Specific Educational Goals and Education

Level: PGY-1

Service: Cardiac Surgery

Supervision: PGY-1 → Attending

All management decisions will be discussed with the senior resident and faculty.

Duty Hours:

Hours are to be logged into New Innovations on a weekly basis and will be reviewed weekly by the Program Director for ACGME violations and reviewed weekly for delinquencies by the Program Coordinator. Over a four week period; you will not average more than 80 hours a work week, you will have one day in seven free of clinical duty, in-house call will be no more frequent than one in three nights, you should receive 10 hours free between all duty periods and after in-house call and you will not be on duty for more than 30 consecutive hours. If you are assigned more hours than mentioned heretofore or have patient care duties that are extending you beyond these limits, it is your responsibility to notify your supervising resident or faculty so arrangements can be made to relieve you.

Educational Activities:

  1. Recommended Reading
    1. Schwartz's Principles of Surgery
    2. SCORE curriculum modules 
  2. Conferences
    1. Wednesday Resident Educational Curriculum

Competency Based Performance Objectives:

Patient Care:

Goal: The resident will be able to use acquired skills and knowledge of cardiothoracic principles in the management of surgical patients with pathologic conditions of the heart and great vessels.

Objective: The resident will be able to:

  1. Perform pre-operative evaluation, history, and physical examination of cardiac surgery patients.
  2. Obtain and interpret indicated diagnostic studies.
  3. Discuss diagnostic and therapeutic approaches to specific acquired and congenital cardiac diseases with the attending physicians.
  4. Assist with selected cardiac and general surgery cases, such as:
    1. Pacemaker and defibrillator insertions
    2. Saphenous vein harvest and wound closure for coronary bypass operations
    3. Valve and coronary operations
    4. Pericardial drainage operations
    5. Tracheostomy
    6. Minor vascular repairs
  5. Provide post-operative cardiac surgery follow-up care for the following cases:
    1. Coronary surgery
    2. Valve surgery
    3. Thoracic aortic surgery
    4. Pacemaker and defibrillator placement
  6. Perform percutaneous insertion of chest tubes and intravenous, intra-arterial, and pulmonary artery catheters with supervision.

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate knowledge of the anatomy, physiology, and pathophysiologic conditions of the heart and great vessels which are amenable to surgical correction.

Objectives: The resident will be able to:

