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PGY5 – FOURTH YEAR OF OTOLARYNGOLOGY – HEAD AND NECK SURGERY TRAINING (FINAL YEAR OF OTL PROGRAM)

  • Rotation-specific CanMEDS objectives have been elaborated. The residents rotate throughout the three teaching hospitals: the Montreal General, Jewish General and Royal Victoria hospitals.  
  • The PGY5 residents will be able to see patients and define a treatment plan independently; the resident should possess sufficient basic and clinical knowledge and technical skills to undertake the management of patients under the supervision of the appropriate staff.
  • At this level, the resident will be responsible for the supervision and teaching of more junior residents, medical students, the management of patients on the wards, and ensuring coverage of emergency and inpatient consultations.
  • The senior resident will be responsible for many activities within the post-graduate program to include: sitting on post-graduate committees, organization of education activities including rounds, journal clubs and seminars as well as organization of all the vacation schedules.
  • 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.
  • Senior residents (PGY4 & PGY5) at each hospital site are evaluated according to their specific exposure using the One45 system. Evaluations forms are different from the junior residents (PGY2 & PGY3) evaluation. All residents must undergo a STASER or STACER evaluation by attending staff person every six months. They are also evaluated by 360 degree inter-professional evaluation (feedback from allied health care personnel, nurses, secretaries)
  • During their final year in otolaryngology, residents are expected to develop proficiency in the following:

Medical Expert

Operative objectives / experience

Obtain proficiency in the following:
Otology
•    excision of exostosis
•    tympanoplasty
•    mastoidectomy and tympanomastoidectomy
•    ossiculoplasty
•    Canaloplasty
•    stapedectomy
Neurotology
•    facial nerve decompression
•    intratympanic injections
•    surgical excision of middle ear tumors e.g. paraganglioma tympanicum
Rhinology
•    surgical management of epixtasis
•    external sinus procedures
•    drainage of intra-orbital abscess
•    Maxillectomy
Head and neck
•    radical neck dissection,
•    composite resection,
•    laryngectomy
•    thyroid surgery
•    parathyroid surgery
•    parotidectomy,
•    regional flaps,
•    Zenker’s diverticulum repair surgery
•    major flap reconstruction
Facial Plastics and Reconstructive
•    rhinoplasty
•    cartilage graft
•    bone graft e.g. calvarial
•    composite graft e.g. auricular
•    cervicofacial cosmetic surgery (face lift, blepharoplasty)
•    facial trauma and reconstructive surgery
Laryngnology
•    microlaryngeal surgery,
•    endoscopic partial laryngectomy,
•    medialization thyroplasty
•    laser procedures of the airway,
•    repair of laryngeal fracture
•    laryngotracheal reconstruction

Obtain some experience in the following:
Otology
•    endolymphatic shunts
•    vestibular neurectomy
•    posterior fossa surgery
Rhinology
•    advanced rhinoplasty
•    advanced endoscopic sinus surgery techniques for the management of sinonasal neoplasms      

PGY5 - The Expert Role specific objectives the JGH / RVH / MGH

General Skills
•    Understands medical literature its limitations and can argue based on the published literature
•    Participate in the post-operative ward and office management of patients who have undergone major head and neck ablative and Reconstructive surgery
•    Demonstrate a sophisticated approach to imaging studies including independent interpretation of findings
•    Perform fine needle aspiration of neck lesions
•    Biopsy nasal or oral cavity lesions
•    Insert or change a tracheoesophageal puncture prosthesis
•    Incise and drain a wound abscess including a demonstrated understanding of the indications for the procedure
•    Pack a pharyngocutaneous fistula and provide ongoing wound care/debridement
•    Effectively manage pain associated with surgery and malignancy
•    Demonstrate understanding of the indications for tracheotomy in a critical care setting
•    Promptly and effectively assess patients with airway emergencies including airway obstruction and supervise junior colleagues in this situation
•    Perform open and percutaneous tracheostomies
•    Perform percutaneous tracheostomy/translaryngeal tracheotomy with limited consultant supervision
•    Provide effective counseling for patients regarding tracheotomy/stoma care
•    Effectively manage pain associated with surgery (e.g. mastoidectomy, skull base surgery)
•    Participate in the post-operative ward and office management of patients who have undergone otologic surgery, lateral skull base surgery, and general otolaryngological surgery
•    Interpret X-ray and cross-sectional imaging of temporal bones and soft tissues of the head and neck

