathology conference in which complicated cases are
discussed, video strobes and video swallowing studies are reviewed and a treatment
plan is formed.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents on the Miami VA otolaryngology service must demonstrate practice-based
learning and improvement that involves investigation and evaluation of their own patient
care, appraisal and assimilation of scientific evidence, and improvements in patient
care. An electronic portfolio is required of all residents to contain records of, among
other areas of competency, clinical scenarios of both favorable and unfavorable patient
outcomes from which self directed learning may be demonstrated and utilized well
beyond the residency training years. A critical review of current medical literature as it
relates to clinical management and ongoing modification of techniques and methods is
emphasized on the rotation in the context of patient-specific didactic teaching and
dialogue with the Maimi VA otolaryngology faculty. Residents present patients cared for
during their VA rotation at the quarterly morbidity and mortality conference where frank
and open discussion among residents and faculty serves to assess specific patient
treatments and outcomes, with a goal to improve patient care, patient safety, and
outcomes. Direct faculty supervision of clinical and operative performance provides the
foundation for practice based learning and improvement in a progressive fashion
through each post-graduate level. Each resident on the rotation is expected to
demonstrate the ability to recognize their own strengths and weaknesses in clinical and
surgical skills and decision making with appropriate input from the supervising faculty.
Similarly, each resident is expected to show initiative in their efforts to improve
weaknesses as measured by demonstrable improvements in clinical decision making
and surgical skills.
INTERPERSONAL AND COMMUNICATION SKILLS
The Miami VA otolaryngology resident is expected to demonstrate interpersonal and
communication skills that result in effective information exchange and learning with
patients, their families, and other health professionals. This is particularly true as
the VA resident is the sole housestaff representing his service and his patients
within the hospital. Demonstration of these skills is monitored in clinical case
presentations, observation of the resident’s participation in the informed consent
from pre-operative patients, direct observation of resident-patient interactions in the
inpatient and outpatient settings, formal conference presentations, as well as in
clear and precise medical writing techniques.
PROFESSIONALISM
The Miami VA otolaryngology service resident is expected to demonstrate
professionalism at all times, as manifested through a commitment to carrying out
professional responsibilities, adherence to ethical principles, and sensitivity to a diverse
patient population. Otolaryngology residents are carefully monitored throughout their
training to ensure that they demonstrate respect, compassion, and perform with integrity
at all levels. Residents at the University of Miami are actively involved with patients and
staff from many diverse economic, cultural, religious, and social backgrounds. Faculty
provide direct feedback regarding resident interactions with patients, hospital staff,
departmental staff, and physicians. Unprofessional behavior, and in particular patterns
of behavior, are monitored by both the program leadership and the senior resident
leadership such that appropriate interventions may be undertaken. The faculty are
responsible for demonstrating ethical and professional behavior at all levels of
interpersonal interactions, serving as role models for the housestaff.
SYSTEMS-BASED PRACTICE
The Miami VA otolaryngology resident is expected to demonstrate an understanding of
the principles of systems-based practice, as manifested by actions that demonstrate an
awareness of and responsiveness to the larger context and system of health care and
the ability to effectively call on system resources to provide care that is of optimal value.
In addition to didactic lectures on this topic, examples of systems-based practice are
highlighted on the Miami VA otolaryngology rotation during interactions between
residents and ancillary services or hospital staff to illustrate the concept of the medical
care team and the physician’s part in that team. While preparing patients for discharge
from the hospital, residents serve as the primary organizers of the complex network of
support services needed for postoperative care. Residents facilitate home health
needs, outpatient rehabilitation services, and coordination of follow-up care, all within
the unique health care delivery system managed by the Veteran’s Administration.
EDUCATIONAL GOALS & OBJECTIVES: RESEARCH ROTATION
The educational program provides a structured research experience sufficient to result
in an understanding of the basic principles of study design, performance, analysis, and
reporting. At all times during their training, all residents are expected to be involved in
research or scholarly activity. All projects should be conducted with the ultimate goal of
publication in a peer-reviewed journal. Every resident obtains or is assigned a mentor
from the teaching faculty for each project. The faculty mentor is responsible for
providing guidance and supervision of each specific project. Research experiences
may involve clinical or basic science research investigations, and should reflect careful
advice and planning with the appropriate faculty member. Facilities and protected time
for research by the residents are provided, as well as guidance and supervision by
qualified faculty.
