• At the JGH there is a modern, state-of-the-art clinical out-patient facility, with 8 examination-treatment rooms, an electronystagmography testing room, 3 audiological testing suites, speech language-pathology offices, a conference room, and a dedicated residents’ room.
• The Department runs the following clinics: General Otolaryngology Clinic, Head and Neck Oncology Clinic, Resident’s Clinic for in-patient and out-patient consultations, Otology Clinic, Nasal and Sinus Clinic, Voice/dysphagia Clinic, and a Laser Clinic. In addition, extensive Speech-Language Pathology Services are integrated into the services for Head and Neck cancer patients, with a Laryngectomy Support Group and an Oncology Nurse Pivot.
• The CanMEDS roles have been implemented into our training process and now serve as the foundation upon which we structure our practice and teaching. The following will serve to demonstrate the educational objectives, strategies and evaluation process at the JGH.
• Available resources for Residency Training include:
- Complete audiological services including ABR and OAE.
- Computerized electronystagmography testing.
- Speech therapy department, including a speech and swallowing therapist for the oncology service.
- Clinical services within the department include head & neck radiology, head & neck pathology, and multi-disciplinary teams for skull base surgery and oncology patients.
- Departmental conference room and library.
- Designated Residents’ Room.
1. MEDICAL EXPERT
• The PGY2 year will focus on acquiring expertise in obtaining an appropriate history and performing a comprehensive head and neck examination.
• Residents at the PGY2 level should focus on acquiring a sound basic science knowledge base in head and neck anatomy and physiology as they pertain to otolaryngology.
• The PGY2 residents will learn basic office-based ENT procedures such as laryngoscopy, biopsies, minor excision of head and neck lesions as well as basic operative procedures.
• The OR responsibility will progress with the resident’s seniority and individual abilities.
• Junior residents (PGY2 & PGY3) at each hospital site are evaluated according to their specific exposure using the one45 system. Evaluations forms are different from the senior residents (PGY4 & PGY5) evaluation.
• The PGY2 residents will learn basic office-based ENT procedures such as laryngoscopy, biopsies, minor head and neck lesion excisions as well as basic operative procedures. The OR responsibility will progress with the resident’s seniority and individual abilities. Their technical training is designed to meet the requirements as outlined in the rotational objectives of the McGill Department of Otolaryngology – Head & Neck Surgery Residency Handbook. All of the general otolaryngology clinics, sub-specialty clinics and surgeries are supervised by Attending Staff. Regular informal quizzing as well as structured written and oral examinations serves as part of the evaluation process, using the One45 framework. All residents must undergo a STASER or STACER evaluation by a JGH staff person during each of their rotations at the hospital.
• The main exposure / evaluation of the residents at the JGH in descending priority order are in the domains of:
- head and neck surgery
- otology
- rhinology
- laryngology
- facial plastic reconstructive surgery
- general otolaryngology
• The Expert Role specific objectives are
General skills
- Take a relevant, appropriately-detailed history from a patient presenting for otolaryngology assessment
- Perform a detailed, thorough head and neck examination
- Perform effective flexible nasopharyngolaryngoscopy with accurate interpretation of findings
- Perform effective anterior and posterior nasal packing for epistaxis
- Incise and drain a peritonsillar abscess including recognition of the signs and symptoms associated with a peritonsillar abscess
- Manage a tracheostomy/change a tracheostomy tube
- Perform rigid esophagoscopy with or without removal foreign body
- Promptly and effectively assess patients with airway emergencies including airway obstruction
- Perform open and percutaneous tracheostomies
- Accurately assess patients suffering facial trauma including ordering appropriate investigations
- Participate in the post-operative ward and office management of patients who have undergone ENT surgery
- Pre-operative assessment and preparation of patient for surgery
- Management of post-operative patient care issues (e.g., pain, labs, wounds)
- Interpret X-ray and cross-sectional imaging of the head and neck
Head and Neck Oncologic Surgery
- Diagnose and accurately stage malignancies of the upper aero-digestive tract
- Principles of communication/ speech/swallowing and the challenges encountered in head and neck cancer patients
- Perform fine needle aspiration of neck lesions
- Effectively biopsy nasal or oral cavity lesions
- Manage head and neck oncology in-patients with attention to the unique airway and nutritional needs of these patients
- Pack a pharyngocutaneous fistula and provide ongoing wound care/debridement
- Effectively assist at major head and neck ablative surgical procedures (pharyngolaryngectomy, neck dissection etc.)
- Effectively plan incisions, dissect tissues, and close wounds
- Demonstrate attention to issues surrounding end-stage malignancies such as end-of-life care and palliation
- Demonstrate a basic grasp of adjuvant therapies for the treatment of head and neck malignancies (radiotherapy, chemotherapy) and management of their complications
Facial Plastic and Reconstructive Surgery
- Demonstrate basic understanding of the hierarchy of reconstructive options for defects in the head and neck
- Understand indications for and design of local and regional flaps/grafts in the cervicofacial region.
