Goals and Objectives for Medical Students and Core Orthopaedic Surgery Residents
McGill Orthopaedic Oncology
After completion of their rotation in orthopaedic oncology medical students and junior residents will:
1 Be informed on the basic features of bone and soft tissue tumors
2 Be initiated to the conduction of a musculoskeletal oncology patient questionnaire and physical examination
3 Recognize some of the most common symptoms and physical anomalies related to this patient population
4 Recognize some of the radiographic features of benign and malignant bone and soft tissue tumors
5 Outline a simple differential diagnosis relating to bone and soft tissue tumors
6 Be knowledgeable about the use and utility of blood and imaging studies
7 Be initiated to the principles of tumor biopsy
8 Gained some basic knowledge of the most common tumors histology
9 Understand the treatment possibilities for common tumors including the surgery, chemotherapy and radiotherapy
10 Understand prognostic factors and figures
11 Know some of the principles of treatment in metastatic bone disease including palliative care and pain control
12 Have some notions about quality of life, function and health status for the oncology population
13 Be initiated to specific needs of cancer patients including those at palliative stage
14 Be introduced to how to show empathy, availability, support and compassion to patients and family
15 Improve their verbal communication ability to patient and family
During their rotations resident would be expected to:
1 Perform oncology questionnaire and physical examination of new and follow up patents
2 Elaborate on the differential diagnosis, an investigation plan and treatment of patients
3 Attend to surgical management Performed needle and open biopsies
Knowledge is acquired through:
1 Rotation through the MSK oncology unit
2 Attendance to multidisciplinary musculoskeletal oncology clinics
3 Attendance to the weekly Sarcoma tumor board
4 Attendance to the monthly MSK tumor multidisciplinary teaching round
5 Orthopaedic seminars
Goals and Objectives for Medical Students and Core Orthopaedic Surgery Residents
McGill Orthopaedic Oncology
Medical Expert/Clinical Decision Maker
Describe the curriculum (i.e., organized teaching in basic and clinical sciences) that assures residents cover all relevant areas. The residents receive organized teaching in basic and clinical orthopaedic oncology through a two months rotation as either R4 or R5 level through the musculoskeletal oncology subdivision. Resident are either alone during this rotation or under the supervision of a fellow. Exposure is also gained by attendance to multidisciplinary musculoskeletal oncology clinics twice a week, attending operating room for tumor cases once a week, and mandatory participation through the many sarcoma rounds and conferences: Weekly sarcoma tumor board Friday morning, monthly MSK tumor multidisciplinary teaching round (starting September 2004) and through orthopaedic seminars once or twice yearly. In addition tumor cases are presented at hospital rounds held every other Thursday morning where residents demonstrate their ability to perform tumor patient questionnaire, physical exam and outline a plan of investigation and treatment.
Communicator
Through their MSK oncology rotation residents become more familiar with cancer as a disease and how it impacts on the patients and its family. Residents are encouraged to address patients concerns about their condition and prognosis at the level of their knowledge and expertise either at the clinic, operating room or on the ward. They are present when diagnosis is announced and discussed and when difficult treatment issues are addressed.
Through the tumors rounds the residents to acquire teaching and communication skills. Residents are expected to communicate with other residents and attending staff with regard to patient management, diagnostic and surgical techniques. During these rounds, presentations are frequently given by the residents to the attending staff, residents, medical students, and nurses.
Tumor rotation residents see all patients preoperatively in the pre-admission clinic. This clinic runs in the same location and at the same time as one of our MSK oncology clinic. At this time, they are available to answer questions concerning the patients’ medical condition and upcoming surgery. In many cases, they provide the patients with sufficient information regarding the risks and benefits of treatment so that they can make an informed choice of management options. In the case of pediatric orthopaedics, this involves communicating this information to the patient’s parents. They may be involved in obtaining an informed consent for an operative procedure. This interaction of the residents with the patients is continuously supervised by the attending staff.
Residents must obtain the ability to communicate effectively with other members of the health care team. Continuous feedback from allied health staff regarding resident’s interaction with them is common. This is especially important for the cancer patients where
psychological, social and financial issues frequently needs to be addressed. Appropriate feedback is given to the residents.
