Goals and Objectives for the Orthopaedic Surgery Resident
McGill Foot and Ankle Surgery
I. Medical Expert
General Requirements for R2-R5s:
a) Basic Scientific Knowledge:
- To study the mechanics of gait and assess for abnormalities.
- To study the basic science of arthroses of the foot and ankle, to understand the biochemical changes in degenerative cartilage, and to evaluate the effect of abnormal alignment on the weightbearing ability of the foot.
b) Basic Clinical Knowledge:
-To evaluate the patient presenting with foot pain and diagnose common foot and ankle conditions such as plantar fasciitis, ankle osteoarthritis and ligamentous injuries.
-To understand the natural history of evolving diabetic neuropathy as it affects the foot and develop a plan for management.
-To understand the effect of rheumatoid arthritis on the forefoot and the resulting deformities.
c) History and Physical Examination:
-To be able to perform a complete history of a presenting foot and ankle patient including previous lower extremity trauma or surgery,
-To ascertain the region of the presenting complaint, the quality of pain or dysfunction and the precipitating/ relieving factors.
-To perform a full foot and ankle physical examination including musculoskeletal, vascular and neurological examination.
d) Interpretation and Utilization of Information:
-To be able to diagnose common foot and ankle pathology and formulate a reasonable treatment plan for the patient.
-To make appropriate decisions when ordering diagnostic tests such as x-rays, CT scans and MRIs to maximize the cost / benefit ratio.
e) Clinical Judgment and Decision Making:
-Similarly to the previous section, to be able to effectively diagnose common orthopaedic problems of the foot and ankle and to order appropriate tests to confirm the diagnosis. To make safe and reasonable surgical decisions regarding treatable pathology.
-To evaluate the whole patient and tailor treatments to accommodate the individual patient, for instance to recognize that a rheumatoid arthritis patient may find it impossible to ambulate non-weight bearing on crutches due to other joint pathology especially in the upper extremity.
-To realize that the diabetic foot patient often has multi-system involvement and to help coordinate the care as much as possible.
f) Technical Skills Required in the Specialty:
-To evaluate the surgical skills of the resident especially fine motor control required in most cases of foot and ankle.
-To assess casting techniques to ensue proper immobilization is acquired.
Specific Requirements:
PGY-2 Level:
To be introduced to the sub-specialty of foot and ankle. To learn the anatomy of the foot and to apply it to the clinical situation. To learn how to perform a physical examination of the foot and to learn the signs of specific abnormalities.
PGY-3 Level:
To expand on the knowledge of clinical conditions and to appreciate the treatment modalities available for specific conditions. To learn the operative approaches to specific joints and bones in the foot and ankle. To perform basic operative cases such as bunionectomies, arthroscopies and neuroma excisions.
PGY-4 Level:
To acquire further skills and knowledge of the pathological conditions of the foot and ankle. To be able to recognize certain pathological conditions such as posterior tibialis tendon dysfunction, osteochondral defects of the talus and complex fractures of the midfoot and the hindfoot. To develop skill at performing osteotomies, arthrodeses, and arthroscopies. To recognize and manage peri-operative complications.
PGY-5 Level:
To demonstrate detailed knowledge of complex problems of the foot and ankle and to be able to formulate a treatment plan to effectively address these problems. To understand fully the principles of gait and foot biomechanics. To manage complex peri-operative complications. To be able to perform complex cases such as triple arthrodeses, ankle arthroplasty and arthrodesis, and hindfoot malalignment correction.
II. Communicator
General Requirements for R2-R5s:
a) Inter-professional Relationships with Physicians:
To judge the trainee’s ability to effectively discuss cases with other physicians within the specialty and outside so that coordinated care of the patient is effectively accomplished. To be able to help run a trauma code with other disciplines to ensure the safety and best care for the patient.
b) Communications with Other Allied Health Professionals:
To evaluate the ability to discuss patient care especially with nurses and physiotherapy to ensure the correct treatment and therapy of the patient is coordinated.
To ensure that adequate pre- and post-op orders are written legibly in a timely fashion to maximize patient care.
c) Communications with Patients:
To assess the trainees ability to speak to patients in a clear and straightforward manner especially when obtaining operative consents.
d) Communications with Families:
To evaluate the ability of the resident to speak with family members especially when obtaining permission for surgical procedures on incompetent patients.
To ensure the resident is able to effectively discuss any complications that may arise and communicate in a empathetic manner to the family.
e) Written Communication and Documentation:
To evaluate the resident’s ability to write a legible history and physical.
To be able to write adequate post-op orders, progress notes and transfer notes to rehabilitation hospitals.
To be able to dictate in a coherent fashion a detailed operation report that includes the procedure, the complications and the blood loss so that a covering physician is able to understand adequately.