- Harvest split and full-thickness skin grafts
- Effectively assist at major reconstructive surgical procedures (e.g. harvest of pedicled or free tissue transfer)
- Refinement of tissue handling, tying, and suturing techniques
Laryngology
- Develop a differential diagnosis of dysphonia
- Develop a differential diagnosis for dysphagia
- Diagnose basic pathology of the larynx
- Diagnostic approach for and management of vocal cord paralysis
- Understanding of laser applications in Head and Neck surgery
Neurotology/Otology
- Take a relevant, appropriately-detailed history from a patient presenting for vestibular/dizziness assessment
- Perform a detailed, thorough examination of the vestibular system
- Perform myringotomy and tube insertion with consultant supervision
- Participate in the post-operative ward and office management of patients who have undergone otologic surgery and lateral skull base surgery
- Interpret X-ray and cross-sectional imaging of temporal bones and soft tissues of the head and neck
- Be able to interpret conventional audiometry and tympanometry in adults
- Understand the principles and application of auditory brainstem response (ABR) and otoacoustic emissions (OAEs)
- Understand the principles and application of electronystagmography including interpretation of findings
- Accurately diagnose benign positional vertigo and demonstrate a rational approach to its treatment
- Perform, in an effective manner, the particle repositioning maneuver
Rhinology
- Perform a relevant history on patients presenting with sinonasal complaints
- Perform diagnostic nasal endoscopy (rigid and flexible) including preparation of the nose and accurate interpretation of findings
- Perform biopsy of sinonasal lesions
- Provide post-operative care for patients post sinus surgery including appropriate medical therapy and endoscopic debridement
- Develop an appreciation of the indications for endoscopic sinus surgery
- Gain experience with basic endoscopic sinus surgery such as handling of endoscopes and instruments, local anesthetic infiltration, polypectomy
- Acquire familiarity with indications for surgery and approaches for management of nasal obstruction including nasal septoplasty
- Perform inferior turbinate reduction with direct consultant supervision
2. Communicator
The vital importance of effective communication in the practice of medicine is taught to the residents. Both verbal and written communication is emphasized. The Jewish General Hospital is situated in the heart of the most multi-ethnic neighborhood in Montreal and our trainees have the opportunity to communicate with patients from a multitude of cultural, ethnic and linguistic backgrounds. The residents are encouraged to enlist the assistance of interpreters when necessary. The importance of establishing a doctor-patient relationship based on trust and understanding is crucial. The resident evaluation process is multi-faceted and includes: observation during the implementation of their clinical duties, STACER evaluation, review of their written notes, evaluations of their OR dictations and patient discharge summaries. The department uses the McGill Simulation Center on an annual basis, using actors acting like patients to teach residents the communicator role of CanMEDS.
The communicator role is evaluated especially on:
- Demonstrate effective establishment of therapeutic relationships with patients and their families
- Present histories, physical findings, and management plan to consultants in an organized, efficient, and confident manner
- Obtain and synthesize relevant history from patients, their families, and communities
- Demonstrate the capacity to recognize the psychological, occupational and social consequences of speech and voice disorders, particularly relevant to vocational demands
- Prepare clear, accurate, concise, appropriately detailed clinical notes, consultation notes, discharge summaries, and operative reports
- Demonstrate the capacity to recognize the psychological, occupational and social consequences of speech and voice disorders, particularly relevant to vocational demands
- Recognize unique issues related to head and neck patients particularly relevant to patients with cancer of the head and neck including end-of-life discussions
- Prepares, participates, and presents effectively in organized rounds and seminars
- Respect diversity and difference, including gender, religion and cultural beliefs on decision-making
- Address challenging communication issues effectively, such as obtaining informed consent, delivering bad news, and addressing anger, confusion and misunderstanding
3. Collaborator
The practice of medicine today has evolved to a point where working in isolation is not possible or desirable. Medicine, particularly in a tertiary care academic institution, is practiced in a multi-disciplinary team format. The residents must actively participate in tumor boards, and multi-specialty teaching rounds. They are encouraged to recognize the appropriate time to enlist help. Their training also teaches them how to collaborate with the patients as well as family members in the decision-making and management process. They have the opportunity to collaborate with supervisors on their various research projects. The progression from R2 to R5 mirrors the progression of responsibility in the various seminars and teaching rounds. The evaluation process for this aspect of their training seeks feedback from other specialists, peers and allied health professionals (360 degree evaluation). The department uses the McGill Simulation Center annually, hiring actors to portray patients in certain scenarios, to teach residents the collaborator role of CanMEDS.
The collaborator role is evaluated especially on:
- Demonstrate an understanding of the team structure of an in-patient service (the resident team) and fulfill his/her role in this structure
- Demonstrate recognition and respect for the opinions & roles of other team members
- Recognize the advantages for optimal patient care provided by a Multidisciplinary head and neck oncology team.