3. Collaborator
The residents are given the opportunity to learn collaborative skills by working in a team. Residents are expected to delegate activities effectively to their junior residents but most often the MSK oncology rotation has only one senior resident rotation and as such work even more closely with the attending staff and oversees all the tumor service activities. Residents also learn how to appropriately consult other physicians in the treatment of orthopaedic patients. Residents are given the responsibility to actively manage the patients on the ward and to consult other physicians, as deemed necessary, to assist in treating the patient. All activities are overseen by the attending staff. As well, residents collaborate with the multidisciplinary team during the Tumor Clinic. They learn how they must collaborate as part of a multidisciplinary team in order to treat musculoskeletal tumors. They learn how transfer patient information to the rest of the multidisciplinary team. They also coordinate the patient’s treatment in lieu of the requirements by the radiotherapists and chemotherapists. This activity is overseen by the attending staff.
4. Manager
Residents are required to effectively carry out their work and prioritize their activities. This includes the management of patients in the clinic and operating room. Residents are required to use the current information technology in the hospitals to obtain blood and x-rays results. Their ability to obtain and utilize this information is continuously being evaluated.
The residents play a role in the planning, booking and execution elective surgery. The residents are expected to prioritize surgical needs, find appropriate time in the operating room and make certain the appropriate tumor implants are selected and available. These management and administrative skills are crucial to the residents’ performance.
Sarcoma tumor board provide an objective review of tumor cases presented. Peer review of the assessment and treatment is provided. A final consensus result in appropriate management.
Morbidity and Mortality Rounds are held at regular intervals every three months. Tumor case are part of these rounds. Residents are responsible for all aspects of this evaluation, which consists of chart review, evaluating the technical aspects of the surgical procedure and postoperative care. The residents present the complications, either medical, surgical or oncological, as well as discuss the possible changes to avoid these complications in the future.
5. Health Advocate
The resident’s integral role in planning investigation and treatment for tumor patients prepares the residents for their role as a health care advocate. Residents can thereby appreciate the difficulties with limited resources under the Canadian Health Care system and become able to effectively prioritize what needs to be done and how to use the resource efficiently. They also get familiar to the provision of timely management and care to be given to the cancer patient and knowledgeable about how this can affect patient outcome..
Risk factor associated with primary or secondary tumors are sought after by residents so patients can be instructed about how this has or could affect their well being (e.g. smoking)
Oncology is an area where ethics play a significant role. Trainees have to address and resolve ethics issues. We maintain closed contact with ethicians and other resources such as CNS in Oncology, palliative care specialists to insure proper teaching and decision making.
6. Scholar
Direct observation at hospital and inter-hospital rounds with regards to the ability of the resident to present cases in a manner which is clear, concise and imparts reference material to staff, peers, paramedical personnel and medical students is an important mechanism in evaluating communication skills.
As well, when residents see patients in the out patient clinics they are required to review the case with the attending staff. This gives the staff the opportunity to evaluate the residents’ communication skills. In the outpatient clinic, the residents are constantly communicating with nurses, cast technicians, etc… This behaviour is closely monitored by the attending staff.
Local hospital and inter-hospital rounds, tumor seminars, meeting where resident present tumor related papers are ways for the residents to acquire teaching and communication skills during their MSK oncology rotation.
Occasional journal clubs about MSK oncology provide the residents with the means to critically appraise the literature and evaluated statistical analysis. Online computers are available on wards and clinics and allow immediate access to web site on tumor and to medical literature for quick appraisal.
All orthopaedic residents are expected to carry out a research project each year. This includes MSK oncology. These usually consist of clinical projects. As such, the residents must carry out a literature review and appraisal of it. This is done in conjunction with an attending staff. This research is then presented to the Division of Orthopaedic Surgery and the Visiting Professor for scientific appraisal.
Additionally, the residents are continuously exposed to ongoing clinical research through their oncology rotation. Local or national projects are an important part of our activities.
Residents are ask to provide some clinical information or fill forms on patient status and familiarize themselves with the common tools used in the functional assessment and quality of life of cancer patient.
Finally OSCE exams are done twice a year and include topics on tumor. These address the knowledge of trainees and insure proper communication skills.
Rotation Specific Objectives Musculoskeletal Oncology
The following document is intended to guide you in some of the specific knowledge and skills you should develop on this rotation. This document is intended to augment but not replace the “Objectives of Training and Specialty Training Requirements in Orthopedic Surgery” and the “Specific Standards of Accreditation for Residency Programs in Orthopedic Surgery”. A copy of these documents is supplied in your residency handbook and is also available on the Royal College website.
The resident is expected to be able to describe the rotation specific objectives prior to or at the commencement of the rotation.
It is understood that a residency in Orthopaedics is a continuum. Senior residents will be able to meet the same objectives as junior residents as well as the senior objectives.
