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PGY2 - ROYAL VICTORIA HOSPITAL (JUNIOR RESIDENT ROTATION)

1.  MEDICAL EXPERT

•    The MGH site is a pioneer in the study of voice disorders. Patients with voice disorders and dysphagia are seen in the state-of-the-art Voice Laboratory, nearby the main clinic area, with the support of Speech Pathologists. Residents get their laryngology exposure mainly in this hospital including stroboscopy.
•    The MGH site is a Level 1 trauma centre. Therefore, there is a steady flow of clinic patients and in-patients with all types of injuries to the head and neck, allowing for the resident to develop expertise in this area.
•    The MGH Laser Centre provides access to C02, YAG and pulsed dye lasers.
•    Junior residents (PGY2 & PGY3) at each hospital site are evaluated according to their specific exposure using the One45 system. Evaluation forms are different from the senior residents (PGY4 & PGY5) evaluation. All residents must undergo a STASER or STACER evaluation by a MGH staff person during each of their rotations at the hospital.
•    The main exposure / evaluation of the residents at the MGH in descending priority order are in the domains of:
­      - Laryngology, residents are exposed to numerous laryngological procedures in  the voice lab and dysphagia clinic
­      - otology
­      - head and neck 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 indirect laryngoscopy
-    Perform effective head mirror, flexible and rigid nasopharyngoscopy 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
-    Incise and drain a wound abscess including indications for the procedure
-    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 head and neck surgery
-    Interpret X-ray and cross-sectional imaging of the head and neck
-    Understand regional anesthesia

Head and Neck Oncologic Surgery
-    Management of Head and Neck surgical complications with supervision
-    Can effectively manage pain
-    Recognition and management of Head and Neck emergencies such as acute airway obstruction, post-operative hemorrhage, and blunt/penetrating neck trauma
-    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
-    Manage pain in post-operative head and neck oncology patients
-    Manage surgical airways (e.g. tracheotomy, laryngectomy stoma) in post-operative head and neck oncology 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.)
-    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

Plastic and reconstructive surgery
-    Demonstrate basic understanding of the hierarchy of Reconstructive options for defects in the head and neck
-    Excise cutaneous lesions of the head and neck with appropriate closure/reconstruction of the resulting defect.
-    Harvest split and full-thickness skin grafts
-    Effectively assist at major Reconstructive surgical procedures (e.g. harvest of pedicled or free tissue transfer)
-    Become familiar with diagnosis and treatment of facial nerve disorders and reanimation strategies
-    Harvesting of nerve, tendon, fascia grafts with supervision
-    Refinement of tissue handling, tying, and suturing techniques
-    Diagnosis and treatment of cutaneous lesions of the cervicofacial region with appropriate closure/reconstruction of the resulting defect.
-    Anatomical basis for and design of local and regional flaps in the cervicofacial region (types, indications and techniques)
-    Indications for the various types of grafts & implants used in facial plastic surgery: (FTSG, STSG, Bone grafts, Cartilage grafts, etc)
-    Surgical principles employed in facial reanimation surgery.
-    Assessment of facial aesthetics and evaluation of patients presenting for consideration of cervicofacial cosmetic surgery/procedures.
-    Approach to facial analysis of patient presenting for esthetic nasal surgery, with consideration for cosmetic and functional aspects of the nose
-    Indications and execution of external nasal reduction under local anesthesia, including the administration of appropriate local anesthesia blocks
-    Diagnosis and treatment and post operative care of patients suffering from facial trauma (e.g. orbitozygomatic, mandible fractures)

Laryngology
-    Take a competent vocal history and develop a differential diagnosis of dysphonia
-    Develop a differential diagnosis for dysphagia
-    Perform indirect rigid laryngoscopy
-    Perform video stroboscopy
-    Perform FEESST and interpret findings
-    Perform microlaryngeal surgery with microlaryngeal instruments, CO2 laser and microdebrideur
-    Understand intraoperative airway management during microlaryngeal surgery
-    Understanding of laser applications in Head and Neck surgery risks (laser safety) and manage complications