  1. Describe and demonstrate a working knowledge of the heart and great vessels, including:
    1. Cardiac chambers (atria and ventricles)
    2. Cardiac valves (mitral, aortic, tricuspid, pulmonic)
    3. Coronary arteries
    4. Intrinsic neural conduction system
    5. Extrinsic neural innervation (sympathetic and parasympathetic)
    6. Great vessels (cavae, aorta, innominate artery, carotid arteries, and subclavian arteries)
  2. Describe and demonstrate working knowledge of cardiac physiology, including:
    1. Determinants of cardiac output (heart rate and stroke volume)
    2. Interactions and control mechanisms (preload, afterload, contractility, Frank-Starling Law, peripheral resistance)
    3. Determinants of myocardial oxygen consumption
    4. Normal pressures, waveforms, and oxygen saturation in cardiac chambers
  3. Identify the control mechanisms and normal physiology of peripheral vessels. Relate each of these to a clinical example:
    1. Arterial autoregulation
    2. Venous flow regulation
  4. Interrelationship of cardiac output, peripheral blood flow, and auto regulation
  5. Discuss the information obtained from the history and physical examination pertinent to cardiac and peripheral vascular pathophysiology. Determine the interactions of those details and their implications on planned surgical procedures and outcomes. Consider the following for risk assessment and perioperative management:
    1. Patient age
    2. Risk factors for cardiovascular disease (family history, smoking, hypertension, diabetes mellitus, hyperlipidemia, and obesity)
    3. Symptoms/signs associated with coronary artery disease, ventricular dysfunction, and valvular dysfunction
    4. Pulmonary dysfunction (pulmonary hypertension, chronic obstructive pulmonary disease [COPD], previous pulmonary resection)
    5. Neurologic abnormalities
    6. Renal dysfunction
    7. Hematologic abnormalities
    8. Hepatic dysfunction
    9. Cerebrovascular, peripheral vascular, or aneurysmal disease
    10. Gastrointestinal considerations
    11. Metabolic, nutritional, genetic, immune, and oncologic abnormalities
    12. Psychiatric conditions, psychological and social interactions
    13. Re-operative chest surgery
    14. Miscellaneous considerations (prior operations including vascular or valvular prostheses, substance abuse, dental status, interactions of medications)
  6. Discuss the use and interpretation of cardiovascular diagnostic tests in identification of cardiovascular pathology, including:
    1. Electrocardiography
    2. Echocardiography (transthoracic and transesophageal)
    3. Traditional roentgenography
    4. Cardiac catheterization and arteriography
    5. Peripheral vascular arteriography
    6. Vascular ultrasonography
    7. Computer and magnetic resonance imaging
    8. Radionuclide scintigraphy (multi-gated acquisition [MUGA], stress, and Persantine thallium)
  7. Demonstrate the use and principles associated with various cardiac monitoring methods, including:
    1. Intra-arterial and central venous pressure transducers
    2. Pulmonary artery catheters
    3. Left atrial catheters
  8. Temporary percutaneous and intracardiac pacing wires
  9. Discuss techniques, mechanisms of action, and potential complications for mechanical and pharmacologic support of the circulation, including:
    1. Inotropic agents (dopamine, dobutamine, epinephrine, norepinephrine, amrinone, isoproterenol)
    2. Pre- /after- load agents (Nipride, nitroglycerine, Neo-synephrine)
    3. Intra-aortic balloon pump
    4. Ventricular assist devices
    5. Cardiac pacing
  10. Describe and assess the operative indications, risk, and expected outcomes associated with several cardiac surgical procedures, including:
    1. Coronary artery bypass and minimally invasive direct coronary artery bypass surgery
    2. Valvular replacement/repair (aortic, mitral, tricuspid)
    3. Operations of the ascending aorta, aortic arch and descending thoracic aorta
    4. Permanent pacemaker/automatic defibrillator insertion
    5. Pericardial drainage procedure
  11. Discuss the complications of cardiac surgery and methods used to reduce their incidence. Complications: death, myocardial infarction, stroke, bleeding, arrhythmias, low cardiac output syndrome, cardiac tamponade, pneumothorax, sternal and extremity wound infections, respiratory and renal failure
  12. Review the management of post-operative cardiac surgery patients in the intensive care unit.
  13. Discuss the pathophysiology of acquired cardiac disease including:
    1. Myocardial ischemia
    2. Valvular heart disease (stenotic and regurgitant)
    3. Endocarditis
    4. Ventricular aneurysms
    5. Thoracic aneurysms
    6. Trauma to the heart and great vessels
  14. Summarize the management of the following post-cardiac surgery variances, including the monitoring, prevention, and the therapeutic intervention of:
    1. Arrhythmias (ventricular and atrial)
    2. Bleeding (correction of coagulopathy, indications for re-exploration)
    3. Infection (methods of prophylaxis, empiric and culture-specific therapy)
    4. Low cardiac output and hypotension
    5. Post-operative hypertension
  15. Demonstrate working knowledge and use of the following post-operative support systems:
    1. Cardiac drugs (inotropic, chronotropic, afterload-reducing, anti-platelet, beta-blockade, ACE inhibition, diuretics)
    2. Mediastinal and pleural drainage
    3. Mechanical ventilation, airway management systems
    4. Temporary and permanent pacemakers
    5. Intra-aortic balloon pumps and other ventricular assist devices
    6. Dialysis and ultrafiltration
    7. Cardiopulmonary bypass and extracorporeal membrane oxygenation
  16. Summarize the diagnostic evaluation and indications for each of the following surgical procedures:
    1. Coronary artery bypass grafting
    2. Adult valvular repair and replacement procedures (mechanical vs. bioprosthetic)
    3. Resection of ventricular aneurysms
    4. Resection and grafting of thoracic aneurysms
    5. Combination operations of valve replacement and coronary artery bypass grafting
    6. Surgical treatment of idiopathic hypertrophic subaortic stenosis
  17. Discuss the evaluation and therapeutic options available for surgical management of cardiac trauma such as:
    1. Traumatic transection of the aorta and other great vessels
    2. Blunt and penetrating cardiac and great vessel injury
  18. Outline the post-hospitalization follow-up and management of cardiac surgery patients to include:
    1. Instructions to the patient
    2. Follow-up clinic visit (including physical examination, electrocardiogram [ECG], Chest x-ray)
    3. Long-term follow-up for coronary and valve patients (including anticoagulation adjustment where indicated)
  19. Evaluation and surgical management of advanced heart failure