The research rotation is a four month protected block of time in the PGY 3 year during
which the resident is expected to complete a clinical or basic science research project
worthy of presentation at a national Otolaryngology or related meeting and publication in
a peer reviewed journal. The resident is prepared for the experience by developing and
writing out his or her research plan in conjunction with their faculty mentor well in
advance of their actual research rotation. This research plan that has been prepared by
the resident is presented to the Resident Research Committee, and the faculty reviews
and assesses the scientific merit and feasibility of the proposal. Securing of appropriate
regulatory requirements prior to beginning the study is emphasized, including
submission of timely IRB protocols, submission of animal use protocols to the UM
internal animal care & use committee, and documentation of compliance with
appropriate HIPPA regulations. The resident is expected to learn the importance of the
preparation and planning of their research project, the critical nature of the regulatory
oversight of clinical & laboratory animal research, how to pose a testable hypothesis
and finally the importance of sound scientific methods in research design. The
techniques of the project will be taught by the faculty mentor and will vary by the nature
of the specific project. Assimilation and analysis of data will be conducted, and this data
will be prepared for local presentation at the resident research day. It is expected that
study results will be submitted for presentation and publication at a national meeting,
with the resident primarily responsible for manuscript preparation by assuming the role
of the first author. In addition to the long-standing expectation that each resident
submits one manuscript per year for publication, a new and added expectation for the
2008-2009 academic year requires that each resident submits a manuscripts for a
competitive resident research awards at least once during their residency. It is the goal
of the research educational program, and specifically the scientific foundation
established during the research rotation, to provide each resident with the capability to
fulfill these expectations.
Specific guidelines for the research rotation are as follows.
Timetable for Proposal Submission
6-12 Months Before Rotation:
 Consult with faculty members about research interests and choose a mentor
 Plan a project
4 Months Before Rotation:
 Submit a written proposal of the research plan to the Resident Research
Committee
 Modify the research plan as recommended, and submit the final proposal to the
committee within 1 week of your presentation
2-4 Months Before Rotation:
 With the assistance of faculty mentor, prepare an application to the School's
relevant institutional review board that governs the treatment of animals
(Institutional Animal Care and Use Committee) or human subjects (Medical
Sciences Subcommittee for the Protection of Human Subjects) for approval
of your experimental protocol
 Order any special equipment, supplies, or animal subjects that will be required
1 Week Before Rotation:
 Prepare laboratory or clinic space and organize equipment needed to perform
study
2 Weeks Before End of Rotation:
 Prepare a short written report and a ten minute oral presentation to the Research
Committee that provides an update on your research progress
2 Months Following Rotation:
 Submit a written report of project findings to the Research Committee in the
format of a journal publication in consultation with your mentor. Submit an
abstract to a national society that sponsors a meeting at which it would be
appropriate to present the results of your project.
Research Proposal
The research proposal is modeled after an NIH grant application.
1. Specific Aims:
 Brief outline (~1 paragraph) describing the goals of your project, their
significance, and how the study will be accomplished. Formulate and present the
hypothesis to be tested by the study design.
2. Introduction:
 Review the history of the topic
 Present a detailed review of the critical studies that are most relevant to the
problem
 Summarize the unanswered questions on this topic that need to be studied
 Provide the rationale and background information for your choice of experimental
approach and subject
3. Materials and Methods:
 describe animal or human subjects to be studied
 provide a detailed description of the experimental protocol
 describe the form of the data that will be acquired
 discuss the equipment that will be used to obtain the data
 give the method of statistical analysis to be used in the analysis of data and the
value to be used to achieve statistical significance
4. Expected Outcome:
 describe how the data will be analyzed
 discuss how the data address the question posed in the abstract
5. Schedule of Experiments:
 outline how your time will be organized to: perform the experiments, analyze
data, write up the results
6. Estimated Budget:
 Detail the expected costs including those covering: purchase and maintenance
of experimental subjects, compensation for human subjects, drugs, chemicals,
computer supplies, copying, other materials
7. Bibliography
Research Committee Members
Thomas Van De Water, PhD, Chair of Committee
Simon Angeli, MD
Adrien Eshraghi, MD
Elizabeth Franzmann, MD
Brian Jewett, MD
Xue Liu, MD, PhD
Donna Lundy, PhD
Jose Ruiz, MD
Zoukaa Sargi, MD
Giovana Thomas, MD
Donald Weed, MD
Research Expectations and Chandler Society Research Presentation
All residents at the PGY 2 level and above will present their research at the annual
Chandler Resident Research Day. For PGY 2 residents it is hoped that this
presentation will form the foundation for the work performed during their PGY 3
research rotation, but an unrelated project may be presented. PGY 4 and 5 residents
are encouraged to present follow-up studies related to their PGY 3 research project if
these represent substantially new contributions beyond that which has already been
presented. Unrelated projects may also be presented. Awards are given after critical
evaluation of each project by both UM (non-Otolaryngology) and nationally recognized
visiting faculty. Residents are also strongly encouraged to present their work at national
meetings and to prepare their findings for publication in peer reviewed journals. Faculty
mentors work closely with the residents so that the latter can achieve their research
goals.
Each resident and fellow selects a faculty member and a topic for their research
presentation at the Annual Chandler Society Research Day. You need to have chosen
a topic and a faculty mentor and submit that information to Dr. Weed by September 1.
An abstract is due by May 1. Prizes are awarded on Research Day for first, second and
third place in the resident category and first prize for the fellow category. Also, if there
are medical and/or graduate students who also completed a research project, they, too,
may compete for a first-place prize in the student category. This will be decided on an
as needed basis each year.