Neurotology/Otology
-    Take a relevant, appropriately-detailed history from a patient presenting for vestibular/dizzy assessment
-    Perform a detailed, thorough examination of the vestibular system
-    Effectively manage pain associated with surgery (e.g. mastoidectomy, skull base surgery)
-    Perform myringotomy and tube insertion with consultant supervision in clinic
-    Be able to perform diagnostic bedside tests such as the head-thrust (Halmagy) maneuver
-    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 perform and interpret conventional audiometry and tympanometry in adults
-    Understand the principles and application of auditory brainstem response (ABR) and Otoacoustic Emissions (OAEs)
-    Understand the principles of VEMP and be able to interpret results
-    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 an effective manner, the Hallpike maneuver
-    Can perform tympanometry and interpret findings
-    Attend Skull Base Clinic and understand controversies in patient management
-    Present cases at Skull Base Tumor Board

2. Communicator

The resident is expected to specifically learn the importance of being a good communicator in establishing relationships with patients and physician colleagues. The resident must elicit and gather information effectively, taking into account patients’ concerns and expectations about the illness and must deliver information back to the patient and family in a humane manner.  The MGH sees patients from all types of ethnic and cultural backgrounds and exposes residents to the rich cosmopolitan nature of Montreal society while also sensitizing them to differences that must be taken into account in terms of treatment and communication. The importance of gathering information is illustrated in the specialty as a whole and in all the subspecialties individually. Specific, pertinent information must be elicited from the patient presenting with laryngology problems while the information elicited may be quite different for patients presenting with head and neck problems or sinus difficulties.  In laryngology, it is extremely important to elicit a very detailed voice history as well as the life style history including home and work environment.  During the head and neck clinic, the information will be quite different and certainly the role of the communicating information particularly as it pertains to prognosis becomes very important.  It is crucial for the resident to be empathetic and sensitive in the manner in which the information is delivered and communicated.  Residents must also learn how to work with their peers, their colleagues, and allied health personnel and with staff. Effective and accurate communication allows for more efficient and high quality health care delivery.
At the R2 level, residents are explicitly taught the importance of communication, and learn through role modeling from staff and senior residents. At the more senior levels, residents themselves become role models and will further refine their own skills. This may include communicating difficult information to the patient (e.g.: poor prognosis, end-of-life issues), and dealing with complex family/patient dynamics. The department uses the McGill Simulation Center annually, hiring actors to portray patients in certain scenarios, to teach residents the collaborator role of CanMEDS.  Residents are assessed by direct observation during clinical activities and, to some extent, in examinations.

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
-    Recognize unique biopsychosocial issues related to deafness and the deaf community
-    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
-    Prepare clear, accurate, concise, appropriately detailed clinical notes, consultation notes, discharge summaries, and operative reports
-    Discuss common (e.g. tonsillectomy) procedures with patients and their families in a clear and understandable form including risks/benefits, informed consent, and post-operative care
-    Prepares, participates, and presents effectively in organized rounds and seminars
-    Demonstrate the capacity to recognize the psychological, occupational and social consequences of speech and voice disorders, particularly relevant to vocational demands
-    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

Otolaryngologists work in partnership with others involved in patient care. Residents must learn to collaborate effectively with patients and a multidisciplinary health care team in order to provide optimal patient care, education and research.
General otolaryngology, as well as each subspecialty, involves multidisciplinary interaction. In the Voice Laboratory, junior residents under direct staff supervision show and teach patients about their diagnoses with the help of digital imaging. They also interact regularly with speech-language pathologists in formulating and implementing treatment plans. In the Head and Neck clinic, collaboration with radiation oncologists, medical oncologists, nurses, social workers, dieticians and many other involved allied health care personnel is continuous and essential to optimizing care in these highly complex patients. All residents actively participate at MUHC multidisciplinary rounds at a level that commensurate with level of training. R2’s are expected to present cases, suggest treatment plans, and contribute to discussions involving other disciplines. They must also recognize their own limits and enlist help/consultation when appropriate. Contribution to these activities increases in complexity from the R2-R5 level with chief residents expected to lead and direct discussions. Research conducted through the Voice lab or other subspecialties necessarily involves ongoing collaboration with co-authors and contributors. This interaction is paramount during the enrichment year (PGY3 & PGY4). Residents also participate in committees from the PGY3-PGY5 level, which involves collaboration with peers and staff.
By the end of the rotation, residents should be able to effectively consult with physicians and health care professionals as well as contribute effectively to inter/multidisciplinary activities.  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 and roles of other team members
-    Recognize the advantages for optimal patient care provided by an interdisciplinary cleft palate clinic
-    Identify appropriate situations where the interdisciplinary team is most useful
-    Identify the situations and instances where consultation of other physicians or health care professional is useful or appropriate
-    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