Specific Requirements:
PGY-2 Level:
To learn how to communicate effectively with patients and their families. To learn how to document concisely and accurately procedures, physician orders, and any complications. To learn how to be an integral member of the health care team.
PGY-3 Level:
To develop more sophisticated skills in communicating with patients and colleagues. To learn to become more understanding of patients emotional needs as well as their physical needs. To recognize and effectively diffuse stressful situations.
PGY-4 Level:
To become a confident advocate for the patient. To become a leader of the health care team in charge of patients’ welfare. To ensure that the management of the floor is well coordinated and that any problems arising are effectively communicated with the patient, the attending staff, and nursing personnel.
PGY-5 Level:
To be the advocate for the patient. To have developed the necessary skills required in clinical practice to effectively communicate with patients, families, and other health care professionals.
III. Collaborator
General Requirements R2-R5s:
To be able to interact within the medical team efficiently and to consult effectively and prudently.
To be able to delegate effectively to other members of the healthcare team.
Specific Requirements:
PGY-2,3 Level:
To learn their role in the interdisciplinary team. To recognize their limitations. To learn to respect the opinions of the more senior team members and to learn from their experience.
PGY-4,5 Level:
To develop and coordinate care plans for the complex patient. To interact effectively with other members of the multidisciplinary team. To be able to accept and respect the opinions of other medical specialists. To be able to perform administrative roles; for example creating call schedules.
IV. Manager
General Principles for R2-R5s:
a) Understands and Uses Information Technology:
To be able to use effectively the current technology especially computers, personal palm pilots, and operating room equipment such as the C- arm fluoroscopy unit.
b) Uses Health Care Resources Cost-Effectively:
To judge that the trainee orders appropriate investigations and is aware of the cost for these investigations especially imaging tests such as CT scans, MRIs and arthrograms.
c) Organization of Work and Time Management:
To ensure that the work on the busy foot and ankle service is accomplished in a timely fashion.
To organize the daily work so that inpatients and outpatients are seen and treated.
To attend important clinics so that adequate exposure is obtained not only of operative patients but of non-operative conditions as well.
Specific Requirements:
PGY-2 Level:
To learn how to effective manage a busy in hospital service. To attend outpatient clinics to be exposed to non-operative conditions. To learn to order specialized investigations that are appropriate and cost efficient.
PGY-3 Level:
To build on their knowledge of in hospital management. To be able to judge the value in specific investigations and to judge the need for further investigation when warranted.
PGY-4 Level:
To be able to run an in hospital service independently and to seek advise when appropriate. To be able to track patient investigations with computer technology. To organize the junior residents work schedules to ensure each team member is effectively utilized.
PGY -5 Level:
To act as a supervisor for the team and to step in when their advise or knowledge is required. To ensure that the overall management of the service is carried out efficiently and effectively.
V. Health Advocate
General Requirements for R2-R5s:
a) Advocates for the patient:
To evaluate the trainee in his ability to protect the patient from medical error and to ensure the best outcome for the individual. To identify determinants of health affecting patients (ie poverty, education, social support systems).
b) Advocates for the Community:
To evaluate the trainee’s ability to discern the impact certain diseases have on society such as communicable diseases and pandemic diseases such as type 2 diabetes.
To be knowledge of the health care system in Canada and to be an advocate for constructive change.
To be aware of community based resources and public education programs and to inform patients regarding them.
VI. Scholar
General Requirements for R2-R5s:
a) Motivation to Read and Learn:
To judge the trainee on his knowledge of orthopaedics especially his ability to “read around” operative cases.
To evaluate the resident at fracture and subspecialty teaching rounds during the week especially his knowledge of the cases, the treatment and the complications.
To hold regular journal clubs to discuss current issues in foot and ankle surgery.
b) Critically Appraises Medical Literature:
At regular journal clubs the trainee should be able to read a published article and judge the merits of the research based on the methodology.
c) Teaching Skills:
To evaluate the resident’s ability to teach other healthcare individuals and more junior residents especially at teaching rounds, at the bedside of the patient and in the operating room.
d) Completion of Research Project:
To be able to initiate, perform and successfully present a research project related to foot and ankle.
VII. Professional
General Requirements for R2-R5s:
a) Integrity and Honesty:
To evaluate if the resident is responsible in his duties and honest in reporting his failures to supervisors. To evaluate if the resident is reliable in his care of the patient’s on the service.
b) Sensitivity and Respect for Diversity:
To evaluate if the trainee is sensitive to patients needs especially regarding issues related to age, gender, religion, and culture.
c) Responsible and Self-disciplined:
To evaluate if the resident has insight into his/her own limitations and seeks guidance and advise when necessary.
To be able to act as a post-graduate student and be self-disciplined in keeping up with the reading of foot and ankle pathologies.
d) Communicates with patients with Compassion and Empathy:
e) Recognition of own Limitations, Seeking Advise when Needed:
To evaluate the residents ability to self-evaluate, and recognize when to confer with the senior residents or attending staff.
