Goals and Objectives for the Orthopedic Resident
McGill Pediatric Orthopedics
I. Preamble
- One teaching unit, 2 hospitals: the Montreal Children’s Hospital (MCH) and the Shriners Hospital
- Trauma calls are taken at MCH
- Most Trauma and any elective cases needing ICU’s postoperatively are done at the MCH.
- Most elective pediatric orthopedic surgery is done at the Shriners (congenital, metabolic, developmental, neuro-orthopedics. . .)
- Rounds: Trauma rounds once a week at MCH
- Indication rounds once a week at the Shriners
- Bedside rounds once a week in each hospital
- Shriners Grand Rounds are held once every two months on Thursday mornings not
- coinciding with McGill Grand Rounds.
- Teaching session (case presentation, text-book discussion, formal presentation or Journal Club) twice a week (Wednesday & Friday morning)
- Mortality-Morbidity rounds according to hospital specific requirements
II. Specific Pediatric Objectives
2.1 Medical Expert
2.1.1 Basic Scientific Knowledge:
- Be able to understand anatomical, physiological and biochemical differences with the adult
- Be able to understand the physiology of the growth plate and growth in general
- Be able to understand the phosphocalcic metabolism and its pathologies
2.1.2 Basic Clinical Knowledge
- Physiological variants (axis of lower limbs)
- Stages of neurological development
- Principles of children’s fractures (mechanicsm, epidemiology, classification of growth plate injuries)
- Principles of bone and joint infections
2.1.3 History and Physical Examination (See 2.1.5)
2.1.4 Interpretation and utilization of information (See 2.1.5)
2.1.5 Clinical judgment and decision making
R2-3 must be able to do a comprehensive physical examination of a pediatric patient with the following diagnoses:
- DDH, Legg-Calvé-Perthes, tibia vara, simple foot deformities, SCFE
- As well must be able to diagnosis, treat, and make clinical decisions concerning most pediatric traumas.
R4 are expected to be able to do the same for more difficult pathologies such as clubfoot, cavus foot and other more complex foot deformities (CVT), neuro-orthopedics, benign tumors as well as spine deformities (scoliosis, spondylolisthesis). Should be able to completely diagnosis and manage pediatric trauma and its complications.
R5 same as above and must know how to deal with complex pediatric problems such as skeletal dysplasias, congenital limb deficiencies (upper and lower limb) as well as complex spine problems (congenital scoliosis and kyphosis)
2.1.6 Technical skills required in the specialty
R-2-3 must be able to perform all closed reductions of fractures and dislocations as well as all tractions and cast techniques. In addition, they must understand the principles of external fixation and know the simple anatomical approaches to common fractures (forearm, elbow, ankle).
R4 must know all the surgical approaches of pediatric fractures requiring open reduction. The most common surgical approaches to the hip, the femur, as well as the foot (posteromedial release) and the spine (posterior) must be understood.
In addition, R4’s are expected to be able to recognize and manage postoperative complications.
R5 are expected to approach a clubfoot as well as know the indications of pelvic osteotomies and their techniques. R5 are also expected to be able to apply the principles of Ilizarov and the selection of the levels for spine fusion. The anterior approach to the spine must be known.
2.2 Commicator
While interprofessional relationships with physicians and other allied health professionals are not specific to pediatrics, it is very different for the communication with patients and families. The resident doing a pediatric rotation must understand that a child is not a small adult. Bedside manners must be adapted to the age of the patient; compassion and patience are expected. Communications with parents and families are crucial as a source of information. Time-consuming activity, it must not be overlooked.
2.3 Collaborator
R 2-3 are expected to collaborate very closely with nursing, resulting in a team approach. At this level, lots of learning can be done on the ward with experienced people.
R4 and R5 though more independent (are expected to seek advice for medication dosages specific to pediatrics).
2.4 Manager
The pediatric rotation is an opportunity to differentiate the cost/effectiveness of several common treatments (traction versus surgery for femur fractures for example)
Organization of work and time management: not specific to pediatrics
2.5 Health Advocat: Must understand important determinants of pediatric health such as poverty, education and the family background. Must know the public policy related to pediatric health. (child abuse for example)
2.6 Scholar: No specific pediatric objectives
2.7 Professional: No specific pediatric objectives
Rotation Specific Objective Pediatric Orthopaedics
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 Orthopaedic Surgery” and the “Specific Standards of Accreditation for Residency Program in Orthopaedic 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
Cognitive & Diagnostic
Junior Resident (R2-R3)
- Understand normal musculoskeletal anatomy, growth, and development in the child including common angular and torsional variants.
- Understand the anatomy and pathologic basis of the disorders leading to a limp in a child.
- Understands the mechanisms, patterns, assessment, management, and potential complications related to common pediatric fractures and dislocations.
- Recognition and management of common overuse syndromes.
- Recognition of non-accidental trauma and pathologic fractures.
- Demonstrate knowledge of specific surgical approaches as relates to the pediatric population.
- Understands the mechanisms, patterns, assessment, management, and potential complications related to osteomyelitis and septic arthritis.
- Understands the principles of management of children with:
- Common hip disorders
- Angular and torsional deformities
- Limb length discrepancy
- Understands the principles of diagnosis and assessment of pediatric benign neoplasia interpretation of imaging and other diagnostic tools specific to the pediatric population.