Residents function as managers on a daily basis when they make decisions involving resources, co-workers, tasks and to some extent policies.  They do so in the settings of individual patient care, practice organizations and in the broader context of the health care system. This means they must be able to prioritize and effectively execute tasks through collaboration with colleagues.  As managers, residents are in positions of leadership, and must respect the responsibility that comes with such a position.
During the rotation at the Montreal General Hospital, residents must learn about the structure, financing and operation of the Canadian health care system and its facilities as they pertain to the practice of otolaryngology; this is important in learning to function effectively within that system.  The resident must also be able to optimally use information technology in making clinical decisions.  As active members of the health care team, resident managers must have a clear gradation in responsibility from the junior to senior to chief level. This begins with time management, which includes working effectively and in a timely manner within time constraints.  Junior residents must acquire efficiency skills in learning to perform multiple duties within a certain time limit.  They must learn to prioritize tasks and distribute their time accordingly.  Senior and chief residents are expected to assist junior residents in time management skills and in helping prioritize patient care issues. Senior and chief residents must learn to balance their time between clinical duties and the stress of studying for final exams.  Chief residents also assume a greater responsibility in terms of the call schedule they manage and put together within the accepted collective agreement guidelines.
Junior residents are expected to learn the availability, costs, risks and benefits of all of imaging resources.  They must learn about the availability of beds and when these should be used to admit patients.  Junior residents must also be familiar with available manpower in terms of allied health care personnel which may be in the form of secretarial support, nursing availability and support, physiotherapy, social services and so on.  Junior residents must be able to access information and find and retrieve data both for direct patient care and when necessary for research purposes.  Senior residents must understand these resources and assist junior residents in deciding how to best prioritize and allocate their use. R5 residents will also be expected to acquire some skills in terms of future practice management that may be learned through seminars offered at the faculty level. All of these managerial skills apply to general otolaryngology as a whole and to all of its sub-specialties. The department uses the McGill Simulation Center annually, hiring actors to portray patients in certain scenarios, to teach residents the manager role of CanMEDS.
By the end of the MGH rotation, residents should have the following competencies; be able to utilize time and resources effectively to balance patient care outside activities and personal commitments; demonstrate an ability to allocate finite health care resources effectively and efficiently within the health care system; be able to acquire and apply information technology in a proficient fashion for self-learning and optimal patient care.
The evaluation of this role is multi-faceted and as for the others roles includes direct observation during clinical activities. Residents at all levels may be required to locate and retrieve pertinent data which may impact patient care and may later be asked to what degree they were successful in achieving this.  Residents will also be evaluated in terms of their ability to complete, in a timely manner, tasks assigned and important hospital documents such as operative reports and discharge summaries.  Finally, the ability to act effectively as a manger may also be evaluated both in oral and written exams that may take the form of impromptu quizzes at any time during the rotation.

