Thoracic Senior Rotation

INTRODUCTION

This rotation at the Montreal General Hospital site is designed for a six months rotation to meet the requirements of the Objectives of Training in Cardiac Surgery.

Definition:

Thoracic Surgery is the surgical specialty concerned with management of diseases of the lungs, esophagus and mediastinum.

General Objectives:

Residents will demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to thoracic disease.  In addition, all residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis.

On completion of the educational program, the graduate physician will be competent to function as a consultant thoracic surgeon.  This requires the resident to:

• Provide scientifically based, comprehensive and effective diagnosis and management for patients with thoracic disease.
• Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other health care professionals.
• Counsel patients and others on aspects of prevention of all thoracic disease, including risk factors, and genetic and environmental concerns.
• Maintain complete and accurate medical records.
• Effectively co-ordinate the work of the health care team.
• Be an effective teacher of other physicians (including medical students and house officers), other health care personnel and patients.
• Be proficient in professional and technical skills related to thoracic surgery.
• Demonstrate personal and professional attitudes consistent with a consultant physician role.
• Be willing and able to appraise accurately his or her own professional performance.

• Be willing and able to keep his or her practice current through reading and other modes of continuing medical education.
• Be able to critically assess the thoracic literature as it relates to patient diagnosis, investigation and management.
• Be able to participate in clinical or basic science as a member of a research team.

These elements of competence are expanded as detailed objectives, for greater clarity, in the following pages.  The terms Aeffective@ and Aappropriate@ are used frequently in these statements.  AEffective@ is defined for the purpose of this document as Aadequate to the present problem(s) and patient attitudes and activity@.  Throughout this document, the term Athoracic disease@ includes the lungs, esophagus and mediastinum.

The detailed objectives describe minimal standards and in no way exclude the necessity for master of additional knowledge, skills or attitudes necessary for the most effective management of patients with thoracic disease.

Specific Objectives

MEDICAL EXPERT

Clinical Decision-Maker:

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.
• Provide scientifically based, comprehensive and effective diagnosis and management for patients with thoracic disease.

Disease of the Thorax:

Knowledge:

• Anatomy, embryology, physiology and pathology of the lung, pleura, tracheobronchial system, mediastinal esophagus and chest wall.
• Natural history of treated and untreated surgical diseases of the non-cardiovascular thoracic organs, including benign and malignant lung and esophageal diseases, trauma, congenital anomalies, infection and their complications.
• Pharmacology, indications for and complications of drugs commonly used in the specialty.
• General principles of pre-operative assessment, anesthetic management, post-operative monitoring and management of thoracic surgical patients.
• Principles of hemostasis and nutrition, including intravenous hyperalimentation, as they apply to the specialty.
• Knowledge of respiratory failure and support, including ventilators and membrane oxygenators.
• Knowledge in oncology, staging of cancers, tumor immunology, adjuvant chemotherapy, radiotherapy and immunotherapy in thoracic malignancies.
• Interpretation, indication and complications of invasive and non-invasive diagnostic methods, including pulmonary function tests, esophageal function tests and diagnostic imaging.
• Role of endoscopy, thoracoscopy, laser and video-assisted (VATS) technologies in the diagnosis and management of thoracic surgical patients.
• Knowledge of lung transplantation, including organ preservation for transplantation, immunology and pathophysiology of allograft rejection, immuno-suppression and its complications.

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CLINICAL SKILLS

• Be able to obtain a complete history from the patient and a collateral history where necessary.
• Perform an appropriate physical examination.
• Understand appropriate laboratory, functional and imaging procedures as they relate to pulmonary, esophageal and mediastinal disease.
• Formulate an appropriate differential and provisional diagnosis.
• Outline an appropriate plan of laboratory investigation.
• Outline an appropriate therapeutic plan.
• Exhibit appropriate clinical judgement in outlining a differential diagnosis and an investigative and therapeutic plan, taking into account matters such as the patient=s age, general health, risk and cost of investigative procedures, risk and cost of therapeutic interventions, and epidemiology of the diseases.

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​TECHNICAL SKILLS

Technical and clinical competence in all procedures commonly performed in general thoracic surgery, including the ability to select the procedure appropriate to the clinical situation, and to recognize his or her limitations.