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for cardiothoracic procedures

Objectives: The resident will demonstrate the ability to obtain informed consent, outlining the risks and benefits

Goal: Communicate effectively to discharge patients after surgery.

Objectives: The resident will demonstrate the ability to instruct patients regarding monitoring for cardiothoracic complications:

Goal: Communicate effectively as a member of the healthcare team.

Objectives: The resident will demonstrate the ability to communicate effectively by:

  1. Providing appropriate check out when handing patients to another team member
  2. Requesting consults from other services with appropriate information
  3. Dictating operative reports in a timely fashion

Professionalism:

Goal: Maintain patient confidentiality

Objectives: The resident will demonstrate

  1. The ability to protect health-related patient information per HIPAA compliance
  2. List and be aware of sites in the hospital and clinic where loss of privacy for the patient may occur

Goal: Maintain appropriate professional relationships

Objectives: The resident will demonstrate professional interactions with:

  1. Medical students
  2. Nursing and support staff
  3. Supervising faculty
  4. Consulting residents
  5. Physician peers
  6. Patients and their families

Practice-Based Learning and Improvement

Goal: Identify personal and practice improvement strategies

Objective: The resident will demonstrate:

  1. Receptiveness to faculty instruction and feedback
  2. Ability to use medical information with the ability to access information through traditional and online sources to support their educational experience

Goal: Use medical evidence to evaluate cardiothoracic practices

Objective: The resident will demonstrate the ability to:

  1. Discuss studies regarding cardiothoracic surgery

Systems-Based Practice

Goal: Provide safe patient care

Objective: The resident will:

  1. Attend Crew Resource Management courses as required by the hospital
  2. Follow recommended protocols in the OR for patient safety
  3. Demonstrate compliance with Medical Center policy for surgical site identification
  4. Demonstrate compliance with Medical Center policy for patient identification

Duties/Responsibilities:

  1. Serve as PGY-2 on the cardiothoracic service
  2. Appropriate, professional supervision of student teaching in light of educational goals
  3. Attend clinic as assigned
  4. Manage OR patients with supervision
  5. Assist with consultations to the cardiothoracic service as assigned by the Attending
  6. Round on post surgical service patient's as instructed.
  7. Attend educational conferences
  8. Complete surgical case logs
  9. Dictate in a timely fashion
  10. Take night call as assigned

Evaluation:

  1. Performance feedback will be given to the resident as appropriate for educational events and mid-term progress will be discussed.
  2. Global evaluation will be performed by the cardiothoracic attending physicians at the completion of each rotation. Surgical case logs will be evaluated for the appropriate number and breadth of procedures and will be present in the resident's portfolio to be reviewed at the Program Evaluation meeting held twice yearly.
  3. At the completion of this rotation, the resident is required to complete a rotation evaluation form assessing the quality of the rotation. The resident should also address the teaching undertaken by the attending physicians on the rotation at the conclusion of this rotation.

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