Head and Neck Oncologic Surgery
•    Rapidly stage malignancies of the head and neck and develop approach to surgical management
•    Appropriate use and recommendation of alternate/adjuvant therapies for management of malignancies of the head and neck
•    Effectively perform a transnasal esophagoscopy and understand the findings
•    Comprehensive management of complications from Head and Neck surgery with limited consultant intervention
•    Comprehensive understanding and management of Head and Neck emergencies such as airway obstruction and trauma
•    Perform pan-endoscopy independently with accurate interpretation of findings
•    Perform lymph node and neck mass biopsy limited consultant intervention
•    Effectively perform cervical echography and ultrasound guided fine needle biopsy
•    Perform excision of submandibular glands with limited consultant intervention
•    Perform excision of branchial cleft cysts and thyroglossal duct cysts with gradually decreasing degree of consultant intervention
•    Perform parotidectomy with increasing degree of autonomy
•    Perform neck dissections with increasing degree of autonomy
•    Perform thyroidectomy, parathyroidectomy with limited consultant intervention
•    Perform excision of oral cavity lesions with and without laser
•    Perform medial maxillectomy with consultant supervision
•    Perform composite resections as well as pharyngolaryngectomies with increasing degree of autonomy
•    Perform more extensive maxillectomies with consultant supervision
•    Assist at anterior craniofacial resections

Facial Plastic and Reconstructive Surgery
•    Demonstrate sophisticated understanding of the hierarchy of Reconstructive options for defects in the head and neck
•    Formulate plan for reconstruction of head and neck defects with attention to form and function
•    Design and harvest flaps for major Reconstructive surgical procedures with direct consultant supervision
•    Perform or assist at microvascular anastomosis for vessels and nerves in free tissue transfers
•    Perform or assist at microvascular anastomosis for vessels and nerves in free tissue transfers
•    Diagnosis and treatment of facial nerve disorders and reanimation strategies
•    Diagnose, evaluate and perform treatments of cutaneous malignancies including appropriate reconstruction.
•    Observe, assist in and perform various types of local and regional flaps in cervicofacial reconstruction
•    Approach to facial analysis of patient presenting for esthetic surgery
•    Observe, assist in and perform septorhinoplasty including an evaluation of the nasal valve, open vs. closed approaches, as well as grafting techniques
•    Perform septorhinoplasty with direct consultant supervision.
•    Observe, assist in cervicofacial cosmetic surgery such as blepharoplasty, rhytidectomy, forehead lifts, and various facial implants.
•    Observe, assist in and perform Facial reanimation including skin resurfacing, chemical peels, microdermabrasion, and laser peels
•    Observe, assist in and perform cosmetic procedures such as botox injection and soft tissue injectable fillers (hyaluronic acid derivatives, collagen, etc.)
•    Observe, assist in and perform scar revision including techniques such as Z - plasty, W - plasty, and geometric broken line closure, etc.
•    Management of patients suffering from facial trauma including the techniques of soft tissue repair and closed/open reduction of facial fractures and post-operative care.
•    Perform surgical repair of mandible fractures including the use of M-M fixation and plates.
•    Management of mid facial fractures including choice of incisions and repair materials.
•    Perform or assist at repair of orbitozygomatic and frontal sinus fractures

Laryngology
•    Perform indirect rigid laryngoscopy and video-stroboscopy
•    Develop a differential diagnosis and management plan for dysphonia
•    Develop a differential diagnosis and management plan for dysphagia
•    Management of vocal cord paralysis including investigation, medical therapy, and surgical therapy
•    Perform office-based laryngeal procedures
•    Perform rigid suspension laryngoscopy
•    Perform microlaryngeal surgery with microlaryngeal instruments, CO2 Laser, microdebrideur
•    Understanding of intraoperative airway management during microlaryngeal surgery
•    Perform thyroplasty and other laryngeal framework surgeries
•    Perform, with supervision, endoscopic laser resections of early tumors of the larynx
•    Diagnosis and management of airway and aerodigestive trauma
•    Assist at and begin to perform airway reconstruction (e.g. laryngotracheoplasty)

Neurotology / Otology
•    Accurately assess patients suffering temporal bone trauma including ordering appropriate investigations
•    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 and application of electronystagmography including interpretation of findings
•    Accurately diagnose benign positional vertigo and demonstrate a rational approach to its treatment
•    Perform the particle repositioning maneuver
•    Develop a rational approach to vestibular rehabilitation and participate in delivery of this care
•    Participate in and demonstrate understanding of the indications for surgical treatment of vertigo (includes labyrinthectomy, vestibular nerve section, endolymphatic sac surgery, and posterior canal occlusion)
•    Observe performance of and interpret electrocochleography
•    Perform and interpret electro-diagnostic testing of the facial nerve
•    Elevate a tympanomeatal flap with limited consultant intervention
•    Perform tympanoplasty with limited consultant intervention
•    Perform ossiculoplasty with consultant supervision
•    Perform mastoidectomy with consultant supervision
•    Demonstrate a rational, organized approach to medical management of disorders of the facial nerve
•    Demonstrate a rational approach to selection of patients for cochlear implant surgery
•    Assist in performance of cochlear implant surgery and actively participate in post-operative rehabilitation and assessment
•    Assist at/observe surgery for treatment of otosclerosis
•    Assist at and demonstrate a logical approach to surgery for treatment of lateral skull base lesions including acoustic neuromas, other benign CPA lesions, and petrous apex lesions
•    Attend Skull Base Clinic and understand controversies in patient management
•    Present cases at Skull Base Tumor Board
•    Participate at skull base surgeries and perform some of the procedure under supervision