Senior Resident (R4-R5)
- Understand the principles of management of children with:
- Complex Neuromuscular Disease
- Congenital musculoskeletal deformities
- Spinal deformities
- Metabolic bone disease/skeletal dysplasia
- Pediatric benign neoplasia
- Understand mechanisms, patterns, assessment, management, and potential complications related to pediatric fractures and dislocations.
- Understand the anatomy, pathology, assessment, and management complex hip disorders.Understand the principles of management of pedicatirc polytrauma
- Understand the principles of operative/non-operative management of:
- hip dysplasia in normal and neuromuscular patient
- clubfeet & other foot deformities (Cavus, planovalgus foot)
- spinal deformity
Technical
Junior Resident (R2-R3)
- Assessment and management of simple fractures including appropriate analgesia/anesthesia techniques & cast applications and principles.
- Demonstrate proficiency in clinical examination in the following areas:
- Assess the limping child
- The hips of infants and children including Barlow and Ortolani maneuvers
- General limb length
- Scoliosis examination
- Demonstrate the ability to:
- perform percutaneous pinning of fractures
- apply skin and skeletal traction
- apply a Pavlik harness
Senior Resident (R4-R5)
- Assessment and management of complex pediatric fractures including:
- physeal injuries
- compound fractures
- multiple trauma
- compartment syndrome, and neurovascular compromise
- carry out non operative treatment of children’s clubfoot
- Operative management of:
- Septic arthritis including arthrogram and arthrotomy
- Osteomyelitis
- Slipped capital femoral epiphysis
- Management of benign bone conditions
- Perform appropriate investigation including biopsy for suspected pediatric neoplasia
- Demonstrate the ability to apply a hip spica cast
2. COMMUNICATOR
- Understands the role of communication in fostering patient satisfaction and compliance as it relates to pediatrics, parents and care givers.
- Elicits psychosocial information pertinent to the health of the patient including: socioeconomic background, ethnic, cultural, and spiritual values.
- Demonstrates the ability to deliver information to the pediatric patient and their support group in a way which is understandable.
- Understands and obtains informed consent using medical knowledge and awareness of current consent legislation and the Canada Health Act.
- Demonstrate the ability to describe procedures to the pediatric patient and patient support group.
- The ability to obtain an appropriate informed consent for patients undergoing interventions
3. COLLABORATOR
- Junior Resident (R2-R3)
- Demonstrate an understanding of the unique collaborative nature of pediatric care.
- Understand and develop patient care plan with other members of the inter professional health care team.
- Demonstrate the ability to work within an inter professional team in regards to research and administrative duties.
- Senior Resident (R4-R5)
- Demonstrate the ability to lead an inter professional team.
- Develop a care plan, integrate all members of the team needed and follow the plan to completion in regards to medical or nonmedical issues around the care of the pediatric orthopaedic patient.
4. MANAGER
- Junior Resident (R2-R3)
- Access and allocate infinite health care efficiently within a health care organization.
- Understand the structure, financing, and operation of the health care system and function effectively within it.
- Senior Resident (R4-R5)
- Lead the physician team and allocate manpower resources in regards to patient care.
- Understand the role of the physician in regards to administrative duties in health care.
- Demonstrate the ability to manage time allocation to inter and intra personal learning and duties.
5. HEALTH ADVOCATE
- Junior Resident (R2-R3)
- Recognize and understands the psychological, social, and physical determinants of patient health.
- Understand patient advocacy issues in regards to family, care giver and social care network.
- Understands the medico legal obligations associated with non accidental trauma.
- Recognize the emotional stress for patients and families faced with orthopaedic conditions and optimize psychosocial support network for the pediatric patient.
- Senior Resident (R4-R5)
- Promotion of the determinants of health in the community at large as it relates to the pediatric population.
- Demonstrate the knowledge of resources available to those patients in need of community based care
- Understand the role of community based advocacy in regards to patients with special needs.
- Demonstrate the need to service as a patient advocate for scarce resources for the patient with special needs.
6. SCHOLAR
- Junior Resident (R2-R3)
- Demonstrates ability for self directed learning and critical appraisal of the literature.
- Demonstrate stratified level of knowledge of pediatric orthopaedics with teaching of the junior members of the pediatric health care team.
- Recognize gaps in knowledge and implement a plan to improve their knowledge base.
- Senior Resident (R4-R5)
- Demonstrates the ability to resolve previously identified deficits in knowledge and technical skills.
- Identify possible areas of research in pediatrics orthopaedics.
- Continue to develop teaching models for patient and colleague education.
7. PROFESSIONAL
- Junior Resident (R2-R3)
- Demonstrates the ability to work within the scope of clinical and technical acumen and obtains responsible and timely patient referrals.
- Practice ethically consistent with the obligations of a physician and expectations of the community in regards to gender, culture, ethnicity, race, spiritual values and socioeconomic standard.
- Demonstrates the ability to put patient and parents at ease and inspire confidence in the treatment plan.
- Senior Resident (R4-R5)
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- Provides efficient, authoritative consultation to the referring source.
- Serve as a role model to the junior members of the health care team in regards to a balance between professional and personal roles.
- Understand the legislation in regards to treatment of the pediatric patient or patients otherwise unable to understand the scope of treatment needed for care.
- Demonstrates ability to identify and remediate weakness in their managerial, administrative or education skills in regards to care of the pediatric patient.