• Upon completion of this rotation, the resident will be able to perform and understand the indications for all thoracic incisions, including median sternotomy, posterolateral thoracotomy, anterolateral thoracotomy, and emergency room thoracotomy.
• The resident will be able to perform a full range of pulmonary resections, including lobectomy, pneumonectomy and wedge resections, and institute appropriate pleural drainage for each procedure.
• Perform a wide range of procedures for esophageal malignancy, including Ivor-Lewis esophagectomy, trans-hiatal esophagogastrectomy, and bypass procedures.  This will require the ability to provide anatomic exposure in the neck and abdomen.
• Understand and perform procedures for restoration of normal esophageal motility and gastro-esophageal competence with abdominal and thoracic procedures, including video-assisted thoracoscopy.
• Be able to resect mediastinal tumors by the anatomically indicated procedure, including cervical and thoracic approaches.
• Perform reconstruction procedures on the diaphragm by an abdominal or thoracic approach.
• Experience in laser surgery as applied to the specialty.
• Competence in the critical care of thoracic surgical patients in the intensive care unit.
• Competence in the operative and non-operative management of all aspects of thoracic trauma.

COMMUNICATOR

• Establish therapeutic relationships with patients/families.
• Obtain and synthesize relevant history from patients/families/communities.
• Listen effectively.
• Discuss appropriate information with patients/families and the health care team
• Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other health care professionals:
• Communicate effectively and regularly with patients and their families.
• Be considerate and compassionate in communicating with patients and families, being willing to provide accurate information appropriate to the clinical situation, with a reasonable attempt at prognosis.
• Communicate effectively with staff surgeons, medical colleagues, including referring physicians, in both the in-patient and out-patient setting.
• Communicate effective and appropriately with nurses and paramedical personnel.
• When ordering investigative procedures, ensure there has been adequate communication about the patient with the person who will actually be doing and/or reporting the diagnostic study.
• Counsel patients and others about aspects of prevention of thoracic disease including risk factors, and genetic and environmental concerns.
• ​Recognize that complete patient care requires that, in addition to the need for making a correct diagnosis, a search for risk factors for the disorder be undertaken;
• Recognize that treatment for a patient with thoracic disease may require in addition to specific medical and surgical interventions, the elimination of risk factors and genetic counselling.

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COLLABRATOR

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

• Be an effective teacher of other residents (including medical students and house officers), other health care personnel, and patients.
• Provide instruction to medical students and more junior residents at a level appropriate to their clinical education and professional competence.
• Willingly share knowledge with others with whom they are associated, thus ensuring the most effective delivery of health care to patients.

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MANAGER

• Utilize resources effective to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, life-long learning and other activities.
• Be proficient in professional skills related to the specialty.
• Demonstrate the following professional skills in time management:
• Recognize that effective use of time depends upon punctuality.
• Recognize that effective use of time requires planning.

• Develop speed as well as accuracy in clinical skills.
• Reserve time for reading and keeping current with the thoracic literature.
• Establish routines for carrying out regular activities and adhere to them.
• Maintain complete and accurate medical records.
• Record and maintain a complete and accurate medical record for every patient seen; this record will include the patient=s history and the findings on physical examination (including the thoracic examination) a differential diagnosis, a provisional diagnosis, a plan for management, appropriate progress notes, and a comprehensive discharge summary.
• Effectively co-ordinate the work of the health care team.
• Organize and supervise the more junior residents and medical students on a ward and/or consultation service in a manner that ensures the efficient and effective delivery of health care for the patients;
• Indicate, by treatment plan, that for the optimal treatment of many patients with thoracic disorder, a team approach is necessary; members of the team may include nurses, rehabilitation personnel (physiotherapists, occupational therapists, speech therapists, etc.), psychologists, social workers, etc.
• Identify where an important role(s) can be played by disease focused lay groups with regard to helping the patient and/or family and to facilitate its happening.

HEALTH ADVOCATE

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.
• To learn about community resources and related patient support groups; provide assistance to access programs (e.g. home care, occupational and physiotherapy, drug plans, application for nursing homes, etc.) and participate in their activities.
• To educate, be able to generate and access information (e.g. printed material, video tapes, web sites) and be available as a resource person to counsel patients effective on thoracic disorders.
• To counsel patients on the importance of taking responsibility for their own well-being and recognize the important determinants predisposing to thoracic disorders (e.g. smoking cessation).
• Understand the role of national and international bodies (e.g. Canadian Thoracic Society etc.) in the promotion of pulmonary health, and the prevention, detection, and treatment of thoracic disorders.
• ​Develop, implement and monitor a personal continuing education strategy.