To be able to accept constructive criticism and to use it to improve both technically and clinically.
To strive to balance professional and personal roles and responsibilities in a mature manner .
To demonstrate ways of resolving conflicts and strain.
f) Understands Principles of Ethics; Applies to Clinical Situations:
To evaluate the trainee’s understanding of moral and ethical practice as it applies to the care of the patients under his care.
To have knowledge of provincial regulations as it applies to unprofessional conduct and the policies for recognizing and the reporting of such behavior.
VIII. Global Evaluation of Competence and Progress:
This is an overall assessment of the trainee taking into consideration level of training, time spent on the service and the overall performance of the individual. It reflects the diligence, competency and progress made during the rotation.
Rotation Specific Objectives
Foot and Ankle Clinical Teaching Unit
Jewish General Hospital
The following list of objectives is intended to provide a basis for your learning opportunity on foot and ankle. This document is intended to augment but not replace the “Objectives of Training and Specialty Training Requirements in Orthopaedic Surgery” and the “Specific Standards of Accreditation for Residency Program in Orthopaedic Surgery”. A copy of this document is supplied in your residency handbook and is also available on the Royal College website.
1. Medical Expert
Cognitive and Diagnostic
Junior Resident
-Understand normal musculoskeletal anatomy of the foot and ankle.
-Understand gait assessment.
-Understand common pathologic conditions of the foot and ankle.
-Recognize and manage common fractures of the foot and ankle.
-Recognize and manage common sports injuries of the foot and ankle.
-Demonstrate knowledge of the common surgical approaches in foot and ankle.
Senior Resident
-Understand and manage complex disorders of the foot and ankle including congenital and acquired.
-Recognize and manage complex diabetic foot pathology including ulcerations and Charcot fracture-dislocations.
-Understand complex fractures of the foot and ankle including Pilon fractures, Lisfranc fracture-dislocations, and calcaneal fractures.
-Understand and manage foot compartment syndrome.
Technical
Junior Resident
-Assess and manage simple fractures/dislocations of the ankle in the Emergency room including sedation techniques and casting.
-Demonstrate an ability to perform open reduction and internal fixation on simple ankle fractures and metatarsal fractures.
-Perform a detailed vascular and neurological examination of the foot.
Senior Resident
-Assess and manage complex foot and ankle fractures including application of a bridging external fixator for Pilon fractures, closed reductions of Lisfranc fractures and later open reduction and internal fixation of Lisfranc fracture dislocations.
-Assess and manage open fractures of the foot and ankle.
-Assess and manage plantar foot abcess.
-Assess and manage complex foot conditions including rheumatoid forefoot, aquired pes planus, and pes cavus deformities.
-Orders appropriate investigations for foot pathologies.
2. Communicator
- Understands the importance of communication in the cooperation and compliance of the patients and their families.
- Is able to obtain an informed consent for patients undergoing surgery. Demonstrates the ability to explain procedures to patients in a clear and concise manner.
- Is able to illicit information regarding patients’ social supports and occupation to aid the patient after discharge.
3. Collaborator
-Develop patient care plans with other members of the health care team including nurses, physiotherapists, occupation therapists and social workers.
-Demonstrate the ability to work within and as seniors, lead, a team of orthopaedic residents and medical students.
-Develop discharge plans for each patient and involve appropriate team members to accomplish smooth discharge.
4. Manager
Junior Resident
-Assess and allocate medical care within the hospital setting.
-Understand the costs of health care on society and function effectively and efficiently to control costs.
Senior Resident
-Lead a health care team and allocate manpower resources for patient care
-Understand a physician role in hospital administration.
-Be able to manage time efficiently to balance duties and learning.
5. Health Care Advocate
-Recognize and understand the psychological, social and physical determinants of patient health.
-Demonstrate a knowledge of resources available to the patient in need of community based care.
-Demonstrate how to promote health and prevent injury in the community at large.
6. Scholar
Junior Resident
-Demonstrates ability for self directed learning and learns to appraise the foot and ankle literature.
-Demonstrates ability to teach the medical students on the rotation.
-Recognizes knowledge insufficiencies and technical weaknesses and works to improve them.
Senior Resident
-Demonstrates ability to teach the junior residents and medical students in a structured and supportive manner.
-Identifies areas for potential foot and ankle research.
7. Professional
Junior Resident
-Demonstrates an ability to work professionally in a team completes consults in a timely fashion.
-Seeks advice when dealing with rare conditions or pathologies outside scope of knowledge.
Senior Resident
-Provides efficient and definitive advice on the consult service.
-Recognizes when to seek advice when confronted with unfamiliar conditions.
-Demonstrates compassion and empathy when dealing with the patients and their families.