- Demonstrate collegial and professional relationships with other physicians, office and clinic support staff, operating room personnel, and emergency room staff
- Recognize the expertise and role of allied health professionals such as speech language pathologists, audiologists, technicians, nurses, and clerical staff
4. Manager
Effective management skills come in to play at many levels of medical practice. The residents must demonstrate judicious use of medical tests and resources. They will be able to explain the particular purpose of each test ordered. They will learn to perform a type of cost-benefit analysis. The residents will be sensitized to the critical issue of bed utilization. A crucial component of their training is the acquisition of personal time management skills. They will be expected to respect schedules, commitments and call schedules. They will be taught to use information technology to access information and manage their responsibilities. The senior residents will be expected to delegate effectively and organize the work distribution of junior residents and medical students. Residents will be evaluated by way of observation, written and oral exams and creation of case scenarios. They will be assessed based on timely completion of assigned tasks and projects. The department uses the McGill Simulation Center annually, hiring actors to portray patients in certain scenarios, to teach residents the manager role of CanMEDS.
The manager role is evaluated especially on:
- Utilize resources effectively to balance patient care duties, learning needs, educational responsibilities & outside activities
- Allocate finite health care resources in a wise, equitable, and ethical fashion
- Utilize information technology to optimize patient care and life-long learning including facile use of hospital IT resources (e.g. filmless radiology, electronic charting)
- Actively participate in preparation, presentation, analysis, and reporting of morbidity and mortality rounds
- Accurately identify criteria for patient admission to hospital in the urgent/emergent situation as well as the implications of such decisions
- Serve in administrative and leadership roles, such as participate effectively in committees and meetings.
5. Health Advocate
The residents will become advocates of their patients’ health. They will learn to counsel their patients regarding health risks such as smoking and alcohol, noise exposure and occupational hearing health, and will provide tools for change. The residents will be encouraged to involve themselves in public health education, such as public lecture series held in the hospital or university. The evaluation of these attributes and skills will be conducted via close observation of their doctor-patient interactions.
The health advocate role is evaluated especially on:
- Recognize and respond to opportunities for advocacy within Otolaryngology, both for your patients as well as for the community in which we practice and populations at large
- Encourage behaviors that promote hearing protection and conservation at work and at home
- Facilitate patients' access to local and national resources available for the hearing impaired
- Encourage behaviors that reduce/eliminate risk factors for the development of head & neck cancer (e.g., tobacco, alcohol, sun exposure)
6. Scholar
The residents will be expected to develop a reading plan from their R2 year onwards. They will use actual cases as well as the literature to constantly update their knowledge. Our weekly rounds and frequent journal clubs will provide them with ample opportunity to critically review the literature. The supervisors will encourage the utilization of evidence-based medicine as it applies to decision-making. The residents will be inspired towards life-long learning and will be encouraged to develop a teaching dossier early on in their careers. During their progression from R2 to R5 years, their teaching responsibility will increase. A variety of modalities will be implemented to evaluate their scholarly activity. Staff will review their research proposals and manuscripts. Their presentations will be evaluated and supervisors will assess their teaching assignments. Every resident presents a research project once a year that is presented at our Annual Resident Research Day/James D. Baxter Lectureship held in the spring.
The scholar role is evaluated especially on:
- Actively participate in the teaching of medical students (didactic, in clinics, and on wards/in OR)
- Facilitate learning in patients and other health professionals
- Actively participate in preparation and presentation of weekly rounds and grand rounds
- Demonstrate a critical appraisal of research methodology, biostatistics, and the medical literature as part of monthly Journal Clubs
- Develop, implement, and monitor a personal educational strategy and seek guidance for this educational strategy as appropriate
- Contribute to the development of new knowledge through participation in clinical or basic research studies
- Demonstrate commitment to evidence based standards for care of common problems in Otolaryngology
- Demonstrate the evolving commitment to, and the ability to practice life-long learning.
7. Professional
The residents will demonstrate appreciation and sensitivity for cultural diversity. They will be expected to treat colleagues as well as all hospital employees with dignity and respect. They will be able to disagree with fellow physicians in a diplomatic and constructive fashion. The importance of punctuality will be highlighted. We will expect the care that they provide to be of the highest level, delivered ethically and with compassion. The evaluation process will be achieved by close observation, and feedback will be solicited from allied health professionals, senior residents and office support staff (360 degree evaluation). The department uses McGill Simulation Center annually, hiring actors to portray patients in certain scenarios, to teach residents the ethics role of CanMEDS.
The professional role is evaluated especially on:
- Deliver highest quality care with integrity, honesty, and compassion
- Exhibit appropriate professional and interpersonal behaviors
- Practice medicine and Otolaryngology in an ethically responsible manner
- Recognize limitations and seek assistance as necessary
- Seek out and reflect on constructive criticism of performance
- Endeavour to develop an appropriate balance between personal and professional life to promote personal physical and mental health/well-being as an essential to effective, life-long practice
- Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation (e.g.: recognize and respond to other unprofessional behavior in practice, understand the legal and ethical codes of practice