Rhinology
•    Perform effective rigid nasal and sinus endoscopy
•    Biopsy nasal cavity lesions
•    Participate actively in the post-operative office management of patients who have undergone sinus surgery including pharmacotherapy and debridement
•    Interpret X-ray and cross-sectional imaging of the paranasal sinuses
•    Demonstrate a sophisticated approach to selection of the surgical candidate for treatment of nasal obstruction and chronic rhinosinusitis, including indications for endoscopic sinus surgery and the extent of the procedure to be performed.
•    Effectively prepare patients for endonasal surgery such as septoplasty and endoscopic sinus surgery, including he informed consent process (description of risks/possible complications)
•    Perform nasal septoplasty including choice of incision, method of septoplasty, and closure materials with decreasing degree of direct consultant supervision
•    Perform inferior turbinate reduction with limited consultant supervision
•    Refine knowledge of paranasal sinus anatomy and perform surgical techniques of endoscopic polypectomy, uncinectomy, ethmoidectomy, and middle meatal antrostomy with decreasing degree of direct consultant supervision
•    Perform endoscopic sphenoidotomy and frontal recess dissection with direct consultant supervision
•    Acquire familiarity and assist at endoscopic approaches to the pituitary gland
•    Perform surgical treatments for epistaxis including endoscopic sphenopalatine artery ligation and anterior ethmoid artery ligation as well as internal maxillary artery ligation
•    Acquire familiarity with techniques for the management of benign sinonasal neoplasms such as inverted papilloma (e.g. endoscopic medial maxillectomy)

Communicator Role

As a communicator the otolaryngology resident should effectively facilitates the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. The resident is thought and evaluated on these issues:

•    Demonstrate effective establishment of therapeutic relationships with patients and their families
•    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
•    Recognize unique biopsychosocial issues related to deafness and the deaf community and recognize their unique communication requirements
•    Demonstrate the capacity to recognize the psychological, occupational and social consequences of speech and voice disorders, particularly relevant to vocational demands
•    Obtain and synthesize relevant history from patients, their families, and communities
•    Prepare clear, accurate, concise, appropriately detailed clinical notes, consultation notes, discharge summaries, and operative reports
•    Present histories, physical findings, and management plan to consultants in an organized, efficient, and confident manner
•    Respect diversity and difference, including gender, religion and cultural beliefs on decision-making
•    Discuss common procedures with patients and their families in a clear and understandable form including risks/benefits, informed consent, and post-operative care
•    Address challenging communication issues effectively, such as obtaining informed consent, delivering bad news, and addressing anger, confusion and misunderstanding
•    Participate, and present effectively in organized rounds and seminars

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
•    Prepare clear, accurate, concise, appropriately detailed clinical notes, consultation notes, discharge summaries, and operative reports
•    Discuss more complex procedures (e.g. tympanoplasty, thyroidectomy) with patients and their families in a clear and understandable form including risks/benefits, informed consent, and post-operative care
•    Prepare, participate, and present 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
•    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
•    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

Collaborator Role

As collaborators the otolaryngology residents effectively work within a health care team to achieve optimal patient care. The resident is thought and evaluated on these issues:

•    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
•    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
•    Recognize the advantages for optimal patient care provided by an multidisciplinary Head and Neck oncology team

The collaborator role is evaluated especially on:
•    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
•    Recognize the advantages for optimal patient care provided by a multidisciplinary head and neck oncology program

Manager Role

As managers the otolaryngology residents are integral participants in health care organizations, making decisions about allocating resources, and contributing to the effectiveness of the health care system. The resident is thought and evaluated on these issues:

•    Utilize resources effectively to balance patient care duties, learning needs, educational / teaching responsibilities & outside activities and personal life
•    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
•    Use patient information tools effectively
•    Demonstrate an appreciation of the importance of quality assurance/improvement, such as patient safety initiatives
•    Take care of charts and use head and neck patient database
•    Demonstrate ability to lead a health care team
•    Serve in administrative and leadership roles, such as participate effectively in committees and meetings

The manger role is evaluated especially on:
•    Demonstrate ability to lead a health care team
•    Utilize resources effectively to balance patient care duties, learning needs, Educational/teaching responsibilities and 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)
•    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
•    Recognize the advantages for optimal patient care provided by a multidisciplinary head and neck oncology program

Health Advocate Role

As Health Advocate the otolaryngology residents responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations. The resident is thought and evaluated on these issues:

•    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, UVA/UVB sun exposure)

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.
•    Demonstrate familiarity with important determinants of health relevant to Otology such as environmental noise exposure
•    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 and neck cancer (e.g.: tobacco, alcohol, UVA/UVB sun exposure)

Scholar Role

As Scholars the otolaryngology residents demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge. The resident is thought and evaluated on these issues:

•    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
•    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

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)
•    Demonstrate the evolving commitment to, and the ability to practice, life-long learning


Professional Role

As professionals the otolaryngology residents are committed to the health and well-being of individual s and society through ethical practice, profession-led regulation, and high personal standards of behavior. The resident is thought and evaluated on these issues:

•    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 others unprofessional behavior in practice, understand the legal and ethical codes of practice

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