The manager role is evaluated especially on:
-    Utilize resources effectively to balance patient care duties, learning needs, Educational/teaching responsibilities and outside activities
-    Use patient information tools effectively
-    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)
-    Demonstrate an appreciation of the importance of quality assurance/improvement
-    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
-    Take care of charts and use head and neck patient database
-    Serve in administrative and leadership roles, such as participate effectively in committees and meetings

5. Health advocate

The importance of the physician resident as a health advocate to the patient and community at large is self-evident. The specific objectives including acquiring an ability to demonstrate an understanding of the determinants of health by identifying socio-economic and personal risk factors in the development of certain pathologies and how to apply preventive/ corrective measures. Residents must also understand and be familiar with current policies that affect health either in a positive or negative fashion in order to effect change. These principles must be applied in the management of individual patients, the patient population as a group and finally the general population. In laryngology, residents must have a solid understanding of risk factors such as tobacco, alcohol, vocal abuse, improper singing technique and inadequate vocal hygiene. Similarly, in Head and Neck Oncology, residents must be knowledgeable in the potential risk factors for the development of carcinoma including such as tobacco and alcohol.  The resident must be involved in educating both the patient and the public as a whole to the dangers involved with these lifestyle choices.  In doing so, the residents may play an active role in prevention, and treatment by making tobacco cessation resources available to the patient.  Residents must also be aware of their impact on patient care.  It has been clearly demonstrated that smoking cessation advice coming directly from a physician with some time spent on explaining available resources has the greatest potential positive impact on a successful outcome. In the public forum, residents may actively involve themselves and they must understand that may be involved in implementing changes to public behaviors and public policies. For example, residents should be aware of organizations such as physicians for smoke free Canada. They may also get involved, particularly at the senior and chief resident level, in public education by giving many lectures or seminars and speaking within the school system.

As a health advocate, the junior resident is also involved in obtaining investigations and implementing treatment in a timely manner.  Junior residents are expected to learn this role and acquire information about the risk factors and how they can use the information as health advocates. Senior residents are expected to acquire more of the leadership roles in helping teach junior residents, in role modeling situations, and within the public forum.  They may be evaluated by direct observation in the clinical setting as well as in written documents and rounds, where they may be asked questions. Patients, patients’ families, and allied health care personnel may also be involved in evaluating the resident’s ability to function as a health care advocate. By the end of the rotation, it is expected that the residents will be able to identify the health determinants in individual patients and therefore intervene accordingly and effectively.  The resident must also be able to recognize issues, settings and circumstances in which he may be a potent advocate on behalf of the patient and act appropriately.

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
-    Recognize and promote policies that enable early identification of hearing impairment through infant and childhood screening programs
-    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 and neck cancer (e.g.: tobacco, alcohol, UVA/UVB sun exposure)

6. Scholar

The role of scholar is extremely important in otolaryngology. It requires the resident physician to continually ask and seek answers to questions in a lifelong pursuit of learning. Junior residents must develop a basic reading plan, which allow them to acquire the essential nuts and bolts needed to practice otolaryngology. This type of activity is essential in promoting competency and mastery of the discipline of otolaryngology. Specific objectives for residents include; asking clinical questions and acquiring the skills to answer those clinical questions. In the voice laboratory, for example, a resident physician may ask a question with respect to the treatment of a vocal condition. The question may then be partially answered by the staff in attendance, and the resident may be further directed and appropriately guided towards a literature search on the matter to further answer the question.  This may in turn lead to a treatment plan and its implementation. Reviewing the literature and answering one question often leads to asking many other questions, which may be occasionally addressed in clinical or basic science research projects. Senior residents have increasing responsibilities in terms of helping junior residents answer questions and assisting them in accessing information technology to answer the questions.  Junior residents may pose a simple research question that they wish to further investigate and publish.  More advanced basic research with some knowledge of epidemiology is expected at the R4 level in which a major research project is developed.  This research project may be part of any of the subspecialties of otolaryngology, including, of course, voice.  Senior and chief residents are expected to pose more complex questions and be able to understand and critically appraise the available literature in answering these questions.  This means reading major otolaryngology textbooks.  For the purposes of rounds and interesting cases, residents are directed outside of the textbook to the literature. Senior and chief residents, while using major otolaryngology textbooks must acquire the skills to do an in depth literature review when necessary and must also understand the need for ongoing education by consulting recent publications and journals, whether they be at the library or online. Junior residents must be taught how to connect the information they have acquired to the skill of evidence-based medicine, which means applying that information to decision-making and treatment plans.  Chief and senior residents must refine this skill and assist in teaching it to junior residents.  Not only is the responsibility in teaching applied to junior residents, but also to other allied health professionals.  Furthermore, residents, particularly in their senior years, are encouraged to develop a teaching dossier.

