Specific Educational Goals and Education

Level: PGY-2

Service: Liver and Small Bowel Transplant

Supervision: PGY-2 → Fellow → Attending

All management decisions will be discussed with the Fellow and faculty.

Duty Hours:

Hours are to be logged into GMEOne 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: Through the acquired skills and knowledge of transplant principles the resident can demonstrate the ability to manage the transplant patient. The resident can demonstrate the ability to manage diseases and injury of the liver.

Objective: The resident will be able to:

  1. Evaluate potential candidates for living-related and cadaveric vascularized organ transplantation, including:
    1. Clinical suitability
    2. Strength of social support
    3. Expected graft and patient survival
  2. Participate in the pre- and post-operative surgical management of patients after vascularized organ transplant.
  3. Assist/perform kidney, pancreas, and liver, and small intestine transplantation.
  4. Participate in the perioperative management of immunosuppressive drug therapy, including monitoring drug levels and treating potential toxicities.
  5. Participate in the evaluation of patients suspected of organ rejection to include:
    1. Laboratory and radiologic testing
    2. Administration of immunosuppressive (IS) agents
    3. Following patients for potential acute and chronic side effects
  6. Participate in the preparation and handling of multiple organ harvest in the brain dead patient.
  7. Define suitability characteristics of organs for transplantation.
  8. Manage post-operative surgical complications, including wound infection, anastomotic stenoses and leaks, and lymphocele formation.
  9. Perform history and physical examination specifically focused on liver and biliary system.
  10. Select and interpret appropriate laboratory and radiologic evaluations in the work-up of the jaundiced patient to include:
  11. Alkaline phosphatase, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), direct and indirect bilirubin, prothrombin time (PT) and partial thromboplastin time (PTT)
    1. Endoscopic retrograde cholangiopancreatography (ERCP)
    2. Percutaneous transhepatic cholangiography (PTC)
    3. Liver-spleen scan
    4. Hepatobiliary nuclear scan (HIDA
    5. MRCP
    6. Ultrasound
    7. Computed axial tomography
    8. Arteriography
  12. Assist in management of patients with bleeding esophageal varices including the use of vasopressin, Sengstaken-Blakemore tube, and sclerotherapy
  13. Assist in the perioperative management of patients undergoing hepatobiliary surgery.
  14. Assist in the perioperative management of patients undergoing liver and intestinal transplantation.
  15. Perform uncomplicated hepatobiliary surgery under supervision, such as cholecystectomy, both laparoscopic and open, with operative cholangiography.
  16. Assist with hepatobiliary and transplant operations.

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate an understanding of the history of clinical transplantation and interpret the guidelines for preparing patients for organ transplantation. Demonstrate a working understanding of the fundamental immunologic principles governing organ transplantation and immunosuppression. Demonstrate understanding of the potential metabolic, physiologic, and malignant side effects of immunosuppressants.

Objectives: The resident will be able to:

  1. Demonstrate a working knowledge of the history and evolution of clinical transplantation, including:
    1. Early vascular surgery
    2. Concept of tolerance
    3. First successful organ transplants
    4. Introduction of immunosuppressive agents
  2. Describe the anatomic and biologic terms associated with organ transplantation, donor and recipient relationships, and grafting between species.
  3. Explain the human leukocyte antigen (HLA) complex, including its genetic location and composition, pattern of inheritance, and the difference between Class I and II antigens of the major histocompatability complex (MHC).
  4. Discuss the role of tissue typing in the identification and preparation of patients for organ transplantation.
  5. Discuss advanced age as a positive consideration in solid organ transplantation by considering the importance of:
    1. Physiologic status vs. absolute age in years
    2. Rates of organ rejection and its severity among the elderly
    3. Elderly compliance with medical regimens
    4. Extended life expectancy
  6. Define the criteria for organ and tissue donation; apply these criteria to critically ill patients.
  7. Explain the clinical definition of brain death, including a discussion of the available laboratory and radiologic studies to support the clinical criteria.
  8. Analyze and formulate a plan for management of the organ donor.
  9. Outline the development of organ preserving solutions and techniques, and describe the currently practiced methods for handling and storing vascularized organs.
  10. Discuss the current method for the allocation of organs for transplantation, including consideration of the need, availability, and philosophical biases surrounding organ donation. (Be prepared to utilize the algorithm for assigning organs based on the results of HLA typing, PRA, blood type, age, and time-waiting)
  11. Explain the united organ sharing (UNOS) method for assigning organs to potential recipients. Discuss how local procurement agencies function to optimize the donor organ pool and facilitate coordination of organ harvesting and their subsequent distribution.
  12. Analyze and outline the indications for kidney, pancreas, liver, and small bowel transplant; relate the relative frequency of these operations as well as rates of patient and graft survival.
  13. Specify the various drug schemes for induction, maintenance, and rejection therapy, including new "rescue" therapies.
  14. Describe the mechanism of action, dosing schedule, and side effects of the following immunosuppressive drugs:
    1. Azathioprine
    2. Prednisone
    3. Anti-lymphocyte globuli
    4. Cyclosporin
    5. Anti-T3 monoclonal antibody
    6. Tacrolimus (FK506
    7. Anti IL-2R Moa
    8. Mycophenolate mofetil
    9. Rapamycin
  15. Analyze the short- and long- term risks of chronic immunosuppression:
    1. Opportunistic infections
    2. Cardiovascular problems
    3. Autoimmune diseases
    4. Lymphoproliferative disease
    5. Rejection
  16. Evaluate the diagnostic maneuvers to detect hyperacute, acute, and chronic organ rejection.
  17. Describe the anatomy of the liver and biliary system, including commonly found variations.
  18. Describe the physiology and function of liver and biliary system to include:
    1. Glucose metabolism
    2. Protein synthesis
    3. Coagulation
    4. Drug metabolism
    5. Reticuloendothelial system
    6. Function of bile in fat metabolism
  19. Explain the formation of bile, its composition, and its function in digestion. Describe the pathophysiology of gallstone formation.
  20. Correlate bile formation and composition with disease states affecting the biliary system such as gallstone formation and biliary obstruction.
  21. Outline the work-up and differential diagnosis of the jaundiced patient.
  22. Discuss various types of liver cysts (echinococcal or hydatid, nonparasitic) and the appropriate management of each.
  23. Discuss the principal characteristics of and the treatment for the following:
    1. Metastatic lesions to the liver
    2. Primary malignancies of liver and biliary tree
    3. Benign tumors of the liver
  24. Summarize the etiologies and management of pyogenic and amebic hepatic abscesses.
  25. Explain types of infectious hepatitis (A, B, C) with:
    1. Modes of transmission
    2. Diagnosis
    3. Time course for serologic conversion
    4. Natural course
  26. Outline the pathophysiology, evaluation, and management of the following:
    1. Choledochal cysts
    2. Caroli's disease
    3. Sclerosing cholangitis
    4. Primary biliary cirrhosis
    5. Secondary biliary cirrhosis
    6. Cholangitis
    7. Gallstone pancreatitis
    8. Benign biliary strictures
    9. Acute cholecystitis
    10. Symptomatic gallstones
    11. Acalculous cholecystitis
    12. Biliary dyskinesia
    13. Congenital biliary atresia

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for transplant 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 transplant 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 transplant practices

Objective: The resident will demonstrate the ability to:

  1. Discuss studies regarding the transplant procedures

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 Transplant 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 Transplant service as assigned by the Chief Resident
  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 Transplant 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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