1. MEDICAL EXPERT
1.1. Cognitive and Diagnostic
1.1.1. Junior/Senior Resident
1.1.1.1. Obtain appropriate history and perform physical examination relating to a tumour and be competent in assessing the following:
1.1.1.1.1. Size of the tumour and its relationship to fascia
1.1.1.1.2. Neurovascular and articular involvement
1.1.1.1.3. Lymphatic involvement
1.1.1.1.4. Sites of metastatic potential for primary MSK tumours
1.1.1.1.5. Organs systems likely to metastasize to the MSK system
1.1.1.1.6. Tumour characteristics including issues specific to age and gender
1.1.1.2. Describe the different bone and soft tissue tumour classes and their behaviour:
1.1.1.2.1. Primary lesions
1.1.1.2.2. Benign
1.1.1.2.3. Benign Aggressive
1.1.1.2.4. Malignant
1.1.1.2.5. Metastatic lesions
1.1.1.3. Describe the presentation, radiologic characteristics and natural history of the most common primary bone tumour types:
1.1.1.3.1. Chondroid lesions
1.1.1.3.2. Osteoid lesions
1.1.1.3.3. Fibrous lesions
1.1.1.3.4. Others- unicameral bone cyst, hemangioma, histiocytosis, lipoma, eosinophilic granuloma, giant cell tumour, aneurysmal bone cyst, ewings sarcoma, adamantinoma, chordoma, hemangiopericytoma
1.1.1.4.Describe the presentation, radiologic characteristics and natural history of different primary soft tissue tumour types:
1.1.1.4.1. Fibrous lesions
1.1.1.4.2. Lipoid lesions
1.1.1.4.3. Muscle lesions
1.1.1.4.4. Vascular lesions
1.1.1.4.5. Nerve lesions
1.1.1.4.6. Others - myxoma, fibrosarcoma, malignant fibrous histiocytoma, pigmented villonodular synovitis, giant cell tumour of tendon sheath, myositis ossificans, tumoral calcinosis
1.1.1.5. For a given MSK tumour:
1.1.1.5.1. Formulate a differential diagnosis and stage the tumour (according to the Enneking Musculoskeletal Tumour Society (MSTS) System)
1.1.1.5.2. Describe the appropriate biopsy principles of MSK tumours.
1.1.1.5.3. Formulate a treatment plan for the different tumour types
1.1.1.5.4. Describe the multidisciplinary approach to
1.1.1.5.4.1. Ccurative treatment
1.1.1.5.4.2. Palliative care
1.1.1.6. Formulate treatment plans for complications in MSK oncology surgery.
1.2. Technical
1.2.1. Junior/Senior Resident
1.2.1.1.To be able to perform with proficiency:
1.2.1.1.1. Open biopsy of bone and/or soft-tissue lesion
1.2.1.1.2. Stabilization of metastatic disease
1.2.1.1.3. Treatment of common benign tumours
2. COMMUNICATOR
2.1. Deliver information to patients and family in a humane manner so that the patient and family understand the options of care and are able to participate in the decision-making process
2.2. Demonstrate an ability to listen effectively and address patients concerns
2.3. Develop strategies for delivering bad news and discussing end of life decisions
2.4. Effectively communicate with others involved in the multidisciplinary care of the oncology patient
2.5. Provide timely and appropriate consultation as requested
3. COLLABORATOR
3.1. Describe the roles and responsibilities of the members of a multidisciplinary oncology team
3.2. Develop a working relationship with the appropriate pathologist and radiologist
3.3. Participate in Sarcoma tumor boards and Morbidity and Mortality rounds
3.4. Describe support groups in the community who can assist the oncology patient and their families
4. MANAGER
4.1. Prioritize the investigation and management of the oncology patients
4.2. Understand the balance of allocation of healthcare resources, balancing effectiveness, efficiency and access with optimal patient care
4.3. Describe appropriate waiting times for the oncology patient
5. HEALTH ADVOCATE
5.1. Understand the risk factors associated with the development of a malignancy
5.2. Describe strategies to decrease the societal risk of malignancy
5.3. Communicate to patients their individual risk factors
6. SCHOLAR
6.1. Pose a research question and describe how they would go about answering the question
6.2. Prepare and present an appropriate lecture/presentation including critical appraisal of the literature; describe how this information could be integrated into practice
7. PROFESSIONAL
7.1. Demonstrate ethical practice in the management of the oncology patient including respect for issues regarding gender, ethnicity, religion, age and cultural.
7.2 Demonstrate honesty, integrity, commitment, compassion, respect and altruism