Upon completion of the rotation, the resident should be able to develop and implement a personal continuing education strategy, which, for the junior resident, means a reading plan through residency.  For the senior and chief resident, this includes evolving from basic textbooks to current journals and being able to assess the pertinent literature.  Residents should also critically look at sources of medical information and this type of appraisal is discussed informally during clinics and also at rounds and other educational activities. Self-learning by residents facilitates the learning of patients, students, residents and other allied health professionals.  Ongoing reading and research be it clinical or basic in nature, ultimately contributes to the development of new knowledge. Success in attaining these objectives may be evaluated by verifying the ability of junior residents to complete simple assignments and in the case of chief residents, the completion of more complex assignments including complex research papers.  Chief and senior residents may be directly observed teaching junior residents and allied health care personnel, both in the clinical setting, on the ward, and in the operating room. During hospital round presentation, the degree in depth to which a particular case or problem has been researched and evaluated can easily be assessed

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 hospital and Grand Rounds
-    Demonstrate a critical appraisal of research methodology, biostatistics, and the medical literature as part of monthly Journal Clubs
-    Practice the skill of self-assessment
-    Develop, implement, and monitor a personal Educational strategy and seek guidance for this Educational strategy as appropriate
-    Demonstrate the evolving commitment to, and the ability to practice, life-long learning
-    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
-    Actively participate in weekly academic rounds series including advance preparation for the topic(s)

7. Professional

Professionalism in otolaryngology is essential in assuring the highest standards of excellence in clinical care and ethical conduct. Specific objectives for the resident physician include self-discipline, which includes a sense of punctuality, which applies to beginning the clinics on time, arriving at prearranged meetings on time, and arriving to the operating room on time. At the junior resident level, this involves being very familiar with timetables within the hospital setting and being able to meet them. Residents must learn a sense of responsibility that comes first for the patient and their family. These responsibilities must be met over and above other commitments particularly in cases of emergency. Residents must learn to balance their responsibility to patients/families with a balanced home life. The otolaryngology clinic at the Montreal General Hospital and all of its subspecialties treat patients from a wide variety of cultural backgrounds.  Residents must be familiar with the cultural diversities to which they are exposed and demonstrate sensitivity and respect for these cultural diversities.  On a personal level, residents must learn to address their peers, colleagues, staff and other allied health professional with the utmost respect and courtesy.  Differences in opinion must be discussed and debated and resolved on a professional level, without resorting to outbursts or foul language, both of which are highly inappropriate and unprofessional.  Residents must also learn the importance of adhering to the ethical codes to which physicians are bound. This is illustrated on a day-to-day basis in the clinic and on the wards where ethical issues involving patient information or treatment planning arrives regularly.  Residents must learn to resolve these issues by understanding the involved legalities, speaking to other allied health professionals and ethicists, and by a great deal of personal thought as well. Junior residents are primarily preoccupied with familiarizing themselves the cultural and ethnic diversity around them, the rules of the hospital setting, and their learning responsibilities.  As they become comfortable during rotations, they are expected to expand their knowledge in these areas.  Senior and chief residents have more of a leadership role in assisting and teaching junior residents about cultural diversity and familiarizing them with the resources available in solving ethical or personal differences.  Residents are also expected to act as role models in terms of what it means to be punctual and responsible professionals.  The department uses the McGill Simulation Center annually, hiring actors to portray patients in certain scenarios, to teach residents the professional role of CanMEDS.

Residents are evaluated on an ongoing basis regarding punctuality and attendance at different clinical events.  Their sense towards responsibility toward the patients and in terms of balancing their professional and personal lives is evaluated on an ongoing basis through observation during clinical activities, and at the end of the day. Residents' sense of respect and courtesy towards colleagues and other health professional may be evaluated as well by obtained feedback from nurses, secretaries, OR staff and clinical staff (360 degree evaluation).
 
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
-    Endeavor 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